A Century of Caring: 100 Years of NICU Nursing

Born in the USA – The History of Neonatology in the : A Century of Caring By Anne M. Jorgensen, RNC, MS, NNP, DNPc

taken place in neonatology and the responsi- newly constructed U.S. birth registry in bilities we have carried as neonatal nurses and 1915, showing an infant mortality rate of we wonder how time has passed so quickly, 99.6/1,000 live births,2 there was increasing especially the last two decades. In the U.S., awareness (public and political) that infant it is widely agreed that modern neonatology mortality reflected the overall health and began in the 1960s. However, for more than a welfare of our nation. Since 1900, especially century, countless nurses and physicians have in the past 50 years, dramatic improvements dedicated their professional lives to improv- in the care of preterm and term infants have ing the standards of care provided for high- taken place in all areas of neonatal care. risk and preterm infants. Since I was a small child, my father would remind me: “To know Thermoregulation your future, you should study your past.” The The Incubator purpose of this article is to provide a brief but America’s first hospitals for premature infants illuminating look back on the history of neo- were established at the turn of the 20th cen- Introduction natology, and to encourage all of you to rec- tury at fairs, amusement parks, and exposi- It is hard to believe that during my lifetime ognize that you are a part of this journey. tions. In 1896, Martin Couney, a former stu- the first neonatal unit was established and dent of Parisian physicians, Stéphane Tarnier neonatology became a subspecialty of pediat- In the Beginning, and Pièrre-Constant Budin, inventors of the ric medicine; it is hard to believe that I was Turn-of-the-Century America incubator, is credited with bringing the incu- a minted nursing school graduate working in As the 19th century bid its farewell, Ameri- bator to the United States. Doctor Couney, a neonatal intensive care unit that took part cans looked over their shoulder with awe at known as the “Incubator Doctor,” was the in the surfactant trials. It is hard to believe remarkable strides that characterized the in- first person to offer specialized care for pre- that we relied solely on a bear-cub ventila- dustrial revolution. Yet, despite urban explo- mature infants in the US. In 1901, Couney tor and extremely high inspiratory pressures sion and technological advance, nearly 20% set up his first incubator show at the Trans- to support infants with respiratory distress of all infants in American cities never lived Mississippi Exposition in Omaha, Nebraska. syndrome. My mind’s, eye allows me to look to see their first birthday. Industrialization in From there, Couney went on to exhibit his back and see the fragile skin of the preterm the 19th century, characterized by employ- premature babies at the Pan-American Expo- infant with a perfectly circular-shaped trans- ment of women in factories, decrease in breast sition in Buffalo, New York.3 In the 40 years cutaneous oxygen monitor burn. I can almost feeding, child abandonment, and increasing following, the “Incubator Baby Side-Shows” feel the corrugated vent tubing throbbing need for foundling homes, resulted in the were at nearly all of the large expositions with humidity. highest recorded infant mortality: more than or World’s Fairs in America, beginning in Considering that the average age of a nurse 230/1,000 births in 1870.1 Many infants 1898 and continuing until 1943. Couney’s today is 49 years, I am not alone with my died immediately from respiratory distress longest running incubator exhibit was at memories. Many of us, including nurses, phy- syndrome, and others died in the first few Coney Island, New York. This exhibit, called sicians, and respiratory therapists who work weeks of life from hypothermia, infection, or the Luna Park Incubator Exhibition, was in the NICU, share the same experiences. weight loss. By the early 1900s, pediatricians the longest running show at Coney Island. With quiet pride and grounded responsibil- began to take increasing interest in improv- The incubator baby shows featured entire ity, we look back on the infants and families ing the health of newborns and preventing rows of incubators, staffed by rotating shifts we have cared for and we feel satisfied. We death by emphasizing adequate feeding and of physicians and nurses. By the 1930s, Ju- look back on the dramatic advances that have prevention of infection. Moreover, with a lius Hess, Chief of Pediatrics at the Michael

8 | June 2010 NICU Currents Reese Hospital in Chicago, became the lead- that maintaining body temperature by con- improve the health of poor women and chil- ing expert on prematurity. He developed the trolling the thermal environment significant- dren, the U.S. Congress enacted the National Hess incubator, which was capable of deliv- ly decreased low-birth-weight mortality.10 Supplemental Feeding Program for Women ering oxygen to the baby inside. The Hess With this discovery, thermal management and Children (WIC) in 1972. Whey-pre- incubator was used in the U.S. in the first became a cornerstone of neonatology. dominant formulas for preterm infants were dedicated transport vehicle in Chicago. The introduced in the 1980s.18 incubator was heated by coils and plugged Growth and Nutrition into the ambulance. Growth Categories Parenteral Nutrition By the 1940s, a modern-like incubator Beginning in the late 1950s, Farquhar in The infusion of intravenous fluids was a with clear plastic walls was introduced. The Scotland10 and Gellis and Hsia11 and Corn- major turning point for the care of preterm visibility afforded by the modern clear plas- blath12 in the U.S. reported that infants of infants. Initially, peripheral venous nutri- tic incubator was recognized immediately, poorly controlled diabetic mothers were tion was primarily in the form of glucose. “Nurses and doctors stared at the naked ba- “overgrown” and at increased risk for hy- Development of micro-infusion pumps fa- bies as if they were seeing them for the first poglycemia, respiratory distress syndrome cilitated the accurate administration of IV time.” Naked infants were examined more (RDS), hyperbilirubinemia, hypocalcemia, fluids to extremely preterm infants. Numer- completely, observed more closely, and treat- and hypertrophic cardiomyopathy. On the ous investigators attempted to infuse protein ed more actively than ever before.4 other end of the growth curve, Gruenwald13 hydrolysates to the preterm or postsurgical recognized that fetal undergrowth might be infant, but it was Dudrick and Wilmore who Thermal Regulation the result of placental insufficiency. War- worked initially with laboratory animals in Although various incubators were designed kany et al.14 are credited with introducing Rhoads’ department and developed the basis and used in Europe and the U.S., it was not the term “intrauterine growth retardation,” by which high caloric IV preparations, with until the 1950s, with the work of William commonly known today as intrauterine appropriate nitrogen concentrations, could Silverman, Richard Day, and colleagues at growth restriction. In 1967, Lulu Lubchen- be infused into large-caliber vessels.19 These Columbia Presbyterian, (known then as Ba- co, from Mile High City in Denver, Colora- techniques were rapidly applied to the care bies Hospital), in New York, that the benefits do, published the seminal paper reporting a of the low-birth-weight infant. of modifying body temperature were demon- growth classification based on birth weight, strated. In one of the first randomized, con- categorizing newborns into three groups: Delivery Room Resuscitation trolled trials in neonatology, they were able small, appropriate, or large for gestational The Apgar Score to demonstrate improved survival in preterm age.15 Lubchenco’s work led to improved In 1957, Doctor Virginia Apgar suggested infants who were kept in incubators that assessment and management of problems that a newborn should be assessed in the de- were 4° warmer than in the control infants.5 that were unique to specific growth catego- livery room with a scoring system based on Soon thereafter, the factors that affect the ries and provided a standard for postnatal 5 parameters—heart rate, respiration, reflex equation of heat loss versus heat production growth for preterm infants. activity, tone, and color— within the first were elucidated.6 The importance of radiant minute, and if necessary at 5 minutes.20 The heat loss led to the introduction of radiant Nutrition following year (1958), Dr. Apgar proposed warmers, both in the delivery room and in As early as the 1850s, preterm infants were that someone other than the delivering ob- premature nurseries. It was also noted that reported to be gavage fed with soft rubber stetrician or midwife should be caring for an important component of heat production catheters;16 polyethylene tubes were intro- the infant and giving the Apgar Score.20 was the presence of brown fat.7 It was dem- duced in the 1950s.17 Secondary to concerns Since then, the Apgar Score is used in deliv- onstrated that not all infants of low birth about oxygenation, respiratory status, and in- ery rooms throughout the world. Improved weight (LBW) were born preterm but might fection, it was common practice to withhold delivery room assessment and management be small for gestational age or experience feeding the preterm infant for the first few led to respiratory management immedi- IUGR.8 Some were found to have difficulty days of life, or longer. Clinical disorders such ately at birth that included bag-and-mask maintaining their body temperature, largely as hypoglycemia and hyperbilirubinemia ventilation or endotracheal intubation and because they lacked brown fat. Because other coupled with difficult IV access, reinforced assisted ventilation for infants failing to substrates were used to produce heat, they the need to re-think traditional feeding prac- establish spontaneous respiration. Suction- also developed low blood glucose levels. For tices and ultimately led to present-day feed- ing of the oropharynx with the head on the different-sized infants, at different postna- ing management. After the discovery of the perineum, followed by prophylactic endo- tal ages, a range of temperatures, called the chemical composition of milk in the 1890s, tracheal intubation and suctioning to pre- neutral thermal environment,9 was found to various percentages of protein, fat, and car- vent meconium aspiration became delivery minimize energy expenditure. In 1958, Dr. bohydrate were used for infant feeding, with room protocol.21 The establishment of a na- William Silverman’s seminal report showed formula feeds introduced in the 1920s. To tional resuscitation program in the United

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States codified neonatal resuscitation in a respiratory function of preterm infants, pre- apnea, heart rate, and blood pressure monitor- way that could be taught to thousands of vent ROP, and care for infants of lower birth ing. The use of CPAP resulted in a dramatic physicians and nurses.22 weights and younger gestational ages. improvement in the successful respiratory sup- port of premature infants. The first generation Respiratory Disorders Surfactant of ventilators designed specifically for neonatal In the early 1900s, the treatment for apnea In 1959, Dr. Mary Ellen Avery and her col- use, the Baby Bird I and Bournes BP 200, were or cyanosis was spirit of ammonia and a league, Dr. Jere Mead, described the mecha- introduced. The first successful use of extracor- small dose of whiskey.23 By the 1930s, pre- nism underlying the failure of premature in- poreal membrane oxygenation (ECMO) took mature and cyanotic infants were given oxy- fant’s to expand, and to retain air. For the place in 1975.27 ECMO eventually reduced in- gen. The notion of “if a little is good, a lot first time, Avery and Jere reported that hyaline fant mortality from 80% to 25% for critically should be better” was espoused and liberal membrane disease was not caused by the pres- ill infants with acute reversible respiratory and use of oxygen was the standard of treatment ence of something in the lungs but rather by cardiac failure unresponsive to conventional for cyanotic infants.24 Without the ability to the absence of something.26 They recognized therapy in conditions such as persistent pulmo- measure the infant’s interior oxygen level, that infants who died of hyaline membrane nary hypertension, meconium aspiration, and the only way to determine whether or not disease lacked a substance in the called sepsis. By the mid 1970s, umbilical lines were an infant was getting enough oxygen was to surfactant. When it became clear that the prob- routinely used and by the 1980s, pulse oxim- observe color. Unfortunately, liberal oxygen lem involved retaining air, mechanical respira- etry was introduced,28 rapidly gaining popular- use, coupled with inability to measure arte- tors were modified to provide positive pressure ity because it was a non-invasive way to mea- rial oxygen tension, proved to have devastat- in the alveoli at the end of expiration, as well. sure oxygen saturation. Furthermore, because ing consequences, and many preterm infants In addition, understanding the cause of the so- there was no heating device, the position did developed retrolental fibroplasia, now called called hyaline membrane disease pointed the not need to be changed frequently. Remark- retinopathy of prematurity (ROP). RLF was way to two new treatments: steroid injections able advances in the respiratory management responsible for more childhood blindness— for pregnant women to encourage a fetus at of preterm infants soon followed.

The ’90s are widely considered the decade of the micropreemie. Successful treatment of these newborns, with gestational ages of 23 to 25 weeks and birth weights of 500 to 750 grams… an estimated 8,000 cases—than all other risk for premature birth to speed up the pro- Evolution of the causes combined. The association between duction of natural surfactant, and development Neonatal Intensive Care Unit oxygen therapy and RLF was eventually de- of surfactant products that could be placed in With hospital births increasing from fewer termined by Kate Cambell of Australia in the lungs of babies born before they were able than 5% in 1900 to more than 50% in 1921, 195125 and liberal use of oxygen was directly to produce this substance on their own. Mary hospital nurseries began appearing, and pedia- linked to ROP and blindness. Consequently, Ellen Avery’s and Jere Mead’s description of tricians assumed a larger role in neonatal care.29 respiratory management strategies shifted to surfactant deficiency as the etiology of HMD, a The care of the newborn entered the academic the other extreme, characterized by oxygen disease that caused an estimated 25,000 deaths setting through the work of Julius Hess, Chief restriction. Oxygen concentrations greater per year, soon followed. This led to what many of Pediatrics at Michael Reese Hospital in Chi- than 40 percent were considered dangerous consider the greatest success in modern neo- cago. In 1922, the Sarah Morris Premature and incubators were designed so that no natology, the development and administration Center, the first unit solely for premature in- more than 40% oxygen could be delivered, of surfactant to premature infants. The use of fants, opened. Julius Hess’ textbook “Prema- unless a baffle on the back of the incuba- surfactant to treat what we now know as respi- ture and Congenitally Diseased Infants,” was tor was closed. Undoubtedly, many infants ratory distress syndrome has revolutionized the the first book devoted to newborns.30 Hess es- died because they were deprived of adequate field of neonatal medicine, reducing neonatal tablished concepts of research in the newborn, amounts of oxygen. By the end of the 1960s, mortality from RDS by 40%. developed the Hess Incubator, and became measuring arterial oxygen tension for all neo- the leading American expert on prematurity. nates receiving supplemental oxygen became Advances in Respiratory Management The Sarah Morris Hospital at Michael Reese standard of practice. Our ability to measure Respiratory monitoring improved with trans- Hospital promoted advances in aseptic tech-

PO2 with micro samples of blood, decreas- cutaneous oxygen assessment, followed by niques, neonatal transport service, and nasal ing from 2 ml to 0.5 mL, and subsequent- transcutaneous carbon dioxide, pulse oximetry, feeding. By 1948, both the American Academy ly to 0.2–0.3 mL, enabled us to improve routine blood gas monitoring, and noninvasive of Pediatrics and World Health Organization

10 | June 2010 NICU Currents uniformly defined prematurity as infants with Hyperbilirubinemia which supported family-centered, individu- a birth weight less than 2,500 grams. In 1942, the link between Rh factor and alized developmental care for premature On August 7, 1963, Patrick Bouvier Ken- erythroblastosis fetalis was identified. In infants while shortening ventilator days nedy, the third child of President John F. Ken- 1946, Doctor Louis Diamond described and improving developmental outcomes of nedy and First Lady Jacqueline Bouvier Ken- double-volume exchange transfusion NICU graduates. In the late ’80s, family- nedy was born. He was born at 34 1/2 weeks’ through the umbilical vein for treatment of centered care expanded, with sibling visita- gestation with a birth weight of 2,112 grams erythroblastosis fetalis.32 Phototherapy, in- tion policies, support groups, antepartum (4lbs, 10oz), by repeat cesarean section at the troduced in United States by Jerold Lucey in consultations, parental rooming-in, kan- Otis Air Force Base Hospital, in Cape Cod the 1960s, became the mainstay of treatment garoo care (skin-to-skin contact between (Massachusetts). Because of progressive respi- for both preterm and term infants.33 There parents and infants), and multidisciplinary ratory distress, the baby was transferred to Bos- was contentious debate about its safety in developmental committees. ton Children’s Hospital, where he was placed the early days, but it now is an established in a hyperbaric oxygen chamber, and died at 39 and accepted treatment modality. Between Genetics and the Human Genome hours of life from hyaline membrane disease. 1990-2000, there was a rise in kernicterus In 1952, and Francis Crick The morning after his death, Patrick’s obituary cases, attributed to many factors, including identified and described the double heli- in The New York Times pointed out that, at that early discharge, late preterm birth, and ex- cal structure of DNA, for which they re- 34 time, all that could be done “for a victim of clusive breast feeding. Newer phototherapy ceived the 1962 Nobel Prize in Medicine. hyaline membrane disease is to monitor the in- strategies include bili-blankets that can be In 1959, Dr. Jerome Lejeune, in Paris, de- fant’s blood chemistry and to try to keep it near wrapped around the infant to obviate the scribed trisomy of chromosome 21 in Down 35 normal levels. Thus, the battle for the Kennedy need for eye protection. Within the past Syndrome. This was followed by extensive baby was lost only because medical science has few years, a new phototherapy light source, investigations of chromosomal syndromes using high-intensity light-emitting diodes, in man, further advanced by techniques for not yet advanced far enough to accomplish as has been shown to be at least as effective as banding and identifying deletions and trans- quickly as necessary what the body can do by conventional phototherapy.36 locations. In 1963, Dr. Robert Guthrie de- itself in its own time.” More than any other scribed a test for detecting phenylketonuria single event, the death of this infant served to The Micropreemie in the newborn period. This was followed ignite public and medical awareness to the need The ’90s are widely considered the decade by methods for detecting other metabolic, for neonatal intensive care and soon led to the of the micropreemie. Successful treatment genetic, and endocrinologic diseases by mass establishment of NICUs around the country. of these newborns, with gestational ages neonatal screening, now carried on through- Just two years later, in 1965, the first Ameri- of 23 to 25 weeks and birth weights of out the United States. In 2000, Drs. Francis can newborn intensive care unit (NICU), de- 500 to 750 grams, was made possible by S. Collins and J. completed the signed by Dr Louis Gluck, was opened at Yale surfactant replacement therapy, improved mapping of the human genome. 31 Hospital in New Haven, Connecticut. In perinatal management (including prenatal 1975, the American Board of Pediatrics estab- steroids), new technologies for maintaining 2010 and Beyond lished the Subspecialty Board of Neonatology. temperature, precision micro-management Over the past 100 years, there have been re- After the 1976 report Toward Improving the of fluid delivery, sophisticated nutritional markable advances in the care of the neonate Outcome of Pregnancy by the AAP, American management, and continued improve- and dramatic progress in reducing the infant College of Obstetrics & Gynecology, and the ment in ventilatory management (e.g., pa- mortality rate. Each year in the U.S., over National Foundation, premature care became tient-triggered ventilation, high-frequency 500,000 infants are born premature. Infants increasingly centralized in regional NICUs, ventilators, pressure and volume support at the borderline of viability in both weight with dramatic improvements in survival. The ventilators, and computerized pulmonary and gestation are surviving. Over the past concept of concentrating the sickest patients in function graphs and trends). century, the outlook for infants with birth regional centers persists. For those infants who weights of 1 kg has changed from 95% mor- are less acute, the expanding numbers of neo- Developmentally Supportive Care tality to 95% survival. With the enormous natologists, neonatal nurses, and respiratory Beginning in the 1970s, there was increas- progress made in neonatology during the therapists have enabled the establishment of ing awareness that the parents and families past decade, and with every indication that nurseries that are capable of providing a high were important participants in the care pro- it will continue, neonatal nurses and physi- level of care in community hospitals. As a re- vided for preterm infants. Maternal-infant cians should be proud of their accomplish- sult, some degree of de-regionalization has oc- bonding was fully described, and fathers ments and look forward to the future. l curred, with many infants being cared for in obtained “nonvisitor” status. Heidelise Als state-of-the-art neonatal units, by board-certi- introduced the Newborn Individualized De- The references for this article fied neonatologists, closer to home. velopmental Care and Assessment Program, are available at www.anhi.org

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