Pivotal Milestones in Neonatal Care
The past 150 years have seen dramatic changes in neonatal mortality and morbidity in the developed world.
In the UK before the 1950s, little scientific effort was directed at the premature or seriously ill infant. There was very limited equipment, virtually no laboratory determinations and mothers were not allowed in the nursery for fear of infectious diseases. As much as newborns benefited from advances in medicine, they also suffered from a lack of knowledge. The 50s and 60s were the years of early starvation, when the first feeding was delayed for 2/3 days because of concerns about pneumonia.
Most physicians consider the 1960s to be the start of current modern practice of newborn medicine and the nursery became the neonatal intensive care unit (NICU).
During the 1970s, remarkable advances occurred in the respiratory management of the premature infant. The landmark study by George Gregory illustrating the success of Continuous Positive Airway Pressure (CPAP), resulted in a dramatic improvement in the successful respiratory support of premature infants, which at the start of the 70s was only 10% for infants with birth weights under 1,500 grams in the UK. The first generation of ventilators designed specifically for neonatal use were introduced, nurses expanded their roles in the neonatal intensive care unit, and families became an integral part of the care giving. Parent support groups were developed, fathers obtained ‘non-visitor’ status, and breastfeeding was encouraged.
The 1980s heralded further significant advances in knowledge and technologies in the field and resulted in substantial declines in infant mortality rates. Despite the advances in the 70s, in 1975 almost one out of two babies born prematurely with birth-weight of 1,500g or less died in the perinatal (first 7 days after birth) and neonatal period (28 days after birth). By 1995 this ratio had fallen to one in six (1). Evidence provided in the BLISS report (2) showed that premature babies of even 27/28 weeks’ gestation age had an 88 per cent survival rate.
A major factor contributing to the UK reduction of neonatal mortality and positive long-term outcomes for premature and ill newborns has been the development of neonatal intensive care units (3)(4)(5). Technology may not have provided all the answers but it has made a huge difference.
The evolution and development of newborn medicine has been surrounded by controversy and a lack of resources. Fundamental ethical questions remain and should remain in our minds for complex issues like the viability of severely premature babies and the long-term outcomes. These more complex ethical and cost issues, and medical and technical advances are hot topics in the developed world, while in the developing world the agenda is a call for more resources to implement low tech, low cost basic solutions. This highlights the gap between rich and poor countries.
1) Gilbert, W.M., Nesbitt, T.S., and Danielsen, B. (2003), ‘The cost of prematurity: quantification by gestational age and birth weight’, Obstetrics and Gynecology, 102:3, 488-92.
2) BLISS (2005), Special Care for Sick Babies: Choice or Chance? London report cited references: Project 27/28, Confidential Enquiry into Stillbirths and Death in Infancy, April 2003 and Riley K, Wyatt JS, Roth S, Sellwood M. Changes in survival and neurodevelopmental outcome in 22 to 25 week gestation infants over a 20 year period (abstract). Pediatric Research. 2004: 56(3): 502
3) Department of Health Expert Working Group on Neonatal Intensive Care Services (2003), Report of the Neonatal Intensive Care Services Review Group.
4) American Academy of Pediatrics (2004), ‘Policy Statement: Levels of Neonatal Care’, Pediatrics, 114:5, 1341- 47.
5) BLISS (2005), Special Care for Sick Babies: Choice or Chance? London.