Clinical Guidelines for Management of Infants Born Before 25 Weeks' Gestation: How Representative Is the Current Evidence?

S Peart; M Kahvo; T Alarcon-Martinez; K Hodgson; S H Eger; S Donath; L S Owen; P G Davis; C C Roehr; B J Manley

doi:10.1016/j.jpeds.2024.114423

Clinical Guidelines for Management of Infants Born Before 25 Weeks' Gestation: How Representative Is the Current Evidence?

J Pediatr. 2024 Nov 27:114423. doi: 10.1016/j.jpeds.2024.114423. Online ahead of print.

Authors

S Peart¹, M Kahvo², T Alarcon-Martinez³, K Hodgson⁴, S H Eger⁵, S Donath⁶, L S Owen⁴, P G Davis⁴, C C Roehr⁷, B J Manley⁴

Affiliations

¹ Newborn Services and Newborn Research, Royal Women's Hospital, Melbourne, Australia; Department of Obstetrics, Gynaecology and Newborn Health, The University of Melbourne, Melbourne, Australia; Murdoch Children's Research Institute, Melbourne, Australia. Electronic address: Stacey.peart@thewomens.org.au.
² St Michael's Hospital, Bristol, UK.
³ Newborn Services and Newborn Research, Royal Women's Hospital, Melbourne, Australia.
⁴ Newborn Services and Newborn Research, Royal Women's Hospital, Melbourne, Australia; Department of Obstetrics, Gynaecology and Newborn Health, The University of Melbourne, Melbourne, Australia; Murdoch Children's Research Institute, Melbourne, Australia.
⁵ Division of Children and Adolescent Medicine, Oslo University Hospital, Oslo, Norway.
⁶ Murdoch Children's Research Institute, Melbourne, Australia.
⁷ National Perinatal Epidemiological Unit, Oxford Population Health, University of Oxford, Oxford, UK; Newborn Services, Southmead Hospital, Bristol, UK; Faculty of Health Sciences, University of Bristol, Bristol, UK.

PMID: 39613140
DOI: 10.1016/j.jpeds.2024.114423

Abstract

Objective: To determine whether management guidelines for infants born extremely preterm are representative for those infants <25 weeks' gestation.

Study design: Three guidelines were reviewed: the 2022 European Consensus Guidelines on the Management of Respiratory Distress Syndrome, the 2017 American Academy of Pediatrics Guidelines for Perinatal Care, and the 2020/21 International Liaison Committee on Resuscitation guidelines. All referenced studies for overlapping recommendations were reviewed. Data extracted included the total number and proportion of infants <25 weeks' gestation in the original articles referred in the guidelines. Where the exact number of infants <25 weeks' gestation was unobtainable, this was conservatively estimated by statistical deduction.

Results: Eight recommendations were included in two or more guidelines: 1) antenatal corticosteroids, 2) antenatal magnesium sulphate, 3) delayed cord clamping, 4) thermoregulation at birth, 5) initial oxygen concentration at birth, 6) continuous positive airway pressure, 7) surfactant, and 8) parenteral nutrition. 519 studies (n=409,986) informed these 8 recommendations, of which 335 (64.5%) were randomized controlled trials (RCTs) (n=78,325). Across all studies, an estimated 59,360 (14.5%) infants were <25 weeks' gestation. Within RCTs alone, an estimated 5,873 (7.5%) infants were <25 weeks' gestation. 196 (37.8%) studies did not include any infants <25 weeks' gestation.

Conclusions: Infants born <25 weeks' gestation are not well-represented in the evidence used to develop major clinical guidelines for infants born extremely preterm . Future studies should provide evidence for this population as a distinct cohort.

Keywords: border of viability; intensive care; neonatology.