Humane Neonatal Care Initiative
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"Where are you going, neonatal medicine?"

Adik Levin
MD, PhD, Director of Newborn and Premature Children's department, Children's hospital, EE0018 Tallinn, Tervise 29, Estonia

In almost all East European countries the old health care system is broken now, and most of these countries are thinking how to integrate into a new one.
 
The main problem for these countries is that modern medicine is very expensive. In this letter I would like to share my opinion with you.
 
Nowadays premature and full-term newborns are given medical care in maternity units, or children's hospitals' neonatal units. It should be pointed out it is only during the last 20 years that a child has become able to feel itself safe in a maternity home or unit, and that the attitude towards the child has become more humane. The mother stays with her child and breastfeeds it at the early first hour of life. The international organisations World Health Organization (WHO) and UNICEF have started to pay attention to the breastfeeding problem. They have called into being the Baby-friendly Hospital Initiative and worked out the steps to a baby-friendly hospital.
 
A great number of hospidals in many countries are striving to be given the name of "baby-friendly hospital". On the one hand, everything seems to be alright, on the other hand, I dare to say that there is still much to be done. In every great hospidal there are both maternity and neonatal units. Very few neonatal units are really baby-friendly, as in most units children have to be in hospital without mothers and are completely under the care of medical staff.
 
I am not accusing anybody, I am just describing the real situation in modern hospitals. Can a hospital be baby-friendly if the steps are followed in its maternity unit but ignored in the neonatal unit?
 
The situation is totally abnormal, we try to be friendly to healthy children but forget about sick and pre-term babies. It should be evident that the latter need a baby-friendly hospital much more than healthy newborns. I would like to dwell upon this problem a bit more thoroughly.
 
Now in neonatal medicine there exist two trends in hospital treatment of sick newborns and premature babies. One of them is the socalled humane trend that is considered to be typical of developing countries. The other trend, the technical one, is characteristic of developed countries. This trend has led to the excessive use of technical equipment and high technology.
 
I think that the best in the future is to combine both these trends, when we use all humanistic things and basic equipment necessary for the treatment process. In this third trend the sequence of importance is as follows:
 
*Person number one is the child. During its first hour, day, week and month of life, the child is entitled to be exposed to all biological, psychological, bioenergetic and other factors that the child has been intended to be exposed to by nature.
 
*Person number two is the mother. She must be enabled to be in contact with her child 24 hours a day, not only in the first days at the maternity hospital, but also later, during the whole of the baby's first month of life, no matter where the child may be.
 
Conditions will be the the same for the child and the mother. The mother must preliminarily be informed of her important role in the life of her sick newborn during its first month of life when the child is adjusting itself to the life after birth. Thus, 24-h breastfeeding and a smooth transition from tube-feeding to breastfeeding can be guaranteed. It would be ideal if fathers could join their child and wife at the hospidal 24 h a day (e.g. spend the night at the hospital and leave it for work in the morning). Only then we could speak of a family-friendly hospital.
 
*Person number three is medicine that regards the mother as a sanogenic (healthpromoting) factor for the child, bearing in mind that the newborn and the mother form a closed psychosomatic system.
 
Humane neonatal medicine combines all biological and psychological fators that are indispensable for the normal development of the child with the optimum use of technical equipment, as a result of which it is possible to carry through baby-sparing therapy and at the same time help the mother. Such an arrangement can only be applied when the mother is with her child in hospidal 24 h day until the baby is discharged from hospidal.
 
After physical separation mother-and-child bonding doas not break off (Klans & Kennel 1982). After the birth of the child the physical umbilical cord between the infant and the mother is severed. However, the mother and infant remain connected by what we have conceptualised as a "biological and psychological umbilicus" (see Fig. 3).
 
The biological umbilicus includes many elements:
* Vaginal delivery without the use of medications
* Natural birth
* Extra early feeding
* Extra early physical contact between the mother and the child
* Feeding with breast-milk in the late neonatal period (Kangaroo method)
* The newborn baby's touch with the air expired by its mother
* Minimal contact with constatly interchanging medical staff
* Continued contact between mother and child in the late neonatal period.
 
Our data indicate that the continued contact between mother and child in the neonatal period (7th-28th day) is important for the child's health. We see less infections and better immunological defence barrier in the groups with continued contacts between mother and child compared with groups of children without continued contact with their mothers (Levin 1991).
 
In order to ensure optimal development of the infant and mother, it is necessary to maintain the integrity of the biological umbilicus throughout the first month of life as a minimum. The child is born to this world comparatively sterile. Nature has created a special biological incubator, the optimum use of which guarantees that the environment of the child is favourable.
 
The biological umbilicus plays an important role in moulding the biological health of the child. After delivery the influence of the psychological umbilicus continues. The psychological umbilicus represents the social and emotional bond between the mother and the baby.
 
Continuous mother-and-child contact has a positive influence on the child's psychological development, and, what is even more important, we have got to regard mother and child bonding as a closed psychosomatic system where the child's psychosomatic condition depends on the mother's psychological state and vice versa.
 
I think that breastfeeding problems for sick and newborn and premature children can be resolved better when we have continuous (24 h) contact between mother and child in hospital. This has also been proved by the WHO and UNICEF. In the conclusions and recommendations of the workshop, "Lactation Management and the Baby-friendly Hospidal Initiative" (BFHI) organised by the WHO and UNICEF in collaboration with Wellstart International and World Alliance on Breastfeeding Action (St. Petersburg, 25-28 August, 1993), it has been noted that feeding breast milt is possible for low birth weight infants as well as sick children and is in the best health interents of these babies. The BFHI should therefore be implemented in children's hospitals as well as maternity units.
 
On the basis of these principles and our own experience we have worked out 13 steps for neonatal units. The Baby-friendly Hospital Initiative in neonatal units must include many more principles than only breast-feeding (Levin 1994, Harrison & Marshall 1994), as follows:
 
1. Develop a neonatal unit where the mother can stay with her sick baby 24 h a day.
2. Every staff member should develop an increased knowledge of the care of mother and infant, including the psychology of both members of the dyad.
3. The staff should be organised to teach breastfeeding techniques to every mother and to encourage its use.
4. Decrease the psychological stress of the mother during her adaptation, following her admission to the unit.
5. Instruct mothers in nursing and teach them how to hand express breastmilk, if the baby is on tube-feeding.
6. Unless medically indicated, newborns are to be given no liquid other than breastmilk.
7. Attempt breastfeeding on demand with certain guidelines, tube-feed the breastmilk if necessary.
8. Give up offering soothers and teats to breastfed babies.
9. Reduce to the minimum the number of tests and examinations.
10. Use as much as possible mother-and-child skin-to-skin and air-to-air contact, reduce the use of technical equipment in child care (incubators, etc).
11. Bring the use of aggressive therapy to the minimum, with more attention to its improvement (antibacterial and infusion therapy).
12. Consider the mother and the infant as a closed psychosomatic system. Everyday rounds should focus not only on the infant but also the needs the mother (include a gynaccologist and other specialists).
13. Allow healthy family members (father, grandparents or helpers) to visit the mother and baby during their prolonged stay at the hospital.
 
When we use these 13 principles it is not necessary to have so many medical staff in the hospital. To use mother as one of the important humanistic factors is cheaper than having a large medical staff and using modern, very expensive medical equipment.
 
I believe that for the mothers to be in a hospital with the child at all times is very hard. Maybe the mother has problems with another child at home for example. But in this critical situation the number one person in this family is the sick child.
 
In these countries (in almost all new East-Europe) where the family cannot trust medicine, this problem is decided more easily and mothers try much more of the time to be with their sick children. Also it is true that in every individual case the family decides the problem for themselves in the best way. The best is when the child is not in hospital for a long time, and when it is possible to continue the treatment at home.
 
For all new countries it is important to know what is the basic equipment. I agree with the colleagues of mine who try to make minimum use of respirators, replacing them whenever it is possible. To my mind, the incubator is a prison and it is extremely difficult for any person to be in it. What would adult patients say if they were placed in one for a prolonged period of time? In this respect, a great step forward has been taken by Swedish neonatalogists who have successfully used heated water mattresses (Tunell 1988).
 
Of course, this does not mean that there is no need whatsoever for respirators and incubators, but they should be used only when medically indicated. Last but not least, the child's continued contact with apparatus can endanger the development of the biological defence barrier.
 
I am sure that the problem with basic equipment for East European countries Neonatal Departments is larger and will need special discussion in future. But it is essential that hospital and neonatal units become baby-friendly now.
 
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