When a baby is born at the edge of viability, the question of what action to take is a difficult and controversial one. The risks of poor outcomes are high, even if the baby survives. The Wall Street Journal highlights a new study that explores the relationship between the decision to pursue active treatment and the rates of survival and impairment. What was surprising was that the variation across centers in pursuing aggressive medical care was substantial, and it is clear that hospitals have different policies in treating babies at low gestational ages.
The article does a great job providing balance to these two approaches (active intervention versus palliative care), weighing a baby’s chances of survival with the risks of suffering from severe impairment in the future. The independent doctor quoted in the story gives a unique perspective on how clinicians may interpret the study’s findings and why aggressive medical interventions at early gestational ages may not be optimal.
Overall, this is solid health news reporting — something we are always happy to see.
This cohort study examined what happens to babies born at extremely low gestational age, providing valuable new information on the likelihood of health outcomes that matter to parents. Those outcomes are also of importance to society from the standpoint of health costs. More reliable information on the possible outcomes for parents who choose one approach or another (palliative care vs aggressive treatment) is of great value. The results of the study could provide a more standardized approach to how health care providers communicate with parents about these most crucial outcomes. The study was not a trial and does not provide any guidance on what to do in such situations, which will always be an individual choice.
Especially in the WSJ, we would expect some mention of the extraordinarily high health care costs that can result from intensive treatment. The decision about which treatment is best in any particular baby’s case should not be driven by costs, of course, but it is important to acknowledge the cost issue for this as well as for other health conditions.
The article does an excellent job quantifying the survival rates of babies at different weeks of gestation receiving active treatment, even differentiating between those who survived without severe neurological impairment and those who survived without severe or moderate neurological impairment.
It sums it up like this: “Those who were born at 22 weeks of gestation and weren’t administered active interventions to help them breathe or their hearts to beat survived only 5% of the time. Of those who received active treatment, 23% lived, 15.4% survived without severe neurological impairment, such as cerebral palsy, and 9% survived without severe or moderate neurological impairment.”
The story also quantifies the percentage of babies at different gestational ages being given lifesaving treatments: “Just 22% of babies born at 22 weeks were given lifesaving treatments compared with 72% of babies born at week 23 and 97% of babies born at week 24.”
These figures give a solid overview of the original research report’s major points.
We particularly like how the article treated this criterion. It is made clear early in the story that aggressive medical treatment in premature babies may be a double-edged sword, since “these infants often don’t survive and, even if they do, many have substantial long-term health problems.”
We also like the fact that the article differentiates between survival and a “functional, fully participatory life.” An independent pediatrics professor, Dr. Elizabeth Rogers, is quoted as saying she wouldn’t change her clinical practice based on the research because “the risks of poor outcome outweigh the possibility of a really good outcome for families,” especially for babies born at an early gestational age.
Early in the story, it is stated that the new study “provides what is thought to be the best, large-scale data in the US to date on this topic.” The authors come from reputable institutions and looked at nearly 5,000 babies born before 27 weeks at two-dozen major hospitals across the country. The babies were then followed to 18-22 months of age.
The article also cautions that the findings aren’t a clear-cut conclusion about when and whether intensive-care treatments should be administered, but the data should help doctors and families make difficult decisions on a case-by-case basis.
A minor point for improvement would be a more explicit mention that the study was a cohort study, not a trial comparing the two outcomes. As with any cohort study, there is the potential for confounding if babies with inherently lower likelihood of survival (regardless of gestational age) were more likely to be given palliative care rather than aggressive care.
The piece does not engage in disease mongering.
The story quotes Dr. Elizabeth Rogers, a pediatrics professor who wasn’t involved in the study. Her comments help balance the story, bringing the research into perspective, and also help shed light on how other doctors might react to the study’s findings.
The article also points out that the research was supported and funded by the National Institutes of Health.
The research is already comparing two alternatives to babies born prematurely: either administer aggressive, intensive-care treatments or palliative care to keep them comfortable. The story states this fact in the first paragraph.
The story didn’t touch on availability, but availability isn’t really an issue here. The babies received various treatments at different hospital centers. Active interventions ranged from ventilation and chest compressions to intubation.
Although studies exploring survival and neurodevelopmental impairment have been published, the story explains that this new research is thought to be the best, most large-scale data in the US on this topic — namely how the decision to pursue active treatment across hospitals influences rates of survival and impairment for extremely preterm babies, or those born at 22 to 24 weeks of gestation.
We couldn’t find any evidence online that the WSJ story was based on a press release, like this one from the University of Iowa. Plus, the inclusion of independent voices suggests original reporting.