J. Pediatr. (Rio J.) vol.92 número6

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www.jped.com.br

ORIGINAL

ARTICLE

Opinions

of

Brazilian

resuscitation

instructors

regarding

resuscitation

in

the

delivery

room

of

extremely

preterm

newborns

夽

,

夽夽

Cristiane

Ribeiro

Ambrósio

a,b

_,

_Maria

_Fernanda

_Branco

_de

_Almeida

c

_,

_Ruth

_Guinsburg

c,∗

a_Universidade_Federal_de_São_Paulo_(UNIFESP),_São_Paulo,_SP,_Brazil

b_Universidade_Federal_de_Uberlândia_(UFU),_Departamento_de_Pediatria,_Uberlândia,_MG,_Brazil

c_Universidade_Federal_de_São_Paulo_(UNIFESP),_Escola_Paulista_de_Medicina,_Divisão_de_Medicina_Neonatal,_São_Paulo,_SP,_Brazil

Received2October2015;accepted5February2016 Availableonline31May2016

KEYWORDS

Newborninfant;

Bioethics;

Resuscitationorders; Cardiopulmonary resuscitation; Fetalviability

Abstract

Objective: TodescribetheopinionsofpediatricianswhoteachresuscitationinBrazilon

initi-atingandlimitingthedeliveryroomresuscitationofextremelypreterminfants.

Method: Cross-sectional study with electronic questionnaire (Dec/2011---Sep/2013) sent to

pediatricianswhoareinstructorsoftheNeonatalResuscitationProgramoftheBrazilianSociety ofPediatrics, containingthreehypothetical clinicalcases:(1) decisiontostartthe delivery roomresuscitation;(2)limitationofneonatalintensivecareafterdeliveryroomresuscitation; (3)limitationofadvancedresuscitationinthedeliveryroom.Foreachcase,itwasrequested thattheinstructorindicate thebestmanagementforeachgestational agebetween23 and 26weeks.Adescriptiveanalysiswasperformed.

Results: 560(82%)instructorsagreedtoparticipate.Only9%oftheinstructorsreportedthe

existenceofwrittenguidelinesattheirhospitalregardinglimitationsofdeliveryroom resuscita-tion.At23weeks,50%oftheinstructorswouldinitiatedeliveryroomresuscitationprocedures. At26weeks,2%woulddecidebasedonbirthweightand/orpresenceoffusedeyelids.Among the participants,38%wouldre-evaluatetheir deliveryroom decision andlimitthe carefor 23-weekneonatesintheneonatalintensivecareunit.Asforadvancedresuscitation,45%and 4%oftherespondents,at23and26weeks,respectively,wouldnotapplychestcompressions and/ormedications.

夽 _Please_cite_this_article_as:_Ambrósio_CR,_de_Almeida_MF,_Guinsburg_R._Opinions_of_Brazilian_{resuscitation}_instructors_regarding_{resuscitation}

inthedeliveryroomofextremelypretermnewborns.JPediatr(RioJ).2016;92:609---15.

夽夽_Study_carried_out_at_the_Division_of_Neonatal_Medicine,_Department_of_Pediatrics,_Escola_Paulista_de_Medicina,_Universidade_Federal_de

SãoPaulo,SãoPaulo,SP,Brazil;andNeonatalResuscitationProgram,SociedadeBrasileiradePediatria,SãoPaulo,SP,Brazil.

∗_{Corresponding}_author.

E-mail:ruthgbr@netpoint.com.br(R.Guinsburg).

http://dx.doi.org/10.1016/j.jped.2016.02.012

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Conclusion: Difficultycan be observed regardingthe decision to not resuscitatea preterm infantwith23weeksofgestationalage.Atthesametime,asmallpercentageofpediatricians wouldnotresuscitateneonatesofunquestionableviabilityat26weeksofgestationalagein thedeliveryroom.

PALAVRAS-CHAVE

Recém-nascido; Bioética;

Ordensquanto

àConduta(Ética Médica); Ressuscitac¸ão Cardiopulmonar; ViabilidadeFetal

Opiniõesdosinstrutoresdereanimac¸ãobrasileirosquantoàreanimac¸ãoemsala departodeemrecém-nascidospré-termoextremos

Resumo

Objetivo: Descreveropiniõesdos pediatrasqueensinamreanimac¸ãonoBrasil arespeito de

iniciarelimitarareanimac¸ãoemsaladepartodeneonatospré-termoextremos.

Método: Estudotransversalcomquestionárioeletrônico(Dez/11-Set/13)enviadoaos

instru-toresdoProgramadeReanimaçãoNeonataldaSociedadeBrasileiradePediatriacontendotrês casosclínicoshipotéticos:1)decisãodeiniciarounãoareanimação;2)limitaçãoounãodos cuidadosintensivosapósareanimaçãoemsaladeparto;3)limitaçãoounãodareanimação avançadaemsaladeparto.Paracadacasofoisolicitadaaindicaçãodacondutaparacadaidade gestacionalentre23-26semanas.Aanálisefoidescritivapormeiodafrequênciadasrespostas.

Resultados: 560(82%)instrutoresconsentiramemparticipar.Apenas9%instrutoresafirmaram

existiremseuhospitalnormaescritasobrequandonãoiniciarareanimaçãoemsaladeparto. Com23semanas,50%dosinstrutoresfariamareanimaçãoemsaladepartoe,com26semanas, 2%baseariamsuadecisãonopesoaonascere/ounaaberturadafendapalpebral.Dos entrevis-tados,38%reavaliariamsuadecisãoelimitariamocuidadonaUTIamedidasdeconfortopara nascidosde23semanasreanimadosnasaladeparto.Quantoaosprocedimentosdereanimação avançada,45%e4%com23e26semanas,respectivamente,nãoindicariamtaismanobras.

Conclusão: Observa-se dificuldadenaopc¸ão denão reanimar neonatos com23 semanas de

gestac¸ãoe,aomesmotempo,umpequenopercentualdepediatrasnãoreanima,nasalade parto,neonatoscujaviabilidadenãoéquestionada(26semanas).

Introduction

Availabledataindicatethatinfantsatlessthan23weeksof gestationalagearetooimmaturetosurvivewiththecurrent

technology;ontheother hand,thosebornat 25weeksor

morehave significantsurvivalratesandalarge proportion ofthemsurvivewithoutseveresequelae.1---4_Thus,_using_as

guidethesurvivalratesofpretermneonates,theliterature, ingeneral,hasestablishedasthelimitofviabilitytheperiod between22 and 25 weeksof gestational age (GA),below whichthedegreeofbiologicalimmaturityisalimiting fac-tortolifeandabovewhichthebenefitoftreatmentisnot challenged.5,6

However,thereisgreatdifficultyindefiningtheproper managementforfetusesbornbetweentheselimits.During thisperiod,theuncertaintyoftheresultistherule,rather thantheexception,andisthereforereferredtoasthe‘‘gray area,’’ becausesurvival and prognosis areuncertain, and thereisdoubtaboutthebestapproachtobeusedandthe degreeofinvestmentandinterventiontobemade,sincethe dataavailablefordecision-makingarelimited,andalthough theyhelp,theydonotoverruletheuncertaintyorthe pos-sibility oferror. Forthe group ofinfants born in the gray area,twocoursesofactionarepossible:(1)restrictionof

life supportmeasures andthe possibilityof deathas out-come, orincreasein sequelaeifthepatientdoesnotdie; or(2)accesstoallavailabletechnology,havingaspossible outcomesdeathwithpainandsuffering, orthepossibility ofsurvivalwithhighratesofmajorsequelae,orthechance ofagoodclinicalevolution,withsurvivalwithoutsequelae orwithminorsequelae.5,7---10

Therefore, considering the multiple uncertainties, the NeonatalResuscitation Programof theBrazilianSociety of Pediatrics(ProgramadeReanimac¸ãoNeonataldaSociedade BrasileiradePediatria[PRN-SBP])recommendscautionand, considering the additionalinformation obtained after the birth,thedecisionnottoresuscitatemaybemadebythe medicalteaminthedeliveryroomor,ifdoubtsremain,the teammust resuscitate thepatient,take him tothe NICU, and then gather the necessary information, including the family’swishes,inordertoeventuallylimitthelifesupport measures.

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whatBrazilianphysicians thinkabouttheseethicalissues. Thus,theaimofthisresearchwastodescribetheopinions ofpediatricianswhoteachresuscitationinBrazilregarding thedecisionstoinitiateandlimitresuscitationofextremely pretermnewbornsinthedeliveryroom,basedon hypotheti-calclinicalcases,comparingthemaccordingtotheBrazilian macro-regionwheretheprofessionalworks.

Method

After being approved by the Research Ethics Committee

of Universidade Federal de São Paulo and the Board of

theBrazilian Society of Pediatrics,a cross-sectionalstudy

was carried out from December 2011 to September 2013

with pediatricians who were active PRN-SBP instructors.

Sample size calculation was not performed, because the

study aimed to evaluate the universe of active PRN-SBP

instructors.

An electronic questionnaire wasdeveloped, using as a

basis the tool validated and utilized by Martinez et al.11

AllactivePRN-SBPinstructors receiveda linktothe ques-tionnaireby email anda personal password access. After enteringthepassword,theinstructorreceivedan explana-tionof theresearch,and afteragreeingtoparticipateby acceptingtheinformedconsent,accesstothequestionnaire wasprovided.

Thequestionnairehadthreeaxes.Thefirstaxisreferred to the characterization of the interviewee, with demo-graphic and professionaldata. The second axis contained 17 multiple-choice questions and an obligatory answer regarding the current practices on neonatal resuscitation andethicalissuesinvolvedintheresuscitationofextremely pretermneonates.Thelastaxisdiscussedthethreeclinical casesthatarethefocusofthisstudy.Theresponsecontrol foreachinstructorwasaccessibleonlytothemain investiga-tor,andanonymitywasguaranteedregardingthetabulation ofresults.

Asforthethreeclinicalcases,thefirstoneconcernedthe decisiontostartresuscitationinthedeliveryroom:Youare calledurgentlytothedeliveryroomtoassistavaginalbirth ofatwinpregnancy.Thefirsttwinwasbornwithirregular breathingandthesecondwasbornwithpoorvitality,with apneaand bradycardia.Therewasnotime totalktothe parentsaboutresuscitation.Indicate,foreachgestational age(23,24,25,and26weeks),thechoice regardingyour management:1)Youresuscitatethetwonewborns;2)You donotresuscitatethesecond,butresuscitatethefirst;3) Youdonotresuscitateeitherofthem;4)Youverifyifthe eyelidsarestillfusedineachnewbornandmakethe deci-siontoresuscitate;5)Youverifythebirthweightofeach patientandmakethedecision.

The second case concerned the limitation or not of neonatalintensive care afterresuscitation in thedelivery room:Assumingthatthetwonewbornsfrom Case1 were resuscitated in the delivery room by the on-duty pedia-trician,whoreferredthemtotheNICUwhereyouareon call.Currently,thepatientsareinthetransportincubator, receiving free flow oxygen and showing intense respira-toryeffort.Indicate,foreachgestationalage(23,24,25, and26weeks),thechoiceregardingyourmanagement:1) Providecomfortcare(heatandfreeflowoxygen);2)Provide

continuous positive airway pressure (CPAP) nasally; 3) Providemechanicalventilationandsurfactant.

The third case addressed the limitation of advanced resuscitation in the delivery room: You are called to the deliveryroomtoassistanextremelypretermneonateborn duetoplacentalabruption.Youtalkbrieflytothemother andexplain about the possibility ofthe child being born in critical condition and dying in the delivery room. The motherasksthateverythingbedonetosavethenewborn’s life.Thepatientisbornshowingapneaandsevere brady-cardia,isquicklyintubatedafterfailedmask ventilation, andremainswithheartrate(HR)<60bpmdespiteadequate ventilation.Indicate,foreachgestationalage(23,24,25, and26weeks),thechoiceregardingyourmanagement:1) Indicatechestcompressionsandadrenaline,andconsiders umbilicalcatheterizationforvolumeexpansion;2)Maintain onlyventilation,transferthepatienttotheNICU,andwait forthe newborn’sdeath;3)Suspendventilationandwait forthenewborn’sdeathtooccurinthedeliveryroom.

Thestatistical analysiswasdescriptive. Thequalitative variablesweredescribed by frequencyof events, andthe quantitative variables, by measures of central tendency. All answers were analyzed for the group as a whole and according tothe regionwhere instructors worked (North, Northeast,andMidwestvs.SouthandSoutheast).The com-parison of the responses according to the five Brazilian macro-regions where the interviewed instructors worked wascarriedoutbychi-squaredtest,withalevelof signifi-canceofp<0.05.

Results

During the study period, there were 829 instructors, of

whom130wereinactiveand14refusedtoparticipate.Thus,

the final target population of the study consisted of 685

activePRN-SBPinstructors.Ofthese,560instructors(82%) answeredthequestionnaire.Thedistributionofinstructors

whoansweredthequestionnaireperstaterangedfrom76%

(São Paulo) to 100% (Amazonas, Rondônia, Roraima, and

EspíritoSanto).

Thegeneralcharacteristicsoftherespondentsareshown inTable1.Themeanageoftherespondentswas45±9years (range:27---67). As for religion, of the 517 whoprofessed theChristianfaith,68%wereCatholics,15%Spiritualists,7% wereevangelicalProtestants,and2%professedother Protes-tantbeliefs.Intermsofplaceofresidence,theinstructors weredistributedasfollows:68(12%)intheNorth,179(32%) intheNortheast,36(6%)intheMidwest,208(37%)inthe Southeast,and 69 (12%) in theSouth, with363 (65%) liv-inginthestate capitalsand197(35%)inthecountryside. Regardingtrainingandprofessionalperformance,thetime sincegraduationfrommedicalschoolwasonaverage22±9

years(range:4---45)andthetimeworkinginneonatologywas 16±8years(range:1---40).

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Table1 Generalcharacteristicsofthe560instructorsof theNeonatalResuscitationProgramoftheBrazilianSociety ofPediatricswhoparticipatedinthestudy.

Variable Number Percentage

Age≥45years 296 53

Femalegender 440 79

Stablerelationship 435 78

Haschildren 443 80

Christian 517 92

Religionisveryimportant 349 62 BoardCertificationin

Pediatrics

467 83

BoardCertificationin Neonatology

306 55

Neonatologypractice ≥10years

403 73

Worksinadeliveryroom 490 88 Worksinapublichospital 419 75 Worksinauniversityhospital 243 43 WorksinaNeonatalICU 452 81 Personalexperiencewith

end-of-lifedecisions

226 40

ICU,intensivecareunit.

weightby 299(67%),with33%reportingthatthey

consid-eredgestationalageasthesolecriterionforthedecision,5% reportedconsideringonlybirthweight,and62%considered bothcriteria.For355(80%)respondents,thereported ges-tationalageusedtolimitresuscitationwasbelow24weeks,

andfor263(59%)pediatricians,thebirthweightlimitwas 500g.

Table 2 shows the percentage of answers to the alternatives related to Case Study 1, according to the gestacionalage(GA)ofeach patient.The greatertheGA, the greaterthe chance theinterviewee wouldresuscitate the two twins. However, even at 23 weeks, 50% of the assessedresuscitationinstructorswouldresuscitatethetwo neonates; at 26 weeks, 2% would base their decision on thebirthweightand/orthepresenceoffusedeyelids.This behavior wasobserved for the instructors asawhole and alsoaccordingtotheirworkarea(chi-squared:p=0.694).

Table 3 shows the percentage of answers for the alternativesrelatedtoCase2accordingtotheGAofeach patient. The greater the GA, the greater the chance the respondentwouldoffer fullintensive care, i.e., mechani-calventilationandexogenoussurfactantreplacement.Part oftherespondentsconsideredthepossibilitythatoncethe neonatewasresuscitatedinthedeliveryroom,theywould reviewthedecisionandprovidecomfortcareintheNICU, as38%oftheassessedpediatricianswouldlimittheICUcare tocomfortmeasuresfornewbornsat23weekofGA effec-tively resuscitated in the delivery room, the same being mentionedby3%ofrespondentsforneonatesat26weeks. Suchbehaviorisobservedfortheinstructorsasawholeand alsoaccordingtotheirareaofwork(chi-squared:p=0.141). Table 4 shows the percentage of answers for the alternatives relatedtoCaseStudy 3,according tothe GA of eachpatient.It isobserved onceagainthat thehigher theGA,thegreaterthechancethattheintervieweewould offer advanced resuscitation, starting chest compressions andmedicationstoresuscitatethenewborn.At23weeks,

Table2 Decisiontostartresuscitationintwinswhenthefirsttwinhad,soonafterbirth,irregularbreathingandthesecond twinhadapnea,accordingtogestationalageandtheBrazilianregionwherethepediatricianworks.

22weeks 23weeks 24weeks 25weeks 26weeks p-Value

Resuscitatesbothtwins 0.694

Brazil 191(35%) 276(50%) 431(78%) 504(91%) 528(95%) SouthandSoutheast 96(36%) 151(56%) 218(81%) 254(94%) 262(96%) North,Northeast,andMidwest 95(34%) 125(46%) 213(77%) 250(91%) 266(97%)

Resuscitatesonlythefirsttwin 0.621

Doesnotresuscitateeithertwin 0.443

Brazil 195(35%) 104(19%) 19(3%) 4(0.7%) 3(0.5%) SouthandSoutheast 102(38%) 51(18%) 8(2%) 1(0.2%) 1(0.2%) North,Northeast,andMidwest 93(34%) 53(18%) 11(3%) 3(1%) 2(0.4%)

Verifiesthepresenceoffusedeyelidstodecide 0.567

Brazil 52(9%) 55(10%) 31(6%) 12(2%) 1(0.2%) SouthandSoutheast 22(7%) 24(7%) 19(6%) 6(2%) 1(0.2%) North,Northeast,andMidwest 30(10%) 31(12%) 12(5%) 6(2%) Zero

Verifiesbirthweighttodecide 0.167

Brazil 50(9%) 47(9%) 27(5%) 15(3%) 12(2%)

SouthandSoutheast 25(9%) 23(9%) 8(3%) 5(2%) 6(2%) North,Northeast,andMidwest 25(9%) 24(8%) 19(6%) 10(3%) 6(1%)

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Table3 TypeofcareprovidedtothetwinsinCase1attheneonatalintensivecareunitifthosepatientshadbeenresuscitated, accordingtogestationalageandBrazilianregionwheretheinterviewedpediatricianswork.

Offerscomfortcare 0.141

OffersnasalCPAP 0.491

Providesmechanicalventilationandsurfactant 0.566

p-Value,significancelevelaccordingtothechi-squaredtest.

55% of the assessedinstructors would offer full advanced

resuscitation to the patient and, at 26 weeks, 4% would

interruptresuscitationeffortsinthissituation.Such behav-iorisobservedforinstructorsasawholeandalsoaccording totheirregion(chi-squared:p=0.738).

Discussion

Themostimportantfindingsofthisstudyare:thesignificant

response rate (82%), which allows us toknow anddepict

the practices of professionals who teach resuscitation in

thedeliveryroominBrazil;thedifficultyinchoosingnotto resuscitatechildrenatthelowerlimitofthegrayzone,at 23weeksofgestation;thepresenceofasmallpercentageof pediatricianswhodonotresuscitateneonatesinthedelivery roomwhoseviabilityisnotquestioned(26weeksgestation);

the extreme difficulty in the delivery room management

for neonates with24---25 weeksof gestation,with hetero-geneousandnotnecessarilyconsistentopinions;andfinally,

thefactthatthereportedneonatalresuscitationpractices arerelativelyuniforminBrazilfromaregionalpointofview. Inasimilarquestionnaireondecisionsmadeinthe

deliv-ery room sent to neonatologists in the state of Illinois,

UnitedStates,theresponseratewas66%.Amongthe

neona-tologists who answered the questionnaire, 55% said they

wouldnot resuscitatea neonate bornat 22 weeksof GA,

astheupperresuscitationlimitfor85%ofthese profession-alswouldbe23---25weeks.12 _Those_authors_concluded_that

physicians,todecideonresuscitationinthedeliveryroom, areinfluencedbytheparents’opinionaswellastheirown experienceandopinion.Moreover,thefearofbeingsuedand theethicalteachingsduringmedicaleducationalsoplayan importantroleinthisdecision.Peerzadaetal.,13 _in_2006,

reportedthat94%ofSwedishneonatologistswhoanswered aquestionnaireconsideredfutileanytreatmentinneonates below23weeksofgestationandthatresuscitationofthose at23weekshaduncertainbenefits,statingtheywouldnot followtheparents’wishesiftheywantedresuscitation.The findingsof this study show a very differentprofile of the

Table4 Managementofaborninpoorconditionduetoplacentalabruption,thatmaintainsheartrate<60bpm,evenafter intubation,whenthemotherhasrequestedthateverythingshouldbedonetosavethenewborn’slife,accordingtogestational ageandBrazilianregionwheretheinterviewedpediatricianswork.

Offersadvancedresuscitation 0.738

InterruptsPPV,transferstoICU,andwaitsfordeath 0.576

InterruptsPPVandwaitsfordeathinthedeliveryroom 0.811

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assessedpediatricians. Brazilian physicians have difficulty

in making the decision not to start resuscitation, as 50%

of resuscitation instructors would start resuscitation in a patientat 23 weeks, a fact that is in opposition totheir

own opinions, since 88% of them have previously

consid-eredthattheGAlimitforresuscitationshouldbearound24

weeks.Thismismatchbetweenwhatpediatricianssaythey

practiceandwhatthey thinkis theidealinvolves several issues,especiallythe lack of clear guidelinesand criteria forthelimitationoftherapeuticefforts,inadditiontothe

misperceptionsthatpermeateanswersthatdependon

con-ceptsrelatedtowhatisethical,whatismoral,andwhatis legal.Suchbehavioralsoseemstobethereality in South America,asFajardoetal.14 _showed_in₂₀₁₂_that, _in_Latin

Americancountries,theusualpracticeistoprovide inten-sivecareandnottolimitlifesupport,differentlyfromwhat ispracticedinNorthAmericaandEurope.

Regarding advanced resuscitation, there seems to be great dissent among the instructors who participated in the study in relation to providing chest compressions and medications to extreme preterm infants, as 45% of respondents wouldnot perform advanced resuscitation in 23-weekneonates,while55%wouldperformtheadvanced procedures.Extremelypretermnewbornswhoreceive car-diopulmonaryresuscitationinthedeliveryroomhavea 2.9-to3.7-foldhigherriskofdeathand1.5-to2.3-foldhigher riskofsevereneurologicaldamageinrelationthegroupof patientswhodonotneed thisinterventioninthedelivery room.15,16

Itis alsoworthmentioningthat, althoughthereareno recommendations in this respect, fused eyelids and birth weightalsoguided the decisionregarding resuscitation in the delivery room for several interviewees. Perhaps this is due tothe fact that, in practice, GA is not accurately knownin asignificant numberofcases,which meansthat pediatricians try to estimate it throughparameters that, althoughinaccurate,approximatelyreflectextreme prema-turity. Fusedeyelids are present in approximately 20% of livebirthswithGAbetween24and27weeks,andthus,this conditionisnotagoodparameterfordecision-makinginthe deliveryroom.17_Birth_weight_should_also_be_considered_with

caution,asthereis nodirect association between weight andmaturityofthenewborn,withtheobstetricestimateof fetalweightbeingaccurateinonly15---20%ofcases.18,19

Another interesting point observed in this study was relatedtowhere oneshouldwait forthe deathof infants forwhomthedecisionnottoresuscitatewasmade.There is some difficulty for Brazilian pediatricians in keeping the newborn together with the parents in the delivery room, which is a guideline of the American Academy of Pediatrics.20_Such_conduct_may_be_due_in_part_to_the_PRN-SBP

guidelines,whichrecommend,whenindoubtorwhenthere isscarcedatatomakeadecision,andespeciallywhenthe GAisnotknown,thatitisbettertoresuscitateinthe deliv-eryroomandpostpone thedecisiontolimit therapyuntil later,when more datacan be obtained tobetter support thedecision.

Despitethewealthofinformation,thestudyhas limita-tions,especiallythe factthat it isbased onanswerstoa questionnaireandonhypotheticalclinicalcases,whichmay significantlydifferfromtheprofessional’sperformanceina real-lifescenario.Anotherissueisrelatedtothechoiceofa

questionnairewithclosedanswersonasubjectinwhichthe subtletyofspeechmayreflectwidevariationsinpractice. Despitetheselimitations,thisisthefirststudythatdiscloses the opinionsof Brazilian pediatricians regarding interven-tionsearlyinlife.

Moreover, even in the international scenario, the extremelyhighpercentageofquestionnaire responsesand thefactthattherespondentsrepresenttheentire popula-tionofopinionmakersregardingneonatalresuscitationare points to be highlighted, and can be usedfor the devel-opmentof clearerguidelinesonthe ethicaldilemmas the pediatrician faces when treating newbornsat the limit of viability.

This study represents an initial step to understand whatpediatricians thinkandhowtheyactin thedelivery room.Thequestionnaireindicatesthattheresuscitationof extremelypretermnewbornsispermeatedbyambivalence andcontradictions. Afrank andcomprehensive debateon thesubjectduringmedicalgraduation,pediatricresidency and neonatal fellowshipis essential toprovide a broader basis for the discussionand supportof resuscitation deci-sions related to the beginning of life in the presence of borderlinematurityconditionsforextrauterinesurvival.

Conflicts

of

interest

Theauthorsdeclarenoconflictsofinterest.

Acknowledgements

The authors would like to thank the PRN-SBP instructors

fortheirimportantcollaboration;theStateCoordinatorsof PRN-SBPforencouraginglocalparticipation;andthe Brazil-ianSocietyofPediatricsforsupportingtheresearchinthe contextoftheNeonatalResuscitationProgram.

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http://www.sbp.com.br/pdfs/PRN-SBP-Reanima%C3%A7%C3% A3oNeonatal-atualiza%C3%A7%C3%A3o-1abr2013.pdf [cited 09.03.15].