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Re: Attention: The extremely preterm births...

Respected Dr. Pignotti

I am very pleased to read your article “The extremely preterm births. Recommendations for treatment in European countries”. This is particularly very useful in making reasonably correct decision while managing and treating extremely preterm infants. I myself was born at home as a preterm and very low birth weight some 48 years ago [seven months gestation, birth weight 1250 gram (converted from traditional unit, bisouli, to metric unit, gram) as informed by my 85 years old mother] in Sotang, Solukhumbu district (Mount Everest region), Nepal, and interested on the paper that you have kindly presented in ADC. Thank you very much, and Thanks to the Internet!

I would like to express following opinion/comments on it:

(1) It would have been further beneficial to readers/users if you have included extremely preterm births born after in vitro fertilization, including references, if appropriate/possible; (2) Ethical recommendations for treatment/continuation of life of human may be based on parenteral consent/raising, healers’ recommendations, and institutional guidance. But also, philosophical ground should not be forgotten since we still don’t know what ‘instinct’ or ‘particular gene’ drives a baby to mature into a physically, mentally, socially and spiritually healthy adult!

References 1. http://www.durgabhawani.com (Dr. N. B. Basnet) 2. Basnet NB, Noma S, Basnet SB, Igarashi T. Neonatal intensive care unit hospitalization of very low birth weight Japanese infants with congenital heart disease. J Nep Med Assoc 2004;43:28-30.[Available in Popline].

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Re: THE EXTREMELY PRETERM BIRTHS IN FLORENCE

Sir,

I read the article by Pignotti 1 on the recommendations for the treatment of extremely premature infants in European countries. In her article, Pignotti affirms that guidelines for the palliative care of newborns of extremely low gestational age are suggested in official documents. In her table on neonatal care she claims that in Florence palliative care is used in the delivery room for infants born between 22- 24 weeks of gestational age. However, the reported data are inexacts. In fact, in Italy, in March 2008, the recommendations for the treatment of extremely premature infants were approved by “Consiglio Superiore di Sanità del Ministero della Salute” (National Council of Health)2 . This official document enforces assistance to premature infants of every gestational age in the delivery room. As a staff neonatologist working in Florence, at the Careggi University Hospital, which is the largest Maternity ward in Tuscany, I would like to provide further information on our current rules. Delivery of premature neonates of gestational age lower than 29 weeks in Tuscany is allowed only in our hospital as well as at Siena and Pisa University Hospitals. Thus, in the Florence area all very preterm neonates are cared for only at Careggi University Hospital. We alone are therefore responsible for the type of assistance offered at the birth for infants born between 22-24 weeks of gestation. Conventional assistance and not palliative care is administered to preterm infants of gestational age less than 24 weeks (Table 1): this approach has been documented also by the study of Dani C., Bertini G. at al. on the fate of ductus arteriosus in infants at 23-27 weeks of gestation3. In addition, in the time period January 2004 to October 2007, in our Maternity ward 19 preterm infants were born with gestational age less than 24 weeks (Table 1). Of these, 10 survived (52.6%) and the follow-up for 9 of these infants shows normal neurological development for corrected age. Finally, the use of term “cardiopulmonary resuscitation” is misleading. Very preterm infants are actually very rarely resuscitated. Rather they are assisted without the use of cardio-vascular drugs (adrenaline) or cardiac massage. More often they are cared with the use of nasal continuous airways positive pressure (n-CPAP), followed by INSURE (intubation, surfactant, extubation ) treatment. Our results are very positive as shown in infants born at 23 week of gestation and now followed until the age of 3-4 years (Table 1).

REFERENCES

1. Pignotti MS. The extremely preterm birth. Recommendations for treatment in European countries. Arch Dis Child Fetal Neonatal Ed 2008; doi: 10.1136/adc.2008.140871

2. Ministero della Salute. Consiglio Superiore di Sanità. Sessione XLVI. Seduta del 4 Marzo 2008. Assemblea Generale. Raccomandazioni per le Cure Perinatali nelle Età Gestazionali Estremamente Basse