Latent class analysis shows that paediatricians' opinions about the advanced resuscitation of extremely preterm infants were diverse and influenced by personal beliefs.

AIM: The aim of this study was to survey paediatricians, who taught neonatal resuscitation in Brazil, about when they would apply advanced resuscitation in the delivery room for newborn infants born at 23-26 weeks of gestational age. METHODS: This cross-sectional study focused on an electronic questionnaire that was sent to paediatricians who acted as instructors for the Brazilian Neonatal Resuscitation Program from December 2011 to September 2013. The primary outcome was the gestational age at which the respondent would apply advanced resuscitation in the delivery room. Latent class analysis identified the profiles of the instructors, and logistic regression identified the variables associated with belonging to one of the derived classes. RESULTS: The 560 (82%) instructors who agreed to participate fell into three latent classes: pro-resuscitation, intermediate and pro-limitation, with high, intermediate and low probabilities of performing advanced resuscitation in neonates born at 23-26 weeks. In the multivariate model, group membership was associated with the paediatrician's age, years of practice and personal importance of religion and the patient's birthweight, future quality of life and probability of death. CONCLUSION: The opinions of paediatricians performing advanced resuscitation on extremely preterm infants in the delivery room were diverse and influenced by personal beliefs.

Opinions of Brazilian resuscitation instructors regarding resuscitation in the delivery room of extremely preterm newborns / Opiniões dos instrutores de reanimação brasileiros quanto à reanimação em sala de parto de em recém-nascidos pré-termo extremos

Abstract Objective: To describe the opinions of pediatricians who teach resuscitation in Brazil on initiating and limiting the delivery room resuscitation of extremely preterm infants. Method: Cross-sectional study with electronic questionnaire (Dec/2011-Sep/2013) sent to pediatricians who are instructors of the Neonatal Resuscitation Program of the Brazilian Society of Pediatrics, containing three hypothetical clinical cases: (1) decision to start the delivery room resuscitation; (2) limitation of neonatal intensive care after delivery room resuscitation; (3) limitation of advanced resuscitation in the delivery room. For each case, it was requested that the instructor indicate the best management for each gestational age between 23 and 26 weeks. A descriptive analysis was performed. Results: 560 (82%) instructors agreed to participate. Only 9% of the instructors reported the existence of written guidelines at their hospital regarding limitations of delivery room resuscitation. At 23 weeks, 50% of the instructors would initiate delivery room resuscitation procedures. At 26 weeks, 2% would decide based on birth weight and/or presence of fused eyelids. Among the participants, 38% would re-evaluate their delivery room decision and limit the care for 23-week neonates in the neonatal intensive care unit. As for advanced resuscitation, 45% and 4% of the respondents, at 23 and 26 weeks, respectively, would not apply chest compressions and/or medications. Conclusion: Difficulty can be observed regarding the decision to not resuscitate a preterm infant with 23 weeks of gestational age. At the same time, a small percentage of pediatricians would not resuscitate neonates of unquestionable viability at 26 weeks of gestational age in the delivery room.

Resumo Objetivo: Descrever opiniões dos pediatras que ensinam reanimação no Brasil a respeito de iniciar e limitar a reanimação em sala de parto de neonatos pré-termo extremos. Método: Estudo transversal com questionário eletrônico (dez/11-set/13) enviado aos instrutores do Programa de Reanimação Neonatal da Sociedade Brasileira de Pediatria com três casos clínicos hipotéticos: 1) decisão de iniciar ou não a reanimação; 2) limitação ou não dos cuidados intensivos após a reanimação em sala de parto; 3) limitação ou não da reanimação avançada em sala de parto. Para cada caso foi solicitada a indicação da conduta para cada idade gestacional entre 23-26 semanas. A análise foi descritiva por meio da frequência das respostas. Resultados: Consentiram em participar 560 (82%) instrutores. Apenas 9% afirmaram existir em seu hospital norma escrita sobre quando não iniciar a reanimação em sala de parto. Com 23 semanas, 50% dos instrutores fariam a reanimação em sala de parto e com 26 semanas 2% baseariam sua decisão no peso ao nascer e/ou na abertura da fenda palpebral. Dos entrevistados, 38% reavaliariam sua decisão e limitariam o cuidado na UTI a medidas de conforto para nascidos de 23 semanas reanimados na sala de parto. Quanto aos procedimentos de reanimação avançada, 45% e 4% com 23 e 26 semanas, respectivamente, não indicariam tais manobras. Conclusão: Observa-se dificuldade na opção de não reanimar neonatos com 23 semanas de gestação e, ao mesmo tempo, um pequeno percentual de pediatras não reanima, na sala de parto, neonatos cuja viabilidade não é questionada (26 semanas).

Opinions of paediatricians who teach neonatal resuscitation about resuscitation practices on extremely preterm infants in the delivery room.

OBJECTIVE: To describe the opinions of paediatricians who teach resuscitation in Brazil regarding resuscitation practices in the delivery room (DR) of preterm infants with gestational ages of 23-26 weeks. METHODS: Cross-sectional study with an internationally validated electronic questionnaire (December 2011-September 2013) sent to the instructors of the Neonatal Resuscitation Program of the Brazilian Society of Paediatrics on parental counselling practices, medical limits for resuscitation of extremely preterm infants and medical considerations for decision-making in this group of infants. The analysis was descriptive. RESULTS: Among 685 instructors, 560 (82%) agreed to participate. Only 5%-13% reported having opportunity for antenatal counselling parents: if called, 22% reported discussing with the family about the possibility not to resuscitate in the DR; 63% about the possibility of death in the DR and 89% about the possibility of death in the neonatal unit. If the parents did not agree with the advice of the paediatrician, 30%-50% of the respondents would follow the procedures they advised regardless of the opinion of the parents. The higher the gestational age, the lower is the percentage of paediatricians who believed that parents should participate in decision-making. Only 9% participants reported the existence of written guidelines at their hospital on initiation of resuscitation in the DR at limits of viability, but 80% paediatricians reported using some criteria for limiting resuscitation in the DR. CONCLUSION: The picture obtained in this study of Brazilian paediatricians indicates that resuscitation of extremely preterm infants is permeated by ambivalence and contradictions.

Opinions of Brazilian resuscitation instructors regarding resuscitation in the delivery room of extremely preterm newborns.

OBJECTIVE: To describe the opinions of pediatricians who teach resuscitation in Brazil on initiating and limiting the delivery room resuscitation of extremely preterm infants. METHOD: Cross-sectional study with electronic questionnaire (Dec/2011-Sep/2013) sent to pediatricians who are instructors of the Neonatal Resuscitation Program of the Brazilian Society of Pediatrics, containing three hypothetical clinical cases: (1) decision to start the delivery room resuscitation; (2) limitation of neonatal intensive care after delivery room resuscitation; (3) limitation of advanced resuscitation in the delivery room. For each case, it was requested that the instructor indicate the best management for each gestational age between 23 and 26 weeks. A descriptive analysis was performed. RESULTS: 560 (82%) instructors agreed to participate. Only 9% of the instructors reported the existence of written guidelines at their hospital regarding limitations of delivery room resuscitation. At 23 weeks, 50% of the instructors would initiate delivery room resuscitation procedures. At 26 weeks, 2% would decide based on birth weight and/or presence of fused eyelids. Among the participants, 38% would re-evaluate their delivery room decision and limit the care for 23-week neonates in the neonatal intensive care unit. As for advanced resuscitation, 45% and 4% of the respondents, at 23 and 26 weeks, respectively, would not apply chest compressions and/or medications. CONCLUSION: Difficulty can be observed regarding the decision to not resuscitate a preterm infant with 23 weeks of gestational age. At the same time, a small percentage of pediatricians would not resuscitate neonates of unquestionable viability at 26 weeks of gestational age in the delivery room.

Initiation of resuscitation in the delivery room for extremely preterm infants: a profile of neonatal resuscitation instructors.

OBJECTIVE: The goal of the present study was to examine the decisions of pediatricians who teach neonatal resuscitation in Brazil, particularly those who start resuscitation in the delivery room for newborns born at 23-26 gestational weeks. METHODS: The present study was a cross-sectional study that used electronic questionnaires (Dec/11-Sep/13) sent to instructors of the Neonatal Resuscitation Program of the Brazilian Society of Pediatrics. The primary outcome was the gestational age at which the respondent said that he/she would initiate positive pressure ventilation in the delivery room. Latent class analysis was used to identify the major profiles of these instructors, and logistic regression was used to identify variables associated with belonging to one of the derived classes. RESULTS: Of 685 instructors, 82% agreed to participate. Two latent classes were identified: 'pro-resuscitation' (instructors with a high probability of performing ventilation on infants born at 23-26 weeks) and 'pro-limitation' (instructors with a high probability of starting ventilation only for infants born at 25-26 weeks). In the multivariate model, compared with the 'pro-limitation' class, 'pro-resuscitation' pediatricians were more likely to be board-certified neonatologists and less likely to base their decision on the probability of the infant's death or on moral/religious considerations. CONCLUSION: The pediatricians in the most aggressive group were more likely to be specialists in neonatology and to use less subjective criteria to make delivery room decisions.

Initiation of resuscitation in the delivery room for extremely preterm infants: a profile of neonatal resuscitation instructors

OBJECTIVE: The goal of the present study was to examine the decisions of pediatricians who teach neonatal resuscitation in Brazil, particularly those who start resuscitation in the delivery room for newborns born at 23-26 gestational weeks. METHODS: The present study was a cross-sectional study that used electronic questionnaires (Dec/11-Sep/13) sent to instructors of the Neonatal Resuscitation Program of the Brazilian Society of Pediatrics. The primary outcome was the gestational age at which the respondent said that he/she would initiate positive pressure ventilation in the delivery room. Latent class analysis was used to identify the major profiles of these instructors, and logistic regression was used to identify variables associated with belonging to one of the derived classes. RESULTS: Of 685 instructors, 82% agreed to participate. Two latent classes were identified: ‘pro-resuscitation’ (instructors with a high probability of performing ventilation on infants born at 23-26 weeks) and ‘pro-limitation’ (instructors with a high probability of starting ventilation only for infants born at 25-26 weeks). In the multivariate model, compared with the ‘pro-limitation’ class, ‘pro-resuscitation’ pediatricians were more likely to be board-certified neonatologists and less likely to base their decision on the probability of the infant’s death or on moral/religious considerations. CONCLUSION: The pediatricians in the most aggressive group were more likely to be specialists in neonatology and to use less subjective criteria to make delivery room decisions.

Aspectos éticos do nascimento no limite de viabilidade / Ethical aspects of birth in the limit of viability

Apesar dos grandes avanços ocorridos, nos últimos anos, no cuidado intensivo neonatal, recém-nascidos pretermo com idade gestacional abaixo de 25 semanas ainda apresentam altos índices de mortalidade e morbidade, de tal forma que familiares e médicos enfrentam dificuldades para decidir a respeito da instituição e/ou continuação da reanimação desses bebês. Trata-se, portanto, de um problema ético/moral complexo com profundo impacto na vida dos recém-nascidos pretermo (RNPT) sobreviventes e dos seus familiares, além das implicações para o sistema de saúde e a sociedade. O presente trabalho pretende discutir alguns aspectos éticos que possam contribuir para o debate contemporâneo a respeito da decisão de reanimar ou não RNPT extremos.

Despite recent advances in neonatal intensive care, prematures born at less than 25 weeks gestation have high rates of morbidity and mortality. Parents and doctors face difficult decisions concerning instituting and/ or continuing resuscitation and intensive care of these babies. This is, therefore, a complex ethical/moral problem with a strong impact on the lives of the surviving prematures and their families, as well as for the health care system and society. This paper will discuss some ethical issues that may contribute to the contemporary debate about the decision to resuscitate or not extreme preterm infants.

Aspectos éticos do nascimento no limite de viabilidade / Ethical aspects of birth in the limit of viability

Apesar dos grandes avanços ocorridos, nos últimos anos, no cuidado intensivo neonatal, recém-nascidos pré-termos (RNPT) com idade gestacional abaixo de 25 semanas apresentam altos índices de morbimortalidade, de tal forma que familiares e médicosenfrentam dificuldades para decidir a respeito da instituição e/ou continuação da reanimação a ser estabelecida nesses casos. Trata-se, portanto, de problema ético-moral complexo com profundo impacto na vida dos RNPTs sobreviventes e dos seus familiares, além das implicações para o sistema de saúde e a sociedade. Este trabalho pretende discutir alguns aspectos éticos que possam contribuir para o debate a respeitode reanimar ou não RNPTs extremos.

Despite the great advances made in recent years in neonatal intensive care, preterm newborn infants (RNPT) with gestational age under 25 weeks present high rates of morbidity and mortality, therefore, families and doctors face difficult decisions about the institution and/or continued resuscitation to be established in these cases. It is, therefore, an ethicalmoral complex problem with deep impact on the lives of RNPT survivors and their families, in addition to the implications for the health system and society. This study discusses some ethical issues that may contribute to the debate about whether or not revive extreme RNPTs.