The History of Neonatal Care
The care of premature babies over the last 150 years
Up until the late 19th century, most doctors did not consider premature babies worth saving. Despite significant advances in other areas of medicine, there was very little interest in the plight of these tiny “weaklings". The prevailing mindset in many cultures was that babies born early were simply not meant to survive.
This article explores some of the advances that have taken place in neonatal care in Western countries over the last 150 years.
Most women gave birth at home until the mid-twentieth century, traditionally accompanied by female relatives or a midwife. Doctors, who were almost exclusively male, were rarely present, although a surgeon was sometimes summoned if the baby was stuck in the birth canal. Doctors who did attend births were usually more concerned about saving the mother than the baby.
Prematurity
Babies born before their due date, no matter how small, were not admitted to the hospital. Families would try desperately to keep the tiny baby alive at home; sometimes placing them in the oven in an attempt to keep them warm. Other problems such as breathing difficulties and the baby’s inability to suckle at the breast were harder to address; resulting in many premature babies dying.
Prematurity is the term given to babies who are born before the 37th week of pregnancy. Even today, despite sophisticated technology and intensive medical and nursing interventions, babies born early often suffer from problems such as:
- Poor temperature regulation
- Respiratory problems
- Poor feeding and slow weight gain
- Poor blood glucose regulation
- Jaundice
- Bowel problems
- Neurological and developmental issues
- Problems with vision and hearing
For more information about classifications of prematurity and its potential complications click here.
What is a Neonate?
The word neonate refers to an infant in the first 28 days of life. It originates from two Latin words; neo meaning new and natal meaning birth. Neonatology has only been a speciality in its own right since the 1970s and is a sub-speciality of paediatrics. In medical terminology, once a baby has reached 28 days, they are classed as an infant rather than a neonate.
Advocates for Premature Babies
Two French Doctors
In the late 1800’s obstetrician, Stephane Tarnier and his assistant Pieree-Constant Budin took an interest in saving premature and low birth weight babies. They recognised the importance of a warm, humid environment and high standards of hygiene. They can also be credited for “Gavage” (tube-feeding); a significant innovation that enabled small, weak babies to be nourished with sterilised cow’s milk, without the need to suckle on a breast.
France was the first country to provide medical and nursing care to premature babies, and it has been credited as the world leader in neonatology.
The first incubators
Dr Tarnier had observed chicks being cared for in incubators and decided to develop similar devices for babies. The first incubator (isolette) Tarnier designed was simply a wooden box with an air vent, with a hot water bottle inside. The box had a glass lid so that the baby could be viewed. Adaptations to the design were made as necessary and the incubator became more sophisticated over time.
The Paris hospital where the incubators were trialled was found to have a much lower mortality rate for premature babies than other hospitals.
Martin Counay’s Infantoriums
One of Budin’s associates, Martin Couney, took the incubators to other European countries and then to the United States, to promote their use. American doctors dismissed them as being too expensive and unnecessary which led Counay to make a radical decision. He approached parents of premature babies and offered to care for them himself.
Before long Counay had established an unofficial special care nursery with his own small team of nurses. Remarkably, he did not charge parents for his services; rather he funded this work in an unconventional and controversial way. He took the babies to circuses and amusement parks and exhibited them in incubators at the side shows alongside other human “oddities”; charging visitors 25 cents to view the babies.
The most famous “infantorium" was at the Coney Island Fair, New York and ran from 1903 to 1943. Counay travelled to several other cities to exhibit the babies at events such as World Fairs in Chicago, Atlantic City and Portland, Oregon. The shows were incredibly lucrative, thus covering the costs of these unusual nurseries. This meant that rich and poor parents alike could bring their babies to Counay to be saved. Most importantly, the majority of the babies survived. Critics were quick to denounce Counay’s exhibitions as exploitative and distasteful, however, they could not argue with the success of his methods.
The Nurses’ Role
Nurses would remove the babies from their incubators several times a day to feed and change them. Wet nurses were employed by Counay to breastfeed the infants who were old enough and strong enough to suckle. The smaller, weaker babies were fed sterilised milk either orally or intra-nasally. Despite maintaining strict rules about hygiene, Counay encouraged the nurses to cuddle and talk to the babies; a radical concept at that time.
One Patient’s Story
One of the “Coney Island Babies" was called Lucille Conlin Horn. Following the death of her twin sister her father was told by doctors that Lucille, who weighed only two pounds, would not survive. He wrapped her in a towel and took her in a cab to Martin Counay’s famous infantorium. Lucille spent five months in 1920 being cared for by Counay’s team of nurses and she not only survived but went on to live for ninety-six years, dying as recently as 2017. You can read her story here.
Shift in Opinion
It is estimated that Counay and his team cared for 6,500 babies over forty years with approximately eighty-five per cent of the babies surviving.
There was a gradual shift in opinion throughout the medical community as doctors were forced to admit that Counay’s methods were highly effective. Hospitals became more welcoming to tiny babies and, thanks to the work of Dr Julian Hess, incubators became more sophisticated, with extra insulation and the means to administer oxygen.
The first American neonatal unit was established in 1960 in Yale New Haven Hospital, Connecticut. In the UK, Bristol and Birmingham were the first cities to create such units.
Louis Gluck, an American doctor, has been credited as one of the most influential doctors in the speciality. He ensured that lectures on neonatology were integrated into the curriculum for medical students and he became deeply involved with research. He was also instrumental in the design and operation of neonatal units. He has since been dubbed the Father of Neonatology.
Ironically, some of the babies cared for in the newly established hospital neonatal units initially suffered from more complications than those in Counay’s infantoriums. The reason? Doctors were inadvertently overdosing the babies on oxygen. Although oxygen is essential to life, high levels can be toxic to premature infants. The unsophisticated methods of Counay and his team had its merits.
The Mystery of Martin Counay
There has been much speculation over the last few decades regarding Martin Counay’s qualifications. Despite calling himself “Doctor Counay" and allowing colleagues and families to think he was a specialist, it has since transpired that there are no records of him graduating from or even attending medical school. It is possible that he was in fact a technician with no formal medical training. Whatever his qualifications, or lack thereof, historians agree that he had a pivotal role in changing the way the world treated pre-term babies. You can read more about this here.
Other Significant Developments
Artificial Ventilation
Mechanical Positive Pressure Ventilation has a complex history but it is generally accepted that its use in babies began around the 1950s. It is highly likely that the experimental procedures and rudimentary devices at that time would have resulted in many infants suffering from over-inflated lungs, airway swelling and damage to their delicate tissues.
Continous Positive Airway Pressure (CPAP), a less invasive method of breathing support, was first used in babies in the 1980s. This is still used today although other non-invasive methods of respiratory support such as High-Flow Nasal Oxygen Therapy (eg Vapotherm, Optiflow) are becoming increasingly popular.
Apgar Score
American doctor Virginia Apgar created a scoring system for newborn babies in 1952 which is now used in almost every country in the world. It provides a standardised assessment of the baby, with measurements at one minute and again at five minutes after birth.
Phototherapy
In 1956 in Essex, England, Dr Richard Cremer and Sister Jean Ward inadvertently discovered that sunlight could break down bilirubin, the pigment responsible for jaundice. Jaundice is very common in newborn babies and is usually harmless but in some cases can lead to complications including brain damage. Cremer and Ward’s discovery led to the introduction of phototherapy several years later, now the standard treatment for certain kinds of neonatal jaundice. One of the leading clinicians in the development of this technology was the American Paediatrician Dr Jerold Lucey.
Anti D
Another significant breakthrough in neonatal medicine (although unrelated to prematurity) was the development of “Anti D” immunoglobulin by Australian researcher John Gorman in the 1960s. Prior to this many babies died from Haemolytic Disease of the Newborn (HDN); a life-threatening condition resulting from a particular type of blood group incompatibility between mother and baby. It is estimated that Anti D prophylaxis has saved the lives of over two million babies in the last sixty years.
Extracorporeal Membrane Oxygenation ( ECMO)
ECMO is a form of life support which utilises a type of heart-lung machine, similar to the bypass apparatus used during open heart surgery. Researchers began experimenting with this treatment in adults in the 1970s with successful outcomes. In 1975 it was used successfully on a newborn for the first time in a Californian hospital. The baby girl was on ECMO for several days following severe meconium aspiration. The doctor primarily responsible for this remarkable innovation was American physician Robert Bartlett.
It is important to note that ECMO is not suitable for all critically ill babies and is only available at some specialist units.
Surfactant
One of the respiratory conditions that commonly afflicts very premature babies is Respiratory Distress Syndrome (previously known as Hyaline Membrane Disease). The underdeveloped lungs are unable to produce sufficient amounts of surfactant; a complex fluid that provides lubrication in the lungs to enable effective respiration. For several decades doctors experimented with various treatments but it was not until the 1980’s that Pulmonary Surfactant Replacement Therapy became approved for use in premature infants. This development has been described as one of the most significant advances in neonatal care.
Modern Neonatal Units
With other modern treatments such as intravenous antibiotics, steroids, parenteral nutrition and sophisticated surgical techniques, neonatal care has become two-tiered - Neonatal Intensive Care Units (NICU) for the smallest and sickest babies, and Special Care Baby Units (SCBU’s)for babies who require a less-intense level of medical and nursing care.
Many hospitals that do not have NICUs rely on a regional Neonatal Transport Team to enable sick babies to be quickly and expertly transferred to a specialist hospital.
Full- term Babies
Full-term babies, as well as pre-term babies, may also be admitted to neonatal units for a myriad of reasons. Some examples are low birth weight, hypoxic injury, respiratory problems, feeding difficulties, jaundice, meconium aspiration and bowel obstruction. Some conditions such as congenital heart defects and hydrocephalus can now be detected antenatally and the baby’s admission to the NICU is often anticipated prior to birth.
Many infants continue to be nursed in neonatal units long after they pass the 28 day mark.
Live video links
One of the most recent innovations in neonatal care is unrelated to clinical treatment. It is the introduction of web-based video cameras to enable absent parents to directly view their baby from home (virtual visiting). These cameras offer ongoing assurance to anxious parents that their little one is settled, comfortable and cared for when they themselves are unable to be present.
End note
Despite the remarkable advances in neonatal care in the last 150 years, doctors are sadly not able to save every baby. Even with modern technology and intense medical intervention, it is rare for babies to survive if they are born before twenty-three weeks gestation. Those who do survive often suffer from long-term health and development problems. Although there have been at least two babies who have survived after being born at 21+ weeks gestation, this is very, very rare.
Thank you for reading. If you want to know more about the infantoriums you might be interested in this book:
Raffel, D. (2019) The Strange Case of Dr. Counay: How a Mysterious European Showman Saved Thousands of American Babies. Blue Rider Press. ISBN: 1524744960 / 978–1524744960
For information about the history of adult and paediatric intensive care units, you can access my other article here:
