Asking the same questions: Premature infant care and the survival of the smallest

Philadelphia General Hospital nursing staff, circa 1895. Image courtesy of the Barbara Bates Center for the Study of the History of Nursing.

By Briana Ralston, PhD

A recent New York Times article stated:

“A small number of very premature babies are surviving earlier outside the womb than doctors once thought possible, a new study has documented, raising questions about how aggressively they should be treated…”

Though this statement was made regarding present studies, it could have easily been published 40 years ago during the early years of neonatal intensive care in the United States. Indeed, our current fascination with saving sick babies is not a recent phenomenon, but one whose roots sink back over the past century.

As I have studied the development of intensive care for sick newborns, this article struck me that, although many aspects of neonatal intensive unit (NICU) care have changed incredibly over the past fifty years, some things have not changed that much. Our desire to save the smallest patients among us has been a consistent driving force in neonatal healthcare throughout the 20th century. Social values of saving sick newborns, developments in medicine and technology, and good nursing care have all influenced and contributed to our ability to save premature babies. As we seek to save our smallest patients, questions linger about whom to save and the impacts of the types of intensive care we give.

Staff nurse and student nurse, circa 1950. Photo courtesy of the Barbara Bates Center for the Study of the History of Nursing

Historically, premature survival rates were much lower than today, particularly for babies born at earlier gestations. At the turn of the 20th century some physicians, such as Martin Couney, gave particular attention to premature infants and cared for them in incubator side shows at World’s Fairs.[1] Julius Hess[2], published textbooks and scholarly literature outlining particular methods for caring for medically fragile infants – with a focus on 30 -32 week gestation as the early premature infants (27 and 28 week gestation was the fine line of viability at the time). By the 1920s, premature infant units opened in hospitals where increasingly sick premature infants received specialized nursing care and had higher chances of survival. These became places where premature infants survived and received more intensive care than they would have in normal newborn nurseries. As the 1950s ushered in the ‘baby boom,’ hospital well baby nurseries swelled with newborns. Premature infants garnered greater attention in the media as they filled their own premature infant units. Physicians and researchers sought to improve respiratory therapies, understand better methods of infection control, and create new improvements to infant incubators all with the hope that they could save more medically fragile ‘preemies.’ They continued to save sicker and smaller patients.[3]

Philadelphia General Hospital student nurse with pediatric patient, 1967. Image courtesy of the Barbara Bates Center for the Study of the History of Nursing

Beginning in the early 1960s, hospitals established neonatal intensive care units (NICUs) where newborns could be grouped together to receive highly specialized nursing care. Research continued in these units as premature infant units closed and NICUs became the standard. With advances in technology and developments in medical treatments, babies born at earlier gestations began to survive with greater frequency. With the advent of the neonatal ventilator, known as the Baby Bird and designed specifically with infants in mind, premature infants suffering from respiratory distress received better respiratory support and had increased chances of survival.[4]

By the early 1980s, babies born at 27-28 weeks survived in greater numbers and the question of who to save as well as the unintended consequences of chronic health problems some of these babies experienced over their lifetimes brought a new dimension to the ethical questions faced by physicians, nurses, and families making decisions about how intensively and who to treat. We still ask these questions today and seek to understand the chronic issues many NICU infant graduates face over the course of their lives. While equipment and medical treatments have changed, our desire to save the smallest and weakest is still a driving force in NICUs today.

©Penn Nursing Science

The NY Times article reflects these ongoing questions and dilemmas we have faced as long as we have sought to save sicker and more medically fragile newborns. But it also reflects our hope – hope that we can save these babies and that they will survive, some to lead normal lives with little to no significant long-term impairment. As we have in the past, we may continue to develop care, medical intervention, and technologies combined with good skilled nursing care that enable the 22 weekers to survive in greater numbers with fewer chronic health issues in the future. While healthcare systems and technology continue to grow and change, some things must not. We must continue to think through how we give intensive care, why we give that care, and the ways we decide to create systems where that care is given.

[1] Silverman, William. “Incubator Baby Side Shows.” Pediatrics 64, no. 2 (August 1979): 127–41.

[2] Hess, Julius. Infant Feeding. Chicago, IL: American Medical Association, 1924.

Premature and Congenitally Diseased Infants. Philadelphia: Lea & Febiger, 1922.

Hess, Julius, George Mohr, and Phyllis Bartelme. The Physical and Mental Growth of Prematurely Born Children. Chicago, IL: The University of Chicago Press, 1934.

 [3] Cone, Thomas. History of the Care and Feeding of the Premature Infant. First. Boston: Little, Brown and Company, 1985.

[4] Desmond, Murdina MacFarquhar. Newborn Medicine and Society: European Background and American Practice (1750-1975). Austin: Eakin Press, 1998.


Briana Ralston, graduated from the University of Pennsylvania with her PhD in 2015. Her work relates to the development of neonatal intensive care units between 1955 and 1982, particularly how nurses were involved in and influenced the development of those spaces as technological systems and complex models of care. She has received funding from the American Association for the History of Nursing, the University of Pennsylvania office of Nursing Research, and from the Barbra Bates Center for the Study of the History of Nursing as a Brunner Fellow. She is currently a fellow with the Bates Center and an adjunct professor at the University of Pennsylvania School of Nursing.

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