EXPERIENCE
AND
REASON-Briefly
Recorded
“In Medicine one must pay attention not to plausible theorizing but to experience and reason together. ... I
agree that theorizing is to be approved, provided that it is based on facts, and systematically makes its deductions from what is observed. ...But conclusions drawn from unaided reason can hardly be serviceable; only those
drawn from observed fact.” Hippocrates: Precepts. (S/tort COfllflhlL?liCatio?lS of factual matt’rial are publisiwd liert’. Comments Out1 criticisms appear as latters to the Editor.)
Treatment
of
Attachment
Disorder
of
Infancy
in
a Neonatal
Intensive
Care
Unit
ABBREVIATION. NICU, neonatal intensive care unit.
As a psychiatric
consultant
in an inner-city
level
III
neonatal
intensive
care
unit
(NICU),
I have
seen
5ev-eral
cases
involving
premature
infants
who
did
not
have
a
caring,
consistent
adult
in
their
lives.
This
neglect
appeared
to contribute
to the
development
of
behavior
problems
(eg,
irritability)
or
feeding
prob-lems
(eg,
failure
to thrive),
and
sometimes
an
infant
failed
to progress
medically
or
experienced
an
exac-erbation
of medical
problems.
These
infants
were
as-signed
the
diagnosis
of reactive
attachment
disorder
of infancy.
This
is a recognized
psychiatric
entity
that
is defined,
as follows,
in the
Diagnostic
and
Statistical
Manual
of Mental
Disorders
(3rd
ed,
revised):
Definition: The essential feature of this disorder is markedly disturbed social relatedness in most contexts that begins be-fore the age of 5. The disturbance in social relatedness is presumed to be due to grossly pathogenic care that preceded the onset of the disturbance. Infants with this disorder present with poorly developed social responsiveness. Visual tracking of eyes and faces and responding to the caregiver’s voice may not be established by 2 months of age; attention, interest, and gaze reciprocity may be absent. The pathogenic care may include persistent disregard of the child’s basic emotional needs for comfort, stimulation, and affection. The clinical pic-ture can be substantially improved by adequate care. Such a therapeutic response is ultimate confirmation of thediagno-Sis.
Associated features. Feeding disturbances may be present. There may be sleep disturbances, and hypersensitivity to touch and sound.
Age at onset. By definition, the age at onset is before age 5. The diagnosis can be made as early as in the first month of life. Course, inipairment, and complications. If care remains grossly inadequate, severe malnutrition, intercurrent infection, and death can occur.
Predisposing factors. All factors that interfere with early emo-tional attachment of the child to a primary caregiver can predispose to this disorder. Other factors that predispose to the disorder are lack of affectionate body-to-body contact dur-ing the first weeks of life, such as a prolonged period in an
incubator or other early separations from a caring adult.’
Prematurity
is not
specifically
mentioned
as a
pre-disposing
condition
for
the
development
of a reactive
attachment
disorder
of infancy,
but
predisposing
fac-Received for publication May 18. 1992; accepted Jul 15, 1992. Reprint requests to (M.S.G.) 30 N Michigan Ave. Chicago. IL 60602.
PEDIATRICS (ISSN 0031 4005). Copyright © 1993 by the American
Acad-emy of Pediatrics.
tors
such
as
a prolonged
period
in
an
incubator
or
other
early
separations
from
a
caring
adult
corn-monly
characterize
the
initial
months
of life
for
many
premature
infants.
Neonatal
medicine
is highly
sophisticated,
and
in-fants
who
never
would
have
been
considered
viable,
now survive.
These
are
the
infants
who
spend
weeks
and
months
in
our
NICUs
on
life
support
systems
with
close
monitoring
of each
breath
and
heartbeat.
Parents
are
understandably
fearful
of
these
infants
and
feel
sometimes
at
a loss
for
how
to
respond
to
them.
Because
their
infants
are
sick
and
often
sus-tamed
by
highly
technological
means,
these
parents
feel
that
the
usual
ways
of
showing
care
to
their
infants
is not
available
to them.
They
feel
not
needed
as
parents
as
well
as
frightened
by
the
NICU
atmo-sphere.
What
results
is
that
they
often
withdraw
from
their
infants.
Physicians
are
preoccupied
with
life-sustaining
measures
so
that
developmental
needs
are
often
given
low
priority
with
the
very
low
birth
weight
infant,
and
nurses
can
be
too
busy
with
routine
procedures
to
pay
constant
attention
to
the
attachment
needs
of the
infants
under
their
care.
As
a result,
many
of
these
infants
will
lie
for
several
months
in
their
isolettes,
receiving
state-of-the-art
medical
care
but
deprived
of the
emotional
care
that
is also
necessary
for
life.
The
following
cases
describe
four
premature
in-fants
who
had
no
interested,
consistent
caretaker
in
their
lives.
These
infants
developed
a reactive
attach-ment
disorder
of infancy
characterized
by
behavioral
problems
and/or
failing
physical
states.
They
are
ex-amples
of
the
need
for
interventions
in
the
NICU
which
address
the
developmental
needs
of
the
sick,
premature
infant
as well
as the
anxieties
experienced
by
the
parents
of
these
infants.
These
four
infants
illustrate
that
medical
care
is
often
not
successful
unless
accompanied
by
developmental
care.
Further
research
and
case
reports
are
needed
to understand
better
the
importance
of
the
integration
of
develop-mental
and
medical
practices.
Case
1
A baby girl who will be called Annie was born to a 16-year-old single mother after a 32-week gestation at a birth weight of 1475 g. Annie had a congenital jejunal atresia that would require two surgeries-a colostomy followed by a reanastomosis of the je-junum. I evaluated Annie and her mother when the infant was 2 weeks old. Her mother was 16 years old, and the neonatologist
wondered how she would cope with such a baby. Annie, at this time, was a responsive infant who made excellent eye contact with
whomever handled her. Annie’s mother seemed to like her; she
expressed fears about Annie’s small size, but she denied the
pres-ence of the colostomy and the need for a second surgical
140
EXPERIENCE
AND
REASON
as long as she could remember. She had never had a good rela-tionship with her own mother, and she hoped that she could give her baby everything she had missed in life. She had taped inside the infant’s isolette a picture of herself as an Il-year-old girl on Santa Claus’ lap; it was as if she had gotten into the isolette with Annie.
I saw Annie’s mother on three occasions. She then stopped visiting her infant. Annie, at 2 months of age, had her reanasto-mosis procedure, but she was having feeding problems. She was vomiting her milk. A postsurgical bowel obstruction was ruled out. In addition, behavioral problems had developed. Nurses com-plained to me that she was irritable and inconsolable. Now when I held her she maintained an alert state, but she would not make eye contact with me but would look away from my face. Her feeding intolerance, inconsolability, and gaze aversion character-ized the development of a reactive attachment disorder of infancy in an infant whose mother had withdrawn from her and who had no other consistent caretaker to hold her and talk to her. This particular NICU did not have primary care nursing. Intervention at this time was directed at both Annie and her mother. Her mother and I met, and we discussed her fears in caring for Annie, including her fear that Annie could die or would never be normal. When these fears were verbalized and understood, the mother began visiting and holding her infant. She visited several times a week, and those days she did not visit, she asked me to hold Annie. After 2 weeks, Annie had become a pleasant, related infant. She was less irritable; she liked being held and she maintained a gaze response with her caretakers. She also began to tolerate for-mula feedings.
Annie was seen in follow-up when she was 5 months of age. She was eating well, and she smiled, laughed, and babbled in a social interaction. She appeared to be a healthy baby. Her mother was pleased with Annie, but she reported she felt more like a baby-sitter than a mother. The mother’s difficulty in feeling like a mother would require further therapeutic intervention.
Case
2
Timmy was born at 31 weeks’ gestation at a birth weight of 1134 g. He was exposed to cocaine in utero, and he experienced all the complications of prematurity including respiratory distress syn-drome and severe bronchopulmonary dysplasia. He required me-chanical ventilation for a lengthy period of time. I was asked by the attending neonatologist to see Timmy when he was 4 months of age. He required high ventilatory settings and any attempt to wean him from his ventilator resulted in respiratory failure.
I observed Timmy in his isolette. He appeared to be a very unhappy infant. He thrashed about, arching his back, and he kept his eyes tightly shut, not focusing on anyone or anything. Nurses reported to me that this was his usual behavior, and nursing notes emphasized his irritability and frequent cyanotic episodes. Inquir-ies about family revealed that no one visited limmy and that he had never been held. The only touching he had experienced in his 4-month life was during routine tasks, such as diapering, or dur-ing medical procedures, such as respiratory therapy. Timmy had not experienced the nurturing and attention parents normally give their newborns, and he developed a reactive attachment disorder of infancy. All attempts to involve his mother in his care were
unsuccessful, and the family requested that the State assume re-sponsibility for him. Because there was no one else available, such as a trained volunteer, who was familiar with the behavior of this type of infant, I began to hold Timmy on a daily basis at the same time each day.
The first week ‘flmmy was restless in my arms, but when he was offered a pacifier, which he had not previously experienced, he gradually would become calmer and then mold to my body. After several days he opened his eyes and made fleeting eye contact with me. He was less irritable in his isolette, and his neonatologist began to decrease his ventilator settings. Three weeks after the intervention of daily holding began, Timmy pulled out his endotracheal tube. For the first time, he could breathe on his own with supplemental oxygen via a tot tent or nasal cannula.
By 6 months of age Timmy had become a responsive infant who would try to find me with his eyes when I approached his crib, talking to him, and he would lift his arms up as a signal of wanting to be picked up. His respiratory status remained fragile, especially at those times when he was not able to elicit a response from a caretaker. On two occasions he required mechanical ventilation for a 3-day period, and both these times followed a 5-day absence on
my part. A medical workup during each respiratory decompensa-tion was negative for findings. His physical well-being was de-pendent on my daily intervention of holding him and relating to him.
At 8 months of age, Timmy was transferred to a new unit within the hospital where he could have primary care nursing. He now related with lengthy periods of gazing into my eyes and lifting his hands to my face, and then he would look away when he had experienced enough stimulation. He was a playful infant, and we developed a repertoire of games, such as patty cake or play with a favorite toy. When I was away, another familiar caretaker would hold and interact with Timmy daily as I had been doing. Timmy was hospitalized until he was 21 months of age; five of these months were spent in a rehabilitation institute. He experi-enced fewer episodes of respiratory distress although he still re-quired oxygen via a nasal cannula. He was discharged to a foster mother who liked this babbling, smiling infant, and they devel-oped a relationship. limmy continues in his foster home to progress in all spheres of development-motoric, cognitive, and social-and at the time of this writing he is being weaned from his oxygen.
Case
3
Jessica was born at 28 weeks’ gestation with a birth weight of
794 g. This was the first baby for her 18-year-old mother and
slightly older father. Jessica initially required mechanical ventila-tion, and at 2 months of age, she began to be weaned from her ventilator. She was briefly in an Oxyhood, but then complications of sepsis and bilateral pneumonia necessitated a return to mechan-ical ventilation. A protracted medical course followed, during which time Jessica was a very sick infant. Jessica’s failing medical condition came to my attention when she was 3 months old. At this time I observed her in her isolette; she was an irritable infant who attempted to cry as she thrashed about. When I lightly placed
my hands on her head and trunk, she calmed and briefly alerted. When I removed my hands, she again became fussy. Nurses told me that the parents visited Jessica each weekend but they did not touch her or talk to her. I thought that Jessica’s failing medical condition could be symptomatic of a reactive attachment disorder of infancy. When I met with Jessica’s mother to discuss her feelings about her infant, she conveyed that she was a worried, concerned parent who would do anything she could for her daughter. How-ever, she explained how helpless she felt as a mother. She thought Jessica, right now, needed the doctors and the nurses and, as a mother, there was little she could do for her baby. I explained to the mother that she really could do a lot, that her voice, touch, and smell were very important for Jessica to experience. Her mother was able to see how peaceful Jessica became when she stroked her and talked to her and how her pulse oximeter reading quickly changed from 85 to 100. The mother began to visit Jessica several times in the ensuing week. Within days, Jessica markedly im-proved. In a week’s time she showed increased alerting behavior with eye contact while vigorously sucking on a pacifier. In less than 2 weeks’ time Jessica was extubated and breathing room air. Jessica’s mother now was holding her and Jessica would mold to her body while gazing into her eyes. Both obviously enjoyed this experience. She began to do well with her bottle feedings and after a 4 #{189}-month hospitalization she was discharged home at a weight of 2260 g. I saw both parents at the time of discharge. They were pleased withJessica and excited to be able to finally take her home.
Case
4
Billy was born after a 30-week gestation at a birth weight of 1134 g. He had a difficult first 6 months of life, with complications of bilateral pneumothoraces, pneumonia, and a grade I
intraven-tricular hemorrhage. He required a lengthy period of mechanical
ventilation. At 9 months of age he had a tracheostomy because of subglottic stenosis.
From birth, Billy’s mother, father, and maternal grandmother rarely visited him. His mother was 21 years old, and she had two other children, aged 2 and 3. Significantly, she had previously given birth to another premature infant who was cared for in a different NICU and who died at 7 months of age. His mother and grandmother agreed that they feared Billy, too, would die. Because they could lose him, they did not want to become close to him. Understanding these fears did not help to overcome them. Billy’s family continued to visit him infrequently, and his mother even-tually told me that she had become pregnant again.
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When Billy was 8 months of age, his neonatologist asked me to evaluate his development. At this time, he was receiving supple-mental oxygen via a nasal cannula; he was feeding by bottle and spoon, and he weighed 3180 g. He had many caretakers in his life, and he had not developed a noticeable attachment to any partic-ular person. He was liked by the NICU staff, but lived in a busy, noisy unit that did not have primary care nursing. I observed Billy. He looked unhappy. He had a fixed stare, and he infrequently made fleeting eye contact with a caretaker. He did not smile or babble, and he could not roll over or reach for objects. He did not appear to enjoy his feedings, and he often refused his formula and baby food. Billy was a withdrawn infant with symptoms of failure to thrive, developmental delay, and halting medical progress. As a result of institutional life and the lack of a consistent, caring adult in his life, Billy had developed a reactive attachment disorder of
infancy.
I began to hold Billy daily. When held, he arched his body, became irritable, and usually looked away from my face. When he finally calmed in my arms, he would fall asleep, using the holding experience for soothing purposes. On occasion, he would interact by briefly gazing into my eyes, touching my face, or showing a small smile, but most of the time he appeared sad and lifeless. Attempts were now made to provide him with primary care nurses on the day shift, but Billy did not develop an intense attachment to either myself or any of his nurses. He continued to be a poor feeder, and he always weighed less than 4536 g. He looked like a marasmic infant. He frequently experienced
hypo-xemic episodes requiring increasingly high concentrations of
oxygen.
When Billy was 14 months old, he began a downhill medical course. He was more withdrawn, and he required increasingly high concentrations of oxygen and eventually mechanical venti-lation with 100% oxygen. Respiratory syncytial viral pneumonitis was diagnosed. At almost 17 months of age, he died. The major finding on autopsy was severe end-stage bronchopulmonary dys-plasia with fibrosis.
DISCUSSION
These
four
infants
became
symptomatic
when
they
did
not
experience
closeness
with
a consistent
care-taker,
and
a reactive
attachment
disorder
of infancy
was
diagnosed.
The
first
three
infants
showed
marked
improvement
in
their
physical
conditions
and
behavioral
symptoms
when
they
had
consistent,
predictable
attention
from
a caring
adult.
In the
sec-ond
case
this
was
a child
psychiatrist
and
in the
other
two
cases
the
infants’
mothers
fulfilled
this
role.
The
fourth
infant,
Billy,
who
received
intervention
at
8
months
of age,
never
really
responded,
and
he
even-tually
died.
All
four
infants,
as well
as
many
others,
raise
the
important
question:
What
are
the
develop-mental
needs
of the
premature
infant?
The
developmental
needs
of the
premature
infant
have
not
been
as well
understood
as their
physiolog-ical
needs
and
their
medical
problems.
Proper
stim-ulation
of
the
premature
infant
has
been
a
contro-versial
topic
for
decades.
The
adverse
effects
of
overstimulation
have
been
pointed
out
by
investiga-tors
such
as
Long
and
Lucey
and
Gorski.
Long
and
Lucey2
have
shown
that
sudden
environmental
noise
can
lead
to
crying
and
then
to
hypoxemia
and
ele-vations
in
intracranial
pressure,
a possible
precipi-tant
for
an
intraventricular
hemorrhage.
Gorski
et al3
have
shown
that
stress
created
by
mistimed
handling
can
cause
a bradycardiac
episode.
Als
et
al4
have
shown
that
those
infants
who
do
best
as evidenced
in
reduced
ventilator
and
oxygen
dependency,
earlier
success
in breast-
or bottle-feeding,
and
better
devel-opmental
performance
at 9 months
of age
have
been
shielded
as
much
as
possible
from
loud
noise
and
bright
light.
They
have
been
carefully
positioned
and
nested
to
enhance
motoric
and
state
organization
as
well
as self-regulatory
activity.
Some
of Billy’s
symp-tomatology
such
as his
frequent
hypoxemic
episodes
could
be
attributed
to the
brightly
lit,
noisy
environ-ment
in which
he
lived.
What
makes
for
proper
stimulation
of the
prema-ture
infant
has
not
been
as
well
defined.
A
round-table
of
infant
experts
has
underscored
the
need
for
further
interdisciplinary
research
to study
the
short-term
and
long-term
effects
of
infant
stimulation.5
Along
this
line,
the
attachment
needs
of
the
prema-ture
infant
requiring
interaction
from
a consistent,
caring
adult
have
not
been
understood
in
the
same
way
that
these
attachment
needs
have
been
studied
and
understood
in the
full-term
newborn.
Spitz6
was
one
of the
first
investigators
to document
the
effects
of
maternal
deprivation.
He
followed
infants
cared
for
in
an
institution
where
they
were
deprived
of
their
mother
and
a mother-substitute.
These
infants
showed
markedly
compromised
growth
and
devel-opment
as
well
as
frequent
infections
and
a
high
mortality
rate.6
He
observed
other
infants
who
were
separated
from
their
mothers
for
a 3-month
period.
These
infants
developed
symptoms
of
sadness,
weepiness,
withdrawal,
developmental
delay,
and
refusal
to
eat
and
loss
of
weight.
When
the
infants
were
reunited
with
their
mothers,
they
recovered
in
a sudden,
dramatic
way.
Spitz
and
cautioned,
though,
that
with
a long-lasting
separation
this
de-pressive
response
can
become
irreversible.
The
infant
in
case
4,
Billy,
could
have
experienced
too
much
deprivation
for
too
long,
so that
he could
not
respond
to the
maternal
care
that
finally
was
available
to him.
John
Bowlby,
a pioneer
in
the
field
of attachment
theory,
underscored
the
need
of
the
newborn
and
older
infant
to have
contact
with
a caretaker
for
the
purpose
of
closeness,
ie,
attachment,
and
indepen-dent
of the
fulfillment
of physical
needs
such
as
hun-ger.
The
full-term
newborn
signals
in
obvious
ways
his
need
for
human
contact
and
his
response
to that
contact,
ie,
crying
and
then
quieting
to
the
human
voice
or touch.8
Recent
infant
research
has
shown
the
importance
of the
mother
for
the
full-term
newborn.
Newborns
recognize
their
mother’s
voice9
and
smell,10
and
they
prefer
the
human
face
to an
inani-mate
object.1#{176}
Understanding
the
attachment
needs
of
the
pre-mature
infant
can
be
a more
difficult
task
than
un-derstanding
the
full-term
newborn’s
signals
for
closeness.
Often
the
premature
infant,
because
of
me-chanical
ventilation,
cannot
cry,
or
he
or
she
is not
able
to alert
and
gaze
(crying
and
gazing
being
sig-nals
that
mobilize
parental
or caretaker
proximity).
It
is not
uncommon,
then,
to
view
the
very
low
birth
weight
infant
as
too
fragile
to
benefit
from
interac-tion
with
a caring
parent,
which
is what
the
mother
in case
3 expressed
to me.
Investigators
are
attempting
to
understand
better
the
premature
infant’s
attachment
needs.
Als11
has
alerted
us
to
the
premature
infant’s
attentional/
interactive
system.
The
interactive
system
becomes
more
defined
with
increasing
gestational
age.
How-ever,
it is present
in
even
the
newborn
of
27
weeks
gestational
age.
Als
emphasizes
the
vulnerability
of
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142
EXPERIENCE
AND REASONthe
premature
infant.
She
advises
careful
monitoring
of
the
infant’s
behavior
for
state,
motoric,
and
auto-nomic
changes
(drowsiness,
gaze
aversion,
color
changes,
breathing
difficulties,
hypertonicity)
which
signal
that
the
infant
has
had
enough
stimulation.11
Other
work,
too,
has
acknowledged
the
premature
infant’s
need
for
human
contact.
Field12
has
shown
that
infants
who
receive
massage
three
times
a day
gain
weight
faster,
show
more
organized
behaviors,
and
are
discharged
home
earlier
than
infants
who
do
not
receive
this
intervention.
The
Kangaroo
Method,
holding
the
infant
against
the
mother’s
bare
chest
and
breast-feeding,
is
now
used
in
some
NICUs.
Whitelaw
et
a113 reported
that
babies
who
have
ex-perienced
skin-to-skin
contact
with
their
mothers
cry
less
often.
VandenBerg
has
noticed
in
preliminary
results
of a study
that
premature
infants
with
bron-chopulmonary
dysplasia
who
are
held
daily
for
a
minimum
of 2 hours
by
the
same
volunteer
are
dis-charged
home
at an
earlier
date
than
infants
who
do
not
receive
this
intervention.
The
infants
who
were
held
achieved
better
state
control,
showed
more
alerting,
and
were
more
responsive
to
caretakers
than
the
control
infants
(VandenBerg
K,
personal
communication,
1991).
Our
premature
infants
need
consistent,
caring
adults
in
their
lives
to
touch
them,
hold
them,
and
talk
to
them.
Ideally,
these
caring
adults
should
be
the
infant’s
parents.
These
parents
require
help
to
feel
at
ease
in
our
NICUs
as
well
as
to
understand
how
they
can
play
a parental
role
with
their
infants.
Interventions
of this
type
will
enhance
our
state-of-the-art
medical
care
and
prevent
the
development
of
symptoms
characteristic
of
reactive
attachment
dis-order
of
infancy.
The
above
cases
and
my
observa-tions,
along
with
those
of
seasoned
neonatologists,
confirm
that
those
babies
who
have
caring
parents
at
their
bedsides
always
do
better
with
fewer
compli-cations
than
the
neglected,
abandoned
infants.
Vol-unteer
baby-holding
programs,
the
construction
of
NICUs
that
include
special
rooms
for
visiting
par-ents,
liberal
visiting
hours,
primary
care
nurses,
and,
in
one
NICU
that
I know
of,
primary
care
doctors,
attest
to increasing
understanding
of the
attachment
needs
of
the
premature
infant.
As
we
continue
to
understand
better
how
to
interact
with
our
prema-ture
infants,
it will
be
interesting
to
see
the
effect
of
this
developmental
care
on
their
progress
and
future
lives.
ACKNOWLEDGMENTS
I thank Paul C. Holinger, MD, Stephen L. Patt, MD, Steve Shel-don, DO, and the Rush-Presbyterian-St Luke’s Psychiatric Study Group for their helpful comments in the preparation of this paper.
MARLENE S. GOODFRIEND,
MD
Dept of Pediatrics
University of Health Sciences/The Chicago Medical School
Dept
of Pediatrics
Mount Sinai Hospital Medical Center Chicago, IL
REFERENCES
I. American Psychiatric Association, Committee on Nomenclature and Statistics. Diagiiostic tiiid Statistica! Manjia! of Menta! Disorders. 3rd ed,
revised. Washington, DC: American Psychiatric Association; 1987:91-93 2. Long JG, Lucey iF. Noise and hypoxemia in the intensive care nursery.
Pediatrics. 1980;65:143-145
3. Gorski PA, Huntington L, Lewkowicz D. Handling preterm infants in hospitals: stimulating controversy about timing stimulation. In: Gun-zenhauser N, ed. Infant Stimu!atiou: For Whom, What Kind, When and Hozv Much? Johnson and Johnson Baby Products Company; 1987:43-51 4. Als H, Lawhon G, Brown E, et al. Individualized behavioral and
envi-ronmental care for the very low birth weight preterm infant at high risk for bronchopulmonary dysplasia: neonatal intensive care unit and de-velopmental outcome. Pediatrics. 1986;78:11 23-1132
5. Gunzenhauser N, ed. Infant Stimu!ation: For Whom, What Kind, When and How Much? Johnson and Johnson Baby Products Company;
1987:182-185
6. Spitz R. Hospitalism: a Follow-up report. Psyclioana! Study Chi!d.
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7. Spitz R, Wolf K. Anaclitic depression: an inquiry into the genesis of
psychiatric conditions in early childhood. 2. Psychoana! Study CJ,i!d.
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8. Bowlby J.Attacl:,nt’nt and Loss: Attaclnnt’nt, New York, NY: Basic Books; 1969;1 :265-298
9. Ockleford EM, Vince MA, Layton C, Reader MR. Responses of neonates to parents and others’ voices. Earhi Hum Dez’., 1988;18:27-36
10. Stern DN. TIir’ Iiit’rpersoiiaI Wor!d of the Infant. New York, NY: Basis Books; 1985:38-42
11. Als H. A synactive model of neonatal behavioral organization: frame-work for the assessment of neurobehavioral development in the prema-ture infant and for support of infants and parents in the neonatal inten-sive care environment. Pliysica! Occit;i Titer Pediatr. 1986;6(3/4):3-55 12. Field TM. Neonatal stress and coping in intensive care. Infant Mental
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1990;2:57-6513. Whitelaw A, et al. Skin to skin contact for very low birth weight infants and their mothers. Arc/i Dis Child. 1988;63:1377-1381
Dishwasher
Effluent
Burns
in
Infants
Burns
are
a significant
cause
of injury
in children,
and
hot
liquid
scald
is
the
most
common
form
of
pediatric
burn.1
The
depth
of scald
burns
depends
on
the
water
temperature
and
the
duration
of contact.2
To
our
knowledge,
scalds
in
infants
resulting
from
hot
dishwasher
effluent
being
forced
into
the
kitchen
sink
while
children
are
being
bathed
have
not
been
reported
previously.
A
specific
plumbing
arrange-ment
may
favor
the
occurrence
of
this
type
of
acci-dent.
Two
such
cases
were
managed
at
our
institu-tion
and
form
the
basis
for
this
report.
Case
1
CASE
REPORTS
A 6-month-old boy was being bathed in the kitchen sink by a care giver while the dishwasher was running. The child was sit-ting on a sponge ring over a sink drain that was occluded with a plunger-type drain cover. The child began crying suddenly and was lifted from the sink by the care giver, who noted that the dishwasher effluent was backing into the sink. The child suffered deep burns of his perineum and thighs, which required hospital
admission and 4 weeks to heal. The dishwasher drain entered the
top of a garbage disposal. Since that time, the parents have noted that when the garbage disposal is not completely clear, hot water from the dishwasher enters the sink during the drain cycle.
Received for publication Apr 1, 1992; accepted Jun 29, 1992.
Reprint requests to (R.L.S.) Shriners Burns Institute, 51 Blossom St. Boston,
MA 02114.
PEDIATRICS (ISSN 0031 4005). Copyright © 1993 by the American
Acad-emy of Pediatrics.
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1993;91;139
Pediatrics
MARLENE S. GOODFRIEND
Treatment of Attachment Disorder of Infancy in a Neonatal Intensive Care Unit
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Pediatrics
MARLENE S. GOODFRIEND
Treatment of Attachment Disorder of Infancy in a Neonatal Intensive Care Unit
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