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COMMENTARIES 501 2. Dietz WH, Gortmaker SL. Do we fatten our children at the television

set? Obesity and television viewing in children and adolescents.

Pedi-atrics. 1985;75:807-812

3. Pate RR, Ross JG. The national children and youth fitness study, II: factors associated with health-related fitness. I Phys Educ Recreation

Dance. 198758:93-95

4. Tucker LA. The relationship oftelevision viewing to physicalfitness and

obesity. Adolescence. 198621:797-806

5. Williams TM, Handford AG. Television and other leisure activities. In: Williams TM, ed. The Impact of Television: A Natural Experiment in Three Communities. Orlando, FL: Academic Press mc; 1988:143-213

6. Gerard J.TV networks want Neilsen to change rating methods. New York Times. December 14, 1989

7. Hammond EC, Horn D. Smoking and death rates-report on forty-four

months of follow-up of 187783 men, II: death rates by cause. JAMA. 1958;166:1294-1308

8. Fleiss JL. Statistical Methods forRates and Proportions. 2nd ed. New York, NY: John Wiley and Sons; 1981:60

9. Miettinen OS. Proportion of disease caused or prevented by a given exposure, trait or intervention. Am JEpidemiol. 197499:325-332

10. Gortmaker SL, Dietz WH, Cheung L Inactivity, diet and the fattening of America. IAm Diet Max. 199090:1247-1255

11. Dietz WH, Strasburger VC.Children, adolescents, and television. Curr Probl Pediatr. 1991;21:S-31

12.Dietz WH. Prevention of childhood obesity. Pediatr Clin North Am.

198633:823-834

Effects

of Technologic

and

Sociocultural

Changes

on the

Practice

of Neonatal

Medicine:

A

View

From

France

ABBREVIATIONS. MAP, medically assisted procreation; IVF, in

vitro fertilization; ECMO, extracorporeal membrane oxygenation.

When one considers the changes that have oc-curred in trends of perinatal mortality or the propor-tion of severe handicap in infants or adults in most Western countries in the past 20 years, there has been

a profound change in the prognosis for life and for

long-term sequelae after perinatal distress. The

tech-nical reasons for this extraordinary progress are

straightforward. But it is much more difficult to

Un-derstand the profound effects on the quality of the lives that have come into being as a result of these advances. Indeed, it is hard to assess the precise con-sequences directly related to the new technology as opposed to effects related to the long separation of mother and child after an abnormal birth and in pathologic states of the newborn. In this paper, Iwill

review the present status of these issues as seen from a French point of view. This outlook takes into

ac-count the principal technical advances that have re-sulted in the survival of increasingly immature and

seriously ifi neonates. It is based on improved means of assessing the neonate that have come about with a

better understanding of the perceptive capacities during fetal life, as well as the importance of cultural

Received for publication Aug 7, 1992; accepted Oct 20, 1992.

Reprint requests to (J.P.R) Professor of Paediatrics, Service de M#{233}decine

N#{233}onatale, Maternite Port-Royal, 123, Boulevard de Port-Royal, F-75014

Paris, France.

PEDIATRICS (ISSN 0031 4005). Copyright ©1993 by the American

Acad-emy of Pediatrics.

changes in developed countries that have been made possible by new techniques of procreation. Above all, the current view recognizes the increase in na-tional and personal wealth that has made it possible for parents to consider obtaining “a child at any

price . . .“-a child-object to be purchased like any

other desired possession. The last notion raises the question of restraints on the cost of perinatal medi-cine in particular, and medical care in general. What are the limiting factors in aggressive modern medi-cine, ever more technical, but ever less human?

ANALYSIS OF TECHNICAL PROGRESS

There can be little doubt that the most significant technical progress in neonatal medicine has occurred in the present era. There were very few changes be-tween 1900, when Pierre Budin’s manual on the care of premature newborns was published,’ and 1965 to

1970, when the first successful attempts were made

at artificial ventilation of sick neonates. Budin dem-onstrated that simple measures to keep small new-borns (weighing less than 2500 g) clean, warm, and fed with human milk reduced neonatal mortality from about 70% to 25%.’ Budin’s views on the im-portance of reducing heat loss and on the need for cleanliness to protect the neonate from the risk of nosocomial infections are still valid today.

Beginning in 1965, many neonatal teams in West-ern countries began to intubate and ventilate neo-nates with respiratory distress. Up to 1970, the

mor-tality

rate remained high in premature neonates

weighing less than 1200 g at birth. Between 1970 and 1980, the transformation from passive to intensive neonatal care was virtually complete at the Port-Royal center which was the first unit to routinely admit premature newborns with respiratory distress syndrome. Before 1970, about 80% of neonates

weighing less than 1200 g at birth died. In the next 10 years the numbers were reversed: after 1980, about 80% survived in good condition. This remarkable change came about as the result of considerable ad-vances in knowledge about fetal and neonatal phys-iology and because of the physical means made available to French obstetricians and pediatricians for the purpose of improving the condition of the fetus in utero and of the neonate after birth.

The period of rapid change, fascinating because of the large number of lives saved, was dominated, nev-ertheless, by the coldest aspects of technology and science. The fetus and the neonate were looked on and, indeed, were treated as marvelous experimental models that might confirm or refute the insights gained from extensive animal research. Nonetheless,

there is little doubt that the care of the newborn, and particularly of the premature newborn, has been greatly improved because of a deeper understanding of pulmonary and cardiovascular pathophysiology, increased effectiveness of artificial ventilation and the use of surfactants, and wider use of parenteral nutrient solutions to promote growth. Similarly, progress in understanding the wide range of physi-ologic handicaps of extremely premature infants has made it possible to use potent drugs much more safely and effectively than in the past.

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502 COMMENTARIES

In the decade from 1980 to 1990, improvements and long-term results were much less spectacular. Technical advances were also less striking. Increased knowledge concerning the perceptive functions of the fetus and, thereby, the premature newborn has made it possible to evaluate the effects of therapies in some, but not all, centers.

Research and Cultural Influences: Consideration of the Perceptive Capacities of the Fetus in the Practice of Pen-natal Medicine. Human beings, and more specifically pregnant women, have always been aware, instinc-tively, of the perceptive abilities of the human fetus. Ancient texts, particularly Sanskrit documents of the Hindu culture, confirm this impression. Marie-Claire Busnel2 has collected these sources on fetal and neo-natal sensory perception in a published work that summarizes all the recent scientific data and descrip-tions of traditional customs in various ethnic groups. Advances in embryology and neurobiology have demonstrated that sensory receptors are established very early in embryonic development. And animal experiments have demonstrated that the very early establishment of different perceptive systems and early sensory stimulation are both indispensable for harmonious cerebral growth.3 Neurobiologists have now clearly shown that there is interaction between genetic control of neural development and modula-tion of this development by sensory stimuli. Periph-eral stimuli are intimately involved in the control of neuronal proliferation and migration and in synaptic growth. Thus, the fetus is a perceptive being, and, in all likelihood, sensory stimuli participate in the emerging development of consciousness.

Studies in developmental biology have established that very early and excessive stimulation of embry-onic cells results in accelerated differentiation. But abnormal stimuli may also bring about cessation of growth and, as a consequence, affect ultimate func-tional capacities. Needless to say, there is justifiable concern that the unprecedented survival of ex-tremely immature newborns has exposed this unique population of humans to inappropriate sensory stim-ulation with unknown, and perhaps deleterious, long-term consequences. It is important to keep these concerns in mind and to be aware of how little we know about the precise sensory needs of the devel-oping fetus and the premature neonate.

Social, Cultunal, and Technologic Changes: “A Child at Any Price,” But Also the Child as an “Object. While the above-noted studies of fetal physiology were car-ned out, parallel studies of the regulation of the men-strual cycle were undertaken. These have afforded a deeper understanding of human fecundity and, as a result, treatment of infertility has become more effec-tive. The various techniques used are classified un-der the general heading of “medically assisted pro-creation” (MAP). Without going into details about the various procedures, it is important to understand the principal reasons for doubts expressed by the majority of pediatricians who care for infants born after MAP.

France has been a leader in these developments: since the first baby born after in vitro fertilization (IVF) in 1982, the number of centers carrying out

these procedures has grown rapidly. At Port-Royal, we have been acutely aware of the increasing num-bers of babies born by MAP (particularly IVF) admit-ted to our neonatal unit.4 Initially, 3% to 5% of our admissions were the result of MAP; the proportion increased progressively and has stabilized at 18% to 20% of admissions. These neonates are for the most part premature and undersized. There are several reasons for this. Many are the result of a multiple pregnancy brought about by the implantation of sev-eral fertilized ova to increase the chance of a success-ful pregnancy (the success rate is about 12%). Al-though it is now forbidden to implant more than three fertilized ova, many groups continue to do so. As a result, it becomes necessary to undertake “re-ductions” with the obvious risks for the remaining fetuses and for the mother.

Another main criticism of the MAP activity is the failure, from the outset, to organize a systematic fol-low-up of the resulting children. In the past 2 years, the principal centers have begun to undertake long-term follow-up of their experience. Unfortunately, the early-established groups (with 10-years of expe-rience) cannot provide follow-up results, and the same failing applies to groups in other countries around the world. We do not, therefore, have the data needed to make an informed prediction about the long-term outlook for children born as the result of MAP.

At present, pediatricians should insist on the im-portance of evaluating the possibility of unfavorable consequences in children born as the result of MAP technology. Given the importance of innumerable known and unknown influences on pregnancy out-come and on postnatal development, we should be uneasy about the lack of follow-up information. It is unfortunate that biologists, medical research work-ers, and obstetricians who developed the new tech-nologies and put them into practice gave no thought to what should have been a principal concern: the possibility of baneful results in the offspring pro-duced by such heroic measures.

These disconcerting issues have been obscured from public view. The average person is fascinated by the ever more powerful technology. Many women, equally captivated, are led to believe that

MAP will allow them to have a “miracle child”; this

reification, when the idea takes on a concrete dimen-sion, leads to unrealistic expectations. The demands of many women and couples have become distorted; they speak about “the infant” as they would about an object. It is sad to see how casual some of the mdi-cations for MAP have become. The frivolous, often incomprehensible decisions result, all too often, in catastrophe. For example, IVF was carried out in a 23-year-old patient, about 3 or 4 months after she had stopped taking an oral contraceptive, because “she had not succeeded in becoming pregnant.” Several fertilized ova were implanted, resulting in a triple pregnancy, and delivery occurred at 26 weeks; all three of neonates were dead on admission to the neonatal unit. Another example is that of a woman who succeeded in having a child after two attempts at IVF, then found herself pregnant again at an earlier

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COMMENTARIES 503

interval than she had planned. She appeared at the same center, asking for “voluntary termination of

pregnancy!” These bizarre situations are all too

fre-quent; they reflect an attitude in which the child has become a desired object, wanted by a couple or a

single woman to satisfy any number of superficial whims, eg, for egotistical reasons, to become better “socially assimilated,” or to demonstrate that after 20 years of an active professional life, “I am capable of having a child.” But, we must ask: What kind of a child?

All these imponderable considerations should be enough to restrict the use of MAP, or, at the very least, the indications should be quite exceptional. So-ciety will, undoubtedly, see the need to limit

drasti-cally the financial drain of this technology. The costs

must take into account not only the relatively modest amount of MAP and the surveillance of pregnancy, but also very often the huge cost related to

prema-turity: stay in a neonatal intensive care center ($1,200

per day) or a center for respiratory support or neu-romotor handicap for weeks or months;

rehabilita-tion sessions for respiratory difficulties, language training, or psychotherapy; support needed to

im-prove scholastic performance; and, often, financial aid to a family overwhelmed by the costs of rearing a child with severely disabling conditions.

WHAT FACTORS LIMIT MODERN ANTENATAL AND NEONATAL PRACTICES?

As indicated above, the practices in antenatal and

neonatal medicine have changed profoundly over the past 20 years. This change has come about as the

result, principally, of technical advances stemming

from research that has allowed a better

understand-ing of the fine details of developmental physiology. Additionally, therapeutics has become increasingly specific: illnesses leading to serious threats to life or

to profound dysfunction are identified more

specifi-cally and treatment is more mechanism-oriented

than in the past. However, the practical limits of

these activities in France have already been

recog-nized in some, but not in all, instances. I can illustrate the point with two examples.

Neonatal resuscitation has advanced remarkably,

particularly between 1970 and 1985; now extracorpo-real membrane oxygenation (ECMO) has been put forward in the past few years. ECMO had been in-vestigated in 1970 to 1972 and abandoned because of technical problems with the hardware. Moreover, even in principle, there was a problem: ECMO

re-quires alteration of cerebral circulation that may

af-fect long-term central nervous system prognosis, an outlook already undermined in candidates by seri-ous perinatal distress. But a number of neonatal groups have brushed these questions aside as they

prepare anew to carry out an ECMO program.

How-ever, to carry out this demanding technique, many persons must be hired and trained. Now the public

health administration in France has, in effect, im-posed a limit on the development of an ECMO

pro-gram by forbidding the creation of new posts.

On the other hand, limits have not been declared or acted upon, for example, in the MAP field

requir-ing ovarian stimulation techniques. The procedures are carried out without a precise understanding of the consequences of this stimulation for the patient, and with too little knowledge about the quality of the ova so obtained. Moreover, several attempts are often made, without warning patients, especially women over the age of 40, about the risks accompanying pregnancy even if implantation is successful.

There are other examples of the dilemmas, but

they would merely emphasize my point: at the end of the 20th century, medicine is in danger of becoming

“a slave of technology.” The patient receives, only too

often, the doctor’s technologic support, to the detri-ment of attentiveness, advice, and benign surveil-lance.

Dominated by the preoccupation with using tech-nologic weaponry, doctors and medical teams risk involvement in a relentless struggle only to

achieve

acts of maintenance or the creation of life at any cost. We doctors risk what is uniquely human about us when we consider only our technical skills and over-look the subtlety of the demand and quality of life.

Thus, at present, the future appears somber. Many things will undoubtedly change, as medical teams become aware of the problems we have created. Not the least of these are the limits imposed by the enor-mous costs of the new technology that place it

be-yond the reach of most countries with competing

priorities. For example, a budgetary crisis in the hos-pital in which I work was created when there was an enormous increase in expenditure. A huge deficit was incurred in the hematology department, where costs have multiplied 100-fold as a result of services provided to acquired immune deficiency syndrome patients.

In an era that revolves around quantitative values

and social welfare, there needs to be a radical change in consciousness. A return to common sense is cm-cial, if we are to avoid becoming pawns in a chess game with unknown rules. From now on, I suggest,

it will be important to reexamine the factual

knowl-edge derived from science and to rediscover our tra-ditional values if we are to begin to formulate sane rules for playing the game of life. The ever-present menace of sickness and death cannot be dismissed lightly, but the threat should not be used as the over-riding justification for the unbridled use of our tech-nical prowess that has become materialistic and pol-luting. Surely the stages in the life of our species are inevitable; progress should be measured by the ex-tent to which we manage the vital issues in a “rea-sonable fashion.”

ACKNOWLEDGMENTS

Iwould like to thank Doctors W. Silverman and C. Lim for their help.

J. P. RELIER, MD

Service de M#{233}decineN#{233}onatale Maternit#{233} Port-Royal

Paris, France

REFERENCES

1. Budin P, Demelin L. Manuel Pratique dAccouchements et d’Allaitement. Paris, France: Doin; 1904

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504 COMMENTARIES

2. Busnel MC, Herbinet E. LAube des SL’ns: Les Cahiers du Nouveau-Ne No.

5. 8th ed. Paris, France: Stock; 1991

3. Lecanuet JP, Granier-Deferre C, Busnel MC. Sensorialit#{233} foetale: onto-g#{233}n#{233}sedes syt#{232}messensoriels, consequences de leur fonctionnement

foetal. In: Relier JP, Laugier I,Salle B, eds. M#{233}decine Pdrinatale (Foetus et Nouveau-Ne). Paris, France: M#{233}decine-Sciences Flammarion; 1989:201-225

4. Relier JP, Couchard M, Huon C. The neonatology experience with IVF

babies. In: Consensus Meeting on the Place of In Vitro Fertilization in Infer-tility Care. Copenhagen, Denmark: World Health Organization-EURO; June 18-22, 1990

Childhood

Lead

Poisoning:

Definitions

and

Priorities

ABBREVIATIONS. Pb, lead; CDC, Centers for Disease Control.

By using motor developmental status as the out-come measurement, Dietrich et al,1 in the current issue, have tried to lend objectivity to the controver-sial question of whether neurologic damage in child-hood can be attributed to low lead (Pb) levels. Pre-vious prospective studies have shown a lack of consistency between Pb exposure and many mea-surements of cognitive development and language skills. Children who have elevated blood Pb levels are frequently subject to other neurologic risk condi-tions, including poverty, disorganized family situa-tions, low maternal intelligence (IQ) and education, and poor nutrition, particularly anemia. The problem is to separate the effect of Pb from the confounding variables. This is particularly difficult when the effect of Pb is small (eg, 3 to 5 IQ points) and the effect of the other confounding variables (eg, maternal IQ) is greater. Under these circumstances, the adequacy of controlling for confounding variables is critical. Al-though numerous studies of low Pb effect have been published, their perspectives have ranged widely be-tween considering multiple variables and consider-ing none at all, while including all confounding van-ables is almost impossible. Possible omissions include prenatal factors, such as quality of prenatal care and maternal nutrition, paternal IQ, and educa-tional interventions, such as enrollment in Head Start.

Before 1970, concern about childhood Pb poison-ing centered on symptomatic disease, generally re-quining blood Pb levels >70 pg/dL (3.38 pmol/L), with Pb encephalopathy rarely occurring at <100 pg/dL (4.83 pmol/L). Clinical findings such as lead lines in the gums and bones, basophilic stippling in red blood cells, and lead chips in the intestines have essentially disappeared from pediatric practice as Pb values dropped to <50 pg/dL (2.41 pmol/L), the level considered necessary for symptomatic disease. With the onset of environmental regulations in the early 1970s, particularly elimination of Pb from

gas-Received for publication Oct 22, 1992; accepted Oct 29, 1992.

Reprint requests to (E.J.S.) Dept of Pediatrics, Kaiser Permanente Medical Center, 280 W MacArthur Blvd. Oakland, CA 94611-5693.

PEDIATRICS (ISSN 0031 4005). Copyright © 1993 by the American Acad-emy of Pediatrics.

oline and paint, blood Pb levels in US children have dramatically and steadily fallen from an earlier mean of 17 pg/dL (0.82 pmol/L) in the early 1970s to a current mean of 6 pg/dL (0.29 pmol/L). For exam-ple, a 1970 study of San Francisco inner-city children showed that more than half had blood Pb levels >20 pg/dL (0.97 pmol/L), whereas a second study in 1991_19922 found only I .7% with comparable levels,

a 30-fold decrease.

With steady disappearance of symptomatic lead poisoning and falling mean blood Pb levels in US children, interest has centered on whether low blood levels, previously thought safe, could cause neuro-logic changes in small children, affecting such func-tions as intelligence, behavior, and speech. Studies beginning in the late 1970s, which are still controver-sial, have suggested that such low blood Pb levels could. Although too small to be clinically significant in individual children (eg, an IQ change of 3 to 5 points), this Pb effect is claimed to be important when applied to large populations. Responding to these studies, the Centers for Disease Control (CDC) has steadily decreased the blood Pb level indicative of lead poisoning from 40 pg/dL (1.93 pmol/L) in 1970, to 30 pg/dL (1.45 pmol/L) in 1975, to 25 pg/dL (1.21 pmol/L) in 1985, and finally to 10 pg/dL (0.48 pmol/L) in October 1991 .‘ Furthermore, in the latest

CDC report universal blood Pb screening was nec-ommended for all children between 9 months and 6 years old and a costly strategic plan was developed encompassing testing, monitoring, treatment, and Pb abatement. Critics have claimed that the evidence for low Pb level effect does not warrant such action be-cause of the problems of small effect, confounding variables, and questionable outcome measures. Com-plicating the problems of small effect and confound-ing variables are charges of investigator bias, faulty methodology, flawed statistics, and overstated con-clusions.

Accusations of poor investigative technique and misconduct have been leveled against Dr Herbert Needleman, the leading proponent of low Pb dam-age in children, and he is currently being investi-gated by the University of Pittsburgh and the National Institutes of Health.4’5 The charge of mis-conduct referred to falsification, fabrication, and pla-gianism, and his attorney has indicated that Needle-man has been cleared of misconduct as defined. Questions concerning methodology, documentation, scientific validity, and unwarranted conclusions await the release of the full report. These criticisms are important because Needleman has been a pnin-cipal advisor to the federal government on lead is-sues, he played a pivotal role in the CDC decision to lower the definition of lead poisoning, and his work has great influence on other investigators in the field. The costs of a total Pb screening, treatment, and abatement program are also a source of controversy. The 1991 CIX Strategic Plan to Eliminate Childhood Lead Poisoning6 estimated the total program cost nationwide at $974 million over a 5-year period, an apparent gross underestimate. For example, the Cal-ifornia Department of Health Services7 estimated that the first year of a state screening program would

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1993;91;501

Pediatrics

J. P. Relier

Medicine: A View From France

Effects of Technologic and Sociocultural Changes on the Practice of Neonatal

Services

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1993;91;501

Pediatrics

J. P. Relier

Medicine: A View From France

Effects of Technologic and Sociocultural Changes on the Practice of Neonatal

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