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A time for hope: guidelines for the perinatal management of extremely preterm birth
  1. Annie Janvier1,2,3,4,
  2. Keith J Barrington1,3,
  3. Antoine Payot1,2,3,4
  1. 1 Department of Pediatrics, University of Montreal, Montreal, Quebec, Canada
  2. 2 Bureau de l’Éthique Clinique, University of Montreal, Montreal, Quebec, Canada
  3. 3 Division of Neonatology, CHU Sainte-Justine, Montreal, Quebec, Canada
  4. 4 Clinical Ethics Unit, Bureau du Partenariat Patients-Familles-Soignants, Unité de recherche en éthique clinique et partenariat famille, CHU Sainte-Justine, Montreal, Quebec, Canada
  1. Correspondence to Dr Annie Janvier, Pediatrics and Clinical Ethics, University of Montreal, montreal, Canada; anniejanvier{at}

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With improvements in perinatal care, even the most immature babies can now survive, the majority of survivors having good long-term outcomes. At the very limits of what modern perinatal care is able to achieve, for the smallest babies, there are ongoing debates and passionate disagreements about institution of intensive care. To help clinicians make decisions about life-sustaining interventions, many national academic societies have developed policy statements. Guidelines usually describe a risk-based approach for interventions in the ‘peri-viable’ period by dividing preterm infants into three categories: ‘beneficial’, where intervention is generally recommended, ‘grey zone’ where interventions follow the decision of parents and ‘futile’, where comfort care is recommended.1 Unfortunately, many policies divide infants into these categories using gestational age (GA) alone: based on imprecise estimates of completed 7-day periods of gestation. However, prognosis depends on many variables, and several academic societies now propose also using other factors to make important decisions.

The new framework from the British Association of Perinatal Medicine (BAPM) takes a welcome, and slightly different approach, describing a process for arriving at decisions, rather than offering rigid recommendations. The previous BAPM framework was more directive, strongly suggesting comfort care at 23 weeks gestation, up until 23 weeks and 6 days, but active intensive care for most infants born at 24 weeks1. During the same period, the French policy statement had similar GA cut-offs to make life-and-death decisions,1 but in the French statement babies born at …

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  • Funding The authors have not declared a specific grant for this research from any funding agency in the public, commercial or not-for-profit sectors.

  • Competing interests None declared.

  • Patient consent for publication Not required.

  • Provenance and peer review Commissioned; internally peer reviewed.

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