This year, the National Association of Neonatal Nurses (NANN) celebrates its 25th anniversary. That is quite a milestone!! While 25 years is a long time, NANN is young compared with many organizations. Yet our early leaders, when they met back in 1984, recognized the need for an organization that focused on the particular needs of neonatal nurses. Neonatology was considered a relatively new specialty, but it was clear that our ability to provide specialized care for neonates improved infant morbidity and mortality. It was also clear that we were experiencing rapid changes in technology, knowledge of disease process, and awareness of developmental needs of neonates. It was essential to have an organization that would help neonatal nurses keep abreast of new research and technology. We needed to learn to care for babies and families, and we wanted to share triumphs and failures we experienced on a daily basis. In the nearly 30 years that I have worked in this field, I have seen tremendous changes and improvements in how we care for babies and families. As neonatal nurses, we could not be a mere sidearm of another organization. Having our own educational programs, publications, networking opportunities, and the support of leadership and research was essential.
It has been said that if we do not learn from our past, we are doomed to repeat our mistakes. Those of us who have been in nursing for a long time sometimes say that if one does not like a particular trend, we can just wait awhile and it will go away and be replaced by something else we did not like before and will not like now. That might be fine when dealing with staffing structures or shared governance models but not so good when dealing with neonates and families. It is essential that we learn from past successes and past mistakes and proceed with caution when new innovations are proposed as the next best thing. Much of what we do has been the basis of caring for babies for over 125 years.
The obvious place to begin is in the late 1800s, when a French obstetrician Stephane Tarnier, recognizing the need to keep small babies warm, created an incubator modeled after the chicken incubator displayed in the Paris zoo.1 Not only did he have to design an incubator, he had to convince his colleagues that it made a difference, not a small task. However, his ability to demonstrate a nearly 50% reduction in the mortality of small babies made an impact and led to the presence of incubators in all maternity hospitals in Paris. The drop in mortality was likely due to not only incubators but also specialized nursing care, breast milk provided by wet nurses, and the rescuing of infants who would otherwise have been abandoned.1
Pierre Budin, who succeeded Tarnier at the Paris Maternite hospital, recognized the importance of not only incubators but also keeping mothers involved with their baby's care, including assistance with caring for her baby after discharge. Despite this foray into family-centered care, incubators were expensive, even in the 1880s. To help pay for these incubators and the care of the babies, another French physician Alexander Lion created "incubator charities," charging a small admission fee for the public to view premature infants in the incubators, a practice that led to exhibits at world's fairs and amusement parks in Europe and the United States. Many babies were separated from their families for long periods of time, leading to difficulty when the time to reunite the baby and the mother came.
Martin Couney, a physician and showman, set up a popular "incubator show" at Coney Island that remained until the 1940s. We are properly appalled by the idea of babies being a sideshow, but we cannot dismiss the amount of data gleaned from the care of these babies. Data were kept regarding temperature, feeding techniques, and type of food. Dr Zahorsky, in 1904, managed the exhibition of premature infants at the Louisiana Purchase Exposition in St Louis, Missouri.2 He took care to impose safeguards against infection, studied techniques for feeding, and studied appropriate temperatures at which to keep the incubators. The nurses caring for the infants kept meticulous records of temperatures, growth rates, feedings, and use of oxygen. He recognized the dangers of spreading infections from one infant to another. He discovered the need for disinfecting incubators and equipment and providing a clean air supply. While the medical community at the time took little notice of Dr Zahorsky's discoveries, these are all principles that we base our care on today-thermoregulation, infection control, and nutrition.
Incubator shows gradually fell out of favor, and care of premature babies in the 1930s and 1940s occurred primarily in hospitals. Thermoregulation continued to be a concern, with establishment of appropriate isolette temperatures and neutral thermal environments.3 Oxygen was used on a liberal basis in the 1940s and 1950s, and as incubators became more airtight, it was possible to provide higher oxygen levels. Reports of improvement in periodic breathing and cyanosis led to use of higher concentrations of oxygen with minimal concern.4 It was not until the early 1950s that retrolental fibroplasia was recognized as a principal cause of blindness in preterm infants and the possibility of oxygen toxicity was considered.4,5 Because it was difficult to determine a safe level of oxygen and measure oxygen levels in infants, oxygen restriction became popular, limiting oxygen concentrations to 40%. This increased the number of infant deaths due to respiratory distress syndrome and the incidence of cerebral palsy in survivors.4,6,7 Today, we still struggle with the appropriate level of oxygen for our preterm infants. We focus on trying to avoid the pitfalls of hyperoxia and retinopathy of prematurity. We must, at the same time, avoid hypoxia and damage to brain tissue and other organs.
Despite the use of breast milk by Budin and Zahorsky, in the 1950s, it was common practice to withhold feedings and fluids in preterm infants for 72 hours after birth. This was due to a fear of aspiration and a belief that preterm infants were edematous and therefore fluid overloaded.4 Complications of hypoglycemia, hyperbilirubinemia, and acidosis led to a rethinking of this practice. While we do not starve preterm infants today, we continue to struggle to provide optimal nutrition, particularly for the very low birth-weight infants. Experimentation with preterm infant formulas started in the 1960s and 1970s, sometimes leading to electrolyte imbalances, acidosis, and formation of lactobezoars. Continued research in total parental nutrition, breast milk and breast milk fortifiers, infant formulas, vitamins, and feeding regimes leads to improved growth and development, but we have made many mistakes along the way.4,8,9
Despite epidemics of puerperal sepsis (pelvic infections following delivery) in hospitals, the idea of simple handwashing did not become acceptable as a means of prevention until the late 1870s. Those in charge of the incubator shows practiced strict aseptic methods including handwashing, and, in some places, glass barriers between the public and the incubators.1,2,8 Education about handwashing continues to this day, and audits of daily practice suggest that our handwashing frequency and techniques leave much to be desired.
Antibiotics were not introduced until the 1930s and 1940s, and the use of antibiotics even then resulted in penicillin-resistant Staphylococcus aureus. The recognition of the increased risk for sepsis in preterm infants has led to a number of experiments in antibiotic treatment and antibiotic prophylaxis, sometimes with disastrous results. Sulfisoxazole led to increased incidence of kernicterus, and chloramphenicol led to cardiovascular collapse. Bathing infants with hexachlorophene led to skin blistering and neurological toxicity.8 The use of Epsom salt enemas to treat respiratory distress led to magnesium toxicity. Today, our skin care practices seem to be much better, but we have not overcome the problem of drug-resistant organisms and have yet to discover the perfect antibiotic with no adverse effects.
The effort to treat respiratory distress syndrome has led to its own set of problems. Steroid therapy remained a common treatment for chronic lung disease in the 1980s and 1990s until reports in 1998 and 1999 showed an increase in neuromotor dysfunction and cerebral palsy.9-11 While we have had great success with improved ventilation and surfactants, we have also been quick to jump on new therapies such as high-flow nasal cannula oxygen therapy, without a lot of data regarding its use in neonates.
The objective of a professional organization is to support education, networking, research, and dissemination of information. It is to establish standards of care for the profession, guidelines for care of patients, and policy statements regarding nursing practice and professional issues. Our founding members and early leaders knew this and knew the importance of neonatal nurses coming together to discuss common concerns and share new information. These founders-Charles Rait, Tracy Karp, Pat Johnson, Linda Bellig, and others-worked hard to establish NANN. Neonatal nurses have developed policies, standards of care, and publications. They have served on committees to support education, research, and public policy. In doing so, neonatal nurses have established a way for us to share information and hopefully avoid repeating mistakes. Only by sharing ideas and knowledge can we learn from what works well and what does not. This year, as we celebrate 25 years, we will focus on some of the areas in our specialty practice, looking back at our history and forward to our future.
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