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Consistent use of intensive care for extremely premature babies increases survival, but costs are high

Care of extremely premature newborns (23 to 26 weeks' gestation) in the United States has been more aggressive than in some European countries. Many U.S. neonatologists offer intensive care to all infants considered to have any chance of survival. European neonatologists are more selective because they view the care as futile or likely to result in poor long-term outcomes. When intensive care is used for all rather than selected extremely premature babies, it increases survival, but costs, including disability and increased resource use, may be high concludes John Lorenz, M.D., of Columbia University.

In a study supported by the Agency for Healthcare Research and Quality (HS08385), the researchers examined perinatal management, mortality, prevalence of disabling cerebral palsy (DCP), and resource expenditure (number of hospital days with and without assisted ventilation) for two groups of extremely premature infants born in the mid-1980s, one in New Jersey and one in the Netherlands. Electronic fetal monitoring (100 vs. 38 percent), cesarean section (28 vs. 6 percent), and assisted ventilation (95 vs. 64 percent) were more commonly used in New Jersey than in the Netherlands. Survival to age 2 (46 vs. 22 percent) and the prevalence of DCP among survivors (17 vs. 3 percent) were significantly greater in New Jersey at age 2 than in the Netherlands at age 5.

Ten percent of New Jersey deaths occurred without assisted ventilation compared with 45 percent of Dutch deaths. A total of 1,820 ventilator days were expended per 100 live births in New Jersey compared with 448 in the Netherlands. Overall, near universal versus selective initiation of intensive care was associated with 24.1 additional survivors, 7.2 additional cases of DCP, and 1,372 additional ventilator days per 100 live births. There is hope that refinement of neonatal intensive care ultimately will decrease the prevalence of disabilities among survivors. Until that happens, there remains a moral dilemma to which there are no easy answers, conclude the researchers.

More details are in "Comparison of management strategies for extreme prematurity in New Jersey and the Netherlands: Outcomes and resource expenditure," by Dr. Lorenz, Nigel Paneth, M.D., M.P.H., James R. Jetton, B.A., and others, in the December 2001 Pediatrics 108(6), pp. 1269-1274.

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