Overview of Treatment

Preemie in isolette
There are many types and degrees of intervention that premature babies may go through. The more premature a baby is, the more likely she will require some form of intervention due to her condition.

Recreating the environment of the womb

As much as possible, the experience and treatments in the Neonatal Intensive Care Unit (NICU) are done to provide time so that a baby can mature as naturally as possible outside the womb. Often, the stay in the NICU is precautionary: once the baby has settled into her artificial environment, she is simply monitored while she catches up on the time that would have been spent maturing in the womb.

Simulating as much as possible the environment of the womb is a kind of treatment. Like the womb, the NICU is dark, quiet, and warm, and the baby is protected from knocks and infection. Depending on her degree of prematurity, a baby may require other support, particularly with breathing and cardiovascular issues. Premature babies may also require support for their body chemistry in some way. Frequently this may mean ensuring the right balance of fluids and electrolytes that the premature baby’s body cannot yet regulate on its own because of an immature kidney or gastrointestinal tract.

All these interventions may occur even though there is nothing “wrong” with the premature baby. Often, the only thing “wrong” with premature babies, especially those who are only a few weeks premature, is that they are in the wrong place and still need time to develop and adjust to the outside world.

The combination of all these treatments can be considered an “intensive care package” in that the benefits of each individual intervention may not be as apparent as the package as a whole. In other words, the sum of treatments in the NICU is often greater that the individual parts.

Treating specific conditions

Beyond creating an environment that will encourage premature babies to develop normally, treatments address distinct problems or conditions. Usually, treatment follows diagnosis. However, if doctors deem that the risk of waiting for a diagnosis outweighs the risks of beginning treatment, an intervention may begin right away even if a diagnosis has not been confirmed. For example, if an infection is suspected, the doctor will likely not wait the hours needed for a laboratory to confirm the infection and antibiotics, the usual treatment for infection, will begin right away.

This concept of risk versus benefit applies to all treatments. Although it is usually extremely small, all treatments carry some risk. However, the probable benefit of treatment often outweighs the risk of not doing anything.

Group statistics and the individual premature baby

When a premature baby has a certain condition, physicians often know the right course of treatment because of research. Over time, evidence has built up that for a particular condition, a certain treatment tends to work. But there is a measure of uncertainty: what generally works for the majority of patients, even the overwhelming majority, may not work in an individual case. It can be difficult to know whether a particular baby will respond to a certain treatment and how well.

When treatment does not work

The goal of treatment is to improve the condition of the baby. If a premature baby has an infection, the goal of the treatment, antibiotics, is to fight off the infection.

Sometimes, usually only in the more severely premature babies, treatment does not work and the prospect for success using further treatments is not good. In these cases, which are sad for all involved, the temptation may be to continue treatment anyway. These temptations are usually motivated by emotional considerations of the parents. In these situations, parents may feel a need to “do something” even though doing something will not make the premature baby well and may subject the baby to further risks and additional discomfort.

It must be remembered that treatment is not a goal unto itself. Rather, it is a method to try and reach the goal: improving the condition of the premature baby. The desire to continue treating a premature baby despite the overwhelming likelihood that the treatment will fail is understandable, given the circumstances. Parents want to feel that they did everything they could. They often feel that they could not live with the guilt if they did not do everything. Treatment decisions must be made in the premature baby’s best interest and, in some rare cases, the decision not to continue treatment may in fact be in the baby’s best interest.

Jonathan Hellmann, MBBCh, MHSc,  FCP(SA), FRCPC

10/31/2009


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