• How Early is Too Early?

    The giant toll of saving the tiniest babies

    Three decades ago, most in­fants born at 28 weeks ges­tation – 12 weeks prema­ture – did not survive their first year. Today, more than 90 percent do. Medical science has pushed the en­velope of survival thanks to improve­ments that include better ventilators, wider use of prenatal steroids, artificial surfactant (developed in part based on research at Cincinnati Children’s) and other advances in neonatal care.

    Survival odds for infants born at a once-unimaginable 25 weeks have soared beyond 50 percent. There are isolated reports of survival for infants born as early as 21 weeks and as small as 260 grams (9.17 oz.).

    “With these kinds of improve­ments, people start asking, how low can we go? Why not 24 weeks, 23 weeks, or even lower?” says James Greenberg, MD, Co-Director of our Perinatal Institute.

    Shifting Focus to the Quality of LIfe

    However, Greenberg adds, our abil­ity to rescue ever younger and smaller preterm infants is approaching a point where the risks and required resources outweigh the potential benefits.

    “It’s true that survival has contin­ued to improve for extremely low gesta­tional age babies. But it’s also clear that the incremental cost is exponential,” Greenberg says. “Many of these babies have long-term problems. The current model with its singular focus on caring for progressively smaller, more imma­ture babies is not economically sustain­able or biologically plausible.”

    Physician-scientists at Cincinnati Children’s are focusing more on devel­oping ways to keep babies in the womb longer. “If we can change a 28-week delivery to a 32-week delivery, out­comes will be better. Even a few days longer in the womb are beneficial,” Greenberg says.

    One sign of progress: A four-year effort led by the Ohio Perinatal Quality Collaborative (supported by Cincinnati Children’s) is improving health outcomes and saving costs by reducing elective C-sections in the last few weeks of pregnancy. “At first, ob­stetricians fought it, but the protocols were well enforced and we have signifi­cantly fewer late-preterm births now,” Greenberg says.

    IVF Course Correction

    Meanwhile, IVF technology has im­proved to help correct a problem of its own making.

    As more women delayed child-bearing into their 30s and 40s, demand grew for ever more complex in vitro fertilization (IVF) treatments. In the early days of IVF, fertility specialists needed to transfer multiple embryos in hopes of generating just one live birth. But over time, multiple embryo trans­fers became more of a problem than a solution.

    They caused a spike in IVF-re­lated multiple births, many of which were preterm and required intensive care, says Maurizio Macaluso, MD, DPH, Director of Biostatistics and Epidemiology.

    “Now as success with IVF has improved, the emphasis has started to shift toward single-embryo transfer,” Macaluso says.

    Most treatment cycles still involve two transferred embryos. But the num­ber of cycles involving four or more embryos has dropped from 32 percent in 2001 to 10 percent in 2010, accord­ing to the CDC. Meanwhile, single-embryo transfers have climbed from 6 percent in 2001 to 15 percent in 2010.

    As a result, the numbers of mul­tiple births stemming from infertility treatments have begun to fall.

    In 2001, 64 percent of births af­ter IVF treatment were singletons, 32 percent were twins and 4 percent were triplets or more, the CDC reports. By 2010, 70 percent of births were single­tons, 29 percent were twins and just one percent were triplets or more.

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    The current model of saving the tiniest, most fragile premature infants "is not economically sustainable or biologically plausible," says Dr. James Greenberg.