Based on local registry findings, the survival rate for preterm babies at 26 weeks gestational age is almost 45%. Those born at 27 weeks have a survival rate of about 50%; and those at 29 weeks, about 80%. After 31 weeks gestation, the survival rate is 90%.
Besides the survival rate, there is the quality of life to consider.
Preterm babies or premies, depending on how early they are, can have no health problems or all sorts of health concerns.
In the United States, preterm babies make up about 8-10% of all deliveries (according to the US National Library of Medicine).
Dr Irene Cheah, consultant paediatrician and neonatologist, says that of the deliveries in Malaysian government hospitals, about 20,000 of the total 480,000-490,000 in a year are preterm.
This means about 4-5% of deliveries in local government hospitals are preterm.
Reasons for preterm
Babies are born premature because of maternal or baby factors.
Among them are:
* The mother has an infection in the uterine area.
* The mother has kidney problems, high blood pressure or other medical conditions.
* The mother needs to go for cancer therapy.
* The baby is not growing well or the growth is slowing down. This means that the placental environment is no longer healthy.
* Cervical incompetence.
* Multiple babies. This will definitely be a pre-term delivery because there's just a limited space in the uterus.
Delaying the birth
If the mother comes to the hospital as soon as she detects signs of labour, the birth can be delayed by a day with drugs.
In the United States, this is done with the use of nitroglycerin patches. In Malaysia, drugs called tocolytics are used instead.
Dr Cheah urges parents to come in to the hospital as soon as possible if they detect labour symptoms but are not at 40 weeks yet.
“It's important for parents to detect that they could be in labour and to come in early because then the doctors can slow down the labour if they are in established labour. This will delay labour by a day so that they can be given steroids to mature the baby's lungs,” she explains.
If it is not established labour, then the mother just needs to rest and will be able to go home after the doctors are certain it is false labour.
“The steroids used to mature the baby's lungs are safe unless the mother has medical conditions like heart problems but even then it's quite safe. It has been proven by evidence that the steroids have a very positive effect on reducing morbidity and mortality in babies because they mature the baby's lungs. The dose that we give is not chronic. It's just two injections which are given 12 hours apart.
“In essence it promotes the formation of the lung surfactant which is what we want and that helps the lungs to inflate better and stay open once the baby takes a breath. The two doses are enough,” explains Dr Cheah.
Which doctor?
The doctor that attends to the premature baby (also called a preemie baby) is called a neonatologist.
If the mother has health problems which are already known to the doctors, then the neonatologist might be called in to speak to the couple. In such situations, the doctors know for certain that the baby will be delivered prematurely.
The neonatologist and obstetrician would speak to the couple on what they need to do and the risks involved.
However, if the mother suddenly goes into labour early, then there's no time for the neonatologist to consult and advise.
Then the neonatologist doesn't get involved until the baby is delivered.
The short-term risks
According to Dr Cheah, in developed countries the doctors will try to deliver the baby no earlier than 22 weeks. However, in Malaysia, typically the outcome is not good for babies delivered before 26 weeks.
“In developed countries as well as here, the lower the gestational age, the higher the risk of complications and long-term problems.
“In their first few weeks of life, many of the preterm babies, especially the small ones (below 1,000g), will need to be ventilated and assisted in respiration. If the baby is unstable, there is a higher risk of bleeding in the brain, bleeding from the lungs and getting an infection because their immune system is not mature. Their skin is thin so it's easier for bacteria to enter. On top of that, the baby may be premature in the first place because of maternal infection.
“If the baby is on prolonged ventilation or if the mother had an infection, it may result in the baby having chronic lung disease at one month plus of age,” says Dr Cheah.
The long term risks
“The long-term risks depend on what happens during the post-natal period and the mother's antenatal history and how premature the baby is. If the child has chronic lung disease, he or she may be oxygen-dependent for the first six months. Of course, that is a small percentage – maybe 5%.
“If there is bleeding in the brain (hydrocephalus) then the baby may need to have a shunt put in to divert the fluid from the brain into the abdominal cavity where it is safely absorbed into the blood stream.
“There are also developmental delays that can happen. If your child is very premature, below 28 weeks, there is a 30% chance of developmental delays. If you are more than 28 weeks, then maybe there is a 10% chance. Those above 32 weeks with a smooth course at postnatal care, chances are it will be okay,” says Dr Cheah.
Other long term risks include an increased risk of vision problems purely because of the prematurity and the clinical course.
“If the baby is premature and has instability of oxygen levels in the blood stream, there is an increased risk of retinopathy which is a condition where the vessels in the eye are growing wildly. Usually, we start checking for that three weeks before they are discharged. If the child has it, he or she may need laser treatment to prevent it from getting worse,” informs Dr Cheah.
The baby's vision will still have to be monitored after that.
Apart from the baby's vision, the hearing and developmental progress will also have to be checked.
There may be schooling and learning problems as they get bigger. In fact, babies born before 25 weeks generally have a lot of problems with learning and socialising, informs Dr Cheah.
The ones above 28 weeks generally fare better.
How well the baby does depends on the mother's history, the baby's clinical course after birth as well as what happens after they go home because then the environmental factors come into play – the parents, the education level, the amount of bonding and the amount of stimulation.
Multiples
For multiple baby deliveries, the babies might not necessarily have the same medical problems or even have to stay in the hospital for the same number of days.
For some, one twin does better than the other. And, for some they are both equally ill.
Usually the bigger one or the firstborn tends to fare better. So, for some, one baby does go home much earlier than the other. If they are going to be discharged around the same time, the hospital generally encourages the mother to room in and look after both babies at the hospital so that they are equally bonded.
Otherwise, there is a tendency for the mother to be more attached to the one who goes home first and the second one is disadvantaged in more ways – being ill, staying longer and having less bonding with the mother.
How long is the hospital stay?
The whole hospital stay depends on the gestational period and the birth weight. Generally, babies are discharged at about 1.7-1.8kg. Some babies are discharged only when they are bigger if they have more problems or are oxygen-dependent.
On average, the bigger babies, from 34-36 weeks, would stay about 20 days.
The ones below 28 weeks would stay two to three months. The ones in between would stay about a month or two.
The very small ones, below 1,000g, would be in the NICU (Neonatal Intensive Care Unit) for about a month because they do not have enough muscles to breathe on their own.
Even after they are out of the NICU, they would have to be warded until they are big enough.
If the baby has other problems apart from prematurity like heart disease or liver disease then the hospital tends to keep them a bit longer until they are really thriving very well.
Breast milk
Dr Cheah also stresses the importance of giving the preemies breast milk.
“Breast milk is easier for the baby to digest. It actually promotes gut growth. So, on top of the value of the milk, it also has a lot of good properties that help the baby to reach full feeding mode easily. Once they reach full feeding mode, their feeding lines come out and there is less risk of getting an infection. So, the clinical course in the hospital tends to be good.
“We give the babies expressed breast milk. Initially, we give it through a tube that goes straight into their stomach. Once they reach about 34 weeks we give them the breast milk by cup,” she says.
Going home
While it is much welcomed, taking baby home is also usually very stressful for the family.
“When they're going home, the baby has to adjust to the sleep cycle, to the lighting, and to night and day.
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