Terrie Inder, MD, MBChB
One in nine infants is born prematurely or around 12 percent of all births in the United States. Any time that you are born more than four weeks early from your due date, which is 40 weeks of time in the uterus, you are defined as being born prematurely. The children that are at greatest risk for problems, including cerebral palsy or major learning difficulties, are those who are born very early, and that’s more than 12 weeks before their due date. From current literature we know that if you’re born from 22 weeks, just over halfway through the pregnancy, you can survive, so many of these infants now survive, but unfortunately go on to face later challenges.
The most common adverse outcome of being born prematurely is suffering from problems in learning and leading to problems in schooling later in life. Around 50 to 60 percent of prematurely born children will have to repeat a grade by the time they reach middle school.
In studies that have been undertaken at the Brigham and Women’s Hospital and at other institutions, we have found that magnetic resonance imaging of a baby’s brain when they are born prematurely is the best predictor of the likelihood that they are going to have later problems either before going to school or even during the school years.
For instance, if we image the brain and find that the brain looks completely fine, just as if the baby had been born at full term, we know even if that baby was born 14 weeks early that baby will have no risk of major problems at any stage in life. It would be as though they were born full term. That occurs in about 25 percent of prematurely born babies. However, on the other extreme, in about 20 percent of premature babies, we find major alterations on the MRI scan and that predicts somewhere between a 50 to 80 percent chance of major problems. So we can offer more therapy services and support to the family and the infant to provide the best possible chance of avoiding those later disabilities.
The environment is very important to the way the newborn brain is formed, particularly when you are born prematurely and you are in a neonatal intensive care unit. One example of this is we studied the amount of auditory exposure that a baby has, depending on the environment the baby is in, and how much adult language exposure there is around the baby. We found if the baby was in a very quiet environment where there wasn’t a human voice being heard, that the area of the brain involved in language didn’t develop. Whereas if the baby was actually in a very noisy environment where there was a lot of talking going on then the baby’s the language area did develop. Most importantly, when we followed up on those children two years later, the children in the environment with good language exposure had nearly ten IQ points more in language development than those who had been in the very quiet environment, emphasizing that the brain will take the information around it to influence its development.
So the information that we have acquired from research studies of brain development in high risk infants, including prematurely born infants, is directly influencing the way in which we are designing our new neonatal intensive care unit here at the Brigham and Women’s Hospital. The types of interventions that we are doing in our design include supporting a family environment, so many of our areas are built as single family rooms where parents can live with their baby and be part of the care team.
One of the philosophies that we have in the Department of Pediatric Newborn Medicine at the Brigham and Women’s Hospital is to consider how we can improve the outcomes of our infants, particularly related to reducing disabilities. One initiative that we have commenced and that will be further expanded and built on in our new Neonatal Intensive Care environment is the Growth and Development Unit. This unit was set up to support families after the intense acute illness period and during the recovery period, which often can still be many, many weeks before discharge to allow them to be in a calmer environment that focuses on therapy services, such as physical therapy, occupational therapy, and soon music therapy to allow them to have recovery from the illness and the severity period.
Around 50 percent of our parents will leave with an anxiety disorder and 25 percent of our mothers will leave with clinical depression. We recognize this early and as part of the philosophy of this unit we have built in support systems to identify and then to intervene before discharge so that we can support the parents in the best possible way.
The new department here of Pediatric Newborn Medicine at the Brigham and Women’s Hospital is focused on family-centered care. Many people utilize that term, but what it means to us is that we are taking care of the entire family, the mother, the father, the siblings, and of course the infant who we have the privilege of partnering with and caring for. The neonatal intensive care experience is not something any parent wants to have, but if you are high risk and you are delivering in a hospital it’s just an incredible insurance to know that you have got the best team to help you if you should need it.
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