On the Neonatal and Newborn Intensive Care Unit of the Altona Children’s Hospital in the PNZ Altona, a peaceful calm prevails this morning. No beeping from machines, no frantic squeaking of shoes from rushing nurses. All vital signs on the central monitoring system glow green. Nothing hints at the struggling for life of the tiny newborns, at surgeries on tiny hearts, or at the concerns of the parents.
Relaxed, the head physician of the Department of Neonatology and Pediatric Intensive Care, Martin Blohm, leads through the rooms. Here too, the high-tech medicine of an ICU is only noticeable at second glance. Wrapped in blankets, a baby weighing barely 1,200 grams lies on the bare chest of its mother. A breathing mask covers the tiny face, cables monitor the heart rate. “In the mornings there are especially many parents here, cuddling with their children,” explains Martin Blohm. The so-called kangaroo care strengthens the emotional bond between child and parents and has positive effects on development.
The familiar heartbeat soothes the child, and the movements of the chest provide breathing stimuli. In a chatty tone, the chief physician talks with the mother about the little girl’s weight gain, who cannot yet maintain her body temperature on her own and needs support with breathing. When she is not cuddling on her mother’s chest, she lies warm and monitored in an incubator. The prognosis is good, Blohm says as he leaves. If everything continues to be as positive, mother and child can go home in a few weeks — shortly after the originally calculated due date.
Support Is Becoming More and More Successful
Premature birth is defined as all babies who are born before the 37th week of pregnancy. Not all of them have to be admitted to an ICU after birth; the majority arrive “only” a few weeks before the calculated due date. They can leave the children’s hospital after a few weeks, sometimes after only a few days. But then there are the very immature preterm babies who are born between weeks 24 and 32 of gestation and weigh less than 1,500 grams. Their share is about 1.5 percent of all newborns in Germany. Thanks to modern medicine, their survival rate has risen sharply over the past decades.
Today, from completed 24 weeks of gestation onward, almost 80 percent of these children survive, compared with 30 percent in the late 1970s — even so, they remain high-risk patients. “When a child is born so early, its organs and bodily functions are not yet mature. Therefore, it needs a lot of medical support until it can survive independently,” explains Blohm.
Thanks to medical progress, this support is becoming increasingly effective. If you immediately think of high-tech medicine with many machines, you are only partly right — in the neonatal intensive care unit the aim is more like “as little technology as possible.” The treatment of premature babies is likened by Blohm to a system that must be kept in balance. The doctors intervene only if a part of this system threatens to tip. Otherwise, they let the child’s development run its course.
Good Bonding With the Parents
An example of this is invasive ventilation. It is used only in emergencies. Instead, lung maturation after birth is supported with medication, and afterward a breathing mask over the nose suffices as support. The child does most of the breathing work itself. This reduces the risk of lung damage. The bonding with the parents has also gained importance. On the Premature Neonatal Intensive Care Unit at the Altona Children’s Hospital, there are single rooms. Mothers and fathers can stay here all day and are involved. They change diapers, feed every two or three hours, or help with daily washing. This is good for the child’s development and fosters bonding.
Breastfeeding is started early as well. Breastfeeding is even possible with a breathing mask. Premature babies today are nearly exclusively nourished with maternal milk, even when a feeding tube is used. Maternal milk provides not only the proteins, fats and carbohydrates of human milk but also immune substances, vitamins, minerals and trace elements. Artificial milk from the lab is only a second-class substitute. If in doubt, the premature babies whose mother has no or not yet enough milk receive donated breast milk. Unlike ICU wards for adult patients, the monitoring devices do not beep here; the alarms are quieter and in some units operate with vibrations. Even the lighting is adjusted to a day-night rhythm. This routine is good for the children. Yet it is not possible to go without high-tech medicine.
With the modern incubators, the vital signs can be monitored. Most examinations today take place directly in the incubator thanks to digital technology, whether X-ray, weighing or ultrasound. This saves unnecessary trips and reduces stress for the tiny patients. The minimally invasive treatment techniques have also evolved. Thus, malformations, typical intestinal diseases, and misdirected blood circulations can be operated on in the ward—even in patients who weigh barely more than 500 grams.
Long-term studies are immensely important for improving the care of children.
Martin Blohm, intensivist
An achievement of progress: the lower limit of medical possibilities has shifted in recent years. In Germany, children are currently treated curatively starting at completed 24 weeks of gestation. Survival below 22 weeks is virtually impossible with today’s medical methods because the lungs are not yet developed. The weight of the child at birth also influences the chances of survival. “The technical possibilities are certainly fascinating, but I don’t know if we can and should push the natural boundary even further,” says Blohm.
Because that is also part of the truth: Even though survival rates are steadily rising, the danger of short- and long-term problems remains high, especially for the tiniest children. Heart and lung problems occur frequently. And particularly the brain is still immature and very sensitive.
Surveys such as the Bavarian Development Study conducted by researchers around developmental psychologist Dieter Wolke from the University of Warwick have been accompanying hundreds of families with preterm babies since the 1980s. Their studies show that preterm children feel the consequences of early birth into adulthood. In addition to cognitive and physical impairments, behavioral problems or delays in language development occur. Psychological issues such as depression also occur more frequently. “These long-term studies are immensely important for improving the care of children. Only in this way can we understand which measures not only save lives in the short term but are also good for the children’s lives in the long run,” says Blohm.
Even Before Birth: Intervening Early
Equally important as a better understanding of late effects and new treatment approaches from an expert perspective is the prevention of premature birth. Although the medical “monitoring” of pregnancy in Germany and many other industrialized nations is intensive.
But not all warning signs of preterm births are recognized in time and corresponding countermeasures are taken. And there are indeed measures: for example, regular ultrasound helps to detect changes in the cervix early. In some cases, a hormone preparation or low-dose aspirin can significantly reduce the risk. Infection prevention is also very important.
Every additional day in the womb is a gain for the children. As their natural development progresses, the physicians can better prepare the children for an early birth. For example, they are given cortisone even before birth. The hormone, normally produced in the adrenal gland, speeds up lung maturation. In the event of birth, they are now better able to breathe independently and require less high-tech medicine.
