A baby born at 23 weeks of gestation is classified as an extremely preterm infant, often called a micro-preemie. This gestational age falls right at the edge of the fetal viability threshold, where survival outside the womb becomes physiologically possible with intensive medical support. The decision to pursue active resuscitation for an infant born at 23 weeks is complex in neonatal medicine. Advancements in technology and specialized care have made survival a reality, but the journey through the Neonatal Intensive Care Unit (NICU) is long and marked by significant medical challenges.
Survival Rates and the Viability Threshold
The concept of “viability” refers to the point when a fetus can potentially survive independently, generally considered to be between 22 and 25 weeks. For an infant born at 23 weeks, the probability of survival is highly variable, depending heavily on the hospital’s specialized care and intervention policy. Current data indicates that for infants receiving active resuscitation and intensive care, the survival rate to hospital discharge is approximately 55 to 60 percent. This rate reflects continuous advancements in neonatal medicine.
The wide range in reported outcomes globally highlights how local medical practice influences a baby’s chance of survival. Hospitals designated as Level IV NICUs, which offer the highest level of comprehensive care, consistently report the best outcomes. Active medical intervention, including the use of antenatal steroids given to the mother before birth, significantly increases the likelihood of survival. The infant’s outcome is a function of both biological maturity and the immediate availability of medical resources.
Biological Challenges of Extreme Prematurity
An infant born at 23 weeks faces immediate challenges because their organ systems are still immature. The lungs are the most profoundly affected organ, being in the canalicular phase, which is ill-equipped for gas exchange outside the womb. The air sacs (alveoli) have not fully developed, and the lungs cannot produce enough pulmonary surfactant. This substance keeps the air sacs from collapsing. This deficiency results in severe respiratory distress syndrome, requiring immediate mechanical assistance.
The brain is vulnerable due to the presence of the germinal matrix, a temporary, highly vascularized region that produces neurons and glial cells. The blood vessels in this area are fragile, making the infant susceptible to sudden changes in blood flow and pressure. This fragility puts the baby at high risk for intraventricular hemorrhage (IVH), which is bleeding into the brain’s ventricles. IVH occurs in approximately 45 percent of extremely low birth weight infants, and severe grades can lead to long-term neurological impairment.
The skin of a 23-week infant is thin and lacks the keratin layer needed to function as an effective barrier. This immaturity results in massive fluid loss through evaporation, which can be up to 15 times greater than that of a term infant. This uncontrolled loss leads to a high risk of dehydration and electrolyte imbalances, complicating fluid management and thermoregulation. Furthermore, the baby lacks the subcutaneous fat and neurological mechanisms required to conserve body heat, making them prone to hypothermia.
Critical Care and Life Support in the NICU
Survival for an extremely preterm infant depends entirely on complex, intensive care designed to compensate for the immaturity of every organ system. Respiratory support is the first and most sustained intervention, beginning with continuous positive airway pressure (CPAP) or, if needed, high-frequency oscillatory ventilation (HFOV). HFOV provides rapid, small-volume breaths that are less damaging to the delicate lung tissue than conventional ventilation. Immediately following birth, artificial surfactant is administered directly into the lungs to replace the missing compound and reduce the surface tension that causes the alveoli to collapse.
Maintaining a stable body temperature requires specialized interventions to manage massive heat loss. The infant is immediately placed under radiant heat and enclosed in a polyethylene plastic bag or wrap to create a barrier against heat loss. They are then moved to a double-walled incubator that uses servo-control technology to automatically adjust the ambient temperature and humidity, often maintaining humidity levels above 60 percent. This environmental control mimics the protective warmth and moisture of the womb.
Nutritional support begins intravenously with total parenteral nutrition (TPN). TPN is a sterile solution containing necessary macronutrients—glucose, amino acids, and lipids—delivered directly into the bloodstream through a central line. Because the digestive system is too immature to handle full feedings, TPN ensures the baby receives sufficient calories for growth. Small, non-nutritive volumes of breast milk, known as trophic feeding, are also introduced early via a tube to stimulate the gastrointestinal tract and promote gut lining maturation.
The process requires continuous monitoring of multiple physiological parameters, including heart rate, respiratory rate, blood pressure, and oxygen saturation. Fluctuations in these values can signal the onset of a complication, such as infection or a change in brain blood flow. This intensive surveillance, managed by a specialized team of neonatologists and nurses, ensures the baby’s fragile physiology is supported until their organs mature enough to function unassisted.
Long-Term Health and Developmental Outcomes
Infants who survive birth at 23 weeks face an elevated risk of long-term health and developmental challenges. One common chronic condition is Bronchopulmonary Dysplasia (BPD), a chronic lung disease resulting from damage caused by prolonged respiratory support and oxygen exposure. BPD can lead to persistent breathing difficulties, airway hypersensitivity, and increased hospital readmissions for respiratory infections.
The neurological vulnerability of the extremely preterm brain places survivors at high risk for neurodevelopmental impairments. The absolute risk of Cerebral Palsy (CP) is estimated to be around 8.5 percent for this group. CP is often linked to early brain injuries like severe IVH. Other neurodevelopmental outcomes include cognitive impairment, learning disabilities, and an increased incidence of Autism Spectrum Disorder.
Eye development is frequently affected, leading to Retinopathy of Prematurity (ROP), a condition where abnormal blood vessels grow in the retina. ROP can cause scarring that pulls the retina away, making it a leading cause of childhood blindness. Survivors also have an increased susceptibility to hearing loss, which may be caused by exposure to mechanical ventilation or certain necessary medications. Consistent, long-term follow-up and early intervention services are essential to address these conditions and maximize the child’s developmental potential.