Kari Raivio: The healthiest children in the world – a scientific achievement worth a gold medal

In recent years, Finns have not had many occasions to celebrate sporting heroes. As much as we keep on waving the flag and cheering in the stands, the number is dwindling of children and adolescents in this small country from which to produce new talents who would subject themselves to years of exertion to get to the top. Others outdo us with their wider populations, more attractive incentives, better training methods or craftier doping tricks.

In many aspects, however, Finland is placed among the very best, but in these areas success is not measured with medals, flags hoisted to the tallest pole nor the tunes of the Finnish national anthem while the crowds cheer. In conjunction with Finland’s centenary celebrations, Statistics Finland compiled an astounding list of international comparisons where we place at the top or very close to it. The list includes 96 indicators, of which only one relates to sports: the number of medals per capita from the Summer Olympics. This is the happiest, most stable and safest country in the world, with the best government, the most independent judiciary and the greatest trust in other people. Not a bad overall achievement for a hundred-year-old!

In the last hundred years, Finland has risen to the global summit also according to various indicators of child health. Such indicators are important, as some of them are included in the Sustainable Development Goals approved by the United Nations. All member states are supposed to reach those goals by the year 2030. Among the global targets is to reduce the mortality rate of infants younger than a week to less than 12 per 1,000 live births (1.1 per 1,000 in Finland in 2017) and those under 5 years of age to less than 25 per 1,000 live births (2.3 per 1,000 in Finland in 2015). In Finland, the maternal mortality ratio associated with births was 3 per 100,000 live births, while the UN target is less than 70 per 100,000 live births. In other words, our country has long since achieved sustainable development in this field. As regards the life expectancy of Finns rising in a century from under 50 to over 80 years, the reduction in infant mortality has been the number one factor.

In improving children’s health, medical research has played an important part, but not by itself. Advances in the standard of living have enhanced the nutritional status in the population, and we have seen few emaciated children with hollowed-out eyes since the Finnish famine of the 1860s. Living conditions and hygiene have improved, reducing the harvest reaped by contagious diseases. What remains a certainty is that the efforts of researchers in developing the prevention and treatment of paediatric diseases, as well as children’s rehabilitation, have been at least as valuable as a triple victory at the Olympics.

Arvo Ylppö, a pioneer of paediatric research in Finland, remains one of the best-known scientists in the country. Ylppö was a top-level researcher educated in Germany who was above all focused on premature infants. To this day, Ylppö’s definition of premature babies weighing under 2,500 grams retains the recognition of the World Health Organization. Such diminutive humans were earlier approached with a fatalistic view, with no attempt to treat premature infants dying of ‘weakness’. Ylppö’s greatest achievement was his insight that premature infant fatalities were the result of somatic or functional causes, making them problems that could be solved. His viewpoint rested on a solid scientific foundation – the autopsies of more than 600 premature infants performed by Ylppö himself.

After returning home in the early 1920s, Ylppö directed his energy to childcare education, to building hospitals and medical institutions (the University’s Children’s Hospital and the Lastenlinna hospital), as well as to training the next generations of researchers. Even after retiring in 1957, he continued to serve as an important advocate of children’s welfare and rights with the authority vested in him by the title of arkkiatri (archiater). In the subsequent decades, neonatal intensive care was developed, once again based on strides taken in research.

My interest in the early stages of the human lifespan was set in motion late in my medical studies, as I was presented with an opportunity to commence doctoral studies at the Children’s Hospital of the Helsinki University Central Hospital on the topic of neonatal hypoglycaemia, or low blood sugar. It had been suspected to cause brain damage, which in fact turned out to be accurate. At the time, in the middle of the 1960s, intensive care was at its infancy. Respirators suited to newborns were not yet available. Deficient lung function is precisely what was and still is the most common problem and cause of death among premature infants. The only way to keep these children alive was to have a nurse sit next to the incubator around the clock, pumping oxygen through a breathing bag into a tube inserted in the infant’s windpipe. If this kept the child’s condition stable for a few days, he or she usually started to recover. It was only in 1975 when the first respirators designed for premature infants became available.

The breathing difficulties of premature infants are caused by the immaturity of the lungs. For pulmonary alveoli to stay open and for oxygen to be transported into the blood, you need an emulsifier, or surfactant. However, this substance only starts to form at the late stage of pregnancy, leaving prematurely born babies to manage without it. Once the fundamental cause of this problem had been identified, the obvious goal was to develop a surfactant treatment with which to substitute for the missing substance until it is produced independently. Researchers of the University of Helsinki also contributed to the research activity, which resulted in an effective form of treatment that has saved the lives of thousands of premature infants.

It would be no task to list several other research advancements that have been adopted to patient care, improving the prognosis of newborns and premature babies in particular. Whereas in the 1960s most babies weighing under 1,500 grams perished, approximately 90% of such babies were still alive at the age of one in the 2000s. The sphere of active treatment is expanding, as today babies born between the 22nd and 24th week of pregnancy, weighing some 500 grams, also receive treatment. The limits are, however, approaching, and the focus of research is indeed in looking into the causes and prevention of premature birth.

In addition to the risk of death, premature birth entails a risk of permanent brain damage. Cerebral palsy is more common among premature infants, as are visual impairment and developmental arrest. The development of therapies has reduced the risk, but it is still there, a factor that cannot be assessed or predicted in the initial treatment phase. And yet, the vast majority are given the opportunity to live their lives to the full and for as long as full-term infants.

Should small premature infants be studied and treated? The answer gleaned from long-term follow-up statistics is a resounding affirmative, and after their early difficulties parents would consider the question itself absurd. My personal faith in the matter was bolstered by two public defences of doctoral dissertations I had the opportunity to witness at the University of Helsinki. Both doctoral candidates were former patients of mine from the Children’s Hospital, and both their birth weights were under 1,000 grams.

Kari Raivio
Chancellor 2003 – 08
Rector (President) 1996 – 2003
University of Helsinki

In the series Science Advocates, people describe the significance of research and research-based teaching for themselves. Read the other instalments on the Researchmatters website (scroll down).