The Challenges of Preterm Birth

World Prematurity Day is recognised every year on 17 November to promote awareness of preterm birth and the problems of preterm new-borns and their families around the world.

Paediatrician and neonatal specialist Dr Sara Watkin, based at Integra Healthcare Ltd, shares a special case in the Cayman Islands of sisters both born prematurely.

Preterm birth is challenging at the best of times, when your baby arrives before, sometimes long before, you are expecting it. However, some occasions are more challenging than others, for instance when the new arrival comes amidst a pandemic, creating a new level of practical and emotional difficulty for the parents and care givers alike, Dr Watkin said.

Zoe, and her recent sister, Renae, were both born prematurely during some of life’s most challenging times. Zoe, was born at just 26 weeks gestation, 14 weeks early, in Cayman Islands Hospital in George Town, in March 2020, just as we headed into a perfect storm of conditions, and when transfer to a specialist centre like St Nicklaus Children’s wasn’t possible.

Dr Watkin said the initial experience with Zoe was a “scary time for parents and us.”

“I am very used to caring for 26-week infants, having spent most of my working life caring for babies from 23 weeks gestation onwards, but we were all just discovering what Covid-19 was going to mean for us. We knew very little about the disease and nothing about whether it might carry extra risks for preterm babies, especially ones like Zoe, when they are already challenged by their degree of prematurity,” she advised.

Zoe was born at a time when George Town Hospital was also facing the challenge of just how to care for patients in general and more importantly, how to keep people safe at a time when we were facing a disease that few understood. That meant restricting access to parts of the hospital and the NICU was one of those.

“Having a preterm baby is obviously a traumatic experience when everything is normal but Zoe and mum found themselves separated for many weeks, a heart-wrenching time for her mum,” she said.

Dr Watkin said in order to help parents and baby bond, she tried to recreate some of what would normally be a shared experience by using phone and video technology.

“To try to ensure Mum was always fully aware, I spent time each day explaining all that was going on and how Zoe was doing. We did daily video calls so Zoe and Mum could be together,” she advised, adding that mum would sing to Zoe during the calls. Little Zoe’s face would light up when she was doing this.

Zoe’s care challenges

At 26 weeks, any baby is going to face a long, sometimes difficult journey, the doctor said. In these early stages, you need the utmost focus on getting things right. Being the tiniest bit off is something that can spiral into a host of more complex issues.

“For Zoe, that could have been a catastrophe because we were unlikely to be able to access a tertiary centre with complicated equipment like nitric oxide or advanced forms of ventilation. At the same time, I was in and out of protective gear multiple times per day, learning to do procedures in my newfound fashionwear, and the stress and newness of this is obviously very tiring. Our neonatal nurses in George Town were facing similar issues too,” she said.

In particular, the lungs are very delicate in premature babies, though using a ventilator can bring on problems in later life.

“In Zoe’s case, we managed to avoid her being ventilated at all, carefully managing her with something gentler called nasal SIPPV and supplemental oxygen. We actually sent her home just three days after her original due date, still on some supplemental oxygen, and on breast milk feeding. By that stage, home was where she needed to be, Dr Watkin informed.

Very preterm infants are highly susceptible to various types of brain injury, so Zoe had regular scans right through her care and these were all normal. She did need two blood transfusions, intravenous feeding and then feeding through a nasogastric tube but despite the degree of prematurity, and with the facilities we have here on our tiny Island, we managed to get her home safely.

“She is now a bonny young lady who I take great pleasure in seeing and who her parents just adore,” Dr Watkin confirmed.

Déjà vu

One risk factor for preterm birth is a previous preterm birth. In August, Mum gave birth to Zoe’s little sister, Renae, at 30 weeks gestation, just as Cayman was exiting its Covid-free bubble.

“This was certainly a feeling of déjà vu,” Dr Watkin confirmed. “I have now had the privilege of managing 24 weeks of combined prematurity in the same family! Although Renae did need some supplemental oxygen, she was discharged home at six weeks of age. To put that in context, we managed to have her home four weeks before she was actually originally due, again on breast milk, and she’s just a beautiful young baby.”