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Care of very premature infants: looking to the future
European Journal of Obstetrics & Gynecology and Reproductive Biology 117S (2004) S29–S32 www.elsevier.com/locate/ejogrb
Care of very premature infants: looking to the future Jean Christophe Roze´a,*, Ge´rard Bre´artb b
a Department of Perinatology, University Hospital of Nantes, France Epidemiological Research Unit for Perinatal and Women’s Health, INSERM U149, Hoˆpital Tenon, Paris, France
Abstract Advances in prenatal care have improved survival rates in extremely preterm newborns, but cerebral palsy rates have not decreased in developed countries over the past 30 years. During the next 10 years we will probably not observe a dramatic improvement in intensive care such as that observed over the last 15 years. The man goal for the coming years will be to improve the quality of neonatal and postdischarge care in order to improve the long-term outcomes of very preterm infants. # 2004 Elsevier Ireland Ltd. All rights reserved. Keywords: Preterm newborn; Cerebral palsy
Foreseeing the future? This is a difficult and possibly misleading challenge. The difficulties apply to prediction of the future care of very premature infants. However, the constant progress over the last 20 years suggests the directions listed below for the next 10 years.
1. Lessons from the past 1.1. Mortality rates Advances in technology have resulted in improved survival rates, even in extremely premature infants. The trend in mortality among infants weighing 500–1500 g at birth in 14 university hospitals declined significantly from 24 to 20% in 1990, after the introduction of surfactants [1]. However, the decline in mortality rates after the introduction of surfactants differs significantly between black and white low-birth-weight infants in the United States. Fig. 1 shows the evolution of the mortality rate among very premature infants during the period 1983–1999, in the course of which new therapies, such as surfactant therapy, became available. In France, we also observed a significant reduction of mortality during the same period. Advances in the organisation of perinatal care in France also modified * Corresponding author. E-mail address: [email protected] (J.C. Roze´).
perinatal and neonatal mortality rates. Fig. 2 shows the evolution of the neonatal mortality rate in very premature infants in the neonatal intensive care unit (NICU) in Nantes, France, reflecting when new therapies became available and when the regionalisation of perinatal care came into force. Fig. 3 shows the numbers of hospitalised and surviving very preterm infants. 1.2. Rate of cerebral palsy The incidence of cerebral palsy has not decreased in developed countries over the past 30 years, despite the widespread use of electronic foetal heart rate monitoring and a five-fold increase in the caesarean delivery rate over the same period. These observations led to the hypothesis that the increased survival rate of premature, neurologically impaired infants masked the actual reduction in cerebral palsy among term infants as a result of the use of electronic monitoring and the avoidance of intrapartum asphyxia [2]. Our knowledge of cerebral development and its interaction with intensive care must be expanded. The example of postnatal dexamethasone therapy is significant. In 1990, Yeh et al. showed that early dexamethasone therapy was associated with a significant decrease in the incidence of chronic lung disease [3]. In 1998, however, Yeh published the results of a follow-up study when infants who had participated in a trial of early dexamethasone therapy were 2-years old: it was found that this treatment could not be
0301-2115/$ – see front matter # 2004 Elsevier Ireland Ltd. All rights reserved. doi:10.1016/j.ejogrb.2004.07.015
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J.C. Roze´ , G. Bre´ art / European Journal of Obstetrics & Gynecology and Reproductive Biology 117S (2004) S29–S32
Fig. 1. Evolution of neonatal mortality for black and for white very-lowbirth-weight infants in the United States, 1983–1999 (adopted from MMWR, July 12, 2002;51(27):589–92).
recommended because of its adverse effects on neuromotor function and somatic growth [4]. The causal relationship between neonatal dexamethasone therapy and cerebral palsy and other neurodevelopmental impairments has been confirmed by other studies. Neonatologists are now prescribing much less postnatal dexamethasone therapy [5]. 1.3. Quality-of-life Health-related quality-of-life can be estimated by longitudinal studies. Very-low-birth-weight (VLBW) children themselves describe their relationships with same-age peers as problematic. Similarly, parents have reported that children who were very premature infants have more social difficulties [6]. Health-related quality-of-life in a cohort of adolescents who were born prematurely was related to the severity of brain ultrasound examination findings during the
Fig. 3. Evolution of numbers of surviving and hospitalised very preterm infants in the NICU of Nantes University Hospital, 1987–2001.
neonatal period [7]. But self-concept and quality-of-life estimates of preterm infants only show poor to moderate correlation with actual cognitive performance and motor function measurements [8]. Progress in school provides a real-life measure of the adaptation of VLBW children in society. The percentage of VLBW children with schooling problems has been high in large epidemiological studies [9]. Schooling problems were observed in 55% of VLBW children: 20% were in special education, 20% were being educated below their age level, and 15% were receiving special help at regular schools. Further large studies following up premature infants into adolescence are required
Fig. 2. Evolution of neonatal mortality for very and extremely preterm infants admitted to the Neonatal Intensive Care Unit (NICU) of Nantes University Hospital, 1987–2001, w = weeks.
J.C. Roze´ , G. Bre´ art / European Journal of Obstetrics & Gynecology and Reproductive Biology 117S (2004) S29–S32
to enhance our understanding of the mechanisms that link perinatal factors and long-term outcome, quality-of-life, and adaptation in society.
2. Looking to the future It seems unlikely that we shall observe so much progress in intensive care (secondary to the appearance of new technologies) during the next 10 years as we have over the last 15 years. The improvement in mortality rate will be stabilised. The limit of viability will not change. However, progress in the quality of perinatal care can and must be the main goal in the next few years, so as to improve the longterm outcome of extremely preterm infants in the future. 2.1. Improvements in antenatal care 2.1.1. Heterogeneity of preterm birth Almost half of all preterm neonates are born after medical decisions; these decisions must be better evaluated. For example, preterm delivery can be accomplished in the case of preterm prelabour rupture of the membranes (PPROM) to prevent chorioamnionitis, foetal infection, and impaired neurological outcome secondary to systemic foetal inflammatory response syndrome [10]. The benefit/risk ratio is still not well known and is probably dependent on gestational age. Further studies must be performed to assess this benefit/ risk ratio, based on end-points such as infants’ status at 2 years or at school age and their quality-of-life. 2.1.2. Genetic approach We believe and hope that knowledge of genetic factors predisposing to preterm delivery or impaired neurological outcome in the case of infection or hypoxia will be augmented. Progress in genetics could allow adaptation of targeted specific perinatal care to high-risk populations [11]. 2.1.3. Decrease number of very premature infants The increased prematurity rate results mainly from an increase in the number of multiple gestations and the increasing use of assisted reproductive technology. The increase in multiple gestations is partly due to higher maternal age. A modification of protocols in assisted reproductive medicine can reduce the number of very premature infants [12]. In the future, we can hope to reduce the frequency of spontaneous very preterm deliveries by better follow-up of pregnancies and appropriate prenatal care taking account of social and economic factors. We can also hope to perform better evaluation of medical decisions resulting in very preterm birth. 2.1.4. Counselling on obstetric management options When the foetal prognosis is uncertain, decisions on the obstetric management need to be made by the parents and by the physicians. Family members must have information on
S31
management options, potential infant survival and long-term outcome to allow them to choose a course of action that is medically appropriate and consistent with their own personal values. Because the relative benefits of different types of obstetric management are not always known, families should be supported in these often difficult and sometimes controversial decisions. Further research must give an answer to decrease the number of unresolved questions [13]. 2.2. Improvements in neonatal care 2.2.1. Advances in technologies Progress in cerebral protection approach, nutritional management, assisted ventilation techniques, surfactant therapy and pain management can improve neonatal care and outcome. Many questions have to be resolved in the next few years: prevention of HIV or periventricular leucomalacia, prevention of injury to the hippocampal or basal ganglia and prevention of disturbance of cerebral organisational events [14]. More advanced knowledge of the links between perinatal events and outcome can help to win this challenge. Moreover, progress in brain imaging could improve our capacity to determine prognosis during the neonatal period [15]. 2.2.2. Integration of social science and behavioural research As biomedical advances in technology continue to help smaller and increasingly sick premature infants to survive, the integration of social science and behavioural research should continue to increase the quality-of-life of future VLBW children. Individualised developmental newborn care consists in care and interventions based on infants’ own behaviour. This type of care seems attractive from an ethical point of view. Some neonatologists recommend general use care, while others are sceptical, thinking that the intervention is cumbersome and time consuming. The Swedish experience of developmental care over the last 10 years has been positive, as it has been very well received by parents and neonatal nurses [16] Although it does not seem to influence short-term outcome, long-term outcome is expected to be improved [14,16]. 2.2.3. Intensive care limitation for extremely premature infants We are now better able to assess the probable long-term outcome of extremely premature infants. Most studies performed in preterm infants born at 22–24 weeks of gestation indicate a very poor outcome. Results of very large cohorts of infants born before 26 weeks of gestation are available from the Vermont Oxford Network. Under 5, 15 and 25% of children born at 23, 24 and 25 weeks of gestation, respectively, have a strictly normal neurological development at 2 years (Vermond Oxford Network, Ross Conference 2002). In Europe, the EPICure Study group showed that severe
S32
J.C. Roze´ , G. Bre´ art / European Journal of Obstetrics & Gynecology and Reproductive Biology 117S (2004) S29–S32
disability is common among children born before 26 weeks of gestation (50% had disability, 23% a severe disability) [17]. The Leiden follow-up project also shows that an adverse outcome (dead or abnormal neurological, psychomotor or mental development) is common (respectively 92, 64 and 35% at 23–24, 25 and 26 weeks of gestation) [18]. Dutch doctors have changed their policy of care of these very preterm babies [19]. Progress may be made in the future, but we probably have to take into account the currently poor long-term prognosis of extremely premature infants: after birth before 24 weeks of gestation for girls and 25 weeks for boys, active resuscitation in the delivery room must not be performed except on fully informed parental demand. Nevertheless, antenatal transfer to a tertiary neonatal care centre is recommended as soon as at 24 weeks of gestation if a premature delivery is expected, so that optimal perinatal care is possible. 2.3. Improvements of follow-up Advances in neonatal intensive care can result in improved survival of extremely premature infants. Progress in the quality of follow-up is essential to help the children and limit the severity of their handicaps [20]. Indeed, implementation of early developmental intervention can improve cognitive outcomes [21–23].
3. Conclusions Progress is possible in some technologies, but we will probably observe a break in technological proceedings compared with the last 15 years. The challenge of the coming years will be to optimise the quality of neonatal and postdischarge care with the aim of improving the long-term outcome of very preterm infants.
References [1] Schwartz RM, Luby AM, Scanlon JW, Kellogg RJ. Effect of surfactant on morbidity, mortality, and resource use in newborn infants weighing 500 to 1500 g. N Engl J Med 1994;330:1476–80. [2] Clark SL, Hankins GD. Temporal and demographic trends in cerebral palsy—fact and fiction. Am J Obstet Gynecol 2003;188:628–33. [3] Yeh TF, Torre JA, Rastogi A, Anyebuno MA, Pildes RS. Early postnatal dexamethasone therapy in premature infants with severe respiratory distress syndrome: a double-blind, controlled study. J Pediatr 1990;117:273–82. [4] Yeh TF, Lin YJ, Huang CC, Chen YJ, Lin CH, Lin HC, et al. Early dexamethasone therapy in preterm infants: a follow-up study. Pediatrics 1998;101:E7. [5] Shinwell ES, Karplus M, Bader D, Dollberg S, Gur I, Weintraub Z, et al. Neonatologists are using much less dexamethasone. Arch Dis Child Fetal Neonatal Ed 2003;88:F432–3.
[6] Wolke D. Psychological development of prematurely born children. Arch Dis Child 1998;78:567–70. [7] Feingold E, Sheir-Neiss G, Melnychuk J, Bachrach S, Paul D. HRQL and severity of brain ultrasound findings in a cohort of adolescents who were born preterm. J Adolesc Health 2002;31:234–9. [8] Saigal S, Feeny D, Rosenbaum P, Furlong W, Burrows E, Stoskopf B. Self-perceived health status and health-related quality of life of extremely low-birth-weight infants at adolescence. JAMA 1996;276:453–9. [9] Hille ET, den Ouden AL, Bauer L, van den Oudenrijn C, Brand R. Verloove-Vanhorick. School performance at nine years of age in very premature and very low birth weight infants: perinatal risk factors and predictors at five years of age. Collaborative Project on Preterm and Small for Gestational Age (POPS) Infants in The Netherlands. J Pediatr 1994;125:426–34. [10] Mittendorf R, Montag AG, MacMillan W, Janeczek S, Pryde PG, Besinger RE, et al. Components of the systemic fetal inflammatory response syndrome as predictors of impaired neurologic outcomes in children. Am J Obstet Gynecol 2003;188:1438–44. [11] Lamont RF. Looking to the future. BJOG 2003;110(20):131–5. [12] Schieve LA, Meikle SF, Ferre C, Peterson HB, Jeng G, Wilcox LS. Low and very low birth weight in infants conceived with use of assisted reproductive technology. N Engl J Med 2002;346:731–7. [13] MacDonald H. American Academy of Pediatrics. Committee on Fetus and Newborn. Perinatal care at the threshold of viability. Pediatrics 2002;110:1024–7. [14] Perlman JM. Neurobehavioral deficits in premature graduates of intensive care—potential medical and neonatal environmental risk factors. Pediatrics 2001;108:1339–48. [15] Counsell SJ, Allsop JM, Harrison MC, Larkman DJ, Kennea NL, Kapellou O, et al. Diffusion-weighted imaging of the brain in preterm infants with focal and diffuse white matter abnormality. Pediatrics 2003;112:1–7. [16] Kleberg A, Westrup B, Stjernqvist K, Lagercrantz H. Indications of improved cognitive development at one year of age among infants born very prematurely who received care based on the Newborn Individualized Developmental Care and Assessment Program (NIDCAP). Early Hum Dev 2002;68:83–91. [17] Costeloe K, Hennessy E, Gibson AT, Marlow N, Wilkinson AR. The EPICure study: outcomes to discharge from hospital for infants born at the threshold of viability. Pediatrics 2000;106:659–71. [18] Rijken M, Stoelhorst GM, Martens SE, van Zwieten PH, Brand R, Wit JM, et al. Mortality and neurologic, mental, and psychomotor development at 2 years in infants born less than 27 weeks’ gestation: the Leiden follow-up project on prematurity. Pediatrics 2003; 112:351–8. [19] Sheldon T. Dutch doctors change policy on treating preterm babies. BMJ 2001;322:1383. [20] Gosselin J, Amiel-Tison C, Infante-Rivard C, Fouron C, Fouron JC. Minor neurological signs and developmental performance in highrisk children at preschool age. Dev Med Child Neurol 2002; 44(5):323–8. [21] Achenbach TM, Howell CT, Aoki MF, Rauh VA. Nine-year outcome of the Vermont intervention program for low birth weight infants. Pediatrics 1993;91:45–55. [22] The Infant Health and Development Program. Enhancing the outcomes of low-birth-weight, premature infants. A multisite, randomized trial. JAMA 1990;263:3035–42. [23] McCarton CM, Brooks-Gunn J, Wallace IF, Bauer CR, Bennett FC, Bernbaum JC, et al. Results at age 8 years of early intervention for low-birth-weight premature infants (The Infant Health and Development Program). JAMA 1997;277(2):126–32.
Care of very premature infants: looking to the future Jean Christophe Roze´a,*, Ge´rard Bre´artb b
a Department of Perinatology, University Hospital of Nantes, France Epidemiological Research Unit for Perinatal and Women’s Health, INSERM U149, Hoˆpital Tenon, Paris, France
Abstract Advances in prenatal care have improved survival rates in extremely preterm newborns, but cerebral palsy rates have not decreased in developed countries over the past 30 years. During the next 10 years we will probably not observe a dramatic improvement in intensive care such as that observed over the last 15 years. The man goal for the coming years will be to improve the quality of neonatal and postdischarge care in order to improve the long-term outcomes of very preterm infants. # 2004 Elsevier Ireland Ltd. All rights reserved. Keywords: Preterm newborn; Cerebral palsy
Foreseeing the future? This is a difficult and possibly misleading challenge. The difficulties apply to prediction of the future care of very premature infants. However, the constant progress over the last 20 years suggests the directions listed below for the next 10 years.
1. Lessons from the past 1.1. Mortality rates Advances in technology have resulted in improved survival rates, even in extremely premature infants. The trend in mortality among infants weighing 500–1500 g at birth in 14 university hospitals declined significantly from 24 to 20% in 1990, after the introduction of surfactants [1]. However, the decline in mortality rates after the introduction of surfactants differs significantly between black and white low-birth-weight infants in the United States. Fig. 1 shows the evolution of the mortality rate among very premature infants during the period 1983–1999, in the course of which new therapies, such as surfactant therapy, became available. In France, we also observed a significant reduction of mortality during the same period. Advances in the organisation of perinatal care in France also modified * Corresponding author. E-mail address: [email protected] (J.C. Roze´).
perinatal and neonatal mortality rates. Fig. 2 shows the evolution of the neonatal mortality rate in very premature infants in the neonatal intensive care unit (NICU) in Nantes, France, reflecting when new therapies became available and when the regionalisation of perinatal care came into force. Fig. 3 shows the numbers of hospitalised and surviving very preterm infants. 1.2. Rate of cerebral palsy The incidence of cerebral palsy has not decreased in developed countries over the past 30 years, despite the widespread use of electronic foetal heart rate monitoring and a five-fold increase in the caesarean delivery rate over the same period. These observations led to the hypothesis that the increased survival rate of premature, neurologically impaired infants masked the actual reduction in cerebral palsy among term infants as a result of the use of electronic monitoring and the avoidance of intrapartum asphyxia [2]. Our knowledge of cerebral development and its interaction with intensive care must be expanded. The example of postnatal dexamethasone therapy is significant. In 1990, Yeh et al. showed that early dexamethasone therapy was associated with a significant decrease in the incidence of chronic lung disease [3]. In 1998, however, Yeh published the results of a follow-up study when infants who had participated in a trial of early dexamethasone therapy were 2-years old: it was found that this treatment could not be
0301-2115/$ – see front matter # 2004 Elsevier Ireland Ltd. All rights reserved. doi:10.1016/j.ejogrb.2004.07.015
S30
J.C. Roze´ , G. Bre´ art / European Journal of Obstetrics & Gynecology and Reproductive Biology 117S (2004) S29–S32
Fig. 1. Evolution of neonatal mortality for black and for white very-lowbirth-weight infants in the United States, 1983–1999 (adopted from MMWR, July 12, 2002;51(27):589–92).
recommended because of its adverse effects on neuromotor function and somatic growth [4]. The causal relationship between neonatal dexamethasone therapy and cerebral palsy and other neurodevelopmental impairments has been confirmed by other studies. Neonatologists are now prescribing much less postnatal dexamethasone therapy [5]. 1.3. Quality-of-life Health-related quality-of-life can be estimated by longitudinal studies. Very-low-birth-weight (VLBW) children themselves describe their relationships with same-age peers as problematic. Similarly, parents have reported that children who were very premature infants have more social difficulties [6]. Health-related quality-of-life in a cohort of adolescents who were born prematurely was related to the severity of brain ultrasound examination findings during the
Fig. 3. Evolution of numbers of surviving and hospitalised very preterm infants in the NICU of Nantes University Hospital, 1987–2001.
neonatal period [7]. But self-concept and quality-of-life estimates of preterm infants only show poor to moderate correlation with actual cognitive performance and motor function measurements [8]. Progress in school provides a real-life measure of the adaptation of VLBW children in society. The percentage of VLBW children with schooling problems has been high in large epidemiological studies [9]. Schooling problems were observed in 55% of VLBW children: 20% were in special education, 20% were being educated below their age level, and 15% were receiving special help at regular schools. Further large studies following up premature infants into adolescence are required
Fig. 2. Evolution of neonatal mortality for very and extremely preterm infants admitted to the Neonatal Intensive Care Unit (NICU) of Nantes University Hospital, 1987–2001, w = weeks.
J.C. Roze´ , G. Bre´ art / European Journal of Obstetrics & Gynecology and Reproductive Biology 117S (2004) S29–S32
to enhance our understanding of the mechanisms that link perinatal factors and long-term outcome, quality-of-life, and adaptation in society.
2. Looking to the future It seems unlikely that we shall observe so much progress in intensive care (secondary to the appearance of new technologies) during the next 10 years as we have over the last 15 years. The improvement in mortality rate will be stabilised. The limit of viability will not change. However, progress in the quality of perinatal care can and must be the main goal in the next few years, so as to improve the longterm outcome of extremely preterm infants in the future. 2.1. Improvements in antenatal care 2.1.1. Heterogeneity of preterm birth Almost half of all preterm neonates are born after medical decisions; these decisions must be better evaluated. For example, preterm delivery can be accomplished in the case of preterm prelabour rupture of the membranes (PPROM) to prevent chorioamnionitis, foetal infection, and impaired neurological outcome secondary to systemic foetal inflammatory response syndrome [10]. The benefit/risk ratio is still not well known and is probably dependent on gestational age. Further studies must be performed to assess this benefit/ risk ratio, based on end-points such as infants’ status at 2 years or at school age and their quality-of-life. 2.1.2. Genetic approach We believe and hope that knowledge of genetic factors predisposing to preterm delivery or impaired neurological outcome in the case of infection or hypoxia will be augmented. Progress in genetics could allow adaptation of targeted specific perinatal care to high-risk populations [11]. 2.1.3. Decrease number of very premature infants The increased prematurity rate results mainly from an increase in the number of multiple gestations and the increasing use of assisted reproductive technology. The increase in multiple gestations is partly due to higher maternal age. A modification of protocols in assisted reproductive medicine can reduce the number of very premature infants [12]. In the future, we can hope to reduce the frequency of spontaneous very preterm deliveries by better follow-up of pregnancies and appropriate prenatal care taking account of social and economic factors. We can also hope to perform better evaluation of medical decisions resulting in very preterm birth. 2.1.4. Counselling on obstetric management options When the foetal prognosis is uncertain, decisions on the obstetric management need to be made by the parents and by the physicians. Family members must have information on
S31
management options, potential infant survival and long-term outcome to allow them to choose a course of action that is medically appropriate and consistent with their own personal values. Because the relative benefits of different types of obstetric management are not always known, families should be supported in these often difficult and sometimes controversial decisions. Further research must give an answer to decrease the number of unresolved questions [13]. 2.2. Improvements in neonatal care 2.2.1. Advances in technologies Progress in cerebral protection approach, nutritional management, assisted ventilation techniques, surfactant therapy and pain management can improve neonatal care and outcome. Many questions have to be resolved in the next few years: prevention of HIV or periventricular leucomalacia, prevention of injury to the hippocampal or basal ganglia and prevention of disturbance of cerebral organisational events [14]. More advanced knowledge of the links between perinatal events and outcome can help to win this challenge. Moreover, progress in brain imaging could improve our capacity to determine prognosis during the neonatal period [15]. 2.2.2. Integration of social science and behavioural research As biomedical advances in technology continue to help smaller and increasingly sick premature infants to survive, the integration of social science and behavioural research should continue to increase the quality-of-life of future VLBW children. Individualised developmental newborn care consists in care and interventions based on infants’ own behaviour. This type of care seems attractive from an ethical point of view. Some neonatologists recommend general use care, while others are sceptical, thinking that the intervention is cumbersome and time consuming. The Swedish experience of developmental care over the last 10 years has been positive, as it has been very well received by parents and neonatal nurses [16] Although it does not seem to influence short-term outcome, long-term outcome is expected to be improved [14,16]. 2.2.3. Intensive care limitation for extremely premature infants We are now better able to assess the probable long-term outcome of extremely premature infants. Most studies performed in preterm infants born at 22–24 weeks of gestation indicate a very poor outcome. Results of very large cohorts of infants born before 26 weeks of gestation are available from the Vermont Oxford Network. Under 5, 15 and 25% of children born at 23, 24 and 25 weeks of gestation, respectively, have a strictly normal neurological development at 2 years (Vermond Oxford Network, Ross Conference 2002). In Europe, the EPICure Study group showed that severe
S32
J.C. Roze´ , G. Bre´ art / European Journal of Obstetrics & Gynecology and Reproductive Biology 117S (2004) S29–S32
disability is common among children born before 26 weeks of gestation (50% had disability, 23% a severe disability) [17]. The Leiden follow-up project also shows that an adverse outcome (dead or abnormal neurological, psychomotor or mental development) is common (respectively 92, 64 and 35% at 23–24, 25 and 26 weeks of gestation) [18]. Dutch doctors have changed their policy of care of these very preterm babies [19]. Progress may be made in the future, but we probably have to take into account the currently poor long-term prognosis of extremely premature infants: after birth before 24 weeks of gestation for girls and 25 weeks for boys, active resuscitation in the delivery room must not be performed except on fully informed parental demand. Nevertheless, antenatal transfer to a tertiary neonatal care centre is recommended as soon as at 24 weeks of gestation if a premature delivery is expected, so that optimal perinatal care is possible. 2.3. Improvements of follow-up Advances in neonatal intensive care can result in improved survival of extremely premature infants. Progress in the quality of follow-up is essential to help the children and limit the severity of their handicaps [20]. Indeed, implementation of early developmental intervention can improve cognitive outcomes [21–23].
3. Conclusions Progress is possible in some technologies, but we will probably observe a break in technological proceedings compared with the last 15 years. The challenge of the coming years will be to optimise the quality of neonatal and postdischarge care with the aim of improving the long-term outcome of very preterm infants.
References [1] Schwartz RM, Luby AM, Scanlon JW, Kellogg RJ. Effect of surfactant on morbidity, mortality, and resource use in newborn infants weighing 500 to 1500 g. N Engl J Med 1994;330:1476–80. [2] Clark SL, Hankins GD. Temporal and demographic trends in cerebral palsy—fact and fiction. Am J Obstet Gynecol 2003;188:628–33. [3] Yeh TF, Torre JA, Rastogi A, Anyebuno MA, Pildes RS. Early postnatal dexamethasone therapy in premature infants with severe respiratory distress syndrome: a double-blind, controlled study. J Pediatr 1990;117:273–82. [4] Yeh TF, Lin YJ, Huang CC, Chen YJ, Lin CH, Lin HC, et al. Early dexamethasone therapy in preterm infants: a follow-up study. Pediatrics 1998;101:E7. [5] Shinwell ES, Karplus M, Bader D, Dollberg S, Gur I, Weintraub Z, et al. Neonatologists are using much less dexamethasone. Arch Dis Child Fetal Neonatal Ed 2003;88:F432–3.
[6] Wolke D. Psychological development of prematurely born children. Arch Dis Child 1998;78:567–70. [7] Feingold E, Sheir-Neiss G, Melnychuk J, Bachrach S, Paul D. HRQL and severity of brain ultrasound findings in a cohort of adolescents who were born preterm. J Adolesc Health 2002;31:234–9. [8] Saigal S, Feeny D, Rosenbaum P, Furlong W, Burrows E, Stoskopf B. Self-perceived health status and health-related quality of life of extremely low-birth-weight infants at adolescence. JAMA 1996;276:453–9. [9] Hille ET, den Ouden AL, Bauer L, van den Oudenrijn C, Brand R. Verloove-Vanhorick. School performance at nine years of age in very premature and very low birth weight infants: perinatal risk factors and predictors at five years of age. Collaborative Project on Preterm and Small for Gestational Age (POPS) Infants in The Netherlands. J Pediatr 1994;125:426–34. [10] Mittendorf R, Montag AG, MacMillan W, Janeczek S, Pryde PG, Besinger RE, et al. Components of the systemic fetal inflammatory response syndrome as predictors of impaired neurologic outcomes in children. Am J Obstet Gynecol 2003;188:1438–44. [11] Lamont RF. Looking to the future. BJOG 2003;110(20):131–5. [12] Schieve LA, Meikle SF, Ferre C, Peterson HB, Jeng G, Wilcox LS. Low and very low birth weight in infants conceived with use of assisted reproductive technology. N Engl J Med 2002;346:731–7. [13] MacDonald H. American Academy of Pediatrics. Committee on Fetus and Newborn. Perinatal care at the threshold of viability. Pediatrics 2002;110:1024–7. [14] Perlman JM. Neurobehavioral deficits in premature graduates of intensive care—potential medical and neonatal environmental risk factors. Pediatrics 2001;108:1339–48. [15] Counsell SJ, Allsop JM, Harrison MC, Larkman DJ, Kennea NL, Kapellou O, et al. Diffusion-weighted imaging of the brain in preterm infants with focal and diffuse white matter abnormality. Pediatrics 2003;112:1–7. [16] Kleberg A, Westrup B, Stjernqvist K, Lagercrantz H. Indications of improved cognitive development at one year of age among infants born very prematurely who received care based on the Newborn Individualized Developmental Care and Assessment Program (NIDCAP). Early Hum Dev 2002;68:83–91. [17] Costeloe K, Hennessy E, Gibson AT, Marlow N, Wilkinson AR. The EPICure study: outcomes to discharge from hospital for infants born at the threshold of viability. Pediatrics 2000;106:659–71. [18] Rijken M, Stoelhorst GM, Martens SE, van Zwieten PH, Brand R, Wit JM, et al. Mortality and neurologic, mental, and psychomotor development at 2 years in infants born less than 27 weeks’ gestation: the Leiden follow-up project on prematurity. Pediatrics 2003; 112:351–8. [19] Sheldon T. Dutch doctors change policy on treating preterm babies. BMJ 2001;322:1383. [20] Gosselin J, Amiel-Tison C, Infante-Rivard C, Fouron C, Fouron JC. Minor neurological signs and developmental performance in highrisk children at preschool age. Dev Med Child Neurol 2002; 44(5):323–8. [21] Achenbach TM, Howell CT, Aoki MF, Rauh VA. Nine-year outcome of the Vermont intervention program for low birth weight infants. Pediatrics 1993;91:45–55. [22] The Infant Health and Development Program. Enhancing the outcomes of low-birth-weight, premature infants. A multisite, randomized trial. JAMA 1990;263:3035–42. [23] McCarton CM, Brooks-Gunn J, Wallace IF, Bauer CR, Bennett FC, Bernbaum JC, et al. Results at age 8 years of early intervention for low-birth-weight premature infants (The Infant Health and Development Program). JAMA 1997;277(2):126–32.