Extremely Preterm Births: Neonatology Works Miracles

The smallest newborn in the world is headed home in good health after 5 months of hospitalization in Tokyo. This Japanese baby boy who weighed only 268 grams when he was born at 22 weeks gestation time (or 24 weeks amenorrhea) has set a new record in neonatal medicine.

In the past 30 years, neonatal medicine has made tremendous progress in managing the care of preterm babies. Edward Bell, Professor of Pediatrics, and Neonatologist at the University of Iowa (USA) states: “I’ve been in this business for 40 years, and I’ve seen the threshold of viability move back about one week every 10 years or so in my practice “.

A preterm birth occurs before the end of 41 weeks of pregnancy (counting from the first day of the last period). A baby is considered to be preterm when he is born prior to 8 ½ months of pregnancy (37 weeks of pregnancy).

Doctors have identified 3 levels of prematurity:

  • moderate preterm babies born between 7 and 8 months of pregnancy (32- 36 weeks amenorrhea)
  • very preterm babies born between 6 to 7 months of pregnancy (28 – 32 weeks amenorrhea)
  • and extremely preterm babies born prior to 6 months of pregnancy (28 weeks amenorrhea).

Some factors contributing to enhanced neonatal medical progress include technological improvements in respirators and the invention of artificial surfactants which facilitate breathing in immature lungs. Whenever possible, prior to delivery, mothers can receive steroid injections to speed up the development of the baby’s lungs. Huge progress has also been made thanks to the attention given to the child’s relationship with his parents, especially the mother-child relationship.

The fact that hospital neonatal units encourage and support the parents’ presence to comfort babies physically and especially emotionally, contributes immensely to the baby’s development. Medical personnel encourages skin-to-skin contact between babies and their parents, and they assist mothers who wish to breastfeed their babies.

A newborn’s survival and development without sequelae is especially related to factors such as: gestational age, weight, birth conditions, gender, and the reasons for prematurity. Risk factors include overall immaturity, notably for the lungs, the digestive system, the brain and the heart. The growth and development conditions for a newborn baby are much more difficult than in utero.

Dr. Jean-Christophe Rozé, Professor of Pediatrics at the University of Nantes explains that “in France, the lower limit of viability is 24 weeks amenorrhea due to complications which are considered unacceptable, such as blindness.” As the vice-president of the French neonatal society he continues: “France is still struggling with its reluctance to make a place for disability. In the care and treatment of extremely preterm babies, the issue is to ensure the best possible overall development for the child, and not just the survival of a lung, a heart, two legs and two arms. In this outlook, the inherent consequences related to prematurity must also be taken into consideration.” But the pediatric professor reports that “recent progress has been made regarding the fear of disabilities and developmental difficulties.”

A national clinical trial conducted on preterm babies born in 2011, (known as “EPIPAGE”) shows that the situation is changing. Professor Rozé explains that “The initial results following hospital discharge showed that France was somewhat behind compared to other countries. Babies born between 24-25 weeks amenorrhea, either had minimum care or were not followed-up. Therefore, a vicious circle developed since the results were not encouraging, and the preterm babies were not actively cared for. This study helped us consider how to actively manage these babies born at 24 weeks, on a nationwide level. Since then the threshold of treatment and care has gradually been lowered”.

Recently, two studies also confirmed this remarkable progress.

The first one, published in JAMA (Journal of the American Medical Association) found that the survival rate of extremely preterm babies in Sweden had increased from 3.6 to 20% for those born at 22 weeks, and that 8 babies out of 10 survived at 26 weeks of age.

A second study in the United States included babies weighing less than 400 grams, and a gestational age of 22-26 weeks, from 21 hospitals from 2008 – 2016. The results found that 13% of these preterm babies survived; the smallest weighed only 330 grams.

Managing health care treatment for these babies represents a very important public health challenge.

Between 50,000 and 60,000 preterm babies are born each year in France (“INSERM” statistics). 85% of these are moderate preterm (32-37 GA), 10% very preterm (28-32 GA), and 5% extremely preterm, born prior to 28 GA. The preterm birth rate in numerous developed countries has risen in recent years. In France, preterm babies accounted for 5.9% of births in 1995, and increased to 7.4% by 2010.

To improve preterm babies healthcare, Professor Jean-Christophe Rozé specifies: “there is a major obstacle which is difficult for the health authorities to understand, that of aiming for an extremely high ratio of health care personnel for each patient. This would mean allotting almost one nurse for each baby, compared to the current ratio of approximately one nurse for every two infants.  Thus the long-term survival for these preterm babies depends on closer follow-up and better monitoring.”

Professor Picaud, the Department Head for Neonates and Neonatal Resuscitation at the “Croix-Rousse” Hospital in Lyon, explains that the survival rates for extremely preterm babies vary greatly from one country to another. “In 2005, the estimated survival for extremely preterm babies born at 24 weeks of amenorrhea in Japan was 77% compared to 31% in France, and 55% in the USA. In Europe, Sweden has the best survival statistics at 67%. Japan is a very wealthy country thus allowing one-to-one care to be implemented: one caretaker (nurse or doctor) for each baby, accounting for their excellent results. Indeed, Japan’s expertise in this field is internationally renowned. In France, there is usually 1 nurse for every 2 babies in resuscitation units, 1 for 3 in intensive care units and only 1 for 6 babies in neonatal pediatric units”.

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