In this phase throughout the country surgery of children was the responsibility of general surgeons who operated on almost everything in adults and children. Undoubtedly the outcome especially the newborns could be described as disastrous. The infrastructure was poor and the human resources were inadequate to support surgery of children especially newborns. The earliest surgery done on babies by a properly trained paediatric surgeon was at the University Hospital by Prof Dato’ K Somasundram. He had his training at the Hospital for Sick Children Great Ormond Street London. Dr Karpal Singh was the Surgical Registrar in General Hospital Kuala Lumpur from 1964 to 1966 and then became the Senior Registrar from 1967 to 1968. During this time he took care of most of the Paediatric and neonatal surgical problems though he did not have full training in Paediatric surgery at that time. There was no special ward for children requiring surgery and they were placed in the Paediatric medical ward. The wards were situated on the ground of the old Malay ward I & II. (Present site of Institute of Pediatric).

This phase of development coincided with the redevelopment of the entire Hospital Kuala Lumpur complex. Hospital Kuala Lumpur was intended to be the teaching hospital of UKM with a Management Board. Various institutes were established. The idea was that UKM will provide the academic umbrella and all specialists in the hospital would participate in service, teaching and research proportionately according to a formula depending on whether they were from the Ministry or UKM. This idea did not come to full realization due to legal impediments. It eventually became a hospital where teaching was done mainly by UKM teaching staffs. This prompted UKM in later years to develop its own hospital for its future growth and development. There was a separate Maternity Hospital with its own special care nursery but without a Gynaecology ward. The main hospital complex consisted of various departments. The Paediatric department had its own Neonatal care ward. Mr Karpal Singh was sent to Melbourne for training in Paediatric surgery in 1970 and returned with an FRACS in Paediatric surgery in 1972. He recommenced proper paediatric surgical practice in February 1972 in Unit 1 under Dato’ K A Menon. I came into the picture of Paediatric surgery in Malaysia at Hospital Kuala Lumpur in August 1976 after my Fellowship and a stint at Hospital for Sick Children Great Ormond Street (GOSH) and University Hospital. I was asked to start the department of surgery of UKM. In January 1976 the academic department of surgery UKM was established and soon followed by the establishment of the UKM surgical unit at HKL which took over Surgical Unit III from Mr Husin Salleh who resigned leaving two medical officers Dr Ahmad Zulkifli Laidin and Dr Yusha Abdul Wahab. Later in the year when Mr Karpal Singh resigned, the Paediatric surgical unit under Unit I was transferred to the UKM surgical unit together with Dr Leela Perumal as the medical officer. The UKM unit was on call every third day for general surgery and every day for Paediatric surgery with a single surgeon and three medical officers. Later Dr Freda Meah, Dr Bahari Habib Mohd and Dr Ismail Abdullah joined the unit in general surgery. This unit was later assisted by a Canadian trained Malaysian surgeon Dr Bakri Musa who also had some training in Paediatric surgery for close to a year before he was transferred to Johor Bahru. There was now a greater degree of awareness on the need for more and better trained surgeons to deal with children especially babies. It was during this period that there was serious planning for new Paediatric facilities which was initially supposed to be a children hospital. It was my dream, vision and hope when I took over the unit that one day we will be able to provide the kind of care for children similar to the ones that were provide by the developed countries like the one I saw at the children hospital in London. 1. Children will be treated differently from adults 2. Healthcare facilities addressing the special of children 3. Children requiring hospitalization will be treated in a hospital that is designed especially for children. 4. Children will be cared for by healthcare personnel specially trained to treat and care for children 5. The hospital would be well known as a teaching and research hospital. Up to 1976 most of the surgery done on neonates was for anorectal malformations. Other surgery like Intestinal Atresias and Hirschsprung’s disease were also done but the outcome of surgery was not well documented (Figure 1)

After 1976 there were significant improvements in the surgery of children at HKL despite the numerous challenges of this new surgical service. The infrastructure support for newborns was poor. Initially the other surgical units also insisted on carrying out surgery in children, as was the practice throughout the country. It was not surprising that the outcome of surgery then as measured by the neonatal surgical mortality rate was horrendous compared to the present day situation.

In the initial period of my undertaking the service the outcome of surgery especially in the newborn was dismal. We were handicapped not only by the lack of appropriate surgical instruments like small size scissors and forceps to do surgery in children but also by a lack of trained nursing staff in the operating theatre. The operating theatres were cold and there were no equipments like warming blankets to keep the child warm throughout surgery. The diathermy apparatus were big and not of the right size for children especially babies. We had to improvise ways to keep the baby warm during surgery. Despite these efforts many babies after long surgery became cold and hypothermic which led to metabolic complications like acidosis. Sclerema neonatorum a complication of hypothermia was quite common. It was not surprising that many babies died after surgery except for the simple conditions that did not require prolong surgery. The ward nursing staffs were also not well trained to handle children especially the low birth weight and premature babies. There was not a single case of oesophageal atresia that survived surgery for the first three years (Figure 2). Many of them died soon after surgery. A few survived for about two weeks. Better result was obtained for other abdominal operations and in Diaphragmatic hernias especially those that did not require preoperative ventilation or presenting late.

With the concentration of most Paediatric care in one unit the overall survival of neonates after surgery gradually improved. Initially the other units also carried out surgery of the newborn but with better outcome demonstrated by Unit 3 (UKM) and as words spread around about our successes more patients were referred directly to the unit and later the other units gave up entirely their work on children. As a result, the period between 1976 and 1981 saw some encouraging improvement in the postoperative survival of neonates compared to the years before that. In 1970 the postoperative mortality for neonates undergoing thoracic or abdominal operations was 75%. In 1975 it was 51.8% but in 1976 it began to drop rapidly from 47.6% to 10.3% in mid 1981 (Figure 3). The mortality rate for all operations in the neonates has since remained below 15%. This was a measure of success in the effort to improve the care of children especially neonates.

Oesophageal atresia was dubbed as the ‘epitome of modern surgery’ by NA Myers whom I worked under at the Royal Children Hospital Melbourne. Success in the surgery for this condition is cited not only as a measure of the skill of the surgeon, but also a reflection of the quality and sophistication of a Paediatric surgical unit and its supporting facilities. Prior to 1976 there was only a single survivor for this condition. After 1976 the first survivor was reported only in 1979 followed by a few more successes. During the period of 1976 to 1981 the total mortality for this condition was 38% and the deaths were mainly in the high-risk groups with severe associated anomalies or with very low birth weight (Figure 4).

The tremendous improvement in the survival of neonates with oesophageal atresia can be attributed to the establishment of a special neonatal unit and special care nursery at the General Hospital (HKL) main complex in 1980. The Intensive Care Unit was also improved with the purchase of open incubators and monitoring equipments. With better-trained nurses and neonatal specialists from the Ministry of Health working together with the neonatologist from UKM there was an overall improvement of the care of the sick newborns. The achievements were also contributed in no small measure by a group of dedicated anaesthetists from both HKL and UKM and improved facilities in the intensive care unit. The dramatic fall in the postoperative mortality of neonates was a landmark achievement of Hospital Kuala Lumpur. There can be no doubt that the involvement of UKM specialists in the care of patients at the hospital led to an overall improvement in patient care of the whole hospital.

The post 1980 period saw a greater degree of recognition for Paediatric surgery as a very special branch of surgery with many interests shown by trainee doctors and nurses. Paediatric surgery was undertaken entirely by the UKM surgical department. There was greater support from the administration of the hospital in providing more personnel and financial resources for the purchase and upgrading of equipments especially in the operating theatre and Intensive Care Unit. It was during this period that many trainees offered themselves to be trained. There was news that a children hospital was in the pipeline but there was slow progress and work only started in the early 80’s at the old site of the Paediatric wards. There was considerable delay in the progress of the hospital. Construction work of the new Institute started around 1984 but soon stopped after the stage of piling. I can still remember seeing steel structures left visibly protruding above ground for quite some time after cessation of work. A photograph taken on 20 thMay 1985 showed that shrubs and trees have overtaken the structures. This raised concern in many quarters and was even raised in Parliament by Dato’ Zainal Abidin an MP from Kedah. It was discovered that the ground was soft and of lime stone and the foundation would not take all the floors that had been originally planned. There was a long period of waiting and coupled with the recession of 1987 the construction only recommenced in 1989. A few floors had to be scrapped from the original design. It now consists of three levels with remnants of a staircase that can still be seen going up from level three to a non-existent floor. I was appointed Dean of the Faculty of Medicine UKM in February 1984 and was able to obtain from the University additional financial resources for the unit.

The Paediatric service of HKL finally moved to the new Institute of Paediatrics in May 1991. There were considerable discussions at various levels on what name to give to this new facility. Finally it was decided to name it the Institute of Paediatrics or Institut Pediatrik to be consistent with the name given to the other Institutes in HKL. It was decided that the new facility was only for general paediatrics and general surgery. Following protests from Dr Sivanantham the head of department of Orthopaedics, the scope of service was expanded to include orthopaedic surgery but orthopaedics would have to share the wards with general surgery. Thus from the very start the facility was not adequate for the needs of all children and it was never designed to be a comprehensive children hospital. Beside the considerable delay in the construction of the Institute, its floor space was reduced and when it was finally ready it was already outdated in its design. Despite this, it was a significant development in the care of children in general as for the first time most of the children in HKL were put under one roof. Unfortunately there were not enough beds to include patients in all the surgical specialties. In the early part only general surgery and orthopaedic patients were admitted to the Institute. The Institute could not initially be provided with all the facilities like a Burn unit, physiotherapy and supporting diagnostic services. Over the years some renovations were done to include some of these services. Some diagnostic services like MRI and CAT scan are still shared with the adult patients in the main block and patients have to be transported there with some risks. The decade between 1990 and 2000 can be considered as a great decade for Paediatric surgery. There were many outstanding surgeons from UKM and HKL and surgeons in training in the unit. More complex surgeries were performed with success due to better peri-operative care of patients especially neonates. The neonatal surgical mortality from 1990-93 remained at an acceptable level of 9.3% to 11.9% (Figure 5). When HUKM was opened in 1997 all UKM members of the team had to move to Cheras to their own teaching hospital

The Paediatric surgery department then came entirely under the Ministry of Health. Many improvements were achieved by using funds obtained from donations by the public and corporate organizations. Without the generous contributions of the public it would not have been possible to improve the facilities and reach the level of child friendly care that has been achieved by the Institute of Paediatric. This effort to develop and promote a more child friendly healthcare for children culminated in the formation of the Child friendly Healthcare Association of Malaysia to develop standards and criteria and promote child friendly practices. I was the inaugural President.