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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 aggressive 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.
Baby Friendly Hospital Initiative, Human Neonatal Care Initiative
At the end of 1980s and the beginning of 1990s, the 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-neonatologist, I find the movement to be on the whole positive as it enables the baby to feet comfortable under the conditions of the maternity wards. However, I am worried about the fate of sick and pre-term 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 birth weight infants and sick newborns and that it is in the best health interest of these babies. However, not very much has changed since then. Infants in units for sick 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 maternity 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 they 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 feel lonely, although highly qualified nurses surround them. Still there is a growing 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 "biological 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 anemia, leading the infants to a stressed situation (11, 12). The number of tests and examinations therefore should be reduced to the minimum.
Attention should be paid to the problem of aggressive therapy. At present, there is a tendency towards decreasing the amount of drugs used, but this process is still in its 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 newborn infants. The 10 steps of the BFHI are inadequate for sick and pre-term 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).
- The mother should be able to stay with her sick baby for 24h a day.
- Every staff member should care for the mother and the infant and should be able to cope with psychological aspects.
- The staff should promote breastfeeding to every mother and learn the techniques of expressing breast milk.
- The psychological stress of the mothers should be decreased during the whole treatment period.
- Unless medically indicated, newborns should not be given anything other than breast milk.
- If the infant cannot suckle, breast milk should be given by tube and preferably by the mother.
- The number of tests and examinations should be reduced to a minimum.
- 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.
- Aggressive therapy should be reduced to a minimum.
- The mother and infant should be considered as a closed psychosomatic system. Everyday ward rounds should focus not only on the infant but also on the needs of the mothers (include a gynecologist and other specialists).
- 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 might have a wider name: the Humane Neonatal Care Initiative (14).
After we introduced the policy of mothers staying with their sick and pre-term 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 very serious and thorough discussion.
- Wolf H, Charrondiere R, Heising E. First "baby-friendly" hospital in Europe. Lancet 1993, 341: 440
- Klaus HM, Kennel JH. Parent-infant bonding. 2nd ed. St Louis: CV Mosby, 1982
- Tunell R, Sarman J, Holmer I, Elnas S. The evolution of different methods to provide to newborn babies by the use of a baby thermal manikin. Proceedings of 3rd International Conference on Fetal and Neonatal Psychological measurements. Malmö: Ronneby Brunn, 1988
- Ludinoton-Hoc SM. Hadood A, Anderson GC. Psychologic responses to skin-to-skin contact in hospitalized premature infants. J Perinatal 1991; 11: 19-24
- Charpak N, Ruiz-Pelaez JG, Charpak Y. Rey-Martinez kangaroo mother program: an alternative way of caring for low birth weight infants? One year mortality in two cohort study. Pediatrics 1994; 94: 804-10
- Charpak N, Figueroa Z, Ruiz JG. Kangaroo mother care. Lancet 1998; 351: 914
- Levin A. Aspects of social-biological and medical-psychological factors and contact of infants with their Mothers in neonatal care unit. Doctor degree thesis. Moscow, 1991
- Levin A. Potapova A, Rattasep E, Krooni ND, Donchenko MR. Biocentosis in pre-term and sick full-term newborns. J Pediatric Moscow. 1988; 8: 14-8
- Levin A. What future course do you take, neonatal medicine? Int. Child Health: A Digest of Current Information 1995; 6: 41-4
- Levin A. Where are you going, neonatal medicine? (Letter to the Editor). News and views from Estonia. Initiative Crit Care Nurs 1995; 11: 49-52
- Levin A. The Mother-Infant Unit at Tallinn Children's Hospital, Estonia: a truly baby-friendly unit. Birth 1994; 21: 39-44
- Harrison L, Klaus HM. Commentary: a lesson from Eastern Europe. Birth 1994; 1: 45-6
- Levin A. Monography: Hospital for newborn babies in Russia. Leningrad: Medicina, 1989: 101
- Levin A, Listopad T. Humanistic neonatal medicine in paediatric hospital, sharing tools for personal/global harmony. First Annual Conference on Conflict Resolution, St Petersburg, 1994: 65-8