Premature birth has always been a challenge, but the past few decades have seen revolutionary advances in neonatal care. On this World Prematurity Day – November 17th, I wanted to reflect on how far we have come in the last few decades. If you are a parent on your journey through the NICU and struggling with the day to day ups and downs you may find this journey enlightening. Let’s take a look at both a personal journey, the broader neonatal landscape and how things changed Nationally and even locally over time. Stay with me and I think you will be amazed at just how far we’ve come.

Much like Dr. Suess’s book I wonder if the people that came before me ever envisioned the places we would go!

---

1974: My personal preterm story

In the 1970s, neonatal care faced significant limitations. For preterm babies, respiratory distress syndrome (RDS) was a leading cause of death. Without adequate treatment for underdeveloped lungs, survival was uncertain, especially for extremely premature infants. We had ventilators of course but with lungs that were immature the risk of air leaks called pneumothoraces was high. Being premature was a very risk proposition.My own family was affected by this as my siblings were born at 34 weeks gestation and my brother had respiratory distress syndrome. In 2024 a baby at 34 weeks with RDS would not cause anyone to worry as we are well equipped with fancy ventilators and most of all surfactant which quickly helps to open up lungs that are “stuck” together. This wasn’t available in those days and it’s hard to believe that just 50 years ago my parents were faced with the knowledge that their son had a 50% chance of survival. He did make it through but survival in the interim has crept up to well over 99%. On this front we have done “real good”.

---

1980: Preemie treated with surfactant!

We knew sine the 1960s that surfactant deficiency was the cause of hyaline membrane disease or RDS as it is also known. If you weren’t aware of it, let me tell you , that we in medicine are a cautious bunch. It took almost two decades for the first produced surfactant to be given to a preterm baby. This monumental event which really changed Neonatology occurred in 1980. Fujiwara and colleagues reported a landmark paper Artificial surfactant therapy in hyaline-membrane disease which demonstrated that in ten infants given exogenous surfactant their oxygen needs declined quickly along with support needed on the ventilator. It would take another ten years before the FDA in the United States would approved exogenous surfactant use broadly for preterm infants. What can I say? I told you we are a cautious bunch!. This widespread adoption of surfactant was a landmark change in practice that singlehandedly marked a dramatic shift in the chances of survival for preterm infants.

---

1998: My Journey Begins – 28 Weeks is Thrilling!

By 1998I entered the field of neonatal care as a Pediatric resident. I witnessed firsthand the thrill of saving lives once considered impossible to rescue. While many centres are now offering resuscitation at 22 or 23 weeks gestation it is hard to believe that babies born at 27 – 28 weeks were considered high risk at this point. In 2024 a baby born at such an age is considered a bigger preemie compared to those at 27 and 28 weeks which I suppose has a lot to do with perspective! Nonetheless, the past 26 years have seen our expectations for survival and importantly survival without morbidities increase dramatically for those born at 26 – 28 weeks for sure.

---

2015: Challenging the Threshold of Prematurity to 23 Weeks

Fast forward to 2015, and the threshold of viability was pushed even further. Babies born at 23 weeks gestation in our centre had traditionally been considered too small to survive. Prior to 2015 we would seldom see a baby born at this gestational age resuscitated. It was apparent though when taking the temperature of the room so to speak in North America that the tide was turning and resuscitation was being offered. An important paper in this regard that gave everyone in neonatal care some pause to reflect was the paper Between-hospital variation in treatment and outcomes in extremely preterm infants by M Rysavy et al. The paper demonstrated variability in outcomes at the edge of viability around 22 to 23 weeks but really enlightened many by showing that not only were some hospitals resuscitating infants at these ages but they could actually do reasonably well enough.

The scatterplots are taken from the same paper and demonstrated a lot of variation in outcomes between 24 hospitals. Some did not have great outcomes while others did. The data begged for Neonatologists to ask a critical question. What are some centres doing to achieve such incredible results and secondly if results can be so good, should we continue our patriarchal ways and decide for families what we are and are not prepared to do or should families be central to the decision?

---

2017: A Shift Toward Shared Decision-Making

The Canadian Pediatric Society was under pressure between 20015 – 2017 to change the recommendations for periviable births. The statement from the CPS was quite prescriptive in its approach to offering resuscitation with fairly rigid goal posts at 23 weeks for consideration of resuscitation and language which insisted resuscitation should or should not be offered at a given gestational age.

In 2017, neonatal care saw a significant shift in approach, emphasizing shared decision-making between medical teams and families. The CPS statement was revised to reflect carefor extremely preterm infants that became more personalized, with parents playing an active role in decisions about their baby’s care. This collaborative approach fostered trust, empowered families, and ensured that care aligned with their values and goals. The current statement Counselling and management for anticipated extremely preterm birth included the following recommendation:

“When both early intensive care and palliative care are considered to be equal care options, the management plan should be decided upon after engaging in a SDM process with parents. The SDM process should be ongoing as the pregnancy continues”

Shared decision making or SDM became front and centre in this statement and continues to be the standard for discussions with families today. In the event of equipoise and uncertainty it should be the family that ultimately decides based on their beliefs and values whether one tries to resuscitate or not. After birth the extent to which we continue care needs to centre around the family as well.

---

2023: Redefining Viability at 22 Weeks

In 2023, the line between impossible and possible was redrawn yet again. Advances in neonatal technology and medical expertise made it feasible to care for babies born at just 22 weeks gestation in our centre and elsewhere. We were a little later to the game so to speak as other centres had already been doing so but we arrived. Publications from Sweden and Japan were growing and demonstrating that not only was survival possible at this gestational age but that survival without significant disability was a real possibility. In Japan for example a publication last year Management and outcomes of periviable neonates born at 22 weeks of gestation: a single-center experience in Japan found a survival rate of 83% at 22 weeks gestation. There remain questions about whether populations in Sweden and Japan are perhaps different from other areas of the world but at the end of the day both countries forced all of us Neonatologists to question what was impossible and possible. No doubt the next decade will see refinements that don’t just focus on survival but optimizing outcomes as well!

---

2024: Breastfeeding and Kangaroo Care Take Center Stage

Looking to 2024, we have seen a focus on the benefits of breastfeeding and skin to skin or kangaroo care.

Breastfeeding and kangaroo care (skin-to-skin contact) have emerged as vital components of neonatal care, offering powerful benefits for both babies and their families. These practices not only promote bonding but also improve immune function, growth, and neurological outcomes for preemies. Looking at the sections that preceded this one you no doubt can see the importance of research and technological development in the care of these babies. We certainly could not have achieved levels of survival without disability without advances in our understanding of ventilators, ultrasound to assess organs and the hemodynamics system and more.

What is astounding to me though is that the focus has shifted back to the basics. Breast milk, love and caring. Increasing rates of breast milk consumption by preterm infants have been linked to reductions in sepsis and chronic lung disease to name just a couple of benefits. Skin to skin care has led to reduction in oxygen need, apneas and bradycardia and more. Technology is amazing but more and more we are getting back to the basics which once again centres around the family unit.

---

The Future: Hope and Innovation

The story of neonatal care is one of hope, perseverance, and constant innovation. From the early days of battling RDS to redefining viability and promoting family-centered care, every milestone represents a step closer to ensuring that every baby, no matter how small, gets the best possible start in life.

As we honor World Prematurity Day, let us celebrate the progress we’ve made and continue working toward a future where preterm birth no longer carries the same risks. Together, we can ensure that every baby—no matter how tiny—is given the chance to thrive.

Here’s to the tiny warriors and the big-hearted teams who fight for them every day.