Games with children

but it is equally likely that these infants could

have had an upper airway obstruction pattern

which the monitor cannot detect. Making the

alarm louder, as they suggest, will not solve this

problem. People quickly adapt to loud sounds.

Apnea monitors have been used in intensive

care nurseries since 1969. These devices have

achieved widespread uncritical acceptance.

Visi-tors are impressed by them. They contribute

much to the atmosphere and noise pollution

surrounding modern intensive care.

Unfortu-nately, there are no studies to demonstrate that

their use has had any effect on morbidity,

mortal-ity, or intact survival. There are studies which

indicate that impedance devices falsely report

numerous artifacts, movement, heartbeat, and

vibrations from nearby equipment.4 They are

incapable of detecting upper airway obstruction,5

broken apnea,6 and disorganized breathing,” all of

which cause repeated bouts of hypoxemia. In

addition to failure to detect 40% of apneic

episodes even in an intensive care setting, they

are very susceptible to improper use and are

difficult to adjust. They are unreliable even as

accurate indicators of respiratory rate and should

actually not be used for this purpose. A study by

the Emergency Care Research Institute found

them to be “generally unreliable.” Finally, they

do not detetct hypoxemia and hypoxia, which are

certainly most important effects of apnea.6 I

believe we should seriously question the

combined use of these expensive, probably

inef-fective devices in the intensive care nursery; more

studies with better and different devices are

certainly needed before their use in the home can

be recommended.

REFERENCES

1. Alarms and false excursions. TIme Economist, May 21,

1977, p 86.

2. Stein IM, Shannon DC: The pediatric pneumogram: A new method for detecting and quantitating apnea in infants. Pediatrics 55:599, 1975.

3. Peabody JL, Gregory GA, Wills MM, et al: Failure of conventional respiratory monitoring to detect hypoxemia. Pediatr Res 11:539, 1977.

4. Dyro JF: Apnea .\fonitors: latrogenic Problems in

Neonatal lntensice Care: 69th Ross Conference on Pediatric Research. Columbus, Ohio, Ross Labora-tories, 1976, pp 65-69.

5. Warburton D, Stark AR, Taeusch HW: Apnea monitor failure in infants with tipper airway obstruction.

Pediatrics 60:742, 1977.

6. Peabody JL, Philip AGS, Lucey JF: Disorganized breathing: An important form of apnea and cause of

hypoxemia. Pediatr Res 11:540, 1977.

Games with children

A child whispers into the ear of another child

who tells the next who whispers to another who

transmits to the fourth and so on until the chain of

whispers ends with the last child who loudly

announces the message received. Peals of laughter

and delight occur when the anticipated distortion

of fact happens! Of course, if the chain is short, a

very careful player can transmit a message intact.

But, make the chain long enough or the message

sufficiently complicated and even the most

fastid-ious child will have difficulty preventing a

message from becoming distorted in its passage.

Fooling around with facts is fun as long as

everyone knows a game is being played.

Unfortu-nately, sometimes the game is played without

intention.

It has been more than 13 years since Beutow,’

Day,2 and their respective co-workers confirmed

a fact that William Silverman published six years

earlier. Since then, there has been no published

contradiction of this fact. But, as expected,

trans-mitted along a chain of 13 years, multiple

distor-tions of the message have occurred. Simply stated,

Silverman, Beutow, and Day demonstrated that

premature infants raised in differing thermal

environments have different rates of survival and

that of the environments studied, one was clearly

better by this measure than were the others.

The obvious distortion is that among all of the

commercially available thermal control devices

used in today’s modern intensive care nurseries,

not one is designed to recreate the environmental

conditions that Beutow and Day documented as

best enhancing infant survival.

J.F.L. Silverman, Fertig, and Berger published data in

1958 comparing

the survival

of premature

infants

housed in humidified single-walled incubators

convectively heated to maintain air temperatures

of 28.3 C to 29.4 C to the survival of matched

infants cared for using incubators convectively

heated to maintain air temperatures of 31.1 C to

32.2 C. The infants in the warmer incubators had

a 20% higher survival rate than those in the colder

incubators.

Two articles appeared in 1964: one written by

Beutow, Klein, and Klein’ and the other by Day,

Caliguiri, Kamenski, and Ehrlich.2 In these

inde-pendent studies, the survival of infants cared for

in the incubator demonstrated to be beneficial in

the 1958 study by Silverman was compared to the

survival of infants cared for using a new incubator

described by Agate and Silverman in 1963. The

COMMENTARIES 667

enclosed humidified device that was ventilated by

a forced air system. It differed from the old

incubator in that it was heated by an overhead

radiant heat source that warmed when the

infant’s skin temperature fell below a preset

value. In the studies reported by Beutow and

Day, a specific preset skin temperature value of

36 C arbitrarily was selected for purposes of

control. In both studies, infants cared for in the

enclosed, ventilated, humidified, and skin

servo-controlled radiantly heated incubators had 20%

higher survival rates than did comparable babies

cared for in the incubators that were only

convec-tively heated to maintain air temperatures of 31.1

C to 32.2 C. Although we still do not know why

babies in this special incubator did so well,

hypotheses concerning the mechanisms can be

generated from what we do know about the

environment created within the chamber of the

device.’

For example, the incubator environment was

extremely stable. Apnea induced by sudden

thermal changes may have been minimized

because of this stability.5 The incubator top wall

was heated to about 38 C and the air temperature

cycled in a very narrow band around 32 C. In

such an incubator, conductive heat losses are

probably of no consequence and, when

humid-ifed, the evaporative heat losses are minimal.

Using the published wall and air temperatures as

factors, it can be calculated that the

environ-mental or, more correctly, operative temperature

in the incubator chamber was around 35 C when

the infant’s skin temperature was around 36 C.6

The resulting narrow gradient of 1 C between the

environment and skin temperatures would have

been expected to reduce heat losses to a minimum

level, and a baby contained in such an incubator

very likely would be in what has been defined as a

“neutral thermal environment,” an environment

in which an infant has no need to perform extra

metabolic work to defend a normal body

temper-ature.7

That neutral thermal conditions actually

existed within this incubator when an infant’s skin

temperature was maintained at 36 C was

suggested in a 1966 study by Silverman, Sinclair,

and Agate.8 This could be used to support what

has become a distorted, albeit logical, conclusion

that preservation of energy is related to the

demonstrated enhancement of survival. However,

the following statement made by Silverman in

1964 still is valid today:

It would seem quite reasonable to assume that the set of conditions which permits the neonate to perform physiologic

functions at the lowest energy cost should be associated with the highest rate of infant survival. Although the “neutral” thermal state should satisfy this survival requirement, it must be emphasized that the assumption has not been subject to a critical test and as a result we must await more evidence before it can be accepted.9

As mechanistic guesswork sometimes is of

potential value, it is also always dangerous and

does not alter our iguorance of facts. The only

facts of which we are not ignorant is that babies

survived better in the special incubator and that

this incubator is no longer manufactured.

The only modern-day device that has been

documented to cause what appears to be a

duplication of the favorable environmental

char-acteristics is a computer-controlled enclosed

incubator system described in 1976.’ In a clinical

trial, this computerized incubator also was

demonstrated to improve infant survival. This

trial again supports the previous conclusion that,

whatever the mechanism, the environment

studied by Beutow and Day can be of great

benefit to premature well-being. But even this

conclusion must be accepted with caution since

the computerized environment has never actually

been proved to be the same as the environment

sanctioned by Beutow and Day. In fact, the only

certain similarities that the computer-controlled

system shares with the radiantly heated enclosed

incubator are that it is one of the few that has

been subject to clinical testing and that it is also

commercially unavailable.

In spite of the uncontested accumulation of

evidence to support the clinical use of the

radi-antly heated enclosed incubator, marketing of the

device was abandoned. Production was stopped

because of real problems that developed with

materials used in the manufacture of the

incuba-tor. These problems, although not

insurmount-able, were considered unworthy of solution since

easier and alternative methods were available to

keep a baby’s skin temperature controlled to a

preset value. The presumption, at the time, was

that maintenance of such a fixed skin temperature

is the only really critical single factor that makes

incubators good for babies. This was not only a

presumption; it was presumptious, since a study

has never been published in which skin

tempera-ture is separated from the character of the

envi-ronment used to achieve this superficial skin

temperature control. In fact, as demonstrated by

Day in 1941, there is nothing known to be

physiologically normal about a baby when its

temperature is fixed at a particular degree.”

In any case, without evident justification, skin

temperature has become the focus of control

at Viet Nam:AAP Sponsored on September 8, 2020

www.aappublications.org/news

design in incubator manufacture. This focus is

evident in the design of both convectively heated

enclosed incubators and the radiantly heated

unenclosed incubators, neither of which has ever

been proved safe or appropriate for infant care.

The generally unstable and stressful

environ-mental characteristics within servocontrolled

convectively heated incubators have been fairly

well documented.45’2 The environment within

the chamber of such a device is bizarre, almost to

the point of unpredictability, and bears little

similarity to the stable, relatively predictable

climate that existed in the abandoned radiantly

heated enclosed incubator.

Because the use of available convectively

heated systems is without scientific basis, it is easy

to be lenient with the increasing use of similarly

unproven, open, radiantly heated devices to keep

babies warm. The argument usually offered in

support of this practice includes the fact that

infant accessibility is improved when impeding

walls are removed from the warming device.

Although this may be a fair argument if

accessi-bility is the subject of discussion, it is an irrelevant argument when discussing ways to provide babies

with thermal protection that has been

docu-mented to enhance infant survival. It must be

emphasized that the lack of published clinical

proof and of favorable evidence that open radiant

heaters are appropriate for use during the care of

premature infants, is not offset in the slightest by

the too frequently heard offhand claim that many

nurseries use only radiant heaters and never have

any temperature control problems. If such

state-ments are tnie, they should be docuniented and

published. If untrue, they may well be viewed as

another example of our propensity for creating

new bandwagons to add to the historical parade

of therapeutic mistakes.

Obviously, the challenge of this commentary

extends far beyond simply stimulating physicians

to demand that manufacturers reproduce the

radiantly heated, convectively ventilated

en-closed incubator. Such a reproduction would not

be very difficult since, unlike the whispered

thoughts of children, the design of the abandoned

incubator has been preserved in the original,

undistorted, published, and unchallenged articles

of Silverman, Beutow, and Day. But, in this era of

advances in newborn care, retreat to past

tech-nology would be an anomaly since the continuing

authoritative preeminence of 13-year-old data

does not necessarily establish that the data are

definitive, or for that matter, even pertinent

when applied to the care of any particular infant.

Best use of the data that exist will only be possible

by careful review of the established facts and by

designing studies to test the limits of our present

and very incomplete information.

The data of Beutow, Day, and Silverman is

often interpreted as a demonstration of the mortal

importance of keeping all infants warm. This is

one example, among many, of a conclusion that

needs limit testing. Their studies did not prove

that thermal differences influenced the survival of

all babies, but affected, rather, only a very limited

and well-defined group of infants. In particular,

the only demonstrably sensitive population

included those infants with respiratory distress

syndrome who weighed between 800 and 1500

gui. It may be appropriate to provide exquisite

protection for all premature infants, but this

conclusion is unsupportable using any of the data

thus far published. In addition, interference with

homeothermal adaptation, cardiorespiratory

function, auditory and visual development, and

other physiologic and social mechanisms when

infants are exposed to manufactured

environ-ments has only been suggested by existing studies,

but these implications provide just cause for

temperance when considering the routine

place-ment of all infants in severely controlled thermal

environments. More than a need for temperance,

however, is the need for expanded data.

Unfortunately, fresh studies that deal with

problems in neonatal thermal regulation are very

few at present. It would appear that the state of

our knowledge of controlled thermal

environ-ments rests on a plateau as research talents are

directed toward other vital interests. Pending a

renewal of data gathering, it is, at the very least, a

time for great caution.

Distorted logic has led to the design of

incuba-tors in use today. These incubators give no more

assurance of providing infants with appropriate

thermal protection than children are provided

assurance of safety when using commercially

available toys. Remember, an inappropriate

incu-bator can keep a baby warm just as an unsafe toy

can make a child laugh. Everyone knows that

some children die laughing.

PAUL

H.

M.D.

College of Medicine

231 Bethesda Avenue

Cincinnati,

REFERENCES

COMMENTARIES 669 2. Day RL, Galiguiri L, Kamenski C, et al: Body

tempera-ture and survival of premature infants. Pediatrics

34:171, 1964.

3. Silverman WA, Fertig JW, Berger AP: The influence of the thermal environment upon the survival of newly horn premature infants. Pediatrics 22:886, 1958.

4. Agate FJ, Silverman WA The control of body temper-ature in the human premature infant by low energy infra-red radiation. Anat Rec 136:152, 1960. 5. Perlstein PH, Edwards NK, Sutherland JM: Apnea in

premature infants and incubator-air-temperature changes. N Lug! I ItI(’(l 282:461, 1970.

6. Hey EN, Mount LE: Heat losses from babies in incuba-tors. Arch DLc Child 42:75, 1967.

7. Adamsons K Jr, Gandy GM, James LS: The influence of

thermal factors upon oxygen consumption of newborn human infant. I Pediatr 66:495, 1965. 8. Silverman WA, Sinclair JC, Agate FJ Jr: The oxygen (‘Oct

of minor changes in heat balance of small newborn infants. Acta Paediatr Scand 55:294, 1966.

9. Silverman WA: Diagnosis and treatment: Use and misuse of temperature and humidity in care of the

newborn infant. Pediatrics 3,3:277, 1964.

10. Perlstein PH, Edwards NK, Atherton HD, Sutherland JM: Computer-assisted newborn intensive care.

Pediatrics 57:495, 1976.

11. Day RL: Regulation of body temperature during sleep.

Am I Dis Child 61:734, 1941.

12. Ayrmsley-Green A, Roberton NRC, Rolfe P: Air temper-ature recordings in infant incubators. A re/i Di.c

Child 50:218, 1975.

JOHN LOCKE IN 1684 DESCRIBES THE REMARKABLE RECOVERY OF A

6.YEAR-OLD DUTCH GIRL FROM A DREADFUL BURN OF THE SCALP

While visiting the medical school at Leyden in 1684, John Locke

(1632-1704), the celebrated English physician and philosopher, met Dr. Lucas

Schacht (1634-1689) who showed him the remarkable case of a 6-year-old girl

who had recovered after having lost about one third of her skull from a

frightful burn.

Locke wrote the following (his spelling has been retained):

Frid. Nov. 17 [1684]. I was Sarah Vander Speck a girle about 6#{189}years old a great part of whose scul I had seen yesterday by Dr. Schafte [Schachtl who is professor mnagnificims. viz. 2 of occipitis and a great part of the 2 ossa bregmatis which togeather could not I think be lesse then #{189} of the scull.

The story in short is this. This girle when she was about 1#{189}old being left alone by the fire in her standing stoole fell down on the hearth and was found lying with her head neare the moderately snial turf fire at her mothers returne quite senselesse. She had lain there soe long that not only her head clothes and haire were burnt but the flesh of her head also and the bones of her scul which were afterwards taken out were burnt black on the out side, and retaine that colour still, the fire seemeing also by the appearance it has still to have penetrated the inside of the scul but not soe as to make it blak. The uper part also of one (I thinke her right) eare was burnt away. This accident happend on the 6th December. She was in this posture committed to the care of a chynirgiois of the towne, since dead, who seeing soe dangerous a case desired a physitian might be joyned to him soe Professor Schaft was cald under whose care the case soe well succeeded that though they tooke out about a 3d part of the scul for the os occipitis was taken oimt with the ossa bregmatis as far as the os frontis forwards and as low almost as the top of the ears on both sides, yet all the time she had not any the least soporiferous or convulsive accident or any feaver onl’ one fit of a tertian which was oweing to an other occasion. The pieces of the scul began to be taken out in May following the burning and they are in 3 peices in the custody of Dr. Schaft. The girle is now fat and plump eats and drinkes sleeps and enjoys a good health and sense as any of her age and condition, goes to schoole and plays as brisquell amongst her companions onl’ when she falls some times the jolt will set her head a bleeding to that degree that the mother has

apprehensions of the great 1

REFERENCE

Noted by T. E. C., Jr., M.D.

1. Dewhurst K: Jo/mn Locke (16.32-1704), Physician and Philosopher. London, The Wellcome Historical Medical Library, 1963, pp viii, 264, 265.

at Viet Nam:AAP Sponsored on September 8, 2020

www.aappublications.org/news

1978;61;666

Pediatrics

Paul H. Perlstein

Games with children

Services

Updated Information &

http://pediatrics.aappublications.org/content/61/4/666

including high resolution figures, can be found at:

Permissions & Licensing

http://www.aappublications.org/site/misc/Permissions.xhtml

entirety can be found online at:

Information about reproducing this article in parts (figures, tables) or in its

Reprints

1978;61;666

Pediatrics

Paul H. Perlstein

Games with children

http://pediatrics.aappublications.org/content/61/4/666

the World Wide Web at:

The online version of this article, along with updated information and services, is located on

American Academy of Pediatrics. All rights reserved. Print ISSN: 1073-0397.

American Academy of Pediatrics, 345 Park Avenue, Itasca, Illinois, 60143. Copyright © 1978 by the

been published continuously since 1948. Pediatrics is owned, published, and trademarked by the

Pediatrics is the official journal of the American Academy of Pediatrics. A monthly publication, it has

at Viet Nam:AAP Sponsored on September 8, 2020

www.aappublications.org/news