Neonatal palliative care and end-of-life decision-making

Overview & Definition

Picture a couple at 22 weeks' gestation, told their baby has a lethal skeletal dysplasia, or a 24-week preterm infant whose severe intraventricular haemorrhage is now complicated by progressive hydrocephalus. Your job is not to decide alone, and it is not to walk away. It is to work out, with the family, what is now in this baby's best interests, and to make the time the baby has as good as it can be. [1] [8]

Neonatal palliative care is active, holistic care of the fetus or newborn with a life-limiting or life-threatening condition, and of their family, focused on quality of life, comfort and dignity whether or not disease-directed treatment continues. It is not a euphemism for doing nothing, and it is not only what happens at the very end. A lethal anomaly discovered antenatally opens perinatal palliative care, which begins at the diagnosis and runs through pregnancy, delivery and the newborn period so that the family is prepared and supported rather than ambushed by crisis. [2] [3]

A few terms do most of the work. A life-limiting condition is one with no realistic prospect of long survival or cure (anencephaly, bilateral renal agenesis); a life-threatening condition is one where cure is possible but may fail (extreme prematurity, severe HIE). Life-sustaining treatment for a newborn includes ventilation, CPR, surgically placed nutrition and hydration, and cardioactive drugs. Withholding means never starting such a treatment; withdrawing means stopping one already begun, and the two are morally equivalent. [11] [10]

The phrase that binds it all is the best-interests standard: for a baby who cannot decide for themselves, you weigh the benefits of continued treatment against its burdens from the baby's point of view, with the parents as partners and a second senior clinician and the team in consensus. When treatment can no longer achieve its goal, you limit disease-directed care, intensify comfort, and stay with the family. [10]

Classification

Start from when the question arises, not from a statute book. The pathway you follow depends on whether the life-limiting condition is recognised antenatally, at the threshold of viability, after birth, or during an unexpected deterioration — and the safeguards are the same in every pathway. [8]

The antenatal pathway opens when fetal imaging or testing diagnoses a lethal anomaly — anencephaly, bilateral renal agenesis, a complex chromosomal syndrome, or an inoperable cardiac lesion. Here perinatal palliative care begins before birth: a plan is made with the parents for a bereavement-prepared delivery and, often, comfort-focused care from the moment of birth. [2] [3]

The periviability pathway engages at the threshold of viability, where gestation, birthweight and condition make prognosis genuinely uncertain. Here the decision is rarely comfort-versus-cure at the outset; it is about the intensity of resuscitation and intensive care, made with the parents on the basis of the best available prognostic data. [7] [8]

The postnatal diagnosis pathway opens when a life-limiting or life-threatening condition is found after birth, or when a progressive condition evolves. Palliative care is introduced in parallel with disease-directed therapy so that the transition, if it comes, is a shift of emphasis rather than an abrupt abandonment. [6] [10]

The unexpected deterioration pathway engages when a newborn arrests or deteriorates without a plan — a catastrophic brain injury, a sudden collapse. Here you ask whether resuscitation itself is non-beneficial, and whether a time-limited trial is more honest than an irreversible decision made under pressure. [12] [11]

[2] [7] [10]

Epidemiology & Risk Factors

Most newborns who die in intensive care do so after an active decision to limit or redirect treatment rather than after failed resuscitation, and this pattern has held across neonatal units over recent decades. Descriptive work in neonatal intensive care shows that withdrawal or withholding of life-sustaining treatment precedes the majority of deaths, not the reverse. [5] [6]

The newborns most often facing end-of-life decisions share recognisable profiles: extreme prematurity with severe brain injury, lethal or complex congenital anomaly, severe hypoxic-ischaemic encephalopathy, inoperable complex congenital heart disease, and progressive lethal metabolic or neuromuscular disease. Antenatal diagnosis has shifted some of these conversations earlier, into pregnancy, where perinatal palliative care can be planned. [1] [2]

The threshold of viability is where prognostic uncertainty concentrates the difficulty. Outcomes after extremely preterm birth are strongly related to gestational age, birthweight, sex, antenatal corticosteroids and singleton versus multiple gestation, but no single factor is decisive, and the band of genuine uncertainty is wide enough that shared decision-making with the parents is the only defensible approach. [7] [8]

Conflict grows where the 'false hope' window stays open. Evolving prognoses, optimistic early messaging, and families told different things by different clinicians all feed a sense that more time will bring a different answer. Prior loss, mistrust, cultural or religious expectations of miracle, adolescent parents, and low health literacy each raise the chance that a redirection conversation lands as abandonment. [9] [6]

Social determinants change access to the supports that make neonatal palliative care humane. Rurality and remoteness, migrant or refugee status, poverty and language discordance all alter whether a family meets perinatal palliative care, ethics support and bereavement services before a crisis forces the conversation in a delivery suite at three in the morning. [6] [9]

[1] [5] [6]

Pathophysiology

There is no enzyme for futility, but there is a mechanism. The trajectory of the underlying condition shapes when redirection becomes appropriate, and the balance between benefit and burden shifts as the disease evolves. [12]

A fatal anomaly opens life with the burden side of the balance already exceeding the benefit side — an anencephalic newborn cannot survive, and intensive intervention adds suffering without altering the outcome. A progressive condition shifts the balance over time as burdens accumulate, so a baby who 'tolerated' intensive care a fortnight ago may now be bearing a burden that no longer buys meaningful benefit. An irreversible catastrophic brain injury opens what Wilkinson called the window of opportunity — a period when prognosis is clearest and a redirection, if it is to happen, is most defensible; as time passes the picture muddies and the same decision becomes harder to make and to execute well. [12] [8]

Physiological futility is a factual claim: the treatment cannot achieve its goal, so a ventilator cannot oxygenate, or CPR cannot restore a perfusing rhythm. Qualitative (overall) futility is a value judgement: even if the treatment works physiologically, the overall burden to the baby exceeds any achievable gain. Both can justify limitation, but only the first is purely factual — which is why qualitative futility demands shared deliberation with the parents, not a unilateral declaration at the cot side. [11] [10]

Cumulative burdens erode the benefit side silently. Pain, repeated procedures, prolonged ventilation, loss of bodily integrity, and separation from family all count, and they accrue in a newborn who cannot tell you they have had enough. The dying process itself generates predictable symptoms — pain, agitation, dyspnoea, secretions and seizures — and a redirection plan that ignores them produces a distressed death. This is why withdrawal of ventilation is reframed as an active comfort procedure: opioid and benzodiazepine are given for symptom relief, the family is present, extubation is planned, and aftercare is arranged. [4] [11]

[10] [12] [4]

Clinical Presentation

From the doorway, a well-run neonatal redirection meeting looks calm, private and unhurried. The room is right, the right people are present, a professional interpreter is booked if needed, and it is clear who is leading the conversation and why it is happening now. [6]

An antenatal counselling session for a lethal fetal anomaly presents the perinatal palliative care decision. The couple has just received devastating news, and your task is to give them space, share what is and is not known, and begin to shape a plan for the pregnancy, the delivery and the baby's care at birth — without rushing them toward a decision they are not ready to own. [2] [3]

A periviable infant in the delivery room presents the intensity-of-care decision. Here the question is rarely comfort-versus-cure from the first breath; it is whether to offer full intensive care, a modified or delayed approach, or comfort care, decided with the parents on the best available prognostic information and revisited as the baby's course unfolds. [7] [8]

An extreme preterm infant with progressive post-haemorrhagic hydrocephalus and cystic periventricular leukomalacia presents the limitation question on the unit. Each week of complications narrows the prognosis, and the window-of-opportunity logic applies: a decision reached in the clearest window is more defensible than one deferred until the picture is muddy. [12] [5]

A term infant with severe hypoxic-ischaemic encephalopathy unresponsive to therapeutic hypothermia presents the acute withdrawal decision. Here the prognosis, not the family's wishes alone, may drive the team's recommendation, and the timing of the conversation matters. [12]

A family may present ambivalence, false hope, or a request to 'do everything' that masks unspoken fears — fear of their baby dying in pain, of being abandoned by the team, of losing their child without having tried. A reassuring, agreeable family can still hide an outdated or misunderstood plan, so you check what is actually documented, not just what was said. [9] [6]

Differential Diagnosis

When the team feels a newborn is being overtreated, your first task is to work out what kind of problem it is. The label changes everything downstream. [10]

[10] [11]

Discriminate physiological futility from a prognosis you simply find grim. A neonatal treatment is physiologically futile only when it cannot achieve its goal; a low probability of survival in extreme prematurity is not the same as futility, and conflating them forecloses a time-limited trial that might still be appropriate. [11] [7]

Distinguish a redirection decision from brain death. Brain death in the newborn is death; testing for it follows age-specific clinical and, where required, ancillary criteria, and it is not a treatment withdrawal. Conflating the two is a serious and examinable error. [11]

Separate a value dispute from a factual dispute. When the team and parents disagree about the prognosis, more information, a second opinion and time may resolve it. When they disagree about what an acceptable outcome would be for this baby — what counts as a life worth living — that is a value dispute, and it belongs with ethics and, if needed, the courts. [10]

When prognosis is uncertain, prefer a time-limited trial over a permanent decision. Treat intensively to a defined endpoint — a number of days, or a specific reassessment — and agree in advance what will happen if the trial fails. This respects uncertainty without committing a newborn to indefinite non-beneficial treatment. [10] [12]

Clinical & Bedside Assessment

Open a neonatal redirection meeting by setting the scene and giving a warning shot. Name who is present, state that the meeting is about the direction of care for the baby, and prepare the parents before delivering hard information. [6]

Then assess the medical facts that drive the balance. What is the diagnosis and prognosis? Is the deterioration reversible or a progression of the underlying condition? Can the treatment still achieve its goal, or is it physiologically futile? What cumulative burden has the baby already borne? [11] [10]

Assess the parents' understanding, values and fears. What matters most to this family? What would they want for their baby? What cultural, spiritual or faith framing shapes how they hear the prognosis? Bring trusted community or faith support into the room when the family wants it, and always use a professional interpreter when there is any language barrier — never a family member. [6]

Bring a second senior clinician and the wider team to consensus before proposing redirection. A limitation recommendation that comes from one registrar in isolation is fragile; one that emerges from the treating team, documented and shared, is defensible. [10]

Assess whether prognosis is certain enough to redirect now, or whether a time-limited trial is more honest. Certainty is rare in neonatology, and a defined trial often serves the baby better than a premature permanent decision. [10] [12]

Assess the baby's current symptoms and anticipate the dying process. Pain, agitation, dyspnoea, secretions and seizures are predictable, and a comfort plan that ignores them produces a distressed death. [4]

Investigations

There is no blood test for best interests, but several investigations confirm the irreversibility or prognosis that a neonatal redirection decision rests on. Cranial ultrasound, MRI, EEG and amplitude-integrated EEG clarify prognosis after brain injury, and metabolic and genetic testing define lethal syndromes; they inform but never replace the best-interests judgement. [12] [8]

A time-limited trial of intensive neonatal treatment is itself the investigation of an uncertain prognosis. When you cannot know whether a baby will recover, you treat intensively to a defined endpoint and then reassess, turning uncertainty into information rather than paralysis. [10]

Multidisciplinary inputs function as adjuncts to the decision. Perinatal palliative care, clinical ethics, social work, chaplaincy and allied health each bring a perspective the treating team lacks, and involving them early is part of the assessment, not an admission of failure. [6]

Symptom assessment tools guide comfort care after a redirection decision. Validated neonatal pain and discomfort scales help you anticipate and treat what the dying process will produce, so comfort is planned, not improvised. [4]

In extreme prematurity, prognostic markers — gestational age, birthweight, sex, antenatal corticosteroid exposure and singleton versus multiple gestation — inform but never replace the best-interests judgement, and the wide band of uncertainty is exactly why the decision is shared with the parents. [7]

When a redirection decision is genuinely contested, the appropriate 'investigation' becomes the consultation itself: a second opinion, an ethics consultation, or legal advice is the right next step rather than another scan. [10]

Management — Resuscitation

When a newborn with an active comfort or limitation plan deteriorates, you escalate comfort, not resuscitation. An active limitation order means you do not initiate CPR or escalation the plan has already judged non-beneficial. [11] [10]

Distinguish a reversible intercurrent event from progression of the underlying condition. A baby on a comfort plan may still develop a treatable, distressing problem — a blocked tracheostomy, a painful fracture, a treatable seizure — and you treat what relieves suffering even as you hold the overall direction. [4]

If a newborn arrests before any plan exists, ask whether resuscitation itself is non-beneficial. In a baby with end-stage disease, a prolonged arrest, or a clearly irreversible cause, CPR may add burden without benefit, and the team may reasonably not attempt it — but this judgement must be defensible and documented. [11]

Allocate roles so comfort and family support run in parallel. One clinician leads symptom care, another supports the family, and the comfort plan is handed over explicitly at every shift change so the direction of care never depends on who is on. [6]

Reframe withdrawal of neonatal ventilation as an active comfort procedure. Opioid and benzodiazepine are given for symptom relief, the family is present, extubation is planned, the baby is held skin-to-skin where possible, and aftercare is arranged — this is the opposite of abandonment, and the family needs to hear that. [4] [11]

Anticipate and treat the reversible symptoms of dying: pain, dyspnoea, agitation, secretions and seizures are predictable, and a comfort plan that does not address them produces a distressed death. [4]

Management — Definitive & Stepwise

Use a sequence you can defend out loud in a viva, anchored on the best-interests balance and the perinatal palliative care framework. [1] [10]

[1] [6]

Structure the conversation with a recognised framework — SPIKES, the Serious Illness Conversation Guide, or Ask-Tell-Ask. Set the scene, ask what the parents understand and what matters most, give a warning shot, share the prognosis honestly, explore their values, and agree a plan you both own. [6]

Decide between continuing treatment, a time-limited trial, and comfort-focused care using the certainty of prognosis. When the trajectory is clear and burdens outweigh benefits, redirect. When it is uncertain, run a time-limited trial with a defined review date. [10] [12]

Operationalise a neonatal DNACPR or Allow Natural Death decision as part of an overall comfort plan, never as an isolated order. An order that says 'no CPR' but leaves ventilation, escalation, symptom care and feeding undefined is incomplete and examinable. [11]

End-of-life symptom management in the newborn

The predictable symptoms of the neonatal dying process are pain, agitation, dyspnoea, secretions and seizures, and each has a comfort regimen. The doses below are example regimens reproduced from a neonatal end-of-life symptom management review — verify every dose against your local neonatal protocol and pharmacy guidance before use, and titrate to the baby's comfort. [4]

For pain, oral, sublingual or intravenous morphine at 0.05 to 0.1 mg per kg per dose every 3 to 4 hours is a typical starting regimen, titrated to comfort. For agitation and irritability, exclude and treat pain first, then add morphine for dysphoria or intravenous midazolam at 0.05 to 0.1 mg per kg per dose. For dyspnoea and air hunger, morphine at the same weight-based dose relieves the sensation of breathlessness, supported by positioning and gentle suction. For secretions (the 'death rattle'), glycopyrrolate at 0.04 to 0.1 mg per kg per dose orally or intravenously every 4 to 6 hours, with repositioning and family reassurance, is standard. For seizures, intravenous phenobarbital at a 20 mg per kg loading dose, with midazolam for clusters, treats promptly for comfort. [4]

[4]

The fear that opioid or benzodiazepine will shorten a dying newborn's life is a recognised barrier that causes under-treatment and distressed deaths. The doctrine of double effect applies: the intended outcome is relief of suffering, the dose is titrated to comfort, and any life-shortening effect is foreseen but unintended. Under-treating a dying baby's pain to avoid this fear is not neutral — it is harm. [4] [11]

Conduct a planned withdrawal with attention to setting, family presence, symptom medication given before extubation, and aftercare. Integrate perinatal palliative care early and in parallel with disease-directed therapy, so comfort expertise is already in place when the balance shifts. [1] [6]

Specific Subtypes & Scenarios

Antenatal diagnosis of a lethal fetal anomaly. Begin perinatal palliative care before birth. Plan a bereavement-prepared delivery, agree what will and will not be offered at birth, and where appropriate offer comfort-focused care from the moment of delivery with the family present. [2] [3]

Periviable infant at the threshold of viability. The decision is about the intensity of resuscitation and intensive care, shared with the parents on the best available prognostic data. Avoid presenting comfort care and full intensive care as the only two options — a modified or time-limited approach often fits the uncertainty best. [7] [8]

Extreme preterm infant with severe bilateral IVH and progressive hydrocephalus. The window-of-opportunity logic applies: prognosis is clearest early. Weigh the probability of severe neurodevelopmental outcome against the burden of prolonged intensive care, and either continue, run a time-limited trial, or redirect to comfort — with the family, second neonatologist and team. [12] [5]

Newborn with inoperable complex congenital heart disease. Transition from cardiac surgical intent to comfort by redefining success. Parallel-track palliative care early so the shift is a change of emphasis, not an abrupt abandonment of the team the family trusts. [6]

Term infant with severe HIE unresponsive to therapeutic hypothermia. Apply the window-of-opportunity logic. Confirm prognosis with neuroimaging and electrophysiology, and if recovery to a meaningful baseline is not achievable, bring a recommendation to the family within the clearest window. [12]

Progressive lethal metabolic or neuromuscular disease. Run a goals-of-care conversation early in the disease course, not only at the terminal admission, so the plan is documented and survives an out-of-hours deterioration. [10]

Parents requesting continued ventilation the team judges futile. This is a value dispute, not a factual one. Engage ethics consultation, mediation and a second opinion; if consensus cannot be reached, seek a court declaration rather than overriding or capitulating unilaterally. [10]

Parents expecting a miracle, from a faith community or migrant background. Use a professional interpreter, pace the conversation for trauma, and bring a trusted faith leader into the room. Honour the hope while sharing the prognosis honestly. [9] [6]

Adolescent or very young parents of a life-limited newborn. Communicate age-appropriately, assess decision-making capacity, and bring extra psychosocial support; the gravity of the decision is the same even when the parents are themselves children or adolescents. [6]

Sudden unexpected deterioration before any plan. Recognise when resuscitation itself is non-beneficial — a prolonged arrest in a baby with end-stage disease — and shift the team's energy to family-centred care rather than continuing CPR that cannot succeed. [11]

Complications & Pitfalls

• Treating an isolated DNACPR/Allow Natural Death order as a complete neonatal comfort plan. [1]
• Equating the emotional weight of withdrawing neonatal ventilation with a moral difference from never starting it. [11]
• Declaring futility unilaterally without a second neonatologist, the MDT and ethics input. [10]
• Conflating brain death in the newborn with a treatment-limitation decision. [11]
• Continuing invasive neonatal treatment past the point of benefit because no one raised limitation early. [12]
• Withholding opioid or benzodiazepine for fear of respiratory depression, causing a distressed death. [4]
• Using family members as interpreters for high-stakes neonatal end-of-life meetings. [6]
• Framing comfort care as giving up rather than redirecting to the baby's comfort and the family's experience. [9]
• Failing to anticipate and treat the predictable symptoms of the neonatal dying process. [4]
• Letting a value dispute escalate to court without first trying ethics consultation, mediation and time. [10]

[1] [4] [11]

Prognosis & Disposition

A good neonatal palliative process pays off in the short term. A peaceful death, better family bereavement adjustment and reduced staff moral distress all follow a conversation in which the parents understood, were heard, and felt accompanied to the end. [6] [9]

A time-limited trial is an appropriate disposition while neonatal prognosis evolves. Treat intensively to a defined endpoint, agree in advance what happens if the trial fails, and convert the trial into a definitive plan at the reassessment rather than letting it drift. [10]

A contested redirection may require keeping the baby in hospital pending ethics or court resolution. Do not discharge a deadlock to an unsafe environment, and do not press ahead with a unilateral withdrawal while a value dispute is live. [10]

Some newborns can be discharged home on a comfort plan with community palliative and bereavement support. Coordinate with community services, write an accessible plan, and ensure the family knows who to call and what to expect. [6]

Court or guardianship processes change who must be notified. Hand over the comfort plan at every shift change — what will and will not be offered, what symptom medication is in place, and what escalation is live — so the direction of care never depends on who is on. [1]

Bereavement follow-up and staff debrief belong to the disposition, not an afterthought. A structured debrief helps the team process a difficult withdrawal, and bereavement contact with the family — including sibling support — closes the relationship rather than ending it abruptly. [6] [9]

Special Populations

Periviable and extremely preterm infants. Decisions turn on gestation, condition, long-term neurodevelopmental outcome and parental values; prognostic uncertainty is the norm, and shared decision-making is the only defensible approach. [7] [8]

Newborns with severe neurodisability or lethal chromosomal syndromes. Avoid quality-of-life bias. Weigh benefits and burdens in the baby's own terms and lived experience, not in an outsider's projection of what their life is worth. [10]

Technology-dependent newborns. Review the ceiling of care and goals over time. A tracheostomy, home ventilation or feeding tube that was right may, as a condition progresses, sit above the burden line. [6]

Newborns of adolescent or very young parents. Communicate age-appropriately, assess capacity, and bring extra psychosocial and safeguarding support. [6]

Indigenous families. Run culturally safe, kinship-inclusive goals-of-care conversations. Identify kinship decision-makers and respect wishes around dying on country where the family seeks it, while still verifying legal authority. [6]

Migrant and refugee families. Use professional interpreters, pace the conversation for trauma, and explain local norms and palliative services the family may not know exist. [9] [6]

Out-of-home care and child-protection contexts. Identify the statutory decision-maker for a major neonatal limitation decision. Routine care may sit with the carer; a limitation decision usually does not. [10]

Faith communities expecting miracle. Engage respectfully and honestly. Share the prognosis, avoid false reassurance, and bring a trusted faith leader into the conversation when the family wants one. [9]

Socioeconomic disadvantage and low health literacy. Use teach-back, plain language, time and written materials. A plan a family cannot understand or afford to enact at home is not a workable disposition. [6]

Rural and remote families. Plan transport, local support and telehealth so a comfort plan is enactable close to home rather than only in a distant tertiary centre. [6]

Evidence, Guidelines & Regional Differences

Catlin and Carter's 2002 neonatal end-of-life palliative care protocol is the landmark that gave neonatology a structured approach to palliative care, and it set the expectations — comfort, family presence, memory-making and bereavement — that the field now takes for granted. [1]

Breeze, Lees and colleagues established perinatal palliative care for the prenatally diagnosed lethal fetal anomaly, and Limbo and Wool's framework articulates the trajectory of perinatal palliative care from diagnosis through delivery and bereavement. [2] [3]

Kenner, Press and Ryan's recommendations set a family-centred, integrative standard for palliative and bereavement care in the NICU, while Lam and colleagues' descriptive report of end-of-life practices in two NICUs grounds the field in observed rather than theoretical care. [6] [5]

For prognosis at the threshold of viability, the EPICure cohort (Wood, Marlow, Costeloe and colleagues) remains the foundational anchor for the neurodevelopmental outcomes that frame periviability counselling. [7]

The general best-interests and limitation machinery applies directly to the newborn: the RCPCH 2015 Larcher framework and Truog's 2008 SCCM consensus establish the benefits-versus-burdens balance, the moral equivalence of withholding and withdrawing, and active, planned, family-centred end-of-life care. Wilkinson's window of opportunity shapes the timing of withdrawal after catastrophic neonatal brain injury, and Meert and colleagues set out parental bereavement needs that the disposition must meet. [10] [11] [12] [9]

For the symptom burden of the dying newborn, Cortezzo and Meyer's review consolidates the comfort regimens — morphine, midazolam, glycopyrrolate and phenobarbital — that underpin neonatal end-of-life symptom management, and is the source for the doses reproduced on this page. [4]

[1] [7] [11] [4]

Exam Pearls

[1] [4] [11]

References

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2. [2]Breeze AC, Lees CC, Kumar A, Missfelder-Lobos HH, Murdoch EM Palliative care for prenatally diagnosed lethal fetal abnormality. Arch Dis Child Fetal Neonatal Ed, 2007.PMID 16705007
3. [3]Limbo R, Wool C Perinatal Palliative Care. J Obstet Gynecol Neonatal Nurs, 2016.PMID 27497619
4. [4]Cortezzo DE, Meyer M Neonatal End-of-Life Symptom Management. Front Pediatr, 2020.PMID 33042931
5. [5]Lam V, Kain N, Joynt C, van Manen MA A descriptive report of end-of-life care practices occurring in two neonatal intensive care units. Palliat Med, 2016.PMID 26934947
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7. [7]Wood NS, Marlow N, Costeloe K, Gibson AT, Wilkinson AR Neurologic and developmental disability after extremely preterm birth. EPICure Study Group. N Engl J Med, 2000.PMID 10933736
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11. [11]Truog RD, Campbell ML, Curtis JR, Haas CE, Luce JM, Rubenfeld GD, Rushton CH, Kaufman DC Recommendations for end-of-life care in the intensive care unit: a consensus statement by the American College of Critical Care Medicine. Crit Care Med, 2008.PMID 18431285
12. [12]Wilkinson D The window of opportunity for treatment withdrawal. Arch Pediatr Adolesc Med, 2011.PMID 21383270