Strengthening Newborn Intensive Care

STRENGTHENING NEWBORN INTENSIVE CARE

In recent decades considerable advances have been made in strengthening perinatal care by focusing on evidence-based obstetric practices together with a family-centred approach. Evidence-based knowledge has provided striking and much-needed technological improvement in maternal and newborn care, but the application of a family-centred approach, particularly when complications develop in pregnancy and childbirth, has been deficient.Family-centred care is based on recognition of human rights in perinatal care.While maternal rights have been increasingly recognised – through, for example, the emerging emphasis on the importance of non-coerced and unbiased informed choice and consent by mothers – the recognition of neonatal rights has lagged far behind.While rooming-in and close maternal newborn contact for normal term babies was initiated as early as 1982, (1) and has becomean increasingly accepted maternal right worldwide, at least for normal term babies, such practices are still rarely found in neonatal intensive care units globally.This letter is a sincere and urgent appeal to the United Nations and other global, professional agencies to raise awareness of, and to address, this gap in human rights, and family-centred care,in neonatal intensive care centers.

For decades, high-tech neonatal intensive care units havenot given sufficient attention tothe human rights of newborns.In most centers,attention has been paid primarily to the physical aspect of a baby’s health, neglecting the equally important emotional and social health necessary for development of a whole human being.At such a time they are psychologically vulnerable.Close contact with their infant and participation in decisions about their baby’s care is every new family’s right, yetthey are excluded from the NICU environment for some, if notfor much of the postnatal hospitalization period.Caregivers may avoid working in an open, participatory manner that allows and encourages mothers and familiesto see and hear everything that happensto her or their child. Open disclosure and collaboration requires that caregivers explain to parentsthe need for tests and treatments for their infant, often resulting in the reduction of unnecessary tests (2). The former Soviet Union provides a striking case study of an approachthat isolates the parents from the infant’s care. This system is still in place in many of its health care centres.The Soviet system never allowed mothers to see their babies in the NICUs by order of the Moscow Health Minister.Postpartum mothers were considered to pose a threat of infection to their children. The ideology of the Western world and the totalitarian power of physicians in neonatal departments created the myth that they were ‘almighty’and could treat children without the presence – or permission - of the mother (family). Mothers of infants in NICUsin the Soviet Unionwere expected to play the so-called ‘guest-mother’role to be able to see their children, often only once a week, with fathers being totally prohibited from visiting.While this approach is, perhaps extreme, it is by no means unique to the former Soviet Union countries.

Two alternative, but to some extent complimentary, approaches to maternal and newborn care have emerged over the past few decades, one in the West and the other in a former Soviet country – Estonia. The Baby Friendly Hospital Initiative(BFHI) was developed in the West in the 1990s and was introduced into the former Soviet Unionand other countries at about this time, firmly establishing the importance, and practice of breastfeeding newborns, particularly normal, term infants. Strongly supported by United Nations agencies such as WHO and UNICEF, this program went far in creating awareness of optimal feeding methods and the importance of maternal-newborn contact and closeness from birth onwards.It was not, however, directly addressed towards the newborn requiring intensive care.In addition, its focus was on the importance of breastfeeding, rather than on the inherent needs, and rights, of both the mother(family) and the newborn to have psychologically sensitive and supportive care in addition to good clinical practice. Both the BFHI’s lack of attention to the NICU setting as well as its neglect of the rights of parents and newborns to sensitive and supportive comprehensive obstetric and postpartum care were clearly voiced by Chalmers in the British Journal of Obstetrics and Gynaecology in 2004 (3) .

In contrast, in 1979, a decade prior to the development of the Baby Friendly Hospital Initiative in the West, a more comprehensive approach to neonatal intensive care wasintroduced intoEstonia by Dr Adik Levin, a neonatologist at the Tallinn Children’s Hospital. This approach – the Family Centred Neonatal Care Initiative (formerly called the Humane Neonatal Care Initiative) emphasised both the importance of breastfeeding babies in NICUs as well as the crucial role played by mothers and fathers in providing love and continuous, close physical contact with their sick and preterm newborns from the earliest possible moments after birth. (4-13). Parental involvement in the physical care of their premature and/or sick infant was also essential in providing adequate technical care – prompted by a shortage of nursing staff at the time.It is well acknowledged that when normal term babies are unwell, their mother’s (and father’s) love and close contact provide much needed (and clinically beneficial) emotional and psychological support for both the infant and its parents. Yet this need in preterm and sick newborns has been regarded as of minimal or no importance in contrast to the overarching importance of high-tech, impersonal, medical care provided in isolated incubators or NICUs away from parental interference and controlled by autonomous health care professionals.In addition to providing emotional support for their newborns, encouraging mothers and fathers to play an active and close participatory role in the NICU setting also contributes to more careful and measured clinical care from caregivers who are held accountable to the parents.Such sentiments are endorsed by the Pucon Declaration regarding the ‘Humane Neonatal Care Initiative’ (attached) .

In recent decades, evidence-based practice in obstetric and neonatal care has been clearly acknowledged globally and increasingly frequently introduced.At the same time there has been growing awareness that psychosocially sensitive and family centred care during pregnancy and at labour and birth, are also crucial to providing a psychologically healthy start to the new family.Again, these developments have largely but not exclusively – been applied to the normal pregnancy. Today, it is incomprehensible to believe that ‘good’ (and satisfying) parenting experiences and practice – including the challenging task of caring for a sick and preterm newborn -could be conceived of occurring without tremendous emotional and practical support for such parents, both at the time of birth and in the following postnatal period.With the rise of preterm obstetric intervention (particularly induction), increased use of assisted reproductive technologies, as well as the increasing rate of birth among older mothers – all of which are contributing to an increased number of newborns being admitted to NICUs - the importance of providing psychologically supportive care during pregnancy, at birth and especially when their infants are admitted to NICUs,is becoming increasingly crucial.

While the UNICEF/ WHOBabyFriendlyHospital Initiative was eagerly supported for a decade or so following its introduction in the early 1990s,(14) financial and organizational support from these UN Agencies has been largely withdrawn in recent years.Sadly this support was lost before the movement could be clearly extended into NICUs or to encouraging psychologically supportive obstetric and neonatal care that respected human rights of the newborn and mother or family.In recent years an Oslo based group has drawn attention to the need to apply thebreastfeeding principles incorporated in the Baby Friendly HospitalInitiative into the NICU setting.(15)While this movement to enhance the use of human milk in the NICUis to be admired, it again relegates the importance of acknowledging the human rights and psychological needs of sick and preterm newborns, to a secondary role.It falls short of taking a necessary and comprehensive approach to providing optimal care for babies admitted to NICUs – one that ideally incorporates rooming-in of mothers with their babies 24/7, breastfeeding and/or breastmilk for neonates, and maternal or family care of the baby in conjunction with professional medical attention. This program requires a clear recognition of the human rights and psychological needs of both parents and their sick and preterm newborns.The Oslo development threatens to repeat this error of omission by focussing primarilyon the breastfeeding of newborns in NICUs without fully considering and developing a program that incorporates the psychological needs as well as the human rights of newborns and their parents in this environment.This letter serves as an urgent request to consider the matter in its full context and not to, yet again, provide an incomplete approach, as proposed by the Oslo initiative,to resolving this issue.

The name ‘Baby Friendly Hospital Initiative’ has, in reality, been largely misleading. It is, in essence and as originally conceived, a Breastfeeding Friendly Hospital Initiative.To be truly ‘Baby Friendly’, hospitals need to incorporate both breastfeeding support as well as ‘friendly’ or emotionally and psychosocially supportive obstetric and neonatal care, which is respectful of the human rights of babies and their parents.We appeal to you to truly live up to the full potential of the name “Baby Friendly Hospital Initiative’ in future developments.It is our sincere hope and wish that the Committee for the Rights of the Child (CRC), the headquarters of the WHOin Geneva, and such regional offices as Copenhagen and New York, as well as the headquarters of UNICEFin Geneva and New York, at least, will heed our appeal to take urgent action to meet the rights and needs of newborns and their parents in NICU settings in the most comprehensive and appropriate manner.

The signatories to this letter call upon you to discuss the problem of how to protect both the rights of children (newborn and premature) and mothers (families) in hospitals/ maternity hospitals as well as to draw up an internationally accepted relevant program /document. The professionals who have signed this letter are all staunch supporters of breastfeeding,having contributed to strengthening breastfeeding of all newborns, but also stand for the human rights of both children and mothers (families) as a priority.We pledge our support and assistance in developing such a comprehensive program.

Signatories:

Dr Adik Levin MD, Ph.D, MSc.D.FABM.

Head of Neonatal and Infant Department 1979-2004, Tallinn Children’s Hospital

Candidate UN CRC from Estonia 2004-2005

Tallinn, Estonia

Dr Beverley Chalmers (DSc(Med); PhD)

Adj Full Prof, Dept Obstetrics and Gynaecology

Affiliate Investigator, OttawaHospital Research Unit

University of Ottawa

Ottawa, Canada

Mary Renfrew

Professor of Mother and Infant Health

Mother and Infant Research Unit

School of Nursing and Midwifery

Director, Applied Health Research

College of Medicine, Dentistry, and Nursing

University of Dundee

11 Airlie Place

Dundee DD1 4HJ

UK

Michael S. Kramer, MD

Professor,

Departments of Pediatrics and of Epidemiology, Biostatistics and Occupational Health,

McGillUniversity,

Faculty of Medicine

Montreal, Canada

Janusz Kaczorowski PhD
Professor and Research Director
Holder of the Docteur Sadok BesrourEndowed Chair in Family Medicine
Holder of the GSK-CIHR (GlaxoSmithKline-Canadian Institutes of Health Research)Endowed Chair in Optimal Management ofChronic Disease
Department of Family and EmergencyMedicine
University of Montreal
University of Montreal Hospital ResearchCentre (CRCHUM)
Head: Health Care Systems and Services, Hôtel-Dieu

Fernando Pinto (MD)

Pediatrician

Child Neurologist

Full Professor of the University of Chile

Past-Director of the "Paediatric, Infant Surgery and Child Neurology Department of the University of Chile" ,reelected during 3 periods ( 12 years ).

Past-¨President of the Chilean Pediatric Society.

Past Director of the Chilean Society of Pediatric Neurology

Past Vice¨President of the Chilean Society of Ultrasound in Medicine.

Head of Pediatric Department In CoyhaiqueHospital.

GJ Hofmeyr

Effective Care Research Unit,

University of the Witwatersrand/FortHare;

Eastern Cape Department of Health.

South Africa

Dr Nanette Jolly MB BCh IBCLC

Port Elizabeth

South AfricaNan Jolly

Nora Klein

Associate Clinical Professor, Pediatrics

BaylorCollege of Medicine, Houston, Texas

Fellow of AmericanAcademy of Pediatrics: breastfeeding Section

Fellow of the Academy of Breastfeeding Medicine

Member, Texas Pediatric and Houston Medical Societies

Matias Viera (MD)

Paediatrician

Past Prsident Punta Arenaas Pediatric Society,Subsidiary of Sociedad Chilena de Pediatria

Former Head Pediatric Dept, Hospital Arenas Punta Arenas, Chile

Professor Elza Akhmadeeva, MD, PhD
Chair of the department of Pediatrics
at BashkirState medical University
Chair of the Bashkir branch of Russian Association of Specialists in Perinatal Medicine
Professor Leila Akhmadeeva, MD, PhD, MBA, JD
Professor at the department of Neurology, Neurosurgery and Medical genetics
Chair of International Office
at BashkirState medical University
Chair of the Bashkir branch of Ineterregional Society of Specilists in Evidence Based Medicine

Sallie Page-Goertz, MN APRN, IBCLC, FILCA

Clinical Associate Professor of Pediatrics

KanasUniversitySchool of Medicine

Audrey Naylor. MD, DrPH, FAAP, FABM

President and CEO

Wellstart International

and

Clinical Professor of Pediatrics

University of VermontCollege of Medicine

Concepción de Alba, PhD MD

Assistant Physician in the Department of Neonatology, Hospital 12 de octubre, Madrid, Spain

Professional in NIDCAP

Professor in Paediatrics UCM

IBCLC

ASYA S. MU'MIN
CPT, MD, MC, US ARMY
Tripler ArmyMedicalCenter
Honolulu, Hawai'i

Nadia Badrawi

Chair of the Board

NileBadrawiHospital

Prof.of Pediatrics & Neonatology

CairoUniversity

Kathy Leeper, MD, IBCLC, FABM

Medical Director, Milkworks- a nonprofit breastfeeding center

5930 South 58th St, Suite W Lincoln, NE68516

USA

Mariana Colmenares. MD, Pediatrician, IBCLC.

Hospital Médica Sur Tlalpan

México City

Patrice DeMarco

Motherbaby Unit

Fletcher Allen Health Care

111 Colchester Avenue

Burlington, Vermont05445

Lydia Furman MD FAAP

Associate Professor of Pediatrics

Rainbow Babies and Children's Hospital

References:

1. Klaus HM, Kennel JH. Parent-infant bonding. 2nd ed. St Louis: CV Mosby, 1982

1. 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.

1. Chalmers, B.The BabyFriendlyHospital Initiative:Where Next?British Journal of Obstetrics and Gynaecology, 2004, 111(3), 198-199.

1. Levin A. The Mother-Infant Unit at Tallinn Children’s Hospital, Estonia: A.Truly Baby-FriendlyUnit.Birth 1994;21: 39-44.

1. Harrison L and.Klaus M, Commentary: A Lesson from Eastern Europe“ Birth 21:1 March 1994;45-6.

1. Levin A., von Mühlendahl KEFamilienfreundlichkeit von Kinderkrankenhäusern in Estland und Deutschland.Internationale Sozialpädiatrie 1994;16(7): 430-431.

1. Levin A. Humane Neonatal Care Initiative. Viewpoint. Acta Paediatrica 1999; 88: 353-355.

1. Kennell JH . The Humane Neonatal Care Initiative Acta Pædiatrica 1999; 88: 367 -370.

1. Chalmers B, Levin A. Humane Perinatal Care. TEA Publishers, Tallinn, 2000.

1. Medical-Psychological Work with Mothers in Neonatal Unit.VI Jornada Chileno - Argentina de Pediatria: Cuidados Humanos en la Pediatria del III Mileno. Coyhaique, Chile.17-19.April 2000.

1. Tecnicas de Humanizacion en el Manejo del Prematuro. XLI Congreso Chileno de Pediatria. Pucon (Chile) 28 de Noviembre al 1 de Deciembre 2001. Pucon Declaration28.11.2001 Pucon Chile.

1. Levin.ALetter to EditorAre NICUs Baby-Friendly or Breastfeeding-Friendly?Birth,2013; 40(2) 152-153.

1. O’Brien K, Bracht M, MacDonnell K, McBride T, Robson K, O’Leary L, Christie K,Galarza M, Dicky T, Levin A, Lee SK.A pilot cohort analytic study of Family Integrated Care in a Canadian neonatal intensive care unit.BMCPregnancy and Childbirth2013,13(Suppl 1):S12doi:10.1186/1471-2393-13-S1-S12.

1. Wolf H, Charrondiere R, Helsing E. First "baby-friendly" hospital in Europe. Lancet 1993, 341: 440.

1. The BFHI Initiative in Neonatal Units. Proposal from a Nordic and Quebec working group. Three guiding principles and ten steps supporting Breastfeeding and Family/centered care. Draft for the 1st International conference and workshop on the expansion of the Baby Friendly Hospital Initiative in Neonatal Units. 14th-16th September 2011 in Uppsala, Sweden

PUCON DECLARATION
XLIChilean Paediatric Congress. Pueõn, Chile, November 28, 2001

The Chilean Society of Paediatrics is committed to promote the

"HUMANIZATIONOFPERINATALPAEDIATRICS".

This commitment means to put emphasis on maternaI involvement in the care of the

newborn and preterm infant as well as on the protection of the rights to be breastfed,

to develop a sound mother-child bonding and to get a good care in every

circumstance, including the hospitalization in intensive care units.

This Society wishes to acknowledge the extreme value and positive consequences ofthe" Baby Friendly Hospitals" initiative and states its recognition to PAHO/WHO,

UNICEF and other international organizations working to spread these ideas which

have beenplanted inour and other countries.

Our commitment goes beyond the protection of breastfeeding for a minimun of six

months and extends to maternaI involvement and inclusion of the mother as an active-notpassive- protagonist of child care ideally with the longest possible contact withher ehiId, namely during the 24 hours of the day.

Furthermore, points to the highest rationalization of laboratory tests and treatments todiminish or eliminate physical and psychological pain and to support skin contact

between mother and ehiId.

In accordance with these statements during the XLI Chilean Paediatric Congress in

Pucon, Chile, this society and all its members, in the presence of Professor Adik

Levin subscribe and endorse the 11 points of the Tallin Hospital, Estonia,

methodology: "The Humane Neonatal Care Initiative" aimed to the humanization of

newborn care.

To accomplish this goal our institution invites all the Paediatric Societies of the

world to subscribe to this declaration and asks for support from all the international

organizations working for the health, well being and rights of Man and Child.