Christy King went into labor the morning of Aug. 26. It was not a happy occasion.

Barely 23 weeks into her pregnancy with triplets, King and her husband, Rob, had been warned that challenging times lay ahead.

Each of their children would weigh in at just over a pound. The infants' skin, lungs, eyes and digestive and circulatory systems would be woefully unprepared for life outside the womb. The Kings, first-time parents, would not be able to touch their babies. Doctors and nurses would use extreme care handling them.

If the babies lived, each one would likely need multiple surgeries and other interventions, but even the most advanced care might not save them. Survivors could be blind, deaf, brain damaged and afflicted with at least some neurological, physical and developmental problems.

Neonatologists at WakeMed asked the inevitable and painful question: Did the Kings want doctors to do everything possible to keep their triplets alive? Or would they prefer the infants receive no medical care and instead be allowed to pass on as their parents held them?

The question put the Kings, who live in North Raleigh, at the center of one of medicine's most emotionally charged and difficult ethical debates. How early is too early to try to save the youngest and most fragile premature infants, and how should decisions regarding their care be made?

A panel of British medical experts weighed in on the question in the fall, releasing a report that recommends withholding life-sustaining treatment from infants born at 22 weeks or earlier. A pregnancy is considered full-term at 38 weeks.

A considerable variation

The panel's recommendation might sound extreme, but it isn't controversial among neonatologists -- specialists trained to care for premature infants. Most agree that there is little point in resuscitating babies born at 22 weeks. Their tiny bodies are simply too immature to survive, even with state-of-the-art care.

But there is considerable variation in whether life support is provided to babies born just a week or so later, as the King triplets were. That's where the real ethical dilemmas lie.

These extreme cases make up just a small fraction of the roughly 500,000 infants born prematurely each year in the United States. In North Carolina, babies born before 24 weeks -- infants born at what neonatologists call the "border of viability" -- account for perhaps a few hundred of the approximately 16,000 premature babies born in the state each year.

However, medical care provided to these babies accounts for a disproportionate share of the more than $26 billion spent on premature infants annually in the United States. A 2003 study found that neonatal hospitalization costs for infants born earlier than 25 weeks averaged $202,000, though bills can be much higher. That's nearly 200 times the $1,100 spent on the same care for a healthy, full-term newborn, the study found.

Every decision different

Nationally, 30 percent of 23-week preemies, at best, survive with intensive care. Some hospitals, including WakeMed, typically provide these preemies with routine life support only, such as mechanical ventilation. Whether to provide more aggressive care -- or no life support at all -- often depends on the parents' wishes.

"There's no cookie-cutter approach," said Dr. Thomas Young, a senior neonatologist with WakeMed Faculty Physicians. "Every situation is a little bit different, and every decision is a little bit different."

Other neonatal programs, such as the one at Duke University Hospital in Durham, routinely start 23-week preemies on mechanical ventilators and cardiac support. Parents, with guidance from physicians, might decide later whether to withdraw such care if devastating complications occur.

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