One day in the early 1950s, I attended a pediatric convention in Washington, D. C. In the course of that convention, Dr. Julius Hess of Chicago received a plaque from one of the lay magazines for presumably demonstrating that premature infants fed on breast milk did not develop retrolental fibroplasia.
A fair number of cases of retrolental fibroplasia occurred among infants fed premature infants' special formulas in our premature service at New York Hospital as well as among those at the Boston Children's Hospital, the Babies Hospital in New York, Johns Hopkins Hospital and other highly scientific hospitals. The babies in Dr. Hess' service fed only on breast milk did not develop the condition.
Many of you undoubtedly remember the solution to this mystery. The incubators used by Dr. Hess were old and imperfect, and it was literally impossible to raise the oxygen levels above 40 per cent. Retrolental fibroplasia is today essentially a disease of the past.
Now, two decades later, much more is known about the care of the premature infant. But another serious entity related only to the premature infant has drawn the attention of all pediatricians. This is the respiratory distress syndrome, first described as a specific pathological condition in 1953 under the name of hyaline membrane disease.
To some it may seem that this condition is more frequent today than it was 20 years ago. However, in retrospect, one can remember many premature infants who had the signs and symptoms of RDS but were diagnosed as having congenital atelectasis. A glance at the Mitchell- Nelson textbook of pediatrics of the era confirms that the primary cause of death in the premature was "congenital atelectasis."
In the first two issues of PEDIATRIC ANNALS we have presented to pediatricians an up-to-date survey of the whole subject of prematurity.
The guest editor Dr. Charles H. Bauer, a neonatologist of international reputation, has gathered an outstanding group of authorities from the United States and Europe to discuss all areas of the subject.
The general aspects of the subject were covered in the October issue of this magazine with the exception of the article "Neonatal Septicemia in the Premature" by Dr. Henry R. Shinefield, which appears in this issue. The remainder of this issue discusses the respiratory distress syndrome with present concepts of its etiology, pathology, treatment and sequelae.
Although much more is still to be learned about the causes of prematurity, the knowledge gained during the past 20 years has given premature newborns a greater chance of life and a reduction in certain of the complications and sequelae so often associated with prematurity.
Centrally located intensive care units to which high risk prematures may be brought; the use of phototherapy or transfusions if necessary for hyperbilirubinemia; the assistance by ventilation when indicated plus the monitoring of PO2 and PCO2 in arterial blood with control of acidosis; and the prevention of anemia have all combined to aid in this reduction.
Possibly in the not too distant future hyperbaric therapy will be combined with other forms of treatment to bring to these infants an extrapulmonary source of oxygen.
One aspect of the subject of premature care which is often neglected but is of the greatest importance is the pediatrician's relationship with the parents of the infant. Both Dr. Howard A. Fox and Dr. Bauer in the October issue have touched on this point. The ordeal of the parents is usually extreme. With few exceptions these are people who have been going through the pregnancy in happy expectancy. Most of them have had the mild concern associated with every pregnancy. But suddenly a premature infant is born and a wave of intense anxiety envelops both parents.
"Will the infant live?" "If it lives, will it be as healthy and normal as any other child?" "How can we handle and care for such a little baby, once we get it home?" These are only a few of the questions that should be answered as thoroughly as possible by the pediatrician; it is important that enough time be set aside to discuss all aspects of the baby's condition with the parents. Even if for the time being many of the questions cannot be fully answered and even if the same questions are asked over and over again, the opportunity to talk to the pediatrician relieves a great deal of the parents' anxiety and tension.
Unless adequately relieved before an infant is discharged from the hospital, this anxiety may carry over in the parent's care of the child making them apt to be unnecessarily overprotective, overindulgent and overpermissive.
In an increasing number of modern premature units in the United States, mothers are encouraged to feed and handle their babies while still in the incubators once the infant has graduated from the intensive care period. In most hospitals, once the infant is out of the incubators, mothers are given the opportunity to feed their babies several times a day. If a mother has kept her breast milk flowing and she desires to nurse, nursing can be started also. All of these activities under the supervision and encouragement of the premature nurses give the mother a great deal of reassurance and the knowledge that she is capable of caring for her child successfully.
In former days premature infants were kept in the hospital until they had reached a weight of five pounds. As brought out by Dr. Bauer in his article in this issue, this weight should no longer be held as a fixed standard. Once a premature is gaining well and seems in good physical condition it may be sent home in the care of its mother even if the infant is only slightly over four pounds. Of course this practice is predicated upon the capability of the mother to care properly for the child and the adequacy of the home environment.
Nurses should visit the mother at regular intervals during the first month or so, and the baby should be seen every few weeks by the pediatrician. The mother should feel free to call the doctor or the nurse if she has any questions or if any problems arise.
Parents of prematures should know that once the infants are discharged from this hospital they can be considered and treated as normal newborns. They can be handled and patted and carried around during their waking hours without fear of harming them. As a matter of fact holding the baby while it is being fed or at other times, cuddling it, walking around with it, talking and singing to it are all stimulating to the infant. Usually a premature infant given this high degree of attention will gain weight faster and become more alert than those infants left in the crib most of the time.
Throughout the years that follow, the child who has been born prematurely should be carefully followed by the pediatrician to observe if there are any sequelae, especially among those children who were of very low birth weight and low gestational age, and among those prematures who developed RDS.
A parent should not, however, be given the impression mat his premature child once home and said to be normal is likely to develop some defect. The chances are all in favor of the child's continuing to be normal. If defects do occur, they can be handled when detected.