Meet Mac: one of the youngest babies ever born at St. Boniface Hospital

Wave, May / June 2015

Tiffany Gross lies back on her anti-gravity chair and gently wraps her arms around the tiny infant lying on her chest.

Her son, Mac, was prematurely born on February 9 at 22 weeks and six days gestation - about four months before term. Weighing in at just 630 grams (21 ounces), Mac is the youngest surviving premature baby born at St. Boniface Hospital.

The significance of the event is not lost on Gross or her wife, Rya Dacquay.

"It was terrifying, especially with him being intubated (having a breathing tube inserted into his windpipe)," says Gross. "The chances of his survival were not good," she says. "It was scary, but also the best feeling in the world."

Since then, things have only gotten better. By mid-May, little Mac weighed five pounds and he has been getting stronger every day. "Look at him. He's perfect. He's five times the weight he was when he was born," says Gross.

Mac's progress is partly due to the quality care he has received during his stay at the neonatal intensive care unit (NICU) at St. Boniface Hospital. Over the last 20 years, advances in medical treatments, such as the introduction of steroids to help boost a baby's development and the use of a drug called surfactant to enhance lung capacity, have helped to significantly improve the odds of survival for premature babies.

But Mac's steady growth can also be attributed to something else: a mother's loving touch.

Premature babies enter the world facing a number of health challenges, including stress, high or low blood pressure, increased or decreased heart rate, digestive challenges, little or no respiratory drive, neurological issues and an inability to thermoregulate.

While conventional medicine goes a long way to addressing these potential problems, experts say one should not overlook the important role played by simply letting a baby rest on the chest of his or her mother.

When a baby rests skin-to-skin on a mother's chest for a minimum of one hour a day, remarkable things happen. The baby's breathing and heart rate stabilize, they get more of the deep sleep required for brain growth, and can put on weight rapidly. Studies show the result is that these babies will end up with higher IQ scores, better motor development, and end up having an earlier discharge.

As a result, both St. Boniface Hospital and Health Sciences Centre Winnipeg have incorporated this approach - known as kangaroo care - into their neonatal and intermediate care nursery programs. And moms couldn't be happier.

Walk into the NICU at St. Boniface or HSC Winnipeg and chances are you will find mothers tucked into quiet corners, holding their tiny babies to their chests. All of the babies are hooked up to monitors, but the ones resting on the chests of their moms appear to be more at peace with their surroundings.

Megan Vokey's experience with her daughter, Ashlan, illustrates the point. Ashlan entered this world at 24 weeks, weighing 735 grams (25.9 ounces). "She was the size of a kitten when she was born," Vokey says of her daughter. "I was told she had a 60 per cent chance of making it."

As Ashlan's monitor beeps, Vokey whispers calming words to her. Within seconds, her daughter stabilizes and is again resting comfortably, waving her tiny fingers in the air.

Ashlan's progress since birth can be attributed to kangaroo care, says Vokey.

"She was very little still, and attached to a ventilator to help her breathe. There were a lot of tubes and wires," says Vokey. "I recognized immediately that Ashlan really liked being held. She began to do a lot better. She was able to regulate her temperature and put on weight very well. Everything got better as soon as I was able to hold her," she says. "It's really empowering to know there's something you can do to help your child when you have no control over so much."

While skin-to-skin care is important for every infant, it's essential for those who are born premature.

Diane Schultz, a registered nurse at St. Boniface Hospital, is the resident champion for kangaroo care. Schultz and a group of nurses from the unit met Susan Ludington (a top researcher of skin-to-skin care) at a conference in Phoenix, Arizona six years ago, and her presentation changed their attitudes towards kangaroo care. 

As Schultz explains, while the hospital had always made skin-to-skin care available, the practice wasn't promoted or seen as particularly helpful. That's partly because the conventional wisdom of the day suggested that medicine would be more important in helping to keep a premature baby alive than a mother's touch.

"This conference completely changed our views," Schultz says. "(Now), we do skin-to-skin with almost all babies, from very tiny premature infants requiring lots of medical support to full-term infants with respiratory distress. We also do twins and triplets on mom at the same time."

Dr. Ruben Alvaro, a neonatologist at St. Boniface Hospital and the person who headed the medical team that delivered Mac, says skin-to-skin care plays a vital role in helping a premature baby thrive.

"I think it's very important. Very important," he says. "We know that these babies do better when they are in touch with mom."

Parents are particularly appreciative, says Schultz. When a baby is born premature, the parents often feel powerless. Kangaroo care is something they can do to actively help their child.

"It's very stressful to be in the NICU, because you're worried about the health of your baby. No one expects to be in here," says Schultz. "Parents should never have to sit at the bedside and stare at their baby when they can be holding them. Kangaroo care has given me great job satisfaction because you can see the stress go down in the parents."

While the psychological benefits of a parent's touch may seem obvious in retrospect - all humans love to be touched, especially tiny ones - science suggests premature babies benefit from skin-to-skin care in other ways.

For example, Schultz says, as a mother holds her baby, that infant goes into a deep REM sleep that promotes brain maturation. They do not get the same amount of REM sleep while lying in the incubator or open bed.

In addition, the antibodies on a woman's skin can actively protect her baby by building the infant's immunities, says Schultz. The swapping of cells also leads to changes in the mother's breast milk. "When the baby is held skin to skin, the baby's skin cells get absorbed by the mother and her body reads those cells and the breast milk composition is changed to accommodate the baby's needs," she says.

Skin-to-skin also helps with thermoregulation of the infant. "If the baby cools down, a mother's breasts will recognize that and heat up," Schultz says. "You can actually control the baby's temperature better skin-to-skin than when they are in the incubator," says Alvaro.

Alvaro also emphasizes that premature babies just seem to be more stable when they are with their mothers. "Just the fact that they are in contact with mom's heart rate and mom's skin (causes) them to become more stable. Oxygenation improves, breathing improves."  

Fathers also perform kangaroo care. Skin-to-skin with a father is very important because it promotes attachment and bonding with the infant; it is a psychological benefit where skin-to-skin with mom is a physiological benefit, says Schultz.

"The dads love doing it - it really bonds the family, and it's changed a lot for our parents," she says. "It gives them a sense of control, as they really feel they've made a difference in their baby's care."

Gross says the kangaroo care program has been beneficial in other ways. Her son, Mac, was a twin, but sadly, his sibling didn't survive, and the program has helped her and Dacquay cope with their loss.

"Being able to hold Mac sped up our healing process," says Gross. "The first time we held him, we were still dealing with a whirlwind of emotion. Holding your baby is one of the things you look forward to the most. When your baby is premature, you feel very robbed of something you looked forward to for a long time."

It took a while for Gross and Dacquay to feel comfortable holding their son, simply because he was so tiny. But as soon as they started with kangaroo care, they started to notice a difference.

Before the skin-to-skin care experience, Mac was losing weight. That changed when Gross and Dacquay were allowed to hold him. "He gained weight super fast - he started to pack on the pounds. It's amazing - once he's on us, he's totally relaxed," says Gross. "He breathes with our rhythm, and he's doing so well. It's formed a bond between him and my wife as well."

Since many of the mothers hold their babies for three or more hours every day, there's a lot of opportunity for them to bond with the other mothers in the program. "The other moms have gotten me through this," says Amy Waluk, holding her little girl, Sophia, four weeks old. "It feels like the end of the world at first, but there are some amazing people in here. I think it makes a huge difference - us being around each other and our babies being around us. Little people are much stronger than we are. I'm so proud of my daughter."

Kangaroo care also helps mothers by preventing postpartum depression and increasing breast-milk production. "It makes parents feel wonderful. I've had mothers tell me that they actually feel like moms again. We're helping parents be parents," says Barb Swaine, clinical resource nurse at HSC. "We're so happy we're able to do this for our families."

The hospital has been promoting kangaroo care for full-term babies since the 1980s. It's been allowed in the NICU since 1996. They place stuffed toy baby kangaroos at the bedsides to remind parents when it's a good time for skin-to-skin care. Kangaroo care is also offered at HSC's intermediate care nursery.

"Premature babies used to be kept away from their parents, and they didn't do as well. Now the goal is to get the babies on mom's chest as soon as possible. It's the best place in the world for them," Swaine says. "These babies do better. They tolerate their feeds better and grow better."

For two weeks in April, St. Boniface Hospital participated in a kangaroo care challenge with the NICU at Sunnybrook Hospital in Toronto. "For us, it's not going to be too much of a challenge, but it will be interesting to track how much we actually do it. Some of our moms are holding from four to six hours every day," says Schultz. "We will be charting the time and keeping track of it, and there will be prize draws for staff and parents." (At the end of the challenge, the unit did 663 hours and 15 minutes of kangaroo care, which equals 28 days of holding.)

Incorporating kangaroo care into an intensive care setting means more work for the nurses, but Schultz says the benefits far outweigh any difficulties.

"It took us a while to get used to it and get comfortable with it, but we have a really good team here. I'm very impressed with the people I work with," she says. "There's always somebody willing to help. I think it's brought us closer."

Once babies arrive home, Schultz says recommendations are for one year of continued skin-to-skin care for premature infants (two to six hours a day), and at least three months for full-term babies.

Vokey hopes she'll be able to take Ashlan home soon. The final hurdle is teaching her daughter how to breastfeed.

"She's so much stronger - she's thriving. She's definitely coming home. We've gone through the scary time, and we've survived it," Vokey says. "Holding her is such an amazing thing that six hours feels like one. I'd hold her more if I could. It's the best part of my day, for sure."

Holli Moncrieff is a Winnipeg writer.

***

Miracle babies: Advances in medicine give premature babies a chance at life

Twenty years ago, it was thought that a premature baby would need to be at least 25 weeks old and weigh about 500 grams (17 ounces) to have a decent chance at survival.

Today, babies between 22 and 23 weeks' gestation are being delivered at Winnipeg's two maternity hospitals, some weighing just over 400 grams (14 ounces). And their chances of surviving are hovering around 40 to 50 per cent, and improving all the time. Just recently, at St. Boniface Hospital, Mac Gross entered the world at 22 weeks, six days - the youngest baby ever born at St. Boniface Hospital. He weighed 630 grams (21 ounces). Over at Health Sciences Centre Winnipeg, babies are born as young as 23 weeks.

Premature babies generally face a series of challenges upon birth, says Dr. Ruben Alvaro, a neonatologist at St. Boniface Hospital and the person who headed the medical team that delivered little Mac.

For example, premature babies are not as fully developed as those delivered at full term. "Every organ is immature," says Alvaro, including the lungs, kidneys and heart.

They are also more likely to suffer neurological damage from a bleed in the brain. Infections are a problem because premature babies do not have well- developed immune systems.

So why have more premature babies been able to thrive in recent years?

Alvaro says a lot of the change over the last 20 years can be attributed to two major developments. One is the introduction of prenatal steroids in mothers to help boost the development of the fetus, particularly the lungs and the brain. This helps enhance the baby's health, which of course, also helps prevent infection. "The more stable the baby, the less risk of infection," says Alvaro. The other big advance came with the introduction of surfactant, a drug that is used when a baby is born to boost his or her lung capacity and reduce respiratory stress.

Lung and respiratory issues are among the top health challenges facing premature babies at birth, largely because they are born without sufficient levels of surfactant, a naturally occurring substance found in the lungs that enhances breathing, says Alvaro.

"We all have surfactant in our lungs. Premature babies, when they are born, don't have enough. So we actually give surfactant directly into their lungs to keep the lungs open," he says.

Following the approval of surfactant for clinical use in 1991, "the mortality rate from respiratory stress in premature babies significantly decreased," he says.

Interestingly, delivering a premature baby is not all that much different than delivering an infant at full term, says Alvaro. The real work starts after the baby is born, he says.

Of course, the first order of business is to determine, in consultation with parents, whether the premature baby has a real chance of surviving. Once a decision is made, the medical team begins to prepare for delivery. A premature baby delivery team will include as many as two neonatologists, two to three nurses, and two to three respiratory therapists. "It is not a one-person job," says Alvaro. After the delivery, the team gets larger, including dietitians, pharmacists, physiotherapists and a number of specialists. 
A premature baby's chance of survival is heavily influenced by his or her gestational age, the odds improving week by week, even day by day.

For example, Alvaro says a baby born at 25 weeks will have a 75 to 80 per cent chance of survival. At 24 weeks, a baby will have about a 60 per cent chance of survival. Between 22 to 23 weeks, the baby's chance of survival drops to about 40 to 50 per cent.

"A few years ago, we did not even consider going for babies at 23 weeks because the survival rate was less than 20 per cent. But as we started treating these babies at 23 weeks, we are getting better, and the survival rate has increased significantly over the last 10 years."

Alvaro says it is important to remember that the health of the baby at birth is often more important than its gestational age.

"There are babies born at 25 weeks who are extremely sick because of the condition that triggered the premature labour. So, for example, if the mom had a severe infection that triggered the labour, that baby will not be born in good shape. But if the baby was born prematurely because there was a maternal condition - maternal hypertension or something like that - the baby is usually in better shape because there is no infection or anything, and you can prepare for the delivery better."

Generally speaking, St. Boniface will only deliver a few babies a year at 23 weeks, and about four or five at 24 weeks. "It really depends. We don't want to force anything on parents if the prognosis is not that good."

Of course, every premature baby has his or her own story of survival to tell.
In Mac's case, his medical team swung into action the second he was born. Several steps have to be taken immediately when a premature baby is born, so planning is key, says Alvaro. "Everyone needs to know exactly what their job is."

Mac was born stable, so the team was able to delay clamping the cord for about a minute to get more blood pumping from the placenta to the baby. Then, the team placed Mac into a small plastic bag to help keep him warm and to prevent evaporation of moisture. "It's like a greenhouse effect. We put them in a plastic bag and that helps keep the temperature inside the bag and on the baby."

At the same time, the team inserted a device into Mac's nose to provide pressure to his lungs and keep them open so he could breathe. Once that was done, the team placed a sensor on Mac's hand to monitor oxygenation of his blood.

"When the baby is inside the mom, the oxygen level in the blood is low. When the baby takes the first few breaths, the oxygenation level goes up. We monitor oxygenation in the first few minutes of life to see if we need to do any more intervention." 

As it turned out, Mac spent about five weeks on a ventilator and about nine weeks on a continuous positive airway pressure (CPAP) machine.

Today's Mac's condition is much improved. He is stable, breathing on his own, growing and shows no sign of infections. "His prognosis is good," says Alvaro.

***

About kangaroo care

Kangaroo care, kangaroo mother care and skin-to-skin all refer to the act of a mother or father holding a diaper-clad infant bare chest to bare chest.

The concept originated in Bogota, Colombia, in the early 1980s. At the time, health experts noticed that premature babies who spent a lot of time on their mom’s chest did better than those who didn’t. As the practice grew, infant mortality rates, which were 80 per cent at the time, dropped. The idea of kangaroo care was presented to the world shortly after. Since then, kangaroo care has been extensively researched, showing a multitude of benefits for full-term and pre-term infants, such as:

Full-Term Infants

• Thermoregulation, which in turn decreases brown fat metabolism,
  helping to maintain normal blood sugar levels
• Decreased crying
• More quiet sleep
• Better feeding behaviours
• Increased duration of breastfeeding
• Decreased pain response

Pre-Term Infants

• Decreased mortality
• Increased brain maturity due to increased REM
  sleep
• Decreased nosocomial infections
• Decreased length of stay
• Increased breastfeeding duration
• Better weight gain
• Decreased oxygen requirements
• Decreased apneas and bradycardias

Maternal Benefits

• Increased maternal hemoglobin
• Decreased bleeding postpartum
• Decreased length of stay
• Improves attachment, better interaction
  with infant

Health Sciences Centre Winnipeg and St. Boniface Hospital have been offering kangaroo care in their neonatal and intermediate care nurseries for many years, but the practice has really been promoted in the last five years.

The hospitals have LaFuma anti-gravity chairs that allow the infant and mother to be at least 30 degrees midline, which is better for infant breathing and prevents blood pooling in the mother’s legs.

Republished from the May/June 2015 issue of Wave, Winnipeg’s health and wellness magazine.