November 17th is World Prematurity Day, a day to honour and raise awareness of preterm birth and the challenges is creates for parents, professionals and of course those tiny patients. Around 1 in 10 babies are born prematurely, equating to around 15 million babies born prematurely every year across the World. However, the scale of preterm birth gives little clue to the magnitude of the challenges faced by the parents and their tiny new arrivals. That’s something World Prematurity Day is designed to raise awareness of.
Some History & Statistics
World Prematurity Day came into being with a first international awareness day for preterm birth on 17 November, created by European parent organisations in 2008 and then celebrated as World Prematurity Day since 2011. It’s now embraced by the World Health Organisation, March of Dimes and of course… parents and care professionals.
There are, of course, degrees of prematurity. A preterm birth is officially one before 37 weeks gestation but even 37 weeks can be considered early, a point reinforced in our interviews. Although rates of preterm birth vary by population, ethnicity and many other factors too, the following are typically cited rates of preterm birth:
- 10% of all birth are preterm
- 70% are born between 34- and 36-weeks’ gestation
- 12% are born between 32- and 33-weeks’ gestation
- 10% are born between 28- and 32-weeks’ gestation
- 6% are born before 28 weeks gestation.
More striking is the difference in size of these infants. For instance:
- Typical 40-week term babies average 7.63 pounds or 3,462g
- An infant born at 28 weeks averages 2.22 pounds or 1,005g
- An infant born at 24 weeks averages 1.32 pounds or just 600g
These very low birthweight or extremely low birthweight infants represent an enormous and often unexpected upheaval for their parents but also require the highest standards of what can be extended periods of intensive care by highly specialist doctors.
Despite being an Island nation of just 71,000 people, we are privileged to have a team of just such doctors, at Integra Healthcare Ltd, and we caught up with them in preparation for World Prematurity Day.
Interview with the Integra Newborn Care Team
The Newborn Care Team at Integra Healthcare Ltd consists of 3 paediatricians, all of whom are experienced in managing preterm birth and some of whom have extensive experienced gained over a lifetime of caring for the smallest and sickest preterm infants. Around the World, most preterm care is provided by paediatricians but in well-developed health systems, it is provided by specially accredited doctors called Neonatologists, who do advanced training because of the complex nature of that care. We started with just such a doctor, Dr Sara Watkin, Consultant Neonatologist and Paediatrician at Integra
Dr Sara Watkin
Tell us a little about yourself?
Dr Watkin: I am the lead for neonatal care at Integra and I also provide support and guidance to my colleagues at Health Services Authority when they are faced with particularly small or difficult babies. I trained in tertiary centres across the UK, which are centres of excellence and take referrals from other, smaller places. Before moving here, I was Chief of Service for NICU at the World-renowned hospital University College London Hospitals, where we cared for babies from 23-weeks gestation, many with multiple complex problems, as well as sick term babies. We delivered some of the most advanced care in the world and despite having some of the sickest infants, we were also recognised for exceptional outcomes. I managed a team of over 200 in my NICU, which gives you a sense of the scale of the department. But I also never stopped providing hands on care, as it has been a passion for me since my first days of wanting to become a doctor.
How frequently are you finding issues in preterm birth in Cayman?
Dr Watkin: We definitely get our fair share of babies born prematurely here. I have cared for babies from 24-weeks, often whilst we get them stabilised for transport to somewhere like Miami, but we have also cared for extremely preterm infants on Island when insurance has supported that too. We have the capability here but the 24-7 nature of care of these sickest infants is really challenging when you haven’t got a large team who can run a rota. We also have babies born electively by c-section at around 37-weeks, and although that’s very different to say a 26-weeker, it still gives a higher rate of respiratory problems and runs the risk of lifelong poorer respiratory issues in these children and into adulthood. All premature birth carries and increased risk of problems.
What sort of problems do these infants face?
Dr Watkin: It is more likely a baby that is preterm is going to need help following birth. Babies 28 weeks and under need assistance with their breathing after birth, either from a machine that does the breathing for them, called a ventilator, or a device that makes it easier for them to breathe, such as a CPAP machine. Babies born less than 33 weeks are unable to suck milk for themselves. This means they require their feeding through a tube called a nasogastric tube, and for very tiny babies nutrition is given through a special line that initially goes into the umbilical vein. Very preterm babies are at risk of two very significant, bleeding into the brain and long-term lung disease. We do everything without our power to reduce these things from happening.
What are the challenges faced when providing care for preemies on island?
Dr. Watkin: We have a neonatal unit here at our hospital in George Town. It is very well equipped and is staffed by neonatal nurses. However, because we only have 600 to 800 births a year, it can’t possibly be staffed and equipped like a tertiary NICU in say Miami. For that reason, we do try under to transfer babies who are born or are going to be born before 27 weeks overseas if their insurance supports it. We are very good at watching over smaller babies in the first 24 hours of age if needed before transferring them overseas. However, we are also frequently faced with babies who cannot go overseas for many reasons, from insurance to visas and other issues too. Our team will then care for these infants here, alongside our HSA colleagues and nurses and we achieve really excellent outcomes. It can be very tiring and draining on the teams though. As the main neonatologist for extremely preterm infants, I can find myself literally providing daily care for 16 straight weeks.
How important are development follow ups, especially in premature babies?
Dr Watkin: Developmental follow-ups are really essential. The more preterm a baby is, the more likely they are to have problems with their learning and development. It is imperative to support families of ex-preemies so that their child can reach their maximum potential. We are fortunate to have the Early Intervention Programme here in Cayman run by the Ministry of Education. All extremely preterm babies are referred to this programme, so they are supported in their development in the first five years of life. I am obviously very used to following up ex-preterm infants after more than 30 years in the specialty but I am also privileged to have Dr Sarah Newton in our, who has a special interest in developmental follow up too.
Dr. Jasmina Marinova
Can you introduce yourself for us?
Dr Marinova: Yes, I am one of the paediatricians at Integra seeing many general paediatric patients but I also have an interest in neonatal care too, from training in Bulgaria’s most specialist centre and then in John Radcliffe Hospital in Oxford, in the UK, which is a renowned centre for epidemiological research in preterm infants and a major trials centre because of its links with the National Perinatal Epidemiology Unit, also in Oxford.
We’ve heard that some individuals tend to want to deliver at around 37 weeks believing that they are full term. What are the risks associated with this?
Dr Marinova: There are definitely increased risks when being delivered at 37 weeks. This includes breathing complications because the baby is still not completely developed. This is heightened in moms who deliver via C-Section, which artificially interrupts the natural pregnancy process and denies the baby of some very beneficial changes that happen as a result of a vaginal birth. Further issues can include jaundice, feeding problems and coordination difficulties all being more common following early delivery. It is not recommended to deliver at 37 weeks unless there is medical reasoning behind it. We would say that a woman is not really considered full term in a pregnancy until she is 38-39 weeks in the gestation period and we have to remember that nature designed gestation for 40 weeks, even though there is variation.
How does preemie care differ from full term care?
Dr Marinova: Although we are usually attending deliveries at full term care, the baby is going through the natural stages of birth, assisted by an obstetrician and then the first 24 to 48 hours are spent in hospital until the baby goes home. During this time, they usually do not need any special medical intervention besides the very important baby checks we do. A preemie needs specialised care, including doctors and nurses and a stay in the NICU mostly. Preemie babies have medical issues that we healthcare professionals anticipate and try to act upon, even before they are born, as well as issues we can’t foresee, and so we can find ourselves in and out of the hospital multiple times every day, providing direct care or adjust strategies. It’s very different.
Dr Sara Newton
Tell us a little about yourself?
Dr Newton: I am one of the paediatric and newborn team at Integra, and the Southern Hemisphere member of the group. I am from New Zealand and trained there, in Australia and in Singapore, at one of the larger hospitals in the world for deliveries, KK Women’s and Children’s Hospital, founded in 1858 and now having 830 beds devoted purely to women’s and children’s health. I have a special interest in developmental follow up and also complex paediatric problems, which you can often find in ex-preterm infants.
How important is it to have a skilled or expert team when dealing with premature infants?
Dr Newton: It’s absolutely critical in the smallest, sickest infants. These babies are very small and fragile and often you are faced with multiple challenges in management including their immature lungs, cardiovascular and neurological system, to infection, nutrition and growth. Things can change rapidly, and these babies need constant care from both doctors and nursing staff initially. This is complex intensive care but in a patient that might weigh no more than say a pound of butter. Every decision and care choice really matters and sometimes you need to discuss this as a team too.
Does preterm care differ on Island compared to in other, larger countries?
Dr Newton: The care decisions themselves should be evidence-based and similar from one place to the next but the context is really different. There will be some extreme preterm infants or more unwell preterm infants that require more complex tertiary level care. While in the UK, where my colleagues trained, this may have involved an ambulance ride, here we live on an island and our nearest referral centre is in the USA where transfer involves a care flight or medevac.
I trained in both Australia and New Zealand, where remote isolation was also not uncommon, and our babies would be stabilised in smaller centres and then transferred to tertiary level centres by helicopter or plane. So, in that way it is similar, but the process involved is a lot more difficult, from getting passport for baby, visa for parents, discussions between insurance providers, transport team and accepting hospital. The difference is important because you really don’t want to transport a sick neonate unless you really have to, and this process can take time. It reinforces again the importance of minimising that chance by ensuring optimal care by experienced neonatologists.
Dr Madhavi Manoharan
We discovered that Dr Manoharan is the newest member of the Integra Pregnancy Team and besides her role as an OB/GYN, she is also a Maternal-Fetal Medicine Specialist. We started by asking about that.
What is a maternal-Fetal Medicine Specialist?
Dr Manoharan: It’s a branch of obstetrics that requires more advanced training specifically in high-risk pregnancies and how to monitor and manage babies throughout pregnancy where they have specific problems, such as genetic problems or growth restriction. Many of these same problems also either lead to or require a baby to be born early and so I work very closely with both obstetricians and neonatal colleagues to ensure we manage the pregnancy for the best outcome and then deliver the baby in a carefully planned manner to ensure the best outcome without complications.
What types of things can lead towards preterm births?
Dr Madhavi: We don’t always know for sure what causes preterm labour and premature birth. Sometimes labour starts on its own without warning. Even if you do everything right during pregnancy, you can still give birth early. We do know some things may make you more likely than others to have preterm labour and premature birth. These are called risk factors. Having risk factors doesn’t mean for sure that you will have preterm labour or give birth early. But it may increase your chances. It’s one of the reasons why I am proud of what we offer in Integra because we have all the disciplines that might be needed in a single team, so if the unexpected happens, we are always ready as a team to do what we need to do.
Can anything be done during pregnancy to prevent preterm birth?
Dr Madhavi: If you have any risk factors for preterm birth like a previous preterm birth, your doctor can advise you have ultrasound scans to assess the length of the cervix. This can be done at regular intervals to monitor the length of the cervix, usually once in 2-4 weeks. Enhanced monitoring such as this is part of predicting what is likely to happen. Preventing is more difficult because there is still so much we don’t understand about what causes preterm birth. We can also advise you to have progesterone treatment to reduce your risk for preterm delivery. A lot of what we do is manage the pregnancy carefully to try to safely keep baby inside as long as possible and then plan very carefully for the delivery. The future may hold more possibilities in preventing preterm birth.
Back to Dr Sara Newton
To round off our interview, we asked for a few words on World Prematurity Day.
Dr Newton, any take-away messages on World Prematurity Day?
Absolutely. Having a premature baby can mean a very long emotional road for families, with lots of ups and downs, and it is crucial we support parents’ emotional wellbeing and help them navigate this usually very unexpected roller coaster journey, that may last for months, sometimes even past the baby’s due date.
Empowering new mums and dads to bond with their baby and be involved in baby’s day to day care is important, from gentle eye care to changing nappies to kangaroo cuddles (baby is placed skin to skin on mum or dad’s chest, which is great for baby as well as parent). Sadly, the current pandemic and limited hospital visiting has made this road even harder for many new parents with premature infants around the world, and my heart goes out to them at this time. As a team, we really believe strongly in the importance of emotional bonding and understand the huge emotional challenges parents face when they can’t visit. We all do our very best to fill that gap by our own communication and by using photos etc. It’s a very challenging time for preterm births.
I also want to say a big thank you also to the incredible NICU nurses out there around the world too, for taking such great care of these precious little ones and their families. We couldn’t provide neonatal intensive care without you too.
And in Finishing…
It is very clear that the Cayman Islands is fortunate to have healthcare professionals of the calibre, and specialist experience. I witness firsthand just how busy they can be and yet how they pulled together as a team. We interviewed them on a very busy day, with team members flying back and forth to the hospital and we are so grateful for their time regardless.
With them, our little ones are in good hands, and it was clear that they are passionate and want nothing but the best for the babies and parents. Happy World Prematurity Day and we acknowledge the work of the doctors and nurses caring for these infants but even more so the challenging journeys being faced by parents, especially at this time, when their baby is born too soon.
