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Determining resuscitation threshold for extremely preterm infants based on the survival rates without severe
Xiao-Yu Dong1, Wen-Wen Zhang2, Jun-Ming Han3
1Shandong Provincial Maternal and Child Health Care Hospital Affiliated to Qingdao University, Jinan, China.
Insights
Resuscitation guidelines for extremely preterm infants in China should be adjusted. Lowering the threshold to 25 weeks improves survival rates without severe neurological injury, offering better outcomes for neonates.
Area of Science:
- Neonatalogy
- Perinatal Medicine
- Public Health Policy
Background:
- Existing guidelines for extremely preterm infant care are primarily based on high-income country data.
- Rapidly industrializing nations like China lack population-specific data for prenatal management and practice guidelines.
Purpose of the Study:
- To evaluate outcomes for extremely preterm infants (22-28 weeks gestational age) in northern China.
- To inform potential adjustments to resuscitation and care thresholds for this population.
Main Methods:
- Prospective, multi-center cohort study of 5838 infants from January 2018 to December 2021.
- Inclusion criteria: gestational age 22-28 weeks, admitted to 40 tertiary neonatal intensive care units (NICUs).
- Primary outcome: death or severe neurological injury before discharge.
Main Results:
- Admission rates increased with gestational age: 4.1% (22-24 wks) to 75.2% (27-28 wks).
- Survival without severe neurological injury varied significantly by gestational age, from 6.7% (22-23 wks) to 84.5% (27-28 wks).
- Lowering the resuscitation threshold to 25 weeks showed a relative risk of 3.62 for death/severe injury compared to 28 weeks, but improved survival rates.
Conclusions:
- Current resuscitation thresholds for extremely preterm infants may be too high for the Chinese context.
- Adjusting the threshold to 25 weeks, based on reliable capacity, can significantly improve survival rates without severe neurological injury.
- Non-medical withdrawal of care decisions occurred in 11.1% of admitted infants, highlighting complex ethical considerations.
Background:
Published guidelines on decision-making and resuscitation of extremely preterm infants primarily focus on high-income countries. For rapidly industrializing ones like China, there is a lack of population-based data for informing prenatal management and practice guidelines.
Methods:
The Sino-northern Neonatal Network conducted a prospective multi-centre cohort study between 1 January 2018 and 31 December 2021. Infants with a gestational age (GA) between 22 (postnatal age in days = 0) and 28 (postnatal age in days = 6) admitted to 40 tertiary NICUs in northern China were included and evaluated for death or severe neurological injury before discharge.
Results:
For all extremely preterm infants (n = 5838), the proportion of admission to the neonatal was 4.1% at 22-24 weeks, 27.2% at 25-26 weeks, and 75.2% at 27 and 28 weeks. Among 2228 infants admitted to the NICU, 216 (11.1%) were still elected for withdrawal of care (WIC) due to non-medical factors. Survival rates without severe neurological injury were 6.7% for infants at 22-23 weeks, 28.0% at 24 weeks, 56.7% at 24 weeks, 61.7% at 25 weeks, 79.9% at 26 weeks, and 84.5% at 27 and 28 weeks. Compared with traditional criterion at 28 weeks, the relative risk for death or severe neurological injury were 1.53 (95% confidence interval (CI) = 1.26-1.86) at 27 weeks, 2.32 (95% CI = 1.73-3.11) at 26 weeks, 3.62 (95% CI = 2.43-5.40) at 25 weeks, and 8.91 (95% CI = 4.69-16.96) at 24 weeks. The NICUs with higher proportion of WIC also had a higher rate of death or severe neurological injury after maximal intensive care (MIC).
Conclusions:
Compared to the traditional threshold of 28 weeks, more infants received MIC after 25 weeks, leading to significant increases in survival rates without severe neurological injury. Therefore, the resuscitation threshold should be gradually adjusted from 28 to 25 weeks based on reliable capacity.
Registration:
China Clinical Trials Registry. ID: ChiCTR1900025234.
