At the same hospital in 2004, Rumaisa Rahman took over the title of world’s tiniest infant, weighing in at 0.57 pounds. She was one of twins, and she spent 50 days on a ventilator in the neonatal intensive care unit at Loyola University Medical Center in Maywood, Ill.
At her five-year checkup, Rumaisa weighed 34 pounds and had grown to 3 feet, 3 inches. She was attending first-grade on an individual learning plan. She wears glasses because of retinopathy of prematurity, an eye problem common in preemies.
Madeline, whose mother had been treated for infertility, was the only survivor among triplets. Her mother, like Rumaisa’s, had severe preeclampsia, a life-threatening condition in pregnant women that can only be cured by delivering the baby or babies. Madeline was on a ventilator for 65 days. She had a heart condition and also had retinopathy.
Madeline also wears corrective lenses, but she drives and is in good health. At 65 pounds and 4 feet, 6 inches, she’s still small. Now a college senior, she’s an honors student majoring in psychology.
Both girls are living proof that even the smallest preemies can survive and lead normal lives, although not all do so well. Updates on their progress appear online Dec. 12 and in the January 2012 issue of Pediatrics.
Dr. Jonathan Muraskas, a professor of neonatal-perinatal medicine and a member of the medical team for both girls, said, “You always worry about [future health] when babies undergo so much stress in the uterine environment. Down the road, as they’re reaching their teens, they’re at risk for diabetes, heart disease.”
Survival in these tiny infants is much more dependent on how many weeks the pregnancy lasts, rather than weight at birth, he emphasized.
“The big story is that gestational age is much more important than birth weight,” Muraskas said. At 25 and 26 weeks, Rumaisa and Madeline were relatively “old” compared to some preemies, and each extra week makes a difference.
“At 23 weeks, survival is about 20 percent — of those that survive, 80 to 90 percent have significant, devastating handicaps,” Muraskas said. “At 27 weeks, newborns weigh about two pounds. The rate of significant neurodevelopmental handicap — blindness, profound deafness, cerebral palsy — drops to about 5 to 10 percent.”
Female preemies do much better. “If Madeline and Rumaisa were male, it would probably be a whole other story,” said Muraskas.
Prenatal steroids — given to prevent severe brain damage and developmental problems — were another factor in their favor, and Rumaisa received surfactant to help immature lungs.
“These are remarkable case reports — these are extremely small babies,” said Dr. Eric Eichenwald, an associate professor of pediatrics at the University of Texas Health Science Center. “The technical aspect of their care is immense. Imagine putting an intravenous catheter in someone that small. They’re at high risk for injury and infection,” he explained.
“The college student [Madeline] is still extraordinarily small; it’s great that’s she neurodevelopmentally normal,” he said.
With tiny preemies, ethical issues often arise.
“The big decision: do you resuscitate a baby the size of a cellphone?” Muraskas asked. “At 25 weeks — today, and even back in the 1990s — chances are that everyone will be resuscitated in the U.S.,” he said.
“At 22 weeks, they commonly resuscitate in Japan,” Muraskas added. “Twenty-three to 24 weeks is what we call the gray area. A lot of it is respecting the parents’ wishes.”
“Another ethical dilemma is when one [unborn] twin is doing better than the other, when do you interfere for the littler baby, putting the more normally developing baby at risk?” Eichenwald added.
“For every baby like this who survives, nine out of 10 don’t,” he said. “It’s important for the public to know that a baby who weighs less than a pound has an extremely low [chance] of survival.”
“The key thing,” agreed Muraskas, “is you don’t want parents to read this and think: ‘My premature baby was two pounds and didn’t survive; did I, or my doctors, nurses, etc., do something wrong?’ The answer is no.”
With patients like Rumaisa and Madeline, “it is rewarding,” he said. “I feel very fortunate to have played a part.”