Twenty-Two Week Preemies, Should We Save Them?

Are you a neonatal intensive care nurse? Do you believe we should save premature babies born at twenty-two weeks? What kinds of treatments does it take to save a fetus whose viability is uncertain?

The New England Journal of Medicine recently published the results of a study showing the outcomes for five-thousand babies, born between twenty-two and twenty-seven weeks, at twenty-four different hospitals. The purpose of the study was to see if differences in hospital practices regarding initiation of treatment for these babies could explain the variation in survival with and without impairment. No babies born between twenty-two and twenty-three weeks survived without treatment. A small number received aggressive treatment, and a fraction survived, some with significant complications.

Researchers hope the study will offer physicians solid data to help them council parents. Undoubtedly, it will fire-up the debate concerning the age of viability. In a summary of a 2014 workshop, the American College of Obstetricians and Gynecologists and the Academy of Pediatrics noted that babies born at twenty-three weeks should be considered viable, as more than a quarter of them survive with intensive treatment. In the summary, it also states that no treatment is helpful for babies born at twenty-two weeks. The gray zone occurs between twenty-two and twenty-three weeks. Survival depends on factors such as birth weight and whether or not the mother received steroids prior to delivery to help the baby’s lungs and brain.

That is a narrow window. If a mother is ready to deliver at twenty-two weeks and six days, do we say, “sorry, there’s nothing we can do?” Add to that gray zone the reality that due dates are an estimation. What if that same mother was really twenty-three weeks pregnant?

In 2001, as a NICU nurse at a large teaching hospital, I cared for a baby born at twenty-three weeks. Her eyes were still fused shut and her skin was so thin the nurses only changed her diaper when absolutely necessary to avoid any injury. We kept her on a ventilator for twenty-four hours, the time it took for her parents to arrive from a community hospital several miles away, where her mother delivered the baby. She died within minutes after a respiratory therapist removed the breathing tube.

During my four year NICU career, I don’t recall any incident of initiating life-saving treatment for twenty-two week preemies. The cut off was twenty-four weeks. Many of those babies did well. For several years after they were discharged home, I kept in touch with some of the families and learned that Baby B was in first grade and reading, or Baby C was seven-years-old and playing soccer. It did my heart good to know they were healthy and vibrant children.

Technology has improved over the past thirteen years – if that twenty-three preemie I cared for in 2001 were born today and received aggressive treatment, maybe she’d survive. I’m not suggesting we stop initiating treatment for extremely premature babies, but with technology pushing us harder and further, with no indication in the near future of it breaking down, I wonder to what extent we are willing to let technology dictate? How far are we willing to turn that knob on the ventilator? What if Baby Z ends up with cerebral palsy, and is never able to walk, talk, or feed herself? And then there’s the flip side. When do we say we need to do more, we can’t give up, we have the medicine, the machines, the formula? What if we inject just one more dose of adrenaline? What if we press one more time on Baby Z’s chest? What if we do nothing and regret it?

As a nurse, I ate those kinds of questions for breakfast. But the answers are gray, and that gray only seems to be getting grayer.

Please, feel free to respond, react, reflect.