CHAPEL HILL--Doctors usually resuscitate extremely premature babies at birth when they are uncertain about how the infants will fare or when they don't know parents' wishes, according to a new study. When parents say in advance what they want done following delivery, doctors tend to follow those wishes.
Resuscitation of such premature infants generally postpones death by only a few days, if death occurs, but does not contribute substantially to over-treatment, the study shows.
"Neonatologists sometimes are criticized in the media and elsewhere for over-treating extremely premature babies," said Dr. Mia W. Doron, clinical assistant professor of pediatrics at the University of North Carolina at Chapel Hill School of Medicine. "We did our study in part because of the controversy.
"We wanted to identify whether physicians' or parents' preferences primarily determine the amount of treatment, to examine what controls resuscitation decisions and to learn whether initiating intensive care significantly postpones death among the babies that don't survive."
A report on the research appears in the September issue of Pediatrics, a medical journal. Besides Doron, the first author, UNC-CH contributors were Drs. Kathleen A. Veness-Meehan and Alan D. Stiles, associate professors of pediatrics, nurse practitioner Elizabeth M. Holoman and Dr. Lewis H. Margolis, associate professor of maternal and child health.
"There is a lot of pain involved in these extraordinarily hard decisions - personal pain for the family and staff, varying amounts suffering for the babies and sometimes great expense," Doron said. "Some babies do fine, but others die within days, weeks or months or have chronic breathing or neurological handicaps such as cerebral palsy. They also can be mentally retarded or blind."
The medical scientists conducted the study exclusively at UNC Hospitals, one of North Carolina's largest tertiary care centers, but say results likely would be similar at most large U.S. hospitals and neonatal practices. They reviewed what happened to all babies born between 23 and 26 weeks gestation during a single year --November 1994 to October 1995. Pregnancies normally last about 270 days or 38.5 weeks.
Researchers also asked the attending physicians to complete extensive questionnaires about what happened during and after delivery and reviewed all medical records.
Three-quarters of the 41 extremely premature babies during the year were resuscitated; 59 percent died, Doron said. Of those born at 24 weeks gestation, 83 percent died, and of those born at 26 weeks, 25 percent died.
"Not surprisingly, resuscitation was more likely to occur in babies with higher gestational ages who were bigger and had better prognoses," she said. "When physicians thought the prognosis for survival was greater than 10 percent, those babies also were apt to be resuscitated. The more certain they were that the baby would not survive and be healthy, the more willing they were to withhold treatment."
When doctors and parents disagreed about how much treatment should be given, all parents wanted more than physicians recommended and usually got it. To avoid unnecessary suffering and expense, all but two babies who died had life-sustaining therapy withdrawn when it looked like they were failing.
"An issue that naturally arises is what the best way is to cut down on this problem which arises because your initial impulse is to help the baby," Doron said. "You have to take a step back and say, 'Wait a minute. Is providing this care really helping'"
"One of the suggestions talked about a lot is simply don't start treating these babies because once you start, both parents and hospital staff get attached to them, and you can't stop. I personally feel that when there is uncertainty about the prognosis, two days of treatment is ethically acceptable to try to get more certain of a baby's chance of surviving to lead a reasonably healthy life."
In most foreign countries, treating very premature infants is less aggressive than in the United States, she said.
By David Williamson
Note: Doron, a mother who works parttime, can be reached at (919) 966-3476 (w) or 682-8375 (h).
Journal
PEDIATRICS