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Intensive Hospital Based Care of Infants in Twentieth Century America

Elizabeth A. Reedy, PhD, RN

In the twenty-first century, immediate, highly technological care for babies born too soon is standard treatment throughout the United States. Premature infants are commonly found ensconced within the walls of hospital-based Neonatal Intensive Care Units (NICU’s) in both large and small hospitals. There specially trained physicians, nurses, and an army of other health care personnel anticipate and meet their every need. While debate continues about the limits of viability of prematurely born infants, those born after at least twenty-four weeks of gestation have increasingly optimistic prognoses. This is, however, a relatively recent development in the care of infants.

Late Nineteenth Century: Premature Infants and Incubator Shows

At the turn of the twentieth century, a baby born prematurely (before thirty-eight to forty weeks gestation) had dismal prospects for survival. Except for a few scattered pockets of medical interest, the knowledge, expertise, and technology necessary to help these infants was not available. "Preemies" who survived more than a day or two were often labeled "weaklings" or "congenitally debilitated” implying an inherent frailty that did not bode for their future. Survival of these tiny infants depended on many factors, chief of which were the degree of prematurity and the infant’s weight at birth.

French physicians introduced the closed infant incubator in the 1880s in response to governmental mandates to decrease the overall dismal French infant mortality rate. (Politicians feared the lack of sufficient soldiers for future wars).[1] In Europe, displays of premature infants in their incubators began appearing in the late nineteenth century at national fairs and exhibitions. Dr. Martin Couney brought the shows to the United States in the late 1890s, and they continued until the 1940s.[2] The small size of the infants, their placement in a machine similar to those used on farms for poultry incubation, and the encouragement of carnival style barkers stimulated the interest of the fair-going public.[3] 

While entertaining, the incubator exhibit’s identification as a side show and location among midway entertainment spectacles initially prevented mainstream physicians from embracing incubators as substantive progress. Their faulty design also posed serious problems. Over- or underheated incubators caused potentially fatal errors. Many physicians, relying on anecdotal rather than statistical evidence, dismissed the incubator as ineffective and even dangerous.[4] Some hospitals provided care for preemies using other means of providing warmth, including open incubators and more traditional methods such as warm bricks in cradles and rooms heated to ninety degrees or more. [5] 

 

 

Early Twentieth Century: Premature Care in Hospitals

In 1901, Parisian obstetrician Dr. Pierre Budin published the first major textbook on the care of preemies. Translated into English in 1907 and available in the United States, The Nursling: The Feeding and Hygiene of Premature and Full-Term Infants became the standard for physicians, nurses, and others interested in premature babies.[6] Its basic tenets, which relied on traditional common sense, still form the basis of care today. They include maintaining warmth, providing adequate nutrition, and preventing infection. During the early decades of the 1900s, a few American hospitals established short-lived premature infant stations. One, founded by Joseph DeLee, M.D., the famed obstetrician, opened in Chicago as the Lying-In Hospital. Funding issues and a lack of interest, however, caused them to close. During the first two decades of the twentieth century, America’s abysmal over-all infant mortality rate overshadowed the plight of premature infants. As deaths of otherwise healthy babies decreased, however, prematurity became a more visible problem.

By the early 1920s, premature infant care in the United States was at a crossroads. Based mainly in the home prior to 1920, over the next two decades, a variety of social, cultural, and technological factors combined to foster the transition from home-based to hospital care. As knowledge about the physiologic details of prematurity and public interest in premature infants grew, the demand for care expanded and culminated in the identification of prematurity as a new disease or condition worthy of treatment by medical professionals. Identifying and isolating premature infants allowed physicians to focus on and specifically treat problems different from those of other infants. These methods, initially unchallenged, and which meant separation of the infants from their parents, were presented to the public as the only possible hope for saving these previously doomed babies.  

Early Twentieth Century: Premature Infant Care Expands

In 1922, two events placed premature care permanently within the realm of physician-directed and hospital-based nurseries. One was the establishment of a premature infant station under the direction of Dr. Julius Hess at the Michael Reese Hospital in Chicago. At Michael Reese, medical personnel separated premature infants from the "normal" newborn and pediatric populations. The hospital hired nurses solely to care for and to develop specific procedures to aid these premature babies.[7] This was the beginning of hospital-based intensive care for premature and low-birth-weight babies. The Infants’ Aid Society of Chicago, a local women’s philanthropic group endowed $85,000 to secure the station’s future. 

The second significant event of 1922 was the publication of the first major American textbook devoted to the care of premature infants. Julius Hess’s Premature and Congenitally Diseased Infants provided the most detailed account of hospital-based premature infant care available in the United States.[8] The premature station at Michael Reese soon became the acknowledged leader in premature care. It hosted physicians and nurses from around the country eager to learn and implement the latest procedures. Thus, through Hess's writings and willingness to teach, his ideas and practices quickly became standard treatment for all premature infants. Hess collaborated extensively with Evelyn Lundeen, R.N., the head nurse of the premature unit. Later editions of Premature and Congenitally Diseased Infants list her as co-author.[9] 

During the 1920s, reports on experiences with premature infants multiplied in the professional literature. Most articles were positive, often citing impressive survival rates that discounted infants who expired during the first twenty-four hours in the premature unit.[10]  The case of a one-and-a-half-pound infant surviving more than two years is reported, but the general consensus remained that a birth weight of approximately two pounds represented the limit of viability in most situations.[11] The usefulness of incubators for heat received continuing attention. One study concluded that the infant’s body temperature should be used to regulate the incubators’ heat, a new idea at the time.[12] 

Understanding the Complexity of Premature Care

Through observation and clinical studies, physicians began to understand that premature infants needed individual attention and care. The addition of oxygen as a treatment for the respiratory distress prevalent in premature infants sealed the need for an individual approach to climate control. The commercially manufactured, mechanical incubator that physicians almost universally disavowed in the mid 1910s received acceptance in a revised form in the 1930s. In March 1938, Charles Chapple, M.D. of Philadelphia submitted an application for a patent for an incubator.[13] The Chapple incubator was the predecessor of the Isolette brand of incubator that captured the market by 1950. With updates and revisions, the Isolette and its competitors, remains a fixture in NICUs today.

Prior to the establishment of NICUs in the later 20th century, premature baby units, or stations, opened in many places, although many consisted of only one or two cribs at the edges of regular newborn nurseries. Larger units opened in cities, with Chicago, Philadelphia, Boston, and New York leading the way. Preemies from outlying areas frequently arrived in the arms of their parents or, in a few places, via an incubator ambulance. Thus, years before adult intensive care units and hospital-based emergency transport systems, premature care was setting the standard for critical care.

By focusing on the prematurely born, physicians soon began to appreciate the developmental differences between preemies and full term babies. Respiratory difficulties are directly related to the degree of prematurity. The shorter the gestational period, the more likely the infant will experience serious breathing problems. In the 1930s, oxygen slowly gained a reputation for easing the cyanosis and asphyxia associated with prematurity. Several studies published in the professional journals indicated the benefits of its use and suggested, as one article concludes, “a continuous supply of oxygen seems to be of advantage in treating feeble, premature babies."[14] Physicians administered oxygen for cyanosis, respiratory embarrassment, feebleness, asphyxiation, a birth weight under 1200 grams and to “all others whom it was believed might be benefited."[15] Before the development of the Isolette brand closed incubator, babies received oxygen through masks, plastic tents, or, later, nasal catheters. With closed incubators, the oxygen was piped in through connections in the incubator wall, providing a more consistent flow of oxygen. Since there appeared to be no negative consequences of oxygen and respiratory distress, doctors could justify administering oxygen to all premature infants. Along with the individualized warmth provided by the new incubators, oxygen seemed to promise an end to the most significant causes of morbidity and mortality. 

Public health officials caught up with the problem of premature infants during the 1930s. The United States Children’s Bureau became a “significant campaigner” for premature care during that decade, advising local efforts and providing funding. The Bureau also supported premature-infant research and a follow-up clinic in New York City.[16]  Public health departments in cities and states began to devise strategies aimed at bringing the premature infant to the attention of hospitals, physicians, and nurses.

By 1940, the Children’s Bureau reported that twenty-eight states, the District of Columbia, and Hawaii had community plans either in place or set to begin to ensure that premature infants received the special care they required. Title V, part of the 1935 Social Security Act, included the provision of funds to help set up these plans. Medical and nursing education was often part of the plans, and public health nurses and pediatricians traveled to premature centers in Boston and Chicago for in-depth training, returning to their home states to teach and advise their professional colleagues.[17] 

Meanwhile, media attention to the baby incubator shows grew slowly but steadily. In 1933, the Century of Progress Exposition opened in Chicago. The Baby Incubator Show, located on the midway, promised “living babies."[18] The public health department referred premature babies and local hospitals transferred them to the fair exhibit. Parents brought babies to the exhibit where they received care free of charge. Fairgoers paid admission fees to support the show.[19] Nurses from Michael Reese Hospital staffed the exhibit. [20] It is difficult to determine the benefits, if any, for the premature infants as their day-to-day care was probably similar to that received in the hospital despite the constant parade of people past the incubators, a practice forbidden by most hospitals at that time.[21] The influence of this practice on infection rates and thus morbidity and mortality is unknown.  

The Century of Progress incubator show expanded public interest in premature infants immensely. Press coverage focused on the extremely small size of premature newborns, the special equipment required, the heroic physicians and nurses, and the fight for life by the infants themselves.[22] In May 1934, the birth of the Dionne quintuplets in Quebec, Canada dramatically increased interest in prematurity, particularly in instances involving multiple births. The public could not get enough of the "quints," and newspapers, magazines, and early movie producers obliged. By 1940, premature babies, once ignored, became celebrities in their own right, requiring large amounts of professional care. Increasing the provision of premature care in hospitals meant a decline in the number of premature infants available for incubator exhibits. The 1939 New York World’s Fair held the last major incubator exhibit.[23]   

The World War II Era and Beyond

The entry of the U.S. into World War II in 1941 postponed many public health efforts to benefit preemies, including a major plan for New York City. When the war was over, cities and states across the country renewed these efforts and the resulting plans encompassed the revision of hospital standards, transportation of premature infants to hospitals, financial assistance, and more educational programs to train physicians and nurses.[24]  

 

During the 1940s, premature infants treated in the most up-to-date nurseries could expect to lead normal healthy lives once discharged. At least that is what physicians promised their parents. Although some premature infants demonstrated long-term neurological problems, at the time the risk did not seem great. Other conditions lasting past the neonatal period doctors traced to prenatal influences or poor home conditions.[25] Treatment alternatives increased as physicians adopted apparently successful ideas and procedures used by others. Many times these worked as the doctors hoped they would, but unexpected consequences emerged by the 1950’s.

During the 1950’s, as smaller and more premature babies were saved with increasingly technological treatments and the intensive care of these infants expanded across the country, several problems surfaced. Oxygen, the miracle cure for the respiratory distress associated with prematurity, did save many lives. However, its unregulated use in higher doses and for prolonged periods appeared to be detrimental to some babies. In 1942, the American Journal of Ophthalmology published an article about an apparently new condition, retrolental fibroplasia, or RLF.[26]  By 1950, this disorder of the retinal vasculature became the leading cause of blindness among children in the U.S. By 1956, it became the first acknowledged complication of the treatment of prematurity. Physicians and scientists worked zealously throughout the 1940’s and early 1950’s trying to identify a cause for RLF, ruling out geography, heredity, lack of prenatal care, and early exposure to light. They examined the medical and nursing care of the infants for any discrepancies or omissions that might have triggered RLF. They focused on newer treatments including vitamin therapy, blood transfusions, and various medicines and hormonal supplements. Physicians and others did not seriously consider oxygen in the search for a cause of RLF until the early 1950s. A large scale, multi-hospital study of the effects of oxygen began in 1952 and culminated in 1956 with solid evidence pointing to it as the culprit.[27] Oxygen use was immediately curtailed throughout the world, and rates of RLF dropped dramatically. Unfortunately, without oxygen treatment, deaths due to respiratory failure increased by 1960 even as the incidence of RLF began to rise again. Known now as retinopathy of prematurity (ROP), it continues to affect preemies today.[28] Physicians now believe ROP has many causes. Standard screening procedures identify infants at risk early, and doctors plan treatment accordingly. Clinical studies continue to sort out the best way to prevent the disease and to treat it once it develops. Oxygen, once seen as a panacea for all preemies, remains a major component of respiratory support, however it is carefully controlled and regulated according to individual needs. 

Between 1960 and 1990, the pace of advance in the care of premature infants accelerated dramatically. Neonatology became a medical subspecialty of pediatrics requiring a year or more of postgraduate training for physicians after they served a pediatric residency. Clinical research studies of treatments became standard in the large academic health centers. Incubator technology continued to evolve. The wooden boxes of the 1930s gave way to clear Plexiglas models allowing direct view of the infant without disrupting the flow of heated air. Being able to see the baby gave parents and caregivers the ability to gauge progress and continue hope. For the smallest and sickest preemies, open warming tables allowed immediate access in emergencies while maintaining the necessary environmental temperature. Other innovations included improved venous and arterial access, better antibiotics, and expanded use of imaging techniques to identify gastrointestinal, cardiac, neurological, and other abnormalities or complications quickly and accurately. Perhaps the most important innovation involved the development and refinement of the ability to support and maintain the premature baby’s respiratory efforts.[29]   

Prior to the 1970s most babies born more than three months premature died as they lacked the ability to breathe on their own for more than a short time. Reliable mechanical ventilators for these infants did not exist. Although ventilators had been a staple of adult intensive care units for several years, the technology necessary for the physiologically different neonate did not become available and effective until the 1970s.[30] By the mid 1980s babies born as early as twenty-four weeks gestation could survive their early entry into the world with ventilators, warming beds, and effective medical and nursing care.          

There were complications, however. One major problem was that babies born before thirty-two to thirty-four weeks gestation frequently lacked sufficient levels of surfactant, a naturally occurring substance that maintains the stability of lung tissue, to keep their lungs inflated. Early mechanical ventilators saved many lives but often damaged the babies’ lungs in the process. Bronchopulmonary dysplasia (BPD), abnormal development of the lung tissue, which caused scarring of the lungs with resultant decreases in lung function, was a frequent result of long-term ventilation. Babies with the most serious cases of BPD required tracheotomies. Mechanical ventilation continued in some cases for several years and often played a part in growth and developmental delays. Artificial surfactant therapy, developed during the 1980s and widely available by the early 1990s, led to a significant decrease in the length of time premature infants required mechanical ventilation and eliminated the need in some. This and other new treatments led to a concomitant decrease in the frequency and severity of BPD.[31] 

The introduction of objective measures to assess the newborn premature baby further refined approaches to care. Until the 1970s, preemies were identified mainly by birth weight. Both the American Academy of Pediatrics in 1935 and the World Health Assembly in 1948 cited birth weights of five-and-a-half pounds or less as the definition of prematurity.[32] By the late 1960s, it was obvious this method was insufficient for accurate infant assessment. The gestational age, or the number of weeks the pregnancy lasted, was more specific but difficult to calculate in an objective manner. Then in the early 1970s, the development of a standardized scoring system provided a consistent assessment of the baby's prematurity.[33] Today a combination of physical and neurologic findings, the mother’s estimation of gestation, and sonographic studies determine the degree of prematurity. If the mother has had amniocentesis during her pregnancy, the results of this test may also help determine fetal maturity.[34] 

The last decade of the twentieth century witnessed the continued decrease in mortality associated with premature birth. At the same time, however, there was a rise in the overall number of babies born prematurely to approximately 11 percent of all births in the late 1990s.[35] Several explanations exist for this increase. First, maternity care continued to improve. Women who might have miscarried in an earlier era were able to give birth to a live, albeit premature, baby. At the same time, at-risk mothers such as those living in poverty and adolescents continued to have a lower rate of prenatal care and thus higher rates of premature births. A third and more publicized reason is the increase in multiple births (twins, triplets, etc.) as a result of fertility treatments.[36] There is a documented rise in the risk of prematurity in multiple births, which increases with the number of babies.[37] 

The 1990s was also a time when the limits of viability for preemies, always a point for debate among medical professionals, appeared to stall at about the twenty-two to twenty-fourth weeks of gestation time. For babies born at or before this time, parents and professionals must choose to either initiate resuscitative procedures or let the baby die. Moreover, if resuscitative procedures are initiated, few well-defined parameters exist to help  guide parents in making decisions to either keep going or to stop. In most cases, there is no clear answer.[38]

Conclusion

At the beginning of the twentieth century, many people labeled babies born prematurely, weak or congenitally debilitated. Few measures existed to save them. However, as the century progressed the increased attention showered on all babies benefited those born premature as well. The exhibition of premature infants in incubator shows and articles written in newspapers and magazines presented parents, and the general public, with something previously hidden from view. These infants, tiny, frail and under-developed yet portrayed as ‘fighters’ rather than ‘weaklings,’ could with the appropriate care, survive to live a normal life. The portrayal of these infants as survivors rather than victims enabled the public to respond by labeling them as cute, desirable and worthy of life saving care. They demanded change and doctors, public health personnel and hospitals responded. 

Individuals with an interest in premature babies responded to public interest by developing new techniques, new machines, and new facilities to care for them. When the first permanent hospital unit for premature babies opened in 1922, it signaled the beginning of a new era. In the 1930s, premature care expanded, and doctors found even more ways to ensure survival of ever smaller babies. By mid-century, premature infant care was established as a societal obligation.

Throughout the second half of the century, publicity about premature babies increased steadily along with the ability to care for them. In 1963 Jacqueline Kennedy, wife of President John F. Kennedy, gave birth to a son several weeks early. The baby died a few days after birth due to hyaline membrane disease, also known as neonatal respiratory distress syndrome. This birth and death of an admired president’s baby brought the issue of prematurity to the forefront of popular and professional interest. Between the mid 1960s and late 1990s, continued advancements pushed the limits of viability back so that almost any baby born alive had a chance for survival. Multiple births continued to be more common with accounts of quintuplets, sextuplets, septuplets, and even octuplets receiving attention from the print and broadcast media. Success stories were common; those who died or suffered long-term complications of prematurity got little attention.

The changes in the care of premature infants over the course of the twentieth century while truly inspirational continue to leave room for improvement. Ethical dilemmas are inherent in matters of life and death. Even when a medical treatment or procedure goes exactly the way doctors hope it will, a poor outcome may result. The fact that the patients are infants and unable to give informed consent is a constant. Should the parents have the final say in decisions about treatment? And if not them, who? Does society have responsibilities to a baby whose life is saved but who is neurologically devastated? And if so, what are they? Access to expensive and extensive care is a complex issue confounding families and professionals alike.  

By the late 1990s, neonatal intensive care was available for babies in almost every area of the country. Specialist and sub-specialist pediatricians, pediatric nurses, respiratory therapists, social workers, physical and occupational therapists, nutritionists, and a host of others responded to the needs of babies and the demands of their parents and the public. At the beginning of the twenty first century, research and innovation continue to transform the lives of these babies, giving many more of them the potential for healthy, long, and possibly even notable lives.

References

[1] Karen Offen, “Depopulation, Nationalism, and Feminism in Fin-de-Siecle France,” American Historical Review 89 (1984): 648–76; Richard Meckel, Save the Babies: American Public Health Reform and the Prevention of Infant Mortality, 1850–1929 (Baltimore: Johns Hopkins University Press, 1990), 101-102; and Jeffrey P. Baker, The Machine in the Nursery, (Baltimore: Johns Hopkins University Press, 1996), 45–50, 78–79, 84–85, 93–94.

[2] Baker, Machine in the Nursery, 86–106; and William A. Silverman, “Incubator-Baby Side Shows,” Pediatrics 64, no. 2 (1979): 127–41.

[3] Baker, Machine in the Nursery, 93–94.

[4] Baker, Machine in the Nursery, 152–74.

[5] Amy A. Armour, “Hints for Maternity Nurses,” Trained Nurse and Hospital Review 53 (August 1914): 89–90; Jennings C. Litzenberg, “Long Interval Feeding of Premature Infants,” American Journal of Diseases of Children 4 (1912): 391–409; N.O. Pearce, “Review of Recent Literature on the New-Born,” American Journal of Diseases of Children 18, no. 1 (July 1919): 51–68; and Cone, Premature Infant, 52–53.

[6] Pierre Budin, The Nursling: The Feeding and Hygiene of Premature and Full-Term Infants, Translated by William J. Malloney (London: Caxton Publishing Company, 1907).

[7] Julius H. Hess and Evelyn C. Lundeen, The Premature Infant: Medical and Nursing Care, 2nd ed., (Philadelphia: J.B. Lippincott Co., 1949).

[8] Julius H. Hess, Premature and Congenitally Diseased Infants, (Philadelphia: Lea and Febiger, 1922), Part I, Part II, Chapters 5, 6, 7, 8, 9.

[9] Hess & Lundeen, 1949.

[10] Lila J. Napier, “Method of Caring for Premature and Underweight Babies at the Lying-In Hospital, New York City,” Bulletin of the Lying-In Hospital of the City of New York 13 (1927): 132–34; Julius H. Hess and I. McKy Chamberlain, “Premature Infants – A Report of Two Hundred and Sixty-Six Consecutive Cases,” American Journal of Diseases of Children 34 (1927): 571–84.

[11] D.S. Pulford and W.J. Blevins, “Premature Infant, Birth Weight 680 Grams, with Survival,” American Journal of Diseases of Children 36 (1928): 797–98; Aaron Capper, “The Fate and Development of the Immature and of the Premature Child,” American Journal of Diseases of Children 35 (February 1928): 262–75; Hess and Chamberlain, 571–84; and Aaron Capper, “The Fate and Development of the Immature and of the Premature Child,” American Journal of Diseases of Children, 35 (March 1928): 443–91.

[12] Napier, “Method of Caring for Premature and Underweight Babies,”; William N. Bradley, “The Care of the Premature Baby,” Medical Journal and Record 124 (18 August 1926): 222–25; “Simplifying the Nursing Care for Premature Babies,” Trained Nurse and Hospital Review 78 (June 1927): 633; and Ralph M. Tyson and Edward F. Burt, “Continuous Temperature Records of Premature Infants,” American Journal of Diseases of Children 38 (1929): 944–52.

[13] Charles Chapple Papers. MSS 2/0207–01, Series 2.2, Folder 5. Historical Collections, College of Physicians, Philadelphia.

[14] William P. Buffum and George F. Conde, “The Use of Oxygen in the Care of Feeble Premature Infants,” Journal of Pediatrics 4 (1934): 326–30; Alexander M. Burgess and Alexander M. Burgess, Jr., “A New Method of Administering Oxygen,” New England Journal of Medicine 207 (1932): 1078–82. Burgess and Burgess describe piping oxygen into a box placed over a patient’s head. They were able to achieve oxygen concentrations of 40-50%. In the case of babies, they advised placing the box completely over the baby.

[15] Anne Y. Peebles, “Care of Premature Infants,” American Journal of Nursing 33 (1933): 866–69; Buffum and Conde, “The Use of Oxygen in the Care of Feeble Premature Infants,” 326–30; Daniel A. Wilcox, “A Study of Three Hundred and Thirty Premature Infants,” American Journal of Diseases of Children 52 (1934): 848–62; Julius H. Hess, “Premature Infants – A Report of Sixteen Hundred and Twenty-three Consecutive Cases,” Illinois Medical Journal 67 (1935): 14–25. Quote is from Hess, 18.

[16] Gerald M. Oppenheimer, “Prematurity as a Public Health Problem: US Policy from the 1920s to the 1960s,” American Journal of Public Health 86 (1996): 870–78. 

[17] Ethel C. Dunham and Jessie M. Bierman, “The Care of the Premature Infant,” Journal of the American Journal of Medicine 115 (1940): 658–62.

[18] “A Geographical Map of the Century of Progress Exposition…faithfully executed and drawn in a carnival spirit by Tony Sarg.”  The baby incubators were listed first in the list of attractions. Century of Progress collection, Section 16, box 13, folder 16-197, Main Library, Special Collections, University of Illinois at Chicago. The building was captured in a picture taken from afar that showed a huge crowd around the building and flowing down the Midway.

[19] Official Guidebook, World’s Fair, 1934, 109. Century of Progress collection, Section 16, box 13, folder 16-193, UIC library.

[20] Thomas E. Cone, Jr. History of the Care and Feeding of the Premature Infant. (Boston: Little, Brown and Company, 1985), 9–10, 18–21;  Silverman, “Incubator-Baby Side Shows,” 137. Silverman interviewed Evelyn Lundeen, the head nurse of the premature center at Michael Reese, before her death in 1963. Despite misgivings about the carnival like atmosphere, Lundeen praised the care the infants received.

[21] Henry L. Woodward and Bernice Gardner, Obstetric Management and Nursing (Philadelphia: F.A. Davis Company, 1942), 681; “Nursing Care of Newborn Infants – Excerpts from Children’s Bureau Publication 292, Standards and Recommendations for Hospital care of Newborn Infants, Full-Term and Premature,”; Sister Mary Pulcheria Wuellner, “Safe Nursing Care for Premature Babies,” American Journal of Nursing 39 (November 1939): 1198-1202. Wuellner suggested allowing parents to view their infants through a glass partition.

[22] Tiny Baby Fights to Live,” New York Times (NYT), 8 December 1932; “1¾-Pound Baby Now Normal,” NYT, 25 December 1933; “Baby Weighing 19 Ounces is Reported Thriving,” NYT, 14 August 1934; “One-Pound Baby Dies,” NYT, 15 November 1934; “Gives Birth to 1½ -Pound Baby,” NYT, 23 February 1935; “15-Ounce Baby Fed Now Between Meals,” NYT, 9 February 1936; “Baby Weighs Pound 13 Ounces,” NYT, 2 August 1936; “Tiny Hartford Baby Wins Fight for Life,” NYT, 7 December 1936; “One-Pound Baby Girl Fighting for Life,” NYT, 13 March 1937; “28-Ounce Baby Off Whisky Diet,” NYT, 27 March 1937),; “Nine-Ounce Infant Loses Bid for Life,:” NYT, 27 March 1937; “24-Ounce Baby a New Napoleon,” NYT, 15 August 1937; “24-Ounce Baby is ‘Gaining’,” NYT, 12 September 1937; “1-Pound, 11-Ounce Baby Lives,” NYT, 4 April 1938; “Tiny Baby Gains Weight,” NYT, 23 May, 1938; “Baby of 2¼ Pounds Survives,” NYT, 17 July 1938; “21-Ounce Baby Born at Brooklyn Hospital,” NYT, 18 June 1939; “Bellevue Staff Wins Fight for Baby’s Life,” NYT, 8 October 1940; “27-Ounce Boy Born in England,” NYT, 14 August 1940; “Race to Save Baby Fails,” NYT, 17 February 1937.

[23] Baker, Machine in the Nursery, 105.

[24] Oppenheimer, “Prematurity as a Public Health Problem,” 870–79.

[25] Hess, “Premature Infants, A Report of Sixteen Hundred and Twenty-three Consecutive Cases,” 14-23. Hess reported in 1935 that intracranial hemorrhage was present in over 40% of the infants autopsied after death in his unit. Approximately 11% of the unit’s graduates demonstrated symptoms. Of these 69 were followed and 27 developed physical injuries related to the central nervous system. Nine of the 27 were classified as mentally retarded.

[26] T.L. Terry, “Extreme Prematurity and Fibroblastic Overgrowth of Persistent Vascular Sheath Behind Each Crystalline Lens, Preliminary Report,” American Journal of Ophthalmology 25 (1942): 203–04.

[27] T.L. Terry, “Fibroblastic Overgrowth of Persistent Tunica Vasculosa Lentis in Premature Infants, Etiologic Factors” Archives of Ophthalmology 29 (1943): 54–65; Kate Campbell, “Intensive Oxygen Therapy as a Possible Cause of Retrolental Fibroplasia: A Clinical Approach,” Medical Journal of Australia 2 (1951): 48–50; V. Mary Crosse and Philip Jameson Evans, “Prevention of Retrolental Fibroplasia,” Archives of Ophthalmology 48 (1952): 83–87; Arnall Patz, “The Role of Oxygen in Retrolental Fibroplasia,” Pediatrics 19 (1957): 504–24; Loren P. Guy, Jonathan T. Lanman, and Joseph Dancis, “The Possibility of Total Elimination of Retrolental Fibroplasia by Oxygen Restriction,” Pediatrics 17 (1956): 247–49; Leroy E. Hoeck, and Edgar De La Cruz, “Studies on the Effect of High Oxygen Administration in Retrolental Fibroplasia – Nursery Observations,” American Journal of Ophthalmology 35 (1952): 1248–52; V. Everett Kinsey, “Retrolental Fibroplasia – Cooperative Study of Retrolental Fibroplasia and the Use of Oxygen,” Archives of Ophthalmology 56 (1956): 481–543. For an overview of the RLF story see William A. Silverman, Retrolental Fibroplasia: A Modern Parable, (New York: Grune and Stratton, 1980).

[28] Patz, “The Role of Oxygen in Retrolental Fibroplasia,” 504–24; Mary Ellen Avery and Ella H. Oppenheimer, “Recent Increase in Mortality from Hyaline Membrane Disease,” Journal of Pediatrics 57 (1960): 553-559; G.C. Robinson, J.E. Jan, and C. Kinnis, “Congenital Ocular Blindness in Children, 1945–1984,” Archives of Pediatrics and Adolescent Medicine 141, no. 12 (December 1987): 1321–24; P.B. Campbell et al., “Incidence of Retinopathy of Prematurity in a Tertiary Newborn Intensive Care Unit,” Archives of Ophthalmology 101, no. 11 (November 1983): 1686–88; The Committee for the Classification of Retinopathy of Prematurity, “An International Classification of Retinopathy of Prematurity,” Archives of Ophthalmology 102, no. 8 (August, 1984): 1130–34; D.R. Brown et al., “Retinopathy of Prematurity. Risk factors in a Five-Year Cohort of Critically Ill Premature Neonates,” Archives of Pediatrics and Adolescent Medicine 141, no. 2 (February, 1987): 154–60; Walter M. Fierson et al., “Screening Examination of Premature Infants for Retinopathy of Prematurity,” Pediatrics 100 (1997): 273–74; Gary C. Brown et al., “Cost-Effectiveness of Treatment for Threshold Retinopathy of Prematurity,” Pediatrics 104 (1999): 47-52.

[29] Murdina MacFarquhar Desmond, Newborn Medicine and Society: European Background and American Practice (1750–1975) (Austin, Texas: Eakin Press, 1998): 170–71, 198.

[30] Desmond, Newborn Medicine and Society, 209.

[31] Lynn Singer et al., “A Longitudinal Study of Developmental Outcome of Infants with Bronchopulmonary Dysplasia and Very Low Birth Weight,” Pediatrics 100, no. 6 (December 1997): 987–93; H.M. Hennes, M.B. Lee, A.A. Rimm, and D.L. Shapiro, “Surfactant Replacement Therapy in Respiratory Distress Syndrome. Meta–Analysis of Clinical Trials of Single-Dose Surfactant Extracts,” Archives of Pediatrics and Adolescent Medicine 145, no. 1 (January 1991): 102–04; and Rachel M. Schwartz et al., “Effect of Surfactant on Morbidity, Mortality, and Resource Use in Newborn Infants Weighing 500 – 1500 g.” New England Journal of Medicine 330, no. 21 (26 May 1994): 1476–80.

[32] Julius H. Hess, “A City-Wide Plan for the Reduction of Deaths Associated With and Due to Prematurity,” Journal of Pediatrics 6 (1935): 104–21; Cone, Premature Infant, 62–63. The American Academy of Pediatrics (AAP) passed their resolution on June 7, 1935 in New York City.

[33] Lilly M.S. Dubowitz, Victor Dubowitz, and Cissie Goldberg, “Clinical Assessment of Gestational Age in the Newborn Infant,” Journal of Pediatrics 77 (July 1970): 1–10.

[34] M.C. Haeusler et al., “Amniotic Fluid Insulin Testing in Gestational Diabetes: Safety and Acceptance of Amniocentesis,” American Journal of Obstetrics and Gynecology 179, no. 4 (1998): 917–20; M. Kucuk, “Tap Test, Shake Test and Phosphatidylglycerol in the Assessment of Fetal Pulmonary Maturity,” International Journal of Gynaecology and Obstetrics 60, no. 1 (1998): 9–14.

[35] Joyce A. Martin et al., “Births: Final Data for 2000,” National Vital Statistics Report 50, no. 5 (12 February 2002): 15–18; Kathryn A. Sowards, “What Is the Leading Cause of Infant Mortality? A Note of the Interpretation of Official Statistics,” American Journal of Public Health 89 (1999): 1752–54.

[36] Susan Schindehette, “Coming Up Roses,” People Weekly, 8 December 1997, 54-60; Linda Kulman, “Cigars All Around,” U.S. News and World Report, 1 December 1997, 14; Michael D. Lemonick and Jeffrey Kluger, “’It’s A Miracle,’” Time, 1 December 1997, 34-39; John McCormick and Barbara Katrowizt, “The Magnificent Seven,” Newsweek, 1 December 1997, 58-62; Claudia Kalb, “Families: The Octuplet Question,” Newsweek, 11 January 1999, 33; and “Question Time,” People Weekly, 11 January 1999, 72.

[37] S.E. Jewell and R. Yip, “Increasing Trends in Plural Births in the United States,” Obstetrics and Gynecology 85, no. 2 (1995): 229–32; Diane Holditch-Davis, Dia Roberts and Margarete Sandelowski, “Early Parental Interactions With and Perceptions of Multiple Birth Infants,” Journal of Advanced Nursing 30, no. 1 (1999): 200–10; Robert L. Goldenberg and Dwight J. Rouse, “Prevention of Premature Birth,” New England Journal of Medicine 339, no.5 (1998): 313–20; and  L.A. Schieve et al., “Live-Birth Rates and Multiple-Birth Risk Using In Vitro Fertilization.” Journal of the American Medical Association 282, no. 19 (1999): 1832–38.   

[38] Stephen N. Wall, and John Colin Partridge, “Death in the Intensive Care Nursery: Physician Practice of Withdrawing and Withholding Life Support,” Pediatrics 99, No. 1 (January 1997): 70; Mark Sklansky, “Neonatal Euthanasia: Moral Considerations and Criminal Liability,” Journal of Medical Ethics 27, (2001): 5–11; and Jaideep Singh, John Lantos, and William Meadow, “End-of-Life After Birth: Death and Dying in a Neonatal Intensive Care Unit,” Pediatrics 114, No. 6 (December 2004): 1620–26.

Elizabeth A. Reddy is an Adjunct faculty member at Immaculata University.