My Twitter feed was full of photos of tiny premature babies next to photos of the thriving adults they have turned into, along with emotional testimonies from parents perpetually grateful for the life-saving work of neonatal teams.
I have witnessed the outstanding work by staff in Cork University Maternity Hospital’s Neonatal Unit and I have very close friends whose babies arrived unexpectedly early and whose lives transformed from expectant parents readying nurseries and buying prams, to shell-shocked parents living in the NICU, entrusting staff with their fragile baby and praying that everything will be OK.
Newspapers, including The Echo’s WOW! supplement, published articles and personal accounts of families who survived the ordeal of premature birth and an extended hospital stay, and they expressed deep gratitude at the survival of their babies.
But among all the deserved praise of neonatologists, neonatal nurses and other staff, there was no mention of one of the unsung heroes of neonatal medicine — surfactant.
You may not have heard of it: surfactant is a truly revolutionary therapy that has transformed the outcomes for premature babies. It ranks after antibiotics and vaccinations as the most important medical intervention that has lowered infant mortality rates.
Surfactant is a mucous-like substance that coats the lining of the lungs. It helps prevent them from collapsing by balancing the surface tension inside the lungs, but up until the 1950s doctors didn’t know of its existence or importance.
In the late 1950s, a Boston-based paediatrician, Mary Ellen Avery, was trying to discover why tens of thousands of babies were dying every year from respiratory distress syndrome (RDS).
At the same time, John Clements, a military doctor and research physiologist, was investigating ways to protect lungs from nerve gases. He and his collaborators realised they knew very little about basic lung function and capacity and started conducting experiments.
Clements determined that there is an important substance in lungs that lowers the surface tension in the lungs and stops them from collapsing. His initial scientific paper on the subject was rejected but through mutual acquaintances, he heard of Mary Ellen Avery’s research and shared his initial research findings with her.
Avery investigated the lungs of babies who had died from RDS and compared them to the lungs of healthy animals and discovered that, yes, they were missing an important fluid in their lungs — surfactant.
Babies begin to produce surfactant at about 24 to 28 weeks of pregnancy, and it is found in amniotic fluid between 28 and 32 weeks. Babies are thought to have sufficient levels of surfactant by 35 weeks gestation.
Despite these breakthroughs by Avery and Clements in the late 1950s, clinicians were slow to accept that surfactant deficiency was the cause of RDS and progress to find a cure was slow.
In a tragic twist of history, the first clinical trials with surfactant were spurred by the death of President John F. Kennedy’s third son, Patrick, who was born prematurely at 35 weeks and died two days later from respiratory distress syndrome.
His death highlighted the lack of treatment and clinical trials commenced in the mid-sixties to see if surfactant would improve the outcome of babies with RDS.
Initial trials were disappointing but other important research demonstrated that early steroid treatment for pregnant women at risk of premature birth helped lower the likelihood of RDS.
HSE.ie says that if a woman is thought to have a significant risk of giving birth before week 35 of pregnancy, she will be given an injection of a steroid medication called betamethasone. This helps stimulate the development of the baby’s lungs.
It’s estimated that the use of betamethasone prevents neonatal respiratory distress syndrome occurring in a third of premature births.
Through trial and error in the 1970s, clinicians worked out the optimum ways of administering surfactant to premature babies and in the ’80s animal-derived surfactant from cows and pigs was being used to treat infants.
John Clements thought an animal derived product would potentially be inflammatory so he synthesised an artificial one in the lab. That received FDA approval in 1990 and was used to treat thousands of babies.
There is now a range of animal-derived or synthetic surfactants available to treat patients. More recently, surfactant has been explored as a possible treatment for Covid-19 patients to improve lung function.
Clements’s research into lung mechanics also inspired fellow University College of San Franscisco colleagues to invent CPAP treatment for babies — a ventilation system that delivers continuous airflow and prevents airways collapsing.
Surfactant was the first drug developed exclusively for the treatment of neonates and is a major milestone in the history of neonatal medicine. Its introduction was associated with a 6% fall in infant mortality in the USA — a remarkable achievement.
The World Health Organisation states premature birth is the leading cause of death in children under the age of five worldwide. In high income countries like Ireland, survival rates for premature babies are high because of access to high quality personnel and effective drugs and technology. Sadly, this is not the case in low income countries.
I once spoke to a neonatologist who recalled a volunteer trip to an under- resourced hospital in Africa and his horror that babies were dying for want of the simple treatment of surfactant — standard treatment in Ireland for decades.
Let’s hope the next decade of neonatal medical advances brings further breakthroughs, but more importantly, equal access for all babies around the world to life-saving treatments.