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      Decision‐making around resuscitation of extremely preterm infants in the Philippines: A consensus guideline

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          Abstract

          While the vast majority of preterm births globally occur in low‐ and middle‐income countries, existing published guidelines relating to the decision‐making and resuscitation of extremely preterm infants (EPIs) largely focus on high‐income countries. In 2018–2019, a working group of the Philippine Society of Newborn Medicine aimed to develop the first national guideline relating to the care of EPIs. The working group reviewed data on the outcomes of EPIs in the Philippines, surveyed paediatricians and neonatologists in the Philippines about current practice and held a consensus workshop. This paper describes the guideline development process and presents a summary of the guidelines. The national guidelines endorse consistency in decision‐making. Health professionals should take into consideration the views and wishes of the infant's parents and the availability of resources to treat the newborn infant. Active management would be appropriate to provide for potentially viable preterm infants at moderate to high risk of poor outcomes, where parents have expressed their wish for this management (and where there are resources available to provide this treatment). For such infants, where parents have expressed their wish to withhold active management, palliative management would also be appropriate to provide. The guideline endorses a grey zone for neonatal resuscitation from approximately 24 to 28 weeks’ gestation in the Philippines, reflecting the context for resuscitation in low‐ and middle‐income countries. Disparities in resource availability are themselves an ethical concern for neonatologists and should be a stimulus for advocacy and improvements in health‐care delivery.

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          Most cited references 14

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          Guidelines for the Management of Extremely Premature Deliveries: A Systematic Review.

          Available data on survival rates and outcomes of extremely low gestational age (GA) infants (22-25 weeks' gestation) display wide variation by country. Whether similar variation is found in statements by national professional bodies is unknown. The objectives were to perform a systematic review of management from scientific and professional organizations for delivery room care of extremely low GA infants.
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            Perinatal care at the threshold of viability: an international comparison of practical guidelines for the treatment of extremely preterm births.

            Over the last 2 decades, the survival rate of infants born at or = 25 weeks, compassionate care at < or = 22 weeks, and an individual approach at 23 to 24 weeks, consistent with the parents' wishes and the infant's clinical conditions at birth.
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              Physician counselling practices and decision-making for extremely preterm infants in the Pacific Rim.

              This study was undertaken to evaluate physician counselling practices and resuscitation decisions for extremely preterm infants in countries of the Pacific Rim. We sought to determine the degree to which physician beliefs, parents' opinion and medical resources influence decision-making for infants at the margin of viability. A survey was administered to neonatologists and paediatricians who attend deliveries of preterm infants in Australia, Hong Kong, Japan, Malaysia, Taiwan and Singapore. Questions were asked regarding physician counselling practices, decision-making for extremely preterm infants and demographic information. Physicians counsel parents antenatally with increasing frequency as gestational age increases. Most physicians discuss infant mortality and morbidity with parents prior to delivery. Physicians less frequently discuss the option of no resuscitation of an extremely preterm infant, withdrawal of support at a later time, or financial costs to parents. Severe congenital malformations, perception of a poor future quality of life, parental wishes and a high probability of death for the infant are influential in limiting resuscitation in very preterm infants for a majority of physicians. Less influential factors are parent socioeconomic status, language barriers, financial costs for the family, allocation of national resources, moral or religious considerations, or fear of litigation. Physician thresholds for resuscitation of infants ranged between 22 and 25 weeks gestation and between 400 and 700 g birthweight. We report physician beliefs and practices regarding resuscitation and the counselling of parents of extremely preterm infants in Pacific Rim countries. While we find variation among countries, physician practices appear to be determined by ethical decision-making and medical factors rather than social or economic factors in each country.
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                Author and article information

                Contributors
                dominic.wilkinson@philosophy.ox.ac.uk
                Journal
                J Paediatr Child Health
                J Paediatr Child Health
                10.1111/(ISSN)1440-1754
                JPC
                Journal of Paediatrics and Child Health
                John Wiley & Sons Australia, Ltd. (Australia )
                1034-4810
                1440-1754
                25 July 2019
                September 2019
                : 55
                : 9 ( doiID: 10.1111/jpc.v55.9 )
                : 1023-1028
                Affiliations
                [ 1 ] Oxford Uehiro Centre for Practical Ethics, Faculty of Philosophy University of Oxford Oxford United Kingdom
                [ 2 ] John Radcliffe Hospital Oxford United Kingdom
                [ 3 ] Murdoch Children's Research Institute Melbourne Victoria Australia
                [ 4 ] Institute of Child Health and Human Development, National Institutes of Health University of the Philippines Manila Philippines
                [ 5 ] Philippine Pediatric Society Quezon City Philippines
                [ 6 ] Philippine Society of Newborn Medicine Quezon City Philippines
                [ 7 ] Verbum Dei Manila Philippines
                Author notes
                [* ] Correspondence: Professor Dominic JC Wilkinson, Oxford Uehiro Centre for Practical Ethics, Suite 8, Littlegate House, St Ebbes Street, Oxford OX1 1PT, UK. Fax: +44 1865 286 886; email: dominic.wilkinson@ 123456philosophy.ox.ac.uk
                [†]

                Members of the PSNbM Working Group: Ma. Conchitina T Bandong, Resti Ma. M Bautista, Charito D Corpuz, Luis Emmanuel O Esguerra, Lourdes S Imperial, Jacinto Blas V Mantaring III, Socorro de Leon‐Mendoza, Josie Niu‐Kho, Jean S Tay Uyboco, Belen Amparo E Velasco.

                Article
                JPC14552
                10.1111/jpc.14552
                6771675
                31343809
                © 2019 The Authors Journal of Paediatrics and Child Health published by John Wiley & Sons Australia, Ltd on behalf of Paediatrics and Child Health Division (The Royal Australasian College of Physicians)

                This is an open access article under the terms of the http://creativecommons.org/licenses/by/4.0/ License, which permits use, distribution and reproduction in any medium, provided the original work is properly cited.

                Page count
                Figures: 3, Tables: 0, Pages: 6, Words: 4611
                Product
                Funding
                Funded by: Wellcome Trust
                Award ID: WT106587/Z/14/Z
                Categories
                Position Paper
                Position Papers
                Custom metadata
                2.0
                jpc14552
                September 2019
                Converter:WILEY_ML3GV2_TO_NLMPMC version:5.6.9 mode:remove_FC converted:01.10.2019

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