Neonatology Gives the Tiniest a New Lease on the Riskiest Time of Life: the First Month
Why, with the recent progress, is the U.S. still only 14th on the infant mortality list?
Because we still have a very high rate of prematurity, the leading cause of death in infants. We haven't been able to crack that.
What is the cause of prematurity?
We don't know. In 50 percent of the cases there is no apparent cause. Some experimental drugs, like Ritodrine, may eventually prevent early delivery by relaxing the muscles in the uterus. These drugs need more study, though.
Which women are most likely to give birth prematurely?
Women under age 16 or over age 40. Multiple births and first births also run a higher risk of prematurity and other complications. We know that black and unwed women run a higher risk, but we aren't sure why. It's been suggested that alcoholism, smoking, poor nutrition and other factors associated with poverty may be the cause. Yet the research is inconsistent. American Indians have the same problems, yet they have very few premature births.
What progress has been made in saving preemies?
A decade ago a baby weighing less than two pounds rarely survived. Today, between 50 and 70 percent of them make it. Above three pounds, we can save about 98 percent. Now we are down to one pound. We've even had a 14-ounce baby survive.
What techniques have made these breakthroughs possible?
Monitoring of the fetus has enabled us to predict and prepare for complications at birth. Through amniocentesis, we can detect the Rh-positive blood factor and a number of genetic diseases. Through ultrasound pictures, we can monitor congenital heart disease in the fetus, as well as skeletal malformations and the baby's position in the womb. After birth, ultrasound can diagnose brain hemorrhages, which were difficult to recognize before.
Will infant deaths continue to drop?
Yes. In the last decade neonatology—the branch of pediatrics that deals with the first 28 days of life—has matured. We now have excellent training programs, boards that test doctors' competence and a growing number of hospitals delivering special care.
What is special about the 28-day period, and why does it end then?
We don't know for sure, but it seems to be a natural time of biological adjustment. Even in the Old Testament and the Jewish Talmud, the uniqueness of this period was recognized. In Jewish law, a child is not considered a person until it is 30 days old.
Haven't newborns always received close attention?
Since the early 1900s they have, to some degree—but just premature babies. It wasn't until the late '30s that hospitals began to develop special nurseries for premature infants, and these were usually just incubator stations to keep babies warm and disease-free. In the '40s doctors began to learn more about feeding techniques and babies' response to antibiotics. The revolution really dates to the '60s, when physicians realized that all sick newborns, not just premature ones, needed special attention.
Are you against home delivery?
The child certainly runs a risk. Complications can occur that simply can't be dealt with. Even if a hospital is close, you may not be able to get the baby there fast enough to avert permanent injury or even death. My compromise position is that all hospitals should provide a homelike atmosphere and not force technology on the parents.
What is the best type of delivery?
I favor any method in which the mother is not heavily sedated. Sedation also affects the baby. Most of the time it is unnecessary. Lamaze is one good technique because it prepares the mother psychologically for birth and lessens her need for drugs.
How dangerous are the first weeks of life?
Very. One-third of all deaths in childhood occur on the first day of life. In the first week there are more deaths than in the next 30 years. Altogether, 67 percent of deaths related to birth occur in the first 28 days.
What perils face an infant in the first month?
For full-term as well as premature babies, respiratory problems including pneumonia and hyaline membrane disease, which coats the air passages in the lungs, are the major threat. After these come a variety of infections. Despite a sophisticated array of medicines, the bugs are still winning. But with better nursing care, correct dosages of antibiotics and the rapid development in the '70s of the intensive-care nursery, we've been able to cure many of these ailments.
What services are offered in an intensive-care nursery?
Superb surgery is available: Cysts and tumors can be removed, congenital heart defects corrected. Every metabolic function is monitored, and where necessary, intravenous feeding and respirators are connected to bolster immature organs. There are fluorescent phototherapy lamps for treating jaundice stemming from liver disorders. A team of doctors and nurses is present to swing into action within seconds after birth, which is what you need if you're going to save lives.
What is the cost of treating a baby in an intensive-care nursery?
Rates range from $400 to $600 a day. In rare cases requiring hospitalization for up to six months, the bill can go as high as $150,000. The total, however, is usually split between insurance companies and government programs, with the parents picking up the smallest share.
Who decides when treatment should be withdrawn?
The courts have left this to physicians. We make every effort until a child has no hope of surviving. The crucial factor is brain function: Will a child be able to live in at least a semi-independent way?
Do the parents have the final say?
We consult them at great length and keep them advised of what we're doing at every step. Parents are often willing to stop treatment before the doctors are. They say they feel their child has suffered enough.
Are parents able to visit their babies in the intensive-care nursery?
Yes. We encourage them to at any time of the day or night. They can hold the baby, bring clothing and toys for the crib. Siblings are welcome, too.
What are the emotional strains parents face when their baby comes home?
They often feel they will never be able to care for the infant. After all, so many specialists and so much equipment has been required to do the job. So we reassure them and gradually increase their responsibility.
What are a premature baby's prospects for living a healthy life?
Studies are ongoing, but approximately 95 percent of all premature babies grow up completely healthy. As many as one-third of those who have required care in an intensive-care nursery, however, may have lasting neurological problems. About one or two percent emerge mentally retarded or otherwise seriously impaired.
How do you respond to the criticism that neonatology is simply adding to the ranks of the handicapped and retarded?
That was a widespread fear when intensive-care nurseries got going. But I think we've proven it a myth. You see, we aren't just giving children who would have died a life with handicaps; we're raising the level of care for all babies. So now, many infants who would have had to live with handicaps are enjoying normal lives.