As preterm babies took centre stage on World Prematurity Day, November 15, the focus was on raising more awareness on this issue which has been sidelined in many countries where the rate of neonatal deaths and disabilities have surged in recent years. Senior Lecturer, Department of Paediatrics, University of Colombo and Consultant Neonatologist, University Neonatal Unit, De Soysa Hospital for Women, Dr. Nishani Lucas explained why preterm babies are more prone to premature deaths and disabilities, how they can be reduced and that Lankan doctors have been able to keep these negative statistics to a new low on par with developed countries.
Excerpts of her interview with the Sunday Observer:
Q. On November 15, we observed another World Prematurity Day. Although Prematurity Day has been observed globally since 2011, many readers still do not understand what prematurity is. Define what is Preterm or Premature infant.
A. The duration of a pregnancy carried to completion or term is defined as a baby born after completing 37 weeks of gestation. Preterm or prematurity is defined as a baby born before completion of 37 weeks of gestation.
Q. Is preterm birth (born before 37 weeks of pregnancy) an important cause of neonatal deaths?
A. Prematurity is responsible for around 27% of neonatal deaths in Sri Lanka according to recent studies (RHIMS, FHB, 2018).
Q. What is the average weight of a preterm baby?
A. Preterm babies are born at gestations varying from 24 to 36 weeks. Their birth weights vary from 500g to 2.5kg.
Q. Does that mean he/she is low weight (LBW)?
A. LBW means the birth weight is less than 2.5kg. Frequently, preterm babies are also LBW.
Q. Are LBW at increased risk of death?
A. Low birth weight includes preterm babies as well as babies born at term with growth restriction. Babies with prematurity contribute to neonatal mortality as their organ systems are immature and not ready to survive as an independent organism.
Preterm babies are at increased risk of neonatal mortality due to : immature lungs leading to breathing difficulties and hypoxia, reduced ability to maintain adequate perfusion to maintain oxygenation, fragile blood vessels in the brain that are more prone to rupture with an increased risk of causing intraventricular haemorrhage, gastrointestinal tracts are more prone to necrositing enterocolitis(especially if breastfeeding is delayed) and higher risk of infection due to reduced immunity amid requiring many invasive medical procedures .
Growth restriction due to poor placental flow from the mother results in a baby with hypoxic tissues due to poor blood supply.
This would result in pulmonary hypertension, necrotising enterocolitis, brain ischaemia, etc, with increased risk of neonatal mortality. Prematurity alone causing lower birth weight leads to increased deaths, growth restriction alone causing lower birth weight leads to increased deaths. Both together would lead to an even higher risk of death for the baby.
Q. World reports reveal 15 million babies are born preterm each year, accounting for about one in 10 of all babies born worldwide. What is the number in Sri Lanka?
A. The number of preterm babies born in Sri Lanka is not known as the current information systems collect data based on weight rather than gestation.
However, the system is in the process of change to include the baby’s gestation in the statistics collected.Therefore, we do not have a national figure for preterm babies.
But studies from individual hospitals have shown the rate to be around 10%, similar to the rest of the world.
Q. What do you consider as the most significant challenges of a preterm birth on the infant?
A. Preterm babies are born before reaching full maturity. The earlier they are born the more immature they are. They have immature lungs which lack surfactant (a chemical needed for lung expansion and deficient in preterm babies, is given the lungs via a tube.) to allow it to expand when they breathe. They have poor control of their blood pressure and need drugs to maintain satisfactory blood pressure to perfuse their organ systems. They have fragile blood vessels with increased risk of rupture especially in the brain.
Q. Any other complications which you have not mentioned?
A. They are also at higher risk of infection due to their low immunity levels. In addition, they have higher risk of blindness due to retinopathy of prematurity, and a higher risk of bone disease due to mineral loss, etc.
Q. How can these complications be prevented? Do our hospitals have sufficient facilities?
A. Administering surfactant to the lung, using continuous positive airway pressure (CPAP), using inotropes, using intravenous nutrition in addition to breast milk, brain scans, screening for eye damage, bone damage, proving developmental care given by well trained health professionals are available in the state sector. This is markedly different to the situation in Sri Lanka 10 years ago when neither the facilities nor the required expertise were available. Looking after preterm babies is difficult and expensive, but Sri Lanka is on par with developed countries with the required facilities and expertise. Preterm babies if given the necessary care can develop into their full potential without any disabilities.
Q. ADHD and autism have been linked to preterm birth. Your comments?
A. A preterm neonate may undergo many complications as mentioned above and each of these complications can result in lasting changes. If the baby gets a severe infection, a severe brain haemorrhage or a similar injury after birth, or a baby is already infected or hypoxic during the intrauterine period prior to birth, it can result in brain injury with lasting effects, thus leading to conditions like autism and ADHD.
Q. Studies have also reported that many survivors of preterm birth face a lifetime of disability, including learning disabilities and visual and hearing problems. Do you agree?
A. Although this may be true globally, the Sri Lankan situation is different. While it is true that preterm babies are at high risk of developing complications, it must be pointed out that if they are not having any other co-morbidity like infection, extreme growth restriction or congenital abnormality at the time of delivery, most of them can experience a normal neurodevelopmental outcome.
Expertise with regard to personnel and facilities has vastly improved over the last decade, enabling most of these babies to lead normal lives on par with their peers who were born at maturity. This is true even in Sri Lanka for the preterm babies born in tertiary care hospitals, where they receive the expertise they need.
Q. The current thinking is that children born too soon can survive if they receive the right care in the right place. Do you agree?
A. Yes
Q. What is the right time, right kind of care and right place?
A. Care of the preterm baby starts before birth by the obstetric team, where medications are given to the mother to enhance lung maturity and neuroprotection in the baby as well as reduce the transmission of infection from mother to baby (as infection is a cause for mother going into preterm labour etc.) Also, it is important that mothers going into preterm delivery are identified early, and transferred to a level 3 neonatal care hospital (found in most teaching hospitals), where a neonatologist, trained staff and facilities are available. The baby should be delivered into a pre-warmed plastic bag and transported to the neonatal unit incubator, using a transport incubator, to keep the baby warm.
Thereafter, the baby will be given respiratory support using CPAP which supports breathing through the nose, or for sicker babies by means of a ventilator, by inserting a tube to the baby’s lungs, where the machine breathes for the baby.
Following this, surfactant, a chemical needed for lung expansion and is deficient in preterm babies, is given the lungs via a tube. The baby will be sedated and kept comfortable and pain free. Baby will be monitored continuously for heart rate, breathing, blood pressure, etc. and medications to maintain blood pressure are given as needed. Nutrition is provided by intravenous amino acids, lipids, sugars along with expressed breast milk from the mother given through tube or cup. Medications are also given to treat infection, stimulate breathing, improve gastric emptying in addition to vitamins and minerals. Light and sound are controlled and the baby is laid in a nest to simulate the intrauterine environment.
The baby is screened for retinopathy of prematurity by the ophthalmology team. The baby will also be tested for bone disease and receive calcium, phosphate and vitamin D for its prevention along with iron supplement to prevent anaemia of prematurity. Neurological examination, brain ultrasound is done to assess any neuro injury and mother will be taught physiotherapy to be continued at home, by the physiotherapy team. Once the baby is ready for discharge, a family meeting is held, and taught first aid and how to care for the baby at home.
Q. Are parents allowed to be part of this process?
A. Of course, parents are a vital part of this process and are encouraged to visit, touch, talk, sing and provide skin to skin (kangaroo mother care) to the baby even when the baby is sick. As the baby gets better, parents are encouraged and trained to get more involved in feeding and baby’s care.
Q. As we are amid a Covid-19 outbreak, are preterm babies more prone to be affected by this highly contagious virus than a baby born full term? What are the precautions to be taken in the event of the mother testing positive?
A. There are studies that suggest that preterm babies are prone to be affected by Covid-19, due to higher ACE2 activity which enhances binding of Covid-19. However, there is no epidemiological data to support this at present.
Babies born to Covid-19 positive mothers should not be nursed in the same neonatal unit with other preterms of Covid-19 negative mothers to avoid cross infection. Mother may have to express and send breast milk and avoid handling the baby, until she is Covid-19 negative.
Q. As the message for World Prematurity this year focuses on more awareness raising what is its significance in terms of making a difference to preterm babies and their families?
A. It underscores hope to mothers that preterm babies, especially, without other co-morbidities such as infection or growth restriction can achieve normal neurodevelopmental outcomes, similar to a baby born at term, due to quality care available in state hospitals free of charge as compared to a developed country.
Q. Your message to mothers?
A. The commitment of the mother and the family is an essential component in achieving this success, as the mother and the family have to provide breast milk for the baby, as well as stimulate the baby with play and physiotherapy, keep baby warm, and prevent infection by minimising the number of visitors.