Saving Preemies

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by Jeffrey Kluger,

from TIME Magazine,

Dedicated caregivers are helping the tiniest babies survive—and thrive.

David Joyce was born Jan. 28–well shy of his April 16 due date–in an emergency cesarean section after his mother had begun bleeding heavily. He weighed 2 lb. 11 oz., or 1,200 g, and was just 15 in. (38 cm) tall. An American Girl doll is 3 in. (8 cm) taller. What all this meant was that if David wanted to stay alive, he’d have to work hard at it, and he has.

At the neonatal intensive care unit (NICU) of the Children’s Hospital of Wisconsin in Milwaukee, David had spent every day of his then seven-week life, in the company of 58 other very fragile babies being looked after by a round-the-clock SWAT team of nearly 300 nutritionists, pharmacologists, gastroenterologists, ophthalmologists, pulmonary specialists, surgeons, nurses and dietitians and, for when the need arises, a pair of chaplains.

Under their care, he had grown to 18.1 in. (46 cm) and weighed 5 lb. 11.5 oz. (2,594 g), nourished by breast milk from his mother Melissa Hilger, 26, which was fed to him through a nasogastric tube threaded through his nose to his stomach.

There was a time when David would not have stood a chance. According to government statistics, in 1960 the survival rate for infants under 1,500 g, or 3.3 lb., was 28%. In 2010 it was 78%, and a lot of that improvement has occurred just since the 1980s. The survival for any one baby is dictated first by the calendar. Come into the world at 22 weeks and you have only a 5% chance of making it out of the hospital alive. The odds improve to 26% at 23 weeks, 56% at 24 weeks, 76% at 25 weeks and up into the high 90s at 32 weeks and beyond. Even then, the battle’s not won, since the longer a baby remains in the womb, the fewer health problems there will be later. Still, survival is the first goal.

“Every decade since the 1960s, the age of viability has been reduced by a week,” says Dr. Edward McCabe, medical director of the March of Dimes Foundation.

This kind of progress inevitably raises tough questions. If you can keep a 22-weeker alive, what about 21 weeks, 20 weeks? How low is it fair to go if survival means a lifetime of prematurity-related disabilities? Seventeen percent to 48% of preterm babies, for example, will have some kind of neuromotor abnormality, including cerebral palsy. Cost is another issue. The March of Dimes calculates that babies born before 32 weeks’ gestation run up an average hospital bill of $280,811. Other estimates are lower, but either way, preemie care isn’t cheap. How much of a burden on a family–and suffering by a baby–makes sense?

Fortunately, for most preemies things are not this dire. Thanks to advances that had not been made even a few years ago, the odds of surviving and thriving are improving all the time. Lives that once might have begun and ended in a NICU can now be lived long and well–and there are many reasons that’s true.

The biggest change in the care of preemies occurred very recently–in the past two years, in fact. In 2012 the American Academy of Pediatrics decided to set that right, calling for the formalization of the standards applied to all three levels as well as the creation of a new Level IV designation for NICUs that not only have the staff and ORs to handle the toughest cases but are centrally located and can gather in families from the largest geographical footprint possible.

Fixing the Problems. While the 37-week guideline is the broad rule for how long any one preemie will remain in the NICU, innovative treatments are being developed to get all preemies home sooner and stronger. One of the most powerful–and newly appreciated–therapies is as old as the human species: just plain holding babies as much as possible, a technique called kangaroo care.

More and more, however, the life is saved, the baby does come home, and there are plenty of sunny days and starry nights ahead. In some ways, the work of a NICU will always seem like an exercise in disproportion–an army of people and a mountain of infrastructure caring for a pound of life. But it’s a disproportion that speaks very well of us. The babies, increasingly, are reaping the benefits.

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