Ronald Ariagno, David Stevenson and Philip Sunshine circa 1979

Division Overview and History

The Division of Neonatal and Developmental Medicine was initially established in 1959 when Norman Kretchmer, M.D, became the Chairman of the Department of Pediatrics and recruited Dr. Louis Gluck to be the Chief of Neonatal Medicine. Dr. Gluck was instrumental in educating the faculty, housestaff, and students in the field of neonatology and also initiated several very important studies, the main one of which was the demonstration that bathing infants with hexachlorophene in the delivery room decreased and eventually abolished colonization and infection secondary to Staphylococcus aureus, an organism which had plagued neonatal nurseries for many years.

Dr. Gluck left Stanford to organize the nurseries at Yale University approximately one year later, and Dr. Sumner Yaffe became Director of the division. With a great deal of input from a young and energetic faculty, Drs. Kretchmer and Yaffe submitted an application to the Clinical Research Centers Branch of the National Institutes of health to establish a research center for premature infants. This grant was awarded in 1962 and the first patient was admitted to the Premature Infant Research Center in May of 1963. This was the first clinical research center that was devoted entirely to the study of prematurely born infants, and the Center has continued to be operated and funded since that time.

Dr. Yaffe left for Buffalo in 1962 and dr. Irwin Schafer assumed the Directorship of the Division. Dr. Schafer’s main interest was in amino acid metabolism and inborn errors that could affect newborn infants. Also, the make-up of a premature nursery was changed to that of an intensive care nursery so that infants could be transferred in from other hospitals and all infants with critical illnesses could be cared for in the unit. It was at this time that investigators at Stanford began to use positive pressure ventilation to support infants with respiratory failure. Using techniques that would be considered primitive at this time, these investigators were able to demonstrate that critically ill infants with respiratory failure could be supported with the use of ventilation, and a survival rate of over 40% was achieved. This was a remarkable achievement considering the technology that was available.

Also at this time the philosophy of the Intensive Care Nursery (ICN) was established to invite investigators from other disciplines to participate in nursery-based research projects. Members of the Departments of Medicine, Neurology, and Surgery carried out the studies and interacted closely with faculty members of the Division of Neonatal Medicine.

Dr. Marshall Klaus then assumed the Directorship of the Division in 1964 and brought with him a background in pulmonary physiology. Through his efforts, the Division began to focus on problems of pulmonary disease in neonates including studies of hyaline membrane disease, transient tachypnea of the newborn, and various types of pulmonary aspiration syndromes. Two postdoctoral fellows, Drs. W. J. R. Daily and B. Meyer, began their studies on apnea of prematurity and, working with the principles of impedance pneumography, developed the first apnea monitor that was used in intensive care nurseries. This prototype was produced and marketed by IMI and the project was later sold to Air Shields. From this early prototype, apnea monitors were produced and were eventually used in every nursery throughout the world.

Dr. Klaus, who had worked with other investigators to develop an aerosolized surfactant material, was disappointed in its application for the treatment of hyaline membrane disease, and began to focus on various types of agents that could improve pulmonary blood flow in these infants. Initially, acetylcholine was the agent that was used but it proved to be not only ineffective, but also resulted in a great many adverse side effects that rendered the material useless in newborn intensive care. However, this was one of the first agents that was used as a form of therapy for pulmonary hypertensions. Dr. Klaus’ greatest contribution emanated from combined efforts of a psychiatrist, anthropologist, and social worker who began studies of maternal-infant bonding that lead to an open door policy for parents to enter the nursery and become involved in the care of their infants. Prior to this time, parents were not allowed in the nursery and were merely observers in the management of their babies.

In 1967, Dr. Klaus left Stanford to return to Cleveland, and Dr. Sunshine became the Director of the Division of Neonatal Medicine. Together with Dr. Daily, who joined the faculty after his fellowship, the Division continued its studies on the sue of ventilatory support and developed criteria for initiating ventilatory therapy, criteria for weaning infants from ventilators, and techniques for altering pressures and rates in order to insure optimal ventilation of critically ill babies. Primarily through the work of Drs. Daily and Penelope K. Smith, these criteria were published and were the basis of guidelines for ventilatory support that were utilized by other nurseries throughout the country. The description of bronchopulmonary dysplasia by Drs. Northway, Rosan, and Porter documented the adverse effects of barotraumas and oxygen toxicity in infants who had received ventilatory support. They also suggested methods to improve ventilation and techniques that would mitigate to some extent the adverse effects of ventilator treatment.

In 1972, Dr. Daily left Stanford, and Dr. John Johnson joined the faculty. Dr. Johnson’s major interest was in bilirubin metabolism and the development of methods to detect the rate of bilirubin production. Dr. Roland Ariagno joined the faculty two years later and rounded out the interests in the nursery to include studies of thermoregulation and respiration in the neonate. The strategy of maintaining the nursery as a “clinical research laboratory” continued, and studies by members of the Department of Pediatrics, Internal Medicine, Surgery, Otolaryngology, Ophthalmology, Psychiatry, Pharmacology, Structural Biology, and Obstetrics were initiated and accomplished in the Nursery. Even disciplines outside the Medical Center were involved including members of the Departments of Mechanical Engineering, Biology, and Psychology. A program to evaluate the ethical dilemmas encountered in an intensive care nursery environment was initiated and these studies have continued until the present time.

The Perinatal Outreach Program was initiated in 1967 and members of the Division of with input from the Obstetric service began to develop relationships with hospitals in our immediate community. This Program was integrated with the Infant Transport System that was developed by Dr. Al Hackel, and was successful in enlarging the referral region from as far south as Santa Maria to Crescent City in the north, and as far east as Reno and Carson City, Nevada. The Perinatal Outreach Program was expanded when Cecile Quaintance became the Program Coordinator and she was successful in obtaining support through the state of California’s Perinatal Access Program. The Perinatal Outreach Program has subsequently become consolidated, primarily through the development of intensive care nurseries in Reno, Fresno, Santa Barbara, and Bend, Oregon. The Mid-Coastal California Perinatal Outreach Programs (MCCPOP) has been successful despite the lack of support financially and academically from the Stanford University School of Medicine and the Department of Pediatrics. The Program flourished during the time that Dr. Kent Ueland was a member of the Department of Gynecology and Obstetrics but waned in its effectiveness with Dr. Ueland left. MCCPOP has begun to function more effectively again with the recruitment of Dr. Maurice Druzin who restabilized the obstetrical arm of the Program. MCCPOP has been instrumental in developing very close ties with community hospitals and has resulted in a very substantial patient referral base for not only the nursery but for the obstetrical service as well.

In 1982, the Division of Neonatal Medicine changed its name to the Division of Neonatal and Developmental Medicine, and Dr. Merton Bernfield joined the Division, introducing new ides for the education of physician-scientists in neonatology. A unique NIH training grant was proposed and funded. Although the Division had been able to recruit outstanding postdoctoral fellows prior to this time, the direction that was offered by Dr. Bernfield allowed the recruitment of even more outstanding individuals to the fellowship program. Soon thereafter, the Division added Dr. William Benitz who was one of the first graduates of the new physician-scientist training endeavor. During this time, the Division began to study new techniques for managing patients with severe pulmonary hypertension. High frequency ventilation and extracorporeal membrane oxygenation (ECMO) were introduced and both of these approaches represent important alternatives for the care of critically ill infants with cardiopulmonary failure.

In 1989, Dr. David Stevenson became Chief of the Division of Neonatal and Developmental Medicine and the Director of the NIH-funded Training Program in Developmental and Neonatal Biology. With the move of the ICN to the new Lucile Salter Packard Children’s Hospital (LPCH) at Stanford, the number of intensive care nursery beds increased from 25 to 42 and the number of intermediate care beds increased from 6 to 24. New faculty members were recruited, more than doubling the number of academic neonatologist in the Division, developing new off-site clinical program in the nurseries of two community hospital, El Camino in Mountain View and Washington Township in Fremont, while encouraging and enabling the laboratory-based and clinical research activities of the Division.

In summary, Dr. Stevenson has reorganized and expanded the NIH-funded Training Program through the appointment of new basic science preceptors and improved cooperation with the Beckman Center for Molecular and Genetic Medicine, expanded the competitive and extramurally-funded research activities in the Division, expanded the clinical program in the Division, and expanded the Perinatal Outreach Program. The Division of Neonatal and Developmental Medicine remains the largest well-funded research base in the Department of Pediatrics, complemented by the largest clinical service at LPCH and a strong regional presence. Stanford’s reputation in academic neonatology has been further enhanced regionally, nationally, and internationally, with faculty members of the Division occupying many leadership roles nationally, newborn medicine at Stanford remains in unique league of world-class academic neonatology programs.

The directors of the division are listed below:

Dr. Louis Gluck 1959-1960
Dr. Sumner Yaffer 1960-1962
Dr. Irwin Schafer 1962-1964
Dr. Marshall Klaus 1964-1967
Dr. Philip Sunshine 1967-1976 & 1979-1989
Dr. John Johnson 1976-1979
Dr. David Stevenson 1989-

Major Events in Neonatology at Stanford

• Creation of the Premature Research Center
• Development of mechanical ventilation and indications for use of ventilators (Daily, Thomas, Cave-Smith)
• Development of the apnea monitor (Daily, Meyer)
• Development of outreach education
• Development of follow-up program noting improved outcome of low-birth weight infants

• Description of broncho-pulmonary dysplasia (Northway, Rosan)
• Pharmacokinetics of antibiotics in infants (Axline & Simon)
• Use of EEG to evaluate development (Frank)
• Hearing screening in the nursery (Simmons)
• Radiant warmed transport incubator (Hackel & Moffat)
• Recognition of PDA in causing chronic lung disease
• Surgical closure of PDA in the ICN (Shumway)
• Development of mother’s milk bank at SCVMC (Asquith)

• Recognition, definition and treatment of pulmonary hypertension of the newborn
(Goetzman, Johnson, Stevenson & Benitz)
• Recognition of CMV transmission via blood (Yeager)
• Use of “premie packs” in the ICN
• Improved techniques of TPN

• Building a new ICN
• Use of the nursery as a clinical laboratory
• ECMO at Stanford
• Incorporation of El Camino as part of the Stanford Neonatal Program
• Developmental and Neonatal Biology Training Program

• Development of the Johnson Center (Stevenson, Druzin)
• Addition of nurseries in neighboring communities
• Development of newer imaging techniques (Benaron, Hintz, Contag)
• Simulation laboratory (Halamek)
• Member of the Neonatal Network

• Breastfeeding Program
• Expansion of the imaging program and move to Clark Center
• Center for Advanced Pediatric Education (CAPE)