In an interview with Medical News Today, neonatologist Dr. Charleta Guillory speaks about her work looking after very small babies, how health inequity affects prematurity, and what public health measures she set up to counter these.
In the United States, around
While medical advances have ensured that many babies born prematurely survive and have good long-term outcomes, prematurity remains the
In this Special Feature interview, Medical News Today spoke to Dr. Charleta Guillory, an associate professor at Baylor College of Medicine and the Director of the Neonatal-Perinatal Public Health Program at Texas Children’s Hospital, both in Houston.
Dr. Guillory previously served as the Texas State prematurity campaign director for the March of Dimes. At the time of our interview, Dr. Guillory was on call at the Level 4 neonatal intensive care unit (NICU) at Texas Children’s and would be for the next 6 weeks.
Level 4 NICUs provide the greatest level of care for premature and critically ill babies. This is where the smallest babies, those born before 32 weeks and weighing less than 1,500 grams, are looked after.
Dr. Guillory gave MNT some background information on prematurity and the known risk factors. She also explained how the care of premature babies had changed during her career and how her unit and the families she is working with have coped during the COVID-19 pandemic.
We spoke about the babies’ long-term outlook, how she talks to parents, and what support family and friends can offer.
Dr. Guillory also discussed how the social determinants of health affect prematurity and what public health measures she has developed to address these.
We have lightly edited the interview transcript for clarity.
MNT: What exactly do healthcare professionals mean when they say that a baby is premature?
Dr. Guillory: According to the American Academy of Pediatrics (AAP), preterm birth is the delivery of an infant before completion of 37 weeks gestation.
There are three categories of preterm births: Late preterm infants are born between 34 weeks and 36 weeks and 6 days of gestation, moderate preterm infants are born between 32 and 33 weeks gestation, and very preterm births are born at less than 32 weeks gestation.
In 2019, preterm birth affected 1 of every 10 infants born in the U.S., and this is kind of frightening.
According to the
The CDC explains that in 2019, the rate of preterm birth among African American women was 14.4%. This is [nearly] 50% higher than the rate of preterm birth among white women, where it is 9.3%, and Hispanic women, where it is 10%.
I’m really worried about what’s gonna happen.
MNT: Are there any specific risk factors? Who is more likely to have a premature baby?
Dr. Guillory: There are specific risk factors for preterm birth, including sociodemographic and obstetric factors.
These include maternal reproductive factors, such as a history of preterm birth and maternal age. A U-shaped relationship exists between maternal age and the frequency of preterm birth. Women under 16 and those above 35 have a 2-4% higher rate of preterm birth than those between 21 and 24 years.
Maternal health is also important. We look at infection, anemia, hypertension, preeclampsia, eclampsia, cardiovascular and pulmonary disorders, and diabetes.
Then there are maternal lifestyle issues, such as physical activity, history of substance abuse or smoking, diet, weight, and stress.
There are also specific issues, such as cervical, uterine, and placental factors, including a short cervix, cervical surgery, uterine malformations, vaginal bleeding, and placenta previa or abruption.
Multiple gestation, so having more than one baby, is another risk factor.
And finally, fetal factors, such as the presence of congenital anomalies, growth restriction, fetal infections, and fetal distress, can play a role.
MNT: What do you think is behind this rise in prematurity rates?
Dr. Guillory: I think it’s multifactorial. The social determinants of health are beginning to play a major role, [particularly] access to healthcare, especially with the dismantling of the [Affordable Care Act (ACA)]. We have a lot more people who are not insured.
Access to healthcare [is] a big problem for our mothers. And without that care, especially the prenatal care aspect of it, we’re going to see more premature babies.
Actually, I was looking at the data, and about 60% of our African American moms are not getting prenatal care in the first trimester. We had a baby [here] the other day, and mom had not had any prenatal care.
[Also,] we didn’t expand Medicaid. We had opportunities to expand Medicaid, and in Texas, Medicaid pays for 50% of deliveries.
We also have older moms. [We know that with age, we see an] increased number of premature births. We have moms who are working under stress because they need insurance. So all of this [leads to] increased rates [of prematurity].
With assisted reproductive technology, we have more triplets. Twins, triplets, multiple gestations, that all [adds to] the number of premature births.
MNT: It seems very counterintuitive not to have prenatal care.
Dr. Guillory: Exactly! If you want a healthy nation: we always knew that infant mortality was the best barometer for measuring how well a nation is doing.
We know that premature babies have the highest morbidity and mortality, particularly those born at less than 32 weeks gestation.
MNT: How has the care of premature babies changed during your career?
Dr. Guillory: The biggest challenge initially was survival, mostly from respiratory distress syndrome.
Improvements in the NICUs with the advent of surfactant treatment and antenatal steroid therapy to prevent and treat neonatal respiratory distress resulted in decreased mortality rates of premature infants.
Now, we focus on other things, using a more active management approach to sepsis, necrotizing enterocolitis, etc. With the discovery of the benefits of [breast] milk, survival has improved significantly.
Today, we don’t just want to improve the survival of infants, but we want to focus on improving long-term developmental outcomes.
MNT: Can you tell us a little bit more about how the focus has changed?
Dr. Guillory: There are two aspects to this. One before birth and one after. I [will talk] about the prenatal aspects first and our [obstetrician] partners and our maternal-fetal medicine [partners.]
[Prenatally], those [who are at increased risk of having a premature baby] should not just be taken care of by OB/GYNs. They should be taken care of by maternal-fetal medicine doctors, as these are high risk pregnancies.
These doctors deal with antibiotics for mothers with group B strep; they deal with antenatal steroids and delayed cord clamping. We know [that] if you allow more blood to reach the baby, it causes the blood pressure to stabilize. This decreases the risk of necrotizing enterocolitis and intraventricular hemorrhage.
What has changed is now when the babies come to us, not only do we have [better ways] to decrease respiratory distress syndrome, we have a small baby team or small baby group.
[This team] takes care of these babies specifically. So, not only are there trained neonatologists and neonatal practitioners, but we also have respiratory therapists and nurses at the bedside. We have a team that takes care of the small babies.
When I was first a neonatologist, what we did back then, we wanted babies to survive. Everything was [focused] on getting them to survive. Nobody was talking about survival intact.
Gradually, we got rid of the respiratory distress syndrome, and then [we started to focus on the next set] of complications in the premature baby group.
Premature babies have a high incidence of respiratory distress syndrome, necrotizing enterocolitis, intraventricular hemorrhage, and sepsis. Beyond 32 weeks of gestation, these go down. But before 32 weeks, the incidence is high.
The small baby group works specifically on things such as necrotizing enterocolitis. We know that necrotizing enterocolitis is better when mom’s milk is being used in the NICU. We then had donor milk come into play.
[In the past,] we used to give [a lot of] antibiotics to rule out sepsis. We now have an organized approach to infection. We use specific antibiotic therapy; we don’t keep [babies] on it very long. If the [microbial] cultures come back positive, we [can be] very specific with this.
All to decrease antibiotic resistance. I call it antibiotics stewardship.
Delayed cord clamping helps with intraventricular hemorrhage. Plus, getting babies delivered where they should be delivered so we don’t have to transport them, which increases the risk of intraventricular hemorrhage.
So, there is a shift where providers and the team develop expertise in caring for the small babies.
Source: Medical News Today
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