Intensive Care for Extreme Prematurity–Moving Beyond Gestational Age

Despite the fact that decisions on whether or not to provide intensive care to very premature infants often are based solely on gestational age, other factors also influence the outcome. This prospective study attempted to improve the decision-making process by assessing outcomes for 4446 infants born at 22–25 weeks' gestation. Standardized neurodevelopmental assessments were made by specially trained examiners at a corrected age of 18–22 months. Both the Psychomotor Developmental Index and the Mental Developmental Index of the Bayley Scales of Infant Development were utilized. The 3702 infants given intensive care in the form of mechanical ventilation represented 83% of all those evaluated. Of 4192 study infants assessed at a corrected age of 18–22 months—constituting 94% of the study population—49% died, 61% died or had profound neurodevelopmental impairment, and 73% died or had some degree of impairment. Multivariable analysis of infants given intensive care identified 4 characteristics apart from gestational age, each of which was associated with a reduced risk of death, marked impairment, or any impairment. They included being female, being a singleton birth, higher birth weight, and antenatal exposure to corticosteroids. The reduction in risk of death or neurodevelopmental impairment associated with each of these factors was comparable to that associated with a 1-week increase in gestational age. Outcomes for infants placed on ventilation were more accurately predicted when these additional factors were taken into account than when only gestational age was considered. Female infants in this study were less likely than males to receive intensive care. It was estimated that providing intensive care to all infants born at 22–23 weeks' gestation would have resulted in 0–9 additional survivors for every 100 infants treated. Up to 5 of these additional survivors would have survived without impairment, and up to 3 would have survived with no impairment. The findings in this study bring into question the widespread practice of deciding whether or not to provide intensive care to extremely premature infants solely on the basis of gestational age.