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Neonatology and Neonatal Intensive Care

preemie--bonnet and bear
Neonatology, or the study and care of newborns, is a relatively young medical specialty. Although its development began in the late 19th century, spurred on by the invention of the incubator, neonatology began to have a huge impact in the 1950s and 60s. Prior to this time, about half of all premature babies did not survive.

Knowledge and understanding of the physiology of the premature baby, and the functioning of immature organs, has since accumulated. With the introduction of neonatal intensive care units (NICUs) in the 1960's and early 1970's, survival rates for premature babies and full term babies born with medical problems began to climb. In Canada, over 95% of all babies admitted to a NICU now survive. Survival statistics are similar for most of the developed world.

This incredible improvement in survival is due to increased understanding of newborn baby physiology, better management, and application of newer technologies.

Survival and disability

While the vast majority of deaths due to prematurity are now prevented, the survival rate for extremely premature babies, those born at a gestational age of 25 weeks or less, remains at about 50%. In addition, of those extremely premature babies that do survive, about half will have a disability of some kind, many of them severe.

Despite the incredible technological capabilities of the NICU, it must be recognized that there are limits to what can be accomplished. In the case of extremely premature babies, babies born with a very low birth weight, and babies born with certain medical problems, many cannot be saved. Of those who can be saved, some will have developmental problems that will have an important, and perhaps serious, impact upon their quality of life.

Developmental problems

Developmental problems originate in the brain and can affect the body and the mind. The severity of developmental problems ranges from mild, perhaps hardly noticeable, to severe, to the point that the child will require constant hands-on support and may not be aware of his surroundings. In many cases, with early intervention and therapy, the impact of developmental problems can be modified and diminished. Developmental problems can affect many functions, including body movement and coordination, hearing, understanding, behaviour, learning, socialization, and emotions. As with most conditions arising as a result of prematurity, the babies born most prematurely or with the lowest birth weights are most at risk for developmental problems.

Limits of neonatal intensive care

In many ways, the NICU represents an attempt to simulate, at least in part, the conditions in the womb in an effort to allow a baby time and the right environment to develop to maturity. But the NICU is only an approximation of the environment of the uterus.

Although neonatal research, technology, and knowledge continue to improve the survival and quality of life of premature babies, no amount of research can guarantee that all premature babies, especially those born at the extreme end of prematurity, will survive or be free of disability. At the same time, the vast majority of babies born at 28 weeks or more will go on to thrive as children.

Confronting poor prospects

Parents with a premature baby facing very poor prospects are often confronted with difficult choices. Many people feel that a certain level of quality of life is more important than simply sustaining life itself. Parents and the health care professionals at the NICU are, at times, forced to make decisions in the face of very poor prospects for a baby.

Jonathan Hellmann, MBBCh, MHSc,  FCP(SA), FRCPC