422-99
Acta Paediatr 88: 1-?. 1999
VIEWPOINT
Humane Neonatal Care Initiative
A Levin
Tallitz Ciiildretz's Hi)spital, Talliti, Esto)iia
Levin A. Humane Neonatal Care Initiative. Acta PEediatr 1999; 88: 000-4)00. Stockholm. ISSN 0803-51-53
The author has worked for many years in experimental departments in the former Soviet health system. Now, with integration
into the western health system, many questions are being asked about high-technology neonatal medicine and whether it is
sufficiently humane. The Baby Friendly Hospital Initiative (BFHI) movement is well known all over the world, but
unfortunately it is only used for healthy children in maternity hospitals. A paradoxical situation has been created: the routines
of maternity wards comply with the BFHI, whereas a neonatal intensive care unit in the same hospital may not meet the
requirements of the BFHI. BFHI mainly cover breastfeeding in maternity hospitals. Humane Neonatal Care Initiatives include
minimum a22ressive therapy, minimum contact between sick newborns and medical staff, and maximum contact with mothers;
the number of tests and examinations should be reduced to a minimum. Eleven steps towards the improvement of psychosocial
and medical care in units for sick newborns are presented. This article is intended to provoke serious discussion. 0 Babv
Frieridli, Hospital Initiative, Hii??Zalze Neonatal Cat-e hzitiative
A Lei,itt MD, PhD, Tervise 28. EE0034 Tallin Estonia (Tel. +372 2 525 948 a)itt +372 6 570 606, fa,c. +372 2 525 948 and
+372 6 570 606)
At the end of 1980s and the beginning of 1990s, the g
United Nations International Children's Emergency Fund (UNICEF), the World Health Organization (WHO) and
several other organizations initiated the Baby Friendly Hospital Initiative (BFHI) movement (1). It spread all over
the world and now more and more hospitals are given the name of BFHI every month. What does the BFHI mean?
Is it just another campaign or has it called forth life itself I believe the latter to be true.
In many countries mothers started to understand the importance of breastfeeding. They gathered into groups that
were later called support groups, and insisted that maternity houses should make changes in the care of newborns.
Mothers were worried about the fact that their infants were separated from them instead of being put to the breast.
Many doctors and scientists carried out research and published articles in which it was pointed out that it was
necessary to reorganize the working system in maternity houses. Especially influential was the concept of bonding
introduced by Klaus & Kennel (2), which was later recognized all over the world. The BFHI aimed to
counterbalance the use of high technology, which replaces a number of natural processes with various apparatuses
and devices. Breastfeeding started to fall into oblivion and more and more breast-milk substitutes were used.
As a paediatrician-neoiiatologist, I find the movement to be on the whole positive as it enables the baby to feet
comfortable under the conditions of the matemity wards. However, I am worried about the fate of sick and preterm
newborns who have to be taken care of in units for sick newborns and particularly in neonatal intensive care units.
They are deprived of constant contact with their mothers and are fed, at best, on breast milk from a milk bank. It is
a common view that infants on respirators cannot be breastfed, which to some extent is correct because a majority
of children and those infants who do not need to be artificially ventilated may be given fresh breast milk from their
mothers. A paradoxical situation has been created: the routines of the maternity wards are in accordance with the
BFHI, whereas a neonatal intensive care unit in the same hospital does not have to meet the requirements of the
BFHI.
In different countries 5-7% of children may be ill and it is natural that breastfeeding is at least as important for ill
children as for healthy babies, if not even more important. This issue was raised at the seminar in St Petersburg in
August/September 1993 when it was pointed out that breastfeeding, is also possible for low birthweight infants and
sick newborns and that it is in the best health interest of these babies. However. not verv much has changed since
then. Infants in units for sic@- newborns are still often deprived not only of breastfeeding, but also of other natural
factors such as constant contact with their mothers. In some cases, companies producing-formulas support
pseudoscientific research, the aim of which is to prove that breast-milk substitutes are better than breast milk.
Unfortunately, the present international code functions well only in maternity wards but not in neonatal units, thus
making it possible to break the international code.
Another great problem is that the BFHI concept does not fully correspond to its name. Hospitals have to meet all
of the requirements of breastfeeding for healthy newborns in matemity wards, but the concept of a baby friendly
hospital should include other factors besides breastfeeding.
What about the conditions that have been created for sick newborns? Do we really pay attention to whether thev
feel comfortable? It is obvious that seriously ill infants who have been put on respirators do not feel well. Babies
in incubators who are being, kept under monitor observation feet lonely, although they are surrounded by highly
qualified nurses. Still. there is a crowing tendency towards the humanization of high technology medicine. For
example, in Sweden, heated water mattresses have been constructed (3) and mother and-infant skin-to-skin contact
has been applied (4): mothers try to use the "kangaroo method" (5,6) while visiting, their babies. However, there is
much room for improvement. For instance, constant mother-infant contact favours the biological and
psychological health of an infant in the late neonatal period (from 7 to 28 d)and is far better than contact with
frequently changing medical staff (7, 8).
Our research, which was carried out in the 1990s and is only published in Russia, found that in the late neonatal
period there exist both biological and psychological umbilical cords. These create a favourable
.Ibiolo(,ical incubator" for the child, thus fostering its later biological, physical and psychological development (9,
10).
In modem neonatal care the infants are subjected to several examinations and laboratory tests which may even
cause anaemia, leading the infants to a stressed situation (I 1, 12). The number of tests and examinations therefore
should be reduced to the minimum.
Attention should be paid to the problem of a--ressive therapy. At present, there is a tendency towards decreasing
the amount of drugs used, but this process is still in it early stages.
In summary, I am of the opinion that the concept of a baby-friendly hospital involves much more than just the
breastfeeding of healthy newbom infants. The 10 steps of the BFHI are inadequate for sick and preterm newborns.
According to my experience, the following steps for the improvement of psychosocial and medical care in units for
sick newborns should be applied (13).
1.
The mother should be able to stay with her sick baby for 24 h a day.
2.
Every staff member should care for the mother and the infant and should be able to cope with
psychological aspects.
3.
milk.
The staff should promote breastfeeding to every mother and learn the techniques of expressing breast
4.
The psychological stress of the mothers should be decreased during the whole treatment period.
5.
Unless medically indicated, newborns should not be given anything other than breast milk.
6.
If the infant cannot suckle, breast milk should be given by tube and preferably by the mother.
7.
The number of tests and examinations should be reduced to a minimum.
8.
Mother-and-child skin-to-skin and air-to-air contact should be used as much as possible, and the use of
technical equipment in childcare should be reduced.
9.
Agaressive therapy should be reduced to a minimum.
10.
The mother and infant should be considered as a closed psychosomatic system. Everyday ward rounds
should focus not onlv on the infant but also on the needs of the mothers (include a gynaecologist and other
specialists).
11.
Healthy family members (father, Grandparents or helpers) should be allowed to visit the mother and baby
during a prolonged stay at the hospital.
It seems to me that units for sick newborn babies
mi-ht have a wider name: the Humane Neonatal Care
Initiative (14).
After we introduced the policy of mothers staying with their sick and preterm newborns in 1994, we managed to
increase the level of breastfeeding in this group to 75-80%. It is also obvious that mothers take a more active part
in the care of their babies when these principles have been applied.
Our experience of working with mothers over a period of nearly 20 y has proven to us that the future development
of the neonatal medicine cannot only be highly technological but should also include humane factors. This is the
humane and individual right of the baby in hospital not only to be surrounded with very good apparatus and highly
qualified medical staff, but also to be with his or her mother and. ideally, with his or her father as well.
At the end of the twentieth century and the beginning of next century, in analogy with BFHI in the maternity wards,
infants should be given the right to live under a Humane Neonatal Care Initiative. At the head of the movement
there should be not only mothers and international organizations (UNICEF, WHO, etc.), but also the medical and
nursing staff of the neonatal units. The questions and problems raised in this article need verv serious and thorough
discussion.
References
1.
Wolf H, Charrondiere R. Heising E. First "baby-friendly" hospital in Europe. Lancet 1993, 341: 440
2.
Klaus HM. Kennel JHParent-infant bonding. 2nd ed. St Louis: CV Mosby, 1982
3.
Tunell R, Sarman J, Holmer I, Elnas S. The evolution of different methods to provide to newbom babies by the use of a baby thermal manikin.
Proceedings of 3rd International Conference on Fetal and Neonatal Psychological measurements. rvIalm6: Ronnebv Brunn. 1988
4.
Ludinoton-Hoc SM. Hadood A, Anderson GC. Psvchologic responses to skin-to-skin contact in hospitalized premature infants. J Perinatal 1991. It.
19-24
5.
Charpak- N. Ruiz-Pelaez JG, Charpak Y. Rey-Martinez kangaroo mother program: an alternative wav of caring for low birth weight infants? One year
mortality in two cohort study. Pediatrics 1994: 94: 804-10
Hiei?tiiiie Neoticital Ctire Iiiiii(iiii-e 3
6.
Charpak N. Figueroa Z, Ruiz JG. Kangaroo mother care. Lancet 1998'. 351: 914
7.
Levin A. Aspects of social-biological and medical-psychological factors and contact of infants with their Mothers in neonatal care unit. Doctor degree
thesis. Nloscow, 1991
8.
Levin A. Potapova A, Rattasep E, Krooni ND, Donchenko MR.
Biocentosis in preterm and sick full-terrn newborns. J Pediatr
?vloscow. 1988; 8: 14-8
9.
Levin A. What future course do you take. neonatal medicine? Int Child Health: A Digest of Current Information 1995; 6: 41-4
10.
Levin A. Where are you going. neonatal medicine? (Letter to the Editor). News and views from Estonia. Initiative Cfit Care Nurs 1995; 1 1: 49-52
11.
Levin A. The Mother-Infant Unit at Tallinn Children's Hospital,
Estonia:
a truiv baby-friendly unit. Birth 1994; 21: 39-44
12.
Harrison L, klaus HM. Commentary: a lesson fmni Eastern Europe. Birth 1994; 1: 45-6
13.
Levin A. Monography: Hospital for newbom babies in Russia.
Leningrad: Medicina, 1989: 101
14.
Levin A, Listopad T. Humanistic neonatal medicine in paediatric hospital, sharing tools for personal/global harinony. First Annual Conference on
Conflict Resolution. St Petersburg, 1994: 65-8
Received Aug. 5, 1998. Accepted in revised form Jan. 19, 1999