Importance of Neonatal Orthopaedics as a SubjectChapter 1

High infant mortality rate, a perpetual problem of the yesteryears, continued in the late eighteenth century despite introduction of artificial feeding in the Paris Foundling Hospital. Care of the infants under a physician was not a practice even as late as the middle of the nineteenth century. Further more, home delivery system was the method widely practised in Europe because of non-establishment of lying-in hospitals. The high maternal mortality rate from puerperal fever was a stimulus for the improvement of hospital standard with a rise in the number of skilled obstetricians. With the increase in number of hospital deliveries in the newly established lying-in hospitals, the care of the infants had fallen in the hands of the specialised physicians. Thus, the field of neonatology emerged at about 1950, when a number of paediatricians, better known as neonatologists got interested in the study of the infants within four weeks of life, not only to reduce the high rate of infant mortality, specially among the prematures, but also to know about the pathogenesis of the diseases from which the infants were suffering from the intrauterine life.

The famous story of Licetus Fortunio, who was born as a foetus of 5” length is known to many. He was brought to Jerome Bardi and other physicians of Rapalio by his father in living condition. His father used his medical knowledge and observations from nature and put the foetus in an oven where the heat was measured by a thermometer, and succeeded in rearing him and increased the growth of the baby.

This stimulated Johann Georg von Ruehl⁵ to be instrumental in the manufacture of a double-walled metal incubator in 1835. These incubators were modified with time and the care of the infants improved. The mortality rate of the prematures fell significantly.

In 1893, Budin introduced special unit for the prematures. Julius H. Hess⁶ (1876-1955) founded the first centre for the premature babies in USA at the Michael Ruse Hospital in Chicago utilizing this experience from his study in Germany and Austria.

Diagnosis of prematurity from birth weight was introduced by Alexandra Gueniot⁷ in 1872. But after about eight decades in 1948 World Health Assembly adopted a birth weight of 2500 gm or less as an international definition of prematurity. A decade later, the concept of premature babies was changed to low birth weight babies by an expert committee of WHO.

The intrauterine growth of the baby with respect to gestation was standardised and published by Lubchenco et al⁸ in 1963 and they had categorised AGA as the average size of the baby for the gestational age, SGA the small sized and LGA the large sized baby. Apgar score on the size of the newborn babies was introduced accordingly. Neonatal mortality depended much on the weight of the baby.

The importance of feeding the low birth weight infant gained importance, as a result. Various types of milk other than the breast milk were introduced at different times starting from butter milk, skimmed milk with added carbohydrate and albumin milk. JPC Griffith⁹ in 1912 opined that the breast-fed babies have five times more chances of survival. Prior to this Abraham Jacob¹⁰ in 1873 first proposed boiling of milk. On the contrary various authors showed that the infants had difficulty in digesting casein and/or fat.

The effort continued to improve the survival rate of the premature babies. While early infant feeding was advocated by some authors, other recommended late feeding. Because the infants cannot stand starvation they should be first fed at twelve hours from birth was opined by Hess. The other school of thought about delayed feeding as the swallowing process was imperfect in premature babies and hence the chance of aspiration pneumonia. The method of delayed feeding after about 36 to 48 hours was started in USA first and then in UK. The latter method was questioned by YIppo¹¹ of Finland in early twentieth Century. Various studies showed adverse reports with high incidence of infant mortality and development of disabilities among babies, specially spastic diplegia because of undernutrition. The effect was further grave because of lesser growth of many organs, increase of neurologic handicap and mental defects.

Small piece and Dabies¹² in 1964 reported that early milk feeding reduced hypoglycaemia, neonatal jaundice and hyponatraemia in premature infants. The method was well-established in 1970.3

Various methods of feeding was introduced from time to time as the premature baby suffered from suckling. So, gavage or dropper feeding was introduced. Feeding by indwelling nasogastric tube was first reported by Royce et al¹³ in 1951. Total intravenous alimentation using peripheral veins began at around 1970.

The infant mortality rate though much abated was a problem to the neonatologists because of newer types of infections affecting the infants, specially the premature babies. Budin and his associates showed four different sources—the skin, the umbilicus, the gastrointestinal and the respiratory tracts, for carrying infection and introduced various methods for the cure in special units for the premature.

Even today in a well-equipped modern hospital significant number of foetuses may be infected in utero and a number of neonates can acquire an infection at birth or in the first month of life. Why the newborn babies kept in intensive care units are not immune from sepsis, meningitis is yet unknown. Only explanation towards the cause, is the changing pattern of bacterial infection. However, mortality rate from neonatal sepsis has fallen considerably with the introduction of ICU with an overall improvement or salvation of the premature babies.

With the emergence of neonatology as a super speciality of paediatric, the orthopaedic diseases, specific for the neonatal period have been stressed and got proper importance. The treatment of various neonatal diseases is difficult because of the small size of the baby and still smaller size of the anatomical structures within. Normal foetal posture at birth (Fig. 1.1) shows a flexed attitude, which is continued temporarily in the neonatal period. Effort for improvement in the management of neonatal diseases has been witnessed from the early part of this century with the introduction of drawing of blood by different methods like a modified suction device, intraperitoneal injections of saline and rarely of glucose solution for the treatment of persistent diarrhoea. The method of transfusion of blood through the umbilical vein helped in the subsequent method of exchange transfusion for haemorrhagic diseases of the newborn.4

Intragastric oxygen therapy was introduced by YIppo as early as 1917 to combat respiratory distress of the premature babies.

Iatrogenic diseases in neonates, although not many in number two of them needs special mentioning. Due to sulfisoxazole prophylaxis in early fifties to prevent bacterial infections kernicterus developed. Similarly “Gray syndrome” emerged as a distressing ailment from over use of chloramphenicol.

Neonatologists are now well equipped with different types of biochemical testing procedures, amniocentesis, ultrasonography, foetal monitoring, continuous positive airway pressure (cPAP), mechanical ventilation and other methods.

Despite such improvement, even today 10% surviving infants in advanced countries have major handicap like cerebral palsy. So, the infant care should begin long before birth and in some cases even before conception.