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doi:10.1111/jpc.12798
REVIEW ARTICLE
Fifty years in neonatology Brett J Manley,1,2 Lex W Doyle,2,3,4 Mark W Davies5,6 and Peter G Davis1,2,4 1
Neonatal Services and Newborn Research Centre, The Royal Women’s Hospital, 2Department of Obstetrics and Gynaecology, The University of Melbourne, Research Office, The Royal Women’s Hospital, 4Murdoch Childrens Research Institute, Melbourne, Victoria, 5Grantley Stable Neonatal Unit, Royal Brisbane and Women’s Hospital, and 6Department of Paediatrics and Child Health, The University of Queensland, Brisbane, Queensland, Australia 3
Abstract: Neonatology, the care and study of newborn infants, is a ’young’ specialty. Over the last 50 years, there have been many advances in the way that neonatologists care for newborn infants, particularly those born preterm, leading to dramatic improvements in mortality. To illustrate these advances, we describe four eras in neonatology from the point of view of the junior hospital doctor. Key words:
history of medicine; infant; neonatology; premature.
Neonatology is among the ‘youngest’ sub-specialties in paediatrics, and the term ‘neonatologist’ was only coined in 1960.1 In the subsequent 50-odd years, corresponding quite nicely with the history of the Journal of Paediatrics and Child Health (JPCH), neonatology has undergone an enormous transformation, and the outcomes for neonates, especially those born very preterm, have improved dramatically in Australia and around the world. In 2012, Battin et al. published data from one perinatal centre in New Zealand in JPCH, demonstrating the remarkable improvement in survival of very low birthweight infants2 (Fig. 1) over a 50-year period. In Volume 1, Issue 1 of the Australian Paediatric Journal, now JPCH, published in March 1965, an article by Burnard et al. from Sydney, titled ‘Pulmonary insufficiency in the newborn’ appears.3 In this article, the authors studied premature infants ‘in the lower range of birth weight’ (which was a range between 800 and 1800 grams). During the study period, 68% of babies born in this weight range survived. They noted a ‘tendency to hyperinflation of the lung’ after birth, and episodes of ‘atelectasis and over-distension’ occurring later in the admission. They also noted that ‘some babies displayed the radiographic and clinical features’ of a syndrome of respiratory illness seen in Key Points 1 Neonatology is a ‘young’ specialty that has undergone tremendous change in the last 50 years. 2 Over that time, there has been a dramatic improvement in survival of very preterm infants. 3 The challenge for the next 50 years is to decrease rates of short and long-term morbidity in survivors. Correspondence: Dr Brett J Manley, Newborn Research Centre, Royal Women’s Hospital, 7th Floor, 20 Flemington Road, Parkville, Vic. 3052, Australia. Fax: 03 8345 3789; email: [email protected] Conflict of interest: The authors have no conflicts of interest to declare. Accepted for publication 13 August 2014.
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premature babies that had been recently described by some of the luminaries of neonatal research.4,5 These early observations of chronic pulmonary disease in ‘dysmature’ infants followed the work of Mary Ellen Avery et al.,6 who had identified surfactant deficiency as a cause of the preterm ‘respiratory distress syndrome’ (RDS), also known as hyaline membrane disease. RDS is a disease that neonatologists treat every day and remains a leading cause of morbidity and mortality in preterm infants in 2015. However, the understanding and management of this disease, and many other common neonatal conditions, has changed dramatically with each passing decade. In fact, some of the most important neonatal advances have been made in the last 25 years, during the working lives of many currently practicing neonatologists. To demonstrate the dramatic advances and change in clinical practices across 50 years of neonatology, below we describe four distinct eras from the point of view of the junior hospital doctor.
1975: Dr Harry Casey Harry was exhausted. It was Monday afternoon and he had been the on-call neonatal registrar since Friday morning. So far he had performed 10 exchange transfusions on three different babies with Rhesus isoimmunisation. One of those babies had been admitted from another hospital with abnormal neurological signs – yet another potentially preventable case of kernicterus. On top of that, he had dealt with a grieving mother who had delivered a baby born weighing 750 grams; he had guessed the baby must have been about 26 weeks’ gestation. The little boy was just under the 800 g weight threshold for eligibility for mechanical ventilation as per the hospital guidelines. The baby was offered comfort care, and died in his mother’s arms after 12 h from severe respiratory distress. Harry was sitting in the resident’s quarters reading the recently published work of Liggins and Howie in New Zealand,7 suggesting that mothers at risk of preterm delivery should receive antenatal corticosteroids, when he was called to the
Journal of Paediatrics and Child Health 51 (2015) 118–121 © 2014 The Authors Journal of Paediatrics and Child Health © 2014 Paediatrics and Child Health Division (Royal Australasian College of Physicians).
BJ Manley et al.
Fifty years in neonatology
Fig. 1. Improved neonatal survival of VLBW infants from a single centre in Auckland across the years 1959–2009. From: Battin MR et al., JPC 2012 (with permission from the authors and publisher).
birth suite. There was a lady delivering a baby about 3 months early – ultrasound dating of pregnancies left a lot to be desired. The baby girl weighed 900 g and was vigorous at birth, requiring no active resuscitation, but had early signs of respiratory distress. This might be the chance to use the new ventilator, Harry thought, even if his senior, Bill Kitchen, sometimes referred to ventilators as ‘the work of the devil’. He knew the chances of survival for a baby born
doi:10.1111/jpc.12798
REVIEW ARTICLE
Fifty years in neonatology Brett J Manley,1,2 Lex W Doyle,2,3,4 Mark W Davies5,6 and Peter G Davis1,2,4 1
Neonatal Services and Newborn Research Centre, The Royal Women’s Hospital, 2Department of Obstetrics and Gynaecology, The University of Melbourne, Research Office, The Royal Women’s Hospital, 4Murdoch Childrens Research Institute, Melbourne, Victoria, 5Grantley Stable Neonatal Unit, Royal Brisbane and Women’s Hospital, and 6Department of Paediatrics and Child Health, The University of Queensland, Brisbane, Queensland, Australia 3
Abstract: Neonatology, the care and study of newborn infants, is a ’young’ specialty. Over the last 50 years, there have been many advances in the way that neonatologists care for newborn infants, particularly those born preterm, leading to dramatic improvements in mortality. To illustrate these advances, we describe four eras in neonatology from the point of view of the junior hospital doctor. Key words:
history of medicine; infant; neonatology; premature.
Neonatology is among the ‘youngest’ sub-specialties in paediatrics, and the term ‘neonatologist’ was only coined in 1960.1 In the subsequent 50-odd years, corresponding quite nicely with the history of the Journal of Paediatrics and Child Health (JPCH), neonatology has undergone an enormous transformation, and the outcomes for neonates, especially those born very preterm, have improved dramatically in Australia and around the world. In 2012, Battin et al. published data from one perinatal centre in New Zealand in JPCH, demonstrating the remarkable improvement in survival of very low birthweight infants2 (Fig. 1) over a 50-year period. In Volume 1, Issue 1 of the Australian Paediatric Journal, now JPCH, published in March 1965, an article by Burnard et al. from Sydney, titled ‘Pulmonary insufficiency in the newborn’ appears.3 In this article, the authors studied premature infants ‘in the lower range of birth weight’ (which was a range between 800 and 1800 grams). During the study period, 68% of babies born in this weight range survived. They noted a ‘tendency to hyperinflation of the lung’ after birth, and episodes of ‘atelectasis and over-distension’ occurring later in the admission. They also noted that ‘some babies displayed the radiographic and clinical features’ of a syndrome of respiratory illness seen in Key Points 1 Neonatology is a ‘young’ specialty that has undergone tremendous change in the last 50 years. 2 Over that time, there has been a dramatic improvement in survival of very preterm infants. 3 The challenge for the next 50 years is to decrease rates of short and long-term morbidity in survivors. Correspondence: Dr Brett J Manley, Newborn Research Centre, Royal Women’s Hospital, 7th Floor, 20 Flemington Road, Parkville, Vic. 3052, Australia. Fax: 03 8345 3789; email: [email protected] Conflict of interest: The authors have no conflicts of interest to declare. Accepted for publication 13 August 2014.
118
premature babies that had been recently described by some of the luminaries of neonatal research.4,5 These early observations of chronic pulmonary disease in ‘dysmature’ infants followed the work of Mary Ellen Avery et al.,6 who had identified surfactant deficiency as a cause of the preterm ‘respiratory distress syndrome’ (RDS), also known as hyaline membrane disease. RDS is a disease that neonatologists treat every day and remains a leading cause of morbidity and mortality in preterm infants in 2015. However, the understanding and management of this disease, and many other common neonatal conditions, has changed dramatically with each passing decade. In fact, some of the most important neonatal advances have been made in the last 25 years, during the working lives of many currently practicing neonatologists. To demonstrate the dramatic advances and change in clinical practices across 50 years of neonatology, below we describe four distinct eras from the point of view of the junior hospital doctor.
1975: Dr Harry Casey Harry was exhausted. It was Monday afternoon and he had been the on-call neonatal registrar since Friday morning. So far he had performed 10 exchange transfusions on three different babies with Rhesus isoimmunisation. One of those babies had been admitted from another hospital with abnormal neurological signs – yet another potentially preventable case of kernicterus. On top of that, he had dealt with a grieving mother who had delivered a baby born weighing 750 grams; he had guessed the baby must have been about 26 weeks’ gestation. The little boy was just under the 800 g weight threshold for eligibility for mechanical ventilation as per the hospital guidelines. The baby was offered comfort care, and died in his mother’s arms after 12 h from severe respiratory distress. Harry was sitting in the resident’s quarters reading the recently published work of Liggins and Howie in New Zealand,7 suggesting that mothers at risk of preterm delivery should receive antenatal corticosteroids, when he was called to the
Journal of Paediatrics and Child Health 51 (2015) 118–121 © 2014 The Authors Journal of Paediatrics and Child Health © 2014 Paediatrics and Child Health Division (Royal Australasian College of Physicians).
BJ Manley et al.
Fifty years in neonatology
Fig. 1. Improved neonatal survival of VLBW infants from a single centre in Auckland across the years 1959–2009. From: Battin MR et al., JPC 2012 (with permission from the authors and publisher).
birth suite. There was a lady delivering a baby about 3 months early – ultrasound dating of pregnancies left a lot to be desired. The baby girl weighed 900 g and was vigorous at birth, requiring no active resuscitation, but had early signs of respiratory distress. This might be the chance to use the new ventilator, Harry thought, even if his senior, Bill Kitchen, sometimes referred to ventilators as ‘the work of the devil’. He knew the chances of survival for a baby born
