Respiratory life support use increased for extremely preterm babies after guidance change

Key takeaways:

• The use of respiratory life support in babies born at 22 weeks in England and Wales rapidly went up following a new recommendation in 2019.
• Neonatal care admissions also rose in this patient population.

More babies born at 22 weeks’ gestation in England and Wales received respiratory life support after a new national guidance recommendation was published in 2019, according to results published in BMJ Medicine.

Lucy K. Smith

“For families, the birth of their baby at 22 weeks is extremely distressing and decision-making is emotionally challenging,” Lucy K. Smith, PhD, professor of perinatal health at the University of Leicester, told Healio. “For clinicians, this research offers valuable information for counseling parents at this difficult time, providing information on survival at key time points along the pathway to support their conversations. The research shows an important increase in workload and need for specialized health care and educational resources. For clinicians, this has major implications for additional resource needs for caring for these babies and their families.”

In a population-based cohort study in England and Wales, Smith and colleagues assessed 1,001 babies born at 22 weeks’ gestation to observe how the 2019 national clinical guidance change, which “extended provision of survival-focused care” (respiratory life support) to this population, impacted the prevalence of this care in 2020 to 2021 (n = 477) vs. 2018 to 2019 (n = 524).

Researchers also compared neonatal care admissions and discharge rates between the two sets of years.

Survival-focused care

Between 2020 and 2021, 38.4% of babies received survival-focused care, which was an increase from 11.3% observed in 2018 to 2019 (RR = 3.41; 95% CI, 2.61-4.45). After the guidance was published, receipt of this type of care among babies born at 22 weeks’ gestation went up by 30.7% per 100 births vs. before the guidance was introduced.

“We were surprised about the extremely rapid change in practice when the British Association of Perinatal Medicine published their revised extreme preterm framework in 2019 with a risk-based approach to provision of survival-focused care for babies born at 22 weeks’ gestation in England and Wales,” Smith told Healio. “Clinicians in England and Wales had anecdotally highlighted a rapid almost overnight change in provision of survival-focused care for babies born at 22 weeks’ gestation.

“While most clinical guidelines take a long while to embed in clinical practice, we were surprised to confirm the anecdotal data that there had been a rapid transformation of clinical practice,” Smith added.

Neonatal care, survival

Among babies born at 22 weeks’ gestation, researchers further found that neonatal care admissions went up in 2020 to 2021 vs. 2018 to 2019 (28.1% vs. 7.4%; RR = 3.77; 95% CI, 2.7-5.27), and more survived to discharge following the guidance change (8.2% vs. 2.5%; RR = 3.29; 95% CI, 1.78-6.09).

Despite this rise in survival to discharge, more of these babies in neonatal care also died prior to discharge in 2020 to 2021 compared with 2018 to 2019 (95 babies vs. 26 babies).

Researchers also observed that use of survival-focused care increased for both babies with a birth weight of less than 500 g (8% to 35%) and for those weighing at least 500 g (20% to 48%), as well as for multiple-gestation births (11% to 35%) and singleton births (11% to 39%).

However, survival-focused care increased more for female babies (11% to 46%) than for male babies (12% to 34%), according to researchers.

More babies born in tertiary hospitals who received survival-focused care survived compared with babies born in nontertiary hospitals (n = 47 of 81; 26% vs. n = 5 of 43; 11.6%); however, researchers noted these data reflect that most mothers with babies born at 22 weeks were transferred to tertiary units to receive the recommended care that may have been unavailable at the nontertiary units.

Thirty-nine babies born at 22 weeks’ gestation between 2020 and 2021 survived, and researchers did not find major morbidities among 14 of them when not factoring in bronchopulmonary dysplasia.

Lastly, after the 2019 guidance change, babies born at 22 weeks received more care, as represented through total care days (2020-2021, 6,840 days vs. 2018-2019, 2,535 days).

“Future studies are needed to understand how we can better support both parents and health care professionals with the ethical and emotional experiences and challenges faced when making decisions about caring for babies born at 22 weeks,” Smith told Healio. “We also need research to evaluate the longer-term survival and developmental outcomes of these babies. By collaborating with clinicians and researchers worldwide we can build a vital evidence base to inform and improve the care of these babies born at 22 weeks of pregnancy to help ensure better outcomes for these babies in the longer term.”

Editor’s note: On Jan. 25, the third and fourth paragraphs of the ‘Neonatal care, survival’ section of this article were corrected to clarify the data on changes in rates based on weight, sex and number of births. The editors regret the error.

For more information:

Lucy K. Smith, PhD, can be reached at lucy.smith@leicester.ac.uk.

Reference:

• Three-fold rise in babies born at 22 weeks given respiratory life support in England and Wales after guidelines change. https://www.bmj.com/company/newsroom/three-fold-rise-in-babies-born-at-22-weeks-given-respiratory-life-support-in-england-and-wales-after-guidelines-change/. Published Nov. 7, 2023. Accessed Nov. 20, 2023.