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In 2006, the Nuffield Council on Bioethics convened a working group to explore the ethical, social, economic and legal issues around clinical decisions made in fetal and neonatal medicine1; in response to their report, the British Association of Perinatal Medicine (BAPM), in conjunction with other professional groups, developed a Framework for Clinical Practice for the management of babies born extremely preterm at less than 26 weeks of gestation. In the current era, the outcomes for babies actively managed at 22 weeks of gestation appear similar to those of babies at 23 weeks of gestation at the time of the 2008 BAPM Framework for Clinical Practice.5–8 Reports from other countries confirm increasing survival and improving neurodevelopmental outcome for babies born before 27 weeks of gestation.9–12 Although internationally there remain differences in practice, there is increasing willingness to consider stabilisation at birth and subsequent intensive care for the most extremely preterm babies,13–15 accompanied by greater acknowledgement of the importance of involving parents in perinatal decision-making.16 Reported outcomes are, of course, impacted by willingness to consider active interventions before and after birth.17 This updated Framework for Practice has been developed by consensus, taking into account the most recent available outcome data both from the UK and internationally, and follows wide consultation. The scope has been extended to include births up to 26+6 weeks of gestation, better to align with national recommendations and published data, and we refer to new RCPCH and other national guidance on palliative care of babies as well as guidance on bereavement care for parents who experience loss of a baby.18 19 Prevention of preterm birth is now a national priority and all maternity services should ensure that measures are in place to realise this ambition. Risk-based approach to decision-making A key ethical consideration for decisions about instituting life-sustaining treatment for an extremely preterm baby is the baby’s prognosis—the risk of an acceptable (or unacceptable) outcome if active (survival focused) management is undertaken.

BackgroundDecisions about treatments for extremely preterm infants (EPIs) born in the ‘grey zone’ of viability can be ethically complex. This 2020 survey aimed to determine views of UK neonatal staff about thresholds for treatment of EPIs given a recently revised national Framework for Practice from the British Association of Perinatal Medicine.MethodsThe online survey requested participants indicate the lowest gestation at which they would be willing to offer active treatment and the highest gestation at which they would withhold active treatment of an EPI at parental request (their lower and upper thresholds). Relative risks were used to compare respondents’ views based on profession and neonatal unit designation. Further questions explored respondents’ conceptual understanding of viability.Results336 respondents included 167 consultants, 127 registrars/fellows and 42 advanced neonatal nurse practitioners (ANNPs). Respondents reported a median grey zone for neonatal resuscitation between 22+1 and 24+0 weeks’ gestation. Registrars/fellows were more likely to select a lower threshold at 22+0 weeks compared with consultants (Relative Risk (RR)=1.37 (95% CI 1.07 to 1.74)) and ANNPs (RR=2.68 (95% CI 1.42 to 5.06)). Those working in neonatal intensive care units compared with other units were also more likely to offer active treatment at 22+0 weeks (RR=1.86 (95% CI 1.18 to 2.94)). Most participants understood a fetus/newborn to be ‘viable’ if it was possible to survive, regardless of disability, with medical interventions accessible to the treating team.ConclusionCompared with previous studies, we found a shift in the reported lower threshold for resuscitation in the UK, with greater acceptance of active treatment for infants <23 weeks’ gestation.

Correspondence to Dr Dominic Wilkinson, Oxford Uehiro Centre for Practical Ethics, University of Oxford, Oxford OX1 1PT, UK; dominic.wilkinson@philosophy.ox.ac.uk The 2009 British Association of Perinatal Medicine (BAPM) framework recommended against advanced resuscitation measures (delivery room cardiopulmonary resuscitation, DR-CPR) in extremely preterm infants, noting that: “There is no evidence to support the use of epinephrine by any route, or chest compressions, during resuscitation at gestational age <26 weeks’.1 However, in the updated 2019 framework, published in this issue, the working group reached the opposite conclusion: ‘In the absence of sufficient evidence to justify a different approach in extremely preterm babies, if advanced resuscitation is considered appropriate, the Working Group recommends applying newborn resuscitation algorithms as used in more mature babies”.2 This was one of the more controversial elements of the new framework, generating a number of comments during the consultation phase. [...]DR-CPR might be associated with such low survival that it is regarded as futile.3 Third, there may be a worry that even if infants survive after DR-CPR, they would be so severely impaired that it would have been better if they had died. [...]publications since the 1990s have challenged the notion that it is futile to provide DR-CPR to extremely preterm infants.

Our aim was to develop consensus recommendations from United Kingdom (UK) neonatal specialists on the use of surfactant for the management of respiratory distress syndrome RDS in preterm infants. RDS due to surfactant deficiency is common in preterm infants. Signs, including tachypnoea, recessions, and grunting, usually commence shortly after birth, and increase in severity during the first 12–48 h of postnatal life. Significant RDS may require mechanical ventilation (MV) or noninvasive ventilatory support (NIV), both of which have potential to cause lung injury via a number of mechanisms.1 The aim of RDS management is to provide appropriate respiratory support whilst minimising complications and, ultimately, bronchopulmonary dysplasia (BPD). Treatment with exogenous surfactant reduces requirement for positive pressure ventilation, mitigates risk of pulmonary air leak, and improves survival.1

Women with twin pregnancy are at high risk for spontaneous preterm delivery. Progesterone seems to be effective in reducing preterm birth in selected high-risk singleton pregnancies, albeit with no significant reduction in perinatal mortality and little evidence of neonatal benefit. We investigated the use of progesterone for prevention of preterm birth in twin pregnancy. In this double-blind, placebo-controlled trial, 500 women with twin pregnancy were recruited from nine UK National Health Service clinics specialising in the management of twin pregnancy. Women were randomised, by permuted blocks of randomly mixed sizes, either to daily vaginal progesterone gel 90 mg (n=250) or to placebo gel (n=250) for 10 weeks from 24 weeks' gestation. All study personnel and participants were masked to treatment assignment for the duration of the study. The primary outcome was delivery or intrauterine death before 34 weeks' gestation. Analysis was by intention to treat. Additionally we undertook a meta-analysis of published and unpublished data to establish the efficacy of progesterone in prevention of early (<34 weeks' gestation) preterm birth or intrauterine death in women with twin pregnancy. This study is registered, number ISRCTN35782581. Three participants in each group were lost to follow-up, leaving 247 analysed per group. The combined proportion of intrauterine death or delivery before 34 weeks of pregnancy was 24·7% (61/247) in the progesterone group and 19·4% (48/247) in the placebo group (odds ratio [OR] 1·36, 95% CI 0·89–2·09; p=0·16). The rate of adverse events did not differ between the two groups. The meta-analysis confirmed that progesterone does not prevent early preterm birth in women with twin pregnancy (pooled OR 1·16, 95% CI 0·89–1·51). Progesterone, administered vaginally, does not prevent preterm birth in women with twin pregnancy. Chief Scientist Office of the Scottish Government Health Directorate.

IntroductionMethodologically robust clinical trials are required to improve neonatal care and reduce unwanted variations in practice. Previous neonatal research prioritisation processes have identified important research themes rather than specific research questions amenable to clinical trials. Practice-changing trials require well-defined research questions, commonly organised using the Population, Intervention, Comparison, Outcome (PICO) structure. By narrowing the scope of research priorities to those which can be answered in clinical trials and by involving a wide range of different stakeholders, we aim to provide a robust and transparent process to identify and prioritise research questions answerable within the National Healthcare System to inform future practice-changing clinical trials.Methods and analysisA steering group comprising parents, doctors, nurses, allied health professionals, researchers and representatives from key organisations (Neonatal Society, British Association of Perinatal Medicine, Neonatal Nurses Association and Royal College of Paediatrics and Child Health) was identified to oversee this project. We will invite submissions of research questions formatted using the PICO structure from the following stakeholder groups using an online questionnaire: parents, patients, healthcare professionals and academic researchers. Unanswered, non-duplicate research questions will be entered into a three-round eDelphi survey of all stakeholder groups. Research questions will be ranked by mean aggregate scores.Ethics and disseminationThe final list of prioritised research questions will be disseminated through traditional academic channels, directly to key stakeholder groups through representative organisations and on social media. The outcome of the project will be shared with key research organisations such as the National Institute for Health Research. Research ethics committee approval is not required.

Children of drug-misusing women are a vulnerable group. Data describing the pattern of accommodation placements are lacking. We investigated 10- to 12-year accommodation outcomes of children born to drug-misusing mothers at a single maternity hospital. 94% of mothers were prescribed maintenance methadone during pregnancy and at least 87% poly-drug used.Data were successfully matched for 132 children (29% of the original cohort of 450 babies). These children had a total of 291 placements (median 2 (range 1–6)), only 28.5% of which were with the birth parents. At 10–12 years, 54 (41%) were in the care of their parent(s).83% (109/132) were discharged from the maternity hospital to their birth parents; 41% of these children (54/132) remained with their parents at 10–12 years. Of the 23 children not discharged from the maternity unit to their parents, 70% remain within the care system or have been adopted at 10–12 years of age.

Recognising that improvement in prognosis with increasing gestation is gradual and not stepwise, the guidance recommends that parents are offered advice regarding the predicted outcome for their baby which takes into account gestational age but is modified by known antenatal factors likely to influence outcome, including antenatal steroids, fetal growth, sex, multiple pregnancy and place of birth. A decision not to provide potentially life-sustaining care may be entirely appropriate, but the outcome will always be death. [...]the only valid data are those which record outcomes for babies born alive for whom potentially life-sustaining care was attempted. Association of early postnatal transfer and birth outside a tertiary hospital with mortality and severe brain injury in extremely preterm infants: observational cohort study with propensity score matching.

Alongside the introduction of SCID screening, the NSC and the Joint Committee of Vaccinations and Immunisations have stated that BCG must be delayed to 28 days of age in order to avoid harming babies later shown to have SCID. The significant cost implications of a new BCG service for units with high numbers of eligible babies would fall disproportionately on units with a deprived and ethnically diverse population. In areas where SCID screening is not being piloted—arguably control areas in a non-randomised trial—a draft service specification, supported by robust conversations from Public Health England (PHE), insists BCG immunisation should be routinely delayed even though PHE’s own modelling shows that delaying BCG will increase tuberculosis infection and mortality.3 We contend that neonatal BCG immunisation should not be universally delayed until national rollout of SCID screening is assured, and evidence shows that levels of BCG coverage can be maintained at an acceptable cost by a delayed administration model.

Illicit use of opioids is a global health crisis with major implications for women and children. Strategies for managing opioid use disorder (OUD) in pregnancy have been tested over the past 40 years, but studies have focused on maternal and pregnancy outcomes, with less attention given to long-term follow-up of exposed children. Here, we provide a narrative review of recent advances in the assessment and management of neonatal opioid withdrawal syndrome (NOWS), and we summarise evidence from multiple domains—neuroimaging, electrophysiology, visual development and function, neurodevelopment, behaviour, cognition and education—which suggests that prenatal opioid exposure modifies child development. Further studies are required to determine the optimal management of pregnant women with OUD and babies with NOWS. We identify knowledge gaps and suggest that future study designs should evaluate childhood outcomes, including infant brain development and long-term neurocognitive and visual function.