Family Matters

A 21-Week-Old Baby Survives and Doctors Ask, How Young is Too Young to Save?

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Last month, a baby girl widely considered the most premature European baby ever to survive left a German hospital and headed home. Frieda Mangold was born more than four months early, at 21 weeks and five days. She weighed a smidge over a pound.

Her twin, Kilian, succumbed at six weeks to heart and intestinal complications, but Frieda slowly soldiered on. Her doctor at the Fulda Children’s Clinic, Reinald Repp, said there was “no indication that she will not be healthy,” according to the Daily Mail, and described her survival as a “medical miracle.”

Yet what exactly constitutes a medical miracle is unclear. Any premature baby is at risk for complications — the tiniest of the tiny even more so. News of Frieda’s birth and her tenaciousness after five months of neonatal intensive care has raised an issue that is discussed in medical circles out of clinical necessity, yet rarely reaches beyond hospital confines: how young is too young to save?

(More on TIME.com: Why Delaying Delivery by Just Two Weeks Boosts Baby’s Survival)

Doctors in the U.S. often advise that premature babies born before 23 weeks be given only “comfort care” — swaddled, they’re handed to their parents to hold, free of medical interventions. If parents insist on treatment and the baby weighs more than 500 grams (about 17.5 ounces), “most of us give it a try,” says Gerri Baer, a neonatologist in Rockville, Md., who also happens to be my oldest friend.

Typically, 23 weeks is considered the limit of viability, although there have been some 22-week survivors. Because even early ultrasounds that predict a due date are essentially guesstimates — with a plus/minus range of about five days — it’s tough to definitively date a preterm birth. A full-term pregnancy lasts 40 weeks.

Every week — every day — that a baby stays in the womb affords a better shot at survival because the infant’s development is more complete, a phenomenon that Alan Fleischman, medical director at the March of Dimes, calls a “biological continuum.” This holds true even when babies are not technically premature: a study published in the June issue of Obstetrics & Gynecology shows that infant mortality rates double when babies are delivered at 37 weeks rather than waiting until at least 39 weeks. Potential complications of even relatively late — but still early — births have prompted the American College of Obstetricians and Gynecologists to advise against elective deliveries before 39 weeks.

Babies born around 37 weeks can have breathing problems and require ventilation. But the extremely serious complications occur at much younger gestations: infants born before 26 weeks are at greatest risk for significant disabilities — cerebral palsy, perhaps, or deafness or mental retardation.

(More on TIME.com: A Blood Test to Predict Premature Birth Could Hit the Market Next Year)

In most cases, doctors have a bit of time between the parents arriving at the hospital and the actual delivery to discuss outcomes and prepare. “We sit down and talk with them,” says Baer.

Between weeks 23 and 24, most neonatologists leave the decision about whether to resuscitate in the parents’ hands, and nearly all parents ask doctors to resuscitate. If the baby is so tiny that a breathing tube can’t inserted, however, all bets are off.

For babies born after 24 weeks, doctors generally believe that the benefits of resuscitation outweigh the downsides. “Between weeks 22.5 and 24 is the gray zone,” says Baer, noting that just one in 10 babies born before 24 weeks survives. “Above 24 weeks, every baby gets a try.”

Caring for such fragile babies is a tough, heartbreaking job, and there’s much that’s unknown. Girls, for example, have better outcomes than boys; black girls have the best chance at survival, white boys the worst. Why? “We don’t know,” says Baer.

(More on TIME.comStudy: Preterm Birth Raises the Risk of Childhood ADHD)

Birth weight counts for a lot as well: every additional 100 grams (3.5 ounces), as well as lung-developing steroids administered before delivery, give a baby a notch up on a widely used outcome scale maintained by the National Institute of Child Health and Human Development that can predict how a premature baby may fare. Plugging in the stats for baby Frieda is not an exercise in optimism: even assuming the use of steroids, there is just a 3% chance of survival without “profound neurodevelopmental impairments.”

Still, when it’s your baby, it’s probably human nature to believe you’ll beat the odds. Baer sees that reflected in her conversations with parents-to-be.

“I can tell them what the stats are, but most people are going to believe their kid is going to be okay,” she says. “If you’re in that heightened emotional state, the data is not all that important to you.”

16 comments
EmmanuelleBlander
EmmanuelleBlander

I guess the us is a much better country to live in than ours. I live in Quebec, Canada. Having gone through this experience a few days ago with my baby girl, I can say that here, there is no ethical thought about "how young is too young to save". Here, unfortunately any baby born before 24 weeks has a ZERO chance of survival given the fact that hospitals refuse to give any medical care to them. Whether the baby fights for their life or not, they aren't given any chances of surviving. For my husband and I it was heartwrenching to see our baby girl fight for her life knowing she had a 100% certainty of dying, no matter how strong she was. For us, the hospitals had determined the outcome, not even giving her the slender chance she deserved to have, no matter how slim it was. I just wish the medical system wouldn't have decided whether or not a life was to be, it should simply try its best to help each and everyone, and let things take their course after that.

TishDontuwishuknew
TishDontuwishuknew

My cousin has had THREE babies at 24 weeks and 2 or 3 days. A few years apart. Each baby was born alive, and with all three babies they told her there was nothing they could do and they gave her the baby to hold while it died a few minutes later. With one of the deliveries I was with her. And there is NOTHING more heartbreaking then watching a baby die with doctors and nuses walking by as if it meant nothing.

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stargazer43
stargazer43

This happened to my daughter.  She had been to the hospital twice before the last time when the baby was delivered.  Each time they told her everything was fine and sent her home.  Then the last time a nurse came into the room, gave her an IV and her labor started, hard and serious.  She told me she begged them to save her baby girl.  They did not take the infant to intensive care nursery, they just brought in a small little hat and blanket and told her to hold her daughter until she died.  I am heartbroken!  No one will even investigate.  When my daughter got the medical records, the IV they had given her was not listed, nor was the nurse who administered it.

MarciaDeGuerre
MarciaDeGuerre

How horrible to go through something like this, how horrible for men and women in hospitals to let babies die in the arms of their parents and do nothing to save them, where is our value for human life. These messages have broken my heart and I pray G-d's peace over each one of you. Know that Jesus loves you and I pray any guilt you have in your heart and mind is washed away. Know that your babies are safe and loved in heaven, there is no pain, there is only life and joy. I pray that each of you would feel His love even now as I write this. He knows you and loves you. My son was also a premie and I know how much we want them to live. Blessings to you and I just pray His peace that surpasses all understanding cover you. Love, Marcia

BrendaRenfro
BrendaRenfro

how sad for your loss. our family went thru a similar loss. god bless you  and baby.

AdrianaToledo
AdrianaToledo

I also lost my baby girl at 21weeks 4days. I had an ultra sound a Thursday the ultrasound tec told me my fluid was low but never gave me any reason to be worried it was my first pregnancy so did not know to much well Saturday morning I started noticing that my panties were wet constantly I thought it was just me urinating on my self well that night I went out to my sister in laws house at around 10 I notice some brown spotting I asked my sis if It was normal she said it never happened to her so we went to search the Internet well min after I went to the restroom again and I was bleeding a lot so I went strait to the hospital kaiser since it was the nearest to me well the doctor said you are going to have a miss carriage go home take Tylenol if you start bleeding more go to the nearest hospital I got discharged about 4am, that made me extremely upset well I got home and I was just in to much pain and I was bleeding to much so my husband took me to the hospital I was suppose to deliver, we get there and they stared trying to stop the contractions by the way I already was having contractions when I was at kiser well they did for about 2 days my baby came Tuesday night at 1lb 10 ounces she was tinny well they said the same thing to me they couldn't do anything for her my baby survived in my arms for 36 hrs without any help she cried she sucked on her hand she would make noises when I spoke to her like if she new i was talking to her. Still till this day I still don't understand if she was strong enough to survive for so long on her Owen why didn't they do anything I begged for them to help her but nothing it really sucks to feel so disappointed with the doctors and to feel like I let her down when she fought so hard.

JoanneSandy
JoanneSandy

I lost my daughter as well. She was 21 weeks and 4 days. I went to the emergency room (20 wks) because I was leaking fluid with light spotting. I was told that my cervix had dilated 3-4cm and that I should terminate the pregnancy. I refused to give up and was put on bed rest. At 21wks and 3days I was going to be discharged home on bed rest but when they checked again my cervix had almost completely closed and that they could now try to add some stitches to keep it closed. I was  taken off bed rest in hopes of doing the surgery the following day but that didnt work out either I was later informed that because my cervix was open for so long that there was bacteria in her amniotic fluid and the surgery is no longer an option. Not sure if it was the stress of not having the surgery or being taken off the bed rest or having the doctors constantly telling me that I should terminate (from the date of admittance). My lil girl finally decided to come. She was strong, her lil heart lasted almost three hrs before it finally gave up. I was told the same that she was two young to survive and there would be not hope of resuscitation. There is no more human compassion anymore, we are all programmed to be robots. From day one they counted her as lost but she tried so hard to survive and they didn't even attempt to help her.

Justine
Justine

I just lost my daughter she was 21 weeks and a day shy of 22. This was from a ultrasound given very early in my pregnancy. I never got a second opinion as to how far I was. I told the nurse at the hospital where I delivered that I was leaking amniotic fluid, but she sent me home;  Two days later, I gave birth to her in the hospital before I could get to the triage. My fiance checked me in but after he told them about my contraction and that I was in the bathroom he said they heard me screaming for help. They did not even consider trying to save her, It was just plain "Oh she is not viable". I believe that they should have tried just because the neglect of the nurse. My daughter held a heartbeat for at least a half hour on her own. She was African American, but I don't care what race the baby is, they are all strong and can make it threw. I am so devastated. The tragedy of being neglected, delivering your own baby on a toilet and no one helping her survive, I know she could have. But people turn into robots when it come down to what they read in a manual and they stop having faith and believing because they look forward to a paycheck at the end of the day.


melindajohnson
melindajohnson

@stargazer43  I am sorry for your lost on Wednesday my daughter twins came my grandson lived for 4 hours my granddaughter was born 1hour45mins after her brother she lived for 2 hours I ask the doctors and nurses if it was anything they could do and they keep saying no I thought that as long as that heart was beating they would have at least try to save my babies just sitting here sharing with you it tears my the grandmother and all I can do is be there for my daughter not really knowing what to say to comfort her because I have never lost a child. I am hurting just as bad as my daughter but I know its not the same I am truly sorry for all of these mothers pain the only words I can say is that your angels and my twin angel are with the good lord and they are safe and happy in his arms .hurting grandmom

MarciaDeGuerre
MarciaDeGuerre

How horrible for you to go through something like this. I can't believe they wouldn't help you save your baby, what a horrible rule to follow. I pray G-d's comfort over you as I write, I pray His peace that surpasses all understanding. Know that she is in heaven, safe and loved. My son was also a premie and I know how much you want them to live. Jesus loves you and I pray any guilt you feel over this is erased from your heart and mind. I pray His love sets you free. Love to you from a mommy in NY.

klein123
klein123

@AdrianaToledo I'm so sorry.  At least you can take comfort that she will someday be reunited with her in heaven.  :)

kirsty
kirsty

the doctors these days are gutlees wonders they could of tryd i know what u felling we also felling the same

melindajohnson
melindajohnson

@Justine I am sorry for you lost my daughter just lost twins so I understand a little of what you are going thru I hope you are doing well and have a great support system going thru something like this is hard again I am sorry for your lost

kirsty
kirsty

Doctors these days are to laid back they dont even care a single bit my heart goes out to u and ur family