The Littlest Patients

State-of-the-art neonatal care offers new hope

In our modern society it’s easy to think of childbirth as a fairly straightforward and usually joyous affair – and it is. The majority of babies arrives with nary a need for any serious specialized care, shovel-ready for soft toys and fluffy blankets. But there are also newborns who require round-the-clock medical attention, those whose physical ailments scare the heck out of their parents, whether mom and dad are old hats at parenting or newly minted.

Luckily, families of New Hampshire’s tiniest patients have somewhere to turn. The Granite State is home to three neonatal intensive care units (NICUs), at Dartmouth-Hitchcock Medical Center in Lebanon, Elliot Hospital in Manchester, and Southern New Hampshire Medical Center in Nashua. If a recommended treatment extends beyond the scope of what our local hospitals have to offer, families often are referred to Boston hospitals.

Although the percentage of American babies who require intensive care is fairly low – about eight percent – the medical issues involved are big, and affect the lives of hundreds of thousands of babies, based on estimates from local experts and the Centers for Disease Control and Prevention. And sadly, “there’s a significant death rate in that number,” says George A. Little, M.D., neonatologist at Dartmouth-Hitchcock Medical Center and professor of pediatrics at Dartmouth Medical School.

Early arrivals

The most common reason for a baby to be admitted to a NICU is prematurity, says Marcus C. Hermansen, M.D., neonatologist at Southern New Hampshire Medical Center. “Probably about 9 out of 10 babies are [in the NICU] because of prematurity,” he says, “although we also take care of birth defects, infections and miscellaneous other problems.”

Many of those premature births can be linked to the use of fertility drugs and reproductive technology such as embryo implants. “If you have a multiple gestation – in other words, if you’re carrying more than one baby – statistically you run a much greater chance of being premature,” which means that your baby’s chances of ending up in a neonatal intensive care unit are greater, says Little.

Indeed, “twins come early, triplets come even earlier,” says Hermansen. “A singleton has an average due date at 40 weeks. The average twin is 37 weeks, and an average triplet is 33 weeks, because a woman’s body just can’t keep carrying that amount of baby.”

Survival rates for premature babies depend on how far the pregnancy has advanced, with the odds improving dramatically as time spent in the womb increases. “By 31 weeks, survival is probably 99 percent,” Hermansen says.

Unfortunately, for surviving babies, the struggle doesn’t always end with discharge from the NICU because premature birth can have lasting effects. Again, the likelihood of complications depends on how small and early the baby is. Many preemies only require physical or speech therapy. Others will suffer brain damage, forms of cerebral palsy, mental retardation or some vision and hearing loss, Hermansen says.

Prematurity is dangerous to babies because their organs might not be fully developed, with lungs often a main concern. “You’re dealing with a small, premature baby, sometimes a two-pound baby,” Hermansen says. “Every organ and every system in their body is underdeveloped and functions poorly. They don’t digest well, they don’t breathe well, their kidneys don’t work well, they don’t fight infections and the list goes on.”

The length of time that a baby spends in a NICU naturally varies from case to case, but premature babies typically are discharged when they reach their due date, so some families of early babies have a long haul, with their babies in the NICU for months, says Elizabeth Lydstone, M.S., R.N., director of Women’s and Children’s Services at Elliot Hospital.

Happy endings

As neonatology continues to advance, enhancing the survival chances of smaller and more fragile babies, some neonatologists find themselves grappling with ethical issues that result from saving babies who end up with chronic problems, particularly brain damage. “We have to continue to address that issue,” Little says, “because as we get involved with treating sicker and sicker babies, and particularly smaller or more and more premature babies, the risk of that happening increases.”

And, while developments in neonatology and prenatal care have led to more and more happy endings for families, Little says, “the prematurity rate continues to be resistant to medical and other kinds of interventions.” Women who want to increase their odds of having a full-term pregnancy and a healthy baby should seek regular obstetrical care starting in the earliest stages of pregnancy. “How people take care of themselves, when they receive care and how they plan for their pregnancies are major factors” in birth outcomes, Little says.

If prenatal care is lacking, problems in the baby might not be recognized until the baby is born. In contrast, Little says, if a woman’s doctors know about potential complications prior to the time of birth, neonatologists can work in conjunction with obstetrical care providers so that everyone is prepared and the mother can deliver right next to a neonatal unit, if necessary.

That “perinatal partnership” is key, Little says. To continue to make inroads into the care of newborns and give more babies a better start, neonatologists can’t function alone, but must work closely with experts in obstetrics. “The more we can do to help people have healthy pregnancies before they deliver,” he says, “and the more we can do to work with our associates in obstetrics,” the brighter the future for babies will be. NH

Making It Easier

Some hospitals across the country are boosting their efforts to foster a family-centered, developmentally beneficial atmosphere in their neonatal intensive care units by offering private or semi-private rooms for babies, plus amenities such as decibel meters to monitor sound levels in the room and room-darkening shades to create a womb-like environment, says Elizabeth Lydstone, M.S., R.N., director of Women’s and Children’s Services at Elliot Hospital. Jarring noises in the room are minimized and the amount of light in the room is adjusted as the baby grows, easing the transition to the outside world.

“This has been proven to decrease the length of stay for these babies,” Lydstone says.

“They’re actually discharged a little bit earlier, they are able to wean off oxygen sooner and they’re able to develop more appropriately.”