Neonatology

Divyen Shah and Michael Harrison explain what is involved in this subspecialty of paediatrics

You do not often come across medical students and junior doctors who have a burning desire to become neonatologists, the exception being those tutored by an inspirational teacher. For many senior house officers, the experience of working in a neonatal unit (as part of a paediatric attachment) provides lasting memories of endless rounds of blood gases, cannulations, baby checks, all-powerful midwives, and attending deliveries of newborn babies because of meconium stained liquor.

If, however, you can see past this stage, you will discover that neonatology is an exciting and advancing specialty that is rapidly progressing in training, research, and technology.

Neonatology is a subspecialty of paediatrics, and as such all paediatric trainees will be exposed to neonatology at a tertiary level regardless of the subspecialty they go on to pursue. It is a relatively new subspecialty. Babies were first ventilated with endotracheal tubes in the late 1960s, and ultrasound examination of the head became established only in the 1970s.

MARK THOMAS/SPL

The work

The day to day work of a neonatologist entails looking after babies needing varying degrees of intensive care. Neonatologists are also responsible for the well babies on the postnatal wards. In a tertiary level unit, a notable number of babies will be very premature, under 30 weeks' gestation. Many babies need intubation and ventilatory support from birth.

Neonatologists work closely with the obstetricians, and the delivery unit is usually where the action starts. But care starts before the baby is born. Perinatal liaison meetings are held regularly with obstetricians, specialists in fetal medicine, and clinical geneticists. Other relevant specialists, such as cardiologists, surgeons, and urologists are often involved if they can contribute to the management of babies in whom specific problems have been diagnosed before delivery. The outcome for anticipated problems is better than for problems discovered at birth. Arrangements can be made to deliver these babies electively, in the presence of appropriate personnel and equipment.

Many babies in the neonatal unit receive respiratory support and are monitored with regular measurements of blood gases and serum electrolytes. Premature babies and ill term babies need their cardiovascular status monitored and maintained. Babies are supported with parenteral nutrition until they are able to tolerate breast milk and often require arterial and central venous catheters. In addition, premature infants need monitoring of their glucose concentrations and regular ultrasound examinations of their developing brains.

CC STUDIO/SPL

Therefore, trainees will soon acquire basic practical skills such as managing the neonatal airway, emergencies in the delivery room, assisted ventilation, securing arterial and central venous access, and ultrasound examination of the head. At registrar level, neonatology combines fine practical skills with ongoing clinical management, and opportunities exist for trainees interested in echocardiography and perinatal counselling.

Trainees learn good communication skills; they often have to relay news to parents and are involved in helping parents through the bereavement process. Personal qualities such as empathy, kindness, and humility come into play here.

The training

The Royal College of Paediatrics and Child Health (RCPCH) has established a College Specialist Advisory Committee for Neonatal Medicine (CSAC) to supervise training in neonatal medicine. Training consists of at least two years of paediatrics at senior house officer level, during which time membership of the Royal College of Paediatrics and Child Health (RCPCH) should be gained by completing postgraduate examinations. The MRCPCH exam is made up of two parts. The first part consists of a broad range of theory and multiple choice questions in basic sciences, the
second part consists of written, oral, and clinical sections.

During the years spent as a senior house officer, most trainees will have completed at least six months of general paediatrics, six months of neonatology in a tertiary level centre, six months of community paediatrics, and six months of any other subspecialty of paediatrics. The time spent in a tertiary neonatal unit is probably the most labour intensive part of paediatric training. Trainees may expect not to have much of a social life during this period, and it is not a good time to be preparing for postgraduate exams.

As in other specialties, the next stage of training partly depends on the availability of national training numbers (NTNs) and numbers of applicants. In recent years the numbers of applicants has greatly exceeded the number of NTNs available. While awaiting NTNs, some opt for research while others join locum appointments for training posts. One year of this can count towards the certificate of completion of specialist training (CCST).

Specialist registrars in paediatrics must spend two years on paediatric "core" training, usually in district hospitals, where they gain experience in general and community paediatrics and some neonatology. They can then spend between one and three years in tertiary level neonatal centres, depending on their career needs.

Neonatology in the district hospital

Most district hospitals that provide a paediatric service will also provide some level of neonatal care. Consultant paediatricians in these hospitals usually provide on-call cover for the neonatal unit even if their
special interest does not cover neonatology. Therefore a year spent as a registrar in a tertiary neonatal unit would be of great practical benefit.

Registrars who have spent two years of their training in tertiary level neonatal units can seek accreditation as paediatricians with a special interest in neonatology. Some consider a career as a lead neonatologist in a district hospital providing up to 80% of their clinical commitment in neonatology. In the future, however, neonatal services in the United Kingdom, as in other countries, may be more centralised so that more neonatal intensive care will be provided by tertiary centres, resulting in fewer such jobs.

Tertiary neonatology

Trainees may wish to subspecialise in neonatology, and, after the two core years, the remaining three years leading up to their CCST can be spent in neonatology training. Two years are spent in two separate tertiary centres in the United Kingdom. The final year may be spent abroad, in research, or in an affiliated subspecialty.

Neonatology abroad

During their training, doctors with a background in neonatology have many opportunities to work overseas. In large countries with sparsely populated regions, services are more centralised and registrars can experience transport medicine as with theNew South Wales Newborn and Paediatric Emergency Transport Service (NETS) in Australia. In developing countries, opportunities are available for organising neonatal services with limited resources.

Job prospects

At present the competition for NTNs in paediatrics is fierce. As subspecialties of paediatrics go, there are certainly more neonatologists in the country than there are most other paediatric subspecialists with the exception of community paediatricians. With changes in the delivery of neonatology services predicted, there may, however, be an appreciable increase in the number of neonatologists needed in tertiary centres.

The future

Over the past two decades there has been a decreasing trend in mortality and morbidity in premature infants. Many challenges remain, however, such as preventing the consequences of prematurity, minimising neurological damage resulting from hypoxia and ischaemia in term infants and improving subsequent developmental outcome. The research goes on.

Divyen Shah, specialist registrar in neonatal paediatrics, Department of Neonatology, Hammersmith Hospital NHS Trust, London W12 ONN
Email: divyenshah@doctors.org.uk

Michael Harrison, research fellow in neonatology, Imperial College of Science, Technology and Medicine, Hammersmith Hospital Campus, London W12 ONN
Email: michaelcharrison@hotmail.com

We thank Merran Thomson, consultant neonatal paediatrician, for advice and suggestions.

studentBMJ 2002;10:215-258 July ISSN 0966-6494