What future Course do You Take, Neonatal Medicine?

Adik Levin

The wonderful results that are being achieved nowadays in rendering help to ill newborns and infants of low birth weight (ILB) appear to be of great significance. In many developed countries, good results have been achived in caring for infants between 500 and 700 grams and for those of 1000 grams and above. Included in the good results are care for sick full-term infants at high risk. A question arises, however, as to the quality of the life of a child who weights less than 700 grams at birth. It is well known that, in most cases, rearing and maintaining such children becomes a heavy burden for both the family and the State. This article, however, will not address this subject, as it needs additional research before conclusive results can be published.

As a doctor who has worked for more than 20 years in the former Soviet public health system and who is now trying to integrate himself into a system of national neonatology that is generally accepted in the developed world, I may have some opinions of interest to the reader. I should mention that for many years I worked with full-term newborn infants and ILB in an organization that was not typical of the Soviet public health system. As far back as 1985, we were allowed to develop new systems (discussed later in this paper) by obtaining a special decree from the Ministry of Public Health. In those years, our system was known in almost all regions of the former Soviet Union and used to the extent allowed by local conditions.

During the last five years, I have had an opportunity to acquiant myself with neonatal nurseries in many of the advanced countries of the world and have been very much impressed by the high professionalism, excellent equipment, and rich material bases of these medical institutions. Side by side with technical achievements in the maternity hospitals are humane attitudes towards infants. As an example, often the infant is roomed with the mother and breastfed, a valuable idea that was introduced during the last 20-25 years by Klaus and Kennel. (In my view, they should become candidates for the Nobel Prize.)

The contrast between the humane enviroment for the newborns in a maternity hospital and the atmosphere for an infant born prematurely, or ill, and cared for in the neonatal department of the same hospital, seems both interesting and paradoxial. In the maternity hospital, the infant is protected by his mother, is breastfed, and is in minimal contact with the constantly changing medical staff. On being transferred to a neonatal department, the infant is immediately separated from his mother and left to the devices of high-technology equipment and welltrained nurses. At this point, a question arises: Can this situation be considered optimal for the newborn infant?

In the area of highly developed neonatal medicine, the infant’s mother is regarded as Priority No. 1. Her biological program fulfilled (i.e., the birth of the infant), she is given the opportunity to leave the hospital and attend to situations at home – other children, her husband, etc. One of the reasons for non-hospitalization of the mother in the neonatal department is the expense involved. It should be noted, however, that the expensive equipment (Priority No. 2) which “substitutes”, as it were, for the mother costs far more than that which would be incurred for her accomodation.

It needs to be mentioned also that the mother, as well as other family members, are allowed to visit the infant, as a rule, during daylight hours. However, visiting the infant depends not only on the mother’s and family’s wishes, but on the convenience for the medical staff of the hospital as well. Thus, the infant is completely taken over by the medical personnel. The companies that produce breast milk substitutes are also interested in the distribution of the roles, together with medical needs. It is not all that rare to see these companies financing pseudo-scientific research that tries to show an advantage of breast milk substitutes over breast milk for these prematurely born infants.

The firms that produce sophisticated electronic equipment that contributes to neonatal medicine and allows infant care without mother’s involvement also are interested in such distribution of roles. Thus conditions are created, however paradoxical, for priority no. 3 to be the infant who is either alone in the incubator or left without many natural factors, owing to the mother’s absence.

It is interesting to note that in the pediatric department of these same hospitals, mothers often are roomed with their infants – something that clearly requires special rooms for both the mother and her infant. For some reason the question of her other children and her husband is not considered.

Developments in neonatal medicine may be termed highly technical; furthermore, such technology makes neonatal medicine in many of the advanced countries one of the most expensive branches of medical care. My opponents may argue that in many hospitals, infants are fed either with mother’s breast milk (delivered daily) or by production of milk banks. Quite frankly, although this may be termed an attempt to humanize the highly technological neonatal ward, I feel such efforts barely qualify as “humanistic”. Giving breast milk to an infant is not the same as having him breastfeed. The advantage of the latter over the former is absolutely indisputable.

Speaking of high technology, one should mention that quite often neonatal medicine becomes aggressive. My colleagues abroad often show me computer data of the dynamics of daily blood analysis. They regard it as a great scientific advantage. But I have never heard any good answer to my question of whether or not it is necessary to take so many analyses from the infant – something that often causes laboratory anemia. I believe the infant could give the best answer to this question. One must recognize that the infant (having been in a high-technology environment, with all the facilities it grants) has been through the first difficult “lifestage” overwhelmed by stress.

No one needs to remind us that the infant needs tender loving care. The infant hears, sees, feels and percieves as far as he can, and asks us to give him those things prescribed by nature. He feels pain and fear while being lost among all the machinery and equipment. He needs to have only as many tests as is expedient at the moment, and only as much medicine as appropriate – no more.

One should address another way to make neonatal medicine more humanistic – by making the infant Priority No. 1. Our research has shown that the contact between mother and child is of importance, not only during the first hours and days in the maternity hospital, but later on as well – during the first and second months of the child’s life.

After the physical separation of the infant from his mother, a few invisible but very powerful forces begin to work in th maternity hospital – something we call “biological and psychological navel-strings.” Research has shown that the infant starting his “second life” outside the womb is practically sterile. We have also shown that the longer the infant has contact with his mother during the first one to two months of life, the more he gets protective factors through her milk, the air she exhales and her skin excretions. In contrast, the infant who is exposed to constantly changing medical personnel (who “break” the biological incubator created by nature) doas not have the immunological protection afforded by the infant who spends 24 hours a day with his mother until he has recovered. That is why the mother should be Priority No. 2. and the hospital should create all necessary conditions for her to stay with her infant 24 hours a day. The essence of our conception is that such contact is not only desirable but is of vital importance for the child as well. It is at this stage that medicine is left to become Priority No. 3.

The humanistic direction of neonatal medicine we developed has been in practice in Tallinn (Estonia) during the last 15 years. At the end of 1994, 80 to 85 percent of our premature infants in the hospital were fed not only with breast milk, but breastfed. When necessary, this process was conducted with a gradual passage from catheter feeding to breastfeeding, with strict consideration of the infant’s condition and needs.

There are, of course, descriptions of similar experiences in some countries (e.g. Argentina, Sweden), but unfortunately this humanistic approach to neonatal medicine has diminished somewhat. Opponents point out the negative experiment of Marina Markovitch of Austria, who has completely given up all application of technical procedures. I believe her work to be extreme and not an acceptable way for neonatal to develop, under present circumstances. One must, however, acknowledge that she obtained good results, and her brave challenges to highly developed neonatal medicine are worthy of deep respect and recognition.

We suggest an intermediate approach to the development of neonatal medicine, where components of both trends would be taken into consideration and used positively. There is no doubt that humanistic principles should become the foundation of developments in neonatal medicine. Modern technical achievements should be sensibly applied to the mother and child dyad. Such symbioses would allow a reasonable use of the principles of and conformity to natural laws (i.e. to make the environment for an ill or premature newborn infant more natural). Companies should be involved in producing new equipment and technological means that would serve not as a substitute for the maternal factor, but quite the opposite – as a means to provide the infant with all the positive factors inherent in the biological and psychological “navel-strings”.

The World Health Organization and UNICEF launched a movement known as the Baby Friendly Hospital Initiative (BFHI). As a result, large numbers of maternity hospitals use the ten stages outlined in the initiative. It is noteworthy that this trend is promoted only for healthy children – that is, for maternity hospitals.

In this appeal as Executive Director of UNICEF, [the late] James Grant stated that the principles of BFHI should apply to developed as well as developing countries. He obviously did not intend for this initiative to exclude (as of today) seven to ten percent of all live births – those infants who are born ill or premature.

What I observed in one of the maternity hospitals in an eastern European country – upon which had been conferred the title of Baby Friendly Hospital – confirms my words. This hospital complied entirely with the requirements of the BFHI; however, premature infants in the hospital’s neonatal department are almost completely deprived of maternal milk. The sight of their tied hands in the incubators reminded one rather of a prison than a clinic. I am convinced that during the process of attachment in his “second life”, an infant needs to be with his mother and to receive her milk.

Medical reorientation in developed countries to produce a more humanistic course for neonatal medicine is very complicated. The process would include a reappraisal of present principles – a process that would be long and painful. Developing countries appear to have an easier course, as they are given an historical chance to create a reasonable public health care system, one that starts with the needs of Priority No. 1 – the baby.

It is possible in this article to dwell on all the problems of modern neonatal medicine, but an attempt has been made to focus on the course that needs to be taken, including perfection of neonatal medicine’s achievements. It would be expedient to create a movement for a humanistic approach to neonatology and medicine, in general, and we hope to find organizations or funds to help us create an exemplary model – one that would guide us in the future.