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November 27, 1996, Vol 276, No. 20 >
ARTICLE | November 27, 1996

Viability, Morbidity, and Resource Use Among Newborns of 501-to 800-g Birth Weight FREE

Jon E. Tyson, MD, MPH; Naji Younes, PhD; Joel Verter, PhD; Linda L. Wright, MD
[+] Author Affiliations

A complete list of the members of the National Institute of Child Health and Human Development Neonatal Research Network appears at the end of this article.

Reprints: Jon E. Tyson, MD, MPH, University of Texas Southwestern Medical Center, 5323 Harry Hines Blvd, Dallas, TX 75235.


JAMA. 1996;276(20):1645-1651. doi:10.1001/jama.1996.03540200031027
Text Size: A A A
Published online
Article
References

Objectives.  —To assess risk factors affecting viability and analyze the effects of mechanical ventilation (MV) on neonatal outcome and resource use among extremely premature infants.

Design.  —Inception cohort study.

Setting.  —Neonatal intensive care units of the 12-center National Institute of Child Health and Human Development Neonatal Research Network.

Participants.  —A total of 1126 infants with a birth weight of 501 to 800 g born in network centers between January 1, 1994, and December 31, 1995.

Main Outcome Measures.  —Observed survival; maximum estimated survival (assuming the same survival among infants who died without MV as among infants in the same risk category who received MV); observed and maximum estimated survival without severe brain injury (either interventricular echodensity with ventricular dilation or parenchymal echodensity); hospital stay; resource investment.

Results.  —Overall mortality was 43%; mortality in infants without MV was 93%. A total of 15% of all the infants died without MV. Females, small-for-gestational-age infants, and infants whose mothers received antenatal steroids had an advantage in survival with MV equivalent to an increase in birth weight of 90 g, 57 g, and 67 g, respectively. The corresponding advantage of these infants in survival without severe brain injury was 107 g, 97 g, and 64 g, respectively. Females in the lowest birth-weight group were more likely to die without MV than were larger males with a similar estimated likelihood of survival with MV. Mean hospital stay was 115 days for the survivors, values much greater than the 17.9-day standard for 501- to 800-g survivors under the diagnosis related group system. Resource investment was considerable (127 hospital days per survivor and 148 days per survivor without severe brain injury), but, like outcome, varied markedly between risk categories. Had MV been used for all infants who died, we estimate a substantial increase in resource use and a maximum of 8 additional survivors (no more than 6 without severe brain injury per 100 infants with a birth weight of 501 to 800 g.

Conclusions.  —Although recommendations to initiate or forgo MV for extremely premature infants have often focused on 1 factor (birth weight or gestational age), multiple factors should be considered. Other factors being equal, our analyses support use of MV for females at a minimum birth weight approximately 100 g lower than that for males. The current diagnosis related group reimbursement system can be expected to compromise resources for 501- to 800-g infants who would benefit from MV. Such care entails considerable resource use, although the cost per lifeyear gained is likely to be considerably less than that for many adults given intensive care. Our findings can be used to facilitate more appropriate treatment decisions, determine adequate resources, and better inform the debate about the benefits and burdens of intensive care for extremely premature newborns.

REFERENCES

1 +
Avery G.  Ethical dilemmas in the treatment of the extremely low birth weight infant . Clin Perinatol . 1987;;14:361-365.
2 +
Buchanan N.  Conference report: the very-lowbirthweight infant: medical, ethical, and economic considerations . Med J Aust . 1987;;184-186.
3 +
Hack M, Fanaroff A.  Outcomes of extremely immature infants: a perinatal dilemma . N Engl J Med . 1993;;329:1649-1650.
4 +
Tyson J.  Evidence-based ethics and the care of extremely premature infants . Future Child . (Spring) 1995;;5:197-213.
5 +
Doyle LW, Murton LJ, Kitchen WH.  Mortality with increasing assisted ventilation of very-low-birthweight infants . Am J Dis Child . 1989;;143:223-227.
6 +
American Academy of Pediatrics and American College of Obstetricians and Gynecologists. Guidelines for Perinatal Care . 3rd ed. Elk Grove Village, Ill: American Academy of Pediatrics; 1992;.
7 +
Committee on the Fetus and Newborn, American Academy of Pediatrics. Standards and Recommendations for Hospital Care of Newborn Infants . Evanston, Ill: American Academy of Pediatrics; 1971;.
8 +
Fanaroff AA, Wright LL, Stevenson DK, et al.  Very low birth weight outcomes of the NICHD Neonatal Research Network, May 1991 to December 1992 . Am J Obstet Gynecol . 1995;;173:269-274.
9 +
Arbuckle T, Sherman G.  An analysis of birth weight by gestational age in Canada . Can Med Assoc J . 1989;;15:157-165.
10 +
Ballard JL, Novak KK, Driver M.  A simplified assessment of fetal maturation of newly born infants . J Pediatr . 1979;;95:769-774.
11 +
Constantine NA, Kraemer HC, Kendall-Tackett KA, Bennett FC, Tyson JE, Gross RT.  Use of physical and neurologic observations in assessment of gestational age in low-birth-weight infants . Pediatrics . 1987;;110:921-928.
12 +
Hack MB, Horbar JD, Malloy MH, et al.  Very low birth weight outcomes of the NICHD Neonatal Network . Pediatrics . 1991;;87:587-596.
13 +
Donovan EF, Ehrenkranz RA, Tyson JE, et al.  Inaccuracy at Ballard scores in estimating gestational age of 24-27 week infants of women with known menstrual history . Pediatr Res . 1996;;39:206A.
14 +
Sackett DL, Haynes BB, Guyatt G, Tugwell P. Clinical Epidemiology: A Basic Science for Clinical Medicine . 2nd ed. Boston, Mass: Little Brown & Co Inc; 1991;:117-119.
15 +
Boyle MH, Torrance GW, Sinclair JC, Horwood SP.  Economic evaluation of neonatal intensive care of very-low-birthweight infants . N Engl J Med . 1983;;308:1330-1337.
16 +
Papile L, Burstein J, Burstein R, Koffler H.  Incidence and evolution of subependymal and intraventricular hemorrhage: a study of infants with birth weights less than 1500 g . J Pediatr . 1978;;92:529-534.
17 +
Anand KJS, Hickey PR.  Pain and its effects on the human neonate and fetus . N Engl J Med . 1987;;317:1321-1329.
18 +
Quinn MW, Wild J, Dean HG, et al.  Randomized double-blind controlled trial of the effect of morphine on catecholamine concentrations in ventilated preterm infants . Lancet . 1993;;342:324-327.
19 +
Harrison H.  The principles of family-centered neonatal care . Pediatrics . 1993;;92:643-650.
20 +
Bregman J, Farrell EE.  Neurodevelopmental outcome in infants with bronchopulmonary dysplasia . Clin Perinatol . 1992;;19:673-694.
21 +
Jones R, Wincott E, Elbourne D, et al.  Controlled trial of dexamethasone in neonatal chronic lung disease . Pediatrics . 1995;;96:897-906.
22 +
Simon NP.  Follow-up of infants with necrotizing enterocolitis . Clin Perinatol . 1994;;21:411-424.
23 +
Volpe J. Neurology of the Newborn . 3rd ed. Philadelphia, Pa: WB Saunders Co; 1995;:427-428.
24 +
Hanley JA, McNeil B.  The meaning and use of the area under a receiver operating curve . Diagn Radiol . 1982;;149:29-36.
25 +
Richardson DK, Phibbs CS, Gray JE, et al.  Birth weight and illness severity . Pediatrics . 1993;;91:969-975.
26 +
Tarnow-Mordi W, Ogston S, Wilkinson AR, et al.  Predicting death from initial disease severity in very low birth weight infant . BMJ . 1990;;300:1611-1614.
27 +
Horbar JD, Onstad L, Wright E, et al.  Predicting mortality risk for infants weighing 501-1500 g at birth: a National Institutes for Health Neonatal Research Network Report . Crit Care Med . 1993;;21:12-18.
28 +
Poland RL, Bollinger RO, Bedard MP, Cohen SF.  Analysis of the effects of applying federal diagnosis-related groupings guidelines to a population of high-risk newborn infants . Pediatrics . 1995;;76:104-109.
29 +
Berki SE, Schneier NB.  Frequency and cost of diagnosis-related group outliers . Pediatrics . 1987;;79:874-881.
30 +
Lichtig LK, Knauf RA, Bartoletti A, et al.  Revising diagnosis-related groups for neonates . Pediatrics . 1989;;84:49-61.
31 +
Schwartz RM, Michelman T, Pezzullo J, Phibbs C.  Explaining resource consumption among nonnormal neonates . Health Care Financing Rev . 1991;;13:19-28.
32 +
 Medicare program: changes to the in-patient prospective payment system in fiscal year 1992 rates: final rule (CFR 412, 413) . Federal Register . August 30, 1991;;56( (169) ):43292.
33 +
Phibbs CS, Phibbs RH, Pomerance JJ, Williams RL.  Alternative to diagnosis-related groups for newborn intensive care . Pediatrics . 1986;;78:829-836.
34 +
Immershein AW, Turner C, Wells JG, Pearman A.  Covering the costs of care in neonatal intensive care units . Pediatrics . 1992;;89:56-61.
35 +
Tyson J, Perlman J, Rosenfeld C, Arencibia-Mireles O.  Resource limitations: a major ethical issue in the care of indigent infants <1500 g birth weight? Pediatr Res . 1992;;31:26A. Abstract.
36 +
Baquet D, Fritsch J.  New York's public hospitals fail, and babies are the victims . New York Times . (March 5) , 1995;:1.
37 +
Cohen IL, Lambrinos J, Fein A.  Mechanical ventilation for the elderly patient in intensive care . JAMA . 1993;;268:1025-1029.
38 +
Schapira DV, Studnicki J, Bradham DD, Wolff P, Jarrett A.  Intensive care, survival, and expense of treating critically ill cancer patients . JAMA . 1992;;268:783-786.
39 +
Horbar JD, Lucey JF.  Evaluation of neonatal intensive care technologies . Future Child . 1995;;5:139-161.
40 +
Milner RDG, Richards B.  An analysis of birth weight by gestational age of infants born in England and Wales, 1967 to 1971 . J Obstet Gynaecol Br Commonwealth . 1974;;81:956-967.
41 +
Kramer MS, McClearn FH, Boyd ME, Usher RH.  The validity of gestational age estimation by menstrual dating in term, preterm, and postterm gestations . JAMA . 1988;;230:3306-3308.
42 +
Ballard JL, Khoury JC, Wedig K, et al.  New Ballard score, expanded to include extremely premature infants . J Pediatr . 1991;;119:417-423.
43 +
Allen MC, Donohue PK, Dusman AE.  The limit of viability: neonatal outcome of infants born at 22 to 25 weeks' gestation . N Engl J Med . 1993;;329:1597-1601.
44 +
Fetus and Newborn Committee, Canadian Paediatric Society; Maternal-Fetal Medicine Committee, Society of Obstetricians and Gynaecologists of Canada.  Management of the woman with threatened birth of extremely low gestational age . Can Med Assoc J . 1994;;151:547-553.
45 +
Committee on Fetus and Newborn, American Academy of Pediatrics; Committee on Obstetric Practice, American College of Obstetricians and Gynecologists.  Perinatal care at the threshold of viability . Pediatrics . 1995;;5:974-976.
46 +
Saigal S, Feeny D, Furlong W, et al.  Comparison of the health-related quality of life of extremely low birth weight children and a reference group of children at eight years . Pediatrics . 1994;;125:418-425.
47 +
Saigal S, Feeny D, Rosenbaum P, et al.  Selfperceived health status and health-related quality of life of extremely low-birth-weight teenagers: comparison with term peers . JAMA . 1996;;276:453-459.
48 +
Hack M, Taylor G, Klein N, et al.  School-age outcomes in children with birth weights under 750 g . N Engl J Med . 1994;;331:753-759.
49 +
Torrance GW, Boyle GW, Harwood SP.  Application of multi-attribute utility theory to measure social preferences for health states . Operations Res . 1982;;30:1043-1069.
50 +
Ruark JE, Raffin TA, Stanford University Medical Center Committee on Ethics.  Initiating and withdrawing life support: principles and practice in adult medicine . N Engl J Med . 1988;;381:25-30.
51 +
Young EWD, Stevenson DK.  Limiting treatment for extremely premature low-birth-weight infants (500-750 g) . Am J Dis Child . 1990;;144:549-552.
52 +
Arras JD.  Quality of life in neonatal ethics: beyond denial and evasion . In: Weil WM, Benjamin M, eds. Contemporary Issues in Fetal and Neonatal Medicine 3: Ethical Issues at the Outset of Life . Cambridge, Mass: Blackwell Publishers; 1987;:151-186.
53 +
Strong C.  The principle, 'Patients come first' and its implications for parent participation in decisions . In: Weil WB, Benjamin M, eds. Contemporary Issues in Fetal and Neonatal Medicine 3: Ethical Issues at the Outset of Life . Cambridge, Mass: Blackwell Publishers; 1987;:187-212.
54 +
Kraybill E.  Parental autonomy in situations of moral ambiguity . J Pediatr . 1988;;113:327.
55 +
Committee on Bioethics.  Ethics and the care of critically ill infants and children . Pediatrics . 1996;;98:149-152.
56 +
Malcontent.  Fumes from the spleen . Paediatr Perinat Epidemiol . 1995;;9:370-373.
57 +
Sinclair JC, Fowlie PW.  Reply to Malcontent . Paediatr Perinat Epidemiol . 1995;;9:373-375.
58 +
Watts J, Saigal S.  Reply to Malcontent . Paediatr Perinat Epidemiol . 1995;;9:375-378.

Figures

Tables

Interactive Graphics

Video

Country-Specific Mortality and Growth Failure in Infancy and Yound Children and Association With Material Stature

Use interactive graphics and maps to view and sort country-specific infant and early dhildhood mortality and growth failure data and their association with maternal

1 +
Avery G.  Ethical dilemmas in the treatment of the extremely low birth weight infant . Clin Perinatol . 1987;;14:361-365.
2 +
Buchanan N.  Conference report: the very-lowbirthweight infant: medical, ethical, and economic considerations . Med J Aust . 1987;;184-186.
3 +
Hack M, Fanaroff A.  Outcomes of extremely immature infants: a perinatal dilemma . N Engl J Med . 1993;;329:1649-1650.
4 +
Tyson J.  Evidence-based ethics and the care of extremely premature infants . Future Child . (Spring) 1995;;5:197-213.
5 +
Doyle LW, Murton LJ, Kitchen WH.  Mortality with increasing assisted ventilation of very-low-birthweight infants . Am J Dis Child . 1989;;143:223-227.
6 +
American Academy of Pediatrics and American College of Obstetricians and Gynecologists. Guidelines for Perinatal Care . 3rd ed. Elk Grove Village, Ill: American Academy of Pediatrics; 1992;.
7 +
Committee on the Fetus and Newborn, American Academy of Pediatrics. Standards and Recommendations for Hospital Care of Newborn Infants . Evanston, Ill: American Academy of Pediatrics; 1971;.
8 +
Fanaroff AA, Wright LL, Stevenson DK, et al.  Very low birth weight outcomes of the NICHD Neonatal Research Network, May 1991 to December 1992 . Am J Obstet Gynecol . 1995;;173:269-274.
9 +
Arbuckle T, Sherman G.  An analysis of birth weight by gestational age in Canada . Can Med Assoc J . 1989;;15:157-165.
10 +
Ballard JL, Novak KK, Driver M.  A simplified assessment of fetal maturation of newly born infants . J Pediatr . 1979;;95:769-774.
11 +
Constantine NA, Kraemer HC, Kendall-Tackett KA, Bennett FC, Tyson JE, Gross RT.  Use of physical and neurologic observations in assessment of gestational age in low-birth-weight infants . Pediatrics . 1987;;110:921-928.
12 +
Hack MB, Horbar JD, Malloy MH, et al.  Very low birth weight outcomes of the NICHD Neonatal Network . Pediatrics . 1991;;87:587-596.
13 +
Donovan EF, Ehrenkranz RA, Tyson JE, et al.  Inaccuracy at Ballard scores in estimating gestational age of 24-27 week infants of women with known menstrual history . Pediatr Res . 1996;;39:206A.
14 +
Sackett DL, Haynes BB, Guyatt G, Tugwell P. Clinical Epidemiology: A Basic Science for Clinical Medicine . 2nd ed. Boston, Mass: Little Brown & Co Inc; 1991;:117-119.
15 +
Boyle MH, Torrance GW, Sinclair JC, Horwood SP.  Economic evaluation of neonatal intensive care of very-low-birthweight infants . N Engl J Med . 1983;;308:1330-1337.
16 +
Papile L, Burstein J, Burstein R, Koffler H.  Incidence and evolution of subependymal and intraventricular hemorrhage: a study of infants with birth weights less than 1500 g . J Pediatr . 1978;;92:529-534.
17 +
Anand KJS, Hickey PR.  Pain and its effects on the human neonate and fetus . N Engl J Med . 1987;;317:1321-1329.
18 +
Quinn MW, Wild J, Dean HG, et al.  Randomized double-blind controlled trial of the effect of morphine on catecholamine concentrations in ventilated preterm infants . Lancet . 1993;;342:324-327.
19 +
Harrison H.  The principles of family-centered neonatal care . Pediatrics . 1993;;92:643-650.
20 +
Bregman J, Farrell EE.  Neurodevelopmental outcome in infants with bronchopulmonary dysplasia . Clin Perinatol . 1992;;19:673-694.
21 +
Jones R, Wincott E, Elbourne D, et al.  Controlled trial of dexamethasone in neonatal chronic lung disease . Pediatrics . 1995;;96:897-906.
22 +
Simon NP.  Follow-up of infants with necrotizing enterocolitis . Clin Perinatol . 1994;;21:411-424.
23 +
Volpe J. Neurology of the Newborn . 3rd ed. Philadelphia, Pa: WB Saunders Co; 1995;:427-428.
24 +
Hanley JA, McNeil B.  The meaning and use of the area under a receiver operating curve . Diagn Radiol . 1982;;149:29-36.
25 +
Richardson DK, Phibbs CS, Gray JE, et al.  Birth weight and illness severity . Pediatrics . 1993;;91:969-975.
26 +
Tarnow-Mordi W, Ogston S, Wilkinson AR, et al.  Predicting death from initial disease severity in very low birth weight infant . BMJ . 1990;;300:1611-1614.
27 +
Horbar JD, Onstad L, Wright E, et al.  Predicting mortality risk for infants weighing 501-1500 g at birth: a National Institutes for Health Neonatal Research Network Report . Crit Care Med . 1993;;21:12-18.
28 +
Poland RL, Bollinger RO, Bedard MP, Cohen SF.  Analysis of the effects of applying federal diagnosis-related groupings guidelines to a population of high-risk newborn infants . Pediatrics . 1995;;76:104-109.
29 +
Berki SE, Schneier NB.  Frequency and cost of diagnosis-related group outliers . Pediatrics . 1987;;79:874-881.
30 +
Lichtig LK, Knauf RA, Bartoletti A, et al.  Revising diagnosis-related groups for neonates . Pediatrics . 1989;;84:49-61.
31 +
Schwartz RM, Michelman T, Pezzullo J, Phibbs C.  Explaining resource consumption among nonnormal neonates . Health Care Financing Rev . 1991;;13:19-28.
32 +
 Medicare program: changes to the in-patient prospective payment system in fiscal year 1992 rates: final rule (CFR 412, 413) . Federal Register . August 30, 1991;;56( (169) ):43292.
33 +
Phibbs CS, Phibbs RH, Pomerance JJ, Williams RL.  Alternative to diagnosis-related groups for newborn intensive care . Pediatrics . 1986;;78:829-836.
34 +
Immershein AW, Turner C, Wells JG, Pearman A.  Covering the costs of care in neonatal intensive care units . Pediatrics . 1992;;89:56-61.
35 +
Tyson J, Perlman J, Rosenfeld C, Arencibia-Mireles O.  Resource limitations: a major ethical issue in the care of indigent infants <1500 g birth weight? Pediatr Res . 1992;;31:26A. Abstract.
36 +
Baquet D, Fritsch J.  New York's public hospitals fail, and babies are the victims . New York Times . (March 5) , 1995;:1.
37 +
Cohen IL, Lambrinos J, Fein A.  Mechanical ventilation for the elderly patient in intensive care . JAMA . 1993;;268:1025-1029.
38 +
Schapira DV, Studnicki J, Bradham DD, Wolff P, Jarrett A.  Intensive care, survival, and expense of treating critically ill cancer patients . JAMA . 1992;;268:783-786.
39 +
Horbar JD, Lucey JF.  Evaluation of neonatal intensive care technologies . Future Child . 1995;;5:139-161.
40 +
Milner RDG, Richards B.  An analysis of birth weight by gestational age of infants born in England and Wales, 1967 to 1971 . J Obstet Gynaecol Br Commonwealth . 1974;;81:956-967.
41 +
Kramer MS, McClearn FH, Boyd ME, Usher RH.  The validity of gestational age estimation by menstrual dating in term, preterm, and postterm gestations . JAMA . 1988;;230:3306-3308.
42 +
Ballard JL, Khoury JC, Wedig K, et al.  New Ballard score, expanded to include extremely premature infants . J Pediatr . 1991;;119:417-423.
43 +
Allen MC, Donohue PK, Dusman AE.  The limit of viability: neonatal outcome of infants born at 22 to 25 weeks' gestation . N Engl J Med . 1993;;329:1597-1601.
44 +
Fetus and Newborn Committee, Canadian Paediatric Society; Maternal-Fetal Medicine Committee, Society of Obstetricians and Gynaecologists of Canada.  Management of the woman with threatened birth of extremely low gestational age . Can Med Assoc J . 1994;;151:547-553.
45 +
Committee on Fetus and Newborn, American Academy of Pediatrics; Committee on Obstetric Practice, American College of Obstetricians and Gynecologists.  Perinatal care at the threshold of viability . Pediatrics . 1995;;5:974-976.
46 +
Saigal S, Feeny D, Furlong W, et al.  Comparison of the health-related quality of life of extremely low birth weight children and a reference group of children at eight years . Pediatrics . 1994;;125:418-425.
47 +
Saigal S, Feeny D, Rosenbaum P, et al.  Selfperceived health status and health-related quality of life of extremely low-birth-weight teenagers: comparison with term peers . JAMA . 1996;;276:453-459.
48 +
Hack M, Taylor G, Klein N, et al.  School-age outcomes in children with birth weights under 750 g . N Engl J Med . 1994;;331:753-759.
49 +
Torrance GW, Boyle GW, Harwood SP.  Application of multi-attribute utility theory to measure social preferences for health states . Operations Res . 1982;;30:1043-1069.
50 +
Ruark JE, Raffin TA, Stanford University Medical Center Committee on Ethics.  Initiating and withdrawing life support: principles and practice in adult medicine . N Engl J Med . 1988;;381:25-30.
51 +
Young EWD, Stevenson DK.  Limiting treatment for extremely premature low-birth-weight infants (500-750 g) . Am J Dis Child . 1990;;144:549-552.
52 +
Arras JD.  Quality of life in neonatal ethics: beyond denial and evasion . In: Weil WM, Benjamin M, eds. Contemporary Issues in Fetal and Neonatal Medicine 3: Ethical Issues at the Outset of Life . Cambridge, Mass: Blackwell Publishers; 1987;:151-186.
53 +
Strong C.  The principle, 'Patients come first' and its implications for parent participation in decisions . In: Weil WB, Benjamin M, eds. Contemporary Issues in Fetal and Neonatal Medicine 3: Ethical Issues at the Outset of Life . Cambridge, Mass: Blackwell Publishers; 1987;:187-212.
54 +
Kraybill E.  Parental autonomy in situations of moral ambiguity . J Pediatr . 1988;;113:327.
55 +
Committee on Bioethics.  Ethics and the care of critically ill infants and children . Pediatrics . 1996;;98:149-152.
56 +
Malcontent.  Fumes from the spleen . Paediatr Perinat Epidemiol . 1995;;9:370-373.
57 +
Sinclair JC, Fowlie PW.  Reply to Malcontent . Paediatr Perinat Epidemiol . 1995;;9:373-375.
58 +
Watts J, Saigal S.  Reply to Malcontent . Paediatr Perinat Epidemiol . 1995;;9:375-378.

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