title: Guidelines for the Management of Extremely Premature Deliveries: A Systematic Review.
abstract: OBJECTIVE
  Available data on survival rates and outcomes of extremely low gestational age (GA) infants (22-25 weeks' gestation) display wide variation by country. Whether similar variation is found in statements by national professional bodies is unknown. The objectives were to perform a systematic review of management from scientific and professional organizations for delivery room care of extremely low GA infants.
  
  
  METHODS
  We searched Embase, PubMed, and Google Scholar for management guidelines on perinatal care. Countries were included if rated by the United Nations Development Programme's Human Development Index as "very highly developed." The primary outcome was rating of recommendations from "comfort care" to "active care." Secondary outcomes were specifying country-specific survival and considering potential for 3 biases: limitations of GA assessment; bias from different definitions of stillbirths and live births; and bias from the use of different denominators to calculate survival.
  
  
  RESULTS
  Of 47 highly developed countries, 34 guidelines from 23 countries and 4 international groups were identified. Of these, 3 did not state management recommendations. Of the remaining 31 guidelines, 21 (68%) supported comfort care at 22 weeks' gestation, and 20 (65%) supported active care at 25 weeks' gestation. Between 23 and 24 weeks' gestation, much greater variation was seen. Seventeen guidelines cited national survival rates. Few guidelines discussed potential biases: limitations in GA (n = 17); definition bias (n = 3); and denominator bias (n = 7).
  
  
  CONCLUSIONS
  Although there is a wide variation in recommendations (especially between 23 and 24 weeks' GA), there is general agreement for comfort care at 22 weeks' GA and active care at 25 weeks' GA.
authors.affiliation: Division of Neonatology, Christiana Care Health System, Newark, Delaware; ursula.guillen@gmail.com.
authors.forename: Úrsula
authors.initials: Ú
authors.lastname: Guillén
authors.affiliation: Division of Neonatology, The Children's Hospital of Philadelphia, Philadelphia, Pennsylvania;
authors.forename: Elliott M
authors.initials: EM
authors.lastname: Weiss
authors.affiliation: Division of Neonatology, The Children's Hospital of Philadelphia, Philadelphia, Pennsylvania;
authors.forename: David
authors.initials: D
authors.lastname: Munson
authors.affiliation: CHC St Vincent, Rocourt, Belgium;
authors.forename: Pierre
authors.initials: P
authors.lastname: Maton
authors.affiliation: Department of Paediatrics, Mount Sinai Hospital, University of Toronto, Toronto, Ontario, Canada;
authors.forename: Ann
authors.initials: A
authors.lastname: Jefferies
authors.affiliation: Department of Neonatal Medicine, Karolinska Hospital, Stockholm, Sweden;
authors.forename: Mikael
authors.initials: M
authors.lastname: Norman
authors.affiliation: Department of Pediatrics, University Hospitals Leuven, Leuven, Belgium;
authors.forename: Gunnar
authors.initials: G
authors.lastname: Naulaers
authors.affiliation: Sao Francisco Xavier Hospital, Lisbon, Portugal;
authors.forename: Joana
authors.initials: J
authors.lastname: Mendes
authors.affiliation: Department of Pediatrics, Lisbon Medical School, Lisbon, Portugal;
authors.forename: Lincoln
authors.initials: L
authors.lastname: Justo da Silva
authors.affiliation: Department of Neonatology, Charles University, Prague, Czech Republic;
authors.forename: Petr
authors.initials: P
authors.lastname: Zoban
authors.affiliation: Women & Children's Division, Oslo University Hospital, Oslo, Norway; Faculty of Medicine, University of Oslo, Oslo, Norway;
authors.forename: Thor W R
authors.initials: TW
authors.lastname: Hansen
authors.affiliation: Department of Pediatrics, Oulu University Hospital and University of Oulu, Oulu, Finland;
authors.forename: Mikko
authors.initials: M
authors.lastname: Hallman
authors.affiliation: Division of Neonatology, St Christopher's Hospital for Children, Philadelphia, Pennsylvania;
authors.forename: Maria
authors.initials: M
authors.lastname: Delivoria-Papadopoulos
authors.affiliation: Department of Pediatrics, Nihon University School of Medicine, Tokyo, Japan;
authors.forename: Shigeharu
authors.initials: S
authors.lastname: Hosono
authors.affiliation: Division of Neonatology, University of British Columbia, Vancouver, British Columbia, Canada;
authors.forename: Susan G
authors.initials: SG
authors.lastname: Albersheim
authors.affiliation: Department of Pediatrics, McMaster University, Hamilton, Ontario, Canada;
authors.forename: Constance
authors.initials: C
authors.lastname: Williams
authors.affiliation: Department of Pediatrics, University of Leicester, Leicester, United Kingdom;
authors.forename: Elaine
authors.initials: E
authors.lastname: Boyle
authors.affiliation: Department of Newborn Care, University of New South Wales, Sydney, Australia; and.
authors.forename: Kei
authors.initials: K
authors.lastname: Lui
authors.affiliation: Department of Pediatrics, University of Otago, Christchurch, New Zealand.
authors.forename: Brian
authors.initials: B
authors.lastname: Darlow
authors.affiliation: Division of Neonatology, The Children's Hospital of Philadelphia, Philadelphia, Pennsylvania;
authors.forename: Haresh
authors.initials: H
authors.lastname: Kirpalani
mesh_terms: D036861:Delivery, Obstetric / Q000592:standards*; D005260:Female; D006801:Humans; D062071:Infant, Extremely Premature; D007231:Infant, Newborn; D017410:Practice Guidelines as Topic; D011247:Pregnancy; D047928:Premature Birth / Q000628:therapy*