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Dutch doctors change policy on treating preterm babies

BMJ 2001; 322 doi: https://doi.org/10.1136/bmj.322.7299.1383 (Published 09 June 2001) Cite this as: BMJ 2001;322:1383
  1. Tony Sheldon
  1. Utrecht

    The leading centre for the treatment of premature births in the Netherlands has decided in principle to stop the active intensive treatment of babies born before 25 weeks' gestation because of research showing poor prognosis.

    Neonatologists at the University Medical Centre in Leiden argue that many babies born before 25 weeks do not survive and those who do are likely to develop serious problems in later life. Elsewhere in the Netherlands, treatment is not offered until 26 weeks, though in neighbouring countries and in the United States there are limits of 23 or even 22 weeks.

    The head of neonatology at the Leiden centre, Dr Frans Walther, explained that the hospital had decided to increase the limit from 24 to 25 weeks because its own study of premature births from 1996 and 1997 showed that 66% of those born at 23 and 24 weeks died. Of those who survived, half had severe physical or mental handicaps by the age of 2 years. By contrast, at 25 weeks, 40% survived and with fewer handicaps.

    Dr Walther emphasised that decisions to “forgo, initiate, or withdraw” medical care remained “controversial and emotionally charged” and should be taken with “full participation of the parents.” Infants born before 25 weeks would still be given “vigorous support” if the parents wished and the medical team considered the infant viable at birth.

    The decision to raise the limit has emerged as a long term joint study by the Leiden centre and TNO-PG (a Dutch research and consultancy body on health) was published this week in a major Dutch medical journal. The project on preterm infants and infants who were small for gestational age collected data from 1983 until 1997 on 1338 infants born at 32 weeks or earlier or with a birth weight of 1500 g or less (Nederlands Tijdschrift Voor Geneeskunde 2001;145:989-97).

    The 14 year study showed that 30% of infants died within two years and 10% had severe disability or handicap. Although the rest had no severe disability at school age, half of them had serious difficulties in everyday life. “The burden of these mild developmental abnormalities and behavioural and learning disorders increases with age,” the report concluded.

    The chairman of the ethical committee of the Dutch Association of Paediatric Medicine, Dr Louis Kollée, said that the centre had taken a “wise decision,” which was generally accepted by the profession. He emphasised that 25 weeks was not a “sharp cut-off point” but a guideline in principle not to offer active intensive treatment immediately after delivery. Each case was still considered on its merits.

    The policy of the Royal College of Paediatrics and Child Health in the United Kingdom is that each individual case has to be decided on its merits. In a practice framework on withdrawing and withholding treatment, which it published in 1997, it set out situations in which it would be appropriate for medical staff to discuss with families the option of discontinuing life-sustaining treatment when its effects were likely to be futile or even cruel.

    College spokesman Dr Harvey Marcovitch said: “To deny treatment on the basis of a low intact survival rate would be as illogical as a blanket ban on treating certain poor prognosis malignant disorders.”


    Embedded Image

    Embedded Image

    This pair of silver umbilical cord tweezers, thought to date from the 18th century, was due to be auctioned at Christie's, London, on Thursday, in a sale of medical instruments and models. The tweezers are in the form of the beak of a pelican, the body of which opens to reveal a baby in swaddling clothes in the exposed recess. The bird is standing on a pierced floral decoration, and one of the finger loops is supported on the back of a tortoise to enable the tweezers to stand upright on a flat surface.

    (Credit: CHRISTIE, MANSON & WOODS LTD)

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