© Shutterstock Preterm birth significantly increases risks for infants, leading to immediate health issues and long-term developmental challenges. Effective growth monitoring in neonatal intensive care units (NICUs) is essential for improving outcomes, as it enables the identification of infants at risk for conditions like extrauterine growth restriction (EUGR). However, the choice of growth chart is vital for accurate assessments. A recent study highlights the challenges in monitoring extremely and very preterm neonates, revealing discrepancies between growth charts. It emphasises the need for standardised growth monitoring practices in NICUs to better support preterm infants and improve their long-term health outcomes.   Prevalence of growth restrictions A retrospective study of 462 preterm infants born before 32 weeks of gestation at the University General Hospital of Heraklion in Greece (2008-2022) examined the impact of early feeding practices on growth outcomes. Utilising the Fenton 2013 and INTERGROWTH-21st growth charts, the study assessed how different feeding strategies influenced rates of Extrauterine Growth Restriction (EUGR).   Significant discrepancies in growth chart assessments for preterm infants The findings revealed considerable discrepancies in the classification of SGA and EUGR depending on the growth chart used. According to the Fenton2013 growth curves, 6.3% of the neonates were classified as small for gestational age (SGA) at birth, whereas the INTERGROWTH-21st curves identified 9.3% as SGA. This discrepancy was even more pronounced at discharge, with 45.9% of neonates being classified as having EUGR based on the Fenton2013 weight curves, compared to only 29.2% with the INTERGROWTH-21st curves. These findings highlight significant differences in growth restriction prevalence depending on the growth reference used. These differences were observed through the calculation of z-scores for birth weight and weight, length, and head circumference at discharge and highlight the urgent need for scientific clarity on the most effective methods for measuring growth and making predictions.   Nutritional and clinical factors  The study also assessed the impact of nutritional practices on growth outcomes. It revealed that the timing of enteral feeding initiation and the duration of parenteral nutrition were associated with EUGR in both growth curves. Specifically, the study observed that an earlier initiation of enteral feeding and a shorter duration of parenteral nutrition were linked to better growth outcomes, reducing the prevalence of EUGR. of detailed and individualised nutritional management in the care of preterm infants.   Implications for neonatal care  The findings indicate a need for further evaluation of growth charts to determine the most appropriate tools for monitoring the growth of preterm infants in neonatal intensive care units. Choosing the right growth reference is crucial because an inaccurate growth chart can lead to some cases of EUGR being missed or identified too late, affecting clinical decisions and long-term health outcomes. By refining feeding plans and monitoring growth closely, healthcare providers can better manage their patients’ nutrition plans and improve their long-term health and well-being. In summary, this research highlights the urgent need for personalised growth monitoring for preterm babies, as it is crucial for accurately tracking their development and improving care, which has important implications for how NICUs around the world manage their patients.   Paper available at: The Prevalence of Small for Gestational Age and Extrauterine Growth Restriction among Extremely and Very Preterm Neonates, Using Different Growth Curves, and Its Association with Clinical and Nutritional Factors (nih.gov) Full list of authors: Kakatsaki I, Papanikolaou S, Roumeliotaki T, Anagnostatou NH, Lygerou I, Hatzidaki E. DOI: 10.3390/nu15153290

Introduction and importance of perinatal palliative care St. Josef Hospital in Vienna delivers comprehensive medical care with a particular emphasis on obstetrics. Our perinatal palliative care (PPC) programme is designed to support families during the challenging period surrounding the birth of a child with life-limiting conditions.   Services and offerings at St. Josef Hospital Interdisciplinary team We have formed a dedicated interdisciplinary team comprising gynaecologists, midwives, neonatologists, nurses, psychologists, and chaplains. This team collaborates closely to provide holistic care tailored to the unique needs of each family. Before birth Our support begins well before birth with thorough counselling sessions. We elucidate the diagnosis to the parents and its implications for their child. Many parents feel helpless and frightened in this situation, making our support and the provision of ample time for decision-making crucial. Often, parents face a difficult journey marked by a loss of control and external pressures. Our PPC programme aims to help them experience a self-determined birth and make the time with their child as meaningful as possible. In preparation, we work closely with the parents and our interdisciplinary team to develop a comprehensive birth plan and a neonatal care plan. These plans consider the parents’ wishes and the child’s medical needs, detailing actions for various scenarios to ensure optimal support and care for both the child and the parents. Advanced Care Planning (ACP) is integral to this process. Whenever possible, the same professionals remain with the family throughout the course of care, fostering a trustful relationship. During birth During birth, we strive to create a stress-free and dignified environment for the family. For deliveries involving palliative care, we provide a dedicated midwife. This one-on-one support is crucial for intensive and personalised care. The dedicated midwife remains continuously present, offering emotional support, monitoring the birth process, and adapting care to the evolving needs of the family. © iStock After birth Post-birth, our primary focus shifts to palliative care, which can extend from a few hours to several weeks, depending on the child’s condition. We ensure that all medical needs, including pain relief, are met to provide maximum comfort. Parents receive ongoing emotional support from our psychologists and chaplains, who assist them in coping with their emotions and processing their grief. We also aid families with administrative tasks and coordination with other institutions to ensure access to necessary resources and services. Additionally, we help families create cherished memories through photographs, hand and footprints, or special farewell rituals, which are vital in the grieving process. If the child lives longer, we facilitate seamless integration with external care facilities, including outpatient services, specialised children’s hospices, and other relevant organisations. After discharge from the hospital, families can opt for outpatient follow-up sessions, if needed. These conversations offer an essential opportunity for continued emotional and psychological support. Conducted by the same psychologists who cared for the families during their hospital stay, these sessions ensure continuity and trust. Implementation The implementation of our PPC programme naturally brought with it challenges, but these were largely related to specific structures of the hospital. Thus, these challenges were very individual, and in the end all initial problems were solved well thanks to an incredibly committed and interdisciplinary team. Conclusion Our PPC programme at St. Josef Hospital Vienna offers a comprehensive and compassionate service that transcends traditional medical care. We provide families in challenging life situations with unwavering support and comfort. The holistic and individualised care provided by our specialised team enables affected families to say goodbye and experience the loss of their child with dignity.

© Pixabay Extremely preterm infants (EPI), born before 28 weeks of gestation, represent a small but significant population in neonatal intensive care units (NICUs). Despite their small numbers, they contribute disproportionately to neonatal deaths and present unique challenges in end-of-life care (EOLC). Although the fundamental principles remain consistent, there are notable differences in end-of-life decision-making and care for EPI compared to other newborns and older children. A recent study investigates the complexities surrounding EOLC for extremely preterm infants, examining antenatal decision-making and care in both the delivery room and NICU, while exploring  potential reasons for these differences and addressing the practical and ethical challenges involved.   Antenatal counselling and decision-making Antenatal counselling plays a crucial role in preparing for the birth of an EPI. Healthcare professionals meet with parents to discuss potential outcomes and care plans. The concept of a “grey zone” has emerged, where parental decisions determine whether survival-focused or palliative care is provided. Recent guidelines have moved beyond using gestational age alone, incorporating other prognostic factors to guide decision-making. Some of these include severe growth restriction, administration of antenatal steroids, place of delivery, singleton vs multiple birth and foetal sex. However, each situation is unique and requires individual consideration.   Delivery room care EOLC in the delivery room presents particular challenges. There is an on-going debate in the medical community about whether neonatal teams should attend deliveries of the most preterm infants (20-21 weeks). While their absence may prevent inappropriate treatment initiation, it can also lead to challenges in symptom management and flexibility in care plans. In some situations, plans to provide comfort-focused care at delivery for an EPI may be revised after birth because either the infant’s condition is significantly better than expected, and/or because the parents change their mind. The latter might occur because of the parents’ response to seeing their newborn infant, or because the infant’s condition is different from what they had been expecting. In general, symptom management for EPI in the delivery room lacks extensive data. Studies indicate that few infants receive comfort medication, highlighting the need for better guidelines. Non-pharmacological interventions are emphasised, but opioids like buccal diamorphine or intranasal fentanyl may be necessary when symptoms are severe. Non-pharmacological measures include the provision of wrapping, warmth, and continuous physical touch from parents as well as avoidance of stimuli such as loud noise, bright lights, or cold air. In conjunction with this, interventions that might cause discomfort (e.g. physical examination, airway procedures, vascular access) should be minimised or avoided.   Global differences in end-of-life care for preterm infants In high-income settings, like in the UK, Europe, and the US, most EPI deaths in the NICU follow end-of-life decisions to limit life-sustaining treatment. However, significant regional variations exist. In South America, East Asia, and the Middle East, decisions to limit treatment for extremely preterm infants, as for older infants (and children), may be made on the basis of judgement that the infant is actively dying despite maximal therapy, a prediction that the infant is highly likely to die if treatment were continued, or based on concern for the child’s quality of life if they survive. Prognostic uncertainty and the perceived difference between withholding and withdrawing treatment can complicate decision-making.   Ethical considerations There is some evidence that end-of-life decision-making appears to be different in the paediatric intensive care unit (PICU) compared to the NICU. A study done in a children’s hospital in the Netherlands revealed that 25% of deaths in the PICU occurred despite full intensive care, while this applied to only 4% of non-preterm deaths in the NICU. While 71% of decisions in the NICU were based on predicted poor quality of life, only 22% were in the  [1]. Furthermore, another study showed that approximately 65% of US health professionals judged it acceptable to withhold treatment in a case of an EPI with poor life expectancy, but only 15% were prepared not to resuscitate a 2-month-old infant with bacterial meningitis and identical prognosis  [2]. This may reflect that neonatologists potentially feel more guilt or responsibility if their patients survive with severe disabilities. Transferring infants to home or to a hospice for EOLC is rare due to physiological instability and logistical challenges. However, this option may be valuable for some families, necessitating better support and training for healthcare providers to facilitate such transfers. In summary, EOLC for extremely preterm infants requires careful planning and empathetic support for families. Further research is needed to improve symptom management and to evaluate the impact of different approaches to care. Practical measures, including non-pharmacological interventions and appropriate medication use, should be considered to ensure the best possible care for these vulnerable infants and their families. Additionally, the place of death and after-death care for patients need further discussion, as they may be valuable options for families.   Paper available at: https://www.ncbi.nlm.nih.gov/pmc/articles/PMC10914670/pdf/main.pdf Full list of authors: Dominic JC Wilkinson, Sophie Bertaud DOI: 10.1016   [1] Snoep, M.C., Jansen, N.J.G. and Groenendaal, F. (2018), Deaths and end-of-life decisions differed between neonatal and paediatric intensive care units at the same children’s hospital. Acta Paediatr, 107: 270-275. https://doi.org/10.1111/apa.14061 [2] Annie Janvier, Isabelle Leblanc, Keith James Barrington; The Best-Interest Standard Is Not Applied for Neonatal Resuscitation Decisions. Pediatrics May 2008; 121 (5): 963–969. 10.1542/peds.2007-1520. https://doi.org/10.1542/peds.2007-1520