Neonatology, defined by the age of the patient rather than by a system of the body, is one of the few ``generalist'' specialties. Although the neonatal age range of about half a year seems narrow, more development occurs between 22 weeks of gestation (the earliest age of viability outside of the uterus) and 1 month after term than between birth at full term and adulthood and certainly than between the beginning and the end of adult life. The fetus has a peculiar two-layered environment consisting of the mother and her external milieu. The fetus is protected by the mother's homeostatic mechanisms, provided that they are intact. On the other hand, the fetus can be threatened by the mother's ill health, from causes ranging from autoimmune disease to physical trauma.
The physiology of the fetus differs markedly from that of the infant after birth. While the homeostatic mechanisms and autonomy of the fetus are developing, it has the benefit of an additional multifunctional organ -- the placenta. Birth and adaptation to extrauterine life are the most dramatic and hazardous events of a person's life, even if birth occurs at full term. Moreover, congenital anomalies and inborn errors of metabolism that cause no grief to the fetus become problems at birth.
In addition to the problems associated with the immaturity of the preterm infant, if his or her development is derailed in the new environment, it sets the infant on a developmental path that is very different from the one that would be followed in utero by an intact fetus. The protective artificial environment of the intensive care nursery in which the preterm infant is raised poses new threats. The infant's deficient homeostasis, together with our inability to mimic perfectly the maternal milieu, creates new causes of disease and new modes of expression for illness. Thus, the spectrum of neonatal disease is enormous. Rare conditions may remain undetected as the affected infants mingle with relatively large numbers of healthy newborn babies.
This two-volume textbook provides very useful reading on fetal and neonatal pathophysiology and clinical aspects of rare as well as common conditions. It also includes some general chapters, including two new ones -- one covering some highlights of the history of neonatology and the other exploring evidence-based medicine. Although the level of knowledge assumed in the reader varies somewhat from chapter to chapter, the book has something for everyone. Many system-related chapters present more than an introduction to current knowledge. Neonatologists and nurse practitioners in training and generalist pediatricians who care for newborn infants should refer to this book frequently. Neonatologists of all kinds (at least those with good eyesight -- the lines are more closely packed by about 8 percent than those in the sixth edition) will use the book as a reference for their work with individual patients. They would profit from reading a chapter a week to maintain their knowledge about fields in which they are not personally absorbed.
The system-related chapters and those on the fetus are rich in detail, accurate, and uniformly and well edited. I especially liked those chapters that were updated by new authors who maintained continuity with earlier editions. References to evidence-based medicine are often tempered by appropriate questions, although most cited guidelines and consensus statements are accepted at face value. The book is quite up to date, covering knowledge that was current as of 2000.
This is a contemporary textbook, in that it emphasizes knowledge based on good evidence; although it does deal with controversial subjects, some of its authors do not provide a clear perspective on gray areas (one example that frequently arises in practice is how to respond to coagulase-negative bacteremia). The necessary cost of writing a safe, evidence-based textbook is a certain thinness in the guidance offered regarding the treatment of patients.
How will the eighth edition of the Fanaroff and Martin book look? I hope to see a more interdisciplinary approach -- as opposed to the current multidisciplinary one -- that would better reflect the generalist nature of neonatology. Chapters jointly authored by neonatologists and perinatologists would provide continuity between considerations relevant to the fetus and the newborn infant and would eliminate redundancies. An interdisciplinary approach combining the expertise of neonatologists and other pediatric subspecialists would reflect the way decisions are made in clinical consultation.
Do textbooks need to be so physically large in the era of electronic information? Perhaps the printed parts of textbooks that relate to organ systems should consist of lively, pithy basic information in the format of the classic textbook and should be backed up by a compact disc containing encyclopedic details in the same format. I would also like to see more history integrated into every chapter. Informing trainees in a lively fashion about the basic and clinical research that led to the dramatic advances in neonatology that have improved the outcomes of sick and immature newborn infants so dramatically during the past half century would broaden their perspective on the present and the future. If they could experience vicariously the excitement felt by witnesses to the past few decades, today's trainees might be inspired to contribute to the continuation of these trends.
Max Perlman, M.B., B.S., F.R.C.P.
Copyright © 2002 Massachusetts Medical Society. All rights reserved. The New England Journal of Medicine is a registered trademark of the MMS.
