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Is neonatal intensive care justified in all preterm infants?
1Department of Paediatrics, Ritchie Centre for Baby Health Research, Monash University, Monash Medical Centre, 246 Clayton Road, Clayton, Victoria 3168, Australia. victor.yu@med.monash.edu.au
Insights
Proactive intensive care improves survival for very preterm infants, including those born at borderline viability. Quality-adjusted survival rates increased without significant disability, showing stable cost-effectiveness.
Area of Science:
- Neonatal Medicine
- Perinatal Healthcare
- Public Health Policy
Background:
- Proactive resuscitation and intensive care are linked to improved survival in very preterm infants.
- Survival rates for extremely low birth weight infants have progressively increased with greater access to intensive care.
- Quality-adjusted survival has improved, with stable cost-effectiveness and efficiency gains, particularly in smaller infants.
Purpose of the Study:
- To analyze the impact of intensive care policies on survival and quality-adjusted survival in very preterm infants.
- To assess the cost-effectiveness and cost-utility of intensive care for extremely low birth weight infants.
- To explore variations in management decisions and perceptions of viability among healthcare professionals regarding extremely preterm infants.
Main Methods:
- Analysis of institution-based and population-based studies on infant survival rates.
- Review of quality-adjusted survival data and cost-effectiveness ratios over time.
- Examination of national and international surveys on physician perceptions and management of extremely preterm infants.
Main Results:
- Increased intensive care provision correlated with progressively higher survival rates across all subgroups of extremely low birth weight infants.
- Quality-adjusted survival rates improved, without a significant rise in survival with disability.
- Cost-effectiveness remained stable, with efficiency gains observed in smaller infants due to regionalization of care.
Conclusions:
- Early and proactive intensive care significantly enhances survival and quality-adjusted survival for very preterm infants.
- Variations in physician perception of viability can lead to suboptimal management, creating a self-fulfilling prophecy.
- Developing tailored policies for intensive care initiation and withdrawal is crucial for both developed and developing countries, considering local factors.
Abstract:
A proactive policy of resuscitation at birth and prompt initiation of intensive care have been shown to be associated with an improvement in the survival of very preterm infants in both institution-based and population-based studies. As a greater percentage of live births were offered intensive care, the survival rate rose progressively in all birth weight and gestation subgroups among extremely low birth weight infants, including those who were born at borderline viability between 23 weeks and 25 weeks of gestational age. Their quality-adjusted survival rate also rose progressively, since the large gains in survival over time had not been offset by significant increases in survival with disability. Cost-effectiveness and cost-utility ratios remained stable overall, with efficiency gains in the smaller infants over time, as more such infants were being born in Level III perinatal centers with the regionalization of perinatal-neonatal healthcare programs. National and international surveys of obstetricians and neonatologists on their perception of viability and their management decisions in extremely preterm infants have shown significant variations on the application use of intensive care in those born extremely preterm. If doctors believe that such infants have little prospect for intact survival, their management would be suboptimal or delayed, thus creating a self-fulfilling prophecy. Both developed and developing countries need to develop appropriate policies for initiating and withdrawing intensive care, taking into consideration their own cultural, social, and economic factors.
