Low-Weight Infants’ Problems Persist, Study Says : Medicine: Survey of extremely small babies finds that many have long-term disabilities. It renews debate over the use of costly technology to save them.
In a study that is bound to fuel debate over the use of expensive technology to keep very tiny babies alive, a team of Ohio researchers has found that children who weighed less than 1 pound, 10 ounces at birth are far more likely than other youngsters to suffer long-term physical and mental disabilities.
Their study, published in today’s issue of the New England Journal of Medicine, is the first to track these “extremely low birth-weight” infants--born three and sometimes nearly four months before they are due--into the early school years.
The research confirms the suspicions of experts that such babies, most of whom would die without neonatal intensive care that costs hundreds of thousands of dollars, are at serious risk for mental retardation, cerebral palsy, learning disorders and behavioral problems.
Although not all of the babies had severe problems, the tiniest infants were 10 times as likely as full-term youngsters to be mentally retarded, the study found. They also fared considerably worse than “very low birth-weight” infants, who weighed less than 3 pounds, 5 ounces but more than 1 pound, 10 ounces.
“The results . . . confirm our hypothesis that these children are at serious disadvantage in every skill required for adequate performance in school,” wrote the authors of the study, conducted at Rainbow Babies and Childrens’ Hospital in Cleveland. “Twenty-one percent of our sample had subnormal mental abilities, and 45% required special education in school.”
For doctors who must make wrenching decisions about whether to keep these extremely premature babies alive or allow them to die, the study renews a troubling question that has been percolating for years.
In an era of concern over rising health care costs, is it worth it to rescue these babies--so tiny they can be held in the palm of one hand--if they are only going to suffer severe disabilities and continue to rack up huge medical bills as they grow older?
“The publication of this data really brings (the issue) into careful focus, and sets the stage for a debate on what we should do,” said Dr. Arnold Platzker, a neonatologist at Childrens Hospital Los Angeles. “It’s a very interesting issue, not only because of the medical science aspect but because of the health care economics aspect.”
Just the other night, Platzker said, he was forced to decide whether Childrens Hospital would accept another hospital’s referral of a baby who needed bowel surgery to survive. The baby weighed just under one pound; California law requires doctors to provide treatment to infants weighing 1.1 pounds or more. The baby’s doctor wanted the surgery performed, but Platzker decided against it.
He explained his rationale: “My feeling was that most likely we would spend several thousand dollars (on the transfer) to bring a baby that would die either before surgery or during surgery, or if he survived it would be a baby that would be one of these million-dollar babies.”
The baby died.
Such decisions are particularly agonizing because doctors have no way of predicting which babies will do well. “It is very difficult to withhold support for a baby you can’t predict the outcome for,” said Dr. Linda Wright, a neonatologist at the National Institute on Child Health and Human Development.
Along with other experts in neonatology and medical ethics, Wright said, research must be conducted to help doctors make better predictions. These experts said the Ohio study also highlights a pressing need for women to get adequate prenatal care, which fosters full-term pregnancies.
And they said the research shows that parents, who in conjunction with doctors must decide whether to authorize heroic measures to save their children, must be better informed of the long-term risks.
“This finding confirms the view that I have held, and that some others hold, that the treatment of extremely premature infants is not treatment, it is experimentation,” said Dr. Arthur Caplan, a medical ethicist at the University of Pennsylvania. “And therefore, it is very important to realize that parents should be given . . . very clear and understandable information in deciding whether to treat.”
H. Gerry Taylor, a psychologist at Case Western Reserve University who helped conduct the Ohio study, said one of the most troubling aspects of the research was seeing parents struggle as their children grew older.
“We’re seeing kids who are falling through the cracks . . . ,” Taylor said. “It seems to me that if (these infants) are going to survive we have an obligation to help them through, not just to say, ‘Well, you made it, you’re home, you’re medically stable, so take it from there, parents.’ ”
The study followed three different groups of children born in the Cleveland area between 1982 and 1986: 68 in the extremely low birth-weight category; 65 in the very low birth-weight category and 61 who reached full-term. It compared children of the same race and socioeconomic status to one another.
Among the findings: Half the tiniest babies had IQs below 85, considered at the low end of average, and 21% had IQs below 70, which brands them mentally deficient. But just 8% of the very low birth weight babies and 2% of the full-term infants had IQs below 70.
When academic skills, visual function, motor function and social skills were measured, the study came up with similar findings. For instance, 27% of the extremely low birth weight babies functioned at below-normal levels in reading, spelling and math, as compared to 9% of very low birth weight babies and 2% of full-term infants. Nearly half the tiniest babies were in special education by second grade.
These infants are a small subgroup of all premature babies, accounting for 0.3% of all births in the six-county region used in the study.
Although no one has calculated the cost of caring for them, Wright estimates that the nation spends $2 billion a year on medical care for all low birth weight babies, defined as those weighing less than 5 pounds, 8 ounces. The figures do not include long-term costs.
Despite the sobering findings of the Ohio study, experts say the news may not be all bad. There have been considerable improvements in care since the children in the study were born, they note, and if a similar study were to be conducted on babies born today the outcome might be different.
According to Wright, more pregnant women are being given prenatal steroids--which helps develop their babies’ lungs, kidneys and brains--when they show signs that they are going to give birth prematurely. And premature babies are now being treated with surfactant, a chemical that can help prevent impaired lung function, which can cause serious long-term health problems.
The Tiniest Babies
While sophisticted technology can keep even the tiniest babies alive, a new study shows that “extremely low birthweight” infants, born at less than 1 pound 10 oz., often suffer serious mental and physical disabilities as they grow older. The following chart tracks the performance of these children once they reach school age, comparing them to “very low birthweight” babies (between 1 lb. 10 oz and 3 lbs. 5 oz.) and to babies born full-term.
Percent of Children functioning at levels below normal Cognitive function (IQ under 70): Extremely low birthweight: 21% Very low birthweight: 8% Full-term: 2% ***
Academic skills (poor reading, spelling and math skills): Extremely low birthweight: 27% Very low birthweight: 9% Full-term: 2% ***
Visual motor function (inability to copy designs): Extremely low birthweight: 17% Very low birthweight: 5% Full-term: 0% ***
Gross motor function (poor hand-eye coordination): Extremely low birthweight: 27% Very low birthweight: 7% Full-term: 0% ***
Adaptive function (poor social skills): Extremely low birthweight: 26% Very low birthweight: 14% Full-term: 2%
