Introductory Salutation and Felicitations from a freshman in Neonatology.
It is an arduous and glorious task to launch a publication with a focus on fetal and neonatal medicine. I am particularly pleased to see that this is emerging from Kerala. So, let me congratulate everyone involved in producing this inaugural issue.
With changing times over the last several years, several developments have taken place in the dissemination of knowledge which is the purpose of medical journals. Print editions are being replaced by open access e-journals requiring publication charges from authors. Some of these journals with profit motives without serious regard for scientific contents have seriously dented the reputation of genuine scientific publications. I hope you can devise an alternative model of information dissemination that can complement the print edition. One option may be to develop an app that might be easily accessible for physicians seeking the information at the bedside like accessing “UpToDate”. I encourage the editorial board of this journal to devise a disruptive way to disseminate salient clinical and research information like integrating the contents with EMR or phones/tablets.
I had the ultimate fortune to work in a tertiary care NICU for some time in Kerala, after being in an academic institution in the U. S. for nearly 40 years. It was a great rewarding experience. The striking realization of the limitations of my knowledge to function in that environment humbled me. The vast array of clinical problems and pathology that I encountered were beyond me, that I openly expressed my benightedness to the trainees which led to a refreshing experience of learning with everyone thus becoming a freshman in this field. Fortunately, with the help of the internet, my knowledge exponentially increased, but more questions popped up almost daily that lacked answers. The feeling that my peers and trainees were more comfortable and confident led me to believe that I can never master this science. Was this because I was formulating unnecessary questions or the culture of asking questions was non-existent in that environment?
Neonatology has gone through tremendous progress over the last 60 years. Examples of these include the discovery of surfactant, RLF (retrolental fibroplasia) which came to be known as ROP, fetal and neonatal pulmonary development, gestational age assessment, fetal growth aberrations, fetal and neonatal glucose homeostasis, bilirubin metabolism, CPAP, neonatal ventilation, thermal regulation, bronchopulmonary dysplasia, apnea of prematurity, necrotizing enterocolitis, intraventricular hemorrhage, periventricular leukomalacia, patent ductus arteriosus, nutrition, neurodevelopmental assessment, pulmonary vascular biology, neonatal pharmacology and therapeutics, mother-infant bonding, breastfeeding, etc.
Over the last several years we saw significant advances in the prevention and management of several neonatal conditions - sepsis, apnea, PDA, IVH, BPD, PPHN, growth restriction, etc. These were possible because of the remarkable research carried out clinically and in the biomedical laboratories. Technological advances in physiologic monitoring, laboratory tests, medications, equipment, (HFOV, ECMO, inhaled nitric oxide) etc significantly contributed to most of the advances in neonatal care. Many misadventures did take place during earlier phases of this journey. Now a stage of maturity and over-caution has arrived in this field. We started asking “where is the evidence” before new therapy is considered. Debates and controversies have become prevalent among care providers. Parents who are internet savvy can get relevant information online. This has led to family-centered care where parents take part in the treatment decisions. The evolution of perinatal ethics is a marker of scientific maturity. From the era of celebrating and proclaiming the smallest baby to survive, we asked how small is too small for a good outcome. Socioeconomic considerations also got into treatment decisions, and we moved away from the paternalistic attitude. Molecular diagnostic aides and genome sequencing have tailored treatment individualistically. Perhaps in the future, cell-based therapies may repair and regenerate organs leading to normal function.
Nurses are partners in the neonatal team and nursing research has added further refinements in this field including but not limited to cluster care, Kangaroo care, nesting, massage, etc. My plea to the editorial board is to request interested nurses and other ancillary staff (physical therapist, pharmacist, social worker, respiratory therapist, occupational therapist and developmental psychologist) to contribute to this journal.
Many clinical studies have lacked the power simply because of the low sample size (n).
Systematic reviews and meta-analyzes were used to address these issues. Cochrane Collaboration came into existence in 1993 with the goal of finding evidence from meta-analysis of randomized controlled trials and systematic reviews. Another major event was the establishment of the Vermont-Oxford network in the early 1990s. Several institutions became members of this, and currently it is the largest neonatal network with participation from around 1400 institutions from 34 countries. It may or may not be feasible to be members of this network in Kerala because of costs and other logistical issues, but a locally developed network of a few tertiary care institutions would certainly be a significant advantage. I urge the office bearers of this journal to consider this. Such networks in Kerala or South India can help in planning retrospective, casecohort, outcome, or prospective randomized controlled studies. All of us have inquisitive minds but lack the resources and tools for further explorations, but in a collaborative network, we can address these. Participants of the network may start several QA/QI studies and develop performance metrics and best practices.
There are several unique discernible differences in neonatal problems seen in India compared to other countries. These include lower incidence of BPD and NEC; higher incidence of infections, ROP, and fetal/neonatal growth restrictions. Whether nutrition, climate (unlikely), environmental factors (pollution), epigenetic factors, etc. play a role in these needs to be determined. As everyone becomes cognizant of the value of the evidence, I hope the clinicians and investigators will start seeking references and desist from quoting individuals (eminence-based!). To that extent, I am confident that your journal will serve a noble purpose. At this time, I am reminded of an African proverb “If you want go fast, you go alone; if you want to go far, go with everyone together”.
I wish this journal the best and hope that this will become the reference tool for every neonatal care provider.
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