Mini Med School X -
Conception, birth and beyond: The challenges of life's beginnings
How small is too small Q & A
Q: Is there a difference in a child’s developmental issues when premature birth was caused naturally or as a result of external influences such as stress or induced labour?
A: This is a difficult question to answer because “natural” premature birth may in fact likely be the result of external influences (that we largely do not understand), many of which would be stressful to the fetus/baby. For instance, “spontaneous premature onset of premature labour” , at the level we understand it currently, is most frequently associated with bacteria which colonise the birth canal becoming more “unfriendly” and cause an infection. This infection, although it may not get into the fetus and placenta, may cause changes in inflammatory substances which trigger changes that initiate labour.
We will be talking more about effects of early stress on modulation of later development in the second last session of Mini Med School. – so hope you will be here then! MFW
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Q: At what stage in a baby’s life do they determine where the baby is on the disability spectrum?
A: "Disability” can mean a lot of different things to different people, and there is a wide range of areas for potential disability (e.g. vision, learning problems, mental handicap, cerebral palsy, hearing problems, behaviour problems etc.) We will be talking more about this at the second last session of Mini Med School. Here are some generalizations in response to your question.
- There are screening tests for many potential causes of disability, so some disabling conditions can be identified before the child has a disability so steps can be taken to prevent that happening, or reduce the effects of the disability of later functioning – e.g. hearing screening in the neonatal period; biochemical screening for inborn errors of metabolism such as phenylketonuria, screening for markers of hormonal insufficiency such as underactive thyroid which affects later intelligence
- In general, more severe problems can be identified earlier, - in utero, or in the neonatal period. Less severe problems later. For instance Mental Handicap can be recognized by developmental testing by 18 months; learning disabilities not till around 5 years. MFW
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Q: Why do boys have more learning disabilities?
A: They have one pair of chromosomes (the sex chromosomes X and Y) where they have only one X, and the Y is a rudimentary other chromosome. All the genetic material on the single X and single Y are not “insured” by having a double copy, like there is everywhere else in the genome. So it would not be surprising to find that males might be in some ways less resilient than females. This would make sense because in your species, where the young need a long period of mothering before becoming independent, you would like the females to be the resilent ones and at least survive till the immatures are grown to self-sufficiency.
Males in general (not just premature males) are over represented in: neonatal mortality and morbility, learning problems, mental handicap, paediatric hospitalization, accidents, successful suicide, trouble with the police, incarceration, and early death etc, etc, etc.
Most laboratory cell cultures are of female cells because female cell lines are more resilient than males.
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Q: When the father is not in the picture and both the baby and mother are in critical condition, how are decisions made? Who decides the outcome of both mother and child?
A: As in all medical decision-making the best available surrogate makes decisions for the the not-yet-competent or not-competent patient. So in the situation you portray that would be the mother. If we required an emergency decision and the mother is under a general anaesthetic, for example, then we would try to get some input from any prior conversations with the mother or in discussion with other family member, to have some sense of what her choice would be for her baby. However, if there is a decision about whether or not to begin intensive care and there is not a decision available, unless intensive care in not a possibility we would embark upon intensive care treatment and then we could discuss things when the Mom is able to do so. The general rule in medicine is to decide in favour of life. Even in a dire medical situation for the baby this would then allow the mother to have some time with the baby; for the opportunity to be able to say "good-bye".
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Q: Other than the statistics of survival rate and possibility of disabilities, is there specific neurological development between 23 and 26 weeks which would dictate a more favorable recommendation or intense care?
A: I am not quite clear what the question is here, but let me try to provide some relevant considerations. There are HUGE and fundamental changes going on in the developing brain between 23 and 26 weeks. At 23 weeks the brain cells that populate the cerebral cortex have just finished migrating there and the cerebrum (the thinking brain) is still smooth with no convolutions. By 26 weeks there has been very rapid growth in the cerebral cortex and the convolutions are becoming established. Further, the vascular system is very different in 23 and 26 week babies which would make the less mature brain more vulnerable to the stresses of intensive care and the risk of bleeding in the brain and poor blood supply to parts of the brain.
At follow up, MRI studies of the volume of the brain show that the tiny premature babies have smaller brains than controls in mid childhood, with the most reduction in brain size in the smallest/least mature babies at birth.
The change in vulnerability and need for intensive care is not LINEAR from 23 – 26 weeks. A 26 weeker is much more robust and resilent than a 23 weeker.
That being said, factors such as twin/singleton, sex, socioeconomic status, parental education etc are strong factors determining ultimate outcome, despite gestational age.
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Q: At what point do decisions not belong to the parents? There have been cases where the baby’s future becomes the government’s decision due to the parent’s cultural views conflicting with the heath of the baby.
A: This is an extremely complex question. This is also exceedingly rare, but causes a great deal of distress for everyone involved when it does arise. First we need to be very clear of the situation, because at times there is a misunderstanding or a lack of information or poor communication which underlies disagreements in decision-making. So understanding and really hearing where parents are coming from is key. We can also ask for involvement of the hospital ethicist or the hospital chaplain to help in such discussions. However, in the very rare instance where the health care team is concerned that the parents' cultural views conflict with what we believe is in the interests of the baby, we do have an ethical obligation to our patient to provide good medical care. Moreover, we have a legal obligation to inform the Ministry of Child and Family Development if there is a situation where we suspect child neglect or abuse. Therefore, we would contact the Ministry of Child and Family Development for their involvement, as there could be a situation where they might be considered by the Court to be the most appropriate surrogate decision-maker for the baby. We always try to work things out with parents, but in Canada the health care team or parents do have the opportunity to ask for help within the Court system if either party believes that the care is not in the best interests of the baby.
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Q: What is the normal delivery disability rate / survival rates as controls? Can they detect some disabilities before birth? Can this be done for premies? Would a surrogate mother be responsible for medical/financial consequences? How can she then make the decision or does she have to take on that responsibility?
A: Discussion of antenatal detection of disabilities was somewhat addressed above. The issue of surrogate mothers and possible responsibility/legal vulnerability is not an issue that is at all clear, and has never, to my knowledge been tried in the courts.
There are some precedents in adoption. In California, birth mothers who have not looked after themselves during pregnancy (e.g. alcohol consumption, not attending antenatal care etc) who have produced children who have been disabled have been sued by the adoptive parents on behalf of the handicapped children……..(only in California).
In Canada, the fetus is not legally considered to be a “person” until the baby is delivered and the cord is cut. There have been some precedents in extreme cases where attempts have been made to “make a woman pay for her lack of care during pregnancy”, which have been unsuccessful, because of the Mother’s rights in the Canadian Charter of Rights and Freedoms.
People who are not able to care for themselves during pregnancy tend to be people who are afflicted by poverty, substance abuse, mental health issues, social disconnection.
We might ask : Do you really want to live in a society that pilliories these people, who are themselves at least socially disabled, rather than building a health and social service system where vulnerable people , particularly those who are pregnant, are supported by society as a whole to deliver a healthy baby – as happens in Sweden – one of the countries with the lowest perinatal mortality rates in the world.
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Should you freeze your eggs?
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