I'm not convinced that we can say categorically that premies were not meant
to survive.  Granted, far more babies who would have died just a couple of
decades back are now surviving, and surviving with remarkably few sequelae,
but some of them have always managed.

Disclaimers: I am not a neonatologist and my experience working with these
babies, beyond helping mothers on post partum to establish milk supply from
the start, is when they are ready to graduate from our intensive care unit,
which does have babies down to about twenty-eight weeks.  Also, this is
anecdotal evidence.

My mother in law was born over eighty years ago, weighing sixteen hundred
grams, which is about three and a half pounds.  Her mother expected to give
birth some ten weeks later.  Of course, estimation of gestational length and
assessment of gestational age are very different now, but in talking to my
MIL's own mother it seems she had a tendency to premature labor.  She was
running to catch a bus when her waters broke and my MIL was born a short
time later.  Her mother had three or four early miscarriages or spontaneous
abortions in the ensuing four years.  Then she was widowed when her husband
got pneumonia and died of it in the course of two weeks, this being the
pre-antibiotic era, and my MIL grew up an only child.  She was exclusively
breastfed from birth, though she was too small to nurse at the breast for
some time.   She slept in a shoebox on the shelf over the stove, and her
mother had to endure all the aunties and their friends coming to pay their
respects, looking in the shoebox and saying 'Imagine that something that
small can LIVE!' as though it were an affront to their sensibilities. 
Yet live she did, and grew to normal adult size, with normal enough
development that she attended school, did well, was employed most of her
life in a job requiring some considerable intellectual abilities, and gave
birth to three term babies herself, all of whom are basically healthy,
mature men today.  She developed asthma at the age of sixty, but she lived
until she was eighty-three herself.

A good friend of mine is fortunate enough to have both her own parents still
alive.  Her father is well over eighty.  His mother was the district midwife
in the rural community where they lived, and he has recounted for his
daughter many times how he was born weighing about four pounds, and since
his mother was the only midwife in her district, she had to simply take him
along whenever she was called out.  She gave him what we now call kangaroo
care, and he was exclusively breastfed from the start.  I have later heard
this story corroborated by young women from the same community, who grew up
hearing about this midwife and how her son came along on births, inside her
blouse, for many months.  He is the father of three and the grandfather of
at least twice that number now, and for all I know he may be a
great-grandfather as I write this.

Neonatology is an important subspecialty of pediatrics here too, and
Norwegian neonatologists have done some landmark research on nutritional
care of extremely small and extremely premature babies.  We use human milk
fortifier much less than what seems to be the norm in North America.  We
also keep babies in the hospital longer, because special care baby units so
far have been spared the pressure to get patients out as quickly as
possible, whatever the cost.  For both these reasons I have never heard of
anyone being sent home with a breastfed baby on fortifier.  If a baby still
needs fortifier, by definition they aren't ready to go home.  I honestly
don't know how many biochemical markers for growth our neos use, beyond
simply weighing and measuring the babies.  I do know that these children no
longer stand out in crowds.  They look, and act, pretty much like everyone
else.  It is entirely uncontroversial to acknowledge that the babies who
thrive on breastmilk are the ones who do best, just as the same is true for
term babies.

Coincidentally, I happened to ask one of our NICU nurses the other day how
many cases of necrotizing enterocolitis he has seen in his nearly twenty
year career working in our unit.  Only about two hundred babies come through
there every year and of course most of them are not micropremies.  He has
seen three outright cases of NEC and about twice that many in which NEC was
suspected but never confirmed.  This is generally attributed to the policy
of introducing colostrum and mother's milk or unpasteurized donor milk per
os as soon as possible after birth, especially for the very smallest and
youngest babies.  

I see I need to ask more about our national criteria for using fortifiers
for extremely premature babies, and if I can remember to do so, I will, and
report back again.  I imagine we can all agree that this is an area where we
are learning huge amounts very quickly, and whatever policy we have today
will likely be different in another few years again.

Rachel Myr
Kristiansand, Norway

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