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Ann Saudi MedAnn Saudi MedAnnals of Saudi Medicine0256-49470975-4466King Faisal Specialist Hospital and Research Centre 10.5144/0256-4947.2008.227asm-3-227LettersReply Al-Aiyan Saleh MD, FRCPCSection of Neonatology, Department of Pediatrics, King Faisal Specialist Hospital and Research Centre, PO Box 3354, Riyadh 11211, Saudi Arabia, T: +966-1-442-7761, F: +966-1-442-7784, alaiyan@kfshrc.edu.saMay-Jun 2008 28 3 227 227 Copyright © 2008, Annals of Saudi Medicine2008This work is licensed under a Creative Commons Attribution-NonCommercial-NoDerivatives 4.0 International License.
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Decisions about whether to resuscitate a newborn baby, and admit him or her to neonatal intensive care; and whether to continue intensive care or replace active treatment with palliative care, are complex, emotionally demanding and may have lifelong consequences.1

Your first point regarding assigning both a lower limit of gestational age and the birthweight of the neonate is ideal but it is not free of confusion. We all agree that gestational age, if accurate, reflects the degree of immaturity which is the main factor in making decision to resuscitate or not. However, caregivers need to be extremely careful before taking such decisions for a specific gestational age unless it has been carefully defined. In contrast, for the birthweight, although it is accurate, there is an overlap in weight between different gestational ages of pre-viable and viable infants.2 Combining both birthweight and gestational age are used for short and long-term outcome but a decision to resuscitate or not commonly takes place within a short time prior to delivery or at the delivery room.

The reports from Saudi Arabia and other developing countries did not delineate the magnitude of the problem, because they included infants with a wide range of gestational ages resulting in less attention to the specific outcome of infants born at the cusp of viability. Moreover, although there is a consensus amongst perinatal care providers that the full gamut of intensive care should be provided at 26-weeks gestation and beyond, opinions and attitudes differ among different countries, centers and individuals with regard to the grey zone between 22 and 25 weeks of gestation.3 Additionally, the recent results of the European program MOSAIC (Models for Organizing Access to Intensive Care for Very Preterm Babies in Europe) evidently showed variations between the European countries.4 MOSAIC is a prospective cohort study of all preterm infants delivered between 22 and 31 weeks of gestation in 10 regions of nine European countries covering 494 463 total live births in 2003. The study showed important differences in the approaches to the organization of perinatal care and a wide variation in neonatal survival. More interestingly, they documented the variation in Europe from extreme approaches, such as Poland, where despite financial and organizational difficulties, the treatment of all infants at the limit of viability is undertaken, to the Netherlands, where active intensive care treatment of newborns born before the 25th week of gestation is not routinely offered. A consensus conference in Australia5 concluded that ‘between 23 weeks and zero days and 25 weeks and 6 days of gestation, it was reasonable to offer the option of non-initiation of resuscitation and intensive care.

In the presence of these variations in treating infants at the limit of viability, I believe that having guidelines is necessary for parents and professionals to make decisions for resuscitating and instituting intensive care for extremely premature and seriously ill babies. These guidelines should be drafted by a group of expert professionals and should be approved by Islamic Scholars to declare their implementation.

It will be very helpful if a Saudi neonatal network is developed to connect all hospitals in Saudi Arabia. The network will maintain a standardized NICU database and provide a unique opportunity for researchers to participate in collaborative projects on a national and international scale. This will give an opportunity to health care professionals, health services researchers and health administrators to participate actively in clinical, epidemiologic, outcomes, health services, health policy and informatics research aimed at improving efficacy and efficiency of neonatal care.
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REFERENCES
1 Nuffield Council on Bioethics Critical care decisions in fetal and neonatal medicine: ethical issues Published: 16 November 2006 
2 Al Alaiyan S   Call to establish a national lower limit of viability Ann Saudi Med 2008 1 1 3 18299657 
3 Fanaroff AA   Extremely low birthweight infants- -the interplay between outcomes and ethics Acta Paediatr 2008 2 97 2 144 5 18254902 
4 Zeitlin J  Draper ES  Kollée L  Milligan D  MD  Boerch K  Agostino R    MOSAIC research group Differences in rates and short term outcome of live births before 32 weeks of gestation in Europe in 2003; results from the MOSAIC cohort Pediatrics 2008 121 4 e936 e944 18378548 
5 Keogh J  Sinn J  Hollebone K    Consensus Workshop Organising Committee Delivery in the ‘grey zone’: collaborative approach to extremely preterm birth Aust NZJ Obstet Gynaecol 2007 47 273 8