New normal in neonatology

Collaboration, expertise, and innovation improve outcomes for premature and critically ill infants

A generation ago, it was generally accepted in the medical community that saving a baby born at fewer than 26 weeks’ gestation was highly improbable at best.

Multiple factors influence whether an infant will survive preterm birth or experience future health problems or disabilities, but most doctors and health systems in the U.S. now define the age of viability as being 24 weeks of gestation—a marked improvement over the past three decades.

Neonatology and maternal-fetal medicine teams with University of Iowa Health Care are working to expand the possibilities in neonatal care even further. Through their work, and the speed and precision with which they provide care, the Neonatal Intensive Care Unit (NICU) at UI Stead Family Children’s Hospital posts survival rates for babies born at 22, 23, 24, and 25 weeks that are significantly higher than survival rates for extremely premature babies born at other U.S. hospitals.

To further optimize survival and long-term outcomes for these tiny babies as well as other critically ill infants, UI neonatologists have implemented a neonatal hemodynamics program, which uses noninvasive diagnostics such as echocardiography (ultrasound) to examine the heart and circulatory system. The goal of this pioneering approach is twofold: save more newborn lives and train a new generation of neonatology experts to care for their most fragile patients.

Expertise at the outset

When a preterm baby is born at UI Stead Family Children’s Hospital, obstetrical and neonatal care specialists—some having monitored mother and child for months in advance—know exactly how to respond. Their expertise is key to why a remarkable number of fragile infants are not only surviving but thriving.  

Minutes after a premature baby is born, nurses place the infant on a warming table to regulate body temperature; neonatologists place breathing tubes as small as 2 mm in diameter into the trachea and thread catheters through the tiny umbilical vein and artery to deliver lifesaving medicines and fluids and measure blood pressure; and imaging technicians examine the infant’s lungs to ensure they are inflating. 

This is a precarious time because micropreemies—babies born before 26 weeks’ gestation—are not just tiny versions of full-term babies that arrive between 37 and 40 weeks’ gestation. A micropreemie’s organs are not yet fully developed or ready to function outside the womb. Eyelids may be fused shut, and the skin is gelatinous, transparent, and unable to sustain contact with clothing until many weeks later. Micropreemies don’t know how to breathe effectively or swallow. Weighing as little as 1 pound in some cases, these tiny babies will spend the time they should have been growing in the womb developing instead with the help of medications, machines, and a highly skilled neonatal team performing deliberate and careful medical calculations to mimic the intrauterine environment. 

Starting out life as a preemie is not hopeless, but it’s important that these babies receive active treatment quickly,” says UI neonatologist Edward Bell, MD. “Even the smallest babies have a chance to live, and if they survive, a good life is likely.

Tradition of tending to tiny babies 

When Bell says that even the tiniest of babies—including extremely premature infants weighing less than a can of soda—have a chance of survival, he knows what he’s talking about. He has spent four decades studying premature infants, devising new ways to keep them alive and guard against health complications such as blindness and neurological impairment as they grow. 

“Starting out life as a preemie is not hopeless, but it’s important that these babies receive active treatment quickly. Even the smallest babies have a chance to live, and if they survive, a good life is likely.”

Edward Bell, MD, neonatologist

In 2000, in an effort to better track premature births, Bell started the Tiniest Babies Registry, a reference for medical teams and parents of premature infants that includes information and updates on the world’s smallest surviving babies—226 infants as of Oct. 19, 2019, all born weighing less than 400 grams, or 14 ounces. 

Regularly contacted by other medical providers as well as global media outlets for his expertise on premature birth, Bell has seen “massive” changes in neonatal care during his career. Some of the changes are surprising even to him in terms of the ability to preserve the future for a baby and its family, as well as the field of neonatology. 

“In an interview with The New York Times about 20 years ago, I said that 24 weeks was the youngest baby we could save, and I didn’t foresee being able to save babies born any earlier because of the rate at which the lungs develop,” Bell says. “I’m happy to say I was wrong; I don’t like to make predictions about what we can’t do because so often ‘can’t’ turns into ‘can.’”

A team from the University of Iowa recently published a paper in the Journal of Pediatrics reporting the excellent survival of extremely premature infants born at UI Hospitals & Clinics and cared for in the UI Stead Family Children’s Hospital NICU. Patricia Watkins, MD (16R, 19F), John Dagle, (91MD, 91PhD, 95R, 97F), Bell, and Tarah Colaizy, MD, MPH, reported that 70% of babies born at 22 weeks over a 10-year period at UI Hospitals and Clinics survived. To offer a comparison, based on the results of a large national study from the Vermont Oxford Network, published in JAMA Network Open last year, 9% of infants born across the U.S. at 22 weeks survived. These excellent outcomes at Iowa have attracted attention around the U.S. and worldwide, and teams of physicians and nurses are coming to Iowa City to learn how the UI obstetricians and NICU team achieve such success. An editorial that accompanied the Iowa paper in the Journal of Pediatrics was titled, “From Iowa: Cautious Optimism?”

A dozen experts for every mother and baby

One reason so many premature and ill babies survive at UI Stead Family Children’s Hospital is teamwork. Nurses, doctors, nurse practitioners, respiratory therapists, nutritionists, social workers, pharmacists, lab technicians, and physical therapists—all with expertise in neonatology—work in tandem to provide optimal care. Even the NICU environmental services staff helps to ensure that every possible challenge is considered. Jonathan Klein, MD, medical director of the NICU, says every voice must be respected for the team to function well. 

“The care of extremely premature infants is so complex that it requires a multidisciplinary team to fine-tune everything. When we have our team meetings, we take input from everyone, including the family. Having 10 or 12 brains working to solve a problem is better than one or two.”

Jonathan Klein, MD, Medical Director, UI Stead Family Children’s Hospital NICU

The NICU team includes maternal-fetal medicine physicians who specialize in taking care of women with high-risk pregnancies. In Iowa, there are only 12 doctors with this experience, and six of them work at UI Hospitals & Clinics. Their expertise—which includes routinely administering antenatal steroids to a mother as early as 21 weeks and five days into a high-risk pregnancy to give her baby’s lungs the best chance to mature—helps optimize the mother’s health and account for the many medical variables that can affect a preterm delivery.

“The collaboration between the neonatology physicians and the maternal-fetal medicine physicians is important because we all work to optimize care for mother and baby,” says Andrea Greiner, MD, interim director of the Division of Maternal-Fetal Medicine in the Department of Obstetrics and Gynecology. “When I’m caring for a mom with a complicated pregnancy, any decision I make will impact the baby and the care that baby will receive in the Neonatal Intensive Care Unit, so it's important for me to be communicating with my NICU colleagues. They have to be ready to accept a complicated newborn.” 

Expanding the boundaries of neonatal medicine

Saving premature infants born before 22 weeks of gestation is a future challenge for neonatologists, says Bell. This could take significant technological advances, he says, including the creation of an artificial placenta to shelter and protect extremely premature babies while their lungs, heart, and women, which is a phenomenon that still puzzles medical teams, and reducing the complications for infants in whom premature birth cannot be prevented.

In addition to growing the neonatal hemodynamics program beyond Iowa through advanced cardiology training for neonatologists, McNamara is also focused on “transforming patient care” with the development of a regional transport service in Iowa. The service would bring women in premature labor or mothers and their premature babies to UI Stead Family Children’s Hospital as quickly as possible to improve newborn survival rates. Also, instead of transporting mothers and babies, a team of neonatal experts could be dispatched to distant Iowa towns and cities.

“One of the most difficult things for me as a neonatologist relates to when babies who could benefit from the care that we provide don’t have access to that care,” says McNamara. “I think we have a professional responsibility and accountability to ensure within our region and within our state that all babies get access to optimal care. I struggle when babies die or have a bad outcome because the system fails them.”