Survival of the Littlest : Neonatology: In the last 50 years the treatment of premature babies has made great advances. St. Joseph’s Hospital in Orange in considered a leader in the field.
ORANGE — Fifty-one years and four months ago, Jeff Tanksley was lying in a blanket-lined drawer in the glow of a single light bulb, fighting for his life. All 26 1/2 ounces of him.
Born three months premature, he created a sensation at Downey Community Hospital, where doctors and nurses--and reporters--hovered over the tiniest infant to be born up to that time in the hospital.
They couldn’t do much else. It was 1940, and the medical specialty that has come to be called neonatology was unknown. Most severely premature babies died, and Tanksley was the smallest of the small. The prescription: keep him warm (the light bulb), watch him and hope.
It worked. Today, Tanksley is 5 feet, 11 inches tall, weighs 185 pounds and is a 20-year veteran of the Orange Fire Department.
He remains aware of his own perilous infancy, and particularly of the hardship such experiences can work on anxious parents who must hand their baby, at least for the time being, over to the care of others.
So whenever he finds himself at St. Joseph Hospital in Orange--after transporting a medical emergency case, for instance--Tanksley pays a visit to the neonatal unit, considered one of the most advanced in the county, to offer the parents concrete hope that their child can develop normally.
“They’ll call me up sometimes and I’ll go in and talk, and it sort of reassures the young parents,” said Tanksley.
“The parents don’t realize what’s involved in premature delivery sometimes. I encourage them, give them a little bit of my history, explain to them that their child can turn out to be normal and healthy because of the advancements in the way they care for them nowadays, as opposed to what I had. It’s amazing what they can do now.”
Doctors from 1940 might be popeyed at the sight of the intermediate care nursery at St. Joseph. It is a thicket of glowing monitors, high-tech incubators and other advanced medical equipment specifically designed for premature infants.
It is that final point--specific equipment--on which the modern evolution of neonatal care turns, said Ragnar Amlie, the medical director of the neonatal units at St. Joseph.
“I think (modern care) sort of started in the early 1970s, because up to that time the equipment used for newborns was modified adult equipment,” he said.
“About that time we began to realize that babies need specialized care. Until then, there was no such specialty as newborn care. We know now that newborns react differently than adults. For instance, if you’re under stress, your heart rate goes up, but with a newborn it goes down. We want to be alerted if the heart rate drops.”
And they are. As part of the cardiac monitoring in the nursery, an alarm in the monitor will sound if the baby’s heartbeat drops dangerously low.
The results are almost instantaneous, because the monitor counts the heart rate every three seconds and automatically multiplies it by 20 to determine the projected number of beats per minute.
Just how far is a machine like the infant cardiac monitor from the care Tanksley got in 1940? Amlie said care in the United States before World War II was similar to what he saw on a recent visit to a hospital in Belize.
“They had shelves with 100-watt bulbs hanging down and the babies under aluminum foil” to keep them warm, said Amlie.
“They had one big oxygen tank over in a corner and a flow meter to control it, and they were flooding this oxygen into the incubators. But they were not monitoring anything. They had no monitoring equipment. They were too poor.
“That would have been about the same amount of equipment we would have had in 1940.”
Why did Tanksley survive? Strong genes, mostly, Amlie guesses.
“He must have been very active at birth,” he said, “and relatively pink. The main thing was to keep him warm. And he must have been fed early. Apart from that, it was survival of the fittest.”
He also had constant care. Tanksley said three nurses and one overseeing nurse were assigned to him around the clock (their names appear in his baby book).
“And my mom had to be there almost constantly to feed me,” he said. “I was so fragile at that size.”
He didn’t stay that way. After three months in the hospital nursery, he went home. By the beginning of February, 1941, he weighed 6 pounds, 4 1/2 ounces.
“I’ve had a normal, active life,” he said.
“They gave me a lot of oxygen when I was first born, and they thought that it might cause some eyesight loss, but it didn’t, until I was about 40 and I started wearing bifocals. I caught up to normal size about the fourth or fifth grade, and I swam in high school for three years on the swim team and the water polo team, and when I was a senior I played right tackle on the football team.”
The statistics suggest that Tanksley should never have developed normally, or even survived.
Amlie estimated that between 5% and 10% of the babies born premature in 1940 who weighed as little as Tanksley at birth would survive.
Today, he said, that figure is between 80% and 90%.
But it was a long time coming, and the history of neonatal care in this century is checkered. In fact, the seemingly obvious necessity of keeping the premature newborn warm was not discovered until just before the turn of the century, said Amlie.
At traveling exhibitions in Europe, he said, doctors demonstrated warming incubators and invited parents of premature newborns to come and use them.
The survival rate increased. The reason, said Amlie, was because the chances of a baby becoming chilled, and suffering a shutdown of circulation to the skin and a consequent lack of use of oxygen, were reduced.
However, “it was forgotten for about 30 or 40 years,” he said. “Nobody really applied that before about 1940.”
Also, the concept of administering oxygen, although accepted early on, often was improperly applied or not applied at all.
In the 1930s, said Amlie, the practice of continuous positive airway pressure was discovered.
It involved connecting the infant to an oxygen pressure system to keep the lungs inflated (lung collapse is a danger in premature babies) and allowing the newborn to breathe against the resistance.
But continuous positive airway pressure was not generally practiced until about 20 years ago, said Amlie. The reason, he said, had to do with a lack of more complete knowledge of the practice and the old idea “that babies and children were regarded as miniature adults--you miniaturize them and all the same principles apply. But they don’t.”
Breathing was, and is, the problem doctors and nurses attack first after a premature birth, and they are winning more and more of the battles.
One reason, said Amlie, is that a phenomenon in preemies called respiratory distress syndrome (RDS) can now be treated with an artificial substance.
Lung collapse, said Amlie, can be triggered by a deficiency in a substance called surfactant. Without it, every time the baby breathes out, his lungs collapse and no oxygen is suppled to the blood when it flows to the lungs.
RDS, said Amlie, caused the death of John F. Kennedy’s newborn son in 1960.
Today, artificial surfactant can be administered.
Feeding, too, is essential early on, and if the baby’s intestines are not yet developed enough to absorb food, it is fed intravenously.
In 1940, said Amlie, many newborns were fed with tiny spoons used to simply ladle formula into the mouth.
(Neonatal intravenous procedures were in their infancy then; when Tanksley required transfusions of blood, adult equipment had to be used, and the needle was inserted into his jugular.)
Modern neonatal care, however, does not wait until an emergency arrives.
“When a baby is born now,” said Amlie, “you already have lots of information, provided the mother has proper prenatal care.” Through the use of ultrasound scanning, doctors can determine the baby’s size, gestation age, heart rate and the amount of amniotic fluid it is moving in.
Ultrasound also can determine if the fetus is distressed in any way, whether its heart rate rises when stimulated and if it is making proper breathing movements.
Through the use of ultrasound and other diagnostic tests, “we can make up a biophysical profile to help us decide how to deliver that baby,” Amlie said.
If the baby is at risk of infection, the doctors can prepare to give the newborn selective white blood cells or antiviral agents--none of which was available before World War II--soon after delivery.
Today, that care is not only physical and not only for the baby. At St. Joseph, a social worker who counsels the parents is part of the neonatal team.
“I think the most common reaction among the parents is fear,” said Sandi Parks, the department manager of the intermediate nursery.
“They want to know if their baby is going to survive. If they have to be in the special-care nursery, they often think, ‘Oh, no, my baby’s going to die.’ A lot of times, seeing other babies in the nursery or hearing other parents talk about their baby is very comforting.”
Mothers are encouraged to give breast milk as soon as the baby can tolerate it, and fathers may donate blood for transfusions.
Today, the nursery often is filled with gowned and scrubbed parents holding their tiny infants and new mothers breast-feeding babies so small that they nearly disappear in their mothers’ arms.
With such care, Amlie said, nearly 90% of the newborns leave the hospital not just alive, but healthy. And they often are allowed to go home at a weight of 4 pounds, 8 ounces, nearly a pound less than would have been allowed only a few years ago, said Amlie.
Also, he said, premature infants who weigh as little as Tanksley did at birth are no longer an oddity. Indeed, national birth statistics show that 85% of babies at that weight are likely to survive today. Virtually none did when the statistics were published in 1947.
Tanksley was one of the lucky ones, and he knows it.
“It’s amazing today,” he said. “They even have incubators with all the monitoring equipment that can be transported by helicopter if they have to take the baby to another center for specialized treatment.
“It’s just a miracle that I survived.”
