On the Role of Infections in Neonatal Mortality: Nelson WE. J Pediatr 1960;56:274-84

Abstract

In 1960, infection was an underrecognized cause of neonatal mortality. In this treatise (most closely aligned with The Journal's 2010 “Medical Progress” manuscripts), W. E. Nelson points out the inadequacy of data existing at that time. He proposes that on careful evaluation (by obtaining appropriate cultures of the placenta and neonate, along with microbiological and microscopic examination at autopsy), infection often was revealed as the immediate cause of death instead of the clinician's recorded cause, such as “prematurity,” “congenital malformation,” “intracranial hemorrhage,” or “hyaline membrane syndrome.” Nelson viewed accurate delineation of the contribution of infection to morbidity and mortality as an opportunity for prevention. Noting that the gradual fall in neonatal mortality (from 44 per 1000 live births in 1915 to 19 per 1000 in 1955) did not mirror the sudden availability of sulfanomides in the late 1930s and penicillin in the latter 1940s, Nelson speculated that improved obstetric care probably was responsible for increased survival, and antibiotic therapy for an ill neonate was not as effective as one might have hoped. Nelson's delineation of prevalent pathogens is noteworthy for the absence of group B streptococcus (whose natural emergence and then suppression by intrapartum chemoprophylaxis would be later events in the history of neonatal medicine), and the absence of fungi, infections with which are modern history (the fallout of prolonged hospitalizations, antibiotic use, and other nosocomial events). Nelson opined that improvement in neonatal mortality due to infection would depend on “meticulous attention to prophylactic measures: (a) prenatal care with emphasis on maternal nutrition, health, and hygiene; (b) delivery under as nearly aseptic conditions as possible; (c) strict isolation in the hospital nursery or preferably in a “rooming-in” unit with the mother; (d) avoidance of premature birth; and (e) avoidance of iatrogenic disease.” This writer was privileged to be one of the last residents “under the influence” of Nelson at St Christopher's Hospital for Children. For us, his most abiding characteristics were toughness and insightfulness. The appalling recent statistics on US infant mortality of approximately 6.9 per 1000 live births provide evidence of Nelson's insightfulness. Preterm births rose from approximately 9.4% in 1981 to 12.7% in 2007 and are primarily responsible for our country's paltry worldwide ranking of 30th in neonatal survival. Nelson used language (and its accountrements, such as commas, quotation marks, italics, etc) extremely carefully. There is a single sentence all in italics in his 1960 article on neonatal mortality and infection: “It is inordinately clear that the one unquestioned helpful contribution the mother can make is to maintain the fetus in utero to term.” Society and healthcare systems and scientific discovery need to help her do just that.