When Babies Are Born Premature

Dr. Charles Neal
Neonatology division head and medical director of the NICU at Kapiolani Medical Center for Women & Children

Where did you receive your schooling and training?

I went to undergraduate school at UC-Santa Cruz. I received my M.D. and Ph.D. at the University of Michigan (UM), studying development of the brain – developmental neuroanatomy. I did my pediatric training at UC-San Francisco and then returned to UM, where I completed my neonatal training. I was on staff at UM for eight years until I joined Kapiolani in 2004.


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Dr. Charles Neal

When is a baby considered premature?

Babies are considered premature when born at less than 37 weeks. We have two distinctions of premature babies. Those born 33 to 37 weeks are called late preterm. Late preterm, though high-risk babies, don’t have as many of the complications as preterm babies, which are those infants born at less than 33 weeks.

What kind of help does the NICU (newborn intensive care unit) administer to babies?

A term baby is 40 weeks, or approximately nine months. Neonatologists think in weeks. A term baby could be as much as three weeks early, a 37-week neonate. In addition to preterm babies, the NICU has a lot of term babies who also are ill, babies with congenital defects or who should have been born normal but were sick with various afflictions. They can be just as critically ill as some of our preterm babies.

Preterm babies who are a month or even two months early tend to have pretty well-developed lungs and intestines. Because of this, they can breathe and digest fairly well, so they don’t often have many complications. However, they do have difficulty keeping warm and sucking and swallowing at the same time, so they have to learn how to eat.

Babies who are 35 to 36 weeks generally do not have to spend time in the NICU, unless they have preterm issues that need support, such as help with their temperature or their feeding. But 34 weeks or less are all admitted to our intensive care unit. The majority of 34-weekers have difficulty feeding and staying warm. When you get down to 33- to 32-weekers, they all have trouble staying warm and eating, and many with breathing. For those under 32 weeks, their lungs almost always are involved. The lower they go in their gestational age, the more premature their lungs are and the more they rely on our technology for support. The limits of survivability are the 23- to 24-week neonates. We see some go home, but they almost always have lifetime problems.

Preterm babies can require close management as they grow up and go to school, because they could have learning issues as well, an unfortunate reality with these groups of babies.

What are some of the causes of preterm birth?

You can do everything right: get prenatal care, not smoke and have a healthy diet – most of our babies are born to moms who have great prenatal care and still go into labor early. We don’t know why it happens. Much of preterm labor remains a mystery to obstetricians.

Another reason for preterm birth is the mom may have complications of pregnancy, such as high blood pressure, diabetes or life-threatening illness. These are situations where carrying a baby to term isn’t compatible with a mom’s survival. Obstetricians will deliver those babies early sometimes.

One thing I do want to touch on is travel. Parents should not take long trips when they’re pregnant. A lot of pregnant families visiting from the Mainland deliver here and they struggle with having a sick preterm infant so far from home. When pregnant, stay home.

What are other difficulties with preterm births?

A big issue is difficulty bonding with and breast-feeding the baby. This is something Mom has wanted to do, but now she has to leave the baby with us and go home. This is further complicated by lack of resources. We often have families from Neighbor Islands or families that live as far away as Waianae or Haleiwa. It is difficult for them to get here every day.

We have more than 900 NICU admissions a year. We’re in the middle of a capital campaign for Kapiolani for building a new NICU. The new unit will have individual rooms so that a parent actually can stay with the baby and not have to leave. Having parents involved closely in the baby’s care will improve outcomes and help tremendously with our breast-feeding initiative and bonding, alleviating the separation these parents feel.

Are preterm babies able to breast-feed?

We get most of our moms to breast-feed. Breast-feeding is everything to us. One of the most influential improvements in neonatal care, and in our NICU in particular in the last five years, was instituting a breast milk-only approach to our babies. It almost eliminates intestinal illnesses that preterm babies get, because they digest their mothers milk so much better than formula. We have lactation consultants who teach our moms how to pump so that even though the baby can’t breast-feed, we can feed those babies Mom’s breast milk. We’ve had many babies who have been here for two or three months and they go home breastfeeding. We find that most people who end up going home and breastfeeding buy a baby sling. Using a baby sling can help with the process of breastfeeding as research has shown that carrying babies in a sling has increased the breastfeeding rate in older babies.

How long in life does being born preemie affect a person?

There’s a lot of information about the effects of early stress on brain development. It is my area of research. Stress affects the way we think, the way we react as human beings. These preterm babies are enduring a tremendous amount of stress during a very important part of their brain development.

It changes the way they are. It changes the way they view life, the way they respond to things emotionally, even the way they deal with change. Preterm babies are probably very different beings growing up than they would have been as term babies. It makes them different in the way they see life, because the brain is saying, well, it’s kind of stressful out there in this world, let’s get you geared up for a stressful world. You go home and may have stability, but the brain has already been wired toward this type of a life and your set point is a little different.

How hard is preemie care on you and your staff?

Everybody deals with it differently. Many of these babies don’t have good outcomes, and this is hard on all of us. Not one of them is ever easy. The thing I try to teach residents and medical students coming through is: Yes, this was hard on me. Yes, I have a lot of very sick babies. But this family only has the one, and this one is the world to them, so we need to do everything we can to help them through this. As difficult as it can be, we love being in there and we love what we do. What I love best in my job is discharging a baby home.