Neonatal care has come a long way in a short time, says Sharon Ní Chonchúir.
EVERY day is a fight when you arrive early into the world. That’s according to the latest heart-wrenching TV ad for Pampers.
The ad follows the real-life stories of families with premature babies in Southampton General Hospital in Britain. It shows the tiny babies in their incubators, all wired up and being fed by tubes.
It shows how careful their parents have to be when they hold them and, in a heart-warming moment, it shows them finally leaving the hospital and going home.
The ad marks the launch of the new Pampers Preemie Protection range of nappies. which are three times smaller than regular new-born nappies and are suitable for babies weighing as little as 1.8lbs (800g).
It’s just the latest example of the progress that has been made in treating premature babies. In the 1960s, there was no tube feeding, no ventilators, or even any neonatal intensive care units (NICUs).
In fact, it wasn’t until US president John F Kennedy and his wife Jackie lost a baby, Patrick, who was born at 35 weeks in 1963, that neonatology as a speciality was born.
Even as recently as the 1980s, babies born earlier than 28 weeks were usually classified as stillbirths because their survival rates were so low.
Today, those babies have a 95% chance of survival, while those born as young as 23 weeks have a 29% chance.
The World Health Organisation defines premature birth as occurring at less than 37 weeks’ gestation. There are approximately 4,500 of these in Ireland every year.
Margaret O’Driscoll, a clinical midwifery manager in Cork University Maternity Hospital (CUMH), was terrified when she first started working with premature babies in 1980.
“I was afraid of how small they were and I thought that only adults could tell you their aches and pains,” she says.
“But, 37 years later, I’ve learned that babies can tell you everything you need to know in their own little ways and I wouldn’t work anywhere else.”
The way these babies are treated has changed entirely in O’Driscoll’s time.
Babies born prematurely are often unable to breathe without support.
Nowadays, they are immediately rushed to the NICU where they are put on ventilators to help their breathing and once they begin breathing for themselves, they are transferred to a continuous positive airway pressure machine (CPAP), which delivers the exact amount of oxygen needed.
All the while, they are attached to monitors, which record their every breath and heartbeat.
Their digestive systems can also be underdeveloped. This means that they don’t have a suck reflex and need to be fed through a tube.
“We keep their incubators warm and humidified,” says O’Driscoll.
“Warm because these infants can’t control their body temperature and humidified because they are used to water in the womb.”
Other modern developments include administering antenatal steroids to mothers at risk of premature labour. These mature the baby’s organs in advance of birth and reduce the risk of brain bleeds.
“There is no silver bullet that improves the outcomes for these babies but a multitude of factors,” says Eugene Dempsey, a professor of paediatrics at UCC, and a consultant neonatologist at CUMH.
“The introduction of these antenatal steroids in the mid-90s was a game-changer. If babies who are delivered at 23 weeks receive these steroids before they are born, their chances are significantly better.”
Magnesium sulphate is also given to mothers at risk of premature labour to reduce the risk of cerebral palsy.
Prof Dempsey identifies other positive developments.
“The establishment of tertiary care centres is one factor,” he says.
“Having hospitals like the Coombe, Holles Street, the Rotunda and ourselves here in Cork, where there is a huge amount of expertise on site means that babies do better,” he says.
“If mothers can be moved here prior to delivery, they do even better again.”
He also says that medical staff are constantly striving to improve delivery room management.
“How we handle babies in their firstfew minutes can have a significant impact,” he says.
“Take ventilation, for example. A lot of premature babies need it but like all interventions, it does have side-effects so we are constantly looking at how we do it so that we can do it in the best way possible for the baby.”
There has also been a move away from formula feeding for premature babies.
“Using breastmilk reduces the risk of necrotising enterocolitis, a potentially fatal condition that attacks he intestine,” says Prof Dempsey.
Cork University Maternity Hospital also takes a multidisciplinary approach to how it treats new-born babies.
“On my ward rounds, I am accompanied by a pharmacist, a dietician, an occupational therapist, a speech and language therapist and a physiotherapist,” says Prof Dempsey.
“We all have a role to play in the baby’s treatment so it’s best if we all work together.”
Prof Dempsey and the entire medical team at CUMH regularly participate in trials that aim to enhance the prognosis for premature babies.
“Unless we continue to challenge the current treatments and ask questions, we are not going to improve the outcome for babies,” he says.
Current trials include managing low blood pressure in premature babies; looking at how long the umbilical cord should be left attached after birth; and ways of nebulising the surfactant (which is what babies’ lungs are missing) so that there is no longer any need for mechanical ventilation.
As a result of these ongoing medical advances, many premature babies survive and go on to lead healthy lives.
Sandra Govern, 42 and from Drogheda, is all too well aware of the role these medical advances have to play. Her first pregnancy ran into difficulty at 29 weeks.
“My membranes ruptured and I was in the labour ward for 48 hours, on steroids for the babies lungs,” she explains.
“Then I was moved upstairs to the pre-labour ward where I stayed for the next five weeks, in virtual isolation because of the risk of infection.”
Her pregnancy reached 34 weeks and five days, at which time a C- section was scheduled. However, the complications didn’t end there.
“During the operation, they discovered I had fibroids and that the baby was fused to my stomach,” she says.
“They struggled to get her out and I lost one-and-a-half pints of blood.”
Her baby — Faith — was taken to the NICU before she could see her.
“The first time I saw her was when the midwife brought a photo of a baby with a million tubes coming out of her,” says Govern.
“Thirty-six hours passed before I could see her for myself.”
Faith had a healthy weight (5lbs 8oz) but she had problems. An infection in her lungs meant she couldn’t breathe properly and she was intubated so that her lungs could develop further.
“At that stage, I was afraid I was going to pull all her wires out and break her,” she recalls.
Govern went home a week after her C-section but Faith stayed in hospital for one more week.
“It was difficult to leave the hospital without her but I was also afraid of my life when we did eventually get her home,” she says.
“Thankfully, everything has gone well since then. Faith had gastroenteritis a week after coming home and had to go back to hospital for one day but that’s the only issue we’ve had in the 15 months since.”
Indeed, everything has gone so well that she decided to have another baby and is expecting her second in mid-September.
Govern is currently being closely monitored by the staff at Lourdes Hospital in Drogheda.
“If I won the Lotto, I’d build them a whole new wing,” she says.
“They looked after Faith so well.”
Despite the best medical efforts, some premature babies do not survive their early start.
Lisa Keeley, 26, from Clondalkin, lost her first baby in January 2014.
She was 25 weeks pregnant when her waters broke and she was immediately rushed to hospital.
“I was told that if I held on for more than 48 hours, the chances were that the baby would continue to term,” says Lisa.
She held on and her condition stabilised to the extent that she was released from hospital three weeks later, on the condition that she reported for check-ups every two days.
Then, when she was 30 weeks and five days pregnant — she went into labour.
Her baby boy Justin was born weighing three pounds and 11 ounces.
“He needed oxygen immediately so I never got to hold him,” she says.
“They wrapped him in a blanket to keep him warm, showed him to me, and brought him to the NICU.”
Everything seemed positive at first.
“Justin was born at five to one and at 2.30pm someone came to tell me he was doing fine,” she says.
“But then at 9pm, the consultant appeared and told me he had died.”
A subsequent autopsy revealed he had contracted an infection of the intestine called necrotising enterocolitis. Since then, she has had another baby. Ayla was born in July 2015.
“I was up the walls during the pregnancy, frightened that she’d be taken off me like Justin was,” she says.
“But the hospital couldn’t have been better. I was seen every two weeks from week eight and Ayla was born healthy at 38 weeks and has been doing great since then.”
Ongoing developments in neonatology mean there will be fewer cases like Justin’s in the future.
CUMH’S Margaret O’Driscoll can already testify to the fact that there are fewer deaths than there were in the past.
“The smallest baby that I’ve looked after was born at 23 weeks and weighed 440g,” she says.
“She was smaller than a pound of butter but everything was there, right down to the fingernails, and she’s running around somewhere today.”
Experiences like this are what keep her going.
“Parents constantly send us photos of their happy and healthy children and they bring them in to see us around their birthdays,” she says.
“Seeing them all doing so well makes the difficult days worth it.”
Families with premature babies who need advice and support can contact Irish Premature Babies at www.irishprematurebabies.com or the Irish Neonatal Health Alliance at inha.ie
Reasons to be hopeful
* 15 million babies worldwide are born prematurely every year. In Ireland, a premature baby is born every 116 minutes.
* In 2015 (the latest year for which statistics are available), 4,411 babies out of a total of 65,869 were born before they came to term. Of those, 3,637 were born between 32 and 36 weeks. 526 were born between 28 and 31 weeks and 248 were born at less than 28 weeks.
* Survival rates are improving all the time. Babies born at 23 weeks have a 29% chance of survival. This goes up to 46% at 24 weeks, 69% at 25, 78% at 26 and 90% at 27. Babies born at 28 to 33 weeks gestation have up to a 95% chance and those born at 34 weeks onwards have the same likelihood of survival as a full-term baby.
* The causes of premature births are still not fully understood. 30% of women who go into labour prematurely have membrane rupture. Another 15% to 20% of these births occur because of medical issues arising with the mother or the baby. However, in up to 50% of cases, premature births occur spontaneously with no known cause.
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