Joseph B. Philips, III, MD

Dr. Klaus returned to Case Western as an Assistant Professor and continued his work on respiratory disorders in the newborn. He described the morphology of the alveolar lining layer and elaborated on the relationship of alveolar surface tension to the alveolar radius (3). He was a co-author of a report on the first attempt at surfactant replacement therapy using aerosolized dipalmitoyl phosphatidylcholine (DPPC), which failed because DPPC is a waxy solid at body temperature (4). 

Stanford University recruited Dr. Klaus back to the West Coast, where he was among the first to use prolonged mechanical ventilation with endotracheal intubation in neonates (5). Among his collaborators was Philip Sunshine, a legend in his own right. While at Stanford, Dr. Klaus observed that mothers whose infants had been ventilated for extended periods had difficult and abnormal bonding with their babies and sometimes demonstrated bizarre behaviors toward their infants, sparking a lifelong interest in maternal-infant bonding. 

In 1967, he was recruited back to Case Western as Neonatal Director, where he remained for the rest of his illustrious career. Again, early work involved the respiratory system. Dr. Klaus contracted polio while a medical student, which left him with a flail arm and weak leg. He was averse to the use of mechanical ventilation unless necessary. This led to a publication showing that intermittent bag and mask ventilation was effective in managing infants with respiratory distress syndrome (RDS) (6). I recall using this technique early in my training and practice years for infants with CO₂ retention. Intermittent bagging was used to bring PaCO₂ levels down. 

Another important innovation was developing a practical device for administering continuous positive airway pressure (CPAP) spearheaded by Dr. John Kattwinkel, one of Dr. Klaus’ many mentees (7). This device was widely used for decades, and variations of it are still used in NICUs today. Another mentee, Richard Martin, MD, began his research career with Dr. Klaus, studying the effect of CPAP on the Hering-Breuer reflex and expiratory time (8, 9). A third mentee, Dr. Avroy Fanaroff, published seminal observations concerning insensible water loss in low-birth-weight infants and showed that the use of a heat shield placed within the single-walled incubators in use at the time greatly reduced insensible losses and improved the thermal environment (10). Observations such as these led to the double-walled redesign of infant incubators. Thus, Dr. Klaus and his early trainees made major contributions to the medical care of premature infants. As important as these contributions were, however, they pale in comparison to the truly monumental and revolutionary advances he pioneered in mother-infant bonding, which led directly to what we now call family-centered care. 

As far back as his residency days, Dr. Klaus had noted the improved family satisfaction with patient care when unlimited family visitation was allowed (1). In those times, family visitation was typically limited to a half hour per week, usually on Sundays. As mentioned earlier, he had also observed at Stanford the sometimes abnormal behavior of mothers whose infants had received prolonged mechanical ventilation. Once established at Case Western, he paired up with John H Kennell, MD, to study mother-infant bonding, forever changing the course of newborn infant care. 

Together with colleagues, they described in detail the initial maternal behavior patterns when mothers were presented with their nude infants just after birth and noted that these patterns were different for term and preterm infants (11). The standard of care at the time was for mothers to have limited contact with their newborns. Klaus and colleagues showed that mothers who had extended contact with their infants spent significantly more time in the “en face” position and fondled their babies more often one month after birth than those who were in a standard-of-care group and that these differences persisted at one year of age (12, 13). It was further shown that speech patterns were different out to two years between the two groups, with the extended contact group having more complex and less commanding speech than the controls (14). The authors postulated that a “special attachment period shortly after birth” was essential for normal maternal-infant bonding. This led to suggestions for change to the standard practice of separating the mother from her baby for extended periods after birth (15, 16). 

Along with Avroy Fanaroff, Klaus and Kennell showed that mothers who visited their premature infants less often were more likely to have disorders of mothering and to abuse or neglect their children more than those who visited more often (17). This observation led to the publication of suggested guidelines for the care of the parents with a normal or high-risk neonate with an emphasis on unrestricted visitation (18, 19). Their recommendation for early mother-baby skin-to-skin contact eventually led to the kangaroo care model and unrestricted nursery visitation, now the standard of care worldwide. Klaus and Kennell also published an important study on the mourning response to the death of their newborn baby (20). 

Dr. Klaus was also an advocate for breastfeeding. He showed that more frequent breastfeeding led to increased milk intake and weight gain in babies in the first weeks after birth and that this was also associated with lower serum bilirubin levels in the more frequent feeding group (21–23). 

Working in Guatemala in collaboration with Dr. Roberto Sosa, Klaus and Kennell showed that the presence of a support person called a doula during labor led to significantly shorter labors, less need for augmentation of labor and cesarean section, and improved neonatal outcomes (24, 25). These observations were confirmed with a large randomized, controlled trial (RCT) in the United States and by a later review of eleven RCTs (26, 27). 

Dr. Klaus authored several important books, the most notable of which is Care of the High-Risk Neonate, which he co-authored with Dr. Avroy Fanaroff and which most of us older neonatologists cut our teeth on and still recommend to trainees interested in newborn medicine (28). This book is now in its eighth edition. Other important books include Maternal-Infant Bonding: The Impact of Early Separation or Loss on Family (29), The Amazing Newborn: Discovering And Enjoying Your Baby’s Natural Abilities (30), Bonding: The beginnings of parent-infant attachment (31), Bonding: Building The Foundations Of Secure Attachment And Independence (32), and The Doula Book: How a Trained Labor Companion Can Help You Have a Shorter, Easier, and Healthier Birth (33). He also produced a video, Amazing Newborn, showcasing the talents and abilities of newborn infants, proving there is more to the neonate than just brainstem responses (34). 

Dr. Klaus mentored numerous trainees. Four of them were most notably honored with the Apgar Award, the highest award bestowed by the AAP Section on Neonatal Perinatal Medicine (SoNPM): Drs. Avroy Fanaroff, John Kattwinkel, Wally Carlo, and Richard Martin. SoNPM also annually bestows the Marshall Klaus Perinatal Research Awards of $5,000 each plus travel expenses to trainees in four categories: Bench or Clinical Research (up to 12 per year), Health Services Research (up to 2 per year), and one each per year for Education Research and Necrotizing Enterocolitis Research. 

Dr. Klaus received numerous obituaries upon his death, including from Pediatric Research (1), Acta Paediatrica (35), The New Your Times (36), Lamaze International (37), and numerous other news and society publications. He contributed as much as anyone ever to the evolution and modernization of newborn care and founded what we now call family-centered care. 

References: 

1. Fanaroff AA, Martin RJ. Marshall Klaus: the impact of a pioneer in neonatology. Pediatric Research. 2018;83(1):6–8. doi:10.1038/pr.2017.269 
2. Klaus MH, Clements JA, Havel RJ. Composition of Surface- Active Material Isolated from Beef Lung. Proceedings of the National Academy of Sciences of the United States of America. 1961 Nov 15;47(11):1858–1859. doi:10.1073/pnas.47.11.1858 
3. Bolande RP, Klaus MH. The Morphologic Demonstration of an Alveolar Lining Lung and its Relationship to Pulmonary Surfactant. The American Journal of Pathology. 1964;45(3):449–463. 
4. Chu J, Clements JA, Cotton E, et al. Preliminary Report: The Pulmonary Hypoperfusion Syndrome. Pediatrics. 1965;35(5):733–742. doi:10.1542/peds.35.5.733 
5. Thomas DV, Fletcher G, Sunshine P, Schafer IA, Klaus MH. Prolonged Respirator Use in Pulmonary Insufficiency of Newborn. JAMA. 1965;193(3):183–190. doi:10.1001/jama.1965.03090030005001 
6. Gruber HS, Klaus MH. Intermittent mask and bag therapy: An alternative approach to respirator therapy for infants with severe respiratory distress. The Journal of Pediatrics. 1970;76(2):194–201. doi:10.1016/s0022-3476(70)80162-7 
7. Kattwinkel J, Fleming D, Cha CC, Fanaroff AA, Klaus MH. A Devide for Administration of Continuous Positive Airway Pressure by the Nasal Route. Pediatrics. 1973;52(1):131– 134. 
8. Martin RJ, Nearmna HS, Katona PG, Klaus MH. The effect of a low continuous positive airway pressure on the reflex control of respiration in the preterm infant. The Journal of Pediatrics. 1977;90(6):976–981. doi:10.1016/s0022-3476(77)80575-1 
9. Martin RJ, Okken A, Katona PG, Klaus MH. Effect of lung volume on expiratory time in the newborn infant. Journal of applied physiology: respiratory, environmental and exercise physiology. 1978;45(1):18–23. doi:10.1152/jappl.1978.45.1.18 
10. Fanaroff AA, Wald M, Gruber HS, Klaus MH. Insensible Water Loss in Low Birth Weight Infants. Pediatrics. 1972;50(2):236– 245. doi:10.1542/peds.50.2.236 
11. Klaus MH, Kennell JH, Plumb N, Zuehlke S. Human Maternal Behavior at the First Contact with her Young. Pediatrics. 1970;46(2):187–192. doi:10.1542/peds.46.2.187 
12. Klaus MH, Jerauld R, Kreger NC, McAlpine W, Steffa M, Kennell JH. Maternal Attachment: Importance of the First Post-Partum Days. The New England Journal of Medicine. 1972;286(9):460–463. doi:10.1056/NEJM197203022860904 
13. Kennell JH, Jerauld R, Wolfe H, et al. Maternal Behavior One Year After Early and Extended Post-partum Contact. Developmental Medicine & Child Neurology. 1974;16(2):172– 179. doi:10.1111/j.1469-8749.1974.tb02738.x 
14. Ringler NM, Kennell JH, Jarvella R, Navojosky BJ, Klaus MH. Mother-to-child speech at 2 years – effects of early postnatal contact. The Journal of Pediatrics. 1975;86(1):141–144. doi:10.1016/s0022-3476(75)80727-x 
15. Lozoff B, Brittenham GM, Trause MA, Kennell JH, Klaus MH. The mother-newborn relationship: Limits of adaptability. The Journal of Pediatrics. 1977;91(1):1–12. doi:10.1016/s0022-3476(77)80433-2 
16. Klaus MH, Kennell JH. Mothers Separated from Their Newborn Infants. Pediatric Clinics of North America. 1970;17(4):1015–1037. doi:10.1016/s0031-3955(16)32493-2 
17. Fanaroff AA, Kennell JH, Klaus MH. Follow-Up of Low Birth Weight Infants – The Predictive Value of Maternal Visiting Patterns. Pediatrics. 1972;49(2):287–290. doi:10.1542/peds.49.2.287 
18. Kennell JH, Klaus MH. Care of the Mother of the High-Risk Infant. Clinical Obstetrics and Gynecology. 1971;14(3):926– 954. doi:10.1097/00003081-197109000-00015 
19. Kennell JH, Klaus MH. Care of the Parents. In: Carlo WA, Chatburn RL, eds. Neonatal Respiratory Care. 2 ed. Yearbook Medical Publishers; 1988:212–235:chap Care of the Parents. 
20. Kennell JH, Slyter H, Klaus MH. The Mourning Response of Parents to the Death of a Newborn Infant. The New England Journal of Medicine. 1970;283(7):344–349. doi:10.1056/NEJM197008132830706 
21. De Carvalho M, Robertson S, Friedman A, Klaus M. Effect of Frequent Breastfeeding on Early Milk Production and Infant Weight Gain. Pediatrics. 1983;72(3):307–311. doi:10.1542/peds.72.3.307 
22. Klaus MH. The Frequency of Suckling: A Neglected But Essential Ingredient of Breastfeeding. Obstetrics and Gynecology Clinics of North America. 1987;14(3):623–633. doi:10.1016/S0889-8545(21)00082-6 
23. De Carvalho M, Klaus MH, Merkatz RB. Frequency of Breastfeeding and Serum Bilirubin Concentration. The American Journal of Diseases of Children. 1982;136(8):737– 738. doi:10.1001/archpedi.1982.03970440081024 
24. Sosa R, Kennell J, Klaus M, Robertson S, Urrutia J. The Effect of a Supportive Companion on Perinatal Problems, Length of Labor, and Mother-Infant Interaction. The New England Journal of Medicine. 1980;303(11):597–600. doi:10.1056/ NEJM198009113031101 
25. Klaus MH, Kennell JH, Robertson SS, Sosa R. Effects of social support during parturition on maternal and infant morbidity. British Medical Journal. 1986;293:585–587. doi:10.1136/bmj.293.6547.585 
26. Kennell J, Klaus M, McGrath S, Robertson S, Hinkley C. Continuous Emotional Support During Labor in a US Hospital: A Randomized Controlled Trial. JAMA. 1991;265(17):2197– 2201. doi:10.1001/jama.1991.03460170051032 
27. Klaus MH, Kennell JH. The doula: an essential ingredient of childbirth rediscovered. Acta Pædiatrica. 1997;86(10):1034– 1036. doi:10.1111/j.1651-2227.1997.tb14800.x 
28. Fanaroff AA, Fanaroff JM. Klaus and Fanaroff’s Care of the High-Risk Neonate. 8 ed. Elsevier; 2026. 
29. Kennel JH, Klaus MH. Maternal-Infant Bonding: The Impact of Early Separation or Loss on Family Development Mosby; 1976. 
30. Klaus MH, Klaus PH. The Amazing Newborn: Discovering And Enjoying Your Baby’s Natural Abilities Da Capo Lifelong Books; 1985. 
31. Klaus MH, Kennel JH. Bonding: The beginnings of parent-infant attachment. New American Library; 1983. 
32. Klaus MH, Kennell JH, Klaus PH. Bonding: Building The Foundations Of Secure Attachment And Independence Merloyd Lawrence; 1996. 
33. Klaus MH, Kennell JH, Klaus PH. The Doula Book: How a Trained Labor Companion Can Help You Have a Shorter, Easier, and Healthier Birth Merloyd Lawrence; 2012. 
34. Amazing Newborn. Documentary. Concord Media; 1977. 
35. Fanaroff AA. Marshall H. Klaus M.D., A Life Sketch. Acta Pædiatrica. 2017;106(12):2068–2069. doi:10.1111/ apa.14066 
36. Roberts S. Dr. Marshall H. Klaus, Maternity-Ward Reformer, Dies at 90. The New York Times. August 25, 2017. Accessed January 31, 2025. https://www.nytimes.com/2017/08/25/ health/marshall-klaus-dead-studied-emotional-bonding-with-newborns.html 
37. Muza S. Remembering Marshall Klaus – Celebrating His Impact on Parents and Babies. August 22, 2017. https://www.lamaze.org/Connecting-the-Dots/Post/remembering-marshall-klaus-celebrating-his-impact-on-parents-and-babies 
38. American Academy of Pediatrics. Marshall Klaus Perinatal Research Awards. Accessed from https://www.aap.org/en/community/aap-sections/sonpm/marshall-klaus-perinatal-research-awards/

Disclosures: The author reports no disclosures.