The Limits of Viability and the Uncertainty of Neuroprotection: Challenges in Optimizing Outcomes in Extreme Prematurity

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Abstract
Among the 500000 infants born prematurely in 2003 in the United States, 79000 were born very prematurely.1–3 These very premature infants, defined as having been born before 32 weeks’ completed gestation, have benefited from collaborative and regional efforts of obstetrics and neonatology. In particular, among infants of extreme prematurity (defined as <28 weeks’ completed gestation), optimizing the intrauterine environment of high-risk pregnancies while concurrently using knowledge from developmental biology and multicenter translational trials has resulted in more aggressive management of respiratory, cardiac, nutritional, metabolic, and infectious-disease complications. This strategy has resulted in significant advances in survival but has come with increasing concern that current management is unable to significantly reduce the high rates of both neurosensory disability (ie, cerebral palsy [CP], blindness, and deafness) and developmental cognitive disability (Bayley mental developmental index of 1 (36%) in 3 had one of the CP syndromes. Among those with severe ROP, almost 1 (24%) in 4 had CP. … Address correspondence to Michael E. Msall, MD, Kennedy Center, Section of Developmental and Behavioral Pediatrics, Institute of Molecular Pediatrics Sciences, Pritzker School of Medicine, University of Chicago, 5841 South Maryland Ave, MC09000, Chicago, IL 60637. E-mail: mmsall{at}peds.bsd.uchicago.edu