Management and outcomes of extreme preterm birth

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The survival and morbidity rates of babies born extremely preterm are linked to care management before and after birth, which tends to vary a lot. Conclusions of a recently published clinical update show that family centred care, preventive measures before pregnancy and the use of guidelines and legislation are key factors for improving health outcomes.

Extreme preterm birth is defined as birth before 28 weeks of gestation. The survival and health status of babies born too soon depends on a variety of factors, including the quality of obstetric care and the management of prematurity.

Due to the rapid-changing nature in management and outcome of extreme preterm birth, a group of researchers published a clinical update and provided an overview of its epidemiology, recent changes, and best practices. The update focuses on high-income countries and covers short- and long-term medical, psychological, and experimental outcomes of individuals born extremely preterm and their families.

Good news first: the survival of babies born extremely preterm has improved in recent years. However, the results for longer-term neurological outcomes are inconclusive. Recent changes in best management practices in preparation for extreme preterm birth include how, when, and to whom to administer steroids, surfactants, and some new treatments such as antenatal magnesium sulphate. The aim is to reduce the baby’s risk of neurological injury. Another new recommendation is delayed cord clamping to allow longer placental transfusion to the newborn.

When it comes to neonatal management, offering both compassionate (“comfort-focused”) or survival-focused (“active”) care is the right way to go. However, there has been a change in best practice for active care concerning respiratory support: current evidence suggests early non-invasive continuous positive airway pressure (CPAP) is better than intubation and ventilation. Regarding clinical decision-making, it is essential to consider the parents’ opinions, religious beliefs, and advice from practitioners close to the family. Recent studies support that closeness and active participation of parents in treatment positively influence bonding and longer-term outcomes for child and family. Other neonatal management areas still need to be determined, e.g. is, the use of prophylactic antibiotics, management of a patent ductus arteriosus, and strategies for controlling pain and discomfort.

The challenges for children and their families continue to be the same. Many children will have fulfilling lives, but they have an increased risk of a wide range of health, learning and social difficulties compared with those born at term. Cerebral palsy, the main motor disorder affecting around 10% to 20% of individuals born extremely preterm, has remained relatively stable over time despite the higher survival rates. Unfortunately, other motor problems like developmental coordination disorder have increased.

Recent studies also confirm that children born extremely preterm are more likely to experience attention-deficit/hyperactivity disorder (ADHD), internalising problems (e.g., anxiety, depression), and difficulties with social interaction. Adults born preterm also have higher risks of socioeconomic problems and are less likely to become parents themselves. The update found little concrete evidence on how to best tackle these problems, but new analyses highlight the importance of encouraging early social interaction and providing educational support.

Lastly, there is still upcoming evidence that extreme preterm birth is stressful for both parents. Interestingly, extreme preterm birth alone does not appear to directly impact relationships; higher rates of relationship breakdowns that occur among parents of surviving children ended up being related to the poor neurodevelopmental outcomes of the child. Nevertheless, early psychological support for parents is still a crucial part of postnatal care.

As part of the conclusions of the update, prevention of preterm and extreme preterm birth begins before pregnancy, with community and public health efforts. Socioeconomic circumstances and environmental risk will continue to be associated with a higher risk of extreme preterm birth. Differences in the provision of care will continue impacting morbidity and mortality outcomes. Therefore, guidelines and legislation are key to preventing and managing extreme preterm birth.

This article is part of the grant agreement for RECAP Preterm, and is co-authored by Nicole Thiele, Vice Chair of the EFCNI Directors Board.

Paper available at: The BMJ

Full list of authors: Andrei S Morgan, Marina Mendonça, Nicole Thiele, Anna L David.