07 – The Incubator Hoax?

Definition: Incubator

Merriam Webster: 

one that incubates: such as

a : an apparatus by which eggs are hatched artificially

b : an apparatus with a chamber used to provide controlled environmental conditions especially for the cultivation of microorganisms or the care and protection of premature or sick babies

c : an organisation or place that aids the development of new business ventures especially by providing low-cost commercial space, management assistance, or shared services.

Early History:

Wikipaedia: An incubator (or isolette) is an apparatus used to maintain environmental conditions suitable for a neonate (newborn baby). It is used in preterm births or for some ill full-term babies. https://en.wikipedia.org/wiki/Neonatal_intensive_care_unit#Incubator

According to official history, ‘doctors took an increasing role in childbirth from the eighteenth century [the beginning of time?] onwards. However the the care of newborn babies, sick or well, remained largely in the hands of mothers and midwives. (Ibid.)

[Hoax alert] The next part of the history I’m quoting in full for the lulz. http:// https://columbiasurgery.org/news/2015/08/06/history-medicine-incubator-babies-coney-island

“It took a war, famine, and poultry to develop the technological breakthrough responsible for saving thousands of premature infants.  The Franco-Prussian war in 1870-1871, along with a concomitant famine, had contributed to a significant population decline in France.  To increase the growth rate, the French needed to start having more babies, as quickly as possible. But one obstetrician realized that if he could find a way to reduce infant mortality, then the population growth rate problem could be solved far sooner.

That French obstetrician was Dr. Étienne Stéphane Tarnier, who, having observed the benefits of warming chambers for poultry at the Paris Zoo, had similar chambers constructed for premature infants under his care. These warm air incubators, introduced at L’Hôpital Paris Maternité in 1880, were the first of their kind. Dr. Pierre Budin began publishing reports of the successes of these incubators in 1888. His incubators had solved the deadly problem of thermoregulation that many premature babies faced.

Dr. Budin wanted to share his innovation with the world, but few in the stubborn medical establishment would listen. Many doctors viewed the practice as pseudo-scientific and outside the realm of standard care. But Dr. Budin was convinced that the Tarnier incubators would save so many lives that he enlisted the help of an associate, Dr. Martin Couney, in exhibiting the new incubators at the World Exposition in Berlin in 1896.

Apparently blessed with skills in showmanship as well as medicine, Dr. Couney took the assignment perhaps a step farther than what Dr. Budin has originally anticipated; Couney asked the Berlin Charity Hospital to borrow some premature babies for this experiment, and they granted his request, thinking that the children had little chance of survival anyway. When he managed to hire a cadre of nurses to fully demonstrate the capabilities of the incubators, he was ready to take the show on the road.

Nestled between exhibits of the Congo Village and the Tyrolean Yodelers, “Couney’s Kinderbrutanstalt,” or ‘Child Hatchery,’ became a wild success. Remarkably, all six babies in the Tarnier incubators survived. From there, Couney took his entourage to the United States where he went on to share his show at virtually every large exhibition and at the World’s Fair. 

He ultimately settled at New York City’s Coney Island amusement park and connected parents eager to save the lives of their premature newborns with circus sideshow visitors willing to pay 25¢ to view the uncannily tiny babies. It was an odd connection indeed, but a brilliant one that kept the warming glow of the incubator lights on for over 40 years, and saved thousands of babies in the process.”

Roll up, roll up, 25c for the chance to see the premature babies. For one week only, dressed in dinosaur costumes, they end the show playing the Titanic theme on kazoos. 

Key Points:

  • Incubators had solved the deadly problem of thermoregulation that many premature babies faced.” 
  • The reason for the continued use of incubators is that they improve the chances of premature neonatal survival.  

Here is the crux of the issue:  incubators are the solution to the problem of thermoregulation and that is the reason why they are still in use. We will see that the artificial environment of the incubator is harmful to the neonate, but the medical experts view this is as  acceptable and necessary because they improve the chances of premature neonatal survival.

Incubator problems

 An initial investigation into the potential harmful effects of incubator exposure lead me to the following lines from an abstract published in the Journal of Perinatal Medicine:

The infant incubator in the neonatal intensive care unit: unresolved issues and future developments. By Antonucci R1, Porcella A, Fanos V, J Perinat Med. 2009;37(6):587-98. doi: 10.1515/JPM.2009.109. https://www.ncbi.nlm.nih.gov/pubmed/19591569

  1. “An unresolved issue is exposure to high noise levels in the Neonatal Intensive Care Unit (NICU).”
  2. “…ambient NICU illumination may cause visual pathway sequelae or possibly retinopathy of prematurity (ROP), while premature exposure to continuous lighting may adversely affect the rest-activity patterns of the newborn”
  3. “The impact of electromagnetic fields (EMFs) on infant health is still unclear. However, future incubators should be designed to minimize the EMF exposure of the newborn.”
  • Well not too bad considering the only alternative is death. Thems the breaks.

 Some further investigation led me to investigate the potential harmful effects of incubators, and Neonatal Intensive Care Units (NICU) in general, on cognitive development. Our first port of call is ‘Impact of the NICU environment on language deprivation in preterm infants’ by Katherine Rand & Amir Lahav. http://www.littlegiraffefoundation.org/images/files/file/RandLahav_2013_NICU%20environment%20and%20language%20deprivation.pdf.

Summary of key points:

  1. Premature birth often leads to compromised neurodevelopment (1–3). One primary problem evident in the preterm population is atypical language development. 
  2. Even in the absence of a known brain injury, approximately 25–30% of preterm infants experience difficulties in language acquisition, which at school age often surface as general behavioural emotional problems, poor verbal comprehension, attention deficits and lower intelligence quotient (IQ)
  3.  Brain imaging studies have shown that neonatal white matter abnormalities at term, are correlated with preterm infant’s neurocognitive outcomes and expressive language assessments at preschool age. White matter abnormalities have also been associated with language subdomains of phonological awareness, semantics, grammar and discourse, but not pragmatics.
  4. Both the incubator and single-room NICU design increase social isolation, cause language deprivation and may heighten the risk of atypical language development.  
  5. Most human conversations in a multibed NICU design are blocked by ambient noise, depriving the infant of meaningful language stimulation.  
  6. Exposure to human speech during the neonatal period, especially mother’s voice, adds linguistic value that can be crucial for the initial wiring of the brain for language acquisition

The paper does not state to what degree cognitive retardation is caused by prematurity when compared with NICU and incubator care. From the tenor of the paper I would suggest that they are indicating that NICU and incubator care is the primary factor but the reader will need to determine this for themselves. The authors make suggestions on how to redesign the NICU units and protocols to increase maternal-neonatal auditory contact, but do not suggest that there is an alternative to said interventions.

As this article develops, please bear in mind the similarities between, the cognitive harm which is associated with infant prematurity, and the known cognitive harm caused by incubators.

 But again, all in all, not too bad if the alternative is death. Thems the breaks.

Potential harm of incubator noise levels.

Apart from these neuro-cognitive developmental problems, there are the broader effects of the incubator noise levels on a neonate. My first clue was from an abstract originally published in the International Journal of Pediatric Otorhinolaryngology: https://www.ncbi.nlm.nih.gov/pubmed/29501298

  1. Preterm infants usually have to spend a long time in an incubator, excessive noise in which can have adverse physiological and psychological effects on neonates. In fact, incubator noise levels typically range from 45 to 70 dB but differences in this respect depend largely on the noise measuring method used. 
  2. A preterm infant in an incubator is exposed to noise levels clearly exceeding international recommendations even though such levels usually comply with the limit set in the standard IEC60601-2-19: 2009 (60 dBA) under normal conditions of use.

There it is, preterm infants are exposed to noise levels exceeding international recommendations and these can have adverse physiological and psychological effects. Whether the international recommendations can even be trusted I will leave that up to the reader. As a reference point, according to sciencedirect.com, rush hour traffic is 60-85 decibels.

The next point of investigation took me to the book, ‘Neonatal pain: Suffering, pain and risk of brain damage in the fetus and newborn,’ edited by Buonocore, Giuseppe, Bellieni, Carlo V. A section from the abstract for the book is illuminating for the traditional medical approach to neonatal care: https://www.springer.com/gp/book/9788847007321

Until the 1980s it was denied that fetuses and neonates feel pain. With the advent of a deeper understanding of the pathophysiology and new diagnostic tools, the last 30 years have seen great developments in this field, but the treatment of neonatal and fetal pain is still a controversial issue and a central topic, not only in specialties directly concerned with it, but also in bioethics’. 

Let me repeat, until the 1980s it was denied that neonates – newborn babies – feel pain. Even now it is a controversial issue! No wonder things are the way they are.

Particularly relevant in this book is chapter 15, ‘Physical Risk Agents in Incubators’ I will summarise the key points. The abstract if this chapter was intriguing enogh that I paid for access to the full text. There will be a tl:dr at the end as the next couple of pages will be a bit dry.

  1. Effects of exposure to noise:
    1. Auditory effects
      1. High levels of noise are responsible for hearing loss. 
        1. A correlation has been well assessed between noise level, exposure duration, and hearing loss.
      2. The auditory system damage risk starts at sound levels of the order of 78–80 dBA.
        1. The Outer Hair Cells (OHCs) of the inner ear are particularly sensitive to noise exposure.
        2. Above noise levels of 100–110 dBA, acute OHC damage effects can cause permanent hearing impairment, but OHCs show generally a good capability of recovering their functionality after acute exposure, 
        3.  A more subtle risk is associated with chronic exposure to much lower levels of noise (as low as 80 dBA), which can cause permanent damage of the OHCs if recovery cannot be fully reached before the next noise exposure.
      3. The immaturity of the neonate reduces the protection of the hearing system from intense noise in babies .
      4. Neonates could be particularly vulnerable to noise, and among them, preterm neonates, which are more commonly exposed for a rather long time to the incubator noisy environment, could be the most vulnerable.
    2. Non-auditory effects.
      1. The nonauditory effects of noise such as annoyance effect can induce psychological and somatic disturbances that can interfere with personal feeling and health, interpersonal relations.
      2. The sound levels that may induce annoyance can be very low.
      3. The most important non-auditory effects are relative to cardiovascular diseases, and sleep disturbances, while direct effects on psychopathology are still controversial.
  2. Noise sources in the incubator.
    1. The main noise sources in the incubator are:
      1. Incubator engine (continuous)
      2. Opening and closing portholes (transient)
      3. Temperature alarm (occasional, short duration)
      4. Baby crying (may be frequent, unpredictable duration)
    2. Incubator noise levels in this study:
      1. Incubator on- typically 50 dBA. Creates sleep annoyance. Very High cf. 
      2. Incubator off 24-36dBA
      3. 25-32dBA: Recommended hospital noise levels to prevent annoyance.
    3. Incubator noise levels in other studies: http:// https://www.ncbi.nlm.nih.gov/pubmed/22791088
      1. On –  68 dB(A) with all equipment switched on (approximately 10 times louder than recommended). 
      2. Incubator off – 53dbA
    4. Reverberating and Resonating characteristics of Incubators:
      1. 81-83dBA – noise levels of neonate crying.
      2. The reverberating and resonating characterising = +3dBA sound intensity 84-87dba
        1. dBA is logarithmic. 
        2. +3db = doubling sound intensity of the babies cry.
        3. See below for a commonly sold ‘elf and safety’ sign.
  1. The design of the incubator are such that it behaves as a resonating cavity which creates persistent standing waves. These can cause annoyance and hearing loss.
  2. Increased neonate sensitivity to noise:
    1. All of the above dBA safety, annoyance and harm levels are for adults.
    2. Research suggests higher noise vulnerability for neonates.
    3. “neonates could be particularly vulnerable to noise, and among them, preterm neonates, which are more commonly exposed for a rather long time to the incubator noisy environment, could be the most vulnerable.”
    4. Alternative study conclusion: “The sound levels, especially at low frequencies, within a modern incubator may reach levels that are likely to be harmful to the developing newborn” http:// https://www.ncbi.nlm.nih.gov/pubmed/22791088
  3. Exposure to Electromagnetic Fields (EMFs)
    1. Neonates in incubators are subject to non-ionizing radiation.
      1. At frequencies above 100 kHz, the main interaction effect is the local heating of tissues. 
        1. Neonates in incubators are not subject to levels this high chronically but maybe close to these levels acutely.
      2. However, risk agents such as non-ionizing radiation exposure may be especially harmful for children and particularly for neonates.
        1. Neonates in incubators are subject to chronic raised levels of non-ionising electromagnetic fields.
      3. Electromagnetic Fields (EMF): Long-Term Effects
        1. an association has been evidenced by some epidemiologic studies between residential exposure to EMF field and risk increase for childhood leukemia, and a possible effect has been hypothesized for brain cancer. 
        2. International Agency for Research on Cancer (IARC), in June 2001, decided to classify the ELF fields as possibly carcinogenic (2B group) for humans.
          1. 2B The agent is possibly carcinogenic for humans.
          2. Remember that EMF may be especially harmful for neonates who are chronically exposed.
          3. NB. There are other researchers whose studies undermine the link between childhood leukaemia and EMF exposures although this does not affect the other potential harms. https://www.sciencedaily.com/releases/2018/05/180521131746.htm
  4. TL:DR
    1. Neonates in incubators are subject to health risk due to physical agents such as noise and electromagnetic fields. (EMF).
    2.  The levels of exposure are near to thresholds for acute effects both in the case of noise and in the case of EMF. 
      1. Neonates are subject to these near acute thresholds chronically
        1. This can be from weeks to even months.
    3. Neonates are immature organisms in development, thus they are more sensitive than the general population to risk agents. 
    4. Imagine being born into an environment of chronic loud noise, at chronic levels that cause constant annoyance and sleep deprivation. Subject to acute levels that cause pain. The noise levels of crying doubled in intensity, and forming standing waves which exacerbate the effect.
    5. Chronic developmental exposure to EMF levels which in adults are possibly carcinogenic.

But again, not too bad if the alternative is death. Thems the breaks.

Further Effects of Incubator Noise and EMF exposure

Noise Exposure

Effect 1: Psychological: 

Social Isolation: http://www.littlegiraffefoundation.org/images/files/file/RandLahav_2013_NICU%20environment%20and%20language%20deprivation.pdf

  1. Both the incubator and single-room NICU design increase social isolation, cause language deprivation and may heighten the risk of atypical language development.  
  2. Most human conversations in a multibed NICU design are blocked by ambient noise, depriving the infant of meaningful language stimulation.  
  3. Exposure to human speech during the neonatal period, especially mother’s voice, adds linguistic value that can be crucial for the initial wiring of the brain for language

Imagine the effect on the baby who has spent nine months in an environment of direct contact with its mother to be separated and placed in an environment of social isolation where the noise levels are such that all other human conversations are blocked.

Effect 2. Physiological: http://www.scielo.br/scielo.php?pid=S0103-21002011000300009&script=sci_arttext&tlng=en

  1. “Preterm infants exposed to prolonged excessive noise are also at increased risk for hearing loss, abnormal brain and sensory development, and speech and language problems.
  2. The newborn body can present different responses, such as: hypoxia, release of adrenocorticotropic hormone and adrenaline in the blood stream, increase in heart rate, systemic vasoconstriction, pupil dilation, increase in blood and intracranial pressure, increase in oxygen consumption and caloric requirements, that can lead to delay in weight gain in the long term. The noise can lead to changes in infants’ states of sleep and wakefulness, making them annoyed and whining, hindering their development” http://www.scielo.br/scielo.php?pid=S0103-21002011000300009&script=sci_arttext&tlng=en

ELF-EMF exposure (extremely low frequency or power frequency fields)

The first study I turned to was a review by Prof. Carlo V. Bellieni, MD, Neonatal Intensive Care Unit, University of Siena, Siena, Italy; and Dr. Iole Pinto, PhD, Director, Physical Agents Laboratory, Tuscany Health and Safety Service, Siena, Italy. https://www.academia.edu/20494351/Fetal_and_Neonatal_Effects_of_EMF

Some of the highlights include:

  1. Although premature babies are often exposed to incubator ELF-EMF for months, little research has been done into the effects of EMFs on newborns, and most has regarded newborn animals.
  2. Those that have, ‘reported that the exposure to high electromagnetic fields can interfere with the sympathetic nervous system in altering babies’ heart rate variability. There is “a large body of information showing that the fetus and young child are more vulnerable than older persons are to chemicals [Makri A, et al. 2004] and ionizing radiation [Preston, 2004].”
  3. Even melatonin production – as was signaled in adults [Wilson et al. 1989] – was inhibited in the newborn by exposure to ELF-EMF [Bellieni et al. 2012b].
  4. “Important bioeffects and some adverse health effects of chronic exposure to low-intensity (nonthermal) non-ionizing radiation have been reported on babies, and important open questions still remain.”
  5. Conclusion: ELF-EMFs produced by incubators influence newborns’ HRV, showing an influence on their autonomous nervous system. More research is needed to assess possible long-term consequences, since premature newborns may be exposed to these high ELF-EMFs for months.

Some of these findings we have come across already. Two things that jumped out at me were the inhibition of melatonin production. Melatonin is produced by the pineal gland which means that the famous ‘third eye’ is being affected.

Also that “the exposure to high electromagnetic fields can interfere with the sympathetic nervous system in altering babies’ heart rate variability…HRV is an index of Autonomous Nervous System activity.” This line of research was hard to follow up but it seems that altered HRV and autonomic nervous system functioning is as a result of chronic stress and/or pain. E.g https://www.ctvnews.ca/incubator-may-alter-a-baby-s-heart-rate-study-1.292516

Kangaroo Care: an alternative?

What is kangaroo care: 

The article “A Comparison of Kangaroo Care Versus Traditional Nursery Care in Healthy, Term Neonates” (Janice Collins, Institute of Midwifery) gives a very good overview of kangaroo care. Here is a link for those interested in reading the entire article. The following abstract provides a very good summary:

Abstract

Kangaroo care is also known as kangaroo mother care, kangaroo baby care, and skin-to-skin care. Although the name varies based upon the geographic area, the concept is that of holding an infant, naked except for a diaper and hat, against the bare chest of an adult for the purpose of providing the infant with a neutral thermal environment, nurturing touch and enhanced opportunity to breast-feed. Most often this adult is the mother or father, but other adults may also provide kangaroo care. Once the infant is positioned upon the caregiver’s chest, a light cotton blanket is folded into fourths and then applied over the infant’s back and extremities. The theory underlying the effects of kangaroo care, is that human infants, like many mammalian infants, are physiologically programmed to achieve and maintain stabilization based upon sensory input derived from continuous physical contact with caregivers. Research has revealed that in premature or stressed infants, metabolic status and temperature stability are enhance both during and after kangaroo care (Bauer, Sontheimer, Fischer, Linderkamp, 1996; Ludington-Hoe, Anderson, Simpson, Hollingsead, Argote, Rey, 1999) Although numerous studies have explored the value of kangaroo care for premature or stressed newborns, the literature describing the effects of kangaroo care for healthy, full-term, newborns is scarce. 

The current predominant model of neonatal delivery room stabilization involves placing the infant in an open warmer immediately after delivery. By its very design, this practice immediately separates the mother and infant during a crucial period of extrauterine adaptation, and may be a venue for delayed neonatal physiological adaptation, reduced breast-feeding and impaired maternal infant bonding (Ludington-Hoe, Nguyen, Swinth and Satyshur, 2000). Kangaroo care represents a delivery room stabilization method superior to traditional methods in terms of cost effectiveness, improved neonatal physiological outcomes, increased breast-feeding initiation, and enhanced maternal- infant bonding (Ludington-Hoe, Anderson, Simpson, Hollingsead, Argote and Rey, 1999). The goal of this study is to explore the use of kangaroo care as a stabilization method for healthy, term neonates in the delivery room. This study will compare the variables of abdomen and toe temperatures, together with the oxygen saturation status of infants who receive kangaroo care at delivery, versus those infants receiving traditional nursery care at delivery.

The history of kangaroo care originated in Bogota, Columbia during the 1970s, as a method of caring for preterm infants. In the absence of incubators and other technical equipment, constant skin-to-skin contact was used as an alternative to maintain a neutral thermal environment. As we saw at the beginning, it is thermoregulation which is the reason that incubators are in use despite the harm that they cause to preterm infants.

Comparison of types of care:

Kangaroo Care: Positioning of a neonate, (naked except for a diaper and hat), prone and upright, between the breasts or upon the bare breast of the mother and underneath her clothing. A cotton blanket, folded into fourths may be placed over the infant’s back. (Ludington-Hoe, Anderson, Simpson, Hollingsead, Argote and Rey, 1999). 

Traditional Nursery Care: Conceptual definition: an inherited, established, or customary pattern of care, thought, action, belief or customs handed down from one generation to another. ( Websters, 1996) The immediate isolation of the neonate into a pre-warmed radiant warmer until rectal temps between 36.50 and 37.00 C are maintained. (Seidel, Rosenstein and Pathak, 2001)

Hospital delivery room stabilization is currently a technologically focused event in which the infant is immediately separated from the mother and placed in a radiant warmer. While this maneuver enhances access of medical personnel to the infant, its physiological benefit to neonates has been called into question. Rosenberg (2002) reminds us of the many physiological tasks the neonate must master in the first moments of extrauterine life: “thermoregulation, metabolic homeostasis, and respiratory gas exchange, as well as undergo the conversion from fetal to postnatal circulation pathways”. We are further reminded by Rosenberg (2002) that the neonatal period is “marked by the highest mortality rate in all of childhood”. This is a period requiring heightened caregiver vigilance and careful adherence to the midwifery principles of watchful waiting, and while supporting the natural events of neonatal extrauterine transition. 

I have emphasised the preceding points because they seem to me to indicate some important points. If we remember the official history that we were given, “‘doctors took an increasing role in childbirth from the eighteenth century [the beginning of time?] onwards. However the care of newborn babies, sick or well, remained largely in the hands of mothers and midwives’”

For me, the most important part of this study is the following:

This study demonstrated that maternal breast temperatures quickly reached the neutral thermal zone range required by their infant by the fifth minute of kangaroo care. Once infant abdominal temperatures reached 36.8 OC, the maternal breast temperatures only varied by 0.1 to 0.3 OC for the remainder of the kangaroo care period. Simultaneously, kangaroo care infants experienced increases in toe temperatures from 4.0 to 6.0 OC from pre-kangaroo care to kangaroo care, but these heat gains were reversed once the infants were returned to their incubators. It was additionally noted that maternal breast temperatures changed 4 times more frequently than did the incubators in the 3 hour kangaroo care period, and changed in 0.1OC increments. By contrast, the incubators did not change their environment’s temperature so minutely and did not respond as rapidly to the infant’s temperature. 

This study suggests that maternal physiology is, by design, a more responsive and superior form of neonatal thermoregulation. Infants allowed kangaroo care were quickly provided with a neutral thermal mircroclimate not only devoid of drafts and exquisitely sensitive to their changing thermal requirements, but also heat shielding. 

The mother’s breasts, as well as providing nourishing sustenance, provide a natural and more responsive form of neonatal thermoregulation than an incubator. I doubt whether even the most dedicated of mother’s could keep this up 24 hrs a day but here is where the father, the grandparents and siblings would be able to play their part in the survival of the baby. And best yet, this can all be done at home without the doctors influence.

NB. That enhanced developmental outcomes are demonstrated by low birth weight infants after kangaroo care.

The main focus of this study was a comparison between traditional nursery care and kangaroo care in healthy, term neonates. What is the effect of kangaroo care on pre-term, low birth weight babies?

Long-term health effects of premature birth:

The question I have been asking myself throughout my research is that, are the known long-term health effects of premature birth caused by the premature birth itself, or perhaps by the treatment that is given by the experts.

Here is a summary of some of the long-term health effects of premature birth: https://www.marchofdimes.org/complications/long-term-health-effects-of-premature-birth.asp

Premature birth can lead to long-term intellectual and developmental disabilities for babies. These can include

  • Learning
  • Communicating with others
  • Getting along with others
  • Taking care of himself

Some long-term disabilities caused by premature birth include:

  1. Behavior problems, including attention deficit hyperactivity disorder (also called ADHD) and anxiety
  2. Neurological disorders, like cerebral palsy, that affect the brain, spinal cord and nerves throughout the body

Premature birth can cause a baby to have lung and breathing problems, including:

  • Asthma, a health condition that affects the airways and can cause breathing problems
  • Bronchopulmonary dysplasia (also called BPD). This is a chronic lung disease that causes the lungs to grow abnormally or to be inflamed. Over time, the lungs usually get better, but a premature baby may have asthma-like symptoms throughout his life. 

Other long term health problems:

  • Intestinal problems, sometimes caused by a disease that affects premature babies called necrotizing enterocolitis (also called NEC).  
  • Infections. These can include pneumonia (infection of the lungs) and meningitis (infection of the brain).
  • Vision problems, like retinopathy of prematurity (ROP). Children born prematurely are more likely than children born on time to have vision problems.
  • Hearing loss, a common birth defect in premature babies. Children born prematurely are more likely to have hearing loss than children born on time.
  • Dental problems, including delayed tooth growth, changes in tooth color or teeth that grow crooked or out of place

Now I think it is likely that there will be some long-term health effects to premature birth, particularly in very low birth weight neonates. However, even from our cursory study we should notice that some of the long-term outcomes of premature birth are precisely those caused by incubators when compared to non-incubator babies and kangaroo care babies. In particular:

  1. The effects of social and maternal isolation:
    1. Learning
    2. Communicating with others
    3. Getting along with others
    4. Taking care of himself
    5. Behavior problems
  2. Retinopaty caused by light exposure
  3. Hearing loss due to noise exposure
  4. Higher levels of infection – possible cause is the reduced rates of breastfeeding c.f. Kangaroo care.

The question now comes down to kangaroo care vs incubators in preterm low birth weight babies. Can it really be that 24-hr incubator care and treatment by doctors is not only unnecessary, but also harmful. Can it be that a natural method of simple constant skin-to skin contact, not only with the mother, but also with the father and extended family, could not only alleviate many of the problems associated with premature birth, but also increase the survival rate of such children.

Kangaroo Care in Low Birth Weight Neonates

Definition of Kangaroo Care

Background Kangaroo mother care (KMC), originally defined as skin-to-skin contact between a mother and her newborn, frequent and exclusive or nearly exclusive breastfeeding, and early discharge from hospital, has been proposed as an alternative to conventional neonatal care for low birthweight (LBW) infants.

This definition comes from a review published in 2016 into 18 studies investigating KMC. Note that the definition includes an early discharge. The results which we are about to investigate include a preterm, low birthweight infant being discharged from hospital early.

From my research the following study, “Kangaroo mother care to reduce morbidity and mortality in low birthweight infants,” seems to be the largest meta-study conducted to date. I had my brain addled a bit reading through it. However, the plain language summary they provide does give a good overview. Some of the most important findings are:

Key results: 

  1. Compared with conventional neonatal care, KMC was found to reduce mortality at discharge or at 40 to 41 weeks’ postmenstrual age; 
    1. and at latest follow‐up, severe infection/sepsis, nosocomial infection/sepsis, hypothermia, severe illness, and lower respiratory tract disease. 
  2. Moreover, KMC increased weight, length, and head circumference gain, breastfeeding at discharge or at 40 to 41 weeks’ postmenstrual age;
    1.  and at one to three months’ follow‐up, mother satisfaction with method of infant care, some measures of maternal‐infant attachment, and home environment. 
  3. Researchers noted no differences in neurodevelopmental and neurosensory outcomes at 12 months’ corrected age.

These results were for continuous KMC (>20hrs). For intermittent KMC the results were inconclusive.

The conclusions of the study were that: “KMC is an effective and safe alternative to conventional neonatal care for LBW infants, mainly in resource‐limited countries.”

These recommendations are for stabilised LBW infants in low-middle income countries (LMICs). This is not because continuous KMC in comparatively ineffective in unstabilized and high-income countries (HICs), but because of the lack of trials to analyse. Or perhaps in other words, in high-income countries they haven’t put it into practice. I wondered if this is because of the understandable fear of going against the medical experts and their complicated technology.

Reading between the lines, as the natural KMC is the new, alternative therapy, and Incubators are the received medical good, natural treatment cannot be recommended without serious evidence. The artificial method is the dogma and the a priori truth. However, the beneficial effect of KMC on breastfeeding at 1-2 months follow up was also found in stabilized LBW infants in high-income countries. I am suggesting that the reason for the reticence in recommending KMC, is  because of the incompleteness of evidence for non-stabilized LBW infants and not because of its ineffectiveness. 

Now why are the recommendations only for resource-limited countries. Is that because the facilities in high-resource countries are far superior?

Even the World Health Organisation recognizes these results but again will only give its recommendations for low-middle income countries. The WHO summarised the findings as  follows:

Neonatal death: 

  • Compared with conventional care, KMC was associated with a 40% lower risk of mortality at discharge or 40–41 weeks postmenstrual age (RR 0.60, 95% CI 0.39–0.92; 8 studies, 1736 babies). 
  • A comparable result was obtained when the analysis was limited to the seven trials conducted in LMICs. In these seven trials, KMC was associated with a 43% reduction in mortality at discharge or 40–41 weeks postmenstrual age, compared to conventional care (RR 0.57, 95% CI 0.37–0.89). 

The only study from HICs that evaluated this outcome found no protective effect for KMC compared with conventional care. 

KMC, as compared with conventional care, was also associated with a 33% lower risk of all-cause mortality for infants at the latest follow-up (RR 0.67; 95% CI 0.48–0.95; 11 studies, 2167 babies). Nine studies conducted in LMICs showed that KMC resulted in a 35% reduction in the risk of mortality at the latest follow-up (RR 0.65, 95% CI 0.45–0.93; 2036 babies).

 In the two trials from HICs (with 131 preterm newborns), the evidence of an effect on mortality was inconclusive, with confidence intervals consistent with a possible 71% reduction as well as over five-fold higher risk of mortality at the latest follow-up (RR 1.25, 95% CI 0.29–5.42). 

Severe neonatal morbidity: Compared with conventional care, KMC was associated with a 44% reduction in the risk of severe infection at the latest follow-up (RR 0.56, 95% CI 0.40–0.78; 7 studies, 1343 babies). The intervention was also associated with a 55% lower risk of nosocomial infection at the time of discharge or at 40–41 weeks postmenstrual age (RR 0.45, 95% CI 0.27–0.76; 3 studies, 913 babies)

Intermittent KMC practice versus conventional care (EB Table 7c) Thirteen of the 18 identified trials in the main review implemented intermittent KMC. 

Neonatal death: From five studies involving 619 babies, there was inconclusive evidence regarding the benefit of intermittent KMC for reducing mortality up to the time of discharge or 40–41 weeks postmenstrual age, compared with conventional care (RR 0.59, 95% CI 0.19–1.81).

 Seven trials with 783 preterm babies also showed inconclusive evidence of reduction in the risk of mortality at the latest followup (RR 0.68, 95% CI 0.26–1.77). Severe neonatal morbidity: All the studies that reported the effects of KMC on hypo- and hyperthermia used intermittent KMC. There was a 66% lower risk of hypothermia at the time of discharge or at 40–41 weeks postmenstrual age (RR 0.34, 95 CI 0.17–0.67), but no significant reduction in the risk of hyperthermia (RR 0.79, 95% CI 0.59– 1.05). Compared with conventional care, intermittent KMC was associated with a 55% lower risk of severe infection at the latest follow-up visit (RR 0.45, 95% CI 0.28–0.73; 6 studies, 680 babies) and 61% lower risk of nosocomial infections at the time of discharge or at 40–41 weeks postmenstrual age (RR 0.39, 95% CI 0.16–0.67; 2 studies, 250 infants). 

For those interested in the results of continous Kangaroo Care for Preterm Infants a very good plain language summary may be found here: https://www.who.int/maternal_child_adolescent/documents/9241590351/en/

This document summarises the key points to be taken away from this article.

Conclusions:

This was a difficult article to write. My conscience was nagging me throughout. I am no medical expert and no expert in statistics. I am not a parent nor an expectant mother. What are my responsibilites in writing this?

I have attempted to read the available literature and summarise it as best as I can. The points which I hope to draw out were:

  • The strange history of incubators.
  • The known harm caused by incubators.
  • How the typical poor outcomes of preterm infants mirror the known harm caused by incubators.
  • That the main benefit of incubator is thermoregulation.
    • That there is a natural method of maternal/familial – neonate thermoregulation called Kangaroo Care.
      • Kangaroo Care seems to me to be intuitively a better solution.
      • Kangaroo Care seems to have good supporting evidence in respect to it being more effective at thermoregulation.
      • Kangaroo Care seems to have good supporting evidence at reducing the short, medium and long term negative outcomes of premature birth.
      • Is this because most of the negative outcomes of premature birth are being caused by the treatment i.e. Incubators?
      • That there will be some increased morbidity in preterm infants seems to be inevitable. Does this create fear and the salve to this fear is artificial environments and trust in experts.
  • For whatever reason, the continuous use of Kangaroo Care is only being supported in poor countries.
  • From reading the policies of hospitals in High Income Countries, only intermittent Kangaroo Care is being supported. This is only for a few hours a day which means that the harm caused by incubator care will still be affective on the infant.
  • Is a possible reason for this to be found allegorically in 1984?
    • That it is only necessary for the party members to be fully indoctrinated.
    • One of the Merriam Webster definitions we were given was: an organisation or place that aids the development of new business ventures especially by providing low-cost commercial space, management assistance, or shared services

Caveat

In this investigation, I came up against what Lesta Nediam described as “the lack of sufficient proof.” Any attempt to draw definite conclusions require some intuition and reading between the lines. This was why the title contains a question mark. My heart was torn over whether even to publish it. I can only imagine what it must be like for a mother to give birth to a significantly premature baby and be faced with the decision of what care to allow her baby to undergo. How difficult it would be to go against the experts. There is a chance that the premature baby may die or develop long-term complications irrespective of what treatment was used.

Because of our programming, for a mother who is being pushed towards incubator care, despite knowing the risks it will always seem like the alternative is infant death.

It seems to me that most of the recorded long-term complications are caused by incubators. If a mother chooses continuous Kangaroo Care, infant death or harm may occur anyway. However, with the programming we have received, the mother may feel or even be told that her folly in ignoring the experts is the reason that the infant died. Some may even blame me for writing this article. 

Finally, all I can say is that I have done my best to comb through the history and the literature and present it the best that I can. I would suggest that no one should rely on me as an expert anymore that any other expert and that they should do their own research. I may have made mistakes in my interpretation, but this is the point, in this world all we can do is investigate the material to the best of our ability and make the best decision that we are able to.

But after all the numbers and statistics, please remember the crux of the issue was that:

  • “Incubators had solved the deadly problem of thermoregulation that many premature babies faced.” 
  • The reason for the continued use of incubators is that they improve the chances of premature neonatal survival.  

Despite everything, we have seen that there is a natural solution to the problem of thermoregulation. Or perhaps more so, the problem of thermoregulation is a problem caused by the medicalisation of child birth and the removal of babies from their mothers. The solution to a non-existent problem is seemingly the cause of most of the negative outcomes of premature birth.

As always, it seems that we are left with insufficient evidence and perhaps, after having done one’s own research we are left with the following intuitive choice:

This:

Or This:

4 thoughts on “07 – The Incubator Hoax?

  1. I can see that this raised a big question as to whether to publish this article, I commend you for taking the decision to go ahead. It was indeed a big dilemma. However the studies you have presented really do say everything you need to know. Thank you for this, it was exceptionally well written, exceptionally well researched and when you happen on a dark topic, unfortunately we cannot just step over them, because they might upset a few people. TBH most people who would be upset by this probably would not have the ability to read it.

    Thank You Daibp, well done for this.

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  2. Excellent, excellent research! Great work.

    One thing, in my view you shouldn’t have hesitated over publishing this though, even for a second.

    You are trying to improve the state of general information in the world. Even if you had found an opposite conclusion you should have published this – someone might correct you, improve your research, etc. Anyway someone may get a huge benefit from your work.

    Also, you are not advising a specific individual as to what they should or shouldn’t do. Perhaps in such a case though the action of the good Samaritan would be to say that you are aware of information about incubators, and to them gauge for interest. Its a tricky one – one to ponder perhaps….

    But think about it from the other side. Doctors and the medical professions in general, advise specific individuals multiple times daily on what they should or shouldn’t do. Take statins, take insulin, take SSRIs, incubate your baby, etc, etc. Unlike you, they *only* see one side. Moreover, they have been trained wrt to psychology to have a particular “doctor’s manner” to convince an unconvinced individual. Worse still, although they shouldn’t, they sometimes take decisions into their own hands, regardless of explicit requests to the opposite. I know this from personal experience.

    So, where is their conscience here? Why are they unable to conduct their own research and provide a balanced view, as you have done? Well, they might say – ‘my education nor my refresher courses didn’t provide me with an update on this… What more could I do?’ It’s a joke. These ‘experts’ do *NOT* know their stuff.

    Part of the reason it is so bad is that they have been trained. Like puppies. They do not think for themselves. They cannot leave room for their conscience, otherwise – how could they get through the day? They do not do this research and instead choose to bury their heads and choose to trust a lying system. On the basis of their ‘education’ they will undertake a course of action that is very likely detrimental to huge numbers of individuals, without a second thought. In the cases you raise, the child, parents, wider family and friends, later generations, etc are all impacted. I’m genuinely unsure whether there are is any other profession that had caused as much physical harm to humanity as the medical profession. (I do exempt care givers – eg nurses – from that group.)

    I know there are some good doctors out there, but really, aren’t even they doing more harm than good if it’s within the system? If they do work from their conscience then great! Of course mistakes happen and things go wrong. I understand. But to take actions on others without having done the due moral diligence is not forgivable.

    Perhaps the only option for a doctor with a conscience is to quit working for the system and stop any actions that harm another. If they need to go into alternative medicine to do that, even if they take a hit on the financial side, in my view they should do that.

    To be honest, it’s wider than doctors – my view is that the only option for any of us with a conscience is to quit working for a system that causes harm. Believing the system’s lies over one’s own conscience is a childish failure of personal responsibility. I know that that’s harsh, but one cannot pretend that the actions you take in this life, at the expense of another, is right just because your degree/your mum/your boss/etc say so.

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  3. Brilliant work. Well-written, well-researched, and clearly well-intended.

    The structure is perfect; the conclusion is an ideal ‘tl;dr’ in a time when peoples attentions spans are, shall we say, ‘stretched’.

    Your overall presentation / thesis makes perfect sense to me. In my own words:

    i) Incubators are a rudimentary solution to a genuine problem.
    ii) Incubators cause a harm all of their own.
    iii) There are other ways to address the very problem which incubators are supposed to solve.

    With an implied conclusion being that the use of incubators is utterly absurd, and possibly even driven by malevolence.

    To look into specific elements of the Medical Hoax, especially with regards to prenatal and neonatal ‘care’ (e.g. ultrasounds, circumcision, vaccinations) is to peer into the heart of darkness of this realm.

    You have clearly spent considerable time doing just that, in order to produce this piece, and for your sacrifice — and you and I both know the sacrifice I am talking about — I cannot thank you enough.

    ‘He who fights with monsters’…

    I am going to go out of my way to promote this piece and I hope that you feel no lingering or residual concern about having published your findings. You have done good work.

    If, IF, there is some kind of ultimate judgement of ones overall contribution to the world around them, then as far as I have any conception if what ‘good’ is, then this piece of research and explication is a most heavy addition to the good side of your ledger, in my personal and humble opinion.

    Well done and thank you once again.

    [I can’t believe I didn’t think of the Incubator Hoax myself. It is all so obvious once you think about it, isn’t it? As in, the moment you start thinking about it, the whole thing is an obvious farce. How many more of these are there left to uncover? WATTBA.]

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    1. Hello JLB,

      sorry for taking so long to reply to your very insightful comment. I’ve noticed when you comment on a piece of my work that you are very good at picking up on the essence of what I was trying to say, or even on some emphasis that I made.

      “[I can’t believe I didn’t think of the Incubator Hoax myself. It is all so obvious once you think about it, isn’t it? As in, the moment you start thinking about it, the whole thing is an obvious farce. How many more of these are there left to uncover? WATTBA.” This is very true. It’s like everything is just sitting there waiting to be discovered. It’s not hiding in plain sight. It’s just not hiding.

      Thanks for promoting it on reddit. Not many people picked up on the key point (as they probably didn’t read it), which is really rather simple.

      The main and almost exclusive function of the incubator is thermoregulation. Kangaroo care is better at thermoregulation when compared. In unstable, very early neonates there isn’t enough data because the research hasn’t been done.

      And there in the reddit comments, people are banging on about incubators and thermoregulation.

      Like

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