Bundles of Joy ... and Worry

At time of life when most of us were alone with the thump-thump-thump of our mother’s heartbeat, eight babies in Houston were wriggling in a close-packed jumble of legs and arms and heads and elbows and tushes. At a time when most of us still had months of lazy lolling ahead in the wet, warm and dark of our mother’s womb, eight babies were entering a strange, bright, dry, noisy world.

It’s strange to think of but true: The Chukwu octuplets born last month were not really “due” until around April 1. Yet already they’ve experienced more medical procedures than many of us deal with in a lifetime.

They’re familiar with the feel of an oxygen mask on the face. Of a slim tube slipped gently down the airway or esophagus. Of catheters piercing the flesh, of electrodes stuck to the skin, of the humming of machines that measure vital signs and keep fragile lungs breathing. They’ve had their brains scanned. Their hearts scanned. They’ve had sedatives, steroids, antibiotics and nutrients infused into their blood. One’s already had surgery. One, sadly, didn’t make it.

It’s amazing just to think that babies this tiny can be tended, kept alive and eventually driven home in a behemoth family wagon along with Mom, Dad and half a dozen sibs. But what does that life-saving effort entail? And what do the babies endure?

We’ll never know what goes on in their heads as they lie there in their incubators. But the more one learns of the electrodes, tubes, gasping lungs and guts that might fail at any moment, the story loses some of its feel-good, Guinness record-breaking flavor.

A few decades back, none of the babies would have survived. But today, by now, several weeks into their lives, the odds for Ebuka, Chidi, Echerem, Chima, Ikem, Jioke and Gorom are better than 90%, say their doctors at Texas Children’s Hospital. There’s a lot more known now about the problems tiny preemies face--from infection, lung failure and guts that don’t know what to do with food--and also about how to treat each challenge.

And while the Chukwu babies are critically ill, and while caring for them calls for plenty of skill and finger-crossing, “for us, I hate to say it, it’s routine,” says Dr. Leonard Weisman, chief of Texas Children’s Hospital Newborn Center. “It’s business as usual. We see 250 babies every year around this gestational age. The only difference was that this time there were eight of them at once.”

Well, not quite at once. Baby Ebuka came first, born vaginally after the babies’ mother, Nkem Chukwu, went into labor 15 weeks shy of her due date. Drugs and bed rest kept the others inside her for about two more weeks, but then Chukwu went into labor again--and this time, nothing could stop her. On Dec. 20, Ebuka’s brothers and sisters were delivered by C-section.

The early delivery came as no surprise. Multiples just come early--and the more of them, the earlier. There’s only so much room in the womb. There’s only so much food and oxygen that a mother’s bloodstream can deliver. At some critical moment, the stress gets too great, and a hormonal decision is made: Let the babies take their chances in the world.

The Going Gets Tough out in the World

But if skimpy rations and cramped living quarters are no picnic, neither is the outside, not for babies like these. Small for their age to begin with, the babies are also three months premature, and their bodies aren’t ready to be born.

Their lungs aren’t ready. They haven’t formed enough of the tiny air sacs needed to deliver oxygen to the blood, and the sacs they have are still low on a crucial protein coating. This “surfactant” stops the sacs from totally collapsing each time a baby exhales: “It’s like the difference between blowing a balloon up from scratch or blowing it up when it’s halfway inflated,” Weisman says.

Their immune systems aren’t ready either. In the last three months of gestation, babies get a slew of disease-fighting antibodies from their mothers. The octuplets didn’t. What’s more, the babies’ white cells aren’t yet up to snuff, and don’t properly kill interloping bacteria and fungi. You can’t dole out antibiotics willy-nilly in neonatal nurseries, or they’d soon be teeming with antibiotic-resistant nasties. So the risk of infection looms large.

The infection risk isn’t helped by the fact that IV lines and catheters must be put in these babies, creating entryways for bugs. Nor is it helped by the babies’ immature skin. Adult skin is as thick and tough as cowhide compared to the Chukwu babies’ thin, papery covering. Adhesive tape can rip their tender skin, as can adult hands that aren’t super-careful.

Guts, brain, heart, liver, kidneys, eyes and ears: None are quite ready for prime time. But if many body systems are underdeveloped, others are more developed than caregivers used to imagine.

“For a long time, people didn’t think any babies felt pain,” says Dr. Rita Agarwal, co-director of the acute pain services at the Children’s Hospital in Denver. As recently as the early 1980s, she says, the standard treatment for newborns getting surgery was a paralytic drug so they wouldn’t thrash about, plus some oxygen.

But attitudes have changed. “Do they feel pain? Absolutely. No doubt about it,” says Weisman. Some studies even suggest that babies may be more sensitive to pain than adults are. Pain raises blood pressure, lowers blood oxygen and sends levels of stress hormones soaring through the roof. Bad things for babies already in serious trouble.

To help deal with the discomfort of masks, tubes and needle sticks, all eight octuplets were sedated for the first days of their lives. And this helped the babies deal with other stressing sensations.

Lights. Noise. Action. Bothersome hands coming into your incubator to fuss with you. Back in the ‘80s, studies revealed what these well-meant attentions were doing. “Even small acts, like lifting their legs to change a diaper, made blood oxygen levels drop,” says Linda Lefrak, neonatal clinical nurse specialist at Children’s Hospital in Oakland. “It was a huge ‘heads up’ that a lot of what we did in day-to-day caregiving was bad for them.”

In that sense, some of the most crucial care the Chukwu babies got when they first arrived at the Texas Children’s nursery was just being left alone.

Reinterpreting Tender Loving Care

Yes, there were things that had to be done: They needed catheters inserted in their bellybuttons so that blood could be tapped from the artery, and so that fluid, sugar and sedatives could flow into their veins. They needed artificial surfactant squirted into their lungs to make up for what they didn’t yet make themselves. Breathing tubes in their tracheas and masks over their mouths, so that mechanical ventilators and extra oxygen could help them stay alive.

But into their warm incubators they went, with no baths, down onto soft sheepskin, nests of blankets, and dressed in Lilliputian diapers. “Everything we use is kind of scaled down,” including breathing tubes, masks and minuscule doses of drugs, says Cynthia Sanders, assistant director of nursing at the neonatal intensive care unit at Texas Children’s.

Over the babies went plastic sheets, so they wouldn’t lose too much water through that super-thin skin of theirs and to help create a womblike place. Lights were kept dim, or off, whenever possible. Carpeted floors, soft trash cans and low voices help keep noise in the nursery to a minimum.

Only later do nurses start bathing the babies and experimenting with things like touch and music, Sanders explains. They take their cues from the babies’ responses: their grimaces, squirmings and vital signs. But Mom gets first dibs on the stimulation, since it’s sparingly doled out.

It was more than three weeks before Chukwu got to hold one of her babies--the largest child, Jioke--just for a moment as she leaned over his incubator.

The smallest baby, Odera, weighed a stunningly light 10.3 ounces. No one knows why she was so tiny, but her doctors’ best guess is that she was simply crowded out in the womb. Her lungs, even for a baby that size, were underdeveloped. Odera died of lung and heart failure, just seven days after her birth.

Another of the octuplets, Gorom, underwent surgery the day before Odera’s death. Her belly began to distend, and an X-ray revealed what the doctors and nurses feared: a rip in the lower intestine, probably caused by the pressure of air she’d swallowed. Gorom’s intestine now pokes out of her side until a time when surgeons can reconnect it.

Today, the babies are all off ventilators. None, so far, have had devastating brain bleeds that premature babies are prone to. But several have had infections requiring treatment with antibiotics.

None of them, as yet, are getting the bulk of their nourishment by mouth. There’s no way they could have done so: Their immature guts just wouldn’t have tolerated it.

Instead, the babies are being fed through a long, slim fiber that enters a vein in the arm or leg and then snakes down into the heart. It’s horrible sounding but actually much kinder than a conventional IV drip. Veins get irritated by the constant flow of nutrients, and you have to keep finding new places to stick in the needle.

Doctors also are trying to scale up the babies’ feedings of breast milk, which is dripped into the stomach through a tube. This is a critical time, Weisman says. The guts need to learn to digest the food and squeeze it along, the way full-term intestines do. Otherwise, those guts can inflame, get infected, even decay.

They’re Still Not in the Clear

More potential hurdles await the kids. Lungs can be damaged by the oxygen treatment and mechanical ventilation--the very things that saved the child’s life. Brain damage from bleeds or lack of oxygen can lead to conditions like cerebral palsy, hydrocephalus and learning difficulties. There can be problems with vision and hearing.

But no one can predict the future for the Chukwu kids. “We get a lot of moms coming back with their babies, and the outcome is very varied,” Sanders says. “The more premature, the more risk they have, but we’ve seen some great outcomes too. You just never know how it’s going to go.”

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The Progress File

Ebuka, girl. Birth weight 24 ounces, born Dec. 8, by vaginal delivery. Weight on Jan. 4: 26 1/2 ounces. The first to be born, Ebuka was also the first to receive oral feedings of formula through a tube and to breathe without the assistance of a ventilator. Receiving larger feedings of breast milk.

Chidi, girl. 27 ounces, born Dec. 20, by C-section. Weight on Jan. 4: 28 1/2 ounces. First, along with Echerem, to receive tiny amounts of breast milk to supplement intravenous feeding. Breast milk and central intravenous feedings suspended during antibiotic treatment for an infection, from which Chidi has now recovered.

Echerem, girl. 28 ounces, born Dec. 20, by C-section. Weight on Jan. 4: 31 ounces. The first, along with Chidi, to receive tiny amounts of breast milk to supplement intravenous feedings. Now receiving larger portions of breast milk.

Chima, girl. 26 ounces, born Dec. 20, by C-section. Weight on Jan. 4: 26 ounces. Breast milk feedings had to be suspended while Chima was treated with antibiotics for a suspected infection, from which she has now recovered.

Odera, girl, 11.2 ounces, born Dec. 20, C-section. A mere 9 3/4 inches long, Odera was small enough to be held in a woman’s hand. On Dec. 26, her blood oxygen levels began to fall and her heart rate to falter. She died the next day from heart and lung failure.

Ikem, boy, 17 1/2 ounces, born Dec. 20, by C-section. Weight on Jan. 4: 17 1/2 ounces. Suffered a severe respiratory setback on Dec. 25-26 but pulled through.

Jioke, boy, 28 1/2 ounces, born Dec. 20, by C-section. Weight on Jan. 4: 32 ounces. Now receiving larger portions of breast milk. The largest of the octuplets, weighing 2 pounds as of Jan. 11, Jioke was the first to be held by his mother.

Gorom, girl, 18 ounces, born Dec. 20, by C-section. Weight on Jan. 4: 18 ounces. Underwent abdominal surgery Dec. 26 to correct a perforation in her lower intestine. The last octuplet of those surviving to come off mechanical ventilator and receive breast milk.