22 AAP News •
www.aapnews.org • September 2015
by James John Cummings, M.D., FAAP
The anticipated birth of
an extremely low gestational
age (less than 25 weeks) infant presents many difficult
questions, including whether to initiate resuscitation after delivery.
Some infants are born at such an immature stage of development that the risk of
death or severe long-term neurologic impairment is exceptionally high. Initiating
resuscitation and offering life support to
these newborn infants may be considered
futile or not in their best interests, but it can
be unclear how to translate these concerns
Approaches vary, driven in part by the
unclear outcomes of these infants, individual perspectives on those outcomes, difficulty
in communicating complex information to
parents at an extremely stressful time and
the emotional distress of the impending
This topic was addressed in two previous AAP
clinical reports. Since those reports, important con-
siderations in this area continue to evolve, including
improved outcomes, changing attitudes of parents
and providers, and new approaches that facilitate
communication with parents. These considerations
are included in a revised AAP clinical report, An-
tenatal Counseling Regarding Resuscitation and In-
tensive Care Before 25 Weeks of Gestation (Pediatrics.
Provide knowledge, support
The intent of this report is to highlight key
areas relevant to counseling in these situations, including: 1) the use and limitations
of gestational age in predicting outcomes,
2) the importance of other determinants of
outcome, and 3) factors that influence decision-making.
Because of the significant limitations of
using gestational age alone, this statement
emphasizes the need to individualize counseling. The report also discusses factors important in communicating with parents and
presents ways to assist them with difficult
Counseling should provide parents with
knowledge and support to help them make
decisions regarding delivery room care and
to help them manage what likely will be
a difficult aftermath. Effective counseling
includes three key components: assessment
of risks, communication of those risks and
ongoing support. Factors that may influence
family or provider decision-making, such as differences in attitudes regarding outcomes or a baby who
looks different than expected at delivery, need to be
carefully considered. Shared decision-making and
family-centered care are the goals.
Key points to consider
• Gestational age is an imprecise predictor of sur-
vival, but 22 weeks generally is recognized as the
lower threshold of viability.
• Most infants delivered between 22 and 24 weeks
of gestation will die or have significant long-
term morbidity; however, outcomes for any in-
dividual case are difficult to predict.
• Decision-making regarding the delivery room
management should be individualized and family-centered, taking into account known fetal
and maternal conditions and risk factors, as well
as parental beliefs regarding the best interest of
• Joint discussions between the parent(s) and both
the obstetric and neonatal care providers pro-
mote optimal decision-making.
• Recognizing and managing barriers to effective
communication facilitate discussion of antici-
pated outcomes and options.
• When a decision is made not to resuscitate a newborn infant, it is important to provide comfort
care, encourage the family to spend time with
the dying/deceased newborn infant, and offer
religious, psychosocial and/or palliative support.
Dr. Cummings, lead author of the
clinical report, is a member of the AAP
Committee on Fetus and Newborn.
Individualized counseling key in decision to resuscitate,
provide intensive care to infants born before 25 weeks
In making decisions about the birth of an extremely low gestational age
infant, parents should factor in considerations like the threshold of viability, long-term morbidity and parental beliefs. Religious, psychosocial
and palliative support should not be overlooked.