Dr. Peter Nathanielsz

DATE August 21, 2001 ACCOUNT NUMBER N/A
TIME 12:00 Noon-1:00 PM AUDIENCE N/A
NETWORK NPR
PROGRAM Fresh Air

Interview: Dana Wechsler Linden and Dr. Mia Wechsler Doron discuss
the experiences related to caring for a premature baby
TERRY GROSS, host:

This is FRESH AIR. I'm Terry Gross.

A woman who gives birth to very premature baby is in for a very different
experience than she planned. Rather than nursing and snuggling her baby, the
baby is likely to be taken to a neonatal intensive care unit with new
technologies which have made it possible for premature babies to survive in
greater numbers than ever before.

My guest Dana Wechsler Linden is a former senior editor at Forbes magazine.
She gave birth to premature twins and had to quickly learn about the medical
options posed by the new technologies. She had the help of her sister, Dr.
Mia Wechsler Doron, a neonatologist at the Newborn Critical Care Center at the
University of North Carolina in Chapel Hill.

The sisters are two of the authors of the new book "Preemies." It's a guide
for parents of premature babies. We asked Dana Wechsler Linden to share her
story and Dr. Mia Wechsler Doron to explain new medical developments in the
field.

I asked Linden if she was expecting a premature birth.

Ms. DANA WECHSLER LINDEN (Author, and Mother of Premature Twins): No, it
came as a total surprise. What happened was that at 25 weeks, I had slight
premature labor pains, and on examination had a slightly dilated cervix and
was hospitalized on just sort of routine bed rest. And in the middle of the
night one night, my water broke, which--just a day or two later, so I was
still at 25 weeks--and that meant that it was inevitable, or almost
inevitable, that I would give birth any time, and it just was a terrifying
waiting game to try to get every additional day I could for the babies in the
womb. And I got about two more weeks before they were born.

GROSS: Dana, did you see your babies as soon as they were born?

Ms. LINDEN: I did. And they were--it was scary. But they were fully
formed, now, to me, in retrospect, beautiful babies. I can't say I thought
that at the time because they were just too tiny and too red and--but all the
fingers and toes were there and they were beautiful little bodies. But I was
terrified. And I saw them for just a second or two and I remember the
obstetrician saying, `These are the healthiest looking 27-week babies I've
ever seen.' And, of course, that provided some relief. And then they were,
within minutes, whisked away to the intensive care unit.

GROSS: How big were they? Compare them to, say, the size of your hand.

Ms. LINDEN: They would fit in it. They were each two pounds. Or one of
them was a few ounces over two pounds and the other was two pounds, and they
would fit in the palm of an adult male hand.

GROSS: Were their eyes developed enough for them to able to open their eyes?

Ms. LINDEN: Yes. They could open their eyes. In fact, one of the most
moving things for me was when I finally got over my fear, which took me the
better part of a day, and went down to the intensive care unit to see them. I
looked at--I think it was Maya(ph), actually--who's my surviving daughter--and
she looked right up at me--and with a--really, you know, holding my gaze, and
it was very moving. So, of course eyesight isn't very good, but their eyes
were fully open and able to see.

GROSS: Were they able to breathe on their own?

Ms. LINDEN: At first they--Maya was ventilated--put on a ventilator almost
immediately because she was struggling to breathe on her own. She came out
crying and gasping for breath, which is great. But she wasn't able to breathe
well enough and--to maintain her health. So she was put on a ventilator
immediately. Ellie(ph), who's my baby who died, was actually the one who
seemed to be stronger at first. And she wasn't put on a ventilator at first,
but then deteriorated somewhat, and after about a day was put on a ventilator.

GROSS: Dr. Doron, is it typical that preemies have to be put on a ventilator
in order to breathe?

Dr. MIA WECHSLER DORON (Author and Neonatologist): It depends on how young
the preemie is, how immature their lungs are, for one, because immature lungs
have a hard time taking in enough oxygen and getting rid of enough carbon
dioxide to maintain the normal functioning of the body. But there are other
immaturity reasons why a premature baby may need to be on a ventilator. The
breathing center in their brains are often not fully mature, so while they
might breathe well for awhile, they'll have pauses where the brain just
doesn't give their body the signal to breathe, and so, if those pauses go on
too long, obviously, that's unhealthy. And also their chest walls, the
cartilage and the muscles are weak and so, oftentimes they have a hard time
keeping their lungs fully expanding and actually making strong breathing
movements. So all of those immaturities together make it more likely for
younger preemies to need the help of a breathing machine than for older ones.

GROSS: Dana, when your twins were born, were they put in incubators? What
kind of incubators were they put in?

Ms. LINDEN: Their first beds in the neonatal intensive care unit were open
beds under warmers, which kept their bodies warm. The reason is that they
were very medically unstable at that point and a lot of things were being done
to them medically--intravenous lines being put in and ventilators being put in
and watched and all kinds of monitoring and testing taking place. And so,
rather than having them in an incubator, which would make it harder for the
doctors and nurses to get to them, they were on what's called a warming bed.
And I think that, unfortunately, Ellie never actually made it into an
isolette. Or I--she did, I guess, for one day. But Maya moved into an
isolette when she was more stable, after about five or six days.

GROSS: Dr. Doron, is the goal in the isolette or, you know, the warming
bed--is the goal to simulate a womblike atmosphere?

Dr. DORON: No, unfortunately, I wish we were better at simulating womblike
atmospheres. The main goal of an isolette is to keep the baby warm, because a
baby can't--a premature baby can't maintain his or her own body temperature,
both because they don't have the layers of fat that are needed for insulation
and also because that's another part of their brain that's not mature, which
is the temperature regulating part, so they need some help.

The other reason that an isolette is used is to enclose the baby--part of what
makes a baby cold are changes in air flow, so by keeping the baby in a box,
then the wind currents don't go by them and cool them off. But also, it
protects them a little bit, not a great deal, but a little bit from infection
as well.

GROSS: You mentioned that sometimes babies are given a cellophane blanket,
it's basically like cellophane wrap. Why is that used?

Dr. DORON: Yeah. Well, that's only for the very smallest babies, the ones
who are not in isolettes. This is used for babies who are still under radiant
warmers, which are those open beds with a heating source from above that we
use when we need to have an extremely good and complete view of the baby at
all times and also need very quick and easy access to a baby in case we have
to intervene medically. But, at the same time, that we need the baby sort of
out there in the open, really, really immature babies have very thin skin that
doesn't hold in their vital fluids very well, and so in an attempt to keep
them from losing so much body water, we cover them with cellophane. Just
like--it sounds a little crass but, the way you would try to keep a sandwich
from drying out. If you have cellophane around the baby then more fluid can
stay inside.

GROSS: My guests are neonatologist Dr. Mia Wechsler Doron and her sister
Dana Wechsler Linden, who gave birth to premature twins. They are two of the
authors of the new book "Preemies." More after a break. This is FRESH AIR.

(Soundbite of music)

GROSS: If you're just joining us, we're talking about premature babies. And
my guests are the co-authors of the new book "Preemies." It's a guide for
parents of premature babies. Dana Wechsler Linden is the mother of a baby who
was born premature. Actually, she had twins; one of her daughters died.
She's a former senior editor of Forbes magazine. Her sister, Dr. Mia
Wechsler Doron, is a neonatologist at the Newborn Critical Care Center at the
University of North Carolina in Chapel Hill.

On the average, what's the youngest preemie who's likely to pull through?

Dr. DORON: Nowadays, in this country, and that means with the very best,
high technological neonatal care, the youngest preemie that most people would
consider to be potentially viable would be a baby born at 23 weeks of
gestation. Now, every once in awhile, you'll hear an anecdotal report of a
22-week baby surviving. But it's unclear whether one, that baby was truly 22
weeks, and how reliable those reports are. But currently the accepted lower
limit of viability is 23 weeks of gestation.

GROSS: Dana, your babies were born at 27 weeks. What kind of technology were
they hooked up to?

Ms. LINDEN: Oh, a lot. It was a disturbing sight. They were both on
ventilators, so essentially, they had a tube going down their mouths and down
their airways to their lungs, and that was hooked up to breathing machines,
machines that gave them oxygen and pressure to keep their lungs breathing. At
first Maya and Ellie both had intravenous lines going into almost every limb,
and they had a lot of different monitors on them--connected to wires which
were connected to machines that made sure that they continued to breathe at
the right rate, that their heartbeat was stable, that their oxygenation was
stable and that their temperature was stable. So all over their bodies were
these various monitors and if any of them faltered, loud alarms would go off.
And that happened quite a bit, as is true for any preemie. It's very scary
for the parents, but the nurses know how to deal with it. They also, because
they had intravenous lines going into their arms, and there's a risk that
through movement, they'll dislodge them, they had splints on both their arms
to try to keep their arms stable.

GROSS: It must have been horrifying for you to see them like this.

Ms. LINDEN: It was definitely horrifying. You know, I remember--again, it
was my first trip down there to the NICU, as the neonatal intensive care unit
is referred to as, and I went with Mia because she came up to New York, where
I gave birth, from North Carolina when it was clear that I was about to give
birth. And I was very scared to go down there and see, and when I got there,
oh, it is just, you know, the worst thing that a parent could ever see--their
baby like that. And I felt faint and it didn't--you know, I was just woozy.
And Mia said, `Dana, she looks great!' And I thought that she was from Mars,
but it was extremely encouraging. And, of course, what she meant was, for a
27-week preemie, she looks great. She looks just the way she should be and
that's a good sign.

GROSS: And Dr. Mia Doron, you're used to seeing babies like that, so it
wasn't horrifying, it was just typical to you.

Dr. DORON: Exactly. And I think one of the things that we tend to--we, the
doctors and nurses who work in intensive care nurseries--we forget how strange
and extraordinary and horrifying these babies, hooked up to all this
equipment, can look to their parents. And one of the things that I learned
after writing the book and talking so much to Dana, is when I talk to parents
and show them their babies and tell them what's going on, is to say things
like, you know, `Here she is on a ventilator. Here's what it's doing, and
that's good,' you know, or, `She looks healthy,' and just really translate may
be obvious to us but not so at all to parents.

GROSS: Let me tell you something I can't understand. When there's--when you
see somebody on a ventilator, it looks so intrusive and so painful and you're
sure that if the tube is pulled out, it's going to scratch or maybe damage the
tubes, you know, the pipes in your body that it had been thrust into. I mean,
you're talking about a baby whose skin is barely developed. Isn't damaging to
stick those through--those tubes down their windpipe?

Dr. DORON: Well, the answer is yes and no. The yes part is that, always
it's more damaging to need to be on a ventilator and to have the injury, even
if it's small, from the tube and even more injurious, is actually the force of
the ventilator, pushing the air into the very fragile air sacs. That does,
indeed, cause small and sometimes large damage to the tissues. So that is
worse than if you don't need it. But if you need it, the alternative is not
getting enough oxygen in, which is actually even more damaging to tissues,
because the cells start to die if they don't get enough oxygen. But you're
right, Terry, the quicker that we can get a baby off a ventilator, the better.

GROSS: Dana, when your two babies were hooked up to all this technology
shortly after they were born, I know it was very painful for you to watch
them. You must have been worried that they were in a lot of pain too, because
they were attached to a ventilator and they had all these monitors and other
kind of invasive things happening. Did you have any way of really knowing if
they were in pain?

Ms. LINDEN: No, and I worried about it tremendously, and I asked about it a
lot, and the nurses, in general, said, `Oh, they won't remember a thing.' I
remember quite a few nurses saying that to me, and I didn't find it very
reassuring, number one, because I didn't want them to be feeling pain at the
time, even if they were going to forget it later, and also, I was skeptical as
to what that meant--that they wouldn't remember. And I know for us with Maya,
we wondered for a long time how that experience had affected her. There was a
lot--for sure, even if she rested comfortably some of the time, there was a
lot of pain that normal full-term babies don't feel.

There were a lot of medical procedures performed on her every day, that--some
of which were painful or uncomfortable, and there was a lot of disruption
compared to what other babies go through. And we wondered for a really long
time--and as she got older--she's now five, but when she was a toddler, she
was extremely clingy. She found being out of sight of us, or even out of our
arms very difficult, and at night she used to scream out, `I can't be alone!
I can't be alone!' And we wondered, did that have something to do with the
experience? But, of course, no one can answer the question.

We went back to the hospital at one point. After she had been home for about
a month, we had to go back to the hospital for some tests, and she wasn't a
fussy baby--a fussy infant, once she was at home. She was actually--she
didn't cry all that much. When we got back to the hospital, she started
sobbing violently, so much so--and she continued--we were there for a couple
of hours and she never stopped sobbing the entire time we were at the
hospital, so that the test results were basically invalidated. And when we
left the hospital and got into a taxi to go home she stopped crying. And it
may have been completely coincidence, in fact, probably it was completely
coincidence. But you can't help but wonder whether she associated the smells
or sounds or sight of the place with pain.

GROSS: Dr. Doron, do you have any insights as a doctor, about how much pain
preemies feel when they're being exposed to these invasive procedures and how
much that pain stays with them psychologically? Whether they remember it or
not, it could still affect them psychologically.

Dr. DORON: I don't have too many insights into the latter question because
there just hasn't been enough research into that. I can tell you that, on the
good side, there is not a higher incidence of psychiatric problems in former
preemies and there is not a higher incidence of severe social problems in
preemies. So, in terms of deep emotional scars, at least by those two
measures it would indicate that these babies are resilient.

In terms of the pain that a baby feels at the time, certainly we know that
premature babies can feel pain and there are several studies now that indicate
that they probably can feel it more intensely, even, than older babies because
some of the pain-dampening mechanisms are not mature or they mature later than
the pain-sensing mechanisms. So...

GROSS: Can you give preemies mini-doses of painkillers?

Dr. DORON: You can, and actually, what the problem for us as doctors is that
it's like we sort of go between a popgun and a cannon. We know that for
babies, preemies included, certain very benign things are actually analgesic.
They have pain-alleviating properties. Sucking on a pacifier actually
decreases pain in a baby. Tasting or sucking on sugar water decreases pain,
and being swaddled in a blanket decreases pain, so we can do that, and those
are not going to hurt any baby.

But then we go from that to something like opiate narcotics, so we use
morphine and we actually use it fairly liberally--most neonatologists
do--morphine or fentanyl, which is a synthetic opiate. And these are very
powerful pain medications with some significant side effects. And the reason
we don't use them even more is that we worry that the reasons these
medications work to alleviate pain is that they change nerve impulse
transmission in the brain, or how nerve impulses are received. Well, over
time that can also change brain development, and right now we just don't have
enough scientific information to tell us what the right balance is to strike.

GROSS: Dr. Mia Wechsler Doron and her sister Dana Wechsler Linden will be
back in the second half of the show. They're two of the authors of the new
book "Preemies." I'm Terry Gross and this is FRESH AIR.

(Soundbite of music)

GROSS: Coming up, life in the womb. We talk with Dr. Peter Nathanielsz
about how the interactions between a pregnant woman and the developing baby in
her womb can affect the child's long-term health. Also, we continue our
conversation about preemies and book critic Maureen Corrigan reviews "The
Rackets" by Thomas Kelly.

(Announcements)

GROSS: This is FRESH AIR. I'm Terry Gross.

We're talking about new developments in saving the lives of very premature
babies. My guests are two of the authors of the new book "Preemies," a guide
for parents of premature babies. Dana Wechsler Linden gave birth to premature
twins. Her sister, Dr. Mia Wechsler Doron, is a neonatologist at the Newborn
Critical Care Center at the University of North Carolina in Chapel Hill. She
works with the new technologies that help preemies continue to develop outside
the womb.

Dr. Doron, you mentioned that the brains of preemies develop differently once
they're outside the womb. What are the differences?

Dr. DORON: Well, one of the differences which we've just learned about
recently is that certain parts of the brain in preemies are not as large as in
full-term babies. And we don't know exactly what that means. It's an
anatomic finding. We also know that preemies have a higher risk of bleeding
in the brain and many of them do have small and sometimes large bleeds, which
can then affect the growth and existence of nerves in the areas where they're
bleeding. And then we also know that they have often a very high incidence of
subtle learning and other neurological dysfunction that is probably indicative
of some either injuries or different patterns of maturation.

Ms. LINDEN: Terry, there are some doctors and psychologists who believe that
it may be possible to lessen the differences in preemies' brain development by
adopting different practices in the intensive care unit. There's a field
called developmental care, which is being applied in more and more intensive
care units. And what it does is to try to make the neonatal intensive care
unit more womblike in any ways that it can. So, for example, some years ago
no one worried about the fact that in NICUs there were bright lights shining
down on the babies all day and all night. Of course, it's not so light in the
womb and there are--the baby gets regular sleep cycles, which are important
for brain development. So now more and more hospitals are either covering the
isolettes with blankets or other isolette covers to give the babies some
darkness to let them sleep and be soothed by that, or dimming the lights at
night.

And sound is another big one. We think that the womb is a relatively quiet
place and the NICU is a deafeningly loud place for a baby. In fact, studies
have shown that just the act of placing a tiny preemie bottle on top of an
isolette is the same decibel level for a baby as a lawn mower going off next
to them or being in an industrial factory. And that's what they hear all the
time and the alarms going off. So the advocates of developmental care are
trying to get better noise control, asking people not to play radios and to
speak quietly, and also to let the babies sleep longer by clustering care
giving so that instead of doing a heel prick for a medical test on a baby and
then maybe 15 minutes later coming to feed them and maybe 15 minutes after
they've finished a meal, changing their diapers--clustering those things so
that in between they can have long periods of sleep. So all of these things
are sort of slight and gradual changes that are taking place in the units.
And some people think that they'll make a big difference in the brains.

GROSS: Dana, were you able to touch or hold your babies after they were born,
you know, in the days that they were in the hospital?

Ms. LINDEN: Yes, to different degrees. With Maya, who was our healthier
baby who survived, I could hold her, I think, after just about three days. It
was scary at first. You know, you have to--you have a lot of wires to juggle
and IV needles you want to be sure you don't pull out, but the nurse would
take the baby--take Maya out of the isolette and place her in my arms and
would put a little visor on her head to shield her eyes from the light so she
could look in my eyes. And it was a wonderful experience.

And then not long after that, after she was off all breathing assistance, I
started doing something called kangaroo care, which is basically holding your
baby skin-to-skin against your chest. Kangaroo babies are born premature and
they develop outside the womb or do a lot of their developing outside the womb
after they're born. Anyway, this is done by more and more mothers now in
neonatal intensive care units. It feels great to a mother. To me it did.
And one gets the sense that it feels great to a baby, so I spent three or four
hours every day in the hospital doing that with Maya.

With Ellie, she was so sick and she never really could be really picked up
until we knew that she was dying and efforts stopped being made to keep her
alive and--at which point I did hold her. But before that, really all I could
do was to give her my finger and she would grasp it. And when she was
healthier, she had a really strong grasp. And as she got sicker, she didn't.

GROSS: What happened to her?

Ms. LINDEN: What happened was that one night in the middle of the night she
developed what's called a pneumothorax, a tiny little tear in her lung.
Perhaps, although one doesn't know, it was from the pressures of the
ventilator. And they treated that exactly the way pneumothoraxes are treated,
with a little tube in the chest. And then she had a second pneumothorax a few
days later. And then it became clear that perhaps around the time of the
pneumothorax, because blood pressure in a baby can fluctuate very violently at
a time like--when that happens--perhaps at that time she had a bleed in her
brain--the kind that Mia was talking about, but it was a very severe one. And
so she became sicker and sicker and sicker, and that's it. That was it. We
knew about a day before she died that she wasn't going to make it and so we
were able to hold her without the tubes for a while until she died.

GROSS: When it looked like both of your babies might pull through, did you
worry that if they did live, they might be so physically, emotionally or
psychologically damaged by all the high-tech procedures they were going
through that it would be a difficult life for them?

Ms. LINDEN: I did. I worried about it a lot. Mia was very helpful to me.
The statistics were helpful, to some extent, because they were 27-weekers and
most 27-weekers pull through just fine. Ellie was in the minority. And so
that helped, but I didn't eat for weeks. You know, I learned--I felt abnormal
in my extreme reactions and it took me a long time to realize that what's
normal for parents of preemies is to feel despair and terror and a lot of pain
and a lot of guilt, all of which I felt. But the psychological part, it's
really amazing. I don't think it was until Maya was about three years old
that I started to realize she was gonna be OK. Every time she got a cold I
thought, well, this is the other shoe dropping and...

GROSS: Well, I imagine it's terrifying to take a baby home who's--you know, a
preemie who's been in the hospital under 24-hour surveillance with all these
high-tech monitors. And suddenly you're there alone with them and you're
probably afraid that they're going to not make it.

Ms. LINDEN: Absolutely. Absolutely right. And, actually, Maya came home
twice, unfortunately. She didn't, at first, make it at home in a way. She
stopped breathing three days later. She turned blue and was--we rushed her
back to the hospital and she was put right back on a ventilator again. We
think she got some kind of infection at home, although we have no idea why or
from where.

When she came back the next time she came home with a monitor, which a lot of
preemies--not most, but some go home with. And she had that connected to her
for about six months all night. And that allowed me to sleep because I knew
that if there was no alarm going off, she was OK.

And in the first year I sort of--especially after she had the incident when
she first came home and stopped breathing--I wanted to watch her all the time
to make sure that didn't happen again. But after that, again, partly because
of writing the book and having Mia as my sister giving me advice on this, I
knew that there is a dangerous syndrome that can develop, which has been
dubbed `vulnerable child syndrome,' with parents being overly protective and
hurting their child as a result because of their early vulnerability. And I
really fought hard against that. I don't know if I was successful or not. It
was a matter of hiding my own feelings of protectiveness, but I--I think we
did OK.

GROSS: Dr. Doron, as a neonatologist, what is the most amazing thing you see
on a typical basis now?

Dr. DORON: Hmm. I--to me the most amazing thing is--we have reunions every
year of the graduates of our nursery. And the most amazing thing to me is to
see a baby so tiny and so sick and barely looking like any baby that you would
know. And then the next time I see that person, they're absolutely beaming,
smiling, running around, indistinguishable from any other child. So I think
those--the success stories are so striking and so amazing now.

GROSS: Well, I want to thank you both so much for talking with us.

Dr. DORON: Thank you so much.

Ms. LINDEN: Thank you, Terry.

GROSS: Dana Wechsler Linden and Dr. Mia Wechsler Doron are two of the
authors of the new book "Preemies."

Coming up, life in the womb and how it affects the long-term health and
well-being of the child. This is FRESH AIR.

(Soundbite of music)

* * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * *

Interview: Dr. Peter Nathanielsz discusses fetal development and
impacts on the baby's long-term health
TERRY GROSS, host:

My guest, Dr. Peter Nathanielsz, is the director of the Laboratory for
Pregnancy and Newborn Research at Cornell University. He's researching how a
pregnant woman's diet, stress level and hormonal changes affect her developing
baby's long-term health and well-being. Dr. Nathanielsz is the author of the
new book "The Prenatal Prescription." He claims that fetal programming is at
least as important as genetics in determining long-term health. I asked him
to explain the concept of fetal programming.

Dr. PETER NATHANIELSZ (Cornell University): Fetal programming states that
suboptimal conditions in the womb before birth can alter the trajectory, the
way the fetus develops, in a fashion that will affect lifetime health; that
issues in the womb will change the function of our liver, our pancreas, our
hearts in a way that will be persistent throughout life. And the studies are
just overwhelming to support this.

Now babies in the womb have some very clever tricks up their sleeves. If
you are short of oxygen as a baby in the womb, you protect your brain. You
send most of your blood to your brain. The baby does that. But, obviously,
it's got to take the blood away from somewhere else, so it cuts down the blood
supply to its liver, its gut and its muscles, it stops moving, but it protects
its brain. Now in the short term, that's enormously clever. But in the long
term it means that you grow a small liver. And, indeed, if you look at a
growth-retarded baby, an obstetrician tells that a baby is growth retarded not
by the fact that it's five pounds. If your genes want you to be five pounds,
that's fine. The growth-retarded baby is the baby that's five pounds whose
genes wanted it to be 10 pounds. And you can indicate that baby by measuring
the head circumference and measuring the waist circumference. And if that
ratio is high--if the head-to-waist ratio is high, that is proof positive that
you protected your brain at the expense of your tummy and the organs in your
tummy. Now the smaller your waist girth at birth, the higher the blood
cholesterol at the age of 50. So we are not just what our genes make us. We
are programmed in some measure, at least, by the conditions we experience
prenatally.

GROSS: Now, you know, mothers through history have always felt that they were
eating for two and that they've had to be careful about what they eat.
They're very conscious that it's going to affect the development of their
fetus. What's new about fetal programming, compared to just this general idea
that the things you do are going to affect your baby?

Dr. NATHANIELSZ: Well, I think the real issue is that they're going to
affect your baby for a lifetime. And, you know, that, I think, is an enormous
quantum leap in emphasis. And I do believe this is a new paradigm in
understanding what is important. We can change the health of society much
more quickly by more careful attention to pregnancy than we can ever change it
by changing the gene pool. This is such an amazing period of our biological
lives. The baby--you will never be cleverer, biologically, than you were as a
fetus. You live in one world according to one set of rules, while preparing
for another world where you'll have to live by another set of rules. It is
the synthesis of how the genes work. It's the synthesis of how the
environment affects those genes. To me, it is the single most important story
in human health.

GROSS: Could you give us an example of a disease that you think can be traced
to fetal development and a disease that could perhaps be prevented in fetal
development?

Dr. NATHANIELSZ: Well, Type II diabetes and obesity. We have an explosion
of Type II diabetes and obesity now. It's very clear that although
everybody's looking for the gene for obesity, the gene for Type II diabetes,
it's very clear from the animal studies that undernourished fetuses are born
with pancreases that do not function as well. And then if they live a life of
fast food, as too many of us do, that pancreas is going to be much more prone
to give up and that individual is going to be much more prone to Type II
diabetes.

In the developed world it is the poor who are generally fat. In the
developing world, it is the rich who are fat. And in my book I explain how
biologists now understand that, because the underprivileged baby in the womb,
again, as I mentioned earlier, has some clever tricks up its sleeve. It
prepares for an underprivileged environment outside. If you're a lion cub on
the Serengeti Plain in your mother's womb and you're short of food in the
uterus, that's a pretty darn good indication that there's not much food
outside. There's famine outside. Your mother's not making enough kills, so
you develop already in the womb what's called a thrifty metabolism. You learn
how to grab on to every calorie you can so that when you come out, you're
going to survive this adverse environment outside.

The only problem is that in the developed world, the undernourished baby in
the womb is undernourished because its mother smokes too much, perhaps takes
crack cocaine or in a large and underprivileged proportion of our society,
yes, doesn't get a good diet. So the baby comes out into the outside world
and there's a fast-food store on every corner. Now there's no shortage of
food and there's an explosion of obesity. The Falasha, the Ethiopian Jews,
flown to Israel, born in Ethiopia--probably undernourished in the womb, flown
to Israel overnight to a society where food was plentiful, now have one of the
highest incidences of diabetes and obesity in the world. So these are
conditions that we can prevent if we understand fetal development properly.

GROSS: Let me see if I get you straight. You're saying that if a fetus isn't
well nourished, it assumes that's because there's not a lot of food outside,
and it will be born with a very slow metabolism so that it can preserve and
make use of every calorie it gets. But if it's exposed to a lot of food,
particularly a lot of fatty food like fast food, that slow metabolism is going
to mean that the baby and the adult puts on a lot of weight.

Dr. NATHANIELSZ: Exactly. Exactly. And we know, just as I mentioned
earlier, that you grow a small liver and you can't handle cholesterol. We
know from studies with rats that the actual composition of different types of
cells in the liver of babies that were undernourished as fetuses, is
different. They've grown along a different trajectory. They're prepared for
a different world, and then we in the developed world fool them by giving them
lots of food afterwards.

GROSS: One of the questions you mentioned you're studying in your lab is
premature birth. And I think one of the questions you're asking is: What's
responsible for premature birth? Is it something that the fetus itself is
programmed to do, to come out early? Or is it a response that is coming
directly from the mother's body?

Dr. NATHANIELSZ: Yes. I think that the problem with premature birth is it
almost certainly has several causations. And it's never very clever of
scientists or anybody to use the same term, and we're really rather remiss.
We use the same term for things caused by--from different causations. We now
know that probably somewhere between 40 and 60 percent of prematurity is
caused by low-grade infection. And there are even very interesting studies
that tooth decay--that bad teeth, actually, predisposes to premature birth.
And that's, of course, a very simple thing to cure. Just go to the dentist
before you become pregnant, make sure your teeth are in good order, and keep
them in good order during pregnancy.

How does generalized low-grade infection cause prematurity? Well, we know
that, in the presence of infection, some of the hormones and other compounds
that are produced to combat the infection also stimulate the uterus to
contract. So we have to find out about these mechanisms. Some of them could
very easily be prevented on the social level, as I say, by better dental
hygiene.

Others, we need to know about how the fetus is stressed and how the fetus
sometimes is saying better out than in. There are some forms of prematurity
where probably the intrauterine environment is suboptimal because the placenta
is failing. The baby may, indeed, do better in the neonatal intensive care
unit than inside.

GROSS: Well, Dr. Nathanielsz, I want to thank you very much for talking with
us.

Dr. NATHANIELSZ: Thank you very much, indeed. I've enjoyed it.

GROSS: Dr. Peter Nathanielsz is the director of the laboratory for pregnancy
and newborn research at Cornell University. His new book is called "The
Prenatal Prescription."

Coming up, Maureen Corrigan reviews the new novel "The Rackets" by Thomas
Kelly. This is FRESH AIR.

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Review: New novel "The Rackets" by Thomas Kelly
TERRY GROSS, host:

Novelist Thomas Kelly has been a Teamster and a political advance man for the
New York City mayor's office. His debut 1997 novel "Payback" drew on those
experiences and took readers into the sometimes explosive world of New York
City labor unions. David Mamet has written a screenplay for a film version of
"Payback." Kelly's new novel, "The Rackets," takes readers back for another
insider's tour of New York City. Book critic Maureen Corrigan has a review.

MAUREEN CORRIGAN reporting:

New York City, as its poet laureate Walt Whitman sort of said, contains
multitudes. So many layers of history and ethnic groups and neighborhoods
that even though it may be the most written-about city in the history of the
world, there's still plenty of local lore that slipped through its sidewalk
cracks. That's the most distinctive aspect of Thomas Kelly's latest novel,
"The Rackets."

It's set in Inwood, the neighborhood at the very northernmost tip of Manhattan
island, so far up it's an afterthought to most descriptions of the city.
Until a few decades ago, Inwood was a solidly Irish working-class
neighborhood. Now it's largely populated by Dominican immigrants.

For what it's worth, I have some passing knowledge of the place. An old
friend of mine grew up there. Her father owned one of the once ubiquitous
Irish bars. And I went to college nearby at Fordham, where Kelly himself
graduated. I might well know Kelly himself; practically every other guy at
that Jesuit college had a name like Thomas Kelly.

I think, in this New York memoir, my fellow Fordham alum deftly captures the
cloistered mood of Inwood, imposed by its geography and by decades of
Irish-American insularity.

He mournfully describes its once grand apartment buildings, constructed in the
boom of the 1920s, now deteriorated, as one of his characters observes, into
over-worked tenements and airless elder hostels for longtime residents of the
area. He escorts readers into its die-hard bars and up to the rocky
outcroppings of its dusty parks, where revolutionary soldiers once fired
cannon down on the British, and drug dealers now hold sway.

Reading "The Rackets" is like going on a pilgrimage to the old neighborhood,
just before the wrecking ball hits. On the dangerous walking tour Kelly
conducts, sentimentality vies with street-wise instincts of self-preservation.

Kelly's plot gathers suspense as it goes along, so that by the last 50 or so
staccato pages, what at first seems like an atmospheric but workmanlike plot
about union corruption and FBI and police department dirty tricks, transforms
into a doomsday vision of block by block citywide warfare in which allegiances
keep shifting.

The bloody but unbowed hero of this story is Jimmy Dolan, an Inwood boy made
good. Jimmy put himself through college working construction, then eventually
landed a job as a political advance man for a Rudolph Guiliani-type mayor.
But when Frank Keefe, a thuggish Teamster local president who's locked in an
election battle with Jimmy's father, shows up at a reception at city hall,
Jimmy's old street-fighter temper bursts through his expensive suit. Under
provocation, he shoves Keefe onto his fanny. That fateful push makes the
front pages of the New York tabloids, costs Jimmy his job, and sends him on a
downward class spiral back to Inwood.

Soon enough, Jimmy is back working construction, and along with his old man,
dodging the combined extermination efforts of Keefe's goons, the Russian mob,
and the last flailing vestiges of the Mafia. After one of Kelly's many, many
plot twists, which I won't divulge, Jimmy himself becomes the reformed
presidential candidate for his Teamster local. A seasoned union official
gives him this advice about how to write a campaign letter to distribute to
the rank and file. `Don't be showing off your college skills. Keep it
simple. The members ain't interested in your pretty prose.'

Kelly himself seems to have internalized similar advice in writing "The
Rackets." Some of the characters and situations here are schematic and cliche
phrases abound. I heard so many pugnacious characters described as `thickly
muscled,' I felt like decking somebody myself.

But just when the writing style of "The Rackets," seems stuck on autopilot,
Kelly slips in some quick description or dialogue that startles because it's
so real. Like when a former resident of Inwood returns for a funeral, and
laments, `You can't even buy a Mass card at the bars anymore.' Or when Jimmy,
fresh off a construction site, tells a snooty Manhattan doorman, `Hey, I work
for a living. Sometimes that puts you near dirt.'

"The Rackets" is a tough New York story. Like the city itself, it boasts
plenty of blind alleys full of surprises, amidst its wide, well-traveled
boulevards.

GROSS: Maureen Corrigan teaches literature at Georgetown University. She
reviewed "The Rackets" by Thomas Kelly.

(Credits)

GROSS: I'm Terry Gross.
Transcripts are created on a rush deadline, and accuracy and availability may vary. This text may not be in its final form and may be updated or revised in the future. Please be aware that the authoritative record of Fresh Air interviews and reviews are the audio recordings of each segment.