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Newborn Intensive Care with Sabine Iben MD

Introduction

Cleveland_Clinic_Host: Welcome to our Online Health Chat with Sabine Iben, MD.

Dr. Iben is board-certified in Pediatrics and Neonatal-Perinatal Medicine. Currently she holds an appointment as Assistant Professor at the Lerner College of Medicine and the Neonatal Director of the Fetal Care Center at the Cleveland Clinic. Her work at the Fetal Care Center includes prenatal counseling of parents expecting a baby with a variety of congenital anomalies together with a team of other subspecialists. She also works in the Intensive Care Unit at the Cleveland Clinic and Special Care Nursery at Hillcrest Hospital, attending high-risk deliveries and taking care of preterm infants and other newborns with medical problems.

The Fetal Care Center provides consultation and management for fetal medical and surgical disorders. Our team helps mothers and their primary physician develop a streamlined management plan that carries them through pregnancy, delivery, and after the baby is born. Our goal is to prepare and accompany families as well as optimizing postnatal management of the newborn in order to improve overall pregnancy outcomes and offer prompt subspecialty medical and surgical interventions at delivery when necessary.

Our specialists and staff provide the most sophisticated, state of the art techniques for diagnosis and intervention with compassionate, highly personalized care for mother and baby. Family-centered and continuity of care is an important aspect of our team approach and one of Dr. Iben’s interests. By providing support and appropriate resources to our families we help dealing with the unexpected.

For more information regarding newborn intensive care at Cleveland Clinic Pediatric Institute and Children’s Hospital, please visit us on our website clevelandclinic.org/kids or call us locally 216-444-KIDS (45437) or toll free 800-223-2273 ext 4KIDS (45437).

Cleveland_Clinic_Host: We are thrilled to have Dr. Iben here today for this chat. Let’s begin with some general questions about newborn intensive care.


Premature Birth: Overview

newtonm: What is the definition of a preemie? Is it related to due date (gestation) or weight?

Speaker_-_Dr__Sabine_Iben: Any baby that is born before 37 weeks gestational age is considered a preemie, babies between 35-37 weeks are considered “late preterm” since many of them don’t have significant health issues and can be cared for in the well baby nursery. They are still at risk for complications like jaundice, temperature instability, poor feeding and low blood sugar.

toot_toot: Do all preemies have health issues?

Speaker_-_Dr__Sabine_Iben: Not necessarily, it depends on their gestational age. Issues become more serious in the lower gestational ages. As mentioned in the prior question, babies that are more mature than 35 weeks may not have any.

toot_toot: Is there any way to prevent premature births?

Speaker_-_Dr__Sabine_Iben: There is no golden bullet (or I would be out of a job). It certainly helps to have good prenatal care so risk factors can be identified early and preterm labor can be stopped before rupture of membranes or cervical dilation occurs.

Interventions like bed rest, cerclage, certain medications (terbutaline, magnesium, Indomethacin), hydration with IV fluids may help stop labor. Once the water breaks or the cervix is significantly dilated it is likely that the baby is being born soon.


Birth Defects: Prevention

keeptrying: Exactly how preventable are birth defects? Does prenatal care really make that big of a difference or are the majority of birth defects due to genetics?

Speaker_-_Dr__Sabine_Iben: Birth defects can be due to genetics or toxins like certain medications the mother was exposed to. Frequently no underlying cause can be determined.

Some defects can be prevented by optimizing preconceptional care e.g. getting maternal diabetes under control, avoiding toxic medications etc.

Prenatal care is essential to optimize care for the baby and mother. Some babies might need immediate attention by a sub-specialist not readily available at smaller hospitals. Others may have to be delivered by C/Section or have to be delivered early to prevent stillbirth, so those pregnancies require close monitoring.

babybird213: My daughter is currently taking Accutane® which is known to cause birth defects. Are there many other prescription drugs that have the same risks?

Speaker_-_Dr__Sabine_Iben: There are many drugs that can cause birth defects. Usually the patient is being counseled if the risk is high prior to the drug being prescribed and advised to use birth control to avoid pregnancy.


Premature Labor

kneehigh: What signs should a person look for that they are going into premature labor and at what point do they contact their doctor? I’m worried about my niece who is at risk and want to do what I can to help.

Speaker_-_Dr__Sabine_Iben: The obstetrician is really the one that can give advice about the individual patient, he/ she might advice bed rest/ hospitalization/ a cerclage depending on the underlying risk factors.


Pregnancy and Risk of Premature Birth

mollysmom: I had a premature child about 2 years ago. My husband and I are considering having another child soon. What are the risks that I would have another premature child, and is there anything I can do to prevent it?

Speaker_-_Dr__Sabine_Iben: There is an increase risk for subsequent preterm delivery, but that also depends on why your other child was born early. I would advise to talk to your obstetrician who can optimize your care. Since there a multiple reasons for preterm delivery I can’t really give advice.

soundoff: A good friend of my daughter’s was premature and he is extremely small and tiny for his age (he is 12 and looks like he is 8). She has asked me if he will ever “catch up,” or will he always be this way. What can I tell her?

Speaker_-_Dr__Sabine_Iben: At that age it is hard to tell, he might not have entered puberty yet and have a big growth spurt later on. On the other hand, babies that are born small for gestational age and remain small throughout childhood are not likely to catch up. The pediatrician who follows him has his growth chart available and can make a better prediction.

carrieann: I have read on the Internet about full term, the Fetal Fibronectin Test. Is this test accurate and/or advisable for those at risk?

Speaker_-_Dr__Sabine_Iben: The Fetal Fibronectin (fFN) test is used to identify women with preterm labor at risk for delivering within the following week, if it is negative a delivery within the following 7-10 days is very unlikely, if it is positive there is an about 60% chance of preterm delivery (still 40% will not).


Premature Birth: Genetics

toot_toot: What are the causes of premature birth? Genetic, certain lifestyles or medical conditions?

Speaker_-_Dr__Sabine_Iben: There are multiple causes of premature birth. The more common ones are infection (not always clear why this happens), maternal health issues (particularly severe forms of pregnancy induced hypertension like preeclampsia or HELLP syndrome), cervical insufficiency where the cervix dilates prematurely (predisposes to subsequent preterm deliveries and may require cerclage placement), multiple gestation (the more babies the more premature), abnormal insertion of the placenta, increased amniotic fluid, illicit drugs (especially cocaine), abnormal uterine shape and others.

cantorl: Should everyone go through genetic testing prior to pregnancy to avoid the risk of birth defects? Is genetic testing the same as prenatal counseling?

Speaker_-_Dr__Sabine_Iben: There are screening tests that are currently offered to each pregnant woman. The most important one is a fetal ultrasound between 18- 22 weeks gestational age. Many birth defects and other issues can be identified at that point. A screening test that is done earlier is the quad screen that screens for some chromosomal anomalies (trisomy 13, 18 and 21), spina bifida and some other disorders. This is just a screening test and frequently gives false positive results e.g. an increased risk for Down’s syndrome compared to the age related risk.

One should keep in mind, that risk still might be only 1% and all it does is alert the OB to look even more carefully for other markers on the ultrasound. Chromosomal anomalies can ultimately be ruled out by amniocentesis or chorion villous biopsy (CVS) - the decision whether one of those studies is necessary depends on the suspected risk for the fetus. CVS in the early pregnancy is frequently done because of advanced maternal age or known chromosomal problems in the family. Amniocentesis is done for abnormal quad screens or ultrasound. Especially if there are fetal anomalies identified on ultrasound an amniocentesis can be helpful either in decision making for the parents if they consider a termination but also in the postnatal management of the baby.

If a lethal chromosomal anomaly is confirmed by amniocentesis, unnecessary and potentially painful procedures may be avoided in the newborn and care can concentrate on the babies comfort. Genetic counseling is helpful in certain scenarios.

One example is the family with a history of certain birth defects who need to be informed about their individual risk before planning a pregnancy. Another one is if there are abnormal screening tests to help make the family a decision about further testing. In other cases where there is an anomaly already diagnosed counseling helps to inform the parents what to expect with their baby and recurrence risk.


Premature Birth: Health Issues & Risks

brandywine: What are some of the medical issues related to premature births or low birth weight?

Speaker_-_Dr__Sabine_Iben: There is a long list: the more immature the baby is, the more likely it is that most of those complications will occur. Difficulty breathing/ premature lung disease occurs in almost all of the smallest babies (23-26 weeks gestational age), mostly requiring a breathing tube and mechanical ventilator.

Some of the sicker babies may become oxygen dependent and may even be discharged home on oxygen. Feeding intolerance and the risk for developing a severe gut infection (necrotizing enterocolitis) is a concern in most premature babies, they are usually fed very slowly, increasing the amount of milk every day and watched for signs of feeding intolerance.

Initially most of their nutrition is given intravenously. When they are fed it is again mostly through a tube in the stomach (nasogastric tube) since they don’t have the skills to coordinate sucking and swallowing before about 34 weeks gestational age.

Preterm infant are also at high risk for acquiring a blood stream infection during their hospital stay since their immune system is not ready for the outside world yet, they are considered immunocompromised.

Another issue is apnea of prematurity which means that preemies younger than about 34 weeks gestational age don’t consistently remember to breathe and have episodes of apnea especially during sleep. This can be treated by giving them caffeine and some stimulation during those episodes.

Another concern is the occurrence of intracranial bleeds in the first few days of life which more commonly happen in the smaller babies. More extensive bleeds may result in developmental issues later on.

abc123: If a premature birth is suspected due to a high risk pregnancy, are there any medical problems that can be prevented or even treated while still pregnant?

Speaker_-_Dr__Sabine_Iben: Good prenatal care is very important, as mentioned before there is a variety of problems that can be treated to prevent preterm birth.


Cerebral Palsy

lornad: Can cerebral palsy be prevented? Is it always because of oxygen deprivation during delivery?

Speaker_-_Dr__Sabine_Iben: Cerebral palsy is really a symptom of brain injury due to a variety of causes rather than a disease. There are multiple causes for cerebral palsy and oxygen deprivation during delivery is probably one of the less common ones.

It has been shown that some cases of brain injury occur before birth, can be due to placental insufficiency, congenital heart disease, prenatal strokes, prenatal infections especially with viruses like CMV (cytomegalovirus)and others.

Oxygen deprivation at birth is another one and again can have multiple causes. Premature infants are at higher risk for cerebral palsy due to the occurrence of intracranial bleeds but also due to blood pressure swings, frequent infections, episodes of swings in the blood oxygen concentration etc.

Cerebral palsy can certainly occur in a baby that never had a bleed and wasn’t very sick after birth - maybe due to other prenatal factors.


Premature Birth: SIDS

worriedmom: Are preemies more susceptible to SIDS (Sudden Infant Death Syndrome?)

Speaker_-_Dr__Sabine_Iben: Yes, they are, for unknown reasons. Interestingly, this does not at all correlate with apnea of prematurity. At this point we can’t identify preemies at risk and home apnea monitors that are commonly prescribed are known not to be able to prevent SIDS.


Preemies: Breastfeeding

hopeandglory: I wanted to breastfeed my baby. If he or she is born premature, is this still a possibility?

Speaker_-_Dr__Sabine_Iben: Actually, breast milk is the absolute best source of enteral nutrition for the preemie- it results in better feeding tolerance, less risk for infection and better neurodevelopmental outcomes.

We strongly encourage our mothers to provide breastmilk at least until the babies go home even if they don’t plan on breastfeeding. This involves pretty much pumping exclusively until about 33-34 weeks corrected age. Before that age, the baby is not able to coordinate sucking and swallowing adequately for oral feeds.

We may fortify the breastmilk with additional calories, protein, Calcium and Phosphorus since the requirements for growth in a preemie are higher than in term infants.


Premature Birth: Taking Baby Home

helpme: Can you tell me some things I can do now for when I take my baby home? (I am high risk for a premature birth) What things should I have on hand? Should I tell friends and family that visits are going to be limited? Knowing these types of things will be helpful.

Speaker_-_Dr__Sabine_Iben: Generally, by the time a preemie is going home care is pretty much the same as for a term infant. The exceptions are babies that had a complicated hospital course (prolonged oxygen requirement); have been identified with significant brain injury or still require additional care like supplemental oxygen.

It is always a good idea to practice good handwashing techniques and limit visitors with viral infections, especially toddlers in the winter months.

If a baby is still on the small side when going home you should also be careful taking him/her out in cold weather since he/she may not be able to regulate his/ her temperature as well.

Don’t use positioning devices in the crib. They are being advertised but actually may increase the risk for SIDS, home monitors are generally not helpful either with some exceptions.

In my opinion any mother taking a baby home should be trained in infant CPR. Most hospitals offer that to families of preemies. You also should be comfortable using a bulb syringe to clear secretions. Babies are obligate nose breathers- if their nose is blocked with secretions it may cause problems. Again, any mother should be confident doing this.

If you really end up delivering early you will be surprised what an expert you will become in the babies care just spending time in the NICU.


Premature Birth: Developmental Delay

grannie_smith: What type of developmental delays can I expect to see in my grandson, who was born three months premature, as he grows older? Will he advance more slowly? If I were to follow the developmental guidelines (by age) as seen in many books, do you go by his actual birth date, his due date, or will he not follow these guidelines at all?

Speaker_-_Dr__Sabine_Iben: If you are looking for milestones you should correct his age until about 2-3 years of age (so subtract 3 months from his actual chronological age). Born at a gestational age of about 28 weeks he is at risk for developmental delay but at that age most children actually develop quite normally.

Frequently, motor milestones come a little later. Many premature babies have a somewhat decreased muscle tone for the first few months of life. Subtle delays may be more common but are not easily recognized.

canterbury: My sister was born premature and overcame many problems throughout her growth. She still gets sick more easily, is always cold and has permanent dark circles under her eyes, but is otherwise in perfect health. She is concerned about having children of her own. Is there any correlation between mothers born premature and their having children prematurely?

Speaker_-_Dr__Sabine_Iben: Yes, there is an increased incidence but she has a good chance for a perfectly normal pregnancy. Some women with chronic health issues may have more complications during pregnancy. She should talk to her obstetrician about her concerns.


Premature Births: Research

cantorl: What research is happening in the area of preemies?

Speaker_-_Dr__Sabine_Iben: Wow, this would take about an hour itself just to scratch on the surface. Some of the areas are prevention of lung damage by optimizing respiratory care, optimizing nutrition, preventing necrotizing enterocolitis, prevention of brain injury. High- risk obstetricians work on identifying causes for preterm deliveries and prevention.


Closing

Cleveland_Clinic_Host: I'm sorry to say that our time with Dr. Iben is now over. Thank you again Dr. Iben, for taking the time to answer our questions today.

Speaker_-_Dr__Sabine_Iben: Thanks a lot, those were great questions.

Cleveland_Clinic_Host: There will also be a live pediatric epilepsy chat with Ingrid Tuxhorn, MD is March 26, 2009, 12:00 p.m. – 1:00 p.m. (EST).


More Information

  • For more information regarding newborn intensive care at Cleveland Clinic Pediatric Institute and Children’s Hospital, please visit us on our website www.clevelandclinic.org/kids or call us locally 216.444.KIDS (45437) or toll free 800.223.2273 ext 4-KIDS (4-5437).
  • A remote second opinion may also be requested from Cleveland Clinic through the secure eCleveland Clinic MyConsult Web site.
  • If you need more information, contact us, chat online or call the Center for Consumer Health Information at 216.444.3771 or toll-free at 800.223.2272 ext. 4-3771 to speak with a Health Educator. We would be happy to help you. Let us know if you want us to let you know about future web chat events!
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This chat occurred in January 2009.

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This information is provided by the Cleveland Clinic and is not intended to replace the medical advice of your doctor or health care provider. Please consult your health care provider for advice about a specific medical condition.