The Birth and Growth of the Newborn Unit: a Historical Perspective
Transcribed on the basis of narrations by Prof. ON Bhakoo and Prof. Anil Narang
Prof. ON Bhakoo, after his training in Pediatrics from All India Institute of Medical Sciences, New Delhi joined PGI in 1962. Initially he managed both newborns and older children. A 6-bedded Special Care Newborn Unit came up on the 5th floor of A-block in Nehru Hospital in January 1968, immediately following a 2-week-long Workshop on Neonatology, conducted by Prof Beryl Corner, who visited the unit on behalf of the World Health Organization (WHO). Subsequently, Dr Bhakoo had a stint in UK and after his return in 1970; an 8-bedded Neonatal Unit was established on the 3rd floor. Prof Anil Narang joined the team in 1974 as a faculty member after completing his residency and registrarship in the department of Pediatrics in PGI itself. Dr Bhakoo went on a sabbatical to McMaster University, Canada in 1975-76 and Dr Narang to Oxford University, UK in 1979-80. Subsequently, they started working on establishing a fully equipped modern Neonatal Intensive Care Unit, which saw the light of the day in 1988 in the form of a 8-bedded NICU initially located on the second floor of Nehru Hospital in the main ICU. This was in addition to an 8-bedded outborn nursery (called ‘septic’ nursery in initial years) which already existed in the children ward on 3rd floor. The DM (Neonatology) program started in July 1989.
The NICU moved to its current location on level 3 above GE block in 1992 and the number of intensive care beds was increased to 16. With the opening of Advanced Pediatrics Centre in a separate building, all 40 beds of the neonatal unit were consolidated in its current location in 1996. Dr Subrata Sarkar, of the second batch of DM, served as a faculty member from July 1992 to Jan 1994. Subsequently, Dr Praveen Kumar of the third batch of DM joined as a faculty member in Aug 1994. The faculty strength was augmented further by the joining of Dr Sourabh Dutta, DrKanya Mukhopadhyay, Dr. S Venkataseshan and Dr Shiv Sajan Saini in the following years. The current senior faculty members also have been on sabbatical leaves in Canada and Australia. They have carried on the traditions and legacies established by Profs Bhakoo and Narang who superannuated in 1995 and 2008 respectively. The unit is now actively pursuing the development of a new Mother and Newborn Centre with 130 neonatal beds to cater to the exponential increase in demand over the last few years.
Neonatal care equipment
Since reliable and good quality medical equipment for care of the newborn was not available in the country when the special care neonatal unit came up in PGI, Prof Bhakoo and Prof Narang had to innovate. They planned, designed and fabricated incubating basinets with 15 watts bulbs as the heat source with a thermostat mechanism to avoid over-heating. They also got low cost bulb warmers fabricated from the Biomedical workshop of PGI. This design was later copied and used across numerous medical colleges and newborn units in India. The two leaders also conceptualized and got indigenous phototherapy units manufactured. When Prof Bhakoo returned back from his visit to the UK in 1970, his close colleague and then head of bio-medical engineering, Prof. Peter Rolff, gifted him with a neonatal ventilator. This was the first neonatal ventilator in PGI and perhaps in India. It helped to mechanically ventilate and save many preterm babies. The unit has been actively associated with the Central Scientific Instruments Organization (CSIO) resulting in the development of low cost resuscitation bags and pulse oximeters. Currently, the unit is equipped with the state-of-the-art equipment of a modern NICU, including high frequency ventilators, inhaled Nitric Oxide devices, bedside cranial ultrasonography, functional echocardiography, Doppler, in-house arterial blood gas machines, and ABER.
Contribution at national level
Profs Bhakoo and Narang were founder members of a small group of neonatologists who established National Neonatology Forum of India in 1980. The Newborn Unit of PGI, under the able leadership of Prof Bhakoo and Prof Narang, played a significant role in the progress and evolution of the National Neonatology Forum (NNF). Both of them held several positions of responsibility in NNF for many years and the current faculty has carried this tradition forward. All of the faculty members are active contributors at national level and are chairpersons and members of several committees of NNF. The faculty members of the unit have been technical experts, advisors, members and chairpersons of various task forces and committees of ICMR, DBT, DST, WHO and UNICEF.
International
The international neonatal community holds the faculty and trainees of the unit in high esteem. They have been invited as Visiting Professors to several Universities and by several hospitals across the world. They have had much active collaboration with several international research groups.
Patient services
The present-day Newborn Unit has a 16-bedded NICU for inborn babies and a 24-bed stepdown care area (which also includes a 6-bedded ICU for outborn and infected babies). The unit provides level III and level II care to both inborn and outborn neonates. It caters to nearly 6000 high-risk deliveries and 2000 admissions annually. There are 3 weekly clinics - one postnatal clinic and two High Risk Follow-up Clinics for follow-up assessment and care. The unit provides consultative and supportive services for neonatal surgical ICU and other wards of PGI. It also provides pre and post-op care for cardiac and ophthalmic surgical procedures. Public Health Nurses in the unit conduct home visits in the Tricity to provide continuing care and support in the home environment for high-risk newborns.The neonatal unit at PGI was one of the first to totally stop bottle-feeding more than 25 years ago. As an alternative, spoon/paladai feeding has been adopted and promoted. In-house cranial ultrasonography was established in 1989 while bedside functional echocardiography services are available for last 5 years.
Educational services
Concurrent to the efforts to establish neonatal intensive care, Profs Bhakoo and Narang also had the foresight to realize that our vast country would need many leaders and teachers in neonatology to improve the quality of care being provided and make a dent in the neonatal mortality rates. They conceptualized the first DM (Neonatology) program of the country with this aim and the first batch of 3 trainees was inducted in July 1989. Since the inception of the DM neonatology program, 68 students have joined the course. After passing out, majority of themhave gone on to establish excellent neonatal services in various parts of the country. Some of them went overseas and today they are well recognized as clinical and research neonatologists in USA, Canada, Australia and UK. Training is also provided to residents from several allied departments, including Obstetrics, Pediatric Surgery, Internal Medicine and Anesthesia. The unit also receives short-term trainees and observers from all over India, neighboring countries and from developed nations.
The unit faculty has been involved in conducting workshops and CME programs in India and neighboring countries, such as Bangladesh, Sri Lanka, Nepal, Mauritius and Iran. Faculty members have delivered invited lectures in North America (including PAS meetings), UK and Australia. Currently, the Ministry of Health and UNICEF have designated the unit as a Regional Collaborative Centre for training in Facility Based Neonatal Care.
The unit has taken an active responsibility for in-service nursing education. Nurses are sent to attend national conventions of NNF, workshops and lactation management courses. They are also involved as faculty for nursing workshops. Some have been to USA for further training. Nurses from Canada have visited and spent 2 to 3 week periods for Neonatal Nursing Training on several occasions.
The unit holds regular workshops on neonatal resuscitation; breast-feeding and Kangaroo Mother Care every 6 months. The unit organized WHO-sponsored two-week courses for consultants in 1968 and 1978. NNF workshops on Primary Care of Newborn (1990) and Neonatal Ventilation (1993) led to the production of important recommendations for the country. The unit hosted the hugely successful and path-changing 16th and 24th Annual Conventions of NNF in 1996 and 2004 respectively. The unit started a series of Single Theme workshops in 2002 and so far 9 workshops have been held resulting in the publication of state-of-the-art monographs.
Research and Publications
The unit has had several extramurally funded research projects from ICMR, DBT, WHO and SNL. There is an active collaboration with paraclinical and experimental medicine departments and several students have completed their PhDs in the neonatal unit. The unit has had special research interests in perinatal asphyxia, respiratory problems, neonatal hyperbilirubinemia, neonatal sepsis, quality improvement, nutrition, follow-up of high-risk infants and cardiovascular physiology. Over the years, the students and faculty of the newborn unit have bagged numerous awards, including NNF Gold Medals, NNF Social Neonatology Gold Medals, Indian Academy of Pediatrics SS Manchanda Gold Medal, Institute Major Amir Chand Gold Medals and Asian Society of Pediatric Research best paper prizes, to name a few. Faculty members regularly publish research work conducted in the unit in several internationally and nationally reputed journals. They have published numerous books, chapters in books and monographs. The PGI NICU Blue book-Handbook of Protocols- has received wide recognition.
Computerization of records
With the efforts of faculty and senior residents, the patient records of the unit have been fully computerized since 1995 and the equipment records since 2006.
Philanthropy
Realizing the difficulties faced by families of poor patients, the unit established The Newborn Health Education and Research trust (The NewHEART) in 1999. It is a registered charitable trust which provides financial assistance for drugs, disposables, investigations and procedures for the poor families of infants admitted in the unit.