NEONATOLOGY ON THE WEB

Premature and Congenitally Diseased Infants

by Julius H. Hess, M.D.

Chapter XX
The Future of the Premature Infant

The early small, thin face with its mass of wrinkles in the presence of proper feeding soon becomes rounded out by the deposit of layers of fat, the skin becomes smoother and the face more nearly like that of a normal nursling. There, however, remains for a more or less indefinite period a prominence of the sucking cushions greater than that seen in the normal infant. The enlargement of the tongue may be noted until toward the end of the first year. The same may be true of exophthalmos. The small stumpy nose may also retain its characteristic appearance until the end of the first year. The "doll" type of face is also usually present until after the fourth or sixth month of life.

The infants often show the adenoid appearance, due to the small nose, with its tendency to the development of a posterior rhinitis, and the large tongue. This appearance is lost as the megacephalus disappears.

The other characteristic physical changes, which are evidenced by a short neck, a long, broad trunk, with a deeply seated navel and short legs, and which can usually be noted by the second to fourth month of life, gradually disappear during the second year.

The question is often asked as to what is the ultimate outlook for prematurely born infants who live beyond the first year of life. It is desired to know (1) if they suffer from a higher mortality in early childhood than the full-term infant, and (2) are those that survive normal mentally and physically. In order to answer these questions in the proper way it is necessary to observe the children over a period of years. With institutional children this is often impossible and even in private practice difficult. Usually one must satisfy himself with comparisons at the end of the first year. For this comparison the full-term normal child is used as a basis, but as Pfaundler says, only those who have been similarly fed and raised under the same hygienic conditions can be fairly contrasted.

One observes with the premature as with the full-term child that the breast-fed infants raised among good home surroundings have a lower mortality that the same in institutions, and that the artificially fed have a greater mortality than the breast fed.

Ostreil gives the statistics from the Prague Maternity on 1542 illegitimate prematures. The total mortality of these infants was 52.7 per cent. Of these cases 814 were followed for nine, ten, and eleven years. Of this series 86.6 per cent are living, but these figures include those in whom there was no indication of syphilis, those who received breast milk after leaving the institution, and those weighing up to 2800 gm. Those under 2500 gm. weight and 45. cm. length, who left the institution alive and had, therefore, survived the first weeks, were 86 in number, of which 38 were boys and 48 girls. Of these 51 were alive at the end of the first year, 23 boys and 28 girls, a mortality of 40.7 per cent, or 39.5 per cent for males and 41.7 per cent for females.

Oberwarth's results are shown in tabulated form below. He followed for more than a year 12 infants who weighed less than 2000 gm. and who were, with 2 exceptions, illegitimate and raised under poor hygienic conditions.

Entrance		Later examination			General physical development	Mentality
Length, cm.	Weight, gm.	Age	Weight, gm.	Length, cm.
46.0	1880	17 mos.	10,750	79	Good; has eight teeth, walked at fifteen mos.	Normal
43.6	1890	17 mos.	10,250	77	Walks alone	Normal
43.3	1960	24 mos.	9,700	75	Good; has twelve teeth; walked at fifteen mos.; has a congenital hip dislocation	Very good
41.5	1460	30 mos.	9,750	77.6	Rachitis; anemia; congenital hip dislocation	Normal
40.0	1750	40 mos.	10,900	80	Severe rachitis; not walking	Backward
44.0	1820	54 mos.	15,000	95	Very good	Very good
41.5	1710	60 mos.	10,900	86	Anemia; large head; convulsions	Good
	1250	66 mos.	13,900	103	Flat occipital region	Fair
44.2	1980	6.5 yrs.	14,400	101	Anemic	Nervous
42.5	1710	6.5 yrs.	17,000	106	Anemic for eleven mos.; now 100 per cent hemoglobin	Normal
41.0	1500	6.8 yrs.	16,700	109	Rachitic deformities	Backward
45.5	1950	8.2 yrs.	21,300	123	Good	Normal

A comparison of these results with those attained with a similar group of full-term infants reflects with credit on the future development of the premature. The tendency to anemia and the results of rachitis, to both of which the premature is frequently subject, are not uncommonly seen in the early years of childhood. Whether the lack of resistance is a result of the shortening of the period of intra-uterine nutrition, or whether it is due to extra-uterine factors, more especially underfeeding and improper care during infancy cannot be stated, but we are inclined to believe that the former factor outweighs the latter.

According to Feer, many infants overcome their handicaps and make good progress, so that by the end of the second or third year their measurements are about the same as those of the normal child. Some, however, do not do as well as this, showing tendencies to rachitis, spasmophilia and especially anemia. The pallor developing toward the end of the first year depends in many instances upon the lack of iron deposits which are made in great part during the last few months of intra-uterine life; in other instances it depends upon a lack of development of the blood-making organs.

Wallich and Fruhinsholz analyzed the previous history of older children and adults and also ascertained the later history of the prematurely born. Possibly the earliest instance of prematurity on record is that of the Professor at Padua who was born at the end of the seventh month and lived to be eighty. Other famous prematures include Newton, Rousseau, Voltaire, Cuvier, Victor Hugo, Lamartine and Renan.

The outlook for the future of the premature is shown to depend in a large measure upon the degree of development at birth, as evidenced chiefly by the weight. Of 17 infants weighing between 900 and 1500 gm., studied by Wallich and Fruhinsholz, 41.1 per cent developed into normal adults, a similar percentage were but slightly handicapped, while the balance were much below normal. Of the 25 weighing between 1500 and 2000 gm., 52 per cent were normal and 36 per cent slightly handicapped. Of the 36 between 2000 and 2500 gm., 75 per cent were normal and 22.2 per cent retarded. The last group comprised 65 weighing from 2500 to 3000 gm. of which 78.4 per cent were normal and 20 per cent somewhat under the normal.

The same authors traced back to birth the history of 180 children from Broca's surgical clinic and 620 inmates of the asylum for the epileptic and feeble-minded. Twelve per cent of the former and 8 per cent of the latter were known to be of premature birth. Thus we see that a large percentage of the prematurely born develop normally in both mind and body, while the balance exhibit varying degrees of inferiority, hernias, club feet, enuresis, pavor nocturnus, etc. These signs of degeneracy are seemingly the result of prematurity and of the trauma sustained at the time of delivery.

The studies of Ylppö on the development of the premature from infancy to the school age led him to make certain generalizations. The growth of premature infants (those with a weight below 2500 gm.) discloses a considerable derangement in the first three to five years of life. This discloses itself in that the weight, skull and thorax growth in almost all this class is slower. This retardation in growth is the more marked, the less the body weight and length.

Growth disturbances appear immediately after birth and are proportionately more marked in the first six to twelve extra-uterine months of life. At the end of two to four years there begins a gradual equalization, which in most instances ends at about five or six years. From this period on the curves of growth are parallel with those of full-term children. Only in the case of very small prematures with a birth weight of 1000 gm., the reparation does not seem to be completed by the age of five to six years. The growth in length is up to this time disturbed approximately to the same extent as the mass growth.

The chest, which is proportionately deficiently developed in prematures, also shows on the average, until the age of three years a retardation in growth. In the years following, the breast circumference, however, reaches practically the same value as in full-term children of a similar age. The cross-section of the chest of the premature approaches more the form of an ellipse than a circle. The cross-section area is in the smallest prematures strikingly small in comparison with the body length. The growth of the head is the least disturbed or retarded. This is explained by the fact that the brain growth in premature follows certain individual laws without depending, as a rule, on the development of the body.

The principal point of these growth disturbances in the premature is immaturity. The more immature an infant is born, the more deficient is the function of the various organs in extra-uterine life. Especially in the province of digestion are variations noted in prematures, because of poor utilization, particularly of fat and salts, a qualitative nourishment results which favors the development of growth disturbances.

Besides these and other exogenous factors, certain endogenous factors probably play a passing but noteworthy part in the production of growth disturbances. All these defects, however, gradually disappear or are overcome, so that reparation is completed by the time the premature reaches the school age. From this time on the growth again turns back to the paths which have been designed for the hereditary mass of the child.

Ylppö was able to follow up 89.52 per cent of his cases and thus compiled his figures for the mortality and future development of the premature.

Infants with a Birth Weight Up To 2500 Gm. In Their First Eight Years

Year of Birth	Total No.	Not followed up, per cent	Followed through	In 1918 at end of year of life	Of these still alive, per cent	Of these dead, per cent
1918	48	---	48	1/2	16 = 32.65	33 = 67.35
1917	57	2 = 3.51	55	1	35 = 63.64	20 = 36.36
1916	98	3 = 3.06	95	2	46 = 48.42	49 = 51.58
1915	90	5 = 5.56	85	3	42 = 49.41	43 = 50.59
1914	101	11 = 10.89	90	4	40 = 44.44	50 = 55.56
1913	85	13 = 15.29	72	5	30 = 41.67	42 = 58.33
1912	83	10 = 12.05	73	6	30 = 41.10	43 = 58.90
1911	57	16 = 28.07	41	7	19 = 46.34	22 = 53.66
1910	48	10 = 20.83	38	8	20 = 52.63	18 = 47.37
Total	668	70 = 10.48	598		278 = 46.49	320 = 53.51

These statistics show that only 40 to 45 per cent of the premature infants lived to the school age. Twin prematures showed a somewhat better average -- 50 per cent.

Twins With A Birth Weight Up To 2500 Gm. In Their First Eight Years

Year of Birth	Total No.	Not followed up, per cent	Followed through	In 1918 at end of year of life	Of these still alive, per cent	Of these dead, per cent
1918	9	---	9	1/2	5 = 55.56	4 = 44.44
1917	14	---	14	1	10 = 71.43	4 = 28.57
1916	26	---	26	2	15 = 57.69	11 = 42.31
1915	15	---	15	3	7 = 46.67	8 = 53.33
1914	18	5 = 27.78	13	4	7 = 53.85	6 = 46.15
1913	14	---	14	5	7 = 50.00	7 = 50.00
1912	11	2 = 18.18	9	6	4 = 44.44	5 = 55.56
1911	11	3 = 27.27	8	7	7 = 87.50	1 = 12.50
1910	10	2 = 20.00	8	8	6 = 75.00	2 = 25.00
Total	128	12 = 9.38	116		68 = 58.62	48 = 41.38

In concluding it may be said that the future of the prematures who survive is on the whole good. They seem to be somewhat more subject to hydrocephalus and to psychic and nervous anomalies, such as enuresis and night terrors, and to anemia, rachitis and spasmophilia. Many are precocious, even original children. They tend to remain light in weight and short in length, but this is usually equalized by the time of entering school.

It is generally the case that in those infants who survive, most differences between the premature and the full-term child have disappeared by the time of puberty, and therefore every effort should be made to preserve all perfectly developed premature infants.

Walking and Talking

It is well known that in premature infants we may not expect the development of certain faculties, namely, speaking and walking, at the same time as in full-term infants. Wall states that his premature infants learned to talk seven and a half months later and learned to walk six months later than full-term children. He also reports that certain speech defects, as stuttering and stammering, occurred more frequently in his prematures. These differences, however, became equalized later on.

In general, the smaller the premature at birth, the greater is the delay in its learning to talk. It is rather an exception to the rule when infants that have been born weighing 1000 to 1500 gm. learn to talk before they are two years old. The following table shows when children of Yllpö's series learned to walk and to talk a few words:

The age and number of children when they were able to speak:

9 months to 1 year	3
1 year	9
1 year, 3 months	48
1 year, 6 months	18
1 year, 9 months	54
2 years, 3 months	1
2 years, 6 months	10
2 years, 9 months	1
3 years, 6 months	1
4 years	1
Unknown	37

The age and number of children when they started to walk:

9 months to 1 year	3
1 year	15
1 year, 3 months	46
1 year, 6 months	52
1 year, 9 months	28
2 years	25
2 years, 3 months	8
2 years, 6 months	4
2 years, 9 months	2
3 years	4
3 years, 3 months	1
4 years	1
Unknown	26

The statements as to the time at which the child spoke the first words, and when it started to walk vary widely in individual cases. Only intelligent mothers are able to make reliable statements pertaining thereto. On the other hand the delay in learning to talk and to walk depends in many cases not upon the docility or development of the infants, but upon the efforts of its mother or nurse.

From the preceding facts it follows that the small prematures learn the first sounds and the first words on an average of one year and six months. This occurs then about six months later than in full-term infants. The age at which the child learns to walk is about the same as that at which it learns to talk. This may be regarded as a proof that learning to walk depends in a healthy child upon its mental development.

Constitutional Inferiority

The various lesions, either of traumatic nature, due to delivery itself or extra-uterine life, brought on by deficient resistance or deficient functional capacity of the different organs, result in various clinical symptoms, which have been designated under the collective name "constitutional inferiority." Everything seems to point to the fact that this constitutional inferiority in the strict sense of the word does not occur in a much higher degree in premature infants than in full-term children, if we do not include the various gross anatomical malformations.

We have reason to assume that many prematures who remain weaklings in their later life and show other signs of inferiority, suffered from some constitutional anomaly, intra-uterine, or post-natal trauma, or were born in a state of physiological immaturity. This view seems to be especially strengthened by the fact that the more premature and the smaller the infants come to the world, the more frequently they suffer with idiocy, Little's disease, serious anemias, rachitis and other diseases based upon the condition of deficient resistance.

The proportional diminution of various pathological symptoms with increasing birth weight would be difficult to understand in terms of congenital constitutional lesions. Also the frequent disturbances of growth in premature infants, especially during the first years of life, have some connection with this passing poor condition of the premature. Later, strikingly good reparation of the growth disturbances shows best that this state is not dependent upon congenital constitutional factors.

The Mental Development of the Premature Infant During Early Childhood

In order to review this subject properly, it is necessary to divide premature infants into two large groups: (1) Prematures without pathological changes; and (2) those born with pathological changes due to constitutional diseases and congenital malformations. In the well-developed fetus which has not been damaged during the time of conception, and which is born at an age compatible with a physiological development necessary to meet its needs for life and which suffers no undue traumata during or following birth, a normal mental development may be expected. External influences will affect its mental growth as well as its physical development, therefore, it must be raised in a suitable environment and be judiciously fed. It may be stated that the longer the intrauterine life of the fetus, the less the dangers of interference with its normal mental growth. It is quite natural to expect, therefore, that these immature infants are more subject to mental disturbances and defects than the full-term infant. Abnormalities in development need not be explained by anomalies in the embryo, but rather may be due to direct external traumata of a mechanical, dietetic and of an infectious nature. Thus, there remains no other choice than to make the intra-uterine and extra-uterine noxae responsible for the frequent cerebral disturbances, be they connected with spastic states or idiocy, with or without spasms.

It is our experience that the majority of premature infants born after the thirty-second week into a proper environment without birth injuries, undergo a normal mental development. That these individuals are more subject to rickets, anemia and spasmophilia with their consequent effects on the nervous system is not to be forgotten. But all these conditions are amenable to therapeutic procedures with only a limited after effect.

In the second group belong those suffering from constitutional diseases and congenital malformations. These individuals cannot be classified in groups as to their future development, but each one must be considered individually. While congenital lues usually leaves its mark in the full term, in the premature it is even more grave in its consequences. However, much can be expected from proper and early therapeutic measures. In those suffering from hemorrhages into the cerebrum and spinal cord, it is easy to understand that in the premature infant that has survived in spite of these lesions sequelae may manifest themselves in later life. We would especially impress upon the physician the fact that not all infants with cerebral hemorrhages die in the first days of life but that many survive. Cerebral hemorrhage may not be suspected until late mental and physical signs develop.

The prognosis in this group must always be made with considerable reservations.

However, on the whole, it may be stated that mental development goes hand in hand with physical development. To this broad statement there are, however, many exceptions, and while we do see a number of these infants with good physical development who are of low-grade mentality, in our personal experience we have come in contact with a larger group of premature infants with a high grade of mental development, even to the point of precocity. They tend to remain light in weight and short in length, but this is usually equalized by the time of entering school.

	Fig. 184. Infant born at thirty-six weeks. Birth weight, 1500 gm. Intense icterus, melena, double inguinal, lumbar, and umbilical herniae. Photograph taken at six months. Still showing evidence of megacephalus.
	Fig. 185. Same child, aged two and one-half years.
	Fig. 186. Same child, aged four and one-half years. Megacephalus has entirely disappeared.
	Fig. 187. Infant born at thirty-four weeks. Complication, spastic diplegia.
	Fig. 188. Child shown in Fig. 187, showing standing posture.
	Fig. 189. Child shown in two previous illustrations, showing good results following tendon transplantation. Mental development in advance of age.