Published online September 1, 2008
PEDIATRICS Vol. 122 No. 3 September 2008, pp. 680 (doi:10.1542/peds.2008-1850)

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LETTER TO THE EDITOR

Resuscitation Decisions for Premature Newborns: In Reply

Keith James Barrington, MB, ChB
Annie Janvier, MD
Department of Pediatrics,
McGill University,
Montreal, Quebec, Canada H3A 1A1

We appreciate the interest in our article. Our study was not designed to investigate the motivations behind the answers that were given, and it is likely that Dr Morrison is correct in some of her analyses. However, we think she overestimates the likely concerns of respondents about the potential burden of therapy. The student respondents, many of whom (in anthropology and in law) had no experience of the likely "burden" of neonatal intensive care, had exactly the same responses as experienced physicians. This result suggests to us that it is something intrinsic in the way preterm infants are viewed, rather than any concerns about likely burdens, that drove the answers. Furthermore, physician attitudes to severely burned infants, for example, who often have prolonged hospitalizations, many painful procedures, and long-term disability, are quite different; discussions regarding withholding active care usually only take place for those with almost complete body surface area burns and with a consequent extremely low chance of survival. Having those discussions for a burned infant with a 50% chance of survival would usually be considered inappropriate despite the major burden of care.¹

Many very preterm infants now have brief or no assisted ventilation and fewer painful procedures than before, often with very good pain control. We agree that the understanding of these changes is likely to lag behind advances in practice, but again note the almost identical responses of anthropology and law students and first-year medical students who had very little knowledge of the expected course of a preterm infant in the NICU, either before or since our recent advances.

It may well be true that despite our explicit description of outcomes that the respondents used their own previous experiences and beliefs about outcomes when completing the questionnaire, and we agree that it is likely that media reports influence attitudes toward the extremely preterm infant.

We did not intend to imply that there should be a bias in favor of the preterm infant. Our research seems to have shown, however, a bias against them.^2,3 Many learned societies have position statements regarding the care of the extremely preterm infant in which explicit statements are made that the preterm newborn should receive exactly the same type of consideration as an older infant or child. Despite such assertions, the limits to intervention (usually based on a simplistic gestational-age limit) that are recommended are dramatically different from those few which are available for older individuals. Our research suggests that there is a widespread devaluation of preterm infants, the causes of which may be multiple.⁴ This devaluation leads to professional recommendations and generalized attitudes toward preterm infants that seem out of keeping with their outcomes in comparison with the approach to older patients.

REFERENCES

1. Janvier A, Barrington KJ, Aziz K, Lantos J. Ethics ain't easy: do we need simple rules for complicated ethical decisions? Acta Paediatr. 2008;97 (4):402 –406[CrossRef][Web of Science][Medline]
2. Janvier A, Lantos J, Deschenes M, Couture E, Nadeau S, Barrington KJ. Caregivers attitudes for very premature infants: what if they knew? Acta Paediatr. 2008;97 (3):276 –279[CrossRef][Web of Science][Medline]
3. Janvier A, Leblanc I, Barrington KJ. The best-interest standard is not applied for neonatal resuscitation decisions. Pediatrics. 2008;121 (5):963 –969[Abstract/Free Full Text]
4. Janvier A, Bauer KL, Lantos JD. Are newborns morally different from older children? Theor Med Bioeth. 2007;28 (5):413 –425[CrossRef][Web of Science][Medline]

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PEDIATRICS (ISSN 1098-4275). ©2008 by the American Academy of Pediatrics

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This Article Extract Full Text (PDF) Alert me when this article is cited Alert me when eLetters are posted Alert me if a correction is posted Services E-mail this article to a friend Similar articles in this journal Similar articles in Web of Science Alert me to new issues of the journal Add to My File Cabinet Download to citation manager Request Permissions Citing Articles Citing Articles via CrossRef Citing Articles via Google Scholar Google Scholar Articles by Barrington, K. J. Articles by Janvier, A. Search for Related Content PubMed Articles by Barrington, K. J. Articles by Janvier, A. Related Collections Office Practice Social Bookmarking                         What's this?