Resuscitation Increases Survival of Infants Born at 21 Weeks’ Gestation, Finds JAMA Study
USA: Researchers have found in a single-center retrospective study that more than one-third of infants born alive at 21 weeks’ gestational age who received resuscitation survived to hospital discharge. Of 22 infants born alive, resuscitation was attempted in 17, and six were successfully discharged from the NICU. However, long-term neurodevelopmental outcomes were not assessed, and the findings raise ongoing ethical considerations regarding resuscitation at the threshold of viability.
Advances in neonatal intensive care and growing clinical experience have gradually shifted perceptions around the limits of viability for extremely preterm infants. Traditionally, 21 weeks’ gestation was considered incompatible with survival, but some tertiary centers have begun offering selective resuscitation at this early stage. Despite this evolving practice, robust data to guide clinicians and families remain scarce.
In a new case series published in JAMA Network Open, Rachael M. Hyland from the Division of Neonatology, Department of Pediatrics, University of Iowa, and colleagues examined outcomes of infants born alive at 21 weeks’ gestational age in a level IV academic NICU. The retrospective analysis included all such births at the University of Iowa Hospitals and Clinics between January 2020 and February 2025. Data were extracted from electronic medical records and included detailed information on demographics, treatments, complications, and short-term outcomes during hospitalization, as well as limited postdischarge data where available.
Key findings of the study were as follows:
- During the study period, 22 infants were born alive at 21 weeks’ gestation, while 230 were stillborn at the same gestational age.
- Resuscitation was attempted in 77% of the liveborn infants.
- Among infants who received active resuscitation, six survived to NICU discharge, corresponding to a survival rate of 35%.
- One infant remained hospitalized at the time of analysis, and ten infants died despite resuscitative efforts.
- All infants were delivered vaginally and were inborn.
- Infants who survived were less likely to be from multiple gestations compared with those who did not survive.
- Survivors were more likely to have been exposed to a complete course of antenatal corticosteroids.
- Early cardiorespiratory instability was common among survivors, with most requiring vasoactive support and/or inhaled nitric oxide soon after birth.
- Nearly half of the surviving infants had no intraventricular hemorrhage or only mild (grade 1) hemorrhage.
- Some survivors experienced higher-grade intraventricular hemorrhage, but none required neurosurgical intervention.
- All infants discharged from the NICU required low-flow supplemental oxygen.
- None of the surviving infants required a tracheostomy.
- The rate of attempted resuscitation increased over the five-year study period, indicating an evolving approach to care at this gestational age.
While the findings demonstrate that survival at 21 weeks’ gestation is possible, the authors caution that long-term neurodevelopmental outcomes are not yet known. They emphasize the need for prospective data collection and standardized outcome reporting to better inform counseling, ethical decision-making, and shared discussions between clinicians and families facing periviable births.
Reference:
Hyland RM, Mat HD, Boly TJ, et al. Outcomes of Infants Born at 21 Weeks’ Gestational Age. JAMA Netw Open. 2025;8(12):e2548211. doi:10.1001/jamanetworkopen.2025.48211
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