A Brief History of Neonatology

1. A Brief History of Neonatology It is a common myth that pediatrics has always existed and that neonatology is a spurious subspecialty that was spawned late in its glorious history. In fact, the opposite is true… pediatric cardiology, pediatric surgery, pediatric hematology, even genetics … they all got their starts from neonatology. Phillip V. Gordon Information in this talk has been heavily borrowed from Neonatology on the Web

2. Nothing happened during the dark ages Oldest reference to a caesarean section 715-673 BC Soranus of Ephesus wrote Gynecology which included a chapter on the care of the newborn 98-138 AD (the legend of Julius Cesar’s birth) agrarian society transforming into an industrial society 1200s (the dark ages are over) Hospital for Foundlings, Pope Innocent III (Rome) 1630 (circa 1740) (dawn of the age of enlightenment) L'Hôpital des Enfants-Trouvés, (Paris) St Vincent DePaul & The Daughters of Charity

3. 1650 Large cities become the engines of industrialization The Foundling Hospital, London (founded in 1739) William Hogarth established the first model of a charitable hospital for children The impetus for forceps was as much for the evacuation of the fetus (all too often dead) and survival of the mother as for improved viability 1st diagnosis of Duodenal Atresia 1733 1st diagnosis of Hirschsprung’s 1691

4. By the 19th century foundlings have become a government sanctioned industry (albeit a charitable and subsidized one) Le Tour d'Abandon (The Desertion Tower), Paris 1810-1860

5. Francois Chassier recommends oxygen for the resuscitation of newborns (it is not utilized for another 70 years) 1780 Foundlings = the primary neonatal research population 1st publication of correct average birth weight and length 1753 (Roederer – Germany) 5 ½ lbs 1st description of hypertrophic pyloric stenosis 1788 (today’s average birth weight is 7 lbs) 1st description of Transposition of the Great Vessels 1797

6. 1802 1802 1st description of hydrocephalus in infants Herberden (Scotland) 1803 1st surgical closure of omphalocele by Hey Opening of the Hôpital des Enfants-Malades in Paris, (the 1st children's hospital) 1834 1st description of endotracheal intubation for newborn resuscitation Blundell Growing recognition of positive neonatal interventions (forceps deliveries)

7. 1839 1st description of prune-belly syndrome 1847 First use of ether anesthesia in obstetrics Ground swell of big city support for children’s hospitals 1852-1854 Great Ormond Street Hospital, London; Children’s Hospital of Philadelphia; and New York Nursing and Children’s Hospital are all founded GOSH 1851 CHOP First report of gavage feedings for infants NYNCH

8. Late 19th century = the golden age of neonatology Jean-Louis-Paul Denucé invents the first infant incubator 1857 1901 Pan Am Expo, Buffalo 1904, St Louis Fair

9. 1861 WJ Little 1st describes cerebral palsy 1879 Sigmund Franz Crede prescribes dilute silver nitrate for opthalmia neonatorium (gonorrhea) 1888 Fallot describes his famous tetrology of congenital heart defects Late 19th century = the golden age of neonatology 1882 Bedeirt Heat treatment of milk for 2 hrs at 100 degrees C. for artificial feeding (although Louis Pasteur invented pasteurization 20 years earlier)

10. Continuation of the golden age of neonatology Archibald E. Garrod postulates "inborn errors of metabolism" and their inheritance according to Mendel's Laws 1908 Heidenhain 1st successful repair of congenital diaphragmatic hernia 1902 C.W. Townsend 1st description of "hemorrhagic disease of the newborn“ 1894 Tarnier 1st use of oxygen (O2) in premature infants 1889 The father of genetics alkaptonuria

11. J. B. Sidbury 1st transfusion through the Umbilical Veinin Hemorrhage of the New-Born (Wilmington NC) 1919 Continuation of the golden age of neonatology Ramstedt 1st successful treatment of pyloric stenosis with pyloromyotomy 1912 H. Dam & W. W. Waddell discovery of vitamin K and treatment of coagulation abnormalities of the newborn 1936, 1937 Richter 1st Transthoracic ligation of tracheoesophageal fistula 1913 William Ladd (father of pediatric surgery popularizes both procedures in the USA)

12. Continuation of the golden age of neonatology Landsteiner & Levine Discovery of Rh factor Gregg Congenital cataracts due to Rubella epidemic Clifford 1st clinical recognition of retrolental fibroplasia 1941 Louis K. Diamond Established link between Rh isoimmunization and erythroblastosis fetalis & 1st exchange transfusion via umbilical vein as treatment for erythroblastosis fetalis 1942, 1946 Alexandar S Nadas starts the first pediatric cardiology program (CHOP) (focused on congenital heart disease) 1949 The father of pediatric hematology Carl Landsteiner The father of pediatric cardiology

13. Gleiss RCT: withholding fluid in immediate postnatal period not beneficial 1955 Silverman RCT: Sulfa drugs increase kernicterus 1956 A new dark age emerges as interventions go awry Smith Proposed withholding fluid in premature infants 1949 Patz 1st RCT to link excessive O2 to retinopathy of prematurity (ROP). 1952 Emerson Invention of high-frequency oscillatory ventilation (but not used in infants) 1953 (RDS and chronic lung disease become “incurable”)

14. Sister Jean Ward Serendipitous observation of effect of sunlight on indirect bilirubin level 1956 Mother of phototherapy A black cloud persist despite remarkable advances Introduction of Thalidomide 1957 Joan Hodgman Gray-Baby Syndrome due to use of prophylactic chloramphenicol 1959 Mary Ellen Avery Surfactant deficiency is the cause of respiratory distress 1959

15. Mildred Stahlman pioneers mechanical ventilation as therapy for infant with RDS 1961 A black cloud persist despite remarkable advances Patrick Bouvier Kennedy dies from RDS (34 weeks gestation / 2100 grams) 1963 Now the world could watch as infants with RDS died not in hours, but days, weeks… months because of mechanical ventilation. The Kennedy’s experience spurred the Western World to find a cure for RDS. Birth defects linked to thalidomide 1960

16. Rashkind technique of atrial septostomy developed as rescue therapy for transposition of the great vessels 1967 Wilmore & Dudtrick 1st report of total parenteral nutrition for the neonate 1968 A black cloud persist despite remarkable advances Victor Freda develops Rhogam - the prevalence of erthroblastosis starts to fall 1966

17. NICUs become “Chest Tube Meccas” in the 1970s 2 NEJM case series demonstrate pharmacologic closure of the PDA with indomethacin (the therapy was immediately adopted around the world) 1976 J. Kattwinkel A device for administration of continuous positive airway pressure by the nasal route 1973 GA Gregory invents the Gregory Box for continuous positive airway pressure 1971

18. Exosurf (an artificial surfactant) is shown to be effective by multinational RCTs and is approved by FDA 1990-1991 With the combination of pulse oximetry, gentler ventilation strategies (including the concept of permissive hypercapnea) and completion of the 30 year quest for artificial surfactant, neonatologists go from saving near term infants to ratcheting down the gestational survival limits to the second trimester fetus. Cerebral palsy incidence is unchanged. Neonatology opens Pandora’s Box

19. Neonatology keeps prying open Pandora’s Box What we seem to be learning in the post surfactant age is that the important limits to neonatology may not be viability, it may be the capacity to develop an ex utero fetus into a functional human being who has meaningful quality of life. We are in fact creating entirely new disorders in these survivors. PV Gordon

20. What can we learn from history? • Neonatology has fathered most of the pediatric subspecialties we know today. • Much of our progress has come about because of society, not in spite of it. • Progress had not been always forward, but saltatory, with advances and set backs in accordance with the accuracy of our understanding of fetal and neonatal biology. • There are many Living Legends in Neonatology and there’s still plenty of room for others to join them.