Richard M. Restak, M.D.

The Infant Mind

CHAPTER 33

An Ode to Prematurity  

The brain weight of the mature newborn doesn't differ whether that infant is born in a hospital to well-to-do parents or in a hut to parents whom nature and society may have treated less kindly. Given the chance for a full development within the uterus, the brain will attain the same mass regardless of race or sexual difference. But the brain requires that full nurturing within the womb if it is to develop to its highest potential. Shorten the period, rush things so that the baby brain is forced to deal with the world before that brain is ready and you produce differences nature never intended. For instance, the weight of the brain of premature newborns (a gestational age of less than thirty-eight weeks and body weight of less than twenty-five hundred grams) preterm, and underweight infants varies according to sex and race. The weight is highest for white males, followed by white females, followed by black males, and finally black females.

According to the National Center for Health Statistics, prematurity occurs at approximately a two-to-one ratio when blacks are compared to whites. The percent of white premature babies is 6.4 compared to 13.22 percent for blacks. Among high-risk infants the figures are even more disproportionately distributed between the two groups.

At a regional prenatal health center caring for high-risk cases served by the Case Western Reserve University School of Medicine in Cleveland , Ohio , 75 percent of black males were born prematurely, compared with 80 percent of black females, 48 percent of white males, and 50 percent of white females. Reasons for prematurity? Poor health care of the mother. Smoking and drinking. Malnutrition. Teenage pregnancy. Low income. Little or no education. As a result of these factors, usually more than one, often all of them at once, there emerges a brain that isn't ready, that wants to wait a while but can't. From animal experiments, baby brain specialists know that the spurt in brain growth is determined by the clock. And that clock can't be stopped. The brain must grow in its time lest it not have the chance to accomplish the same thing as well at a later point. Any retardation in brain development, therefore, stands a good chance of never being reversed, with subtle defects remaining in the absence of anything remarkably unusual to the untrained eye.

Learning disabilities, hyperactivity, impulsiveness, attacks of rage these are some of the disturbances which, later in life, may plague the infant born prematurely. One doesn't need to wait that long to encounter difficulties, however.

In one study 50 percent of the mothers of prematures admitted that "real" affection was delayed for several months. They hadn't felt sufficiently maternal to their early arrivals. In that same study mothers were encountered who feared unnecessarily for their baby's health and safety, perceived the baby as somehow "imperfect," and had difficulty becoming properly attached to it.

A premature brain-a small baby-a "poorly responsive" baby-a "poorly responded to" mother-baby brain affecting Mother followed by Mother affecting baby brain-feeding difficulties at first followed by "temperamental incompatibility"-time spent together by both Baby and Mother not enjoyed or looked forward to by either party. Such can be the tragedy of prematurity.

A low birth weight infant, all things being equal, starts out with the odds against him. Mental retardation, cerebral palsy, seizures, learning disabilities-that baby's brain is at increased risk for all of these. He may have been born too soon (less than thirty-seven weeks rather than the usual forty weeks). Or he may have failed to grow adequately within his mother's womb.

Among a hundred infants who are "undergrown for their gestational age" five or ten of them will have a brain that is defective in some way.

If that too-tiny tot is born prematurely, the combination of too small and too soon will produce between thirty and fifty babies with brains less perfect than nature intended. Mothers who smoke, don't eat as they should, and/or ignore their blood pressure can produce small babies with the potential for imperfect brains. It is interesting that of these three factors only one - elevated blood pressure - is a medical condition, strictly defined.

Smoking and eating are behavioral variables that only secondarily produce harmful physical effects. Smoking, nicotine, reduces blood flow from the uterus to the placenta. It cuts down the flow of blood to the baby and injures that baby's brain at the same time it cuts down blood flow to the mother's coronaries and prepares the ground for a heart attack that might not have happened if that mother had only stopped smoking in time.

Malnutrition in the mother is a more complex matter. Not every mother has the last word in what she will eat, how much, how she will pay for it, or whether she can pay for it at all. If a mother doesn't gain enough weight during her pregnancy her infant will be more likely than not to tip the scales at the low end. Malnutrition can be environmentally induced-too little money or too little food or a combination thereof. It can also happen when a mother-to-be, smart enough to know better, attempts to retain what she considers a becoming slimness throughout her pregnancy, starving herself, forgetting that she's now feeding two and not just one.

Caution must be introduced at this point. All the studies on prematures and low birth weight infants rely on statistics. There are plenty of exceptions. Thomas Hardy, for one, was both premature and of a low birth weight. An infant born too small or before his time can, if the circumstances are just right, catch up with his compatriots and conform to the schedules. Only the exceptional infant is that fortunate, however.

"As pre-term infants have been followed into childhood, it has become clear that even children who have had apparently normal developmental progress until school entry are at considerably higher risk for visual motor, attention, language and behavior problems that interfere significantly with adequate school progress," notes Dr. Alfred W. Brann, Jr., a pediatrician and expert on the premature infant at Emory University School of Medicine in Atlanta.

With improvements in the care of premature and low birth weight infants have come corresponding improvements in the "quality" of these infants' brains. The major abnormalities of the past (spastic paralysis, mental retardation, visual and hearing abnormalities, seizures) are rarely encountered today. Instead, the preterm or low birth weight infant suffers from more insidious and subtle difficulties.

"Current investigators report children who developed apparently normal until age eight years, when they first demonstrated significant problems with abstract reasoning," wrote Dr. Brann in 1985.

In one study published in 1981, "Outcomes for infants of very low birth weight," only 76 percent of those born prematurely attended regular schools and exhibited no mental handicaps at eight years of age. In another study premature children on the average scored fifteen IQ points lower than did others who had been born at term.

Obviously a damaged or compromised brain doesn't exist in a vacuum. Each infant-term, premature, or low birth weight-is born into a particular environment which may add to or assuage the adjustment difficulties that brain may encounter. Dr. Gordon Avery of the department of neonatology at Children's Hospital National Medical Center in Washington , D.C. believes that in many cases such things as family stability and maternal intelligence may make the difference between an impaired and a normal brain. "According to the thesis of double jeopardy, biologic brain injury and socioeconomic disadvantage have a greater combined effect than does either alone. Thus, the child with prenatal or perinatal brain insult who is discharged into an unfavorable environment will be at a higher risk for a failure to 'catch up' for school failure and inability to compete." Put simply, the infant brain, particularly the compromised brain, requires the support of loving parents, good nutrition, stimulation, and love. If ignored or understimulated that brain will never be able to compensate for the subtle functional disturbances that we now know result from low birth weight, prematurity, or combinations thereof.

Care and affection make a difference. Instruction, patience, and stimulation make a difference. Fortunately, the infant brain is incredibly malleable and adaptive; it will make up for what it has been deprived of if given half a chance. There is no room for fatalism or pessimism here. The most important factor of all? Overcoming the disappointment of that mother and that father, consumer-minded, who feel that somehow nature has cheated them by giving them a "defective product." If those parents can be convinced of the nearly infinite restorative powers of the infant brain, that child will have a fighting chance.