A neonatal-perinatal medicine specialist, otherwise known as a neonatologist, is a physician who has specialized in the care of newborn babies. They may serve as general pediatricians that provide health assessments for newborn babies and are capable of caring for newborn babies that require critical care. They also provide counseling regarding the care of sick newborn babies. Neonatal refers to the first four weeks after a baby is born. The perinatal period starts at the 24th or 26th week into the pregnancy and ends at birth, although the definition varies from place to place.
Job Description
When a baby is born, a pediatrician is more than capable to provide the care the baby needs. However, when a baby is about to be born sick or premature, the specialized care and expertise of a neonatologist is often necessary. When an unborn baby presents a medical condition or when there is a significant risk of premature birth, a neonatologist provides information on what to expect before, during, and after the delivery. They monitor the condition of the unborn baby to provide the best possible care. When a baby is born sick, the baby is sent to the Neonatal Intensive Care Unit, where a neonatologist can provide constant support for its developing life functions and care for its sickness. Neonatologists also provide advice for the parents of a sick newborn baby. This is especially necessary because a mother who gives birth to a sick baby may often develop irrational guilt or depression. Neonatologists teach these parents how to safely interact with the sick baby and how to provide care at home.
Education & Training
The education required for a neonatologist starts just like any other physician. An undergraduate degree with credits in relevant sciences like Biology, Biochemistry, Anatomy, and others is required. Following an undergraduate degree is at least four years of medical school. The aspiring neonatologist must then undergo residency training in pediatrics that lasts three years, followed by three more years of training in newborn intensive care. In America, a neonatologist must first pass a certification exam provided by the American Board of Pediatrics, followed by another certification exam from the Sub-board of Neonatal-Perinatal Medicine.
History
Prior to the development of neonatology, the infant mortality rate was extremely high. In 1859, the infant mortality rate in England was 45%. Many of the babies who survive die before their first birthday. Until the 1950s, many hospitals would send newborn babies home immediately after they are born.
Pierre-Constant Budin, a French obstetrician, noted three key issues in the support of premature babies, these are the baby’s warmth, feeding, and susceptibility to disease. His mentor, Etienne Stephane Tarnier, developed the first infant incubator to solve the issue of warmth. This crude incubator was a wooden box with a hot water bottle inside, covered by a glass lid. This invention contributed to a significant decrease in infant mortality. The idea comes from an incubation chamber for poultry in the Paris Zoo. The crude incubators for premature babies were introduced in the Paris Maternity Hospital in 1880 and reported great success by 1895. One of Budin’s students, Martin Couney, brought an improved version of this invention outside Paris through an exhibition called “Kinderbrutanstalt”, which is German for “child hatchery”. In the exhibition is a number of incubators, all with premature babies inside. This exhibition was placed in an amusement area and boasted that there were no deaths among all the premature babies. This exhibition became extremely popular in Berlin. At the time, incubators were not used in many hospitals in Europe and America due to its cost and lack of evidence of efficacy. The incubators Couney used also limited access to the baby. Couney offered incubator treatments free of charge and paid for its costs with the admissions to the exhibitions. American hospitals would begin to use incubators around the 1950’s, a few years before Couney’s death.
In the early 1890s, many infants died due to diarrhea, caused by unpasteurized cow milk. In response, Budin recommended the use of mothers’ breast milk instead of cow milk. He educated many mothers in topics, such as nutrition and hygiene. To aid in supporting premature babies who could not feed normally, he introduced the gavage, a process that sends milk directly to the stomach through a tube.
In 1896, a respiratory infection epidemic broke out in the Paris Maternity Hospital. To respond to this, Budin introduced plans for a basic neonatal intensive care unit. These plans are very similar to how neonatal intensive care units function today, with some modifications with the incorporation of new technologies. His plan is as follows:
Group together healthy premature infants
Isolate the sick infants
Separate wet nurse contact between healthy babies and premature babies
Create a room where milk can be sterilized
Keep sterilized milk cool in a separate room
Maintain hygiene among wet nurses
Incubators began to see use in American hospitals in the 1950s. At first, old Couney incubators were used. Then Dr. Julian Hess, an American pediatrician, invented the Hess incubator. This incubator provided heat, humidity and oxygen to a baby. To solve the issue of monitoring and access (the walls of the incubator were still made of wood), the Isolette Infant Care Station was invented. These incubators were built with clear plastic walls instead, allowing the nurses and doctors to easily see inside.
At this point, the rooms that held premature babies were separated into cubicles, each with one baby in an incubator inside. Doctors and nurses had little direct contact with the babies and parents had no direct contact with their babies at all. This was done because the prevailing thought at the time was that the biggest infection vector to a baby was another baby. This way of thinking regarding infections, as well as the design of the rooms that held newborns, changed through the experiments of Dr. Louis Gluck and several associates. Several babies were placed inside the same room, a setup which was considered extremely dangerous at the time. Some of the babies were regularly washed and some of the babies were not. The babies who were regularly washed showed a significantly lower chance of getting sick and had far less pathogens in their cultures than those who were not washed. Their experiment proved that as long as proper hygiene is maintained for the babies as well as their visitors, the risk of infection is very low. This led to a redesign of the rooms that held newborn babies. The cubicles were removed, allowing the doctors and nurses to observe and care for babies easier and more efficiently.
Parental involvement in the care of newborn babies began to be encouraged with the Newborn Individualized Development Care and Assessment Program, developed by the Heidelise Als in the 1970’s. Prior to that, care for babies is primarily based on machines. Research proved the many positive effects of skin contact, now called kangaroo care, between a mother and her baby. Kangaroo care between mother and child was therefore greatly encouraged, and is now recommended for any parent.
Responsibilities
Premature Childbirth
A normal pregnancy will generally last around 40 weeks. If a baby is born before 37 weeks of pregnancy, it is considered premature. In a report submitted to the World Health Organization in 2010, about 15 million babies or more than 10% of babies born worldwide are premature. More than one million of these babies die after birth, with many others who suffer from permanent disabilities.
While the cause of premature childbirth has not yet been pinpointed, many risk factors are known to be associated with it. Some of the risk factors include the following:
Period in between pregnancies – less than nine months between childbirth and the next pregnancy
Previous premature birth
Multiple babies – Twins, triplets, quadruplets, and so on have a higher risk of being premature
Pre-eclampsia – high blood pressure and protein in the urine after the 20th week of pregnancy. Symptoms include headaches, nausea and vomiting, and swelling of the hands and face. The only known solution is to deliver the baby
Chronic illnesses such as diabetes, kidney disease, lupus, etc.
Age – Mothers younger than 18 or older than 40 are at a higher risk of premature birth
Alcohol Consumption
Drug Abuse
Smoking
Infections affecting the vagina, kidney, bladder, and urinary tract
Family history – a family history of premature birth increases the risk of premature birth
Babies who are born premature have some undeveloped organs and systems, such as the lungs, the immune system, the digestive system, etc. Specifically:
Undeveloped lungs make breathing difficult. Additional oxygen may be given through a respirator
Premature babies do not have a lot of body fat, making it more difficult for them to sustain body heat. They are placed in incubators which provide the necessary heat for them.
An underdeveloped liver increases the risk of jaundice, which will then cause brain damage
Premature babies are highly susceptible to infections due to their weaker immune systems
An underdeveloped stomach makes it difficult for babies to process breast milk, so nutrition may be provided through an IV tube.
An underdeveloped brain makes premature babies unable to reliably and consistently breathe on their own.
This puts them at a significant risk of illness that requires specialized care. Neonatal-perinatal medical specialists are trained to handle these conditions. Unlike other physicians, neonatologists do not focus on particular organs or organ systems. Instead, they are trained to care for all systems of newborn babies.
Birth Defects
Some babies do not form normally during pregnancy. They may have problems in organ formation or metabolic function. These conditions are called birth defects. A missing or incorrectly formed body part is called a structural birth defect, while a problem in metabolic function is called a metabolic birth defect. Birth defects generally form within the first three months of a pregnancy, when organs are starting to form. Birth defects can also occur after the first three months of a pregnancy, when the tissues of the baby are forming.
Birth defects are fairly common, occurring in one in every 33 babies in the United States. There are many known risk factors associated with birth defects, although its direct cause is often unknown. Genetics heavily influences the occurrence of birth defects. The mother’s nutrition and lifestyle also influences the occurrence of birth defects. Mothers who drink alcohol, smoke, or use drugs are more susceptible to giving birth to a baby with a birth defect. Mothers over the age of 34 are also more susceptible to the same conditions.
There is no absolute way to prevent birth defects. However, its risks can be managed with proper diet and lifestyle choices, as well as regular consultations with a physician. Many birth defects can be avoided if the mother takes folic acid, a B vitamin that promotes brain and spine growth for the unborn baby. Birth defects can be detected with ultrasound scans. When detected, management can begin immediately.
Conditions and Management
Birth Asphyxia
A primary cause of stillbirths is birth asphyxia, which means the baby could not breathe upon being born. Inside the womb, the mother is responsible for delivering oxygen to the baby using oxygen in the placenta delivered through the umbilical cord. As soon as the baby is born, it takes its first breath to adapt to the changes in environment. If it fails, the baby will asphyxiate and suffer damage to multiple organs, including the heart, lungs, liver, and brain. This damage can be fatal.
Intervention for birth asphyxia is relatively simple. The use of a bag-and-mask or other such devices that aid in breathing is considered an important first step in responding to birth asphyxia. Most infants recover quickly when such techniques are performed. Newborn babies are also very capable of withstanding the lack of oxygen to the tissues. Very few infants who suffer from birth asphyxia require further treatment when ventilation is provided early, but some may require chest compressions or medicine.
Even though the intervention required for birth asphyxia is relatively simple and very cheap, birth asphyxia remains to be the leading cause of stillbirths, contributing to an estimated 900,000 stillbirths each year. The areas with the highest number of stillborn incidences are sub-Saharan Africa and south Asia, particularly in places with poor health services. Ventilation devices like the bag-and-mask may be unavailable or of poor quality, or there may not be adequate training among the health service providers for the diagnosis of birth asphyxia or the relevant interventions needed.
Neonatal Sepsis
Sepsis is defined as damage to tissues and organs caused by the immune system’s response to an infection. The infection may be received from the mother, which shows symptoms soon after childbirth. The infection may also be received from the environment long after birth.
There are known risk factors for neonatal sepsis in childbirth, also called early onset neonatal sepsis. These include premature birth, or bacteria colonies in the birth canal. Other factors include a history of abortion, drug abuse, improper nutrition during pregnancy, low birth weight, or birth asphyxia.
Symptoms for neonatal sepsis include seizures, jaundice, vomiting, body temperature changes, low blood sugar, reduced movement, and reduced sucking. Early detection is key to effectively treating neonatal sepsis, as mortality rates increase dramatically as it is left untreated. Babies who are born normally and receive early treatment usually do not suffer permanent damage. Premature babies who are affected by neonatal sepsis may suffer permanent brain damage, such as hydrocephalus and cerebral palsy. Even without permanent damage, premature babies who suffer from neonatal sepsis will experience slower brain growth.
Babies who get a fever are immediately treated with antibiotics, as laboratory results take a while to confirm the condition. When a mother is known to be infected, or there is some other known risk factor for neonatal sepsis, antibiotics are given as soon as the baby is born. Should bacteria be found in the baby’s stool, blood, or spinal fluid, antibiotics would be given for three more weeks.
Gastroschisis
Sometimes, babies are born with a birth defect that exposes their intestines outside their bodies. This birth defect is called gastroschisis. The intestines are exposed in a hole near the belly button. Depending on the size of the hole, other internal organs like the liver and the stomach may be exposed as well. This birth defect occurs when the abdominal wall does not form correctly while inside the womb. Gastroschisis can be detected early into the pregnancy through ultrasound scans. It is also immediately obvious upon the baby’s birth. If left untreated, gastroschisis can be fatal.
Depending on the size of the hole, gastroschisis can be immediately treated with surgery. For larger holes with more exposed organs, the process of returning the organs inside the body and sealing the hole is done in multiple stages. The other organs are covered with sterile material in between surgeries. While normal bowel function is not maintained yet, nutrition is given to the baby through an IV. They are also given antibiotics to respond to the risk of infection.
Although the cause of gastroschisis has not been found yet, it occurs more commonly among mothers who are younger than 17 or among mothers who smoke or drink during pregnancy.
Esophageal Atresia
Esophageal atresia is a birth defect characterized by a disconnection between the upper esophagus and the lower esophagus. The upper esophagus may close altogether in a pouch or be connected to the windpipe. The lower esophagus may also close altogether or be connected to the windpipe. When a connection to the windpipe is formed, breathing problems may occur to the baby.
Esophageal atresia is considered a surgical emergency, with higher treatment success rates the sooner it is treated. The upper esophagus pouch usually contains a buildup of saliva, which should be suctioned out before treatment. If the saliva is not removed, it may spill into the lungs, leading to choking. If the two ends of the esophagus are close together, a primary repair will be performed, where the two ends will be sewn together. If the gap between the two ends is too large, only the connection between the esophagus and the windpipe will be closed, and the esophagus will eventually be repaired. Until the baby can safely feed through the mouth, nutrition will be provided through IV. After the baby has recovered from the surgical operation, nutrition will be provided through a tube while the esophagus heals. In the case of a primary repair, a tube goes down through the nose and the esophagus and directly to the stomach. For the repair of a wider gap, a tube goes directly into the stomach through the stomach the moment the windpipe connection is closed. This is called a gastronomy tube, which serves to feed the baby and remove excess air from the stomach until the repair operation can continue.
Babies who have esophageal atresia with a connection to the windpipe will often experience acid reflux. To treat this, babies are given antacid medicine, as well as medicine that helps empty the stomach. The amount of medicine needed varies depending on the baby’s weight.
Congenital Hydrocephalus
Surrounding the brain is cerebrospinal fluid, which serves to cushion the brain from impact. This fluid is constantly being produced and drained. A malfunction in the draining of cerebrospinal fluid results in hydrocephalus. The fluid buildup exerts pressure on the brain, leading to impaired brain function. Hydrocephalus can be caused by multiple birth defects. The most common birth defect that causes hydrocephalus in babies is aqueductal stenosis, where a blockage is formed in the cerebral aqueduct. This may be caused by the formation of tissue in the aqueduct, an infection, bleeding, or a tumor.
Hydrocephalus can be found during the pregnancy with an ultrasound scan as early as 13 weeks. Detection is easier around weeks 20 to 24. The treatment method depends on the cause of the hydrocephalus. Normal delivery may be risky for babies with hydrocephalus. A cesarean section may be recommended for a safer delivery.
Once the baby is born, a shunt is surgically inserted into the baby’s brain. A shunt is a tube that drains the excess cerebrospinal fluid into other parts of the body, such as the heart or the abdomen. This will relieve the pressure on the brain and allow the excess cerebrospinal fluid to be absorbed into the bloodstream. This tube will often be replaced with longer tubing as the baby grows bigger.
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