Resuscitation in the "gray zone" of viability: determining physician preferences and predicting infant outcomes.
OBJECTIVE
We assessed physician preferences and physician prognostic abilities regarding delivery room management of exceedingly low birth weight/short gestation infants.


METHODS
We surveyed US neonatologists to assess their behavior in the delivery room when confronted with infants with gestational ages of 22 to 26 weeks. We identified 102 infants in our NICU with birth weights/gestational ages of 400 g/23 weeks to 750 g/26 weeks, whose follow-up care was ensured because of their participation in ongoing clinical trials. We determined 4 proxy measures for "how the infant looked" in the delivery room (Apgar scores at 1 and 5 minutes and heart rates at 1 and 5 minutes) and assessed the predictive value of each marker for subsequent death or neurologic morbidity.


RESULTS
For infants with birth weights of < 500 g and gestational ages of 23 weeks, only 4% of 666 responding neonatologists would provide full resuscitation. In contrast, for infants with birth weights of > 600 g and gestational ages of 25 weeks, > 90% of neonatologists considered resuscitation obligatory. For infants with birth weights of 500 to 600 g and gestational ages of 23 to 24 weeks, only one third of neonatologists responded that parental preference would determine whether they resuscitated the infant in the delivery room. The majority wanted "to see what the infant looked like." For 102 infants with birth weights of < or = 750 g, Apgar scores at 1 and 5 minutes and heart rates at 1 and 5 minutes were neither sensitive nor predictive for death before discharge, survival with a neurologic abnormality, or intact neurologic survival.


CONCLUSIONS
The "gray zone" for delivery room resuscitation seems to be between 500 and 600 g and 23 and 24 weeks. For infants born in that zone, neonatologists' reliance on accurate prediction of death or morbidity in the delivery room may be misplaced.
Singh
Jaideep
J
Department of Pediatrics, University of Chicago, 5815 South Maryland Ave, Chicago, IL 60637, USA.
Fanaroff
Jon
J
Andrews
Bree
B
Caldarelli
Leslie
L
Lagatta
Joanne
J
Plesha-Troyke
Susan
S
Lantos
John
J
Meadow
William
W
D001034:Apgar Score; D001291:Attitude of Health Personnel; D016887:Cardiopulmonary Resuscitation; D003657:Decision Making; D003696:Delivery Rooms; D005865:Gestational Age; D006801:Humans; D052577:Infant, Extremely Low Birth Weight; D007231:Infant, Newborn; D007234:Infant, Premature; D010818:Practice Patterns, Physicians' / Q000706:statistics & numerical data*; D012372:ROC Curve; D012680:Sensitivity and Specificity; D011795:Surveys and Questionnaires; D014481:United States