Thresholds for Resuscitation of Extremely Preterm Infants in the UK, Sweden, and Netherlands

Abstract

Background: It is widely acceptable to involve parents in decision-making about the resuscitation of extremely preterm infants (EPIs) in the gray zone. However, there are different views about where the boundaries of the gray zone should lie. Our aim in this study was to compare the resuscitation thresholds for EPIs between neonatologists in the United Kingdom, Sweden, and the Netherlands.

Methods: We distributed an online survey to consultant neonatologists and neonatal registrars and fellows that included clinical scenarios in which parents requested resuscitation or nonresuscitation. Respondents were asked about the lowest gestational age and/or the worst prognosis at which they would provide resuscitation and the highest gestational age and/or the best prognosis at which they would withhold resuscitation. In additional scenarios, influence of the condition at birth or consideration of available health care resources was assessed.

Results: The survey was completed by 162 neonatologists (30% response rate). There was a significant difference between countries; the gray zone for most UK respondents was 23 + 0/7 to 23 + 6/7 or 24 weeks' gestation, compared with 22 + 0/7 to 22 + 6/7 or 23 weeks' gestation in Sweden and 24 + 0/7 to 25 + 6/7 or 26 weeks' gestation in the Netherlands. Resuscitation thresholds were higher if an infant was born in poor condition. There was wide variation in the prognosis that warranted resuscitation or nonresuscitation. Consideration of resource scarcity did not alter responses.

Conclusions: In this survey, we found significant differences in approach to the resuscitation of EPIs, with a spectrum from most proactive (Sweden) to least proactive (Netherlands). Most survey respondents indicated shifts in decision-making that were associated with particular weeks' gestation. Despite the different approaches to decision-making in the 3 countries, there was relatively little difference between countries in neonatologists' prognostic thresholds for resuscitation.

Figure 1

Lower threshold: Cumulative probability of resuscitation based on the lowest gestational age at which respondents would provide resuscitation. The figure indicates the proportion of respondents prepared to resuscitate at a given gestation if parents request active treatment. (n=158. Four respondents who indicated an ‘other’ free text response excluded) A. For an infant born in good condition (spontaneously breathing with a heart rate of 100) B. For an infant born in poor condition (poor tone, no respiratory effort, heart rate of 40)

Figure 2

Prognosis-based thresholds. Cumulative proportion of respondents being prepared to either provide resuscitation at parental request (solid lines) or withhold resuscitation at parental request (broken lines), as prognosis improved. (n=144 (provide resuscitation), n=137 (withhold resuscitation). For example, if there were a 10% predicted chance of survival without profound disability, 52% of Dutch neonatologists were prepared to provide resuscitation, while 100% were prepared to withhold resuscitation. Respondents (18 and 25, respectively) were excluded in the analyses if they gave only a free text response, i.e. did not indicate a numerical threshold.

Figure 3

Upper threshold: Cumulative probability of non-resuscitation based on the highest gestational age at which neonatologists would withhold resuscitation at parental request in an infant born in good condition. The figure indicates the proportion of respondents prepared to withhold resuscitate at (or below) a given gestation if parents request palliative care be provided.