A small number of very premature babies are surviving earlier outside the womb than doctors once thought possible, a new study has documented, raising questions about how aggressively they should be treated and posing implications for the debate about abortion, reports The New York Times.
The study, of thousands of premature births, found that a tiny minority of babies born at 22 weeks who were medically treated survived with few health problems, although the vast majority died or suffered serious health issues. Leading medical groups had already been discussing whether to lower the consensus on the age of viability, now cited by most medical experts as 24 weeks. The US Supreme Court has said that states must allow abortion if a foetus is not viable outside the womb, and changing that standard could therefore raise questions about when abortion is legal. For most parents and doctors, the new study will intensify the agonising choices faced about how intensively to treat such infants.
The study, one of the largest and most systematic examinations of care for very premature infants, found that hospitals with sophisticated neonatal units varied widely in their approach to 22-week-olds, ranging from a few that offer no active medical treatment to a handful that assertively treat most cases with measures like ventilation, intubation and surfactant to improve the functioning of babies’ lungs.
"It confirms that if you don’t do anything, these babies will not make it, and if you do something, some of them will make it," said Dr David Burchfield, the chief of neonatology at the University of Florida, who was not involved in the research. "Many who have survived have survived with severe handicaps." Results of the study are likely to influence a discussion taking place among professional medical associations about how to counsel parents and when to offer treatment to such tiny babies.
The study, involving nearly 5,000 babies born between 22 and 27 weeks gestation, found that 22-week-old babies did not survive without medical intervention. In the 78 cases where active treatment was given, 18 survived, and by the time they were young toddlers, seven of those did not have moderate or severe impairments. Six had serious problems such as blindness, deafness or severe cerebral palsy. Of the 755 born at 23 weeks, treatment was given to 542. About a third of those survived, and about half of the survivors had no significant problems.
As techniques for keeping babies alive improve, parents face wrenching choices that are sometimes based on whether the estimated age is 22 weeks and one day or six days. The study found that hospitals tend to "round up," with babies closer to 23 weeks more likely to receive treatment. But the authors and other experts also noted that gestational age is an educated guess, based on women’s recollection of their last menstrual period and estimated foetal size. Other factors, including prenatal care and the fact that girls are often a week more mature than boys, should also influence decisions, experts say.
The study, which evaluated cases from 2006 to 2011 at 24 hospitals in a neonatal network supported by the National Institute of Child Health and Human Development, found that four of the hospitals intervened for no 22-week-olds, five intervened for all 22-week-olds and the rest varied. In all, about a fifth of the 357 babies that age were treated. The reasons could include family preferences and hospital policy, the authors wrote. "We can’t really say whether the differences revolve around differences in values, that for some physicians or parents the risk of impairment might outweigh the decision for treatment."
Matthew Rysavy, a medical student at the University of Iowa led the study with Dr Edward Bell, a paediatrics professor there. Bell said, treatment is offered to most 22-week-olds, and he considers 22 weeks a new marker of viability. "That’s what we think, but this is a pretty controversial area," Bell said. "I guess we would say that these babies deserve a chance."
[link url="http://www.nytimes.com/2015/05/07/health/premature-babies-22-weeks-viability-study.html?emc=edit_th_20150507&nl=todaysheadlines&nlid=42505380&_r=0"]Full report in The New York Times[/link]
[link url="http://www.nejm.org/doi/full/10.1056/NEJMoa1410689"]New England Journal of Medicine article summary[/link]