Abstract
Objective This study aimed to provide contemporary data regarding provider perceptions of appropriate
care for resuscitation and stabilization of periviable infants and institutional resources
available to providers.
Study Design A Qualtrics survey was emailed to 672 practicing neonatologists in the United States
by use of public databases. Participants were asked about appropriate delivery room
care for infants born at 22 to 26 weeks gestational age, factors affecting decision-making,
and resources utilized regarding resuscitation. Descriptive statistics were used to
analyze the dataset.
Results In total, 180 responses were received, and 173 responses analyzed. Regarding preferred
course of care based on gestational age, the proportion of respondents endorsing full
resuscitation decreased with decreasing gestational age (25 weeks = 99%, 24 = 64%,
23 = 16%, and 22 = 4%). Deference to parental wishes correspondingly increased with
decreasing gestational age (25 weeks = 1%, 24 = 35%, 23 = 82%, and 22 = 46%). Provision
of comfort care was only endorsed at 22 to 23 weeks (23 weeks = 2%, 22 = 50%). Factors
most impacting decision-making at 22 weeks gestational age included: outcomes based
on population data (79%), parental wishes (65%), and quality of life measures (63%).
Intubation with a 2.5-mm endotracheal tube (84%), surfactant administration in the
delivery room (77%), and vascular access (69%) were the most supported therapies for
initial stabilization. Availability of institutional resources varied; the most limited
were obstetric support for cesarean delivery at the limit of viability (37%), 2.0-mm
endotracheal tube (45%), small baby protocols (46%), and a consulting palliative care
teams (54%).
Conclusion There appears to be discordance in provider attitudes surrounding preferred actions
at 23 and 22 weeks. Provider attitudes regarding decision-making at the limit of viability
and identified resource limitations are nonuniform. Between-hospital variations in
outcomes for periviable infants may be partly attributable to lack of provider consensus
and nonuniform resource availability across institutions.
Key Points
-
Within the past decade, there has been a shift in the gray zone from 23–24 to 22–23
weeks gestation.
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Attitudes around resuscitation of infants are nonuniform despite perceived standardized
approaches.
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Institutional variability in resources may contribute to variation in outcomes of
periviable infants.
Keywords
limit of viability - periviable infants - extremely premature infant - provider attitudes
- institutional resources
