Predicting outcomes in preterm infants: is it time to throw away the ultrasound machine?

It is common practice, nearly universal, I would guess, to perform head ultrasounds in the 1st week of life as a way to predict which very preterm babies will have very poor outcomes, and then to consider redirection of care (an inelegant euphemism for letting the baby die). The American Academy of Neurology guidelines recommend a head ultrasound at 1 week of age, which is sometimes explicitly stated to be for the purpose of “letting the baby die”. What data do we have that this is appropriate, i.e. adequately discriminates between babies with profoundly limited outcomes, and those without?

The short answer is, almost none.

One of the big problems is that the large majority of follow up studies have used Bayley scales of infant development, sometimes other analogous scales, and usually at no more than 3 years of age. The follow up studies I have no problem with, describing our outcomes with the best available tools is appropriate. But then using those gross screening tools to decide which babies lives are worthwhile is very problematic.

I have spoken several times about the limitations of the Bayley, see for example my presentation on predicting outcomes on this blog, the Bayley was designed to screen babies for developmental delay. NOT to decide if their lives were profoundly limited.

A new systematic review Luttikhuizen Dos Santos ES, de Kieviet JF, Konigs M, van Elburg RM, Oosterlaan J. Predictive value of the Bayley Scales of Infant Development on development of very preterm/very low birth weight children: A meta-analysis. Early Hum Dev. 2013 Jul;89(7):487-96  points out how poor the BSID are for predicting later cognitive function. They conclude “MDI scores explain 37% of the variance in later cognitive functioning” which in other words, means that they are about 2/3 useless.

A well-written commentary from a group of physicians from Seattle Children’s hospital discusses the ethics of our current standard approach, and points out how little ethical support there is for what many of us are doing. Mann PC, Woodrum DE, Wilfond BS. Fuzzy Images: Ethical Implications of Using Routine Neuroimaging in Premature Neonates to Predict Neurologic Outcomes. The Journal of pediatrics. 2013 Apr 24. When head ultrasounds are so poorly predictive of long term outcomes, we should reconsider why we do them, and when, and whether they are of any value at all to our patients.

About Keith Barrington

I am a neonatologist and clinical researcher at Sainte Justine University Health Center in Montréal
This entry was posted in Advocating for impaired children and tagged , , , . Bookmark the permalink.

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