The Canadian Medical Association Journal has just published a Commentary by 2 neonatologists from the USA. Batton D, Batton B: Advocating for equality for preterm infants. Canadian Medical Association Journal 2013.
The commentary is in response to the CPS recent statement, produced by the fetus and newborn committee ‘Counselling and management for anticipated extremely preterm birth, Pediatr Child Health 2012:17; 443-6’. (The new document is behind a paywall, if you can’t find another way of getting a copy, let me know, I might be able to help.)
The new commentary is a brief critique of the statement, which, to me, hits all the right buttons; the uncertainty of gestational age assessment, the unreliability of data from centers that practice selective treatment, the impossibility of predicting outcomes before birth, and the fact that the decisions that are being made would be completely unacceptable for any other patient with similar predicted outcomes.
One thing that continues to disturb me is that way that neonatologists have often advocated against our patients. We have promoted standards that no other group would accept, and accepted enormous variations in practice that would be heavily criticized in other fields.
It is about time that we started to advocate for our patients, for standards of care that recognize that these babies deserve appropriate medical care, and have rights as human beings once they are born. I don’t think that life sustaining interventions should always be provided to all preterm babies, but I don’t think that for older children or adults either. We should be pushing for all preterm babies to be given the same benefits, the same opportunities, and the same considerations of their best interest as other patients. We have instead accepted, and even ourselves promoted, arbitrary and non-evidence based limits to be placed on life-sustaining interventions.
The Key Points of the Battons’ commentary are :
• The decision to provide active intervention to extremely preterm infants at the border of viability is difficult but should not be discriminatory.
• Current methods of estimating gestational age are not sufficiently precise for this to be the sole basis for decision-making.
• The error of a self-fulfilling prophecy inherent in withholding active intervention in the delivery room because it is assumed to be futile should be avoided.
• Reported neurodevelopmental disability rates in populations of surviving infants are not sufficient criteria for withholding active intervention in the delivery room.
• Providing antenatal steroids and active intervention initially and then re-evaluating the appropriateness of such intervention with the parents thereafter should be the default approach to care when the infant’s best interests are unclear.