Premature Babies, Neonatal Research, and Difficult Choices
The entryway to the neonatal intensive-care unit in my hospital, Beth Israel Deaconess Medical Center, in Boston, is lined with photographs of children who were born prematurely. Jeremiah, delivered at twenty-four weeks, sixteen weeks early, weighed one pound six ounces. In the picture, he’s a robust teen-ager, seated at a piano. Nearby is a photo of Caroline, a blond ten-year-old in a blue uniform, holding a lacrosse stick. She was born at twenty-five weeks, when her mother’s placenta abruptly tore apart. Caroline has cerebral palsy, and wears an ankle-and-foot brace on her right leg, but she “is able to dance, swim, ride a two-wheel bike, play lacrosse,” and “is very social,” according to the caption below the photo. Across the hall is a photograph of Jackie, who’s on a swing. Her mother’s placenta became infected at twenty-four weeks, and she was delivered “blue,” with collapsed lungs. Jackie was not expected to live through the first twenty-four hours. She’s now eight years old, with a lingering lung problem, but her mother describes her as “a very beautiful girl with lots of energy. Her favorite food is everything.” A few steps away, there is a drawing of a tree with leaves made of paper. On each leaf is the name of an infant who did not survive.
There are forty-eight beds in the NICU, and, on the spring day I visited with Dr. Camilia Martin, most of them were occupied. Martin is a senior neonatologist who co-wrote a textbook primer on NICU treatments, called “Neonatology Review.” She told me that extremely premature infants, defined as those born before twenty-eight weeks of pregnancy, are frequently delivered by Cesarean section. At birth, their eyelids are often fused, and their ears are flat. At my hospital, four medical professionals receive each baby: an attending neonatologist, a fellow in training, a respiratory therapist, and a specialized nurse. Amniotic fluid and debris are suctioned from the baby’s mouth, before he or she is wrapped in warm dry towels and placed on a heated mattress. A continuous positive airway pressure, or CPAP, mask is fitted over the nose and mouth. For many infants, the oxygen delivered by the mask is not adequate, so a tube is inserted into the trachea. Minutes after birth, replacement surfactant, a mixture of fats and proteins that looks like skim milk, is percolated into the baby’s lungs. The surfactant preparation, which comes from the lungs of cows or pigs, keeps the air sacs in the lungs open. When the doctors cut the umbilical cord, they thread a thin catheter, with a bore of about one millimetre, into the umbilical vein; fluids and medications flow through it to the newborn. Another fine catheter is inserted into the umbilical artery to monitor blood pressure and levels of oxygen and carbon dioxide.
After some twenty minutes, the infant is moved to the NICU and placed in an incubator; the ones at my hospital are the Giraffe brand, which is equipped with long-necked lamps and heating elements positioned at the top of a closed plastic dome. “These babies are not prepared to enter the world,” Martin said. “This technology aims to substitute for the loss of time within the mother. Their skin is not developed. You see it’s translucent, without any fat underneath.” Each baby had a unique sheen, a network of blood vessels starkly visible beneath the surface. “They lose a great deal of body heat and water through their skin.” Inside the Giraffe, temperature and humidity are regulated to prevent hypothermia and dehydration.
“As a rule, premature babies need to stay in the NICU at least until what would be their normal gestational age,” which is about forty weeks…