A Brief History of Neonatology

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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
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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
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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 Hirschsprungs 1691
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Le Tour d'Abandon (The Desertion Tower), Paris
1810-1860
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1st publication of correct average birth weight
and length 1753 (Roederer Germany)
5 ½ lbs
1st description of hypertrophic pyloric stenosis
1788
(todays average birth weight is 7 lbs)
1st description of Transposition of the Great
Vessels 1797
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(forceps deliveries)
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1852-1854
Great Ormond Street Hospital, London Childrens
Hospital of Philadelphia and New York Nursing
and Childrens Hospital are all founded
GOSH
1851
CHOP
First report of gavage feedings for infants
NYNCH
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Jean-Louis-Paul Denucé invents the first infant
incubator
1857
1901 Pan Am Expo, Buffalo
1904, St Louis Fair
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1882
Bedeirt Heat treatment of milk for 2 hrs at 100
degrees C. for artificial feeding (although Louis
Pasteur invented pasteurization 20 years earlier)
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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
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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)
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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
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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)
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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
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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 Kennedys
experience spurred the Western World to find a
cure for RDS.
Birth defects linked to thalidomide 1960
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Victor Freda develops Rhogam - the prevalence of
erthroblastosis starts to fall 1966
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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
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Exosurf (an artificial surfactant) is shown to
be effective by multinational RCTs and is
approved by FDA 1990-1991
High frequency oscillatory ventilators become commercially available 1990
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.
Pulse oximetry widely available in newborns 1987
RCT cryotherapy for retinopathy of prematurity 1985
Neonatology opens Pandoras Box
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P.V. Gordon et al. demonstrate that early postnatal steroids in combination with early indomethacin increase spontaneous intestinal perforations 1999-2007
Multiple RCTs test early postnatal dexamethasones for attenuation of chronic lung disease ( associated with CP intestinal perforations) 1999-2001
FDA approves Nitric Oxide for treatment of pulmonary hypertension in the newborn 1997
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
L. Van Marter Cohort study demonstrating antenatal steroids reduce the incidence of BPD 1990
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What can we learn from history?

1. Neonatology has fathered most of the pediatric
   subspecialties we know today.
2. Much of our progress has come about because of
   society, not in spite of it.
3. 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.
4. There are many Living Legends in Neonatology and
   theres still plenty of room for others to join
   them.