The past few months have been commendable for the Cloudnine Team at Whitefield. We had two achievements from our NICU team. With support from our excellent team of doctors and nurses, we discharged our deficient birth weight preterm baby born at 25 weeks in September 2019. In another development, in August, a baby born at 29 weeks was released after a successful duct operation done in-house.
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In the first case baby, Rehana (name changed) was born at 25 weeks in July. The mother was admitted to the hospital in advanced preterm labour pains and progressed to deliver a baby girl through a normal vaginal delivery weighing 770gm. Two hours before the birth, she was given one dose of steroid. Steroids help in lung maturation of preterm babies and reduce the risk of bleeding into the immature brain. Ideally, the last dose of steroid should be given 24 hours before delivery to the mother.
Rehana needed breathing support soon after delivery, and she was given two doses of surfactant (lung medicine which helps babies born with premature lungs). She spent 33 hours on the ventilator (breathing machine), and she was put on a non-invasive breathing support bubble CPAP to help with breathing. CPAP (Continuous positive airway pressure) helps to open smaller airway, thereby preventing collapse/ atelectasis. She needed this non-invasive support for another four weeks, and after one month of life, she was breathing on her own without any assistance.
Rehana was nursed in a humidified incubator soon after birth. Humidification (increasing water content of air) and warming of the atmosphere is done by specialised incubators. These are vital to prevent fluid loss from the skin of preterm babies. Humidification is generally needed for a couple of weeks until the skin gets mature and the incubator/ warmer care is usually required until the baby reaches 33 to 34 weeks of gestation. Kangaroo care (wherein the parent keeps the baby on their bare chest, providing warmth which helps in bonding, weight gain etc.) started when she was stable and continued till she got discharged.
Rehana was put on intravenous nutrition through a specialized catheter via umbilical vein soon after delivery. The umbilical cord which gives nourishment to a developing baby in the womb contains two arteries and veins. Doctors use these blood vessels and put catheters to monitor blood pressure, take samples and also give specialised liquid nutrition and medications. She was started on small amounts of mothers milk through a tube in the food pipe which has tipped in the stomach. Gradually milk feeds were increased, and by two weeks, the baby was getting sufficient milk feeds. Intravenous nutrition was stopped.
The milk was fortified with special powder to provide extra calories and minerals. Small oral feeding was introduced when the baby was around 34 weeks ( suckling and active swallowing start approximately 34 to 36 weeks ), and by 36 weeks she was taking all feeds orally through specialized cup/ palladia. Mother’s milk is essential for these tiny babies and prevents the risk of infection of intestines.
Rehana, fortunately, did not have any bleeding in the brain. She also did not have duct/ PDA, which can cause problems in breathing and heart pumping. She did not develop eye problems/ retinopathy of prematurity (ROP) which may need laser or special injection.
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She went home after spending 78 days in NICU. At the time of discharge, the baby was weighing 2.04 kg. Rehana had a smooth course in intensive care, and we will have to wait for about two years to know the neurodevelopmental outcome of the baby.
What do we know about the outcome of babies born at the threshold of viability (born before 26 weeks of gestation)? Approximately 50 to 60 % of babies born between 24 to 26 weeks survive in the western world. One in four babies (25 %) has intact survival/ near typical outcome. 50% can have mild impairments in development. One in four can have severe problems in one or some of the domains in neurodevelopment( problems in movements/ cerebral palsy, hearing loss, vision loss, severe learning difficulties etc.).
Some of the short term risks include lung problems needing prolonged oxygen or dependence on breathing support, Big duct, risk of gut infection and hospital-acquired infection due to prematurity, risk of severe bleeding into the brain, risk of preterm brain injury, eye problems / ROP needing intervention etc..
Below are short summaries of preterm babies born before 26 weeks under my care.
Last month a 24 week born under my care at Columbia Asia turned 2. He was weighing 580 gm at birth. Now the baby is close to 12 kg and has achieved relevant milestones and developing normally. The baby was on and off the ventilator and was sick for the first four weeks of life, had a laser for ROP and hernia repair before discharge from the NICU.
A 24-week boy, who was 540 gm at birth is currently 21 months old (needed medicine to treat duct, hernia repair and ROP laser).
Another 25-week baby weighing 590 gm at birth) who had a stormy course in NICU (Chronic lung disease,/home oxygen for three months, ROP (VEGF and laser twice) and Lung artery hypertension ) is around 20 months old. The baby is wearing spectacles for long-sightedness and has just started to walk. Reflux/ vomiting was major issue in first 10 months of life. Her twin sister could not make it and died on day 3 of life (birth weight was 480 gm). We lost one 24 weeks baby 3.5 years ago at seven weeks of age due to recurrent NEC/ infection of intestines.
To Know More: About Prematurity Predicaments
Out of 6 preterm babies born before 26 weeks under my care, two have succumbed, and four have been discharged from the NICU. Three out of four babies are currently between 20 to 25 months of age. The latest one, Rehana, has just started her journey at home after being discharged from NICU.
When I started my NICU journey in India after returning from the United kingdom in 2015, I had no local published data to share with the parents whose babies were born at 24 weeks or 25 weeks. I used to quote data from western countries.
At Cloud nine Hospital, Our senior Neonatologist at the Old airport branch Dr Shenoi has been collecting data of such babies across all Cloud nine NICU centres. Currently, we use our local data for counselling the parents.
Footnote; Author is a Neonatologist and In charge of NICU at Cloudnine Hospital Whitefield since June 2018. He was previously working in Columbia Asia Hospital Whitefield as in charge of NICU for three years. The article is meant to give insight to Journey/course and outcome of babies born at 24 to 25 weeks of gestation. The facts stated are based on personal experience at selected local NICU centres in India. The data is small and must be interpreted with caution. This also may not reflect the outcome of such babies in other centres in India.
Must Read: Signs and Symptoms of Preterm Labour