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Active treatment improves survival in smallest US babies
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About 13% of infants survive to discharge when they are born weighing less than 400 g — or slightly less than 1 pound — and those who do survive face an increased risk for neurodevelopmental impairment. However, researchers said active treatment considerably improves the infants’ chances of survival.
According to Jane E. Brumbaugh, MD, assistant professor of neonatal medicine at the Mayo Clinic, and colleagues from the National Institute of Child Health and Human Development Neonatal Research Network, it was assumed in the 1980s that infants born weighing less than 500 g had a mortality rate of approximately 100%. The researchers wrote that this is no longer the case because of increased use of available treatments, including intubation, surfactant therapy, respiratory support, chest compressions, epinephrine, volume resuscitation, blood pressure support and parenteral nutrition.
They added that although some studies on the outcomes of low-birth-weight infants have included children weighing less than 400 g at birth, few details are available on this specific group.
The researchers conducted a retrospective multicenter cohort study that included 205 infants in this weight range who were born between 22 to 26 weeks’ gestational age. All infants were born between January 2008 and December 2016.
More than half of the infants (64.9%) were singletons, and nearly all (86.8%) were born small for gestational age. Active treatment, or any potentially lifesaving intervention, was used for 49.3% of infants at birth.
Brumbaugh said the reasons why about half of the infants in the study were not given active treatment at birth were not assessed, but she speculated that parents and physicians had decided that no active efforts at resuscitation would be made because the chance of survival was extremely low.
The researchers said that 26 infants (12.7%; 95% CI, 8.5-18.9) survived to discharge. However, infants who received active treatment were more likely to survive to discharge (25.7%; 95% CI, 17.6-35.4).
When Brumbaugh and colleagues examined the outcomes of infants born at 22 to 23 weeks’ gestational age and weighing less than 400 g, the found that 17% (95% CI, 6-33; n = 6) survived to discharge after receiving active treatment.
Out of the 90 actively treated infants, 19 (21%; 95% CI, 13-31) were known to have survived at 18 to 26 months’ corrected age. Nearly three-quarters (74%; n = 14) of these infants had moderate to severe neurodevelopmental impairment.
The findings of improved survival following active treatment among infants born weighing less than 400 g suggest that informed conversations about goals of care are warranted, according to the researchers.
“We encourage centers to track the outcomes of their smallest infants and to be cognizant of the possibility of survival when counseling families,” Brumbaugh told Infectious Diseases in Children. “Even infants born weighing less than 400 g have a chance to live if provided active treatment at birth. Children that survive can have a meaningful life. A few appear to be free of any significant delays at age 2 years.”– by Katherine Bortz
Disclosures: Brumbaugh reports no relevant financial disclosures. Please see the study for a list of all other authors’ relevant financial disclosures.
Perspective
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Erin Osterholm, MD
This study has important implications for everyone taking care of preterm infants at the limits of viability. The researchers concluded that infants born with a birth weight of less than 400 g and a gestational age between 22 to 26 weeks are at a 79% risk for mortality before 18 to 26 months corrected age, and that there is significant neurodevelopmental morbidity in survivors. Thus, people may conclude that the medical community should not undertake such resuscitations because of poor outcomes and the potential for suffering. I propose, with the support of this paper, that the decision is far more complex.
Historically, we have been able to challenge assumptions about chances of intact survival at each birth weight and gestational age. In the 1980s, nearly 100% mortality was assumed for infants with a birth weight of less than 500 g, and thus, those children were not resuscitated. This essentially guaranteed a 100% mortality rate. Now, with technological and scientific advancements, this is no longer accurate. We learned that near the limits of viability, no infant survives without active treatment. Conversely, with active treatment, we have seen outcomes continue to improve at younger gestational ages.
When five of 19 infants in this cohort were evaluated as toddlers, they had no significant neurodevelopmental impairment — an unheard-of statistic in previous eras. The literature demonstrates that infants of younger gestational ages born at centers with higher rates of resuscitation efforts consistently perform better on outcome measures than infants from centers with infrequent resuscitation.
What do we do with this information? I think this is where the importance of counseling and informed decision-making involving families are absolutely key. Statistically, we know that the expected morbidity and mortality in infants born weighing less than 400 g remains high, although the ability to predict the outcome for any given child with any amount of certainty before birth is low. What we have learned is that there is not universal mortality nor universal severe morbidity. Thus, we simply cannot counsel families in the prenatal period as if this information is black and white, when in reality, we learn about the individual risks and benefits for each patient over time and alter the plan accordingly. Informed decision-making about the approach to preterm infants at the limit of viability should always be our goal, with frequent reassessment of the validity of the information provided to families, recognizing that our understanding of outcomes at the limits of viability improves over time.
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