EBNEO COMMENTARY: MANAGEMENT AND OUTCOMES OF PERIVIABLE NEONATES BORN AT 22 WEEKS OF GESTATION: A SINGLE-CENTER EXPERIENCE IN JAPAN

[EBNEO]

 

Vonita Chawla from University of Arkansas for Medical Sciences / Arkansas Children’s Hospital reviews the paper "Motojima Y, Nishimura E, Kabe K, Namba F. Management and outcomes of periviable neonates born at 22 weeks of gestation: a single-center experience in Japan. J Perinatol 2023; 43(11):1385-1391. PMID: 37393397" for EbNeo.

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Acta Commentary:

Acta Paediatrica - 2024 - Chawla - EBNEO Commentary Management and outcomes of periviable neonates born at 22 weeks of.pdf

'In 1991, an amendment to the Eugenic Protection Act lowered the limit of viability to 22 weeks of gestation, in Japan (1). Backed by a robust prenatal care program (2), the Japanese longitudinal experience in caring for neonates born at the cusp of viability has led to improved outcomes (3). Subsequently, active resuscitation is offered to most neonates born at 22 weeks GA, i.e.>80% of these neonates are intubated at birth, according to the year 2020 report of the Neonatal Research Network (NRN) Database, Japan (4) despite a lower rate of antenatal steroid use (~50%).

In this study, Motojima et al describe the experience of a single Japanese tertiary center, in caring for periviable neonates born as early as 2013. In this cohort of 29 neonates, overall favorable outcomes are noted with more than 80% survival. Strikingly, only one neonate (5%) in this group developed CP long-term, and only 2 infants (11%) had severe NDI, with the overall greatest impairment seen in the language-social domain.

Key maternal/infant characteristics include universal prenatal care, a considerably higher median birth weight of 512 g (compared to median birth weight of 480 g reported by the National Institute of Child Health and Human Development NRN, 2013-2018) (5), use of C-section as the predominant mode of delivery and comparable rates (5) of antenatal steroid administration (34%), both of which are associated with increased survival in this population (6). Maternal illnesses and other prenatal exposures such as smoking and recreational drugs are not listed.

Cord milking is practiced commonly, which is currently not standard of care for infants <28 weeks GA, due to an increased risk of IVH (7). Interestingly, in this study, the incidence of severe IVH remained low. Other noteworthy management strategies include early enteral feeding (100% of infants fed by day of life (DOL) 1, despite 90% of these infants requiring some inotropic support), frequent use of neonatologist-performed echocardiograms to inform decisions regarding fluid management, PDA, selection/titration of inotropes/vasopressors, etc., and lung-protective approach to ventilation. All infants are on non-invasive respiratory support by 40 weeks PMA. Postnatal steroid use is not mentioned and a distinction between early vs. late onset sepsis is not made. Probiotics are used as early as DOL 0 in some neonates and phenobarbital is the primary sedative used in the first week of life.

Worldwide, several centers have well-established neonatal hemodynamics programs, however, this highly specialized area of neonatology is still evolving and many neonatal intensive care units rely on traditional clinical parameters. This may be one of many reasons for such wide variation in clinical practice and outcomes related to periviable neonates (8). Given the overall improved survival, the American College of Obstetricians and Gynecologists has provided updated recommendations to consider antenatal steroids for GA 22w 0d – 22w 6d (9).

Careful consideration should be given to individual patient factors including maternal comorbidities, presence of fetal/neonatal anomalies, inborn versus outborn neonates, resource availability, and most importantly, expectations of the families when choosing active resuscitation for these infants.'

References

Nishida H, Ishizuka Y. Survival rate of extremely low birth weight infants and its effect on the amendment of the Eugenic Protection Act in Japan. Acta Paediatr Jpn 1992; 34(6):612-6. PMID: 1285508.

Kusuda S, Hirano S, Nakamura T. Creating experiences from active treatment towards extremely preterm infants born at less than 25 weeks in Japan. Semin Perinatol 2022; 46(1):151537. PMID: 34862068.

Miyazawa T, Arahori H, Ohnishi S, Shoji H, Matsumoto A, Wada YS, et al. Mortality and morbidity of extremely low birth weight infants in Japan, 2015. Pediatr Int 2023; 65(1):e15493. PMID: 36740921.

Website for the Neonatal Research Network Database Japan: https://plaza.umin.ac.jp/nrndata/indexe.htm

Bell EF, Hintz SR, Hansen NI, Bann CM, Wyckoff MH, DeMauro SB et al; Eunice Kennedy Shriver National Institute of Child Health and Human Development Neonatal Research Network. Mortality, In-Hospital Morbidity, Care Practices, and 2-Year Outcomes for Extremely Preterm Infants in the US, 2013-2018. JAMA 2022; 327(3):248-263. PMID: 35040888.

Vidavalur R, Hussain Z, Hussain N. Association of Survival at 22 Weeks’ Gestation With Use of Antenatal Corticosteroids and Mode of Delivery in the United States. JAMA Pediatr 2023; 177(1):90-93. PMID: 36315137.

Katheria A, Reister F, Essers J, Mendler M, Hummler H, Subramaniam A et al. Association of Umbilical Cord Milking vs Delayed Umbilical Cord Clamping With Death or Severe Intraventricular Hemorrhage Among Preterm Infants. JAMA. 2019; 322(19):1877-1886. PMID: 31742630.

Silva ER, Shukla VV, Tindal R, Carlo WA, Travers CP. Association of Active Postnatal Care With Infant Survival Among Periviable Infants in the US. JAMA Netw Open 2023; 6(1):e2250593. PMID: 36656583

Website for the American College of Obstetricians and Gynecologists: https://www.acog.org/clinical/clinical-guidance/practice-advisory/articles/2021/09/use-of-antenatal-corticosteroids-at-22-weeks-of-gestation

 

 

[Flavio Martins]

Amazing results! I'd be glad to have those numbers at our NICU!

Can anyone share this article? I'd like to know read it. Thanks!