The Nuffield Council of Biothethics yesterday issued guidelines on the medical care of extremely premature babies in the UK. There have been calls for a review of the treatment offered to severely ill newborn babies due to the rising number born prematurely since the 1980s. Before then, very few babies survived if they were born before 28 weeks. Advances in medical technology mean that, over the past 20 years, those being born earlier are surviving. But many of those premature babies who do survive, especially those born before 24 weeks, are left with serious disabilities. Different countries have adopted different approaches to the issue.
UK
Under current law, doctors and parents can withdraw treatment if they feel it is in the best interests of the baby. But in recent years, there have been several high-profile cases where parents and doctors have disagreed over the appropriate treatment, which has led to court cases to resolve the dispute. St Mary's hospital in Portsmouth and the parents of Charlotte Wyatt, who was born three months prematurely in 2003, have fought several legal battles over her treatment after doctors said she should be allowed to die. Charlotte was born with serious lung and brain problems, but has confounded medical opinion by surviving past her third birthday.
The Nuffield council recommends that babies born before or at 22 weeks should not be routinely resuscitated or receive intensive care. Babies born between 22 and 23 weeks should not usually receive intensive care unless parents make a request and doctors agree. Babies born between 24 and 25 weeks should normally receive intensive care, unless the parents and the doctors agree that there is no hope of survival, or if the level of suffering outweighs the baby's interest in continuing to live. Intensive care should normally be given to babies born after 25 weeks, because they have a sufficiently high chance of surviving and low risk of developing severe disability. But other countries have very different policies.
The Netherlands
Babies born before 25 weeks are not given medical treatment in the Netherlands and, in certain conditions, euthanasia is permitted, according to the Nuffield Council report. Instead, babies born before 25 weeks of gestation are offered palliative care with their parents present and allowed to die in the delivery room, rather than being admitted to intensive care. Only if a baby seemed particularly healthy, or the parents were strongly in favour of resuscitation, might exceptions be made. Euthanasia of severely ill premature babies is illegal. But in certain cases it could be justified to actively end the life of a newborn baby due to the severity of its medical problems.
Two Dutch paediatricians have drawn up guidelines, known as the Groningen Protocol, which lists strict criteria that must be met before a baby can be euthanised. Firstly, the diagnosis and prognosis must be certain; the baby's suffering must be hopeless and unbearable, and confirmed by at least one independent doctor; both parents must give informed consent; and the procedure must conform to the accepted medical standard.
The Dutch Resuscitation Council also issued guidelines on the care of newborn babies this March. It recommends that babies born before 25 weeks of gestation or below 500g in weight should not usually be resuscitated. Doctors do have scope to resuscitate babies born after between 24 and 25 weeks, depending on their vitality. Treatment should only be given to babies born after between 25 and 26 weeks with the consent of their parents.
France
In France, doctors have traditionally been left to decide whether to withhold or withdraw life-sustaining treatment from severely ill premature babies. In the 1980s, the resuscitation of very premature babies was routine practice. Babies would then be re-evaluated and those deemed to have little chance of surviving would either have ventilation to help them breathe withdrawn, or be given an injection to deliberately end their life. But, according to the Nuffield report, a growing number of French neonatologists, the paediatricians who treat premature babies, now have reservations about this approach, and instead want common standards for practice put in place. The National Federation of Neonatologists recently established a review to examine the issue, though it is unlikely to publish guidelines in the near future.
New Jersey, USA
The Nuffield Council's report draws a stark contrast between the practice adopted in Holland and the approach taken in New Jersey, USA. Far more extremely premature babies received resuscitation and intensive care in New Jersey in the mid-1980s than in the Netherlands. One study showed that 95% of babies born at 23-26 weeks in an area of the US state received mechanical ventilation to breathe, compared to 64% in Holland. Double the proportion of babies survived to their second birthday in New Jersey than in the Netherlands, though the proportion with cerebral palsy was five times higher in the former than the latter.
