How Intensive Is Newborn Intensive Care? An Environmental Analysis

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292 PEDIATRICS

Vol. 74 No. 2 August1984

in a footnote to the paper by Lildholdt7:

“Ade-noidectomy has been shown not to influence the

course of otitis media. An equally valid conclusion is that secretory otitis media is a self limiting dis-ease, which is not affected by any of the current methods of treatment.”

Could it be that 1 million children each year have unnecessary surgical procedures involving the tym-panic membrane? Has the availability of third-panty payments fostered the spreading use of these procedures? Is this another reason for the rising

cost of medical cane?

Anyway, for a child with secretory otitis, the best help at this time seems to be a prescription called “tincture of time,” fortified by the realization that many of us in practice today had fluid in our ears when we were children. Did it really cause a degree of retardation? If not, let us declare a moratorium on tube placements until solid data supporting the procedure have been reported.

REFERENCES

GUNNAR B. STICKLER, MD

Department of Pediatrics Mayo Clinic and Mayo

Foundation

Rochester, Minnesota

1. Resnick RH, Iber FL, Ishihara AM, et al: A controlled study of the therapeutic portocaval shunt. Gastroenterology

1974;67:843-857

2. Coronary Artery Surgery Study (CASS): A randomized trial of coronary artery bypass surgery: Survival data. Circulation

1983;68:939-950

3. Smeiiie J, Edwards D, Hunter N, et al: Vesico-ureteric reflux and renal scarring. Kidney

mt

1975;4:S65-572

4. Stickler GB, Brownlee RC Jr: Serous or secretory otitis: Some reflections. Clin Pediatr 1972;11:556-557

5. Kilby D, Richards SH, Hart G: Grommets and glue ears: Two-year results. J Laryngol Otol 1972;86:881-888

6. Brown MJKM, Richards SH, Ambegaokar AG: Grommets

and glue ear: A five-year followup of a controlled trial. J R

Soc Med 1978;71:353-356

7. Lildholdt T: Unilateral grommet insertion and adenoidec-tomy in bilateral secretory otitis media: Preliminary report of the results in 91 children. Clin Otolaryngol 1979;4:87-93

8. Fiellau-Nikolajsen M, H#{248}jsletP-E, Felding JU: Adenoidec-tomy for eustachian tube dysfunction: Long-term results from a randomized controlled trial. Acta Otolaryngol

1982;386:129-131

How Intensive

Is Newborn

Intensive

Care?

An Environmental

Analysis

Each year, approximately 200,000 to 250,000 newborn infants in the United States require

inten-sive care. The length of hospitalization for the

premature newborn usually ranges from 15 to 50

days and occasionally longer.’ Although follow-up studies have shown normal development in most of these infants, evidence continues to indicate

sen-sony and cognitive deficits in very small premature newborns. It has been suggested that contemporary

management of newborns receiving intensive cane

may be responsible for newly recognized iatrogenic complications and may contribute to developmental

deficits associated with pnematunity.25 Both

clini-cians and researchers have begun to question the potential adverse medical and developmental

con-sequences of environmental stimulation for

new-borns in special care units.6 Various

conceptuali-zations have been advanced that these units are:

(1) sensonily depriving, (2) excessively stimulating, or (3) providing dissociated patterns of stimulation.

We have recently completed two studies investi-gating the quantity, quality, organization, and

rhythmicity of stimulation in a tertiary bevel

facil-ity. Systematic observations were conducted in both the newborn intensive care unit (NICU) and new-born convalescent care unit (NCCU) at Women’s Hospital of Los Angeles County-University of

Southern California Medical Center. (Except where

indicated, the findings refer to the environment of

both the NICU and NCCU.) The first study was based on a time sampling analysis of the physical

and social stimulation presented to newborns across three days.7 The second study involved a detailed continuous analysis across two days of the

contacts between a sample of premature newborns and their cane givers.8

Results pertaining to physical stimulation

showed that newborns were not sensonily deprived, but received large amounts of ongoing stimulation.

Newborns were continuously exposed to cool-white

fluorescent lighting with illumination not varying

across day and night. Recording of the acoustic

environment indicated high sound levels. Mean

characteristic sound levels were in the range of 70 to 80 dB (linear). For extended periods, sound levels

Reprint requests to (A.W.G.) Department of Psychology, Cali-fornia State University, Fullerton, CA 92634.

American Academy of Pediatrics.

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COMMENTARIES 293

were potentially hazardous with upper levels reach-ing 118 dB (linear). These noise levels are

compa-rable to automobile traffic and at times the noise reached levels of large machinery. Nonspeech sounds were heard on all observations, and speech

and radio sounds were heard on the majority. Re-condings of bight and sound were also conducted within incubators. These data were virtually

iden-tical with that of the units proper. The continuous white noise emanating from the incubator itself, as webb as nonspeech sounds from the unit, were picked up on all tape recordings. Speech sounds were also identifiable, but they were muffled and indistinct. Hence, newborns in incubators were not sheltered

from the incessantly noisy environment.

A frequency analysis of the sound spectra (31.5 to 32,000 Hz) taken in the units and incubators indicated that the acoustic energy was distributed

in the lower frequencies. The acoustic environment of newborn special cane units is characterized as

high intensities at low frequencies. Analyses were conducted to determine whether there was a sys-tematic pattern to the stimulation across days.

Re-sults showed no significant diurnal pattern on any

of the variables.

The data also revealed that newborns have ex-tensive contact with care givers. However, almost all contacts were with staff members. In spite of an open visiting policy, a minimal percentage of con-tacts involved family members. The average fre-quency of daily contacts ranged from 40 to 70 with some newborns receiving as many as 100 contacts.

Virtually all contacts involved medical-nursing care

with some form of handling. Contacts were brief (two to five minutes in duration) and occurred on

the average of every 18 to 30 minutes. In a given day, newborns received a total of 2.5 to 3.5 hours

of contact with care givers. Analysis by hour and work shift showed no systematic variability across days in the distribution of contacts.

In contrast to the high magnitude of visual,

au-ditony, and tactile stimulation, newborns received infrequent social experiences. Despite the fact that newborns were in contact with persons, they seldom received social types of stimulation. The prepon-derance of contacts between care givers and new-borns may be appropriately described as nonsocial. There were several sources of evidence that support this point.

First, contacts almost exclusively were oriented

toward medical-nursing activities and were seldom oriented toward social events. If social stimulation occurred, it was embedded within routine care. Ap-proaching an infant for the sole aim of providing social stimulation was a rare event. Second, al-though the social climate was greater in the NCCU

than NICU, the large majority of contacts with newborns in both units were devoid of social events. Social touching, rocking, or talking to newborns, all of which have been noted to have particular developmental significance, occurred during less than one third of the contacts. Not rocking new-borns in the NICU was expected. However, rocking hardly occurred in the NCCU either, despite

exten-sive evidence indicating positive effects of

vestibu-lan-kinesthetic stimulation with medically stable newborns. Additionally, social activities occurred

primarily in incubators, even for those newborns stable enough to be removed. The sex of newborns made no difference in social contacts. However, male and female staff differed significantly in fre-quency of social responses displayed toward new-borns. Across all variables, women displayed a higher proportion of social behaviors. As found with visual, auditory, and tactile stimulation, the

occur-rence of social experiences also showed no diurnal

regularity across days. Third, in more than half the

instances when newborns cried during contacts, care givers did not attempt to soothe them. When soothing was applied, it was limited primarily to talking and seldom did it involve social touching on both modalities. A contingency analysis revealed that the sociability of care givers toward newborns

was highly related to the emergence of soothing behaviors. It was found that if cane givers verbally greeted newborns at the onset of contacts, and if newborns cried subsequently during contacts, then the probability of soothing crying newborns in-creased substantially from 15% to 85%. Fourth, the co-occurrence or integration of social sensory ex-peniences was not impressively high. It was not uncommon for newborns to be handled and not talked to, on for newborns to be positioned in such a way that they could not see care givers. In addition to social events not being coordinated, quite often social stimulation was given independent of the

newborns’ behavioral states. For example, in no

more than approximately half the situations when social events occurred, did the newborns have their eyes opened. These data indicated a lack of syn-chrony in the manner in which social stimulation was presented to the newborns. Fifth, as noted previously, although family members were encoun-aged to visit, family accounted for a negligible por-tion of contacts. As reported by others, mothers have been found to provide an important source of

stimulation to their newborns compared with

nuns-ing personnel.9 With respect to social stimulation, many newborns may indeed be sensonily deprived throughout their course of hospitalization in special cane units.

A final analysis addressed the relationship

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REFERENCES

1. Budetti P, Barrand N, McManus P, et al: The Implications

of Cost-effectiveness Analysis of Medical Technology: The

Costs and Effectiveness of Neonatology Interventions. Wash-ington, DC, Office of Technological Assessment, 1981 2. Lucey JF: Is intensive care becoming too intensive?

Pedi-atrics 1977;59 (suppl):1064-1065

3. Korones SB: Disturbance and infants rest, in Moore TD (ed): 69th Ross Conference on Pediatric Research: latrogenic Problems in Neonatal Intensive Care. Columbus, OH, Ross Laboratories, 1976, pp 94-96

4. Peabody JP, Lewis K: Consequences of newborn intensive care, in Gottfried AW, Gaiter JL (eds): Infant Stress Under

Intensive Care: Environmental Neonatology. Baltimore, Uni-versity Park Press, in press 1984

5. Cornell EH, Gottfried AW: Intervention with premature human infants. Child Dev 1976;47:32-39

6. Gottfried AW, Gaiter JL (eds): Infant Stress Under

Inten-sive Care: Environmental Neonatology. Baltimore, Univer-sity Park Press, in press 1984

7. Gottfried AW, Wallace-Lande P, Sherman-Brown 5, et al: Physical and social environment of newborn infants in special care units. Science 1981;214:637-675

8. Gottfried AW, Brown KW, Kazarian AM, et al: Study II

contacts between caregivers and infants: A diurnal microa-nalysis, in Gottfried AW, Gaiter JL (eds): Infant Stress Under Intensive Care: Environmental Neonatology. Balti-more, University Park Press, in press 1984

9. Minde K, Trehub 5, Corter C, et al: Mother-child relation-ships in the premature nursery: An observational study.

Pediatrics1978;61:373-379

10. Hodgman JE: Introduction, in Gottfried AW, Gaiter JL (eds): Infant Stress Under Intensive Care: Environmental

Neonatology. Baltimore, University Park Press, in press 1984

294 PEDIATRICS

Vol. 74 No. 2 August 1984

tween acute medical status and frequency of

medi-cal-nursing and social contacts. Rankings of

medi-cal status correlated highly (0.9) with frequency of medical nursing contacts in the NICU. As

antici-pated, newborns who were more ill received more medical-nursing contacts. In the NCCU, however, no correlation resulted between these variables. This lack of relationship was probably due to the fact that newborns in the NCCU were more medi-cally stable and received more routine types of care. The correlations between medical status and social contacts bore no reliable patterns, suggesting that social factors such as family, attachment, detach-ment, and/on attractiveness of individual newborns may play a significant role in the occurrence of social events.

The overall findings revealed that newborns in special cane units are exposed to a variety of stim-ulation. With regard to visual, auditory, and tactile stimulation, newborns are in no way deprived, but in fact, they are bombarded with physical stimula-tion. On the other hand, special care units are startling nonsocial environments for newborns. In addition, there is little or no organization and rhythmicity of physical and social stimulation built into the treatment plan of newborn special care.

Although the effects of environmental factors in special cane units on the medical and developmental status of premature newborns have not yet been firmly established, there is an emerging body of evidence indicating a relationship between these variables.4 There is no doubt that great strides have

been made in the medical-nursing cane of premature

newborns. However, the extent to which further progress could be accomplished by comprehensive environmental modifications aimed directly at new-borns is worthy of investigation. The history of newborn special cane has been characterized by

many environmental changes in the absence of an empirical foundation of knowledge. For example, there have been shifts in policy as to whether parents, and even physicians, should be permitted into units.’#{176} To facilitate progress in the area of neonatology, systematic efforts should be under-taken to examine the effects of environmental changes in special care units for infants born pre-maturely.

ALLEN W. GOTTFRIED, PHD

Department of Psychology

California State University

Fullerton

JOAN E. HODGMAN, MD

Department of Pediatrics Los Angeles County

University of Southern California

Medical Center

Los Angeles

KATHLEEN W. BROWN, MA

Department of Psychology University of California Los Angeles

Current

Outlook

for Children

Around

the World

The most tragic impact of the deep economic recession of the 1980s is falling on the 1.8 billion children less than 15 years of age who represent 40% ofthe 4.5 billion inhabitants ofthis earth. Two

fifths of the world population still lacks the comfort

of even minimally adequate housing and one third of the world’s work force is unemployed or under-employed.

The result is that 100 million children stay hun-gny every day. Most of the nutritional education programs of the World Health Organization have turned out to be useless in improving protein diet. Sixty percent of the mothers of malnourished

chib-dren are unaware of the fact that their children are

American Academy of Pediatrics.

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1984;74;292

Pediatrics

ALLEN W. GOTTFRIED, JOAN E. HODGMAN and KATHLEEN W. BROWN