Proactive Care at the Edge of Viability: Making the Gray Zone Less Gray? Cody C. Arnold, MD, MSc, MPH a,b , Eric C. Eichenwald, MD a,b One of the great success stories in neonatology is the gains made in survival of the smallest and most immature infants over the past 25 years. 1,2 However, concerns persist that increased survival may be complicated by increased neurodevelopmental impairment (NDI) for infants born at the edge of viability. 3,4 This balance between potential for survival and that of severe NDI weighs heavily on counseling for parents threatened with the birth of an extremely preterm infant. In this issue of Pediatrics, Serenius and colleagues from the Extremely Preterm Infant Study in Sweden (EXPRESS) team address this concern directly. 5 Acknowledging that for some patients the burdens of intensive care (deaths in the NICU but especially long-term morbidity among survivors) may outweigh benefits, they present data to support a proactive approach beginning in utero, aiming to optimize a “trial of life” for infants born at the edge of viability. The EXPRESS investigators recently reported rates of death and NDI at 2.5 years in a cohort of live fetuses at 22 to 26 weeks’ gestation. 6 In the current study, they delve more deeply into previously reported variation in outcomes between regions in Sweden. 7,8 For this purpose, they developed a regional perinatal activity score designed to measure the inclination to provide high-intensity care at 22 to 26 weeks’ gestation. This composite score was calculated based on proportions of patients treated with 4 obstetrical interventions (birth at a level III perinatal center, antenatal steroids, Cesarean delivery, tocolysis) and 4 neonatal interventions (surfactant within 2 hours, neonatologist present at birth, intubation after birth, NICU admission). Dividing 7 regions into 2 groups (3 with higher activity scores and 4 with lower scores), they found that the risk for the composite outcome of death or NDI at 2.5 years was lower in regions with higher activity scores. The risk reductions were confined to the 22- to 24-week strata, and the difference in mortality risk was entirely explained by stillbirths and deaths within 12 hours after birth. These results suggest that with a proactive approach to maternal and newborn care, increased survival may be accomplished without an increase in NDI in 22- to 24-week gestational age infants. However, it may not be that simple. Indeed, in the current study a higher proportion of infants born at 22 to 24 weeks survived in the high- score regions than in the low-score region: 74 of 225 (33%) versus 64 of 231 (28%). However, because gestational age data are presented only in 25- to 26-week and 22- to 24-week strata, the effects of proactive care at 22 and 23 weeks is unclear. In fact, the data suggest that the gestational age for survivors at 2.5 years in the 22- to 24-week strata were similar in the high- and low-score regions. Adjustment for gestational age at birth (in addition to other factors) did not change the odds ratio for NDI at 2.5 years (0.65 unadjusted and 0.63 adjusted), as might be expected if larger numbers of the most immature babies, at highest risk for NDI, survived. This suggests that the beneficial effects associated with the a University of Texas Medical School, Houston, Texas; and b Children’ s Memorial Hermann Hospital, Houston, Texas Opinions expressed in these commentaries are those of the author and not necessarily those of the American Academy of Pediatrics or its Committees. www.pediatrics.org/cgi/doi/10.1542/peds.2015-0536 DOI: 10.1542/peds.2015-0536 Accepted for publication Feb 17, 2015 Address correspondence to Eric C. Eichenwald, MD, Department of Pediatrics, University of Texas Medical School, Houston, 6431 Fannin St, MSB 3.020, Houston, TX 77030. E-mail: Eric.c.eichenwald@uth. tmc.edu PEDIATRICS (ISSN Numbers: Print, 0031-4005; Online, 1098-4275). Copyright © 2015 by the American Academy of Pediatrics FINANCIAL DISCLOSURE: The authors have indicated they have no financial relationships relevant to this article to disclose. FUNDING: No external funding. POTENTIAL CONFLICT OF INTEREST: The authors have indicated they have no potential conflicts of interest to disclose. COMPANION PAPER: A companion to this article can be found on page e1163, online at www.pediatrics. org/cgi/doi/10.1542/peds.2014-2988. COMMENTARY PEDIATRICS Volume 135, number 5, May 2015 by guest on July 18, 2017 Downloaded from