Neonatal & Dev Medicine in the department of pediatrics

Overview & History

Ronald Ariagno, David Stevenson, and Philip Sunshine circa 1979

The Division of Neonatal and Developmental Medicine was initially created in 1959 when Norman Kretchmer, M.D, became The Chairman of the Department of Pediatrics and recruited Dr. Louis Gluck to be the Chief of Neonatal Medicine. Dr. Gluck was instrumental in educating the faculty, housestaff, and students in the field of neonatology. He also initiated several very important studies, the main one was the demonstration that bathing infants with hexachlorophene in the delivery room decreased and eventually abolished colonization and infection secondary to Staphylococcus aureus, an organism that had plagued neonatal nurseries for many years.



Major Accomplishments and Events in Neonatology at Stanford

1962-1967

1967-1973

1974-1980

1986-1990

1990-1999

2000

2002

2003


Division History

1959-1967

Dr. Gluck left Stanford to organize the nurseries at Yale University. Approximately one year later, Dr. Sumner J. Yaffe became Director of the Division. With a great deal of input from a young and energetic faculty, Drs. Kretchmer and Yaffe submitted an application to the Clinical Research Centers Branch of the National Institutes of Health to establish a research center for premature infants. This grant was awarded in 1962 and the first patient was admitted to the Premature Infant Research Center in May of 1963, the first clinical research center devoted entirely to the study of prematurely born infants. The Center has continued to be operated and funded since that time.
Dr Yaffe left for Buffalo in 1962 and Dr. Irwin Schafer assumed the Directorship of the Division. Dr. Schafer's main interest was in amino acid metabolism and inborn errors of metabolism, conditions that could affect newborn infants. Also, the make-up of a premature nursery was changed to that of an intensive care nursery, where infants could be transferred in from other hospitals and all infants with critical illnesses could be cared for in the unit. It was at this time that investigators at Stanford began to use positive pressure ventilation to support infants with respiratory failure. Using techniques that would be considered primitive today, these investigators demonstrated that critically ill infants with usually fatal respiratory failure could be supported with the use of mechanical ventilation yielding a survival rate of over 40%. This was a remarkable achievement considering what kind of technology was available in the 1960's. During this period, a philosophy was established to invite and encourage investigators from other disciplines to participate in nursery-based research projects. Members of the Departments of Medicine, Neurology, and Surgery carried out studies in the Neonatal Intensive Care Unit (NICU) and interacted closely with faculty members of the Division of Neonatal Medicine.
In 1964, Dr. Marshall Klaus became the Director of the Division and brought with him a background in pulmonary physiology. Through his efforts, the Division began to focus on problems of pulmonary disease in neonates including studies of hyaline membrane disease, transient tachypnea of the newborn, and various types of pulmonary aspiration syndromes. Two post-doctoral fellows, Drs. William JR Daily and Belton Meyer, began their studies on apnea of prematurity and, working with the principles of impedance pneumography, developed the first apnea monitor that was used in the NICU. This prototype was produced and marketed by IMI and the project was later sold to Air Shields. From this early prototype, apnea monitors were made commercially available and were used in almost every nursery throughout the world.
Dr. Klaus, who had worked with other investigators to develop an aerosolized surfactant material, was disappointed in its application for the treatment of hyaline membrane disease and began to focus on various types of agents that could improve pulmonary blood flow in these infants. Initially, acetylcholine was the agent used, but it proved to be not only ineffective, but also had many adverse side effects that rendered the material useless in the NICU. However, this drug was one of the first pharmacologic agents to be used to treat pulmonary hypertension. Perhaps Dr. Klaus' greatest contribution emanated from the combined efforts of a psychiatrist, anthropologist, and social worker who began studies of maternal-infant bonding that opened the door for parents to enter the nursery and become involved in the care of their infants. Prior to this time, parents were not allowed inside the nursery and were merely observers of the care and management of their babies.

1967-1973

In 1967, Dr. Klaus left Stanford to return to Cleveland, and Dr. Philip Sunshine became the Director of the Division of Neonatal Medicine. Together with Dr. Daily, who joined the faculty after his fellowship, the Division continued its studies on the use of ventilatory support and developed criteria for initiating ventilatory therapy, protocols for weaning infants from ventilators, and techniques for altering pressures and rates in order to ensure optimal ventilation of critically ill babies. Primarily through the work of Drs. Daily and Penelope K. Smith, these criteria were published and became the basis of guidelines for ventilatory support used by other nurseries throughout the country. The description of bronchopulmonary dysplasia by Drs. William H. Northway and R. C. Rosan published in 1968, documented the adverse effects of barotrauma and oxygen toxicity in infants who had received ventilatory support. They also suggested methods to improve ventilation and developed techniques that would mitigate to some extent the adverse effects of ventilator treatment. The Perinatal Outreach Program was developed during this period as members of the Division of Neonatal Medicine, with input from Obstetrics, began to develop educational and consultative relationships with hospitals and physicians in the surrounding communities. This Program was integrated with the Infant Transport System that was developed by Dr. Alvin Hackel, and was successful in both improving the quality of care for mothers and their newborns and encouraging referrals of sick newborns from as far south as Santa Maria to Crescent City in the north, and as far east as Reno and Carson City, Nevada.

1972-1982

In 1972, Dr. Daily left Stanford, and Dr. John D. Johnson joined the faculty. Dr. Johnson's major interest was in bilirubin metabolism and the development of methods to detect the rate of bilirubin production. Dr. Ronald L. Ariagno joined the faculty two years later and rounded out the interests in the nursery to include studies of thermoregulation and respiration in the neonate. Not long after, Dr. Kent Ueland was recruited to the Department of Obstetrics and Gynecology to form the first Division of Maternal-Fetal Medicine and, with Dr. Sunshine, initiated a close collaboration between Obstetrics and Neonatology that has persisted and is considered a model of cooperation in academic circles to this day. John Johnson left Stanford in 1979, and his fellow, Dr. David K. Stevenson, was appointed to the faculty that same year and continued the work on bilirubin metabolism and its relationship to neonatal jaundice. The strategy of maintaining the nursery as a "clinical research laboratory" continued, and studies by members of the Department of Pediatrics, Internal Medicine, Surgery, Otolaryngology, Ophthalmology, Psychiatry, Pharmacology, Structural Biology, and Obstetrics were initiated and accomplished in the nursery. Even disciplines outside the Medical Center were engaged in collaborative research, including members of the Departments of Mechanical Engineering, Biology, and Psychology. A program to evaluate the ethical dilemmas encountered in a NICU environment was also initiated and these studies still continue today.
In 1980, the Perinatal Outreach Program was expanded when Cecele Quaintance, RN became the Program Coordinator and, along with Drs. Sunshine and Ueland, was successful in obtaining support through the State of California's Perinatal Access Program. The Perinatal Outreach Program subsequently became consolidated as the Mid-Coastal California Perinatal Outreach Program (MCCPOP). MCCPOP was further enhanced by the recruitment of Dr. Maurice L. Druzin who expanded the obstetrical arm of the Program following Kent Ueland's departure. MCCPOP has been instrumental in developing very close ties with community hospitals, physicians, and perinatal staff, as well as establishing satellite high risk services for mothers and their newborns and improving access to quality obstetric and newborn care, either in the local community or through referral to appropriate levels of care when required.
In 1982, the Division of Neonatal Medicine changed its name to the Division of Neonatal and Developmental Medicine, as Dr. Merton Bernfield joined the Division, introducing new ideas for the education of physician-scientists in neonatology. A unique NIH training grant was proposed and funded by the National Institutes of Child Health and Human Development (NICHD). Although the Division had been able to recruit outstanding postdoctoral fellows prior to this time, the direction that was offered by Dr. Bernfield allowed the recruitment of even more outstanding individuals to the fellowship program. Soon thereafter, the Division added Dr. William E. Benitz who was one of the first graduates of the new physician-scientist training endeavor. During this time, the Division began to study new techniques for managing patients with severe pulmonary hypertension. High frequency ventilation and extracorporeal membrane oxygenation (ECMO) were studied and introduced for the care of critically ill infants with severe cardiopulmonary failure.

1989 -1999

In 1989, Dr. David K Stevenson became Chief of the Division of Neonatal and Developmental Medicine and the Director of the NIH-funded Training Program in Developmental and Neonatal Biology. With the move of the NICU to the new Lucile Salter Packard Children's Hospital (LPCH) at Stanford, the number of intensive care nursery beds increased from 25 to 41 and the number of intermediate care beds increased from 6 to 20. New faculty members were recruited, more than doubling the number of academic neonatologists in the Division. The Charles B. and Ann L. Johnson Center for Pregnancy and Newborn Services at LPCH was established in 1997. Dr. Stevenson became the first Director and Dr. Druzin the first Co-Director of the Center, reflecting the original collaborative vision of Dr. Sunshine. The mission for the Charles B. and Ann L. Johnson Center for Pregnancy and Newborn Services was to bring together all perinatal services (low risk obstetrics, high risk obstetrics, genetic counseling, obstetric anesthesia, and the perinatal diagnostic center) with Neonatology and Developmental Medicine and nursing services into a fully-integrated clinical service line and formalize the intellectual partnerships with faculty and staff dedicated to the health and well-being of mothers and infants. This consolidation of maternity services with newborn care has been instrumental in strengthening LPCH's ability to offer a more integrated and synergistic service that is truly family-centered. Furthermore, this merger has fostered a level of coordination and collaboration among clinical and academic departments that is truly exceptional and unique in the health care industry.
The Johnson Center, as a Center of Excellence, is a physician-directed, hospital-integrated, comprehensive clinical, research, and educational program within LPCH and the Stanford University School of Medicine. By successfully aligning professional and institutional goals, the Johnson Center has created collaborative and innovative patient care, research, and teaching. Today, with over 5,000 deliveries a year, the Johnson Center is one of the busiest delivery services in the Bay Area. Approximately 13% of babies delivered at LPCH are admitted to the Johnson Center Neonatal Intensive Care Units, contributing nearly 60% of those patient days. Over the last decade there have been extraordinary advances in maternal and neonatal care, many initiated or explored by Stanford scientists and clinicians based at LPCH. The Divisions of Neonatal and Developmental Medicine, Maternal-Fetal Medicine, and Obstetric Anesthesia in partnership with LPCH aim to provide optimum state-of-the-art care for critically ill and recovering pregnant women and their neonates including patient-oriented research studies to improve care. The Center is dedicated to the mission of the School of Medicine of advancing and exploring innovative and novel biomedical, translational, and clinical research and education through the nurturing and stimulation of interactions among basic and clinical scientists, clinicians, and educators through the School of Medicine, the University, the hospitals, and the community. Through our integrated research, education, patient care, and community outreach programs, we are committed to maintaining the highest standards of academic medicine and patient care.

2000

The Johnson Center's business development strategy builds upon the existing outreach program with its well-established network of successful affiliations. Currently, the Johnson Center runs satellite NICU's under the LPCH license at Sequoia Hospital in Redwood City and Washington Hospital in Fremont. These level II NICU's provide intermediate level care to newborns. Mothers living in these communities can use LPCH satellite Perinatal Diagnostic Centers and Infant Development Clinics close to home. Mothers and babies requiring more intensive specialized care, including surgical intervention, are transferred to the Regional Perinatal Center and NICU at LPCH. The Johnson Center has successfully deployed neonatologists and/or pediatricians to Sequoia Hospital, El Camino Hospital, Washington Hospital, ValleyCare Health System, Salinas Valley Memorial, Dominican Hospital, and Watsonville Community Hospital to improve the quality of care in local NICU's and ensure that there is access to the highly specialized services of the Johnson Center when required.
Dr. Stevenson has reorganized and expanded the NIH-funded Training Program through the appointment of new basic science preceptors and improved cooperation with basic science departments at Stanford within and outside the School of Medicine, expanded the competitive and externally funded research activities of the Division, enhanced its clinical programs, expanded the perinatal outreach services in surrounding communities, and has continued his research activities involving the diagnosis, prevention, and treatment of neonatal jaundice. In 1999, a device incorporating the methodology to use measurements of carbon monoxide in the breath of neonates as an index of bilirubin production was made commercially available by Natus Medical Inc. This technique is now being used to screen infants for hemolysis as a cause of jaundice. In addition, together with Dr. Hendrik J. Vreman and Ronald J. Wong, Dr. Stevenson has developed a new device incorporating blue light emitting diodes (LED's) as a more efficacious and potentially safer alternative light source for phototherapy. In 2002, the first commercially available instrument (neoBLUET) became available and is now in use in a number of hospitals worldwide.

2002

In 2002, Dr. Louis P. Halamek opened the Center for Advanced Pediatric/Perinatal Education (CAPE). This Center is serving as a home for the world's first Simulated Delivery Room and other simulation-based pediatric training programs. In addition, it is an incubator for the development of sophisticated patient simulators, virtual reality task trainers, and realistic simulated and virtual environments into which physicians and nurses at all levels of experience will be immersed. This unique training program seeks to create a permanent training laboratory for physicians and support staff for crisis skill development based on the simulation models of the aerospace industry. Just as pilots make critical decisions during crisis situations in the cockpit, physicians and nurses encounter and respond to medical emergencies in the delivery room. Their decisions carry lifelong consequences for babies and their parents. Yet, unlike the training model used in aerospace, traditional medical education does not systematically prepare physicians and nurses to manage medical crises. Investigations, funded by NIH, are underway to evaluate the impact of such training experiences on actual performance by physicians and other health care personnel at different levels of training.

2003

A new area of emphasis in the Johnson Center is perinatal epidemiology and health outcomes research. This program encourages the integration of research efforts within the Johnson Center and throughout the State through easy access to large population-based data sets for crucial comparative studies that influence State health policies and quality improvement efforts statewide and locally. A critical component of the Center is the California Perinatal Quality Care Collaborative (CPQCC), a network of 90 hospitals in California that have volunteered to submit and compare uniform care processes and outcome data for mothers and newborns. The CPQCC, guided by a representative Executive Board and its Perinatal Quality Improvement Panel, has developed the infrastructure and multidisciplinary partnerships necessary to support a state wide quality improvement process based on the principles of benchmarking data and hospital-based quality improvement efforts. CPQCC is designated by California Children's Services (CCS) as the provider of required CCS outcomes reports for all CCS-approved NICU's in the State of California. In 2003, the Division recruited Dr. Jeffrey B. Gould, a world-class perinatal epidemiologist, to join the Johnson Center faculty and provide leadership for new research initiatives applicable to this large population data set. Dr. Gould's scholarly work is directed toward the development and utilization of clinical and large population databases to measure care strategies and outcomes in order to both evaluate and improve health care for pregnant women and their newborn infants. He has published seminal work in establishing the relationship between socioeconomic status of the mother and delivery of the newborn by cesarean section and the use of zip code level data of the mother to identify small areas with poor outcomes that might be amenable to intervention. Although most work in these areas of epidemiology and public health must use newborn or infant death as the end point, Dr. Gould has devoted recent effort to the development and validation of a user-friendly perinatal morbidity database that will allow study of not only the fortunately rare event of death, but also injury.
The Division of Neonatal and Developmental Medicine remains the largest clinical service at LPCH with a strong regional presence, and it has one of the largest, most well-funded research programs in the Department of Pediatrics. It has extensive training programs and perinatal outreach and education programs. Stanford's reputation in academic neonatology has been further enhanced regionally, nationally, and internationally, with faculty members of the Division occupying many leadership roles. Newborn medicine at Stanford remains unique in its role as one of this country's world-class academic neonatology programs.

Division Directors

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