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Survival of the extremely preterm infant in North America in the 1990s
1Department of Pediatrics, Columbia University, New York, New York, USA. jl1084@columbia.edu
Insights
Neonatal intensive care has improved survival rates for extremely premature infants, especially those born at 25 weeks gestation. However, predicting individual infant survival remains challenging, and the concept of a
Area of Science:
- Neonatalogy and Perinatology
- Critical Care Medicine
- Reproductive Medicine
Background:
- Significant advancements in neonatal intensive care over the past decade have markedly improved survival rates for extremely premature infants.
- Infants born at or after 25 weeks gestation now have a high survival rate, a notable increase from previous decades.
- While survival for infants born at 23-24 weeks gestation is lower, it is not insignificant, and survival reports for even earlier gestations exist.
Purpose of the Study:
- To analyze current survival trends and outcomes for extremely premature infants.
- To evaluate the predictability of survival for individual extremely low-birth weight infants.
- To critically assess the concept and clinical utility of the 'limit of viability'.
Main Methods:
- Review and analysis of current data on the survival of extremely premature infants.
- Examination of the accuracy of existing models for predicting individual infant survival.
- Discussion of the ethical and clinical implications of providing neonatal intensive care.
Main Results:
- Survival rates for extremely premature infants have substantially increased, with most infants >= 25 weeks gestation surviving.
- Survival for infants born at 23-24 weeks gestation, while lower, is considerable.
- Current data are insufficient to accurately predict individual infant survival, and the maximum survival potential with state-of-the-art care remains unknown.
Conclusions:
- The concept of a 'limit of viability' is imprecise and oversimplifies complex clinical and ethical decisions.
- Neonatal intensive care should not be based solely on a minimal chance of survival; a comprehensive assessment of risks, benefits, and values is crucial.
- The term 'limit of viability' should be removed from medical discourse due to its inadequacy in capturing the nuances of care for extremely premature infants and their families.
Abstract:
Survival of extremely premature infants has been significantly higher in the last decade than previously, and may well have improved during this time. The majority of infants greater than or equal to 25 weeks' gestation survive today. Survival of infants 23 and 24 weeks' gestation is significantly lower, but is by no means negligible. Reports of survival of infants less than 23 weeks or less than 500-g birth weight are not unique. Moreover, the maximum survival of infants less than or equal to 25 weeks possible with current state-of-the-art care is not known. Currently available data do not allow survival of the individual extremely low-birth weight or extremely premature infant to be predicted with clinically acceptable accuracy. The concept of a limit of viability is vague and clinically and ethically simplistic. The provision of neonatal intensive care is not necessarily beneficial or justified merely because it affords some minimal chance of survival. This phrase should not be used to summarize the complex issues involved in balancing maternal and neonatal risks and benefits of intrapartum and neonatal care of the extremely low-birth weight or the extremely premature fetus and infant, the suffering of the infant and family, parental values and autonomy, and consumption of limited communal resources. It should be deleted from our vocabulary.