Clinical Pearls & Morning Reports
Published February 15, 2017
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Younge et al. evaluated changes over time in survival and neurodevelopmental outcomes among infants born at 22 to 24 weeks of gestation, as assessed at 18 to 22 months of corrected postnatal age. The study included infants born between January 1, 2000, and December 31, 2011, at 11 academic tertiary care centers. A new Original Article explains.
Q: Is there a consistent approach in the United States to the resuscitation and management of infants born between 22 and 24 weeks of gestation?
A: Care of periviable infants remains a great challenge in neonatal and perinatal medicine. Infants born between 22 and 24 weeks of gestation often die or survive with long-term neurodevelopmental impairment. The approach to resuscitation and management at these early gestational ages varies substantially.
Q: Has mortality declined in recent years among extremely premature infants?
A: Data reported during the past 5 years indicate that mortality has declined among extremely premature infants. Investigators at the Eunice Kennedy Shriver National Institute of Child Health and Human Development (NICHD) Neonatal Research Network (NRN) reported a decrease in mortality over the past two decades, with the greatest gains in survival seen among infants born at 23 and 24 weeks of gestation after 2008. Such studies raise questions about neurodevelopmental outcomes in surviving infants. NRN studies over previous periods have not shown significant improvement in neurodevelopmental outcomes over time among periviable infants, and there is concern that declining mortality in this population may lead to a greater number of infants surviving with neurodevelopmental impairment.
A: The study by Younge et al. showed an increase in the rate of survival without neurodevelopmental impairment from 2000 to 2011 in a large cohort of periviable infants born at a consortium of U.S. academic tertiary care centers. A significant decline in mortality over the study period was accompanied by relative increases in both the rate of survival with neurodevelopmental impairment and the rate of survival without neurodevelopmental impairment. The increase in the rate of survival was not associated with a disproportionate increase in the rate of survival with neurodevelopmental impairment; rather, the rate of survival without neurodevelopmental impairment and the rate of survival with neurodevelopmental impairment increased similarly (adjusted relative risk, 1.27; 95% CI, 0.99 to 1.65).
A: The best measures of neurodevelopmental outcomes in premature infants continue to be debated. In the Younge study, the definition of neurodevelopmental impairment included measures of motor function, sensory impairment, and cognitive delay, which is consistent with the definition used in other studies. Clinicians and families should note that there is likely to be substantial variation in the long-term functioning of children classified as having neurodevelopmental impairment in early childhood. Although early neurodevelopmental assessment is important for the timely identification of children at risk for long-term neurologic impairment or developmental delay, its capacity to predict later functioning is limited. Many children will catch up to their peers by school age, whereas other children will have persistent impairment. Conversely, some children without signs of neurodevelopmental impairment in early childhood will have impairments that manifest at school age.