Tiny survivors: Higher rate of survival for pre-term babies

SINGAPORE - It was painful for market administrator Minnoli John to watch other parents cradling babies in their arms while registering their children's births at the Immigration & Checkpoints Authority building two years ago.

She was there without her one-week-old daughter Nicole and, in fact, had not even carried her baby yet. Born extremely premature at 25 weeks and weighing just 600g, Nicole had to be in the neonatal intensive care unit at the Singapore General Hospital (SGH).

Also, the very act of naming her could have been just a formality as she might not have lived, says Mrs John, 34.

Some parents of premature babies hold off naming their tiny babies in earlier weeks due to uncertainty, says senior consultant Varsha Atul Shah of Neonatal and Developmental Medicine at SGH.

She says: "It will be, son or daughter of so-and so. But once the parents name their child, I can tell that the parents are more confident the child will be okay."

The first two weeks of Nicole's birth were particularly tense, says Mrs John. The baby underwent surgery to fix a large blood vessel that is supposed to close at birth and allow blood to circulate normally.

After a total of 104 days in hospital, including a stint in the neonatal intensive care unit and the high- dependency unit, Nicole was discharged. She weighed 2.92kg.

Premature babies are delivered before 37 full weeks of pregnancy, which occurs in about 6 to 10 per cent of all pregnancies, says consultant Krishnamoorthy Niduvaje at the department of neonatology at the National University Hospital (NUH).

About 300 premature babies are born at NUH each year, which is about 10 per cent of total births. Two per cent of all deliveries occur before 32 weeks, with babies weighing under 1.5kg.

At SGH, about 15 to 17 per cent of 1,500 live births a year are delivered at less than 37 weeks old. The number dips to 5 per cent for babies less than 32 weeks old.

The overall survival rate for premature babies is about 90 per cent at SGH, says Dr Varsha. This number dips to 43 per cent if the baby weighs under 600g at birth or is delivered before 25 weeks of gestation.

Singapore's lightest baby on record, born at the hospital 10 years ago weighing only 415g at 23 weeks, is now a Primary 4 pupil.

The outcome for babies below 23 weeks gestation and 500g is extremely poor, says associate professor Victor Samuel Rajadurai, head and senior consultant of the neonatology department at KK Women's and Children's Hospital.

While the baby's weight and gestation are important, the duration he spends in his mother's womb is "slightly more important" than absolute weight, says paediatrician Low Kah Tzay at Mount Elizabeth Hospital. "Organ function in the baby develops according to gestation, generally," he says.

Despite the largely positive statistics, the pre-term birth of a baby is mentally taxing for parents, says Nicole's father, operations manager Colin John, 39. "Even if she made it, would she be able to walk or talk? These were questions that troubled my wife and me daily," he says.

Premature babies start small and tend to "catch up" as they get older, but may be smaller and lighter than their peers, says SGH's Dr Varsha.

An infant is usually discharged weighing between 1.8kg and 2kg, and breathing normally on his own, though some babies with lung problems return home with home oxygen to aid breathing.

Dr Varsha advises parents of premature babies to calculate the child's age based on the due date, rather than actual date of birth, for his developmental age.

Still, some pre-term babies appear smaller compared to their peers.

Polytechnic lecturer Chao Jang Yuan, 39, once thought a classmate of her daughter Raeanne, aged nine and a Primary 3 pupil, was a Primary 5 pupil. She says: "It turned out that they were the same age, even though Raeanne was about half a head shorter than her."

Raeanne was born at 25 weeks, weighed 705g and was delivered with the water bag - a membrane of amniotic fluid protecting the baby in the uterus - intact. Madam Chao says: "Doctors had to burst open the water bag, which I likened to unveiling a present."

Raeanne was such an early baby that her skin was almost translucent and her ears had not fully popped from her skin, Madam Chao says. It took two months before she could finally touch her newborn via "kangaroo care", where the baby is placed on the mother's bare chest.

She and her husband, teacher Fabian Lim, 41, took Raeanne home after three months when their child weighed 2kg, only to rush back to hospital the next day as milk had gone into her lungs while she was being fed. Raeanne stayed in hospital for another month.

Watching her battle for life was a great lesson, Madam Chao says. "I don't know why but I knew she would survive."

Similarly courageous was Ms Nur Marina Abdullah Chong, 32, who was determined to be strong for her prematurely born twin sons.

She says: "I saw other mums crying in front of their babies' incubators but I didn't want to cry because I might not be able to produce breast milk."

When her husband Mohammad Shahrin Latif, 36, a general manager at a communications company, started to get emotional, she told him to "stop it".

She says: "Once you go into that depression mode, it affects you mentally and becomes a spiral. We just have to pull through."

Ms Marina, a managing director of an art school, gave birth to her twin sons, Mohammad Ehsan and Mohammad Elyas, last June after just 24 weeks.

The twins, weighing 650g and 805g each, were in the neonatal intensive care unit for four months. It was not a smooth ride for them, says Ms Marina, as they underwent blood transfusions and a lumbar puncture, a procedure she describes as "most alarming". This is a procedure where samples of spinal fluid are taken from the spine via a needle, to check for infection.

Parents usually cope well with pre-term labour but some may need to be referred to a psychologist for help to cope with postnatal depression, particularly if the baby needs long-term care and oxygen support in the intensive care unit, says Dr Wong Heng Fok of Thomson Women's Clinic (Tampines).

Some are put in touch with mothers who had a pre-term baby, says Dr Low of Mount Elizabeth. SGH, NUH and KK Women's and Children's Hospital have support groups for families with pre-term babies.

Getting support helps to alleviate any worries or guilt the mother may feel about a pre-term birth.

In many cases, there is no clear cause for a birth not carried to full term, say doctors. Possible causes include conditions such as hypertension, uncontrolled diabetes, infection or high blood pressure; and in cases of multiple pregnancy such as twins of triplets, pre-term birth is more likely. Mums who use tobacco, alcohol or illicit drugs while pregnant are more commonly found to deliver prematurely.

Pre-term deliveries occur with greater frequency among women younger than 19 or older than 40, and among those who had a previous premature delivery, says Dr Krishnamoorthy of NUH.

Medical progress, however, has increased survival chances for premature babies. This includes using glucocorticoids, a form of steriod hormones, before delivering a premature infant to improve his lung maturity. But since the 1990s, an exogenous surfactant, which coats the inside of the infant's lungs to help it breathe, has been used.

All these do not come cheap. Those interviewed for this article were billed between $80,000 and $250,000 for a period of three to four months, before subsidies.

Some insurance plans protect the unborn child and pregnant mother as early as 18 weeks, giving coverage on the mother's life and pregnancy complications such as still birth and preeclampsia.

Still, the bumpy journey of having a pre-term baby has not stopped Mrs John from wanting a sibling for two-year-old Nicole.

"It was a traumatic experience with Nicole but I remember what it was like when she was born and we were so afraid she wouldn't make it, but then, she cried loudly and it was such a joy to hear her voice."

Despite two pre-term deliveries, Ms Marina still wants to have another child, hopefully a daughter.

She says: "The thing about being a mum is that you tend to forget what you have gone through fairly quickly. After seeing how my sons have grown, I think that, yes, I would like to have more children."

PREEMIE SUPPORT GROUPS

Light Weight Club Support Group, Singapore General Hospital

First introduced in the early 1990s, this self-help group was formed by the parents of very low birth weight infants, with support from nurses.

Parenting advice, counselling and support begin in the neonatal intensive care unit till discharge and follow-up appointments.

Activities include educational talks by doctors, monthly club meetings, and tea parties with parents to share experiences on infant care.

Membership is open to parents of pre-term infants. For details, call senior nursing officer Ong Siow Cheng on 6321-4540.

The Early Bird Baby Club, KK Women's And Children's Hospital

For parents of premature babies admitted to the neonatal intensive care unit and special care nursery, consisting of nurses, doctors, medical social workers, dieticians and staff from the rehabilitation department.

Initially called the Tiny Tots Club in 1990, the club later re-formed to become the Early Bird Baby Club in 1997.

Activities include parent-to-parent support sessions during coffee afternoons, educational talks, bereavement support, and homecare services for discharged babies with special needs by volunteer nurses.

NUH Neonatal Parental Support Group, National University Hospital

This support group caters to the needs of parents with newborns in the neonatal intensive care unit.

Activities include monthly parent support sessions with educational talks related to newborns on topics such as kangaroo care, infant nutrition and infant massage; follow-up telephone calls after discharge and home visits.

For details, e-mail suhe_zhang@nuhs.edu.sg

keziatoh@sph.com.sg

This article was published on May 11 in The Straits Times.

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