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New Guidelines 'Improved Survival' of Very Premature Babies

Extending the provision of survival-focused care to babies born at 22 weeks' gestation increased the number of babies receiving respiratory life support and led to a rise in the proportion surviving to discharge, research showed.

The study, published in the journal BMJ Medicine, found that changes to national guidance in England and Wales were accompanied by an almost three-fold increase in duration of neonatal care days for these babies, and had a substantial impact on activity, occupancy levels, and clinical complexity. 

However, overall survival remained low, and more babies died after a period of neonatal intensive care, according to the team, which included researchers from the University of Leicester and Imperial College London. The findings had "major implications for additional resource needs", they said.

Risk-based Approach in Updated Guidelines

The updated guidance from the British Association of Perinatal Medicine (BAPM) in 2019 recommended taking a risk-based approach for premature babies, including those born at 22 weeks. As the impact of the changes on neonatal care provision hadn't been previously evaluated, the researchers assessed retrospective data from January 2018 to December 2021 drawn from two national datasets in England and Wales: MBRRACE-UK and the National Neonatal Research Database.

This data included all live births from 22 weeks onwards, and deaths before, during, and within 28 days of birth, along with details of care and outcomes up to hospital discharge. 

Over the whole period, 1604 (28.5%) of the 5623 premature babies born between 22 and 24 weeks' gestation were stillborn. Of the 4019 babies alive when care was started in labour, 1001 (24.9%) were born at 22 weeks, 1380 (34.3%) at 23 weeks, and 1638 (40.8%) at 24 weeks.

Increased Neonatal Unit Care Use

Among those alive at the start of labour and born at 22 weeks, the number and percentage receiving respiratory life support tripled from 59 of 524 (11.3%) in 2018-2019 to 183 of 477 (38.4%) in 2020-2021. 

The proportion of admissions to neonatal units rose from 7.4% to 28.1%, while survival to discharge from neonatal care, either to home or to other healthcare settings, rose from 13 babies (2.5%) to 39 (8.2%). However, the number who died before discharge also increased, from 26 to 95. 

Total neonatal unit care days provided to all babies born at 22 weeks increased from 2535 in 2018-2019 to 6840 in 2020-2021. 

For those who survived, the team made a postanalysis decision to report 'survival with no major morbidity' after excluding bronchopulmonary dysplasia, since this turned out to be "near universal". While this was "not surprising", they said, it "raises the question of whether bronchopulmonary dysplasia is a discriminatory outcome measure in this clinical population".

Most Survivors Had Major Morbidities

In the event, the numbers for this measure in the 22-week group in 2018-2019 were too low to be reported. Of survivors born in 2020-2021, only 36% (14/39) did not have another major morbidity (such as retinopathy of prematurity or severe brain injury).

The researchers acknowledged that their study was observational, and that they were only able to assess short-term outcomes. However they concluded that "rapid and substantial changes" were associated with the introduction of the revised BAPM guidance. 

The researchers said: "Although the recommendation was intended to be risk-based, we speculate that, on the contrary, approaches have moved from being selective to more widespread provisions of survival-focused care."

They said that as well as more admissions to neonatal units, maternity care was also probably affected because of increased in utero transfers. There were also likely to be impacts on paediatric and educational services to provide for long-term health and developmental needs of these babies, most of whom have major morbidities.

Important Resource Implications

"This change represents an important increase in workload and need for specialised healthcare and educational resources," they said. "As clinical experience caring for this vulnerable group of babies grows, more international research is needed to improve outcomes and identify early prognostic factors, so that prolonged intensive care can be avoided for babies who are unlikely to survive."

Asked to comment by Medscape News UK, Caroline Lee-Davey, chief executive of Bliss, said the charity welcomed the new research and was proud to have contributed to the BAPM framework, especially in ensuring that "parents' perspectives and wishes are at the heart of decision-making in this sensitive area of care".

She agreed that more research is needed "to understand which factors make it more likely a baby will survive at this gestation, and to improve consistency of clinical practice in care delivery. We must understand how decisions are made and which risk factors — including birth weight, sex, gestation, and antenatal interventions — have the most significant impact for survival and morbidity".

She added that there was also an urgent need to understand how best to counsel parents. "We need to ensure that both babies and their parents have access to the right support and palliative care if it is determined that ongoing active treatment is not in their best interest."