Predicting the future is always a dubious endeavor. If I could really do it, I might have a slightly different job. Nonetheless, it is worth considering where we were not long ago and where we might be in the future.
First, where have we come? Remarkably, the last 20 years has seen relatively incremental technological changes. Slightly better breathing machines and the use of a few important new medications such as inhaled nitric oxide. The most important “low tech” approach has been the use of human milk for our small or sick babies. We have learned that none of our technology can beat the incredible value of human milk for infants and that this is especially true for premature ones. We have challenges as I’ve noted before, but overall we are thrilled to see an era in which we are able to support mother’s breastfeeding or providing their milk for their baby that they have expressed with a pump. We offer EVERY baby in the NICU at Texas Children’s Hospital or the Pavilion for Women donor milk if there is not enough of their own mothers milk available to meet their needs. This is a major change in thought in the NICU world, but is based on very solid scientific evidence.
For the future, I do not think we are headed towards some sort of “artificial womb” in which we can raise fetuses to full term from the start or even from the beginning of the second trimester. Over the last 10-15 years, we have improved our care of very small infants, such as those born at 23 and 24 weeks gestation. But we still have a long way to go with these infants and have not really lowered the gestational age of survival much in recent years and I see little likelihood that will happen.
What I believe will happen is that we will continue to focus on improving the short and long-term outcomes of babies who are born prematurely or with other major health problems. This is happening now, using “high tech” approaches or a mix of high and low tech approaches. For example, one high tech approach is new forms of breathing machines for babies (called mechanical ventilators) that breathe with the baby’s breathing rhythm, decreasing the damage that have historically been associated with ventilation.
Neonatologists work with a wide range of other groups in caring for infants. This includes communicating with pediatricians to help us with the care of healthy or slightly ill newborns. It also includes working with nurses and others who assist us around the clock in every aspect of neonatal care. I do not see any shortening of pediatric specialty training in the near future. As with all pediatric specialists, the challenge of increasing student loan debt will continue to weigh on our trainees and new doctors. We need to work on decreasing that debt burden and ensuring that we train enough of all pediatric specialists.
Neonatologists by tradition are all “generalists” in the field. There is no formalized sub-specialty training in areas such as neonatal pulmonary, nutritional, or endocrine/metabolic diseases. In general, infants who need specialized care in these areas are managed together by consulting with the appropriate pediatric specialty service. In the future, I believe these relationships will become more formalized and hopefully regionalized. That is, a baby who has severe chronic lung disease anywhere in our region can be sent to Texas Children’s Hospital where we will have a multidisciplinary team of experts in this problem to manage them.
Finally, I think that we have made huge strides in developing neonatology as a family-centered specialty. Our physicians work closely with families in caring for babies and developing care plans and overall plans for our neonatology program. This trend will undoubtedly increase and we will see parents taking an increasing role in taking care of their infants, even while still in the NICU. This change is critical so we can improve the transition from NICU to home and do our best to keep our babies at home after their initial hospitalization.