Listen as Dr. Rosenfeld shares his perspective on the history of neonatology, advancements in the field, and future directions. We are joined by Charles Rosenfeld, MD, Professor Emeritus of Pediatrics in the Division of Neonatal-Perinatal Medicine at UT Southwestern.
Dr. Neeta Goli:
Welcome to Newborn News, a podcast where we discuss educational topics from medical professionals who care for newborns. I'm your host, Dr. Dr. Neeta Goli, a pediatrician in the UT Southwestern Newborn Nursery. Welcome back to the podcast. In today's episode, we will be discussing the history of neonatology and a career in neonatology. We are recording remotely due to the ongoing COVID pandemic. We have the honor of being joined today by Dr. Charles Rosenfeld, Professor Emeritus in the Division of Neonatal-Perinatal Medicine here at UT Southwestern.
Dr. Neeta Goli:
After graduating from Emory University in the 1960s, Dr. Rosenfeld completed residency, including a chief residency, at Yale and the Albert Einstein College of Medicine. He completed a fellowship in pediatric pulmonary medicine and a research program in perinatology. He joined UT Southwestern as faculty in 1973, and we're lucky to have had him stay here since then. He was the director of the Division of Neonatal-Perinatal Medicine for 28 years, and the division's fellowship director for 29 years.
Dr. Neeta Goli:
His impact on the field of neonatology is indisputable, with countless publications to his name, almost continuous NIH grant funding for his study of cardiovascular changes in pregnancy and fetal development, and a long list of mentees who have themselves gone on to become leaders in the field. He remains active in the division, including in research activities and journal club, and continues to provide mentorship and guidance to those of us in the division. Dr. Rosenfeld, thank you so much for joining us today.
Dr. Charles Rosenfeld:
Thank you very much for having me. It's a beautiful introduction. Thank you. It's a pleasure to be here.
Dr. Neeta Goli:
Well, we're so glad to be able to learn from you today. Just from your perspective, when you were training in medical school and residency, what made you interested in newborn babies, neonatology?
Dr. Charles Rosenfeld:
Well, actually I started off my training in pediatrics with a direct interest in pediatric neurology and had moved to New Haven and then to New York in order to accomplish that goal. But like many trips that people take, I found a detour in the road, and I ran into a fellow in New Haven by the name of Lou Gluck who was the biochemist and pediatrician who was responsible for neonatal care at Yale New Haven Medical Center.
Dr. Charles Rosenfeld:
Dr. Gluck invented the lecithin-sphingomyelin ratio and taught us about phospholipids and surfactant, and I was fascinated by that. Moreover, I was one of the house staff that opened up a brand new neonatal intensive care unit at that time. And we went from an archaic unit to a brand one. I then moved to New York where I was introduced to Larry Gartner, who was an expert in neonatal bilirubin metabolism, and was fascinated by the work that Dr. Gartner was doing in terms of bilirubin brain damage and how you treated it. And I think it was the introduction to these two individuals who waylaid my plans and had me move on to the fact that neonatal care was new and unique. It was early in its formative years, and there was a lot to learn about how to make the diagnosis in the newborn and how to care for these preterm infants. And so it was an exciting period in neonatal medicine and in pediatrics in general.
Dr. Neeta Goli:
What was the general concept of neonatal care at that point?
Dr. Charles Rosenfeld:
Well, it was interesting because at Yale New Haven, they had just built the country's largest neonatal intensive care unit. It was huge, it was poorly designed, unfortunately, as I learned later, but I thought it was pretty exciting at the time. And the concept was, was that there were pre-term babies and term babies who got sick and needed care. And these old formula rooms, which had been converted to neonatal intensive care units were where they were going to be cared for. And basically we were talking about babies that were greater than 1200 to 1500 grams. There were very few kids, newborn infants that were less than a thousand grams at that time. And we were using archaic equipment. In other words, the equipment that we had was really converted from adult care to neonatal care and led to a lot of morbidity. So it was archaic medicine, but it was new and it was exciting and it was going to change.
Dr. Neeta Goli:
It sounds like there was a lot of room for growth and innovation.
Dr. Charles Rosenfeld:
Absolutely, absolutely. And I was fortunate enough to be around people that were involved in meeting those needs in New York city, between Mount Sinai and Columbia and Einstein and NYU. I met all of those folks at meetings that they had in the city on a regular basis.
Dr. Neeta Goli:
So at the time when you were starting in your field, from what you mentioned, Yale had just opened up this neonatal intensive care unit, who were they admitting? What was their, I guess, admission criteria at that time?
Dr. Charles Rosenfeld:
Well, the admission criteria was anything that was preterm and preterm basically meant less than 2000 grams. And so babies who were less than 2000 grams were admitted there. Babies of mothers with diabetes were thought to be at risk, and small, really small kids.
Dr. Charles Rosenfeld:
I can remember one infant that was admitted there that was a thousand grams. And everybody was astonished by the fact that this kid never went on the ventilator, never got sick. And here we were in this neonatal unit called the ICU where the oxygen in the room was probably as high as the oxygen in the isolette because they all leaked. And we were trying to figure out why this little baby was doing so well. When the mom and dad showed up and the mom was probably about five foot eight or five foot nine, and the dad was probably five feet tall. And we then realized that the baby really was reflective of the father's short stature and that the baby might be older than we had expected on the basis of birth weight. So gestational age wasn't a consideration at that point. So it was basically if you look sick or you were small.
Dr. Neeta Goli:
Oh, I see. So the Ballard exam and things like that, weren't in existence.
Dr. Charles Rosenfeld:
No, there was no Ballard exam at that point. The APGAR score was around and that helped us screen some babies.
Dr. Neeta Goli:
Wow. So really just kind of an open field then for you and as a trainee, what kind of things do you think, what skills do you think were important for you to develop early in your medical career? And what do you think is important for trainees now to be thinking about in their early training?
Dr. Charles Rosenfeld:
Well, the skill set that had to be developed at that time in neonatal medicine was to be inquisitive. In other words, to learn how to look at a patient and how to do a thorough physical examination, how to ask questions of the mother and the father about the pregnancy, since this was a whole new area. And we began to realize that what happened in pregnancy affected the baby at the time of birth or even the delivery process, and that we use our time to try and seek answers that would allow us to make the diagnosis and then to provide care. And so that learning to look, learning to put your hands on, learning to think, and then use the evidence that you had at that time, which was pretty minimal, to develop a plan of care was really very important. And I don't think it's really changed today.
Dr. Neeta Goli:
And then you have to work on actually creating the evidence then to go from there.
Dr. Charles Rosenfeld:
Well, we, we began to do that and that's true. As a fellow in Colorado, I sought out questions related to fetal development and I learned fetal physiology. And I think that really set the stage for looking for answers, to questions that related to diagnosis and care. And that was really very important.
Dr. Neeta Goli:
Well, to get into the specifics of that. So the field of neonatology has evolved, obviously quite a bit, since you first started with many new therapies and modalities to improve the survival of these premature infants. For example, in 1960, the estimated survival rate for a one kilogram birth weight, infant was dismal, but now here in 2021 has improved to about 95%. In your view, what have been the biggest advances in the care of premature infants during your career?
Dr. Charles Rosenfeld:
Well, I've been involved with introduction of incredible changes in care over the last 50 years, I've witnessed the introduction of actual infant ventilators instead of modified adult ventilators, the introduction of positive airway pressure, or CPAP the use of surfactant therapy, the implementation of antenatal steroids. Even though we've had all of those, things occur and each of them are unique to themselves.
Dr. Charles Rosenfeld:
I think it really was the understanding of the unique physiology, the pathophysiology associated with development and changes in basic care that really led to the improvement in outcomes. We looked at our data Parkland a few years ago with Jeff Kaiser, he's now the Director of Neonatal Medicine at Hershey. What we found was we said, actually our biggest fall in neonatal mortality occurred before the introduction of CPAP, and before the introduction of surfactant therapy. And we think that related to understanding better the fluid needs and how to warm babies and how to settle babies in, who were born prematurely, even though they were now babies less than 30 weeks gestation. So I think understanding the basic physiology of development has really, really changed our ability to understand how to provide care for disease processes.
Dr. Neeta Goli:
Do you think that happened mostly on an observational level or more from animal studies?
Dr. Charles Rosenfeld:
I think it was a combination. I think a lot of it came from animal studies. People like Giacomo Meschia and Fred Battaglia in Colorado, as well as Abe Rudolph in San Francisco, taught us about the cardiovascular changes that occurred in pregnancy in the fetus and how that transitioned into the newborn. Dr. Meschia and Dr. Battaglia taught us a lot about nutrition and growth prior to birth. That's been carried over into our understanding of the needs of the newborn infant with regard to fluid and calories and electrolytes. I think as we understood the basic physiology through the animal studies, we transmitted that into understanding what went on in the human, and that allowed us then to better understand human physiology and pathophysiology. But the animal studies that were done in those days in newborn sheep and a fetal sheep are just - their value is unquestionable in my mind.
Dr. Neeta Goli:
What has it been like for you to go from, you know, going to work in the Yale neonatal intensive care unit where gestational age, wasn't really a concept in terms of the care of these babies yet to now, we have these advanced level four NICUs with all these therapies and everything. How was that transition? I mean, how have you felt about that whole process living through it?
Dr. Charles Rosenfeld:
I was very fortunate in that when I left New York to go to Colorado, to do my training and research in perinatal medicine, there was a woman there by the name of Lula Lubchenco. And Dr. Lubchenco in conjunction with Dr. Battaglia and others, introduced this whole concept of gestational age and how growth was depended upon the weight and the gestational age. And we now knew what prematurity was, and it was less than 32 weeks. We are less than 35 weeks gestation and it had nothing to do with weight, it had more to do with the duration of pregnancy. When we looked at that, we then realized that also related to neonatal outcome and morality. So the Lubchenco charts really changed at least my concept, how I approach newborn infants in terms of what the risks were. When I came to Dallas, there were no survivors less than a kilogram at Parkland Hospital, that I could find going back to 1968, and I arrived there in 1973. And the introduction of the Lubchenco charts and the risk for mortality after birth changed the thinking of the obstetrician, the pediatrician, the neonatologist, and within two to three years, our neonatal mortality, it dropped 70% just because we now knew how to take care of babies and we knew what the risks were. We had put people in the delivery rooms to take care of the babies immediately at the time of birth, rather than waiting until they got sick.
Dr. Neeta Goli:
Looking forward, what are some hurdles you think neonatology still faces as a field?
Dr. Charles Rosenfeld:
Well, I think where we're headed now is defining, what is viability? And that's been the question all along. It started off when you suddenly had survivors who were less than a thousand grams or less than 30 weeks. And then you had survivors who were in less than 25 weeks gestation, and that's going to have to be an important aspect of how we look at our use of resources and what we can really do as physicians. And that relates to what I think is really the big area of change that's going to occur.
Dr. Charles Rosenfeld:
That is long-term development, understanding where these infants that are born prematurely, that had issues in the neonatal intensive care unit, where are they going to be at 5 years of age, 13 years of age, and at 21 years of age, and what we can do to improve those outcomes.
Dr. Charles Rosenfeld:
In studies that we've done at Parkland Hospital and UT Southwestern Medical Center, we found that preterm babies are at increased risk by six to eight months of age for elevated blood pressure and obesity. We're now seeing those kids at 10 to 13 years of age and the risk for overweight and obesity and elevated blood pressures accounts for 50% of the patients that we’d followed. And so the long-term development and improving the outcome long-term is really what's on the horizon.
Dr. Neeta Goli:
What kind of things do you think will help us get there other than long-term prospective observational studies?
Dr. Charles Rosenfeld:
Well, I think we're going to have to figure out one: how to feed babies in the NICU correctly. We're going to have to address the question of how do we feed them after they leave the NICU. I think that's the same question we have for even term babies, and that is to optimize growth in such a way that we don't put the babies at risk at school-age for the initiation of adult-onset diseases. This whole new area is really exciting, but it extends into general pediatrics. And so the neonatologist is going to hand off more and more babies to the general pediatrician, and they're both going to have to be responsible for deciding how to feed and how to follow and how to implement early learning in these kids in order to optimize outcome.
Dr. Neeta Goli:
And as far as when you said how to feed them properly in the NICU, are you referring to TPN composition, breast milk versus formula, that kind of thing?
Dr. Charles Rosenfeld:
Well, if they're just in with TPN, I can remember when it was first introduced. I did one of the first cases of TPN therapy in New York city as a resident. I used it without any research having been done at all. It was just a surge of case reports out of Philadelphia. When we had a big meeting in Atlantic City with pediatricians, the question was how much research has been done on TPN and what was the best way to administer it. One of the leaders in neonatal medicine pointed out that we hadn't done any research at all. We were doing this anecdotally. That still exists to some extent. And so we're still learning how to optimize total intravenous nutrition, and then to make that transition to oral feedings and how to use breast milk and how to use formulas and additives appropriately. Dr. Luc Brion in our unit has pointed out that micronutrient deficiencies in many babies has led to poor growth and growth disorders, and that by understanding those deficiencies, we can actually reverse the adverse effects of their absence. So we're still learning about how to feed.
Dr. Neeta Goli:
Well, that's exciting. And I mean, it sounds like there's a lot more room and like you said, Dr. Brion is helping get some more knowledge in that area. From a personal standpoint, what do you consider your greatest professional accomplishment or your greatest contribution to the field?
Dr. Charles Rosenfeld:
That's an ego question. You realize that, don't you? It's when you look back and you think about what you did and where the impact has been, it takes a moment of reflection. I published a lot of papers, and there’s a lot of research that I've done, but I don't consider that to be my greatest professional accomplishment.
Dr. Charles Rosenfeld:
When I look back and I think of the things that I've been involved with, what I really believe has been my greatest accomplishment is having had the unique opportunity to teach and mentor students. That began in grammar school when I volunteered in the Dallas Independent School District at the School for Advanced Students. I can remember a red-headed boy at the back of the room asking me a question after I'd given them an overview of animal research in understanding medicine and I was excited because here was a third grader asking questions about what we were doing. That third grader, by the way, went on to graduate from MIT and he's a professor of environmental sciences down at, in Houston. But it extended all the way to graduate education, not just in medicine, but also in the basic sciences. And so, as I look back, I think the fun part, as well as my greatest accomplishment, is having had the opportunity and being given the opportunity to work with students at every level throughout education.
Dr. Neeta Goli:
And that's an impressive legacy you leave as well, as you said, you know, your mentees and trainees are now leaders in the field themselves. So that's a good satisfying legacy to leave. And then again, looking forward, we were talking about hurdles that neonatology faces and advances in the field in recent years. What things do you think are coming through the pipeline that you're most excited about in terms of, you know, potentially even decreased threshold of viability, improved outcomes for the current premature babies that are born? What are your thoughts?
Dr. Charles Rosenfeld:
Well, I think that many of the things you just mentioned that are really going to be important, but as I look back and I think about the comments and the questions that you've made. For example, my comment about the physiology and understanding the growth and development. I think what we're going to see in the next few years is incredible fine-tuning of our understanding and our application of new knowledge, so that we improve what we're doing now to the next level. Molecular biology is going to help us understand the risk for certain areas of growth and development. As we began to explore the role of cellular growth, I think the fine-tuning of what we know now using randomized control trials and using long-term outcomes, quality improvement studies, they're all going to make it easier for us to use evidence-based medicine as our basis for practicing neonatal medicine.
Dr. Neeta Goli:
Dr. Rosenfeld, as I mentioned in your introduction, you do remain active in the division, including in research activities, journal club, and mentorship. Given the current landscape, especially during the past year that we've had with COVID, with high rates of burnout in physicians. What advice do you have for physicians today to stay engaged and motivated and avoid burnout in practice?
Dr. Charles Rosenfeld:
Well, burnout is an issue that occurs in all walks of life, whether it be academic or clinical medicine or being a lawyer or financial advisor. I think the isolation that we've had in the last year or so has affected people differently depending on how you look at life and how you handle life. To me, burnout means that you didn't take time to be with your family and to have your own time in freedom. You have to move away from work intermittently in order to maintain a vision, I think. My recommendation for people, no matter what field they're in, is you have to learn to find time for your family and yourself, you have to learn how to enjoy the time away from work.
Dr. Charles Rosenfeld:
In my respect, I did it by maintaining a vegetable garden in my downtime. And the other way I did it was I vacationed with my family, so that I was able to come back and recharge my battery and take up what I was doing very intensively. So I think that people have to do what they enjoy doing, but at the same time, they have to make sure that that's not all they do, there have to be outside interests. And those interests have to allow you time to think, time to relax, and time to enjoy the things around you, and importantly that's your family, and your children.
Dr. Neeta Goli:
And to close the episode. Is there any, are there any words of advice or anything else that you want our listeners to hear?
Dr. Charles Rosenfeld:
Well, I think for those of us in medicine, what you want to be able to do at the end of a career is look back and say, “Boy, I really did have fun.” And that I did provide the community and the people that I've worked with, something that they might not have had if I had not done what I did. It sounds a little perplexing, but I think that you want to be able to say at the end of your career, that it was a fun time and that you would do it again. That's the way I look at medicine right now. I would change nothing that I've done.
Dr. Neeta Goli:
That is a wonderful. Hope we can all have the same. Dr. Rosenfeld, thank you again so much for taking the time to join us today.
Dr. Charles Rosenfeld:
You're welcome. And thanks for the invitation.
Speaker 3:
Thanks for listening to Newborn News. We hope you join us next time. If you like what you hear, make sure to subscribe and leave us a review. If you have questions, comments, feedback, or suggestions for future episodes, please email me at NewbornNews@utsouthwestern.edu. As a reminder, this content is educational and is not meant to be used as medical advice. Views or opinions expressed in this podcast are those of myself and my guests and do not necessarily reflect the views of the university.