HISTORICAL TRENDS IN NEONATAL OUTCOMES: AN OVERVIEW OF THE 20TH CENTURY

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HISTORICAL TRENDS IN NEONATAL OUTCOMES AN
OVERVIEW OF THE 20TH CENTURY
MERGING THE GOALS OF NEONATOLOGY AND PUBLIC
HEALTH

• Nigel Paneth MD MPH
• Vermont-Oxford annual meeting
• Washington DC Dec 2, 2006

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PUBLIC HEALTH AND NEWBORN CARE A COMPLEX,
ITERATIVE INTERACTION

• Maternal and Child Health has more clinical
  involvement than any other sphere of public
  health
• Pediatrics, especially neonatal care, has had
  more public health involvement than any other
  field of medicine
• Still an uneasy relationship at times
• I will try to focus on the interactions and
  collaborations and how they advanced public
  health together

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SOURCES OF CHILD HEALTH ADVANCES

• General societal changes
• Improved SES and nutrition
• Decreased family size
• Better understanding of health determinants
  nutrition and hygiene, especially
• The public health infrastructure
• Funding
• Legislation
• Specific advances - water supply,
• The medical infrastructure
• Organization of care
• Training advances
• Scientific/clinical advances
• Laboratory
• Machinery
• Surgical
• Pharmacological

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ERAS IN NEWBORN CARE IN THE 20TH CENTURY

• 1900-1925 The era of nutrition, hygiene and
  public policy
• 19251950 The era of pediatric training and
  scientific discovery
• 1950-1965 The era of progress for mothers but
  stagnation for babies
• 1965-1985 The era of newborn intensive care
• 1985-2000 The era of simple interventions and
  incremental gains

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THE THREE KEY MORTALITY OUTCOMES IN MATERNAL AND
CHILD HEALTH

• MATERNAL MORTALITY
• INFANT (1st year) MORTALITY
• NEONATAL MORTALITY (1st month - more closely
  related to clinical advances)
• POST-NEONATAL MORTALITY (1st month to 1st year -
  more closely related to public health advances)

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1 Alaska included in 1959 and Hawaii in 1960. 2
Data from 1972 were based on a 50 sample. 3
Increased in number from 10 States and the
District of Columbia in 1915 to the entire United
States in 1933.
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1 Alaska included in 1959 and Hawaii in 1960. 2
Data from 1972 were based on a 50 sample. 3
Increased in number from 10 States and the
District of Columbia in 1915 to the entire United
States in 1933.
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1 Alaska included in 1959 and Hawaii in 1960. 2
Data from 1972 were based on a 50 sample. 3
Increased in number from 10 States and the
District of Columbia in 1915 to the entire United
States in 1933.
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RATIO OF 1915 MORTALITY RATE TO 2000 MORTALITY
RATE FOR THE 3 PERINATAL MORTALITY RATES

• MATERNAL MORTALITY 74 times
• NEONATAL MORTALITY 10 times
• POST-NEONATAL MORTALITY - 15 times

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NEWBORN CARE AT THE TURN OF THE CENTURY
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Early French incubators by Stephane Tarnier A,
B and by Alexandre Lion - C (from A Schuman
Contemp Pediatr 2006
A
B
C
C
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THOMAS MORGAN ROTCH (1849-1914)

• First US professor of pediatrics (Harvard Medical
  School)
• Percentage method of infant feeding

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THE FIRST ERA 1900 - 1925HYGIENE, NUTRITION,
MOTHERING

• Maternal employment and other behaviors a major
  focus
• Education of mothers in hygienic practices and
  nutrition of children high priority
• Focus on infant mortality rates
• Beginnings of scientific feeding studies

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HIGHLIGHTS OF THE FIRST ERA

• Federal Childrens Bureau established in 1912
• US Birth registry established in 1915
• Sheppard-Towner Act of 1922 federal aid to
  states for child health and welfare

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JULIUS HESS (1876-1955)

• Established first premature unit in US (Chicago,
  1915)
• First US textbook of premature care, 1922

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PERCENT DECLINE (5 YEAR INTERVALS) IN KEY
PERINATAL MORTALITY RATES IN US, 1915-1930
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THE SECOND ERA 1925 1950 TRAINING AND
SCIENTIFIC DISCOVERY

• American Academy of Pediatrics founded in 1930
• Maternal mortality committees. 1,343 of 2,041 NYC
  maternal deaths, 1930-2 judged preventable
• First US blood bank 1937, Cook County Hospital,
  Chicago. 1,500 blood banks by 1950
• 1938 Gross repairs patent ductus in baby
• Sulfonamides early 1930s
• Synthesis of Penicillin by Florey and Chain
  1941
• Citywide premature transport NYC, 1948

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PERCENT DECLINE (5 YEAR INTERVALS) IN KEY
PERINATAL MORTALITY RATES IN US, 1930 - 1950
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THE THIRD ERA 1950-1965PROGRESS FOR MOTHERS,
STAGNATION FOR BABIES

• ACOG founded in 1951
• Difficult times in nurseries oxygen and RLF,
  sulfa and kernicterus, delayed feeding
• Apgar score published, 1953
• Lubchenco growth charts published, 1963
• In 1963, President and Jackie Kennedy have a
  32-week, 2,100 g premature baby who died of RDS
  at 39 hours.

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PERCENT DECLINE (5 YEAR INTERVALS) IN KEY
PERINATAL MORTALITY RATES IN US, 1950 - 1970
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THE FOURTH ERA 1965 -1985 NEWBORN INTENSIVE CARE

• Medicaid enacted 1965. Legislation provides
  funding for newborn intensive care
• 1968, Rhogam first used clinically
• 1971, Gregory et al describe CPAP
• 1976, March of Dimes prescribes regionalization
  of newborn care, with 3 hospital levels
• 1980s many papers showing decline in low
  birthweight mortality related to NIC

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THE BEGINNINGS OF INTENSIVE CARE
Utah NICU 1971
Bird respirator, early 1970s
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PERCENT DECLINE (5 YEAR INTERVALS) IN KEY
PERINATAL MORTALITY RATES IN US, 1970 - 1990
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THE FIFTH ERA 1985-2000SIMPLE INTERVENTIONS AND
INCREMENTAL GAINS THAT ARE NOW SLOWING DOWN

• Folate supplementation prevents neural tube
  defects, 1991
• Sleep position linked to SIDS, 1990-1991
• NIH consensus report on antenatal steroids - 1994
• Surfactant use in nurseries from late 1980s
• Leveling off of infant mortality since mid-1990s

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RESULTS OF THE MRC VITAMIN STUDY (LANCET
1991338131-7)
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(No Transcript)
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PERCENT DECLINE (5 YEAR INTERVALS) IN KEY
PERINATAL MORTALITY RATES IN US, 1990 - 2000
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VOX MORTALITY 1990 -2005
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WHY THE RECENT MORTALITY STAGNATION?

• Absence of new technological or pharmacological
  interventions?
• Saturation of newborn intensive care development
  capacity? (i.e. no boondocks left)
• Breakdown of regionalization?

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NEONATAL CARE IN THE 21ST CENTURY

• Prediction is difficult especially about the
  future (Woody Allen)
• Some predictions nonetheless
• More neonatal energies will be devoted to
  improving neurodevelopment than to improving
  survival
• We will continue to worry about iatrogenesis,
  putting some brakes on discovery
• Preterm birth will be incrementally reduced by
  finding some of the causes, but not all.

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NUMBER OF CHILDREN lt 1,000 G SURVIVING TO AGE ONE
IN THE US 1960-1998
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THE INCREASING PROPORTION OF CP FROM ELBW
INFANTSINNER RING 1960 0MIDDLE RING
1983 16OUTER RING 2001 25
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VOX SEVERE IVH 1990 -2005
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SOME THOUGHTS FOR VERMONT-OXFORD

• Can Vermont-Oxfords goals be merged with those
  of public health?
• Can we make VOX into VOX POPULI (The voice of the
  people)
• I recommend linkage of VOX data to birth
  certificates to obtain a denominator population
  for your rates and an understanding of what
  proportion of regional babies you serve

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PERINATAL EPIDEMIOLOGY

• A discipline that uses epidemiologic approaches
  to investigate human health phenomena occurring
  during pregnancy and infancy either as outcomes
  of interest or as exposures that may lead to
  adverse health states in later life.

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NIH- FUNDED T-32 TRAINING PROGRAM IN PERINATAL
EPIDEMIOLOGY AT MICHIGAN STATE UNIVERSITY
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TRAINING IN PERINATAL EPIDEMIOLOGY AT MSU

• Program funded by NICHD in May 2005
• The only T-32 training program in the nation
  focused solely on perinatal epidemiology
• Support restricted by NIH rules to US
  citizens/green card holders
• We have two post-doctoral positions per year
• Support is for two years
• Accepting applications for 2007-8 until May 2007
• Would love to have a neonatologist in the
  program!
• If interested, email cv to paneth_at_msu.edu