PREMATURE HUMAN BIRTH
THE REALITY OF PREMATURE HUMAN BIRTH
Lana and Michael were excitedly anticipating the upcoming arrival of their first baby in early January. Because Lana’s due date wasn’t for another ten weeks, she and Michael were taking their time with the nursery completion, baby needs acquisition, and the many other items on their baby preparedness checklist.
One uneventful afternoon while completing some paperwork at her office desk, Lana was suddenly aware of an uncomfortable tightness and throbbing pain in her lower abdomen. When she rose from her computer desk chair, she knew that something was wrong. After calling and being advised by her obstetrician’s nurse, she called Michael and asked him to meet her at the nearby hospital. Michael met Lana just as a nurse was wheeling her up to the labor and delivery floor. Lana knew that she was experiencing contractions, but couldn’t understand why this was happening now? It was just too early for her to delivery her baby boy. Lana was only 30 weeks pregnant.
The above narrative, whose role is to present and illustrate a scenario example of the reality of premature birth, will continue throughout this literature review. Our review discusses the subject of premature birth and questions whether or not development interventions have a beneficial impact on the future life of the child born prematurely.
When a child is born preterm, many medical complications can be present which may lead to long-term health challenges. Is it possible that with early comprehensive development intervention provided by the babies’ families and their healthcare providers, premature infants may grow to lead normal, healthy lives, or do they unavoidably face futures fraught with physical, emotional or mental developmental challenges? What preventative measures, if any, can be taken in order to avoid the delivery of a premature baby in the first place, and are those measures effective?
Also in this literature review, we will examine and explore what defines a premature birth, the risk factors that may or may not have contributed to a preterm delivery, the possible physical, mental and emotional complications that may arise and result in the life of a person born prematurely while explaining and questioning the possible medical, psychological and parental interventions which can be made to eliminate or minimize the short- and long-term effects of prematurity. What are the differences in developmental normality between preemies born before and those born after 30 weeks of pregnancy? Lastly, we will identify ways in which a woman can lessen her risk of delivering her baby(s) prematurely.
WHAT IS DEFINED AS A PREMATURE BIRTH?
Allie Montgomery explains in Health News (Oct. 2009) that most human pregnancies last approximately 40 weeks. By definition, a premature birth takes place more than three weeks before the due date, or before 37 weeks gestation. Approximately 13 million infants born worldwide are born premature each year, which equates to 1 in 10 babies, and a million of these will die as a result of their prematurity. (Montgomery, 2009).
The Mayo Foundation for Medical Education and Research (MFMER) states that where most pregnancies go to term without complications, frequently, a woman will go into labor due to one or more of the following risk factors:
Having a chronic condition, such as high blood pressure or diabetes;
Being overweight or underweight prior to becoming pregnant;
Having had a previous preterm labor or premature birth;
Having had multiple miscarriages or abortions;
Carrying multiples (twins, triplets or more);
Having physical problems with the cervix, the uterus or the placenta;
Cigarette smoking, drinking alcohol or illicit drug use;
Having substantial stress, such as the loved one’s death or domestic violence/abuse.
While some of these factors can be identified, treated and closely monitored, some women simply go into premature labor and delivery premature babies without any known risk factors. (MFMER, 2009).
While Lana lay in her hospital bed, her abdomen surrounded by fetal and contraction monitor belts, she received anti-contraction medication in an IV line. Suddenly she realized with disbelief that the rush of fluid between her legs was proof that, despite all of her doctor’s efforts to stop her labor, her baby’s amnionic membrane had ruptured. There simply was no stopping her baby from being born.
As soon as the tiny infant was delivered, he was instantly placed in an incubator and rushed off the hospital’s Level III Neonatal Intensive Care Unit for evaluation and immediate care. His weight was 2.91 lbs. (or 1319 grams), and his length was 15.8 inches. (DeCherney, Nathan, 2003, p. 174).
Lana and Michael were in shock. It had all happened so quickly, and without warning. They weren’t prepared for their child’s birth. These brand new parents now faced the reality of their tiny son’s frail and precarious condition. They named him Marcus.
POSSIBLE PHYSICAL COMPLICATIONS THAT MAY OCCUR
AS A RESULT OF PREMATURITY
Montgomery et al. (2009) explains that a preterm birth gives a baby less time to grow, develop and mature in the womb environment. Once birth has occurred, the baby is now at significant risk of one or more medical and developmental problems. Once a woman goes into early labor, her doctor will go to great lengths to prolong her pregnancy and postpone birth, and although a premature birth is eminent, a few extra days in the womb can result in substantial further development. But, as in our example scenario subject Lana’s case, her doctor’s efforts didn’t prevent her labor and ultimate delivery.
What problems are these preemies at risk for, and how can those risks be lessened? In Paediatrics at a Glance, Lawrence Miall, Mary Rudolf and Malcolm Levene (2007) describe the following premature diseases as well as their basic intervention and treatment protocol. Though there are many physical complications which may occur in a 30-week preemie, three that are common are neonatal respiratory distress syndrome (RDS), intraventricular hemorrhage (IVH) of the brain, and severe inflammation of the intestines known as necrotizing enterocolitis (NEC). Are these diseases easily managed and/or cured? Miall, Rudolf and Levene explain that with immediate treatment and early intervention by doctors and other health professionals, these conditions can be identified, resolved or controlled, and may result in positive prognoses, but not in every case.
Respiratory distress syndrome is a disease mainly caused by a lack of a slippery, protective substance called surfactant, which helps the lungs inflate with air and keeps the air sacs from collapsing. This substance normally appears in mature lungs, but the lack of it in premature lungs
causes significant breathing difficulty. Treatment may include the direct application of artificial surfactant into the lungs possibly combined with the use of a breathing machine or ventilator. The dangers of these two methods of treatment involve the difficulty of determining the appropriate dosage of surfactant, and the possible damage the use of a breathing machine could do the fragile lung tissue. Long-term complications and damage to other bodily organs may exist primarily due to the periods when the brain and organs did not receive enough oxygen. With, however, proper, timely treatment and close monitoring, babies may not suffer any permanent damage, and most do recover without further incident. (Maill, Rudolf, & Levene, 2007).
The MFMER et al. (2009) explains that intraventricular hemorrhage, or bleeding into the fluid-filled areas (ventricles) surrounding the brain, occurs because the blood vessels in the brains of babies born before 30 weeks are not completely developed and are very fragile. These vessels grow stronger after 30 weeks. Routine head ultrasounds are conducted to monitor this potential complication because there may be such symptoms as breathing pauses (apnea), lethargy or a weak suck, or no symptoms at all. The bleeding is difficult if not impossible to stop, but to intervene and treat this condition, which is rated by 4 stages (1 being the least amount of bleeding based on level of the baby’s prematurity) doctors may perform blood transfusions to improve blood pressure, a spinal tap to relieve pressure caused by possible hydrocephalus (water on the brain), or in extreme cases, surgery to insert a shunt or tube to drain the excess fluid. Long-term prognosis depends completely upon the severity of bleeding, and whether or not hydrocephalus developed. Learning and developmental delay potential may be minimized if fluid drainage is thorough enough, and if the brain is exposed to minimal excess fluid and swelling.
Necrotizing enterocolitis is briefly described by C. Sodhi, W. Richardson, S. Gribar and D.J. Hackam in an article written for the U.S. National Library of Medicine and NIH (2008) as a disease which occurs when the intestinal wall dies (necrotizes) and the tissue breaks away. Its cause is uncertain, but it’s believed that a decrease of blood flow to the bowel or bacteria in the bowel may be its cause, and it occurs in many premature infants. As with many health threats involving premature infants, NEC is a serious disease that can cause death in 25% of cases. In most cases, surgery must be performed in order to remove the dead tissue, and create a colostomy or ileostomy, which is to bring the two open ends of the bowel to the outside surface of the body where they can heal, and be reconnected several weeks later. If too much of the bowel is removed due to the extent of the disease, the child may experience digestive and nutrient absorption complications for the rest of his or her life. Surgical NEC survivors are at risk for complications including short bowel syndrome, and neurodevelopmental disabilities. If a child with this condition survives past the first year or so, does having had this disease necessarily dictate a future of digestive problems? According to Sodhi, Richardson, Gribar, & Hackam, (2008), early identification and immediate aggressive treatment helps improve the short and long-term prognosis.
Lana and Michael scrubbed their hands and put on sterile hospital gowns before entering the NICU to visit baby Marcus. Two weeks have passed since his birth. He had been placed on a ventilator for three days following two treatments of surfactant that allowed him to breath more efficiently and comfortably. Marcus’ parents have been very grateful for the doctors’ and nurses’ unparalleled care, especially when one of the nurses discovered that their baby’s abdomen became distended when he was five days old. This discovery prompted the neonatologist to quickly arrange to have Marcus undergo exploratory surgery in the event that he had developed necrotizing enterocolitis, which he indeed had. His life was saved and he lost but a few centimeters of his small intestine. His long-term prognosis was now very good. Aside from the NEC he’d developed, Marcus was doing well. The doctors assured Lana and Michael that he’s had no brain bleeds, no further respiratory issues, and would be soon able to receive some breast milk, which Lana had been pumping for him. She was told that breast milk was “liquid gold” for her premature baby, and she decided to do everything possible to further his chances of healthy growth and development. With this new knowledge of the importance of breastfeeding, Lana committed to providing the best nutrition for her baby: breast milk which was custom-made for her son.
Is breastfeeding her premature infant a way in which a mother can play an important active role in the investment of her premature child’s healthy growth? Several studies, including one at Children’s Hospital in Boston (2009) found more fat, protein, and the minerals sodium, chloride, and iron in “preterm milk” than in “term” milk, which seems to be of benefit for the preterm baby. Can a mother have a positive role in the development intervention for her premature baby’s healthy future? Yes, a mother can pump breast milk for the nurses to tube feed the tiny infant, and then as the baby grows and matures, the mother can breastfeed her baby. Fathers can support and encourage the baby’s mother in her commitment to breast pumping milk for their child. It is also found that premature babies who receive their own mothers’ breast milk develop better eye function. Along with other high-risk babies fed mothers’ milk, premature babies usually perform better on intelligence tests as they grow older. (Children’s Hospital in Boston (2009).
POSSIBLE MENTAL AND LEARNING DISORDERS THAT MAY OCCUR
AS A RESULT OF PREMATURITY
Although the evidence of complications leading to mental or brain dysfunction or disabilities may not be apparent in a premature child’s early infancy, the signs and symptoms may become evident as time passes. B. Hughs, in an article which linked premature babies with mental illness, explains studies done of preschool and school aged children, those born preterm (especially profoundly premature) have been found to experience over twice the rate of mental illness as compared to full-term, normal weight-for-age babies. It is believed that when a baby is born prematurely, a period of brain development is interrupted. It is a time when critical brain connections and critical brain pathways are likely harmed due to premature birth, of which the effects are felt throughout continued brain development. (Hughs, 2009). Is this brain development interruption the cause for future mental illness? Julie Robotham, in a similar article for the Sydney Morning Herald (2009), shows the results of a study by researchers at Sweden’s Karolinska Institute stating that 5.5% of those born very early had been admitted to a hospital for a psychiatric disorder, compared to 2.6% of those born at full-term. A collaborative study between the Stanford, Yale and Brown medical schools compared the brain volumes of two types of 8 year olds: those born prematurely and those born full-term. The researchers found
significant, lingering reductions in the areas of the cerebral cortex responsible for reading, language, emotion and behavior (Stanford School of Medicine, 2004).
In an article entitled Premature Babies: Learning and Disabilities on the About Kids Health website (2009), children born prematurely are more at risk for having a learning disability (LD).
What, if anything, can be done to thwart the progress of a future mental illness? The above article goes on to recommend that parents and other caregivers including pediatricians and other professionals, keep an eye out for possible problems, especially in children who were born extremely premature who are more at risk than children born mildly or moderately premature. Early diagnosis and intervention reduces the length of time that a child spends wondering why he or she is failing at something that others can do easily.
About Kids Health et al., (2009) also states that premature children are often late to talk, and a significant number have trouble understanding what they hear. For some children, these language difficulties persist to school age and affect their ability to learn to read, spell, and write stories. Many of these children have problems with visual and motor processing, which hinder their ability to learn to print and write clearly and automatically. Parents should have their premature child’s pediatrician look out for signs of a learning disability. Children born prematurely also often have working memory and attention problems. Difficulties in math are frequently observed by the middle elementary grades.
There are several types of learning disability assessments that can take place as listed and described by About Kids Health (2009). These may include a psychoeducational assessment, which focuses on learning skills, has interviews with the child, parents, and teachers as well as
psychological tests and brain imaging. These results help guide interventions and provide a starting point (baseline) for measuring progress. Neurodevelopmental assessments measure the basic brain functions that affect learning such as attention, learning and memory, language, visual and spatial processing, higher-order thinking, social thinking, and neuromotor skills as well as academic abilities. Using a range of brain imaging or the results from previous brain imaging, these tests attempt to identify underlying causes for a learning disability or predict the likelihood of a disability occurring. If the assessments have been done through a school, a plan will be made with parents, teachers, and school administrators in order to follow-up on the recommendations that have been made in the psychoeducational report.
If the assessments give a diagnosis and make recommendations for special education, arrangements will be made by the school principal for the child’s case to be brought before a special committee who will decide if the child should be identified as having special needs and what special placement or services can be offered to the child. Together, the school and parents may form a plan of action to allow the child to learn to the best of his or her potential.
POSSIBLE EMOTIONAL DISORDERS THAT MAY OCCUR
AS A RESULT OF PREMATURITY
Children born at between 34 and 36 weeks are around 70% more likely to develop some type of emotional/anxiety/behavioral disorder than children born at term. Babies born at or before 34 weeks are nearly three times as likely to develop a behavioral or emotional disorder. As explained in BMJ Specialty Journals, at ScienceDaily.com (2006), babies born pre-term would benefit from being monitored through every stage of their early development to watch for signs of abnormally-high anxiety or any other behavior which causes concern. Hyperactivity, low attention span, and impulsive behavior characterize the syndrome known as hyperkinetic disorder (HKD). This psychiatric condition includes mood disorders, stress-related complaints and suicide attempts or deaths in teens and young adults. Babies born prematurely are at a greater risk of problems with focusing attention, including development of signs and symptoms associated with Attention Deficit/Hyperactivity Disorder (ADHD). These signs and symptoms can have negative impact on their social, intellectual, and academic development.
BMJ (2009) goes on to explain that there are standardized questionnaires used to measure concerns with behavior in children that are usually completed by a parent and/or school teacher. A majority of children that score high on these questions were most likely born prematurely, and will show problems with behaviors such as inattention or non-compliance, or problems controlling and coping with their emotions.
But premature babies eventually catch up with their peers, don’t they? BMJ, et al. does not agree, but instead explains that although many premature babies “catch up” physically in regards to their growth as time progresses, it appears that behavioral issues do not just go away, but actually remain through childhood. Although less studied, it is probable that these problems also remain into adulthood. Most of these problems, however, can be treated effectively with early behavioral intervention from health care providers, psychologists and with the support, understanding, and commitment of the child’s parents.
In an article on the About Kids Health’s website (2009) on Prematurity and its effects on Behavior and Intellect, behavioral problems are generally categorized into two groups: externalizing behaviors and internalizing behaviors. Examples of externalized behaviors include: defiance, impulsivity, hyperactivity, and aggression. Withdrawal and anxiety are considered internalizing behaviors.
EARLY INTERVENTIONS PROVE BENEFICIAL FOR DEVELOPMENTAL
PROBLEMS DUE TO PREMATURITY
Theresa McNab and James A. Blackman report in an article for Questia (1998) that sophisticated technology in neonatal intensive care units (NICU) has resulted in substantial improvements in the survival of the most premature infants. Although fortunately the prevalence of developmental problems among NICU graduates has not increased with these advances, the total amount of these babies in the community has grown because of the improved survival rate. Many of these babies have long term health problems and are at risk for developmental difficulties. An understanding of the complications of prematurity and other neonatal illnesses as well as of their treatments can better enhance the effectiveness and direction of early intervention services, both in creating effective approaches whose goal is to promote the highest potential of development of medically fragile infants, and in supporting their families during prolonged periods of overwhelming stress and anxiety.
After the neonatologists have applied their care and knowledge which allowed these babies to be discharged from the hospital, premature babies and their families face significant obstacles once they are at home. Ongoing health problems in these children can negatively impact and
delay the normal course of neuromotor, cognitive, language, and social development. Community early intervention professionals such as infant educators; social workers; and physical, occupational, and speech therapists can improve these children’s long-term outcomes by being knowledgeable about these health problems and creating family-centered early intervention strategies. (McNab, Blackman, 1998).
PREVENTING PREMATURE BIRTHS IS KEY
What are the steps that can be followed to lessen a mother’s risk of delivering her baby(s) prematurely? Can these steps be effective? The staff at MFMER stresses that a healthy lifestyle can go a long way toward preventing preterm labor and premature birth. Here is a list of common sense practices and guidelines that every pregnant woman should follow:
Professional, regular prenatal care;
A healthy diet of foods containing folic acid, calcium, iron, protein along with other
essential nutrients (including a prenatal vitamin daily);
The careful monitoring of any conditions such as diabetes and high blood pressure
because these diseases increase the risk of preterm labor;
Follow a doctor’s guidelines for activity and exercise;
Avoid drug and alcohol use, and check with a health care provider before taking any
medications or supplements;
Sexual activity may be off-limits if you have certain complications, such as vaginal
bleeding or problems with the cervix or placenta;
Limit stress. Don’t overdo it. Set aside some quiet time every day, and accept help
Regular dental care should be maintained. Some studies suggest that gum disease may be
associated with preterm labor and premature birth.
If there is a history of premature birth or significant risk factors for premature birth, the doctor may suggest weekly shots of the hormone progesterone. Although early in the research
stages, initial studies suggest that progesterone may help prevent preterm labor and premature birth in some women. (MFMER, 2009).
Focusing from the very first seconds of a premature baby’s life on immediate treatment and intervention can mean the difference between a child with life long chronic disabilities and one who has the fullest potential of leading a happy, healthy, productive life. Although many treatments are controversial and handled differently at different hospitals and with different health specialists, (i.e., artificial surfactant dosage and ventilator use to treat RDS, as well as extreme measures to treat IVH) what matters is getting immediate and appropriate help for whatever condition(s) may exist. Treatment and resolution also may result in a smaller gap between a child and his or her peers, which makes it easier to catch up, and minimizes problems with self-esteem and anxiety over failure. (McNab, Blackman, 1998). We have discovered that parents in addition to medical and psychological specialists’ interventions play an important and vital role in the positive prognoses and healthy futures of the premature infant. However, those born profoundly premature (before 30 weeks), although benefiting from medical care and other early and long-term development interventions, may face certain challenges in the future due to the severity of their prematurity, provided that they survive their first few weeks of life.
Marcus is a happy healthy eight-year-old third grader. He is active in baseball, karate and soccer, is very curious, and loves math. Although he experienced some very early minor problems with digestion when he was under a year old, he has had no lasting effects from his
bout with necrotizing enterocolitis. Marcus does, however, have a reading disability along with a hyperactivity disorder which was suspected by his parents and diagnosed by a professional psychologist at the end of his second grade year. Lana and Michael have been very conscious of any challenges that may arise in the physical, mental and emotional growth and development of their son, which has proven to benefit Marcus’ progress and happiness, and which will most likely pave the way for his healthy and productive future.