Evolving improvement in infant outcomes
In 1963, Jacqueline Bouvier Kennedy went into preterm labor at 34 weeks of gestation and delivered her son Patrick at a community facility. Due to severe respiratory distress syndrome, Patrick was transferred to the Boston Children’s Hospital, and he died shortly thereafter.6 Sixty years later, due to advances in obstetric and neonatal care, death from respiratory distress syndrome at 34 weeks of gestation is uncommon in the United States.
Infant outcomes following birth at 22 and 23 weeks’ gestation continue to improve. An observational cohort study from Sweden reported that at 22 weeks’ gestation, the percentage of live-born infants who survived to 1-year post birth in 2004 to 2007 and 2014 to 2016 was 10% and 30%, respectively.7 Similarly, at 23 weeks’ gestation, the percentage of live-born infants who survived to 1-year post birth in 2004 to 2007 and 2014 to 2016 was 52% and 61%, respectively.7 However, most of the surviving infants in this cohort had one or more major neonatal morbidities, including intraventricular hemorrhage grade 3 or 4; periventricular leukomalacia; necrotizing enterocolitis; retinopathy of prematurity grade 3, 4, or 5; or severe bronchopulmonary dysplasia.7
In a cohort of infants born in Japan at 22 to 24 weeks of gestation, there was a notable decrease in major neurodisability at 3 years of age for births occurring in 2 epochs, 2003 to 2007 and 2008 to 2012.8 When comparing outcomes in 2003 to 2007 versus 2008 to 2012, the change in rate of various major complications included the following: cerebral palsy (15.9% vs 9.5%), visual impairment (13.6% vs 4.4%), blindness (4.8% vs 1.3%), and hearing impairment (2.6% vs 1.0%). In contrast, the rate of cognitive impairment, defined as less than 70% of standard test performance for chronological age, was similar in the 2 time periods (36.5% and 37.9%, respectively).8 Based on data reported between 2000 and 2020, a systematic review and meta-analysis by Backes and colleagues concluded that there has been substantial improvement in the survival of infants born at 22 weeks of gestation.9
The small baby unit
A feature of modern medicine is the relentless evolution of new clinical subspecialties and sub-subspecialties. NICUs evolved from newborn nurseries to serve the needs of the most severely ill newborns, with care provided by a cadre of highly trained subspecialized neonatologists and neonatal nurses. A new era is dawning, with some NICUs developing a sub-subspecialized small baby unit to care for infants born between 22 and 26 weeks of gestation. These units often are staffed by clinicians with a specific interest in optimizing the care of extremely preterm infants, providing continuity of care over a long hospitalization.10 The benefits of a small baby unit may include:
- relentless standardization and adherence to the best intensive care practices
- daily use of checklists
- strict adherence to central line care
- timely extubation and transition to continuous positive airway pressure
- adherence to breastfeeding guidelines
- limiting the number of clinicians responsible for the patient
- promotion of kangaroo care
- avoidance of noxious stimuli.10,11
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