August 2014

The Nation Reviewed

Keeping premature babies alive

By Rachel Buchanan
How neonatal intensive care units rescue the tiniest infants

I stand in the quiet corridor and wait for permission to go in. Minutes pass. Carl Kuschel pushes the swing doors open and nods. He squirts green disinfectant on his hands. I do the same, rubbing my palms together. We enter the realm of the tiny.

Kuschel, the medical director of neonatal services at the Royal Women’s Hospital in Melbourne, walks past three incubators to the corner of the room. He pulls back a curtain to reveal a woman sitting in a puffy recliner. Her arms cradle the baby that is huddled on her chest. It’s her first child, only seven days old. The boy arrived 15 weeks earlier than expected, at 25 weeks’ gestation, and will stay in hospital for the next four months. Beside the pair is the equipment that keeps the baby alive: the incubator, the ventilator (a machine that “breathes” for the baby via a tube into the windpipe), infusion pumps for IV fluids, and a monitor that measures heart rate, respiratory rate, oxygen saturation, blood pressure and more.

The baby is wearing a beanie with brightly coloured stripes. The beanie is miniature but still too big, and the wool sags over the crown of the baby’s head. His delicate face is buried in his mother’s chest, and when she looks up her face is radiant and proud, suffused with love.

 “Did you knit the beanie?” I ask. “How long will your baby be here?” I am an intruder. “Congratulations.” The woman smiles at me tenderly.

I follow Kuschel out. The technical term for what we have just seen is “kangaroo care”. The baby is still on the ventilator but instead of being alone in a see-through box he is warmed by his mother’s skin. “In the developing world it’s the most common way of providing care to pre-term babies,” Kuschel says. “They just rest on their mums.”

Later, I read about how staff at the Women’s perform CPR on newborn babies. In the stress of resuscitation, doctors and nurses can easily lose their rhythm. In response, the hospital did a research trial to pick the best song to keep them on the right tempo, and now the nurses use ABBA’s ‘SOS’: “The love you gave me / Nothing else can save me / SOS.”

It is an appealing sentiment, but love is not enough to save a baby born after only 23 weeks in the womb. Very few babies are this premature – in 2011, of 300,000 live births in Australia, 121 occurred at 23 weeks, 189 at 24 and 219 at 25 – but each one requires an arsenal of nurses, doctors and machines to coax them into full-term babyhood.

“They are totally innocent and they are totally vulnerable,” Kuschel says of his patients. “So the one thing we can be certain of is that if you don’t provide support [at 23 to 26 weeks] those babies will die. If you do provide support, then many of them will survive and will lead totally normal lives.”

Demand for Neonatal Intensive Care Unit cots is rising and in the past two years the Victorian government has funded eight new beds. This year, the government funded another five, allocating $4 million for the equipment and $5.6 million each year to staff them. Each cot needs five or six specialist nurses to provide one-to-one care 24 hours a day. By September, Melbourne will have 100 in total, spread between the Women’s and three other hospitals.

In 1959, a baby born weighing between 501 and 1000 grams (a full-term baby usually weighs 3–4 kilograms) had a 10% chance of survival, but by 2009 that had improved to 60%.

Two things have helped greatly: giving steroids to women who are about to deliver a pre-term baby (the drugs significantly reduce lung disease in the babies); and giving premature babies pulmonary surfactant, the protein that lines the air spaces in the lungs and keeps them expanded.

The equipment is also far more sophisticated. Premature babies in the 1960s were put on adult ventilators. Now, they’re on purpose-built ventilators with touchscreens, and the machines can be programmed differently for each baby. Conventional ventilators deliver between 30 and 60 breaths a minute – the normal breathing rate for a baby – but babies with very severe lung disease may need high-frequency oscillation, which delivers between 300 and 900 infinitesimal breaths a minute by making the baby’s chest vibrate enough to diffuse oxygen and carbon dioxide in and out.

Some of the remedies of the past appear barbaric and hopeless in comparison. The paediatric historian Jeffrey Baker notes that midwives used to tickle the feet or slap the bottoms of babies born too early. They would wave onions under the noses of limp babies or administer brandy or camphor.

Nurses kept premature babies warm by lining their cribs with hot-water bottles. French obstetrician Stéphane Tarnier invented the incubator in 1881. The first one was modelled on a chicken incubator and heated by a thermosiphon, an alcohol lamp and an external boiler.

For several decades from the late 1800s, pre-term babies were put on public view in “incubator baby shows” at fairs and expositions around the world. Admission fees covered the cost of incubation, which many parents couldn’t afford. “The evolution of neonatal intensive care is a bit horrific actually,” says Rod Hunt, the director of neonatal intensive care at Melbourne’s new Royal Children’s Hospital.

At the Children’s, in what they call the Butterfly Ward, there is one intensive care cot per room. Very sick babies, most close to full term, are transferred here after being born elsewhere. Every room has million-dollar views of Royal Park, but the littlest patients are unable to see anything more than light and dark.

Hunt towers over the incubators. He gently lifts a blue and white doll-sized quilt that covers one of them. Beneath is a red-skinned baby, smaller than a kitten. A nurse watches. Big numbers flash on the black screens. The infant ventilator is baby blue. One tube puts air in and one tube takes it out. “Exhalation Port from Patient”, one slot reads. “Fresh Gas to Patient”, reads the other.

“Most pregnancies are normal,” Hunt says. “The vast majority of the population sail through life unaware that neo-natal intensive care even exists, and that is a good thing.” 

Rachel Buchanan

Rachel Buchanan is a journalist and historian. She is the author of Stop Press: The Last Days of Newspapers.

@BuchananRachel

August 2014

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