IMAGES of the tiny feet of baby Amillia Taylor, born in Miami at 21 weeks, were a poignant reminder of the tenuous start to life for very premature babies. It again raised the question: is intensive care for the tiniest and most immature babies worth it?
While parents are faced with one of life’s most heart-rending questions over survival and quality of life for their child, doctors must try to make the best ethical and rational judgments. Most babies are born on time, after 37 to 41 weeks of pregnancy, and are of normal birth weight; 2500g or more. But about 6 to 7 per cent are born prematurely (before 37 weeks) or with a low birth weight (less than 2500g). Even fewer (0.5 per cent) are either very premature, before 28 weeks, or weigh under 1000g.
Caring for the tiniest and most immature babies always involves intensive care. That care is expensive. The cost is measured not only in financial terms, but also by the amount of illness caused by the inability to fund alternative health care programs that have to be foregone to finance neonatal intensive care. For those responsible within the health care system, including those who treat the babies directly, it is obviously vital to evaluate neonatal intensive care thoroughly and compare it with other care programs.
The effectiveness of neonatal intensive care over time is best illustrated by the steadily increasing long-term survival rates in babies born weighing between 500-999g in Victoria over successive eras – from one in four in the late 1970s to three in four by the late 1990s. At the same time the rates of problems with thinking, hearing, walking, talking or seeing in the survivors have remained relatively constant. They affect about half of these children.
At first glance it seems these problems occur far too often and services to help disabled children will be quickly overwhelmed. But about 18 per cent of children who are born on time and who are of normal birth weight will also have these problems. We know this because we have been assessing the long-term outcomes for not only the tiniest, most immature survivors, but also equal numbers of normal birth weight children born on time.
There is no doubt that the overall rate of problems in tiny survivors is too high. At present there are a large number of expensive trials before, during and after birth that have as their major goal to reduce the rate of these problems. Much more research will be required. To fully evaluate neonatal intensive care for the tiniest babies we need to how the changing cost relates to the change in outcomes over time.
These costs are largely determined by how long these babies need help with their breathing after birth. The tiniest or most immature babies cost about $2000 a day in intensive care. They will remain in intensive care until their originally projected birth date. But there is no birth weight or age group where the costs are so high as to even consider withholding intensive care on economic grounds alone.
Neonatal intensive care compares very favourably with most other intensive health care programs, such as adult coronary care, kidney dialysis or organ transplantation. Perhaps surprisingly, neonatal intensive care also compares favourably with many non-intensive health care programs, such as treating high blood pressure or high blood lipids. In the final analysis, the answer to the question of the value of neonatal intensive care will vary with the perspective of the people asking the question. The perspective could be that from across our society but we cannot expect every person in the community to know or understand the issues involved.
Within the hospital, the medical, nursing or other staff have their own views. Then, of course, there are the views of the mothers and fathers of these very tiny babies, both before and after birth. It is important to realise that these views can change with the circumstances of their child. There may be a collective decision between parents and caregivers that intensive care is not warranted at 23 weeks of gestation, whereas it might be warranted after that time.
Survivors of neonatal intensive care usually rate their own health outcomes as superior to that as assessed by health professionals, so they think neonatal intensive care is well worthwhile. Increasingly we will also be able to ask the children of these survivors. Of the many premature babies followed into adulthood by the Royal Women’s Hospital who are now parents, all have so far had children who were not born too early and were of normal birth weight.
The conclusion is inescapable – neonatal intensive care for very tiny or immature babies is clearly worthwhile from all viewpoints that matter.
* Prof Lex Doyle is head of Clinical Research Development, Royal Women’s Hospital
Article from news.com.au