On the pavement outside the front door of the National Maternity Hospital on Holles Street, a neonatal nurse and neonatal doctor are preparing to clamber into a waiting ambulance that is adapted for the transport of critically ill newborn babies.
As consultant neonatologist Prof John Murphy walks by, he stops to have a quick word about what has been a busy week for this transport team, which can be mobilised within 20 minutes of a call. The three Dublin maternity hospitals take turns to supply specialist staff for the National Neonatal Transport Programme and this is the NMH's week on, with the crew about to depart for Cork, having been to Sligo the day before.
I couldn't believe it. A baby that was very blue and unwell suddenly going very pink; the change was so dramatic. That was a key, life-saving event
It’s now a 24/7 transport service, in no small part thanks to Murphy who, as clinical lead for the National Clinical Programme for Paediatrics and Neonatology, oversaw its expansion from a 9am-5pm operation. This speedy, specialised transfer of infants to the Republic’s four tertiary neonatal intensive care units (NICUs) – three in Dublin, one in Cork – is one of many innovations in the care of newborns over recent decades that have all played a part in the saving of thousands of fragile lives.
Back in 1970, for every 1,000 live births in Ireland, 13 babies would die within the first month. By 2019, that rate had dropped to two per 1,000 live births.
“For every 1,000 births, an additional 11 babies now go home alive,” says Murphy, whose 35 years as a neonatologist in the NMH and Temple Street hospital have spanned many advances in the care of newborns. For instance, he can still remember, in 1992, giving the first dose of surfactant, which “looks like skim milk” and helps babies with immature lungs to breathe.
“I couldn’t believe it. A baby that was very blue and unwell suddenly going very pink; the change was so dramatic. That was a key, life-saving event, one of the keys that unlocked the door to survival of small babies. You could put a tube into their windpipe and give it to them and that made their lungs very flexible and that had a huge impact on mortality.”
Tiny babies of just 23 weeks’ gestation now have a fighting chance of life, while the survival rate for those who reach 26 weeks before birth is close on 80 per cent.
Murphy was “surprised and flattered” to be this year’s recipient of the Kathleen Lynn Medal, awarded by the Royal College of Physicians of Ireland (RCPI) for “exceptional service on behalf of children”. Nevertheless, in this interview to mark the occasion, he is quick to deflect any reflection of personal achievement and instead welcomes it as “very good recognition of neonatology, which is not necessarily the most widely known speciality. I think a lot of people don’t know it exists – until they get a small baby who is sick,” he says, sitting in a boardroom at the top of NMH offices on Mount Street.
Once you meet a level of survival and your specialty matures, you begin to look at the quality of survival, that is what you are really after
Neonatology is a speciality in medical and nursing care that only began to emerge in the 1960s. Other professionals, including dietitians, pharmacists, psychologists and clinical engineers who maintain NICUs’ complex equipment, now have vital roles in the field too.
Covering the care of all babies from birth until one month of age, he describes neonatology as “the ‘human turnstile’ through which everyone passes”, as we adapt to life outside the womb. About 10 per cent of babies require admission to a special care baby unit, although the time spent there may range from hours to several months.
The death of baby Patrick Bouvier Kennedy in August 1963, just three months before his father, US president John F Kennedy, was assassinated, kickstarted huge investment into research around prematurity. Jacqueline Kennedy, who missed her husband's trip to Ireland earlier that summer due to the pregnancy, had to have a Caesarean section to deliver their infant son 5½ weeks early. Suffering from respiratory distress syndrome, he lived only 39 hours, despite access to the best medical care the US could offer at the time.
Today, he would be a very routine case in any neonatal unit. Although 7 per cent of babies born in Ireland are premature, defined as less than 37 weeks’ gestation, “only about 1-2 per cent of those are really immature and going to cause all the problems”, says Murphy. Initially, neonatology was all about saving lives but its focus has broadened to trying to minimise lifelong effects of a baby’s early departure from its mothership. The brain is the new frontier in the constant quest for improved neonatal care.
“Once you meet a level of survival and your specialty matures, you begin to look at the quality of survival, that is what you are really after.”
Low birthweight, sometimes no more than half a standard bag of sugar, is not the principal problem in itself. Rather, it is the immaturity of their organs. Also, their skin is thin, resulting in a “lobster red” appearance and making them liable to rapid loss of heat and water, as well as open to infections.
Murphy, described as "a true prince of neonatology and paediatrics in Ireland" in the award citation delivered by Royal College of Surgeons in Ireland -Bahrain vice-president and fellow paediatrician Prof Alf Nicholson, traces his choice of career back to childhood. At home in Cork city he used to watch Dr Finlay's Casebook, a 1960s TV series about a doctor working in the fictional Scottish town of Tannochbrae. "I saw him one day going into a house and seeing a child who was sick and making a diagnosis of meningitis. Then doing a lumbar puncture and the child got better; I thought, 'I'm going to do that'." He successfully applied to study medicine at University College Cork.
During medical training, the sight of a baby with apnoea breathing irregularly, made a big impression on him. There was no treatment for it at the time and it made him think if only there was something that could be done. That was before the administration of caffeine was discovered to be really effective for treating this condition, by improving the contracting of the diaphragm.
After several years of further training in the UK, Murphy was the first consultant neonatologist appointed in Wales, before returning to Ireland in 1986 to become one of three at the NMH. Since then, big changes he has worked through include the handling of sensory issues in neonatal care. "There was a time when people were probably less aware of pain in babies. My rule of thumb is that if I find something painful, the baby is jolly well going to find it painful too."
We have these quiet hours where all the lights go out in the unit and everybody speaks in a whisper and activity goes right down so the babies can rest
Loud noises can be very upsetting for these babies who cannot yet filter stimuli. “The modern intensive care unit is a quiet place. No hoovers are allowed in, the floor must be brushed; phones are put on a light system so less noisy.
“Then we have these quiet hours where all the lights go out in the unit and everybody speaks in a whisper and activity goes right down so the babies can rest.” Things that have to be done for a baby, such as taking a blood sample, a swab, changing a nappy, are planned, to reduce the number of disturbances.
“It’s all an attempt to replicate what goes on in the womb, which is really protective, but also to recognise that over-stimulation of these babies may have consequences on their development.”
Another simple intervention has been the placement of preterm babies in a plastic bag immediately after birth to keep them warm before transfer to an incubator. They can lose up to 1 degree Celsius a minute and when once, he recalls, theatre and corridor windows were hastily closed in an effort to alleviate heat loss, this “phenomenal technique” now does a very effective job.
He’s also seen the introduction of nitric oxide gas for the treatment of respiratory distress syndrome and improvements in minimising brain injuries in preterms through the giving of steroids to mothers at risk of premature delivery.
Tracking how these babies fare after they are discharged is vital. At the NMH, the neonatal department's clinical development psychologist Marie Slevin sees all premature babies back at two years of age for what is known as the Bayley assessment, looking at cognitive skills and speech and language development.
“It is very helpful to be constantly getting the feedback,” says Murphy, who sees upcoming World Prematurity Day on November 17th as a way to mark the impact prematurity has on society. “There are very few families, either parents or grandparents, uncles or aunts, who won’t have come across, or had, a baby that was preterm.”
Incidence of prematurity has gone up, mainly because multiple births are a big factor and the rate of twinning has increased significantly, due to more widespread use of assisted reproduction. The Economic and Social Research Institute reported a twinning rate of 18.8 per 1,000 maternities for 2016, an increase of 22.1 per cent over the previous decade.
At the NMH on November 17th, as at other maternity hospitals, some “preemies” and their parents are invited in to celebrate what is achieved within the walls of their NICU. But these are not the only cohort of former patients that Murphy is always delighted to see come bouncing back.
There are also full-term babies for whom the treatment of therapeutic hypothermia (TH), introduced in Ireland in 2009, has proven to be “one of the most amazing changes” in the prevention of disability resulting from oxygen deprivation during birth. Such babies are at high risk of cerebral palsy.
With TH, a cooling jacket is used to lower a baby’s body temperature to 33.5 degrees Celsius, about four degrees lower than normal, within six hours of birth and until it’s 72 hours old. Nobody yet knows precisely how it works, he explains, “but if we learn more about that, we may be able to use some pharmacological methods as well as this physical method of cooling. It seems to act by slowing down, or cooling, the brain activity – and that way the brain cells get a chance to recover.”
About 70 babies are cooled in Ireland every year, giving good results in the term of outcomes. For every case, antenatal, labour and neonatal data is collected and analysed to help increase knowledge in maternity hospitals about oxygen deprivation and see if and where it might have been preventable.
It has been very rewarding to me to see children who obviously have got a problem at birth and then they have been cooled – and then see them running into you at a clinic
“It has been very rewarding to me to see children who obviously have got a problem at birth and then they have been cooled – and then see them running into you at a clinic, when I would have seen the opposite. As the cooling has gone on, it’s got better and the equipment has got better. And we have got better at managing it.”
Murphy acknowledges the “dichotomy” in keeping preterm babies warm to save life and then cooling some full-term babies to do likewise. “A lot of medicine is counter-intuitive – it doesn’t work out the way you think it’s going to work out,” he says.
Hundreds of trainee paediatricians have benefited from his experience and inspiring passion for the care of the youngest possible members of our population. The training programme set up by the RCPI’s faculty of paediatrics, established in 1992, is, he asserts, “second to none”. About 40 doctors come into it annually after completing their intern year and do an initial two years. They can progress to higher specialist training, which takes another five years.
“They come out at the end of that with their certificate of full training, which is recognised very well internationally. All our young consultants who have been appointed in recent years have all come through our training system, which is very flattering in a way that all these bright young doctors have chosen to stay in Ireland.”
He believes the clinical nature of paediatrics appeals to student doctors. “You have to work out what’s wrong with the child from observation. It’s not as much about tests, as it is with an adult; tests are painful and difficult to do, so you have to go a lot on your clinical skills.”
As for himself, it’s the opportunity to be working with long-term survivors of medical care that he relishes. With a sick, premature baby, there is the satisfaction of setting them up for a lifetime of maybe 80 or 90 years.
You may institute intensive care and then a few days into the intensive care sequence, you find the baby has a major complication, say a brain bleed, and then you reconsider
He has always found writing up individual cases very stimulating. His father, who used to do a lot of writing advised him that “writing gives an existence to what you do, gives us some meaning”. In his “spare” time, Murphy has, since 1989, edited the Irish Medical Journal, now published only online, and plays golf. He’s married to a doctor and two of their three adult children have followed in their footsteps, while the third is a solicitor.
It’s said that the age of viability for preterm babies is lowered by a week for about every decade of improved neonatal care. Last December, the RCPI recommended 23 weeks’ gestation as the threshold for viability, the previous bar of 24 weeks having been set in 2006. “Anecdotally, we were beginning to resuscitate 23 weeks’ gestation babies so we decided we would lower the limit in recognition of that.”
How much lower does Murphy think it can go? "We haven't had survivors of 22 weeks, we don't see that," he says, while acknowledging that they do in Japan. He reckons it would need another fairly significant innovation before the threshold drops again.
Active management of extremely premature babies is ethically complex and when a baby is born at 23 weeks, important conversations have to be held with the parents about the merits and demerits of intensive care. “You may institute intensive care and then a few days into the intensive care sequence, you find the baby has a major complication, say a brain bleed, and then you reconsider.” There are frank discussions when complications arise, in some “very challenging human scenarios”. Maybe a couple has been through three or four rounds of IVF before achieving a pregnancy that has resulted in an extremely premature delivery.
Constant interaction with colleagues and a sense of camaraderie is what he finds “destressing” in the job. “With our team, the junior hospital doctors are teaching every morning and we all go for tea. You’re meeting every day and discussing things every morning, that takes the stress out of situations because you discuss and unburden your concerns and get the best opinions on how to do X, Y and Z. The hospital has that tradition of being a good place to work.”
Will he ever retire?
"I will eventually," he smiles.
But he's certainly showing no sign of it yet.
Neonatal care by numbers
- 19 maternity hospitals in the Republic have an average of 164 births a day between them
- 10 per cent of newborns require admission to a special care unit
- 7 per cent of babies are born premature, ie before 37 weeks' gestation
- 401-1,500g is range for infants classed as "very low birth weight"
- 4 tertiary neonatal intensive care units, three in Dublin and one in Cork, look after the country's sickest babies
- 2 surgical neonatal units, one in Children's Health Ireland at Crumlin, the other in Children's Health Ireland at Temple Street, care for those requiring surgery