Neona­tol­ogy is the study and care of neonates. A neona­tol­o­gist is a pae­di­a­tri­cian spe­cial­ly trained in the care of neonates. A neonate is an­oth­er word for a new­born ba­by and ba­bies are con­sid­ered new­born or neonates un­til they are one month old. Why? Be­cause most ba­bies die in the first month of life. So spe­cial at­ten­tion has to be giv­en to them and spe­cial­ly trained doc­tors and nurs­es care for them. 

Un­for­tu­nate­ly, spe­cial­ly trained neona­tal hos­pi­tal ad­min­is­tra­tors do not ex­ist in de­vel­op­ing coun­tries. Our ad­min­is­tra­tors have dif­fi­cul­ty un­der­stand­ing the need for ad­e­quate nurse:pa­tient ra­tios in a NICU (1:1) or ded­i­cat­ed med­ical per­son­nel or prop­er phys­i­cal sur­round­ings.

Half of all ba­bies who die be­fore they are one year old, die in the first month of their life. And half of those deaths oc­cur in low birth weight (LBW) ba­bies, ie ba­bies who weigh un­der 2.5 ki­los or five pounds eight ounces. The lighter the ba­by the high­er the mor­tal­i­ty. World­wide, it is es­ti­mat­ed that more than 1.4 mil­lion neona­tal deaths an­nu­al­ly are the con­se­quence of in­fec­tions with deaths oc­cur­ring more com­mon­ly in LBW new­borns.

Out­breaks of in­fec­tion are dev­as­tat­ing in neona­tal in­ten­sive care units (NICUs). Neonates are es­pe­cial­ly sus­cep­ti­ble be­cause they have al­most no de­fences against in­fec­tion, have a de­fi­cient im­mune sys­tem which does not re­spond ap­pro­pri­ate­ly to in­va­sion by bac­te­ria etc, their or­gans are pre­ma­ture and do not func­tion well, and the use of in­va­sive de­vices, feed­ing tubes, uri­nary tract catheters, en­do­tra­cheal tubes at­tached to ven­ti­la­tors that breathe for tiny ba­bies who should be in their moth­er’s wombs and in­tra­venous nee­dles for ad­min­is­tra­tion of flu­ids and med­ica­tions and blood and some­times food, is nec­es­sary. All of these are ab­nor­mal and po­ten­tial en­try sites for germs, so in­fec­tions are com­mon and about one in every ten new­borns ad­mit­ted to NICUs de­vel­op in­fec­tions.

Sur­veys con­duct­ed in NICUs in the Unit­ed States in 1999 and in Eu­rope in 2011 have shown that 11.2 per cent and 10.7 per cent of neonates were af­fect­ed by in­fec­tions, re­spec­tive­ly. 

In 2021, the Ger­man Neona­tal Net­work re­port­ed on da­ta col­lect­ed be­tween 2009 and 2017 on 14,926 in­fants with a birth­weight be­low 1,500 gms (just over three pounds). Al­most 12 per cent, of them de­vel­oped se­vere in­fec­tion.

This is a fact of life. De­spite the im­pres­sive ad­vances made in the care of neonates, even in the best of hands deaths from in­fec­tion oc­cur. 

Man­ag­ing such in­fants is com­plex and re­quires mul­ti­dis­ci­pli­nary care ap­proach (clin­i­cians, nurs­es, phar­ma­cists, lac­ta­tion con­sul­tants, so­cial work­ers, bio­med­ical en­gi­neers, at­ten­dants etc) sup­port­ed by med­ical de­ci­sions made dur­ing fam­i­ly-based care rounds.

In 1977 when I re­turned home, we had “Pre­ma­ture” Units at the ma­jor hos­pi­tals. We did not have NICUs.

In those days, half of all the ba­bies ad­mit­ted to the Pre­ma­ture Unit died and no­body cared. The three gen­er­al pae­di­a­tri­cians, who all re­turned with­in three months of each oth­er at that time, walked around in a state of shock for months. Fifty per cent mor­tal­i­ty, about thir­ty each month. That went on for about ten years un­til two Trinida­di­an neona­tol­o­gists re­turned home and the mor­tal­i­ty fell ac­cord­ing­ly. De­spite ma­jor prob­lems in the neona­tal units, it’s fas­ci­nat­ing how far we have come.

One of the ma­jor prob­lems, if not the ma­jor, is that we do not have a prop­er, pur­pose-built NICU in the coun­try. We have con­vert­ed “Prem Units” that are over­crowd­ed and un­der­staffed. We have known this since 2003, when Ja­maican Dr Bar­bara John­son, PA­HO tem­po­rary Ad­vis­er on Pae­di­atrics and Trinida­di­an Yvette Hold­er, Con­sul­tant Bio­sta­tis­ti­cian and Epi­demi­ol­o­gist, pre­sent­ed a PA­HO-spon­sored re­view of the four neona­tal units at POS­GH, SFGH, Mt Hope Women’s Hos­pi­tal and the San­gre Grande Coun­ty Hos­pi­tal, ti­tled, “Analy­sis of peri­na­tal and neona­tal mor­tal­i­ty.”

Their ma­jor find­ing was the “Un­sat­is­fac­to­ry De­sign of the Neona­tal Units at PoS­GH and SFGH, with chron­ic over­crowd­ing at Port-of-Spain, San Fer­nan­do and Mt Hope.” Rec­om­men­da­tions were made to “Ex­pe­dite plans to ex­tend and mod­i­fy the nurs­ery at SFGH; ex­tend the PoS­GH nurs­ery in­to un­used area and erect the new nurs­ery at PoS­GH as pro­posed.” That was 22 years ago.

They al­so found that there were “Reg­u­lar out­breaks of in­fec­tions at the three larg­er in­sti­tu­tions due to a short­age of trained ICU nurs­ing staff with un­sat­is­fac­to­ry nurse-pa­tient ra­tios and an ab­sence of trained ICU ded­i­cat­ed med­ical staff” and rec­om­mend­ed among oth­er things that “In­fec­tion Con­trol Units be strength­ened”.

That some of this has tak­en place is un­doubt­ed­ly true but the ba­bies are still tak­en care of in the old-time “Prem Unit” ar­eas.

De­spite op­ti­mal treat­ment, neona­tal sep­sis con­tin­ues to have high mor­tal­i­ty rates and poor out­comes. While the mor­tal­i­ty rates have de­clined sub­stan­tial­ly, fur­ther progress is dif­fi­cult un­less the rec­om­men­da­tions of the 2003 PA­HO team are fol­lowed. But that de­pends on politi­cians and ad­min­is­tra­tors and it ain’t go­ing to hap­pen soon.