By J. Susan Griffith, M.D.
Research Interpreter #1
I had almost convinced myself that pregnancy was a normal, everyday occurrence, then, at 17 weeks into my pregnancy, I was told those scary words during my ultrasound - "You're having twins!" As a physician, I had taken care of numerous infant twins, many of them in the Neonatal Intensive Care Unit (NICU) of our tertiary-care hospital. Most of them were in the NICU because of premature births and the resulting medical problems. After the "twin diagnosis," my pregnancy worries were compounded. I kept thinking about all of the "preemie" twins I had cared for during my residency. Luckily, my fraternal sons were born only a few weeks early, and did not spend any time in the NICU. Many families are not so fortunate, however.
The general public and the press glamorize higher-order multiple births but they don't seem to realize that ANY multiple pregnancy, even twins, is a high-risk pregnancy and sometimes fraught with problems. This paragraph, from the latest U.S. "National Vital Statistics Reports" illustrates this: The greatly increased risk of adverse outcome associated with multiple gestation pregnancies compared with singleton pregnancies is well documented. In 2003, multiples accounted for 3% of all live births (in the U.S.) but more than one of every four VLBW (very low birth weight) infants. In 2002, the latest year for which data are available, nearly one of every five neonatal deaths (death within the first month after birth) were born in a multiple delivery.
Because so many multiple-birth families are faced with pre-term births, the Research Department of NOMOTC wrote and distributed a survey to study the "Long Term Effects of Pre-Term Multiple-Birth." This survey was to be filled out by parents of pre-term multiples (pre-term was defined as "a gestational period of less than 37 weeks"). The multiples had to have been five years or older at the time the survey was completed (from March through September 2004).
Ninety-two parents of multiples returned completed surveys to NOMOTC. There were 80 sets of twins, 11 sets of triplets, and one set of quadruplets represented in the study. The total number of multiple-birth children was 197. About a third of the multiples were identical. The ages of the children ranged from 5 to 33, but most of them were 5-10 years old. The majority of the multiples were born at a gestational age between 32-36 weeks (with 40 weeks representing the normal pregnancy length), but the range was 25-37 weeks. The birth weight of the multiples ranged from 1 lb. 6 oz. to 7 lbs. 6 oz. However, most of the pre-term multiples in this study weighed between 3 lbs. 3 oz. and 5 lbs. 14 oz. Three of the families had a death of one of the multiples- all three were in a higher-order multiple pregnancy.
Several medical complications can commonly occur as a result of a premature birth. The most common is a respiratory, or breathing, problem. NOMOTC asked these multiple-birth families about the occurrence of some of these complications.
Seventy-three of the pre-term multiples were put on a ventilator to help them breathe (37 percent of the total). The amount of time the infants were on a ventilator varied from just a few hours to 2 ½ months. The majority of the infants were only on a ventilator for 1-14 days. By age five, only one of the children still required supplemental oxygen. This child had been on the ventilator continuously for two months since birth.
Only four of the 197 pre-term infants developed cerebral palsy, two were baby A and two were baby B.
Intra-ventricular hemorrhage (or "bleeding in the brain") occurred in 18 of the pre-term infants, but in just seven of the 92 families. Only one of the infants had a Grade IV bleed, which is the worst in severity.
Ten of the pre-term infants had Hydrocephalus (or "water on the brain"). Just two of the infants required surgery to remove some of the excess fluid.
Fourteen of the infants had a Patent Ductus Arteriosus. This is an area of the heart that should close off once the infant is born and breathing oxygen. Sometimes, in premature infants, this area stays open. Five of the 14 affected infants required surgery to correct the PDA. Five infants had other congenital heart defects.
Sixty-six infants (33.5 percent) required a feeding tube to get nourishment. The amount of time the infants required a feeding tube varied from two days to nine weeks. The majority of the infants had a feeding tube for 1-6 weeks.
Developmental delays and learning disabilities are also a common result of a premature birth. By the age of five, these are the areas they had deficits in and the number of children affected by developmental delays:
Motor Coordination (15 children); Self-help Skills (10 children); Social Interaction (12 children); Language (24 children); and Cognition (6 children).
The pre-term multiples in our study also had the following learning disabilities:
Attention-Deficit Disorder (2 children); Dyslexia (2 children); Speech and language delay (5 children); Auditory Processing Delay (1 child) and Visual Problems (1 child).
Only six of the infants were given the diagnosis of "Failure to Thrive." This happened at the following ages: 3 months, 4 months (2 children); 6 months; 8 months; and 12 months.
As a result of their prematurity, the multiple-birth children in our study had the following complications (note: some children had more than one complication):
- Amblyopia, lazy eye (1 child)
- Anemia (2 children)
- Apnea, breathing problems (8 children)
- Asperger's Syndrome, a type of autism (1 child)
- Asthma (8 children)
- Bradycardia, low heart rate (7 children)
- Broncho-pulmonary dysplasia, a lung problem (1 child)
- Cerebral palsy (4 children)
- Death (3 children)
- Dystonia, a neurological disorder (2 children)
- Emotional problems (1 child)
- Epilepsy, seizures (2 children)
- Growth delay requiring daily Growth Hormone injections (2 children)
- Hernia (7 children)
- Jaundice, a liver problem (6 children)
- Kidney reflux (1 child)
- Meningitis (1 child)
- Necrotizing enterocolitis, a serious intestinal problem (3 children)
- Oral aversion, possibly from tube feeding (1 child)
- Pneumonia (1 child)
- Pneumothorax, collapsed lung (1 child)
- Pulmonary hemorrhage, bleeding in the lung (1 child)
- Reflux, a stomach problem (3 children)
- Renal stones, kidney stones (2 children)
- Retinopathy of Prematurity, a visual problem (10 children)
- Sensory issues (2 children)
- Torticollis, wry neck (2 children)
Finally, by the time these pre-term multiples became school-age children, many of them had special schooling needs. The most common type of help needed was Speech Therapy. Here are the types of help needed by these children (note: some children had more than one type of intervention):
- 504 plan for motor delay (2 children)
- Adaptive physical education (1 child)
- Behavior modification (1 child)
- DD Program (2 children)
- EC1, for hearing loss (1 child)
- ESE placement in mainstream class (2 children)
- Individual education program (2 children)
- Individual literacy program (1 child)
- Learning lab (2 children)
- NILD/SOAR program (2 children)
- Occupational therapy (9 children)
- Physical therapy (4 children)
- Resource room at school (1 child)
- School for the blind (1 child)
- Separation in class, due to one child not talking (2 children)
- Smart Start program (3 children)
- Special education class (6 children)
- Speech therapy (31 children)
- Tutoring (1 child)
- WINGS Program (2 children)
This study definitely shows the possible dangers of pre-term birth in a multiple pregnancy. The majority of the children did very well once they were treated for the immediate types of complications that occur soon after birth. Some had medical problems that continued to require treatment, however. As the multiple-birth children became school-age, there were often special programs needed to help them succeed in school. The most common intervention needed was Speech Therapy. Our "Long Term Effects of Pre-term Multiple-Birth" study indeed illustrates the importance of the prevention of pre-term multiple-birth.