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Delivery room assessment < 25 weeks and prognostic score

Question Type:
Prognostic
Full Question:
In extremely preterm infants (<25 weeks)  (P), does Delivery room assessment with a prognostic score
 (I), compared with Gestational age assessment only (C), change survival to 30 days (O)?
Consensus on Science:
There is no evidence that addresses the clinical prospective use of prognostic scoring (the use of composite survival data using gestational age and other parameters) in infants of less than 25 weeks of estimated gestational age. There is increasing retrospective evidence that prognostic accuracy is improved by using additional information such as birth weight, appropriateness of weight for gestational age, use of maternal antenatal steroids, multiplicity, and gender(Bottoms 1999, 665; Ambalavanan 2005, 1367; Tyson 2008, 1672; Medlock 2011, e23441; Manktelow 2013, e425) (low-quality evidence), but there are no prospective studies showing the postnatal effect of such improved accuracy in predicting outcome.
Treatment Recommendation:
There is insufficient evidence to support the prospective use of any delivery room prognostic score presently described over estimated gestational age assessment alone in preterm infants of less than 25 weeks of gestation. No score has been shown to improve the ability to estimate the likelihood of survival through either 30 days or in the first 18 to 22 months after birth.In individual cases, when constructing a prognosis for survival at gestations below 25 weeks, it is reasonable to consider variables including perceived accuracy of gestational age assignment, the presence or absence of chorioamnionitis, and the level of care available for location of delivery. It is also recognized that decisions about appropriateness of resuscitation below 25 weeks of gestation will be influenced by region-specific guidelines established by regional resuscitation councils.Values, Preferences, and Task Force InsightsIn making this statement, we put a higher value on the lack of evidence for a generalizable prospective approach changing important outcomes over improved retrospective accuracy and locally validated counseling policies. For antenatal counseling, the most useful data would give outcome figures for babies alive at the onset of labor, not just those born alive or admitted to the neonatal intensive care unit. In reality, many are already using such extended data in antenatal counseling to try to provide parents and healthcare professionals with the most accurate estimates for mortality (and morbidity).It would obviously be preferable if there were studies to show that using such data can prospectively improve the outcome for these babies: Does using the most accurate information have a positive influence on the difficult decisions made about whether intensive care should be implemented?There was agreement to amend the treatment recommendation to include consideration of possible inaccuracy of gestational age assessment, as well as to include evaluation for chorioamnionitis, and level of subsequent care that may be available. A question was raised with regard to the fact that we included weights in previous statements about prognosis; however, those were taken out to allow councils to make independent recommendations. Should antenatal steroids be mentioned in the treatment recommendation? The list may become exhaustive as more factors are added (eg, gender).
CoSTR Attachments:
SB NRP 805 FINAL GRADE GRID_n.docx    

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