We studied infants who were born between April 1, 2006, and March 31, 2011, at 24 hospitals included in the NRN. The NRN consists of clinical centers of various sizes and in several U.S. regions, with diverse patient demographics, clinical practices, and outcomes.17,18 Hospitals included in the study analysis contributed data for the entire study period. 
 
 We collected data for liveborn infants who were born before 27 weeks of gestation, including those who died in the delivery room. Data were collected for infants born before 22 weeks of gestation if they weighed 400 g or more; there was no minimum birth weight for infants born at or after 22 weeks of gestation. A total of 213 infants with recognized syndromes or major congenital malformations were excluded, because factors besides prematurity may have influenced the prognosis and treatment decisions for these infants. Three additional infants were excluded owing to missing data about interventions administered in the delivery room. 
 
 Data Collection 
 
 Trained research personnel at each hospital obtained data for all liveborn infants.19 Demographic and clinical information was extracted from medical records. Gestational age at birth was determined by identifying the dates of the mother’s last menstrual period and examining fetal ultrasound images, or if those methods were unavailable, by estimation after birth.20 Birth weight for gestational age was compared with sex-specific growth curves.21 
 
 The institutional review board at each participating site approved NRN in-hospital and follow-up protocols. Written informed consent from a parent or guardian was obtained for the follow-up protocol at 20 hospitals and for the in-hospital protocol at 2 hospitals. For all other hospitals, the institutional review board approved a waiver of consent. The second and fourth authors had full access to all data and were responsible for the data analysis and reporting. 
 
 Active Treatment 
 
 Infants were considered to have received active treatment if they received any of the following interventions: surfactant therapy, tracheal intubation, ventilatory support (including continuous positive airway pressure, bag–valve–mask ventilation, or mechanical ventilation), parenteral nutrition, epinephrine, or chest compressions. We focused on the specific decision to initiate or forgo active treatment after birth and thus did not include obstetrical treatment or later decisions to withdraw treatment (after an infant’s response to treatment could be gauged) in our definition. 
 
 Outcomes 
 
 Data on survival and neurodevelopmental impairment were collected at 18 to 22 months of corrected age. Neurodevelopmental assessment was performed by annually certified examiners and consisted of a structured neurologic examination and developmental and behavioral tests, which have been described previously.22,23 Severe impairment was defined as a cognitive or motor score on the Bayley Scales of Infant and Toddler Development, third edition (Bayley-III) of less than 70 (i.e., >2 SD below the scale mean; mean [±SD], 100±15), severe cerebral palsy, a Gross Motor Function Classification System (GMFCS) level of 4 or 5 (on a scale of 0 [normal] to 5 [most impaired]), bilateral blindness (visual acuity, <20/200), or severe hearing impairment that cannot be corrected with bilateral amplification. Moderate impairment was defined as a Bayley-III cognitive or motor score of 70 to 84, (i.e., 1 to 2 SD below the scale mean), moderate cerebral palsy, or a GMFCS level of 2 or 3. Bayley-III motor scores were ascertained beginning in 2010; all other criteria were assessed throughout the study period. Because impairment is a risk only for infants who survive, we used the following outcomes in our models: survival, survival without severe impairment, and survival without moderate or severe impairment. 
 
 Statistical Analysis 
 
 We used the chi-square test or Fisher’s exact test (if the cell size was <5) to compare the differences in demographic and clinical characteristics between infants who received active treatment and those who did not. We calculated overall rates of active treatment (percentage of all infants who received active treatment) by gestational age at birth in both days and weeks. We used Wilson’s method to derive 95% confidence intervals.24 
 
 We used multivariable multilevel logistic-regression models to assess clustering of active treatment at the hospital level, by gestational age at birth, after accounting for differences in patient characteristics. Models included infant-level receipt of active treatment as a binary outcome and were adjusted for characteristics that were known before or shortly after birth, including the infant’s birth weight (in grams), sex, plurality of birth (singleton vs. multiple), and 1-minute Apgar score (≤3 vs. >3) and the mother’s age (≤19 years vs. >19 years), race (white, black, or other), ethnic group (Hispanic vs. non-Hispanic), enrollment in private health insurance (yes vs. no), receipt of prenatal care (≥1 visit vs. no visits), receipt of antenatal glucocorticoids (yes vs. no), and status with respect to hypertension (including preexisting hypertension, gestational hypertension, preeclampsia, and eclampsia) (yes vs. no), insulin-dependent diabetes (yes vs. no), and chorioamnionitis (yes vs. no). We calculated the intraclass correlation coefficient (ICC) statistic, which represents between-group variation as a proportion of all variation of a dependent variable when data are analyzed by group (e.g., hospital). Using the models described above, we calculated the ICC for active treatment (i.e., the proportion of variation in active treatment that was attributable to an infant’s hospital of birth) by gestational age at birth.25 
 
 To determine how hospital practices regarding the initiation of active treatment in extremely preterm infants relate to the outcomes of survival and survival without impairment by gestational age at birth, we compared pairs of multilevel logistic-regression models for each of the three specified outcomes.25 In these models, the infant was the unit of analysis and the outcome was the dependent variable. Each pair of models consisted of one model that included the hospital rate of active treatment (percentage of infants at a given hospital who received active treatment) as a second-level predictor and one model that did not; the ICC was calculated for each model. The between-hospital variation for a given outcome that could be attributed to the hospital rate of active treatment was calculated as 1−[(ICC of model including hospital rate of active treatment)÷(ICC of model not including hospital rate of active treatment)].25 To account for differences in patient characteristics among hospitals, models were adjusted for the covariates listed previously. For each participating hospital, risk-adjusted outcomes were calculated on the basis of these models by means of the marginal method of regression adjustment.26 
 
 In addition, we considered the possibility that hospital volume may explain some of the between-hospital variation in outcomes; this possibility has been proposed previously.27,28 Sensitivity analyses were performed to evaluate whether hospital volume of extremely preterm births during the study period modified the effect of hospital rates of active treatment on outcomes. 
 
 Multilevel modeling was performed using Stata/MP software, version 13.0 (StataCorp). All other analyses were performed using SAS software, version 9.3 (SAS Institute). Two-sided P values of less than 0.05 were considered to indicate statistical significance. ||||| They weigh as little as a pound yet force some of the toughest choices in all of medicine. Extremely premature babies face big differences in how hard hospitals try to save them, a study finds. 
 
 In this May 2, 2015 photo provided by Tundi and Nate Brady, their 5-year-old son, Dexter, plays at home in Iowa City, Iowa. Born 16 weeks premature, he spent five months in a neonatal intensive care unit... (Associated Press) 
 
 This Sept. 11, 2009 photo provided by Tundi and Nate Brady shows their 3-day-old son, Dexter, who was born about 16 weeks early, attached to a ventilator and feeding tubes under warming lights in the... (Associated Press) 
 
 It is the first major look in the U.S. at how preemies fare according to the care they get. 
 
 There was a wide range — some hospitals always gave active treatment to the youngest preemies as opposed to just comfort care, but others never did. Researchers had no information on how parental wishes affected the decisions versus hospital policy, but said that probably was not the main factor because differences in care from one place to another were so large. 
 
 Parents need to know that "the hospital that you go to might determine what happens to your baby," although many parents are not in a position to shop around when they find themselves in these emergency situations, said one study leader, Dr. Edward Bell of the University of Iowa. 
 
 They also should be given better information on survival odds — not just by gestational age but also by what happens if active care is given, said another study leader, medical student Matthew Rysavy. 
 
 "A doctor might say 'no 22-week infant has ever survived,'" but that might mask the fact that doctors there don't try, because they don't consider such babies viable, he said. 
 
 Trying is not always the right thing to do, and could just prolong dying, independent experts said. Survival odds are influenced by many factors besides care, such as whether the baby is a twin, and even gender — girls tend to fare better. 
 
 "We just seem to be resuscitating more and more tinier babies, and there are consequences," said Dr. Jonathan Muraskas, a neonatologist at Loyola University Medical Center in Maywood, Illinois. 
 
 Despite medical advances, the rates of cerebral palsy, blindness, deafness, asthma and other major problems have not changed much, he said. 
 
 "How low do we go and what are the implications?" he said. 
 
 The study is in Thursday's New England Journal of Medicine. 
 
 About 12,000 babies each year in the United States are born between 22 and 25 weeks gestation. A full-term pregnancy is about 40 weeks. 
 
 Tundi and Nate Brady faced this twice, with different outcomes, when she went into labor with twins around 23 weeks into her pregnancy at University of Iowa Hospitals and Clinics. When the first twin was born, "it was very clear" that doctors did not think she would survive, so the couple declined life support and the baby died 20 minutes later, Tundi Brady said. 
 
 But then her labor stopped and she was able to go another week until her son, Dexter, was born weighing about a pound. Doctors estimated he would have a 40 percent chance of surviving and a 70 percent chance of disability if he did. 
 
 "That was good enough for us," so they chose aggressive treatment, she said. He spent five months in a neonatal intensive care unit and is now a healthy 5½-year-old whose only major medical issue is needing oxygen when he sleeps. 
 
 "We were so lucky," she said. 
 
 The study involved nearly 5,000 babies born before 27 weeks gestation at 24 hospitals in a research group run by the National Institutes of Health between April 2006 and March 2011. 
 
 Researchers looked at rates of comfort care versus active treatment, such as breathing machines, feeding tubes or heart resuscitation. Active treatment was given to 22 percent of babies born at 22 weeks, 72 percent of those at 23 weeks and nearly all beyond that. 
 
 Survival rates were higher for the actively treated babies — 23 percent versus 5 percent for all babies in the study born at 22 weeks, and 33 percent versus 24 percent for those born at 23 weeks. 
 
 Survival without severe impairment also was higher with treatment: 15 percent versus 3 percent at 22 weeks, and 25 percent versus 18 percent at 23 weeks. 
 
 Four hospitals never actively treated babies at 22 weeks, but five other hospitals always did. 
 
 Hospitals' actions had "a dramatic influence" on how infants fared, Dr. Neil Marlow of University College London commented in the journal. Just giving parents survival statistics without saying whether treatment was attempted "is misleading and helps to make poor survival a self-fulfilling prophecy," he wrote. 
 
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 Online: 
 
 Journal: http://www.nejm.org 
 
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 Marilynn Marchione can be followed at http://twitter.com/MMarchioneAP ||||| Advances in medicine have significantly improved outcomes for babies born between 22 and 25 weeks gestation – but not all hospitals provide the care that can save tiny babies, according to research published today. 
 
 Researchers, including UAB's Dr. Wally Carlo, director of the division of neonatology, set out to determine why survival rates among extremely premature babies varied so much from hospital to hospital. They found that some hospitals rarely provided active treatment to babies born at 22, 23 or 24 weeks, according to data from nearly 5,000 births at 24 hospitals. Carlo is one of several co-authors on the study published today in the New England Journal of Medicine. The lead author is Matthew Rysavy, a fourth-year medical student at the University of Iowa. 
 
 The decision to provide treatment to extremely premature babies is a difficult one, because mortality rates are high for these tiny patients. Some babies who survive suffer permanent injuries that can leave them partially or completely disabled. For that reason, some hospitals mostly provide comfort care for babies born at 22 or 23 weeks, allowing the patients to pass away without major intervention. 
 
 Infants at hospitals that provide active treatment the most often have significantly higher rates of survival and lower rates of disability, according to the study. Lumping together the outcomes for babies who received active treatment and those who didn't creates a grim prognosis for extreme preemies. Carlo said more doctors need to be aware of the success rates for active treatment. 
 
 "The main message is that there's potential for more babies to survive without major or severe impairment at gestational ages that physicians once thought was impossible," Carlo said. 
 
 Babies born at or before 25 weeks of pregnancy are considered extremely pre-term, according to the Mayo Clinic. Extremely premature infants usually weigh less than two pounds, have translucent skin and fused eyelids. Most importantly, organs such as the lungs are not developed enough to support life without medical intervention. 
 
 In recent years, neonatologists have been treating more babies born extremely early with surfactant therapy, tracheal intubation, ventilator support and other therapies. Babies born at 22 weeks have an overall survival rate of 5.1 percent, but those who receive active treatment have a survival rate of 23.1 percent. Most of them survive without severe impairment, according to the study. 
 
 A few weeks can make an enormous difference for premature babies. More than 81 percent of babies born at 26 weeks survive. 
 
 While active treatment can help extreme preemies, there is still a limit to what doctors can do. Babies born earlier than 22 weeks have very little chance of survival, Carlo said. Their organs are simply not ready for life outside the womb. Efforts to save babies younger than that may result in needless suffering, and could simply delay the inevitable death, Carlo said. 
 
 "The concern is that you would treat them, and they would live a few days and ultimately die," Carlo said. "That would not be good." 
 
 But as technology advances, the limits of viability can change. Twenty or 30 years ago, doctors usually couldn't save babies born before 28 weeks, Carlo said. But now, more babies born as early as 22 weeks gestation are surviving. 
 
 "The message that potential parents can take is that there is a good chance for survival with a good outcome, even for extremely premature babies," Carlo said.
– A new survey of hospital practices may make it more common for doctors to actively treat a baby born at 22 weeks, at least a week younger than the generally accepted standard for viability, reports the New York Times. The study in the New England Journal of Medicine found that hospitals that chose to treat babies at that age, rather than providing "comfort care" until they die, had at least limited success: Babies at 22 weeks did not survive without active treatment, but they had a survival rate of 23% if they received it. Of the 18 survivors, six had serious issues such as cerebral palsy, blindness, or deafness as toddlers. One of the major takeaways of the study is that hospitals vary widely in their preemie practices, with no real standard on what the treatment cutoff should be, reports the AP. "It confirms that if you don't do anything, these babies will not make it, and if you do something, some of them will make it," the chief of neonatology at the University of Florida, who was not involved with the study, tells the Times. "Many who have survived have survived with severe handicaps." This is the first major assessment of preemie care, and while it shows that most 22-week-olds don't make it, the results could raise pressure on hospitals with a higher age for treatment cutoff to lower it. "The main message is that there's potential for more babies to survive without major or severe impairment at gestational ages that physicians once thought was impossible," a researcher from the University of Alabama at Birmingham tells AL.com.