I. A.1. Better access to advanced neonatal care for low birth weight infants improved newborn survival substantially. Infant mortality rates have been unacceptably high in the past. Bains (1862) reports: “Of the deaths in England in 1859, no less than 184,264 – two in every five of the deaths of the year – were of children under five years of age; and above half of these – 105,629 – had scarcely seen the light, and never saw one return of their birthday”. The nineteenth century contributor accused newborn fragility of the reason for high mortality rates, with special attention to prematurity: â€œIt cannot be supposed, upon reflection, that the Almighty intended these little ones [premature] to dieâ€. According to poor technical possibilities, Bains (1862) considered nutrition errors (rickets prevention, diarrhea etc) mostly. It was not until antibiotic invention in the 1940’s, mechanical ventilation advent in the 1950’s, and surfactant replacement therapy development in the 1980’s that survival of premature and low birth weight infants improved. Matsuo (2005) indicates â€œWhereas few infants with birth weights below 750g were actively treated before the 1980’s, treatment is now accepted practice for most infants born in North America with birth weights of at least 500g, those born at 24 or more weeks’ gestation, or both”. In the early 1980’s, nearly 3 in 4 twins born at 700 grams died within a year of birth and by the late 1990’s, the mortality risk had fallen to 1 in 3 (Almond et al, 2004). This is a large success of medicine in the United States and developed countries in the raised survival of low birth infants over the past three decades. As Goldenberg & Culhane (2007) report, in 1975 infants weighting 500 to 1,000 grams survival rate was approximately 15%. In modern neonatal intensive care units, such small newborns show more than 80% probability of survival. Moreover, mortality for infants 1,000 to 2,500 grams today is rare.
I. A.2. Low birth weight outcomes. The major medical success related to low birth weight is a reduction on mortality, while long-term outcomes remain a concern. There are several long-term outcomes of low birth weight infants. Low birth weight places the infant at a greater risk of later adult chronic medical conditions, as well as recurrence of low birth weight in the offspring. Low birth weight born children are at risk developing long-term neurological, developmental and ophthalmic morbidity. Goldenberg & Culhane (2007) point to neurological complications, such as cerebral palsy, blindness, deafness, and hydrocephaly. For example, their paper describes risk of cerebral palsy in mature infants to be 1-2 per 1,000 births, while infants at the edge of survival 500-600 grams experience 250 cerebral palsies per 1,000 births. In spite of the fact that survival of small infants has grown substantially since the 1970’s, disability among them is still high. Thus, the absolute number of disabled is increasing. Long-term disability is related to fetus growth restriction. For example, those born between 5th and 10th percentile have little increase in neurological complications, while those under 1st percentile are at considerably grater risk.
Studies have established a correlation between low birth weight and high blood pressure, asthma and lung disease among children, as well as reduced IQ (Almond et al., 2004). Low weight infants are at considerable risk of visual impairments. Low weight per seÂ and retinopathy of the premature correlate with ophthalmic disorders at the age ofÂ ten strongly. In their survey, more than half of low birth weight cohort had some kind of ophthalmic problem. Low birth weight is associated with hyperactivity disorders and developmental issues (Pelletier, 2007). Links between low birth weight and problems pertaining to school performance, psychomotor development and emotional well-being are established. Lower birth weight, rather than prematurity alone, may increase the risk for symptoms of attention deficit/hyperactivity disorder in young children. The relation between low birth weight and medical disorders like hypertension, diabetes and heart disease, known as Barker Hypothesis, is under extensive study. These babies may retard in physical growth, develop sleep apnea, jaundice, anemia, and infections.
I. B.1. Definitions of low birth weight. Birth weight is on of the most significant determinants of perinatal and long-term outcomes. According to the World Health Organization, low birth weight infant is a baby weighing less than 2,500 grams. Low birth is not a homogenous pregnancy outcome, instead it comprises infants born prematurely or with intrauterine growth restriction. A preterm infant is one born less than 37 weeks of gestation, regardless of birth weight. A percentile table defines growth retardation (percentage score in frequency distribution). A growth-restricted baby must be under 10th growth-gestational age percentile. Very low birth weight (less than 1,500 grams) and extremely low birth weight (less than 1,000 grams), although mentioned in this paper as needed, are not under direct discussion.
I. A. 2. The incidence of low birth weight. Low weight at birth represents a significant problem worldwide. In most developed countries, the incidence of low birth weight infants is increasing. In the United States, the proportion of low birth weight infants increased from 6.8% in 1980 to 7.4% in 1998. InJapan, the increase over the same period was more dramatic, from 5.2% to 8.1%. With a few exceptions proportions have been increasing in Europe. Nevertheless, due to improved medical support, neonatal mortality rates are 4â€“6 per 1000 newborns in the United States versus 40 per 1000 newborns in developing countries. In Canada, the growth of low weight incidence (6.4% in 1981 to 6.7% in 1992 and 7.1% in 1997) is partially attributed to an increase in multiple births, obstetrical interventions and registration of early gestation births. In 2001, 8% (384 200) of all 4.6 million infant stays nationwide included diagnosis of preterm birth/low birth weight.
II. A. 1 (a) Caring for disabled children requires enormous amounts of physical and emotional energy. Low birth weight children grow up, the family and the society is to keep them alive, socialize them, provide support and raise them. Disabilities in their children place special demands on families and relatives for a long or a life-long time. The family’s lifestyle and leisure activities may never be the same. Time and energy spent on the child primarily, social contacts fail to be supported. As long as a child shows problems with expressiveness, related to attention deficit/hyperactivity disorder, communication within the family may be damaged. Mother is now under pressure to lessen communication with other children or relatives at the expense of the disabled.
Family life will be changed significantly, as the couple meets unknown troubles. Dealing with disabled day-to-day and strains to provide assistance might lead to fatigue and emotional burnout. Negative emotions include depression, anger, anxiety, worries whether enough care provided to the family member. Having a disabled baby is a challenge to the household. The family members now need to re-share their responsibilities. They have to accept possible negative reactions from neighbors, relatives, or colleagues. Stress from many additional demands may affect their own health. However, a disability might actually strengthen the family and develop respect to life and health. Mental qualities adapted, the family may have a chance to cope with the trouble.
II. A. 1. (b) Low weight births is a major health problem both to the individual infant and the entire family and to the society (Shah & Ohlsson, 2002). There will be a family financial burden concerning health care, education, social services, etc. Costs and efforts remain high after the baby discharged home from the neonatal care unit. For example, as long as the child needs to have regular medical physical or instrumental examinations, travel costs may be an unexpected expense for the family budget. Publicity funded programs may be in help, but to overcome bureaucracy obstacles may be a challenge. It is generally accepted, that there is a tendency to a higher separation or a divorce in families with disabled children. Mothers of such babies will not be able to go back to work, or at least will have to decrease working hours. Thus, their social engagement and career ambitions may decrease, on one hand, and family income drop, on the other hand.
Less than 2,500 grams at birth children birth are 1.5 times more likely to be enrolled in a special education compared to normal weight, and the additional cost to the US educational system of teaching such children is USD 322.9 million a year. Some children will need educational specialized institutions or trained tutors to work with, which is also an outgoing. The costs associated with specialized care are enormous. They are either direct or unrelated to the initial hospital costs, including long-term costs associated with neuro-developmental impairments and learning disabilities.
II. A. 2 (a) Socioeconomic status of the mother, and her associated lifestyle, plays a crucial role in the probability to deliver a low birth weight infant. The weight of the infant at birth depends on the length of gestation and intrauterine development. Sometimes a combination of the two takes place. All factors that potentially influence these are under study and appropriate manipulation may influence the weight birth outcome. Socioeconomic variables are generally those composed of income, education and occupation. Social inequalities may result in low birth weight, however, existing behind the traditional socioeconomic concept.
Environment, especially home environment, plays a crucial role in child health and cognitive development. The role of environment in shaping the low birth weight infant has been studied poorly yet. In fact, socio-economic factors, the nature of funding of health care may further contribute to differences in the low birth weight outcomes. Thus, some outcomes that were reported might not correspond to low weight per se but represent social disturbances of the mothers who give bear to small babies. Furthermore, Matsuo (2005) concludes, â€œadverse perinatal conditions resulted in severe educational disabilities, whereas less severe outcomes were influenced by socio-demographic factorsâ€. One may assume that social factors are capable to have a protective effect on behavioral problems.
II. A. 2 (b) Social factors of low birth weight: smoking, alcohol, stress, coffee, and socio-demographic risk factors: age, education, marital status, social class. Matsuo (2005) insists that risk factors for low birth weight are also likely to be determinants mediating the health consequences of low birth weight after birth. Davis et al (2009) indicate low socioeconomic status, chronic stress and perinatal depression are social causes of low weight at birth. Even though two thirds of reasons to deliver a low weight baby fail to be recognized (Matsuo, 2005), the available literature suggests strong correlation between social patterns and the risk to deliver a low birth weight infant. Â Shah & Ohlsson (2002) report tobacco use, coffee consumption, alcohol and cocaine exposure, passive smoking, occupational hazards, extremes in maternal age (U-shaped tendency), low protein diet, bacterial vaginosis, HIV and urinary tract infection are recognized among them risk factors to deliver a low weight infant. Goldenberg & Culhane (2007) add race, poverty and maternal thinness to the risk factors to deliver a small baby.
Many potentially modified risk factors for low birth weight may actually influence individual long-term outcome. Consider smoking, a well known cause of asthma, alcohol with its evident psychomotor negative impact, fertility treatment (reproductive technologies are associated with low birth weight incidence). Farther, poorer social class is generally associated with smoking. Thus, this is a complex indicator to research. Nevertheless, some truly social variables seem to be credible: higher level of maternal education leads to better pregnancy outcomes, marital status in some countries correlates with premature birth well.. However, some claim (Almond et al., 2004) the social influence of factors is exaggerated. Thus, socio-economic effects interact with each other extensively.
II. B. 2 (a) Low birth associated hospitalizations tend to be longer (8 times more) and more costly (20 times more) compared to usual weight infants. Low weight birth is very often an economically devastating condition. As it is reported in the Connecticut state department of public health â€œOn average, hospitalizations for low birth weight newborns were longer (16 days vs. 2.5 days) and more costly (USD 70,000 vs. USD 2,800) compared to â€œnormalâ€ weight infants (>2500g)â€. Almond et al. (2004) come to a conclusion that â€œEven among babies weighing 2000-2100 grams, who have comparatively low mortality rates, an additional pound (454 grams) of weight is still associated with a USD 10,000 difference in hospital charges for inpatient servicesâ€. One tenth of newborns is admitted to neonatal intensive care units due to low birth weight associated conditions. Costs for these 4.6 million infant hospitalizations totaled an estimated USD 12.4 billion according to the 2001 Nationwide Inpatient Sample.
(b) Eight percent of all infant stays included a diagnosis low birth weight account for almost a half of total infant costs (Russell et al., 2007). Eight percent of them included diagnosis of preterm/low birth weight but accounted for 47% of infant costs. Of these, low birth weight makes 90% of costs. To compare with full term uncomplicated newborns, who compose 42% of infant stays but only 10% of all infant costs. The mean cost for a preterm/low birth weight infant stay was USD 15,100, compared with USD 600 for an uncomplicated newborn and USD 2,300 for all other infant hospitalizations. The mean length of stay for preterm/low birth weight, uncomplicated, and all other infants were 12.9, 1.9, and 3.0 days, respectively.
Paying source may be discussed shortly. Private or commercial insurance is the leading reimburse source (50%). Followed by Medicaid (42%), a minority left for self-pay and other sources, like Medicare. Â It is of interest that regardless of which source covers the expenses, they remain high for low birth weight and low for unaffected newborns. Low birth weight medical care imposes enormous costs on the society.
II. C. 1. Biological grounds of low birth weight determine social development, which in turn, may influence economical status. Low weight babies may experience intelligence deficits in both childhood and adulthood. Such children are usually less likely to graduate from high school at an appropriate age. For neurological and sensory capabilities are mandatory for educational performance, this is low birth weight with its nervous system risks in charge for potential educational mischance. Moreover, â€œbiological health at infancy affects development, which, in turn, affects socioeconomic status-producing [generations of poverty and poor health]â€.
II. C. 2. (a) Born small for gestational age may be associated with higher symptoms of parent rated attention deficit/hyperactivity disorder symptoms. Small body size at birth is correlates with attention deficit/hyperactivity disorder symptoms. This behavioral deviation is characterized by inattention, impulsiveness, or hyperactivity. As soon as such children fail to concentrate effectively, their school grades cannot reach proper level. They may have difficulties focusing attention, may not follow instructions easily, and be impatient. To add verbal disturbances, all these symptoms may reveal difficulties in adulthood. For example, failure to get a diploma, dropout risk or low college degree. Negative personal characteristics lead to loss of social productivity. One should remember that treatment strategies for attention deficit/hyperactivity disorder are often consuming, and both psychological and medications must be involved. Direct disbursements may not return in positive results. In this manner, low birth weight is a challenging social occasion.
II. C. 2. (b) Chronic conditions associated with low birth (Goldenberg & Culhane, 2007). Weight at birth less than 2,500 grams places the baby at numerous medical risks. Some of them may be temporary, but many will remain for a long time. Of these, one should recognize minor disorders that would not affect abilities to self-service or earning for the living, like strabismus. However, some more concerning disturbances may still allow social and professional activities if properly controlled. For example, diabetes: if blood glucose level under strict control, it should not preclude the individual from basic living activities of career growth, though at known costs. Most troubling disease are those when a child needs permanent medical spending, but social or proffesional prognosis will remain poor. For example, severe neurological disabilities or cerebral palsy, especially encumbered by blindness will demand special care life-long.
III. Discussion and conclusions. Birth weight is an effective tool to evaluate the effectiveness of nation’s social policy. In the United States, reducing the incidence of low birth weight has been a stated goal of several social programs targeting infant health. Effective health interventions ongoing (like smoking cessation) birth rate of small babies is still high and regarding social realities and amenable conditions will remain so in the near future. Therefore, low birth weight is a grave social concern.
In order to proceed, three variables have been chosen to evaluate the social impact of low birth weight: social economical issues, medical costs and developmental consequences. These variables allow to treat the problem both directly (i.e., direct in hospital costs) and indirectly (related to medical support and other child-oriented spending, and more broad social consequences). Given these systematic options, it was possible to track the numerous loads of low birth weight. It becomes evident that impacts of birth weight on outcome are likely to be driven by an interaction of birth weight and perinatal interventions. The former is under the influence of social and behavioral factors. The latter includes in-hospital treatment strategies and long-term follow-up adequacy. All these patterns challenge the woman, the family, and the society. The mother who gave birth to a potentially disabled child will meet numerous negative emotions and career pitfalls. The family will go through hard times of economic efforts and energy depletion, which is essential to cope with. The society needs to understand the rationale for enormous amounts of costs to be spent on sometimes-disabled individuals.
Social maternal factors are significantly associated with low birth weight. On the other hand, late health problems of low birth weight children may preclude them from achieving high social classes. And though the exact mechanism for this is unclear, one may speculate that social factors translating into biological mechanisms, which affect the course of pregnancy, etiological factors contributing to the development of neurodevelopment disorders, cardiovascular and lung disease, and other maladies are initiated a â€˜feedback’ mechanism acts to associate low birth weight with late consequences.
The direct heavy economical loads of low birth weight are evident. To treat a less than 2,500 grams newborn it is essential to posses a highly specialized stuff of neonatologist, equipped intensive care unit and numerous medical disposables. All these comprise a considerable financial encumbrance. Followed by out-hospital life-long exes, rehabilitation courses and lost work consequences, low birth weight proves to be one of the most difficult pregnancy related issues to address.
It is possible to establish a negative correlation between low birth weight and child developmental outcome. Birth weight has a strong effect on child health outcome, even if social factors controlled. A favorable social environment may be of protective effect, but only to a certain extent. Nonetheless, because longitudinal evidence-based data concerning long-term effect still lack, proper assessment of social variables is not an easy target. Matsuo (2005) gives a glimpse on the complex interaction of birth weight and developmental outcomes: â€œThe observed long-term effects of early life physical development do not constitute inevitable outcomes of childhood development, but are mediated by the chain of social factors that also begins in early lifeâ€.
Developed countries now provide adequate medical support to challenging disorders. What was an irresolvable problem in the past may be more or less approached today.Â Low birth weight infants’ survival leads to demographic changes, economical burden, social overload, as well as medical overwork. As medical policy shifted to a more precise management of low birth weight numerous effects occur that the society needs to cope with.