Survival and Long-Term Neurodevelopmental Outcome of Extremely Premature Infants Born at 23–26 Weeks’ Gestational Age at a Tertiary Center
Ronald E. Hoekstra, MD*, T. Bruce Ferrara, MD*, Robert J. Couser, MD*, Nathaniel R. Payne, MD* and John E. Connett, PhD
* Division of Neonatology, Children’s Hospitals and Clinics of Minneapolis, Minneapolis, Minnesota
Division of Biostatistics, School of Public Health, University of Minnesota, Minneapolis, Minnesota
Objective. Long-term outcome, including school-age function, has been infrequently reported in infants born at ages as young as 23–26 weeks’ gestation. The objective of this study is to report outcome on a large cohort of these infants to understand better the risks and factors that affect survival and long-term prognosis.
Methods. Records from 1036 infants who were born between January 1, 1986, and December 31, 2000, were analyzed retrospectively by logistic regression to correlate multiple factors with both survival and long-term outcome. A total of 675 surviving infants were analyzed at a mean age of 47.5 months for developmental outcome. A subset of 147 surviving infants who were born before 1991 were followed through school-age years using the University of Vermont Achenbach Child Behavioral Checklist and Teachers Report Form. Longitudinal follow-up was performed comparing 1-year outcome with school-age performance.
Results. Gestational age and recent year of birth correlated highly with survival. Maternal nonwhite race, female sex, inborn status, surfactant therapy, single gestation, and secondary sepsis also correlated positively with survival. Normal cranial ultrasound results, absence of chronic lung disease, female sex, cesarean delivery, and increased birth weight correlated favorably with long-term outcome. Infants who were born at 23 weeks were more likely to have severe impairments compared with those who were born at 24–26 weeks. Early follow-up identified most subsequent physical impairments but correlated poorly with school-age function.
Conclusions. Survival continues to improve for infants who are born at extremely early gestational ages, but long-term developmental concerns continue to be prevalent. Early outcomes do not reliably predict school-age performance. Strategies that reduce severe intraventricular hemorrhage and chronic lung disease will likely yield the best chances to improve long-term outlook.
Key Words: prematurity • outcome • neurodevelopment • survival • follow-up
Abbreviations: GA, gestational age • NICU, neonatal intensive care unit • IVH, intraventricular hemorrhage • PVL, periventricular leukomalacia • CLD, chronic lung disease • SD, standard deviation • OR, odds ratio
PEDIATRICS Vol. 113 No. 1 January 2004, pp. e1-e6.
Advances in perinatal and neonatal care during the past 2 decades have improved the prognosis for most preterm infants. Concomitant with these advances, the limits of viability have been lowered to the point where routine resuscitation of infants whose gestational age (GA) is as low as 23 weeks is now occurring in many perinatal centers. Despite this practice, many unanswered questions remain regarding outcome of these extremely preterm infants. Most outcome reports contain relatively few patients.1–4 Survival statistics vary and do not always account for the aggressiveness of support, which can also vary between centers. Long-term outcome information seems unfavorable compared with more mature preterm infants,5,6 but intact survival with normal cognitive function has been reported.7,8 Added benefits of prolonging gestation by weekly increments, when possible, are unclear. This information is crucial when physicians and parents are asked to make important decisions regarding obstetric interventions and neonatal resuscitation. To address these issues better, we report on both survival and neurologic outcome of a cohort of >1000 infants who were born at ages between 23 and 26 weeks’ gestation over a 15-year period and also evaluate factors that have a significant impact on these findings.