John V. Hartline, MD, FAAP
The purpose of this section is to give a brief overview of the onset of neonatology, its evolution from an idea to an entity, and to explore its impact. The focus of this review is on the organizational nature of care for newborns and the remarkable changes in the approach to newborn care over the last century. Detailed and excellent descriptions of the evolutionary milestones of our specialty with emphasis in the advances in medical care for neonates have been written by others. This review's purpose is to emphasize the evolutionary nature of neonatal medicine in the ways it has (or has not) been provided, its principle caregivers, its scope of interest, and loci for caregiving. This context, in addition to the advances in medical capabilities, provides a background as we prepare for unknown future medical advances and for changes in health care organization. Personal and practice success will be highly correlated to the ability to adapt to an ever advancing and ever changing world.
Prior to 1880, a period perhaps best called "neo-not-ology," newborn survival was of the fittest and perinatal concerns were focused on problems of maternal mortality. Unwanted, sick, or small infants in some places were brought to foundling nurseries, where mortality was high and infanticide known to occur.
Near the beginning of the 20th century, the care system for small or sick neonates was unstructured and first became recognized to any degree with the experience of Alexandre Lion, who developed the "Baby Infant Charity" in Nice, France. Neonatal care as a medical entity was in its preconceptual period at that time. The newborn incubator was invented by an adaptation of incubators for chickens, and care for infants was supported by fees charged to see the premature infants. By 1898, Pierre Budin and Etienne Tarnier noted improved survival resulting from providing warmth and feedings. Interestingly, these investigators also reported that mothers of premature infants left in their care would often not want the infant returned or would abandon surviving infants. At the turn of the 20th century, the infant mortality rate in the United States was thought to be ~120 per 1,000 live births, although accurate records were not kept for three more decades.
Using Budin-Tarnier type incubators, Martin Couney brought premature infant care to fairs and exhibitions in the United States. The exhibits were supported by 25-cent fees paid by attendees. Couney described some poor outcomes and again noted the reluctance of many families to reassume care of the babies resulting from "successful" outcomes. Hospital care for premature infants involved the use of Lion incubators at the Chicago Lying-In Hospital beginning in 1898, and in 1914, Julius Hess opened the first unit specifically for premature infants at the Sarah Morris Hospital, also in Chicago. This unit could be the first regional neonatal care unit in the United States. The mainstays of care were temperature regulation, feeding, and sanitation. During this time, the infant mortality rate declined, but this decline was primarily due to a reduction in postneonatal mortality as sanitation, antibiotics, and vaccines were introduced.
In 1948, Virginia Apgar, an anesthesiologist in New York City, developed and tested a newborn scoring system, the Apgar Score, that emphasized the important transitions from fetal to neonatal life and enabled delivery room personnel to succinctly record the infant's status in the minutes after birth.
During this era, pediatric care began to focus on the newborn developed in the several medical centers. The pioneering investigator of the time was William (Bill) Silverman. It was his work that identified oxygen as the cause of retrolental fibroplasia (now called retinopathy of prematurity) and his studies into the detrimental effects of iatrogenic hypothermia led to many lives being saved by simply maintaining a themoneutral environment. Dr. Silverman's contributions went well beyond neonatology, as he was instrumental in the evolution of the randomized controlled trial in clinical research and his contemplations regarding the ethics of neonatal care are pertinent to this day.
1960 is a sentinel year for neonatal care, as Alexander Shaffer coined the term "neonatology" at that time.. If the earlier years were "preconceptual," his neologism could herald the "conception" of our specialty. By then, the infant mortality rate had declined to 26 per 1000 live births, largely due to reduction in post-neonatal infant mortality. Although the term neonatology had been introduced, neonatal care was in the realm of general pediatrics, albeit a few pioneers had begun careers dedicated to the care of the newborn and research in the perinatal period. Pediatricians in general were not warmly welcoming this intrusion into their professional lives.
In 1963, neonatal care came directly into the public eye with the birth and death from respiratory failure of Patrick Bouvier Kennedy, the premature son of President John F. and Jacqueline Kennedy. Patrick was born at 34 weeks' gestation—an age of nearly certain survival now was too early for a president's son at the time! This tragedy led to an explosion in neonatal research resulting in greater understanding of neonatal respiratory physiology and pathophysiology, and eventually in the successes in neonatal respiratory care including continuous positive airway pressure, mechanical ventilation, oxygen regulation, and surfactant replacement.
Also in the mid 1960's, Stanley Graven, a future Apgar Awardee, took time from his studies of placental mitochondria and amniotic fluid lecithin to investigate the health system in the State of Wisconsin. His sentinel work identified that one-third of neonatal mortality could be prevented by care provided in specialized units. Perhaps more importantly, his studies also showed that education provided to basic level hospitals directed toward already known effective measures in delivery room care, temperature and glucose control, and early recognition of respiratory distress and infection could prevent another 1/3 of neonatal mortality. This model did not suggest centralization of all deliveries, but emphasized communication, outreach education, and early identification of fetal and neonatal conditions requiring transfer to specialized units. In short, this model defined, for the first time, a regionalized perinatal system.
1960s and Beyond
In the late 1960s and early 1970s, regionalization was begun in several areas of the United States and Canada with similar effects. Sponsored by the National Foundation March of Dimes, representatives from the American Academy of Pediatrics, the American Congress of Obstetricians and Gynecologists, and the American Medical Association released the first version of Toward Improving the Outcome of Pregnancy (TIOP), which became the bible of regionalization. Nurseries doing the full range of neonatal intensive care were defined as Level III ( later, in some places Level IV was added for that subset of NICUs in hospitals doing heart-lung by-pass, cardiac surgery, and other highly complex and unusual procedures). Level I services were defined as basic neonatal care in the delivery room and nursery, including stabilization for transport. Level II services were less rigorously-defined concept and varied by location. In some states, the care levels were regulated. In its original form, neonatologists would provide the intensive care in the Level III units, whereas Level II care would usually be done by pediatricians and Level I basic care would be within practices of general pediatrics, family medicine, and general practice. Essential to the model in TIOP was an openness of communication among all three levels of care.
Catalyzed by the successes and excitement of this new area of pediatrics, many pediatricians focused their care on newborn infants, and in some places, specialized fellowship training became available. By 1975, the American Board of Pediatrics developed a Sub-Board in Neonatal Perinatal Medicine (NPM) with Dr. Graven as its first chairperson, and examined its first group of applicants: the "birth" of neonatology as a bone-fide subspecialty. By 1975, infant mortality had declined to 12 per 1000 live births, an approximate 90% decline in only 75 years, again largely due to improvements in public health, antibiotics, and vaccines.
Also in the 1970s, neonatology came to the forefront of the debates in medical ethics with two landmark cases: the Johns Hopkins Baby Doe case (1971) involving denial of care to an infant with Down syndrome, and the paper by Duff and Campbell , who described withholding of terminal resuscitations in some dying infants when further intervention was deemed futile [Duff RS, Campbell AG. Moral and ethical dilemmas in the special-care nursery. N Engl J Med 1973;289:890-894.]. Neonatology continues at the leading edge of much of medical ethics as topics such as limits of viability, parental involvement in decision making, and research in children are regular activities of the daily clinical life in practice.
At its birth, 375 physicians became Board Certified in NPM, at which time there were nearly 4 million births in the United States, approximately 10,000 per neonatologist. Estimating from data at the time and if patients and doctors similarly distributed, each neonatologist could have expected to care for about 1000 preterm infants (800 low birth weight infants), of whom 150 were very low birth weight, plus an additional 500 or so sick, full-term infants referred because of infection, trauma, or congenital anomalies. Neonatologists were a scarce entity and there were sick babies a-plenty.
The year 1975 also was the birth of the medical "home" for neonatologists: under the guidance of Joseph Butterfield, the American Academy of Pediatrics' Section on Neonatal-Perinatal Medicinecame into existence. Through its regular meetings in Arizona (Spring) and at the AAP National Conference and Exhibition (Fall), the Section provides educational programming, a place for fellows to present their work, liaisons with other AAP sections and committees, and recognition of our colleagues' efforts. Activities of the Section, guided by its Executive Committee, serve patient care, education, scholarly activity, administrative support, citizenship activities, and career development in both academic and private settings. A detailed description of the Section on Neonatal-Perinatal Medicinecan be found on the Perinatal Web site.
By the mid-1980s, neonatal centers had been developed in all corners of the country. In large part, this expansion was associated with acceptance by, and then demands from, our obstetrical colleagues, who wanted a neonatologist near-by at all times. Similarly, hospitals enthusiastically added neonatal units: some large and needed; and, some small, underused, and inefficient. Although board-eligibility required two years' fellowship training by 1980, there was no uniformly agreed-to curriculum for fellows. The infant mortality rate had declined to 10.4/1000 live births by 1986.
In 1986, Drs. Merenstein and Rhodes chaired a meeting entitled Neonatal Manpower to explore the spectrum of neonatology practices, the first national meeting dedicated to a review of the neonatal workforce. The practice paradigms identified and presented there represented the known variations existing at the time:
University, academic teaching and research: Phil Sunshine, MD;
University-based, multiple hospital delivery of neonatal/perinatal care: Robert Hall, MD;
Neonatology incorporated within a (general) multidisciplinary pediatric practice: Gilbert Martin, MD;
Private (group) neonatology practice in a free-standing tertiary community hospital with pediatric residency: John Hartline, MD; and,
Military: Gary Pettett, MD.
A number of observations arose from the discussions. The specialty was coming of age, this could be called its adolescence—as differing identities were arising within our midst. Based on the number of NPM certified physicians, the workforce had increased to about 1600. As the birth rate had changed little, the ratio of live births to neonatologists had decreased to 2500:1 Each neonatologist was theoretically responsible for the care of about 250 premature infants (200 low birth weight infants) of whom 40 were very low birth weight with an added 125 term infants needing intensive care. Of note, virtually no attrition among neonatologists was observed to that time. If the practice of neonatology confined itself to the intensive care needs of the birth population and regionalization persisted, this ratio was considered by some to be adequate for the intensive care population, the only major problem being maldistribution.
Although at its onset, neonatology was an academic, intensive-care focused endeavor, "Neo-intense-ology," by the mid 1980s nearly 2/3 of practicing neonatologists were in non-university settings. Many neonatologists practiced in large, community hospital NICUs with teaching programs for pediatric residents, but with limited participation in research. In addition to the demand created by obstetrics, pediatricians increasingly were asking neonatologists to
attend deliveries they formerly covered (eg, breech, repeat cesarean, etc.),
keep convalescent former NICU patients on the neonatal service until discharge,
assume care for the healthier 32 to 37 weeks' gestation cohort of preterm infants, and
consult on, and often accept in transfer, larger infants with conditions such as suspected sepsis or hyperbilirubinemia.
Pediatricians could then spend more time in the office and they would resume infant care after discharge.
Neonatologists were also beginning to staff smaller units built in hospitals responding to competitive urges and obstetrical demand. This "deregionalization" succeeded in bringing neonatologists closer to more delivered patients, but it also succeeded in dispersing the intensive care population and drove practices toward the populations of less sick and well newborns. In the late 1980s, in an attempt to enhance the academic experience of neonatal fellows by providing more time within fellowship programs for scholarly investigation, an added year of research was added to the ABP requirements for NPM. At the same time, institutions wishing to certify trainees for the NPM examination would need to apply and demonstrate the essential components of training. Candidates for ABP-NPM certification would have to have documentation from their fellowship of accomplishment in research.
So, at a time when training initiatives were directed at academic needs (added 3rd year for research only), clinical patterns were shifting from Levels III into Level II and even Level I care. Studies at the beginning of regional care and more recently to analyze the impact of deregionalization continue to suggest that proficiency is related to volume and experience, "what you don't use, you lose," but the exact threshold of experience to be able to provide optimal care is yet to be determined.
Throughout the 1990s and into the 21st century, the number of neonatologists has steadily grown and current predictions expect the number to gradually increase to around 4500 by 2015. By that time, demographers expect the birth rate to increase to 4,500,000 live births per year in the US, keeping the ratio between number of neonatologists and live births about constant. But, as pediatric training deemphasizes neonatal care and practices shy away from the nursery, the fraction of all births cared for by neonatology is expected to increase. Much of this increased workload involves Level II and in many locations, Level I normal newborn care. As practices broaden the scope of care within their activities, they vary in their approaches to staffing. Some expand the scope of the neonatologists' clinical work, whereas others have added pediatricians, advanced practice nurses, or physician assistants to provide or assist in providing non-intensive care services. All these models are in existence at this time.
Although developmental follow-up and data collection were mentioned in TIOP, more recent emphases on outcomes analysis and quality initiatives require longer-term analysis, making data collection a reality for private practices as well as for academic centers. Outcomes analysis and quality assurance are essential components of part 4 of the Program for Maintenance of Certification of the American Board of Pediatrics. Some neonatal practices include outpatient follow-up for outcomes analysis and some have neonatologists doing ongoing clinical care for infants with respiratory, neurological, or nutritional problems stemming from their neonatal conditions. Nursery level of care definitions have been recently refined and are discussed in the Guidelines for Perinatal Care published by the AAP in conjunction with the American College of Obstetricians and Gynecologists.
In summary, neonatology has grown from a side-show attraction, through an unpopular, then popular, intensive care subspecialty within pediatrics, to a heterogeneous combination of practice activities up to and including the full range of newborn infant care and outpatient follow-up. An increase in the number of neonatologists has had virtually no impact on the numbers of premature or sick newborns born, but it does create the need for reflection as to what neonatology "is" and where it is going. At present, more and more practices are incorporating coverage of well newborns and many provide coverage for deliveries and/or the nursery at hospitals having no intensive care capability. For those practices, neonatology is an age-based subspecialty of pediatrics covering the full spectrum from healthy to very ill. Training programs emphasize the critical care component of patient care for the 1/3 of fellowship directed toward clinical training; the other 2/3 provides time for scholarly activities. How training program curricula will reflect these changes in practice needs is yet to be seen.
With this wide variety of approaches to neonatal care, individuals seeking practice locations and practices seeking to add or replace colleagues all need to reflect on what neonatology means to them. Only with this in mind can an applicant find the best fit or a practice find the needed colleague. This historical overview emphasizes the uncertainty that has been associated with each developmental level. Successful practices will need to keep their eyes ahead and their minds flexible. We don't know what the future holds. We do know that we'll have to adapt to it.
American Academy of Pediatrics