Rachael Welch was just inches from her newborn son, Zeke, when he stopped breathing for the second time in his five-week life. But she couldn’t have felt farther away.
Standing in Erlanger hospital’s Neonatal Intensive Care Unit, she reached through a small opening in the side of Zeke’s enclosed incubator, past the ventilator, tubes, bandages and monitors. It was just far enough to feel his tiny, almost translucent limbs droop in her fingers but not far enough to do any good.
“He was just pale and lifeless and limp, and I knew something was wrong,” Mrs. Welch recalled. “This whole swarm of doctors and nurses come running in, and I was just standing there in the corner of the room ... completely helpless.”
MEDICAL PROBLEMS COMMON IN UNDERWEIGHT NEWBORNS
* Respiratory distress syndrome: Babies with RDS lack a protein called surfactant that keeps small air sacs in the lungs from collapsing. Treatment with surfactant helps them breathe more easily, but affected babies also may need additional oxygen and mechanical breathing assistance while their lungs mature.
* Bleeding in the brain: Most brain bleeds occur in very low birth weight babies and are mild, resolving themselves with no, or few, lasting problems. But more severe bleeds can cause pressure on the brain that can lead to brain damage. In those cases, surgeons may insert a tube into the brain to drain the fluid, while in milder cases drugs alone can help.
* Patent ductus arteriosus: A large artery called the ductus arteriosus lets blood bypass a baby’s nonfunctioning lungs while in utero, but normally closes after birth so blood can travel to the lungs to pick up oxygen. When the ductus does not close properly — a common phenomenon in premature babies — it can lead to heart failure. Drugs or surgery can often close the artery.
* Necrotizing enterocolitis: This condition affects the intestines, causing feeding difficulties, abdominal swelling and other complications. Babies can be treated with antibiotics and have to be fed intravenously until the bowel heals. In some cases, surgery is necessary to remove damaged sections of intestine.
* Retinopathy of prematurity: Mainly occurring in babies born before 32 weeks of pregnancy, ROP is an abnormal growth of blood vessels in the eye that can lead to vision loss. Most cases heal themselves with little or no vision loss, but in more severe cases the abnormal vessels may have to be treated with laser or freezing therapy.
Source: March of Dimes
The scare was just one of the ups and downs of Zeke’s infancy, which began on Jan. 11, 2007, three months earlier than it should have. A problem with Mrs. Welch’s uterus meant that Zeke and his twin sister, Emmie, were born early and underweight.
Experts classify low birth weight as 5 pounds 8 ounces or less. Babies identified as the most at-risk for serious health complications or death are those weighing 3 pounds 5 ounces or less.
Zeke came into the world at 2 pounds 4 ounces; Emmie was 2 pounds 2 ounces.
Doctors agree that while twins, or any multiples, born prematurely are a leading cause of low birth weight, many cases of underweight babies remain a mystery, said Dr. David Adair, the Chattanooga perinatologist who treated the Welch twins.
Dr. Adair became inspired to solve the mystery after working with countless families such as the Welches, families who have suffered the extreme emotional and financial consequences of low birth weight babies.
Hamilton County’s 11.2 percent rate of underweight births exceeds the national average of 9.5 percent, the highest level in 40 years, national and state data show. The problem is so pronounced nationwide, acting Surgeon General Steven Galson announced recently that developing a national strategy to prevent premature birth is among his top priorities.
Dr. Adair refers to low birth weight as a “multifactorial disease” that “represents a blight on society,” he said.
An increase in preterm Cesarean sections, some of which are not medically necessary, is partly to blame, according to the nonprofit March of Dimes, which is devoted to improving birth outcomes.
But preterm delivery accounts for only part of the problem, according to March of Dimes statistics, which show that two-thirds of all low birth weight babies are premature, while the remaining third are just born too small.
Meg Brasel, a certified nurse-midwife at North Park Ob-Gyn Associated in Hixson, said low birth weight can be attributed to the overall state of the mother’s health.
“Sometimes they’re small because they weren’t getting good nutrition or good oxygen when the mom was pregnant,” she said. “Some of the factors go into the mom not being healthy, so that child is more likely to grow up in a family that has poor nutrition or poor medical care.”
But even mothers who are healthy and carry their babies to term deliver underweight babies, Dr. Adair said.
As methods of improving access to prenatal care and pharmaceutical treatments are studied, Dr. Adair is leading a team of researchers at the University of Tennessee at Chattanooga trying to find if there is a link between low birth weight and exposure to environmental toxins in full-term babies.
Dr. Tom Catron, director of the state Governor’s Office of Children’s Care Coordination, said research like Dr. Adair’s is important in the long term.
“There are things we can do to improve the quality of life for people in these circumstances, but these things are preventable,” Dr. Catron said.
EFFECTS ON FAMILIES
Staff Photo by Angela Lewis
Zeke Welch reaches for a block as his sister Emmie plays during a therapy session in the Welch's home with physical therapist assistant Lisa Battersby, right, talks about play activities.
Between them, Zeke and Emmie Welch have managed to survive respiratory problems, holes in their heart valves, blood pressure issues, staph infections and even a brain bleed — all conditions that doctors say occurred because they did not have the chance to develop fully in the womb.
Gestational age and weight at birth are key factors in birth outcomes, according to Dr. Adair. Especially in premature babies, poorly developed lungs and immature immune systems can make surviving a cold difficult, he said. Underdeveloped babies have trouble eating and therefore must be tube-fed, which always comes with complications, he said.
The likelihood that those children have impaired brain function is higher, Dr. Adair said, as is the likelihood they will need some kind of surgery.
Underweight babies likely develop long-term medical problems that shadow them for the rest of their lives, including diabetes, cardiovascular disease and hypertension.
Smaller babies “have a thing called ‘failure to thrive,’” he explained. “Their systems just don’t seem to ever get over it, because they were so taxed at an early age.”
The Welch twins are now 17 months old and are “not even on the growth chart” for children their age, Mrs. Welch said.
Developmentally, they are 14 months old because of their three-month advance arrival, Mrs. Welch explained. In addition to the physical therapy both twins receive twice a month, Zeke still needs feeding therapy to help him chew and swallow correctly.
To keep the twins’ health in check, the family must be vigilant, said Chris Welch, their father. He and his wife are obsessive about hand-washing and sequestered themselves at home through the winter, he said, since a common cold sent Zeke to the emergency room for three days last Christmas.
“It was like house arrest,” Mr. Welch said with a laugh as he cradled Emmie, the “more robust” of the two, on his lap.
Cost to society
Mrs. Welch said she, her husband and their 5-year-old son, Eli, don’t mind taking extra precautions for the twins. They also are relatively stress-free about finances since the family gets help with the twins’ therapy through Tennessee’s Early Intervention System, a state program that offers free resources to eligible families.
The twins’ stays at Erlanger’s Neonatal Intensive Care Unit — 57 days for Emmie, 70 days for Zeke — were largely covered by federal Social Security and TennCare, Mrs. Welch said.
Treatment for low birth weight babies can cost millions, according to Pat Charles, a spokeswoman for Erlanger. Neonatal Intensive Care Unit bills can run from $20,000 for a relatively short stay to as much as $2 million for a lengthier one, she said.
Such babies also cost employers money, time and productivity, according to a March of Dimes study published last year. Looking at premature babies alone, the study estimated that direct health care costs to employers average $41,610 per child — 15 times more than the $2,830 for a healthy delivery.
Lost productivity for the parents adds about $2,766 to the cost, the study states.
And that’s not including the long-term costs associated with the chronic diseases low birth weight babies are more likely to develop, Dr. Adair said.
The Welch family has not encountered any signs of long-term problems in their case, according to Mrs. Welch. But most such children aren’t so fortunate, Dr. Adair said.
“This is a pool of kids that has damage,” he said. “Not that you can physically look at them and see it, but there’s damage. And it can turn into devastation for them pretty quickly.”