Severely Premature Babies Need Extra Care, But Can Grow Up Healthy
Question: Our grandson was born almost three months early. He was kept in the newborn intensive care nursery for over a month. His lungs were very immature, and he was placed on a ventilator for about three weeks. He is much better now, although he is still in the hospital and requires some oxygen. The doctors and nurses are trying to get him to gain weight. Our daughter has just started to nurse him, although most of his feedings are still given through a feeding tube. When they asked me to hold him, I was really scared because he looked so tiny and fragile. The doctors said that other than having some damage to his lungs, he is a perfectly normal baby. However, I am still very concerned about him. Can you tell us what we can do to help our grandson grow and develop normally?
You must be a very proud grandmother, congratulations! Thanks to advances in medical technology over the past few decades, most premature babies like your grandson are able to survive and actually do very well, although they do face more challenges than healthy full-term babies.
Neonates that are born more than two months early (gestational age less than 32 weeks) have a fairly high chance of developing an immature lung condition called RDS (respiratory distress syndrome). Because of their premature birth, the alveoli (or tiny air-sacs in the lungs) are not able to produce a substance called surfactant. Surfactant is very much like dish-washing detergent. If you recall, detergents make bubbles in water by reducing the surface tension. In a similar way, surfactant keeps the alveoli open and distended, and allows absorption of oxygen from the air, and removal of carbon dioxide produced by other parts of the body.
Without surfactant, the alveoli would collapse, and the baby would have difficulty breathing. One of the major advances in newborn medicine is the development of artificial surfactant that can be given to premature babies through a tube inserted into their trachea (or windpipe). The surfactant will coat the inside lining of alveoli, allowing them to gradually open and function normally for the exchange of oxygen and carbon dioxide.
Unfortunately, many premature babies still require the assistance of a machine called ventilator to help them to breathe. The ventilator keeps the alveoli open, and provides additional oxygen that the child may require. Some babies have to stay on the ventilator for days, weeks, and occasionally even months. As a result, some premature babies develop a lung condition called broncho-pulmonary dysplasia (BPD), likely from a combination of pressure from the ventilator and extra oxygen.
Because of BPD, some premature babies may require supplementary oxygen for weeks or months after birth. Fortunately, this kind of lung damage can improve over time. Although sensitive lung function test can show a difference between older children who have had BPD compared with those that were born at full-term, these children can still participate in almost all childhood activities, including sports. However, children with BPD are more susceptible to viral and bacterial infections of the lungs (especially when they are still very young), and they are also more prone to develop asthma.
Because of their susceptibility to infections, it is most important to avoid giving bad germs to these premature babies. Good hand-washing is an effective method that everyone should practise. I always recommend exposing these babies to as few people as possible, since some may carry germs that they don’t even know. Don’t bring him to baby showers; your daughter can bring lots of pictures for everyone to see. I am not trying to make everybody paranoid, but one should avoid unnecessary exposure to germs. If weather is good, you and your daughter can take him out for walks, even shopping, as long as he doesn’t go to crowded places or being handled by lots of people.
Another important thing that your family can do is getting influenza vaccine (more commonly called flu shot). There are influenza outbreaks each winter in North America, affecting every community large and small. During these outbreaks, many children get sick, and some schools have to be closed. These outbreaks also occur in senior homes and manors. Influenza kills thousands of people every year, mostly seniors, and occasionally young adults and children, especially those who have pre-existing medical conditions.
Premature babies, especially those who have BPD, are very susceptible to influenza. You can prevent your grandson from getting infected by making sure that everyone in his household, as well as close relatives who would look after him, to get immunized with the flu shot. Children over six months of age can be immunized. Therefore, if your grandson has older siblings, they should get vaccinated to prevent them from picking up the virus in school or play groups, and bringing it home to their little brother. The protection from flu shot is not complete, but it does reduce the severity of disease, and hopefully decrease the amount of virus that your tiny grandson gets exposed to.
At the hospital, his doctors likely have arranged for your grandson to receive another vaccine called Synagis. This is not a true vaccine; it is a high tech antibody against the Respiratory Syncytial Virus (RSV). This antibody is produced in mouse, and then modified to resemble human antibody. RSV is another very serious respiratory virus that causes epidemics across North America every winter. Children are especially susceptible, and it spreads through daycares, kindergartens, and schools. Adults can be infected also, although they are less likely to get seriously ill. Premature babies, especially those who have BPD, can get very sick when infected with RSV. Your grandson will need the Synagis once a month, from October or November until April to May, depending on the presence of RSV in your community.
It is also important to remember that regular childhood vaccination is just as important for your grandson as in full-term babies. There should be no delay in getting these vaccinations, and the doctors and nurses likely have given him his first regular immunization already.
In addition to these routine vaccines, I want to let you know about two new vaccines that may benefit your grandson. These vaccines are called Prevnar and Menjugate. Both vaccines are recommended for children at 2, 4, and 6 months of age. Prevnar protects children from serious infections caused by 7 most common strains of Pneumococcus, while Menjugate protects against group C Meningococcus. Unfortunately most provincial programs do not include these vaccines in their routine immunization schedule because they are rather expensive. If you are interested to learn more about these vaccines, you can read about them in two previous columns that I have written (March 5 and April 40, 2002).
I should mention here that clean air at home is extremely important for premature babies, especially those with BPD. Not only that no one should smoke in the house, if any parent or adult smokes, he or she should seriously consider quitting even before your grandson goes home. Those who smoke carry significant amount of cigarette smoke on their body and clothing for a long time. The smoke will irritate the bronchial tubes of your grandson. We have seen healthy young children coming into the hospital with difficulty breathing because their parents smoke. Just imagine what would happen to your grandson with his damaged bronchial tubes, they will be further damaged by cigarette smoke.
I am glad to hear that your daughter is trying to nurse him. This is the best gift any mother can give to their children that no one else can. Although many formulas have been manufactured, even for premature babies, none of them is as good as the mother’s breast milk. If possible, she should try to nurse him for as long as one year, may be even longer, although after the first four to six months, he can start to take solid food gradually.
One important aspect in caring for premature babies is to ensure that they develop normally. Full-term babies are nurtured in their mothers’ wombs for around 40 weeks. During the last few weeks of gestation, large amount of important nutrients pass through the placenta and umbilical cord to the foetus. The brain of these babies are fairly well developed, with most of the brain cells already present, and nerve fibres connecting each other through numerous synapses.
The brains of premature babies are less well developed when they are first born, and they are also more susceptible to injuries during the first few days to weeks of life. It is reassuring to hear that your grandson doesn’t have any brain injury so far. Moreover, premature babies are slower to develop than full-term babies. It is important to stimulate his brain’s development by touching his skin, talking or singing to him, even when he is sleeping. I would recommend lots of cuddling and rocking; it will not spoil him, but instead will help to stimulate his brain, and give him the comfort and security that all babies need (this applies to normal healthy newborns too). Playing tape recordings of lullabies can be useful. Most premature babies can catch up to full-term babies in growth and development between one to two years of age.
Lastly, I should mention here about sleeping position. It is important to keep your grandson on his back when he is sleeping. Premature babies are more susceptible to crib death or sudden infant death syndrome (SIDS) than full-term babies; sleeping on the back can prevent it from happening. However, when he is awake, he can be put on the belly so that he can exercise his arms and legs.
I hope you have gained some insight into the care of your grandson. He may look tiny and fragile; however premature babies can grow and develop to their natural potential. That is, if he has tall parents, he can grow to be just as tall, or even taller. Being tiny at birth does not limit a child’s potential. Most premature babies can finish high school, and even go to college and university. The most important thing is the nurture that he gets at home from his parents and grandparents, as well as other care-takers, including his teachers. The saying that it takes a whole village to raise a child is still very true these days.
[Note to Readers: There are many changes to immunization since the publication of this column. Pertussis vaccine is now recommended for mothers during pregnancy, and for other family members after the birth of a child. Newer and updated vaccines against Pneumococcus and Meningococcus are available. Please read more recent columns, as well as information from your local public health department and family physicians.]