Second Opinion: The BBC television programme Panorama was recently given exclusive access to the largest ever study of extremely premature babies born at less than 26 weeks gestation the so called "miracle babies" who owe their lives to modern neonatal intensive care.
Every year thousands of babies are born prematurely in Ireland and the UK. The Panorama special Miracle Baby Grows Up dealt with the emotive topic of extremely preterm infants born at under 26 weeks gestation. These infants, more than 14 weeks premature, are at the borderlands of human survival.
The programme concentrated on the central question whether they should be rescued and given newborn intensive care.
Concerns were expressed that these infants are too fragile for intact survival. The question repeatedly raised was whether these babies are beyond the current technology and biological understanding.
The study followed a group of infants born under 26 weeks gestation between March and December 1995. The programme focused on where they were now, nine years later. The central concern was that approximately 40 per cent of these children have disabilities.
One of the layers of the programme was whether it was worth it. Did this represent appropriate use of intensive care? Many of the parents of the compromised children were interviewed. When asked the penetrating question, their answers were diffuse given their loyalty to their child on one hand and a realisation of the severity of the handicap on the other.
The programme represents an important milestone in the debate about intensive care for fragile premature infants. The difficulty was that it raised questions but did not provide any solutions for parents facing this dilemma this week or into the future.
Many Irish parents who have through similar experiences in our neonatal intensive care units must have been emotionally disturbed by the programme and its contents. In Ireland 3,000 babies are born prematurely each year of whom 600 are very immature. The programme should have more clearly spelt out that its concerns only related a small subgroup of extremely premature infants and that most premature babies fare well.
When dealing with a borderline intensive care problem and its uncertainty the newborn specialist may lean towards optimism or pessimism. In the Panorama programme there was an optimist and a pessimist. What is the mother of a newly born 25 week gestation to think? If she allows the baby to undergo intensive care mortality will be high and if he survives there is a 40 per cent chance of handicap. On the other hand if her baby survives he has a 50 per cent chance of being normal. The programme graphically illustrated this dilemma.
Newborn intensive care is a new medical speciality. That it is now critically analysing the results of its treatments indicates that it has come of age. The development of newborn intensive care was one of the most exciting stories of the latter half of the 20th century.
"Positive" medical treatment of preterm infants commenced in the 1950s with introduction of incubators, systems for oxygen delivery and the advent of antibiotics. Subsequent decades saw rapid technological expansion and the administration of sophisticated intensive care.
The impact on the survival of babies was dramatic. Mortality for infants weighing 1,000 to 1,500g fell from 50 per cent in 1970 to under 10 per cent at the present time. Previously all infants under 750g died but now survival rates are 50 per cent.
The emphasis in more recent years is about the quality of survival. To have a full and rewarding life these infants like all other children will need a healthy body, enquiring mind and stable personality. This poses major challenges for neonatology.
One of the major reservations about the Panorama programme is that its findings are based on babies born almost a decade ago. The technology and management of these fragile infants has advanced considerably in the last 10 years.
In addition, the high resolution of modern cotside ultrasound means those who have developed brain complications can be more readily identified and intensive care withdrawn where indicated. Thus in 2004 it is easier to anticipate those babies who will do badly and then consider the appropriate withdrawal of intensive care.
The Panorama programme was instructive and honest. It was perhaps tinged with pessimism. It did not offer solutions. Also it did not face the reality that the clock can't be turned back. Attempts to rescue very immature infants will continue. Like all challenges in medicine the current obstacles will be overcome with ever advancing technology.
• Dr John FA Murphy is consultant neonatologist at the National Maternity Hospital,Holles Street, Dublin 2
- Shalini Sinha is on leave