Tiny. So very tiny.

That was Benedict Asiegbu's first thought when he met the moments-old baby girl put in his care last March. In more than 20 years as a neonatologist, Asiegbu had never seen an infant so small survive. At 24 weeks, she was nearly four months premature. At 13.7 ounces, she weighed about the same as two smartphones. The doctor didn't know if the hospital's equipment was small enough for her. Her family had been warned her survival chances were slim.

At 13.7 ounces, she weighed about the same as two smartphones.
COURTESY ALYSSA SPRUILL
At 13.7 ounces, she weighed about the same as two smartphones.

But try, please try, they pleaded with the care team. With steady hands, Asiegbu reached for the thinnest breathing tube he had, about the diameter of a strand of cooked pasta.

It fit down the baby's tiny throat.

That was March 12. MaKenna Spruill, the newborn whose body could be cradled in an adult's hand, is now at home with her mother and four siblings in Atlantic City. Feisty is the word used most often to describe her, now that she is at last the size of a full-term baby — 7 pounds.

MaKenna Spruill smiling in the hospital.
Courtesy Alyssa Spruill
MaKenna Spruill smiling in the hospital.

"Mighty MaKenna," as one of her nurses dubbed her, seems to have already dodged several of the perils extremely premature babies face. She gets her nutrition the usual way, not through a tube.  She is breathing mostly on her own, with some supplemental oxygen. So far she doesn't seem to have the vision problems many preemies have. She is alert and responsive, and makes her desires known – quite loudly, in fact.

Getting this far has required the all-out effort of dozens of direct-care providers, as well as a host of support staff.

Besides Asiegbu, several other Children's Hospital of Philadelphia doctors based at the AtlantiCare Regional Medical Center, and more than 100 physicians, nurses, and staff with the South Jersey health system were involved in her 113-day hospitalization. Some of AtlantiCare's doctors are among those involved in her rigorous follow-up care.

Dr. Richard Wise, left, begins an eye examination, while ophthalmic technician Jeanne Deavis holds 5-month-old MaKenna Spruill very still on the exam chair.
MICHAEL BRYANT / Staff Photographer
Dr. Richard Wise, left, begins an eye examination, while ophthalmic technician Jeanne Deavis holds 5-month-old MaKenna Spruill very still on the exam chair.

Through it all, her grandmother and great-grandmother kept the prayers going. Her siblings sang and read to their baby sister. And her mother Alyssa Spruill, a single parent who pulled shifts at her casino theater job while MaKenna was in the hospital, pumped immunity-bolstering, infection-fighting breast milk every three hours, day and night. Doctors say this has been a significant factor in MaKenna's progress.

Neurodevelopmental impairment continues to be a threat, especially for extremely premature babies like MaKenna, defined as those born at 22 to 24 weeks.  The National Institute of Child Health and Human Development's Neonatal Research Network reports a "small but significant" improvement in outcomes for these children.

But other research finds it is still difficult to predict with any certainty how a child will fare. According to the Neonatal Research Network's outcomes estimator, a baby like MaKenna may face an 84 percent chance of profound neurodevelopment impairment. Having some sort of impairment is virtually guaranteed, at 91 percent, according to the estimator.

But that calculation only allows for babies as small as 401 grams. MaKenna clocked in at a mere 389 grams.

Still, preemies have always surprised people. Albert Einstein, Charles Darwin, and Winston Churchill were all born premature. Isaac Newton was not expected to live more than a few hours. Stevie Wonder is blind due to complications from prematurity.

Alyssa Spruill, right, holds her daughter, MaKenna close after eye drops were administered for her exam.
MICHAEL BRYANT / Staff Photographer
Alyssa Spruill, right, holds her daughter, MaKenna close after eye drops were administered for her exam.

Too early, too small

When a child is arriving far too early, doctors try to explain to parents what the baby may face. They ask them to consider if they want the child to be resuscitated.

Spruill, 30, reported for a routine prenatal medical appointment on March 12 that escalated rapidly into a blood pressure crisis, leaving her doctors little choice but to perform an emergency cesarean section. She knew what she wanted immediately.

"I asked them, 'Please just try,' " Spruill said. "'Try everything to save her.'"

Tiny MaKenna Spruill gets a bubble bath.
Courtesy AtlantiCare
Tiny MaKenna Spruill gets a bubble bath.

The divorced mother of three young sons and a daughter had a history of high blood pressure when she learned she was pregnant with her fifth child.  Though MaKenna's father was no longer in the picture, Spruill and her other children, ages 11 to 7, all were excited to welcome the new baby.

Because of her hypertension, Spruill had been referred to Diane Timms, a maternal-fetal specialist in Atlantic City. When her blood pressure began to rise during the pregnancy, Spruill worked even harder at protecting her health with a prudent diet and regular walks. Even before the March appointment, an ultrasound had shown that the baby appeared small for her gestational age, and Timms detected worrisome changes in the blood flow between the placenta and the baby through the umbilical cord.

On March 12, Spruill's blood pressure had skyrocketed, and she was in preeclampsia, a potentially life-threatening condition for mother and baby. Spruill was in danger of a stroke. Timms sent Spruill to the hospital. If her blood pressure couldn't be brought down, the next step would be to deliver her baby, who likely was too young and too small to make it.

Spruill wept as her mother drove her to the hospital.  "I was kind of already mourning my baby."

Her grandmother was on the phone.

"She said, 'Stop crying and start praying.' "

After a few hours, it was clear that the baby had to be delivered.  Spruill again was in tears, and so were some of the nurses.

"One of them whispered in my ear, 'Just pray, honey. Just pray,' " Spruill said. "I prayed the whole time."

When MaKenna was slipped out and placed on the scales, the neonatal care team's hearts sank. "We looked at each other," said neonatologist Asiegbu. "With babies like that, we usually give comfort care because the size is too small."

But Asiegbu, himself the father of five, knew Spruill wanted to save her baby, and that's what he told his colleagues. "I looked up, and I looked at them. I said, 'You know what? I'm going to try.' "

MaKenna’s fighting start

In the first few weeks of MaKenna's life her skin was so thin her mother could not safely hold her.  Spruill jokingly called MaKenna "my little alien."

MaKenna Spruill, 5 months old.
MICHAEL BRYANT / Staff Photographer
MaKenna Spruill, 5 months old.

One day while Spruill was still in the hospital, one of the doctors told her she should come quickly. MaKenna's breathing was rocky. Monitors blinked with vital signs that were going in the wrong direction.

For reasons she still doesn't know, Spruill started softly singing the old Motown hit "Ain't No Mountain High Enough."

"Then her numbers were OK after that," she said.

Always a surprise

As recently as the 1950s, babies born at less than a kilogram, or 2.2 pounds, were considered stillborn. Today, survival rates of a child about that size can be as high as 90 percent.

The health benefits for skin-to-skin contact between mothers and newborns, including premature babies, are well-known, ranging from facilitating breastfeeding to stabilizing heartbeat to aiding neurological and emotional development.

But for extremely premature infants, especially in their early weeks, that kind of touch may be limited. Plus they are not in the optimal growth environment of their mother's womb during a time of rapid development.

MaKenna Spruill, right, 5 months old, smiles a big smile as her mother Alyssa Spruill talks to her.
MICHAEL BRYANT / Staff Photographer
MaKenna Spruill, right, 5 months old, smiles a big smile as her mother Alyssa Spruill talks to her.

Tonse N.K. Raju, chief of the National Institute for Child Health and Human Development's pregnancy and perinatology branch, says the stimulus of family attention – talking to the baby, being close, touching as much as possible – is extremely valuable.

"I firmly believe those kinds of interactions are very important in promoting the baby's brain growth," Raju said. "Love is very critical for health care."

Once she had to go back to work, Spruill was with MaKenna as often as she could be, talking to her about the family who would welcome her, sometimes singing The Temptations classic, "My Girl." Spruill's mother and grandmother visited and prayed.  MaKenna's brothers and sister gathered by the baby's bedside and held her tiny hand. KaMaya, 9, thrilled to no longer be the only girl, read her new sister Bible stories. The story of Moses – another survivor infant — was the favorite.

KaMaya Massey, 9, leans over to give her sister MaKenna a kiss.
MICHAEL BRYANT / Staff Photographer
KaMaya Massey, 9, leans over to give her sister MaKenna a kiss.

No matter what, Spruill pumped her breast milk every three hours for MaKenna. At work, her supervisor would remind her, though she didn't really need it.

"I could say that breast milk probably was a huge factor in saving this baby," said Jennifer Tioseco, medical director of CHOP Newborn Care at AtlantiCare.

Breast milk's nutrient balance and immunity-boosting properties are well known. Hospitals maintain banks of donated breast milk to help babies whose mothers can't produce enough.

MaKenna Spruill, 5 months, is swaddled and held by ophthalmic technician Jeanne Deavis in the examination chair.
MICHAEL BRYANT / Staff Photographer
MaKenna Spruill, 5 months, is swaddled and held by ophthalmic technician Jeanne Deavis in the examination chair.

But Tioseco said some scientists believe the milk a woman produces may be specific to the needs of her child. "In premature babies because they're such high risk, I can't understate it. It's lifesaving," Tioseco said.

People who spend a lot of time with babies also say that some just have a will that is hard to deny. MaKenna, her caregivers say, seems to be one of those frankly feisty babies.

"She's a miracle in many ways," said Dana Beatty, a NICU nurse for over 20 years who grew close to MaKenna and her mother.

MaKenna had a lot of scary moments, Beatty said. But then she would rally.

"That's why I named her Mighty MaKenna."

The price of survival

What the doctors and nurses never have talked about with Spruill is the financial cost of saving a very premature child. AtlantiCare officials say literally hundreds of their doctors, nurses, and other support staff had a part in caring for mother and child. The lifesaving hospital care for this extreme preemie came to about $240,000, close to 10 times the cost of a full-term cesarean section birth in New Jersey.

Spruill's income is low enough that she is covered by Medicaid, and so is MaKenna. That public health coverage has paid for their care, as well as the baby's continuing treatment needs. Spruill said she has also been told Medicaid will also pay for medical day care if MaKenna needs it later due to disabilities.  This fall after a developmental checkup, the baby may be referred to Early Intervention, a program that offers therapies and support.

Spruill said she also has family she can count on for child care. Her mother and her sisters, she said, will help take care of MaKenna so she can continue to work and support her family.

‘Such a blessing’

On July 3, two days after her original due date and almost four months after she was born, MaKenna Spruill went home. The NICU team gave her mother 113 pink and white carnations, one for each day the baby spent with them. They also made Spruill a bracelet with a bead for every preemie milestone MaKenna reached.

"It's long enough to be more of a necklace now," nurse Beatty said.

Ophthalmic technician Jeanne Deavis, left, hands MaKenna Spruill back to her mother Alyssa Spruill.
MICHAEL BRYANT / Staff Photographer
Ophthalmic technician Jeanne Deavis, left, hands MaKenna Spruill back to her mother Alyssa Spruill.

For the next two years at least, MaKenna will be monitored for possible physical, neurological, or developmental impairments that may present themselves.

"At this particular age, there's absolutely no way to tell," Tioseco said.

Her caregivers were reassured that she has not seemed to have suffered brain hemorrhages, a common danger given preemies' underdeveloped blood vessels.

MaKenna has already been referred to a pulmonologist to watch her lung development and an ophthalmologist to check for eye problems. Cerebral palsy and learning disabilities are among the other possible problems she faces that may not be evident for years.

MaKenna Spruill, 5 months, lies very still as Dr. Richard Wise exams her left eye.
MICHAEL BRYANT / Staff Photographer
MaKenna Spruill, 5 months, lies very still as Dr. Richard Wise exams her left eye.

Spruill prefers to focus on what is.

"I don't want to think about what can happen," said Spruill, herself the child of a single-parent household. "I just feel like I'm going to take it one day at a time and enjoy her."

For now, she knows MaKenna is trying to lift her head like a typical one and a half month old. She's cooing and even yelling "like she's trying to talk," Spruill said. And MaKenna is smiling.

"I feel like even though this whole big thing happened to me, I feel like the bigger part is her. She's overcome so, so much. She really is such a blessing," Spruill said. "I feel blessed."

Story of MaKenna Spruill, 5 months old, an extremely premature baby, and the road to her survival. Alyssa Spruill, her daughter MaKenna Spruill, and her four other kids at home.
MICHAEL BRYANT / Staff Photographer
Story of MaKenna Spruill, 5 months old, an extremely premature baby, and the road to her survival. Alyssa Spruill, her daughter MaKenna Spruill, and her four other kids at home.