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Neonatal intensive care: is it worth it? Developmental sequelae of very low birthweight
1Department of Pediatrics, University of Virginia, Charlottesville.
Insights
Neonatal intensive care has improved survival for premature infants, with stable disability rates despite increased survival. Most very low-birthweight babies thrive, though subtle learning and behavioral issues may emerge later.
Area of Science:
- Neonatalogy
- Pediatric Neurology
- Public Health
Background:
- Neonatal intensive care has advanced significantly, enabling survival of extremely premature infants.
- Concerns exist regarding the allocation of resources and potential increase in disabilities among survivors.
- Global studies show decreasing mortality and morbidity in very low-birthweight (VLBW) infants over the past two decades.
Purpose of the Study:
- To evaluate secular trends in mortality and morbidity for VLBW infants.
- To assess the proportion of VLBW survivors with moderate to severe disabilities.
- To examine long-term neurodevelopmental and behavioral outcomes in VLBW survivors.
Main Methods:
- Analysis of global secular trends in mortality and morbidity for VLBW infants.
- Assessment of disability rates in VLBW survivors over a 20-year period.
- Review of long-term follow-up studies on cognitive function, learning, behavior, and growth in VLBW infants.
Main Results:
- Dramatic decreases in mortality and morbidity for VLBW infants have been observed.
- The relative proportion of moderate to severe disability has remained stable.
- Most VLBW survivors are free of significant functional impairments, though some are at risk for learning problems.
Conclusions:
- Despite increased survival, the rate of severe disability has not proportionally increased.
- Early identification of severe disability is challenging; ethical considerations shift as infants stabilize.
- While severe disabilities are uncommon, subtle learning and behavioral effects warrant ongoing monitoring and research.
Abstract:
A significant portion of the health care dollar has been spent on neonatal intensive care since the early 1970s when technologic developments permitted salvage of very small premature infants. The wisdom of allocating so much for so few has been challenged, especially if the result is an increase in the number of severely mentally and motorically disabled children. Studies from around the world of the secular trends in mortality and morbidity for very and extremely low-birthweight babies uniformly indicate that there have been dramatic decreases in mortality and morbidity in the past 20 years. The relative proportion of moderate to severe disability has remained stable during this period of increasing survival potential. Thus, although the absolute numbers of children with disabilities caused by complications of very low birthweight may have increased slightly, they constitute a small minority of the overall number of children with disabilities requiring special educational and other services. Most surviving children with birthweights less than 1500 g remain free of significant functional impairments. It is often difficult for the clinician to identify early or even midway through the neonatal course which infants will have severe, life-long disabilities. By the time identification is feasible, heroic decisions about life supports are no longer called for. Thus, the ethical issues discussed earlier regarding decision-making based on anticipated quality of life become less relevant as the child's condition stabilizes. Given the generally favorable prognosis for even the smallest premature infant, the clinician is probably best advised to give the individual patient the benefit of the doubt. Undoubtedly, there will be exceptions. The more subtle effects of very low birthweight on learning and behavior are just becoming clear as long-term follow-up studies appear in the literature. Very low-birthweight infants who do not manifest severe disability do seem to be at risk for learning problems, although overall cognitive function is in the normal range. There are other effects of preterm birth. On average, stature appears to remain lower, although there may be catch-up growth later in childhood. Having a very low-birthweight infant places considerable stress on the family, but it is unclear whether this has a long-term impact. Studies have failed to show a consistent influence of preterm birth on long-term behavior. Behavior is likely affected more by the social-emotional milieu in which the child is reared than prematurity itself. The environment seems to take over in importance in affecting cognitive functioning after the first several years of life.(ABSTRACT TRUNCATED AT 400 WORDS)