About 15 million babies worldwide are born preterm, having completed fewer than 37 weeks of gestation. These babies have immature lungs, a reduced ability to maintain a normal body temperature, feed poorly or not at all, and a weak immune system making them dependent on external support systems for survival. This is now the leading cause of death in the first month of life with over 1 million estimated deaths globally every year. Even those infants who survive have lifelong consequences including an increased risk of stunting, learning deficits, visual impairment and hearing abnormalities. As developing countries, including India, have made progress against other preventable causes of death, preterm birth has become an ever-increasing proportion of the burden. There is therefore an urgent need to invest in understanding what causes it, new ways to predict or prevent it, and innovative low-cost solutions to manage those babies born too soon.
The first challenge is in the measurement of gestational age. The gold standard is through ultrasound imaging in the first trimester. However, using ultrasound appropriately requires training to obtain and assess the correct images. Since this is not a routine practice in many settings, mothers are simply asked the date of the last period, leading to widely inaccurate assessments of the date of conception, sometimes by more than 6 weeks. Recently, there have been potentially transformative changes in the ultrasound hardware with changes to the core technology such as moving from a traditional platform of piezo electric crystals to semiconductors, making possible a lower cost and new hardware-software interfaces. In addition, advances in machine learning and augmented reality are promising to lead to the development of software technologies that can enable a point of care ultrasound to be used by less trained health care personnel. In the contexts where sex selection is a major concern, these advances make development of automated ultrasound probes that can block sex selection while still being able to provide key lifesaving obstetric measurements potentially achievable.
Another major challenge is that the preterm baby’s lungs are poorly developed, leading to difficulties in breathing that may require oxygen or mechanical ventilation. In developed healthcare settings, the practice is to administer corticosteroids to the mother if she goes into preterm labor, which will promote lung development of the fetus. However, steroids can increase the risk of infection or reduce blood sugar levels, both of which can be life threatening especially to the baby, and can be difficult to manage in less advanced settings. There are now promising new discoveries, which could lead to a reduction in the dose of the corticosteroids needed to treat this condition, thereby reducing these side effects. This could also enable the use of tablets instead of injections, making them much easier to administer.
Preterm babies are low in surfactants. These are substances produced in the mature lung that help keep them inflated and allows for the absorbance of oxygen into the blood. Products currently on the market are expensive and need skilled administration, putting these beyond the reach of most developing healthcare systems. Innovations in surfactant products that would be more cost effective and easier to administer are being tested now to help address this problem.
For long term sustainable progress, there is need to invest in research to prevent preterm births. There is a recent report that deficiency of selenium, a micronutrient also found in the soil, could be linked to increased preterm births. The investigators used a clever methodology called a genome-wide association study done in a large database and then validated with independent data, both from high resource settings. Efforts are now underway to assess if this finding holds true for Africa and Asia, where selenium deficiency is widely prevalent. Selenium containing proteins play crucial roles in our body functions such as production of antioxidants that prevent inflammation. Many adverse pregnancy outcomes such as preeclampsia and preterm birth have been linked to inflammation. If confirmed, a very promising public health intervention might be to supplement selenium at a population level, as is happening with folic acid.
The birth of preterm babies is a global challenge. These exciting new discoveries offer great promise and could help both advanced as well as developing countries such as India, which, because of its sheer size, has the largest number of preterm births of any country, develop a serious response to this issue.
The article was originally published in Hindustan Times on June 20, 2018