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Extremely preterm births: recommendations for treatment in European countries
  1. Maria S Pignotti
  1. Neonatal Intensive Care Unit, A Meyer Children Hospital, University of Florence, Florence, Italy
  1. Dr M S Pignotti, Neonatal Intensive Care Unit, University of Florence, Viale Pieraccini 24, 50100 Firenze, Italy; m.pignotti{at}

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With the advances in medical technology, the outcome for high-risk infants has greatly improved, and the limit of human viability has shifted towards an increasingly lower gestational age. However, hand in hand with the positive outcome of saving neonates, modern neonatal intensive care has also brought to light several issues of an ethical nature in the care of these infants, especially those considered to be affected by incurable diseases or severely injured during pregnancy, delivery or the early neonatal period, those affected by major and/or multiple congenital abnormalities, and those at the borderline of viability (25 or fewer completed weeks of gestation). The survival rate of extremely preterm infants improved in the early 1990s, largely as a result of greater use of surfactant therapy and antenatal corticosteroids. However, this improvement in survival may not have been associated with a proportionate decrease in morbidity.110 Chronic lung disease, sepsis and poor growth are still common, the neurodevelopmental outcome and cognitive function may be suboptimal, and the effects in adulthood are a concern. At the borderline of viability, the chances of survival increase with each additional week of gestation, and a week makes all the difference in the 22–25-week bracket. In fact, the overall neonatal survival rate is still very low.14 Of those who survive, nearly half will suffer moderate to severe disabilities, including deafness, blindness, cerebral palsy, behavioural dysfunction and poor school performance.5 6 Cognitive impairment and the needs of special healthcare and rehabilitation seem to be extremely common.10 The relation between gestational age and mortality is not linear but exponential. This suggests a biological barrier to survival at about 23–24 weeks’ gestation, such as insufficient lung development. Because …

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  • Competing interests: None.

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