Guest Editorial

Neonatologists have been faced over the last year with sobering realities. Perhaps these have hit all the harder because we have become accustomed to an increasing survival rate of preterm infants. What are these new realities? Largely, they revolve around the high rates of poor long-term development in survivors born at birth weights <1000g.1 If this morbidity, as well as our reduced mortality rates are considered together, then we must acknowledge a ‘mixed’ record. Fortunately there have been some encouraging developments, including the widespread recognition of the role of chorioamnionitis both in precipitating preterm labour and in mediating the deleterious complications of prematurity.1., 2. Given the new information, Goldenberg and Jobe propose a hierarchical set of strategic directions.2 But these visionary strategies still leave us with the practical day-to-day problems. It is notable that one of the ten ‘Key Research Opportunities’ they identified was ‘minimising bronchopulmonary dysplasia’ (BPD).2 Despite the much vaunted high technological solutions proposed (jazzy means of ventilation etc.) BPD remains a real concern. Compounding the problem has been the profound uncertainty into which the neonatal world was thrown by the apparent pall of corticosteroids – once the panacea for BPD.3

So, in a sense it might be said that things are back to basics – ‘keep injurious noxious influences to a minimum, and promote staying away from the ventilator’. It is these themes that can be considered to be the uniting theme of the four contributions to this issue of the journal. For example, the effects of oxygen have been long understood as potentially toxic. The pioneering work of oxygen’s effects on retinopathy of prematurity was outlined by Silverman in a now classic ‘detective story’.4 However, the problem of what are the appropriate levels of oxygen at which to treat the preterm continue to plague the neonatal world and Dr Win Tin’s article exposes the dilemma. Moreover, the management in the delivery room further revisits old ground, as examined in Dr Dunn’s article. Delivery room management is perhaps one of the earliest arenas for newborn therapy, yet has received less than its fair share of systematic study. As Dunn’s article points out, this is rapidly changing as the importance of preventing early lung closure is appreciated. Ventilation of the newborn lung, and how either to avoid it, or to minimise its effects on ‘baro-volutrauma’ by an appropriate PEEP strategy, is the thrust of the article by Monkman. Monkman’s article complements that of Dunn. Finally, the prevalence of BPD, which is increasing in the wake of an increasing survival rate, poses the question of how best to protect the lung-injured lung from the ravages of infection. Dr Paes addresses the question of an immunisation strategy aimed at RSV.