There is widespread agreement that the aim of neonatal resuscitation should be a qualitatively acceptable survival of the child. In the USA guidelines state
50 CHAPTER 3
European and Canadian guidelines propose an active approach at 25 and 26 weeks, and a flexible approach at 23 and 24 weeks, depending on the opinion of the parents and the condition of the infant at birth. Nevertheless, more and more infants born at 23 and 24 weeks are resuscitated, especially in Sweden, Norway and Germany. In future studies the qualities of life of these infants, their neuro- developmental outcome and later academic achievements have to be shown. In the Netherlands, extremely preterm infants are not routinely resuscitated and intensive care will be withdrawn if treatment is clearly futile. This policy is based on reports from the Dutch Medical Association and the Dutch Paediatric Asso- ciation, which argue that withholding or withdrawing life-sustaining treatment in newborn infants with extremely poor prognoses is justifiable medical practice and that decisions should be taken by the medical and nursing team, together
with well-informed parents.39 In Table 3 the Dutch guidelines are illustrated.
Table 3. Consensus on treatment of extremely premature infants at birth in the Netherlands (Dutch Paediatric Association, November 2005).
Gestational age in weeks & days Intrauterine referral to level 3 perinatal center Antenatal steroids Caesarean section Neonatal treatment in the delivery room <24+0 No No Only on maternal indication Family-centred comfort care 24+0 – 24+6 Indicated Can be considered Only on maternal indication Family-centred comfort care, unless an active approach seems justified
25+0 – 25+6 Indicated Yes Rarely on foetal
indication
Active approach, unless comfort care seems more justified
> 26+0 Indicated Yes Yes, unless an
active approach does not seem justified
Active approach, unless comfort care seems more justified If a child weighs less than 500 grams at birth, neonatal treatment will be withheld, except for family-centred comfort care.
Lorentz reminds us how difficult it is to decide before delivery, so an option could be to start intensive care to extremely preterm infants, then reconsider and eventually withdraw treatment. There are little data to support the predic-
tive value of the condition at birth for survival.29 Levene warns us to keep in
mind that treatment of extremely preterm infants (23 and 24 weeks of gesta- tion) should be viewed as an experimental therapy with properly informed con-
sent rather than the automatic process that it often becomes.11 Because of the
often poor long-term neurological and mental outcome of these very immature infants, decisions about justified care should include the alternative of no life-
supporting treatment.40
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