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A little miracle called Madeline

Gestational age and the sex, more than weight at birth, are the critical factors deciding the chances of survival of a pre-term infant.

Madeline Mann was born at 27 weeks gestation in 1989 and her weight of 280 g was equal to infants born at 16 or 17 weeks gestation. — AP

THE SMALLEST-EVER pre-term infant known in medical history — all of 280 g weight and a length of 25 cm, has survived past infancy and turned 15 years old. Madeline Mann was born pre-term as her mother suffered from a pregnancy disorder called preeclampsia, which starved her of essential nutrients.

What is indeed remarkable is that Mann born at a gestational age of nearly 27 weeks (26 weeks and 6 days to be precise) has none of the physical or neurological problems that often afflict such pre-term children as they grow up.

Though Mann was born only 13 weeks premature in 1989, her weight was equal to those infants born at 16 or 17 weeks gestation. Her weight of 280 g is about a third of the weight of babies of a similar age and only a fraction of the three kilograms that newborns normally weigh after a full 40-week pregnancy.

Normal development

Babies born with such drastically low birth-weights tend to suffer severe disabilities such as cerebral palsy, blindness or learning problems. Yet, in the end everything seems fine and Mann seems to suffer from none of the problems other pre-term infants suffer from. Though small for her age at only 136 cm and weighing only 25.4 kg, she has no psychosocial maladaptations.

"The normal cognitive development of our patient is more remarkable than her survival," Dr. Jonathan Muraskas of Loyola University Medical Center, Illinois, U.S., who treated Mann as a newborn, wrote in the New England Journal of Medicine. A significant number of newborns with an extremely low birth weight (1 kg) have shown sub-optimal neurodevelopment outcomes and cognitive function when followed up to school age.

Gestational age

Dr. Muraskas should know best. According to him, the neonatal survival rate improves dramatically from 5 percent at a gestational age of 23 weeks to 90 percent at a gestational age of 27 weeks. Thus Mann born at nearly 27 weeks of gestation had a good survival chance.

According to him, gestational age, more than weight at birth, is a very critical factor deciding the chances of survival. "Prospective studies have demonstrated that newborns delivered before 24 weeks of gestation have been completed are less likely to survive and to survive without deficits than are those delivered after a longer gestation," Dr. Muraskas wrote in the journal.

Gender saved Mann

One more factor, which turned in Mann's favour was her sex. Apart from gestational age at the time of birth, the female sex is a very critical characteristic in newborns at the threshold of viability. "Girls generally have a better prognosis than boys," according to Dr. Muraskas.

The reason is not known however. Fifty-two newborns with at average gestational age of 25 weeks and six days with a birth weight of less than 400 g have been described in the literature. And the number of girls is an astonishing 83 per cent. The University of Iowa Registry for the tiniest babies shows an overwhelming number of infants being females.

Trying to beat the odds are a handful of key medical advances that have happened in the last 30 years that help premature babies survive the traumatic birth. But for these advances, many pre-term babies would have surely died. Pregnant mothers going into premature labour are now routinely given steroids to accelerate the development of the infant's lungs. Also, drugs called surfactants are given to infants, which help open up the lungs.

Despite these developments, babies born at 23 weeks are on the threshold of survival. This is particularly so because the infant's brains, guts and lungs are too immature to cope.

Not surprising then that only less than 40 per cent of infants survive, and the vast majority of those that do survive go on to develop major disabilities.

In contrast, by 27-weeks of age, the infant's organs are matured enough and over 90 per cent survive and only a small fraction suffers severe handicaps.

Doctors' concern

Dr. Muraskas and other doctors are concerned however. They fear that Mann's survival and well-being will send a wrong message that no matter what the weight or time of birth at gestation, pre-term babies can survive. "Extremely low-birth-weight, "miracle" newborns can propagate false expectations for families, caregivers, and the medico-legal community alike.

Gestational age and female sex are critical characteristics in newborns at the threshold of viability," reiterated Dr. Muraskas in his article.

R. Prasad
In Chennai

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