When Arthur Kopelman1 published his commentary, “The Smallest Preterm Infants: Reasons for Optimism and New Dilemmas,” in the American Journal of Diseases of Children in 1978, neonatology was approaching a tipping point in the United States. Prior to the 1960s, most hospitals had little to offer preterm babies beyond incubators and good nursing care. Premature baby nurseries were backwaters of the hospital, dominated by nurses rather than physicians.2 This “hands-off” era came to an end when the routine use of high-oxygen incubators in the 1950s led to the greatest iatrogenic disaster ever to befall neonatal medicine: the blinding of more than 10 000 infants from retinopathy of prematurity.3 Physicians began to play a more active role in caring for premature infants and studying their physiology. Among many examples, Mary Ellen Avery and Jere Mead4 showed that the respiratory distress syndrome of premature infants resulted from a deficiency of surfactant in the lung. Despite such insights, the outlook for small premature infants remained bleak well into the 1960s. In 1963, Patrick Bouvier Kennedy, the president's son, died of respiratory distress syndrome in a tiny hyperbaric chamber at Children's Medical Center at Boston.5
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