SotsiaalministeeriumGonsiori 29, 15027 Tallinn

V.a. Taavi Rõivasminister

22.11.2013Tallinn

EttepanekHaigete vastsündinud ja enneaegsete laste intensiivravi koos perekeskse lähenemise ning hooldusega.

Pöördun Teie poole ettepakuga arvestada uue lastekaitseseaduse väljatöötamisel haigete vastsündinud ja enneaegsete laste huve, kelledel on probleeme tervisega ja nad viibivad haiglas intensiivravi ja spetsialiseeritud osakondades. Sünnitus- ja vastsündinute abi on siiani enamasti olnud peamiselt tervelt sündinud vastsündinud laste keskne. Kahjuks haigete vastsündinute ja eriti enneaegsete (sügavalt enneaegsete) laste ja nende emade (perede) õiguseid on jätkuvalt piiratud. Peame vajalikuks tagada emadele rinnaga toitmise eelised ning lastevanematele, hooldajatele ööpäevaringne ja pidev kontakt oma lapsega juba intensiivravi osakonnas. Peame oluliseks lapse huvidest lähtuvalt kujundada nii lapse kui ka ema(pere) õigusi haiglas läbi perekeskse lähenemise ning hoolduse põhimõtete.

Tõdeme, et lapse õigus tervisele, ravivahenditele ja tervise taastamisele on aastatega paranenud ja Eesti Vabariigi tervishoiusüsteem on teinud märkimisväärsed sammud vähendamaks imikute ja laste suremust. Sügavalt enneaegsete laste osas oleme ette jõudnud paljudest arenenud riikidest ja laste ellujäämise näitaja on praegu 92%. Madal on aga meil elukvaliteedi näitajad. Perekeskne abi haigetele vastsündinutele ja enneaegsete lastele aitab tunduvalt parandada ka elukvaliteeti. MTÜ Lastekaitse Liit vanematekogu arutas haigete vastsündinute ja enneaegsete laste intensiivravi temaatikat koos perekeskse lähenemisega oma korralisel koosolekul 20.sept. 2013.a. kaasates arutellu hr. Dr. Adik Levin´i. Konstateerime, et keskkonnale täiendavalt on vajalik edendada arusaame ja samme perekonna toimetuleku parandamiseks lapse arendamisel, kasvatamise, tervise toetamisel ja seda just vanemate kaudu, keda meditsiin aitab, arstid toetavad.

Pean vajalikuks seega juhtida Teie tähelepanu haigete vastsündinud ja enneaegsete laste meditsiini- ja tervishoiuküsimustele, rinnaga toitmise eelistele ja lapse arenguks olulise lähedussuhte vajadusele emaga. Koostöös Sotsiaalministeeriumiga pean oluliseks püüdlust täiendada Lapse Õiguste Konventsioon, artikkel 24 lõige e) ja kujundada uute lastekaitseseadust eesmärgiga, et kindlustada meditsiini- ja tervishoiusüsteemis lapsevanematele ja lastele informeeritus, hariduse kättesaadavus ning toetus põhiliste teadmiste rakendamisel, mis puudutavad lapse tervist ja toitmist, rinnaga toitmise eeliseid mitte ainult tervetele vastsündinutele aga ka haigetele ja enneaegsete lastele juba intensiivravi osakonnas, tagades ema(pere) ööpäevaringne pidev kontakt oma lapsega, hügieeni, keskkonnatingimuste parandamist ning õnnetusjuhtumite vältimist. Lisa 1: Vastsündinute intensiivravi koos perekeskse lähenemise ja hooldusega

Lugupidamisega

Alar Tammjuhataja

Lisa 1STRENGTHENING NEWBORN INTENSIVE CARE

In recent decades considerable advances have been made in strengthening perinatal care by focusing on evidence-based obstetric practices together with a family-centred approach. Evidence-based knowledge has provided striking and much-needed technological improvement in maternal and newborn care, but the application of a family-centred approach, particularly when complications develop in pregnancy and childbirth, has been deficient. Family-centred care is based on recognition of human rights in perinatal care. While maternal rights have been increasingly recognised – through, for example, the emerging emphasis on the importance of non-coerced and unbiased informed choice and consent by mothers – the recognition of neonatal rights has lagged far behind. While rooming-in and close maternal newborn contact for normal term babies was initiated as early as 1982, (1) and has become an increasingly accepted maternal right worldwide, at least for normal term babies, such practices are still rarely found in neonatal intensive care units globally. This letter is a sincere and urgent appeal to the United Nations and other global, professional agencies to raise awareness of, and to address, this gap in human rights, and family-centred care, in neonatal intensive care centers.

For decades, high-tech neonatal intensive care units have not given sufficient attention to the human rights of newborns. In most centers, attention has been paid primarily to the physical aspect of a baby’s health, neglecting the equally important emotional and social health necessary for development of a whole human being. At such a time they are psychologically vulnerable. Close contact with their infant and participation in decisions about their baby’s care is every new family’s right, yet they may be excluded from the NICU environment for some, if not for much of the postnatal hospitalization period. Caregivers may avoid working in an open, participatory manner that allows and encourages mothers and families to see and hear everything that happens to her or their child. Open disclosure and collaborative decision making about care requires that caregivers explain to parents the need for tests and treatments for their infant, often resulting in the reduction of unnecessary tests (2). The former Soviet Union provides a striking case study of an approach that isolates the parents from the infant’s care. This system is still in place in many of its health care centres. The Soviet system never allowed mothers to see their babies in the NICUs by order of the Moscow Health Minister. Postpartum mothers were considered to pose a threat of infection to their children. The ideology of the Western world and the totalitarian power of physicians in neonatal departments created the myth that they were ‘almighty’ and could treat children without the presence – or permission - of the mother (family). Mothers of infants in NICUs in the Soviet Union were expected to play the so-called ‘guest-mother’ role to be able to see their children, often only once a week, with fathers being totally prohibited from visiting. While this approach is, perhaps extreme, it is by no means unique to the former Soviet Union countries.

Two alternative, but to some extent complimentary, approaches to maternal and newborn care have emerged over the past few decades, one in the West and the other in a former Soviet country – Estonia. The Baby Friendly Hospital Initiative (BFHI) was developed in the West in the 1990s and was introduced into the former Soviet Union and other countries at about this time, firmly establishing the importance, and practice of breastfeeding newborns, particularly normal, term infants. Strongly supported by United Nations agencies such as WHO and UNICEF, this program went far in creating awareness of optimal feeding methods and the importance of maternal-newborn contact and closeness from birth onwards. It was not, however, directly addressed towards the newborn requiring intensive care. In addition, its

focus was on the importance of breastfeeding, rather than on the inherent needs, and rights, of both the mother (family) and the newborn to have psychologically sensitive and supportive care in addition to good clinical practice. Both the onwards. It was not, however, directly addressed towards the newborn requiring intensive care. In addition, its focus was on the importance of breastfeeding, rather than on the inherent needs, and rights, of both the mother (family) and the newborn to have psychologically sensitive and supportive care in addition to good clinical practice. Both the BFHI’s lack of attention to the NICU setting as well as its neglect of the rights of parents and newborns to sensitive and supportive comprehensive obstetric and postpartum care were clearly voiced by Chalmers in the British Journal of Obstetrics and Gynaecology in 2004 (3) .

In contrast, in 1979, a decade prior to the development of the Baby Friendly Hospital Initiative in the West, a more comprehensive approach to neonatal intensive care was introduced into Estonia by Dr Adik Levin, a neonatologist at the Tallinn Children’s Hospital. This approach – the Family Centred Neonatal Care Initiative (formerly called the Humane Neonatal Care Initiative) emphasised both the importance of breastfeeding babies in NICUs as well as the crucial role played by mothers and fathers in providing love and continuous, close physical contact with their sick and preterm newborns from the earliest possible moments after birth. (4-13). Parental involvement in the physical care of their premature and/or sick infant was also essential in providing adequate technical care – prompted by a shortage of nursing staff at the time. It is well acknowledged that when normal term babies are unwell, their mother’s (and father’s) love and close contact provide much needed (and clinically beneficial) emotional and psychological support for both the infant and its parents. Yet this need in preterm and sick newborns has been regarded as of minimal or no importance in contrast to the overarching importance of high-tech, impersonal, medical care provided in isolated incubators or NICUs away from parental interference and controlled by autonomous health care professionals. In addition to providing emotional support for their newborns, encouraging mothers and fathers to play an active and close participatory role in the NICU setting also contributes to more careful and measured clinical care from caregivers who are held accountable to the parents. Such sentiments are endorsed by the Pucon Declaration regarding the ‘Humane Neonatal Care Initiative’ (attached).

In recent decades, evidence-based practice in obstetric and neonatal care has been clearly acknowledged globally and increasingly frequently introduced. At the same time there has been growing awareness that psychosocially sensitive and family centred care during pregnancy and at labour and birth, are also crucial to providing a psychologically healthy start to the new family. Again, these developments have largely but not exclusively – been applied to the normal pregnancy. Today, it is incomprehensible to believe that ‘good’ (and satisfying) parenting experiences and practice – including the challenging task of caring for a sick and preterm newborn - could be conceived of occurring without tremendous emotional and practical support for such parents, both at the time of birth and in the following postnatal period. With the rise of preterm obstetric intervention (particularly induction), increased use of assisted reproductive technologies, as well as the increasing rate of birth among older mothers – all of which are contributing to an increased number of newborns being admitted to NICUs - the importance of providing psychologically supportive care during pregnancy, at birth and especially when their infants are admitted to NICUs, is becoming increasingly crucial.

While the UNICEF/ WHO Baby Friendly Hospital Initiative was eagerly supported for a decade or so following its introduction in the early 1990s, (14) financial and organizational

support from these UN Agencies has been largely withdrawn in recent years. Sadly this support was lost before the movement could be clearly extended into NICUs or to encouraging psychologically supportive obstetric and neonatal care that respected human rights of the newborn and mother or support from these UN Agencies has been largely withdrawn in recent years. Sadly this support was lost before the movement could be clearly extended into NICUs or to encouraging psychologically supportive obstetric and neonatal care that respected human rights of the newborn and mother or family. In recent years an Oslo based group has drawn attention to the need to apply the breastfeeding principles incorporated in the Baby Friendly Hospital Initiative into the NICU setting.(15) While this movement to enhance the use of human milk in the NICU is to be admired, it again relegates the importance of acknowledging the human rights and psychological needs of sick and preterm newborns, to a secondary role. It falls short of taking a necessary and comprehensive approach to providing optimal care for babies admitted to NICUs – one that ideally incorporates rooming-in of mothers with their babies 24/7, breastfeeding and/or breastmilk, ideally with the newborn’s own mother’s milk, and maternal or family care of the baby in the NICU in conjunction with professional medical attention. Such dedicated care by parents would ideally be supported by leave conditions for both parents to support the mother’s stay in the NICU with her baby. This program requires a clear recognition of the human rights and psychological needs of both parents and their sick and preterm newborns. The Oslo development threatens to repeat this error of omission by focussing primarily on the breastfeeding of newborns in NICUs without fully considering and developing a program that incorporates the psychological needs as well as the human rights of newborns and their parents in this environment. This letter serves as an urgent request to consider the matter in its full context and not to, yet again, provide an incomplete approach, as proposed by the Oslo initiative, to resolving this issue.

The name ‘Baby Friendly Hospital Initiative’ has, in reality, been largely misleading. It is, in essence and as originally conceived, a Breastfeeding Friendly Hospital Initiative. To be truly ‘Baby Friendly’, hospitals need to incorporate both breastfeeding support as well as ‘friendly’ or emotionally and psychosocially supportive obstetric and neonatal care, which is respectful of the human rights of babies and their parents. Further, the most admirable Convention on the Rights of the Child, while stimulating significant improvement in the care of children, has paid little attention to the rights of the newborn and particularly to a family-centred approach to their care in addition to breastfeeding. We appeal to you to truly live up to the full potential of the name “Baby Friendly Hospital Initiative’ in future developments. It is our sincere hope and wish that the Committee for the Rights of the Child (CRC), the headquarters of the WHO in Geneva, and such regional offices as Copenhagen and New York, as well as the headquarters of UNICEF in Geneva and New York, at least, will heed our appeal to take urgent action to meet the rights and needs of newborns and their parents in NICU settings in the most comprehensive and appropriate manner. We urgently request that this appeal be directed towards the United Nations General Assembly for adoption during forthcoming discussions on breastfeeding. Specifically, we suggest that the wording of Article 24 (e) of the Convention on the Rights of the Child be amended to read:

“To ensure that all segments of society, in particular parents and children, are informed, have access to education and are supported in the use of basic knowledge of child health and nutrition, the advantages of breastfeeding, which includes healthy newborns, and also infants admitted to the intensive care unit where the mother (family) has full access to the baby, hygiene and environmental sanitation and the prevention of accidents.”

The signatories to this letter call upon you to discuss the problem of how to protect both the rights of children (newborn and premature) and mothers (families) in hospitals/ maternity hospitals as well as to draw up an internationally accepted relevant program /document. The professionals who have signed this letter are all staunch supporters of breastfeeding, having contributed to strengthening breastfeeding of all newborns, but also stand for the human rights of both children and mothers (families) as a priority. We pledge our support and assistance in developing such a comprehensive program.

Signatories:

Dr Adik Levin MD, Ph.D, MSc. D.FABM.Head of Neonatal and Infant Department 1979-2004, Tallinn Children’s HospitalCandidate UN CRC from Estonia 2004-2005Tallinn Estonia Dr Beverley Chalmers DSc(Med); PhDAdj Full Professor, Department of Obstetrics and GynaecologyAffiliate Investigator, Ottawa Hospital Research UnitUniversity of OttawaOttawa Canada

Co-Signatories:

Liis Aedmaa,   Art History BD, Writer, Source Breath therapist, mother of two, TallinnEstonia

Professor Elza Akhmadeeva, MD, PhDChair, Department of Pediatrics Bashkir State Medical UniversityChair of the Bashkir Branch of Russian Association of Specialists in Perinatal MedicineRussia

Professor Leila Akhmadeeva, MD, PhD, MBA, JDProfessor, Department of Neurology, Neurosurgery and Medical GeneticsChair, International OfficeBashkir State Medical UniversityChair of the Bashkir Branch of Interregional Society of Specialists in Evidence Based MedicineRussia

Dr Concepción de Alba, PhD MDAssistant Physician in the Department of Neonatology, Hospital 12 de octubre, Madrid, SpainProfessional in NIDCAPProfessor in Paediatrics UCMIBCLC

Spain

Dr .Lembe Allik,Paediatrician MD, NGO Empowering Birth board member, Source Breath therapist, Birth supporter, mother of threeViljandi Estonia

Dr Pille Andresson MDPresident of the Estonian Perinatology Association (altogether 136 registered members).Lecturer at Tallinn Health Care College.Chief of Neonatology Department of Women’s ClinicEast-Tallinn Central HospitalTallinn Estonia

Dr Polina Andriyanova,Intern, Department of Pediatrics and Neonatology, Penza Regional Institute of Improvement of DoctorsMinistry of Public Health of the Russian Federation, Penza Russia

Dr Juan Denegri Arce Doctor en MedicinaProfesor PrincipalFacultad de Medicina de la Universidad Nacional Mayor de San MarcosLima Perú

Dr Alla Astafieva, Assistant, Department of Pediatrics and Neonatology, Penza Regional Institute of Improvement of DoctorsMinistry of Public Health of the Russian Federation, Penza Russia Kadri Aua Lawer,Breath therapist,  Source Birth supporter, mother of threeTartu Estonia

Dr Pille Andresson MDPresident of the Estonian Perinatology Association Lecturer at Tallinn Health Care College.Chief of Neonatology Department of Women’s ClinicEast-Tallinn Central HospitalTallinn Estonia

Inge Bachaus  NGO Empowering Birth board member,  Source Breath therapist, Birth supporter, mother of three, Tartu Estonia

Dr Nadia BadrawiChair of the BoardNile Badrawi HospitalProf.of Pediatrics & NeonatologyCairo University Egypt

Dr Elizabeth Vilca BallónMédico PediatraPresidente Comité de Apoyo a la Lactancia MaternaHospital Regional del CuscoDocente Universidad Andina del CuscoCusco Perú

Dr Maksim Bazhenov, Head Doctor, Penza Regional Children’s Clinical Hospital nam. N.F.Filatova, Penza Russia

Dra. Julia María Sánchez BermúdezPediatra IBCLCComité de Lactancia MaternaInstituto Nacional de Salud del NiñoLima Perú

Dr Magno W. Santillana BlossiersMédico Pediatra Hospital Nacional Sergio E. BernalesProfesor Universidad Nacional Mayor de San Marcos Lima Perú

Dr Dariya Bratishcheva, Intern, Department of Pediatrics and Neonatology, Penza Regional Institute of Improvement of doctorsMinistry of Public Health of the Russian Federation, Penza Russia

Dr. Mario Moreno Camacho.Pediatra NeonatólogoHospital Provincial Docente Ambato-EcuadorCatedrático Universidad Central del Ecuador y Universidad Técnica de  AmbatoQuito Ecuador

Dra. Virginia Garaycochea Cannon Médico PediatraInstituto Nacional de Salud del NiñoLima Perú

Dr Adriano Cattaneo, MD, MScInstitute for Maternal and Child HealthTrieste Italy

Dery Centeno M.Pediatra Neonatóloga, IBCLCHospital Santa RosaLima Perú

Dr Svetlana Chernitsova, Intern, Department of Pediatrics and Neonatology, Penza Regional Institute of Improvement of doctorsMinistry of Public Health of the Russian Federation, Penza Russia

Dr Carmen ChíncaroPediatra NeonatólogaHospital Nacional Guillermo Almenara, ESSALUDLima Perú

Dr Mariana Colmenares. MD, Pediatrician, IBCLC. Hospital Médica Sur TlalpanMéxico CityMexico

Karina Cristina Hernández CórdovaPediatra Neonatóloga Lima Perú

Binnie A DansbyBS degree from New York University in Art Education Creator SOURCE Process and Breathwork and Ecstatic, Empowering Birth,

North American Pre and Perinatal Psychology and Health Association, Founding member of Global Professional Breathwork Alliance, Author, Teacher, Therapist, Motivational SpeakerLamberhurst, Kent UK

Patrice DeMarcoMotherbaby UnitFletcher Allen Health CareBurlington, Vermont USA

Dr Galina Dolgushkina, Associate Professor, Department of Pediatrics and Neonatology, Penza Regional Institute of Improvement of DoctorsMinistry of Public Health of the Russian Federation, Penza Russia

Dr Marilú Chiang EcheniquePediatraDirectora de Desarrollo HumanoAsociación Benéfica PrismaLima Perú

Dr Anne Eglash MD, FABM, IBCLCClinical ProfessorDept of Family MedicineMedical Director UW Lactation ClinicUniversity of Wisconsin School of Medicine and Public HealthMount Horeb, WisconsinUSA

María Elena FloresLic. NutricionistaEquipo TécnicoDirección General de Promoción de SaludMinisterio de SaludLima Perú

Dr Lydia Furman MD FAAPAssociate Professor of PediatricsRainbow Babies and Children's HospitalCleveland, OhioUSA

Dr Ramziya Galeeva, Associate Professor, Department of Pediatrics and Neonatology,

Penza Regional Institute of Improvement of DoctorsMinistry of Public Health of the Russian Federation, Penza Russia

Lic. Laura GervillaCoordinadora del Programa de Lactancia Materna de la  Fundación Regional El Niño SimónAragua Venezuela.

Vilma Teresa Suárez GigaLic. en Enfermería - IBCLCResponsable Capacitación Materno Infantil "Proyecto en Manos de Mujeres"Future GenerationsLima Perú

Dr Sanjeeva S.P.Godakandage,MBBS (Ruhuna),MSc Com.Med. (Colombo),MD Com.Med.(Colombo),PGC Nutri.Med.(Surrey)Consultant Community Physician,Member of the Academy of Breastfeeding MedicineMember of the South Asia Infant Feeding Research NetworkFamily Health Bureau/Ministry of Health,Colombo Sri Lanka.

Dr Elena Govorova, Resident, Department of Pediatrics and Neonatology, Penza Regional Institute of Improvement of DoctorsMinistry of Public Health of the Russian Federation, Penza Russia

Dr Carmen Gutiérrez GutiérrezPediatra, Neonatóloga IBCLCServicio de Neonatología del Hospital Regional Docente Las MercedesProfesora de la Universidad de Chiclayo-Universidad San Martin de PorresPast Decana del Consejo regional VIII del Colegio Médico del Perú Presidenta Sociedad Peruana de Pediatría Filial LambayequeChiclayo,Perú

Gladys Guevara R.Lic. EnfermeraHospital Santa Rosa, Lima Perú

Katrin HeinrichPsychologist, Source  breath therapist, mother of three Viljandi Estonia

Kadi Helme Medical Student in Tartu University, NGO Empowering Birth board member, mother of oneTartu Estonia

Dr Carmen Eva Zegarra HinostrozaPediatraProfesora Asociada de la Universidad Nacional Pedro Ruiz GalloLambayeque Perú

Dr Justus G HofmeyrEffective Care Research Unit, University of the Witwatersrand/FortHare; Eastern Cape Department of Health.South Africa

Dr Isabel Rodríguez HernándezMagister en Enfermería - Salud Materno PerinatalUniversidad Nacional de ColombiaBogotá, Colombia

Dr Gail M Herrine, MD, FACOG, IBCLC, FABMAssistant Professor of Obstetrics and GynecologyTemple Medical SchoolMedical Director Postpartum UnitTemple University HospitalWomen's Care at NortheasternPhiladelphia USA

Dr Luis Huicho , MD,Pediatrician, Principal Professor of Universidad Nacional Mayor de San Marcos,LimaPerú

Dr Ilya Ilyin, Intern, Department of Pediatrics and Neonatology, Penza Regional Institute of Improvement of doctorsMinistry of Public Health of the Russian Federation, Penza

Russia

Dr Valentin Imamkulov, Intern, Department of Pediatrics and Neonatology, Penza Regional Institute of Improvement of doctorsMinistry of Public Health of the Russian Federation, Penza Russia

Dr Nanette Jolly MB BCh IBCLCPort ElizabethSouth Africa

Dr Janusz Kaczorowski PhDProfessor and Research DirectorHolder of the Docteur Sadok Besrour Endowed Chair in Family Medicine Holder of the GSK-CIHR (GlaxoSmithKline-Canadian Institutes of Health Research) Endowed Chair in Optimal Management of Chronic DiseaseDepartment of Family and Emergency MedicineUniversity of MontrealUniversity of Montreal Hospital Research Centre (CRCHUM)Head: Health Care Systems and Services, Hôtel-Dieu Canada

Tiiu Kõrran, RNVice-president, Estonian Nurse UnionTallinn Estonia

Dr Michael S. Kramer, MDProfessor,Departments of Pediatrics and of Epidemiology, Biostatistics and Occupational Health, McGill University, Faculty of MedicineMontreal Canada

Dr Nora KleinAssociate Clinical Professor, PediatricsBaylor College of Medicine, Houston, TexasFellow of American Academy of Pediatrics: breastfeeding SectionFellow of the Academy of Breastfeeding MedicineMember, Texas Pediatric and Houston Medical SocietiesUSA

Marina Koroljova, RNHeadnurse, Department of Newborn and InfantTallinn Children´s HospitalTallinn Estonia

Dr Tatiana Kuptsova, Resident, Department of Pediatrics and Neonatology, Penza Regional Institute of Improvement of DoctorsMinistry of Public Health of the Russian Federation, Penza Russia

Dr Miriam Labbok MD MPH IBCLC FACPM FABM FILCAProfessorDirector, Carolina Global Breastfeeding InstituteDepartment of Maternal and Child Health University of North Carolina Chapel Hill USA

Dr Leonardo Landa-Rivera MDPediatricianAPILAM - Association for Research and Promotion of BreastfeedingDenia Spain

Dr Kathy Leeper, MD, IBCLC, FABM Medical Director, Milkworks- a nonprofit breastfeeding centerLincoln, NE USA

Dr Mira Leibovich MD. IBCLC, Family Medicine SpecialistMaayanei Hayeshua Medical Center, Newborn nursery and NICURabin Medical Center - Beilinson Hospital, Newborn nurseryBreastfeeding medicine Israel

Dr Elena Loktionova, Intern, Department of Pediatrics and Neonatology, Penza Regional Institute of Improvement of doctorsMinistry of Public Health of the Russian Federation, Penza Russia

Dr Marceli Torres LozanoMédico PediatraJefe de Dpto. de PediatríaHospital de BarrancaLima Perú

Dr Jenny Zavaleta LujánLic. Obstetra Capacitadora del Programa SICAP

Instituto Nacional Materno PerinatalDocente  del Departamento de Obstetricia Facultad de Medicina de la Universidad Nacional Mayor de San MarcosLima Perú

Dr Manuel Sánchez Luna, MD, PhDPresident of the Committee of Standards of the Spanish Society of NeonatologyVice-President of the Union of European Neonatal and Perinatal Societies, UENPS.Vice-President of the World Association of Perinatal MedicineAssociate Professor of PaediatricsDirector of the Neonatology Division and NICUHospital General Universitario "Gregorio Marañón"Madrid Spain

Dr Marina Maksimova, Assistant, Department of Pediatrics and Neonatology, Penza Regional Institute of Improvement of DoctorsMinistry of Public Health of the Russian Federation, Penza Russia

Lic. María  Cristina MalerbaCoordinadora del Equipo de Lactancia Neonatología y Maternidad Trinidad PalermoBuenos Aires Argentina

Dr Iris Pecho ManyariLic. en EnfermeríaUniversidad Peruana Cayetano HerediaLima Perú

Dr Marie-Claude MarchandPediatrician, IBCLCFrance

Dr Guido Mayorga, MD, Pediatrician, Neonatologist, Chief of Neonatology Service of the National Hospital Edgardo Rebagliati and Professor of the Universidad Nacional Mayor de San Marcos. Lima Peru

Dr Guido MayorgaPediatra NeonatólogoJefe de Servicio de Neonatología del Hospital Nacional E. Rebagliati MartinsLima Perú

Ülle MielerBreath therapist,  Birth supporter, mother of fourViljandi Estonia

Dr Angélica Vera MechánLic. Enfermera Esp. en Neonataología Coordinadora UCIN del Hospital Regional LambayequeLambayeque Perú

Marianne Metsanurm-Psychologist at  private school Oonüks, Breath therapist,Keila Estonia 

Jocelina MilluyPuéricultrice- IBCLC, Référente IHABCentre Hospitalier de RoubaixNéonatologieRoubaixFrance

Dr Marianela MugaburuObstetrician, Lactation Specialist and Nursing Student atMiami Children HospitalMiami, Florida USA

Dr Asya S. Mu’min, CPT, MD, MC, US ARMYTripler Army Medical CenterHonolulu, HawaiiUSA

Dr Cristian Andonaire MunaicoPediatra Hospital Emergencias PediátricasAsesor Técnico en Atención Integral - DGSP MINSAProfesor de la Universidad Nacional Mayor de San MarcosLima Perú

Svetlana Müürsepp, RNNurse, Department of Newborn and InfantTallinn Children´s HospitalTallinn, Estonia

Dr Atle MoenHead consultant dr.medDept. of Pediatrics Drammen SykehusVestre Viken Vospital Trust Estonia

Dra. Graciela Nakachi Pediatra Intensivista Instituto Nacional de Salud del NiñoProfesora Principal de PediatriaUniversidad Nacional Mayor de San MarcosLima Perú

Dr Audrey Naylor. MD, DrPH, FAAP, FABMPresident and CEOWellstart International andClinical Professor of PediatricsUniversity of Vermont College of MedicineUSA

Joanna Nemrava, RMPresident/Présidente, Canadian Association of Midwives/Association canadienne des sages-femmesMontreal, Quebec Canada

Dr Ketevan Nemsadze, M.D PhD,FABM, Corresponding member Georgian National Academy of ScienceGeorgia

Dr Victoria Nichols-Johnson, MD, MS, FACOG, FABMProfessor Emerita, Ob/GynSIU School of MedicineUSA

Dr Makiko Ohyama, M.D,PhD, IBCLCDivision of NeonatologyKanagawa Children's Medical CenterJapan

María del Socorro Jiménez Olivares NCJefa del Laboratorio de Nutrición Centenario Hospital Miguel Hidalgo de AguascalientesAguascalientes, México 

Dr Mauro Meza Olivera PediatraJefe de Dpto. de Pediatria y NeonatologíaHospital Regional JA Mendoza O.

Tumbes Perú

Dr Gillian Opie, MBBS, IBCLC, FRACPNeonatal PaediatricianHead of Unit, Mercy Health Breastmilk BankCoordinator Growth and Development ClinicDepartment of PaediatricsMercy Hospital for WomenHeidelberg, Victoria Australia

Ester Öpik, RN, MNScPresident, Estonian Nurse UnionTallinn Estonia

Dr Anne OrmissonAssociate Professor emeritusDepartment of PediatricsUniversity of Tartu, Estonia

Sallie Page-Goertz, MN APRN, IBCLC, FILCAClinical Associate Professor of PediatricsKansas University School of MedicineUSA

Dr Fernando Pinto, MD Pediatrician, Child Neurologist Full Professor of the University of Chile Past-Director, Paediatric, Infant Surgery and Child Neurology Department,University of Chile Past-¨President of the Chilean Pediatric Society. Past Director of the Chilean Society of Pediatric Neurology Past Vice¨President of the Chilean Society of Ultrasound in Medicine. Head of Pediatric Department,Coyhaique Hospital.Chile

Dr Yvette Piovanetti MD FAAP FABM400 Domenech suite 413Hato Rey Puerto Rico

Dr Aleksandr Povolotsky, Intern, Department of Pediatrics and Neonatology, Penza Regional Institute of Improvement of doctorsMinistry of Public Health of the Russian Federation, Penza

Russia

Dr Ivan Prokofiev, Intern, Department of Pediatrics and Neonatology, Penza Regional Institute of Improvement of doctorsMinistry of Public Health of the Russian Federation, Penza, Russia

Dr Larisa Radchenko, Associate Professor, Department of Pediatrics and Neonatology, Penza Regional Institute of Improvement of DoctorsMinistry of Public Health of the Russian Federation, Penza Russia

Dr Milagro Raffo MD, IBCLCPediatrician - NeonatologistAssociate Professor of PediatricsUniversidad Nacional Mayor de San MarcosLima Perú.

Dr Mario R. Ramírez MD FABMPediatricianTorre Auxilio Mutuo Suite 815Hato Rey Puerto Rico 

Dr Marcus RenatoPediatra, IBCLCDocente do Departamento de Pediatria da Faculdade de Medicina - UFRJRio de Janeiro Brasil

Dr Mary RenfrewProfessor of Mother and Infant HealthMother and Infant Research UnitSchool of Nursing and Midwifery Director, Applied Health ResearchCollege of Medicine, Dentistry, and NursingUniversity of DundeeDundee UK

Dr. Juan Rivera, MD, Pediatrician, Gastroenterologist from The National Institute of the Child Health (INSN; Instituto Nacional de Salud del Niño), Perú.

Isabel Rodríguez,Registered nurse Colombia

Merit RooksBreath therapist, IT specialist, mother of fourViljandi Estonia

Dr Elien Rouw, MD, FABMMother/Child Health Care GermanyIm Wasserbett BühlGermany

Katrin Schneider,Teacher MA , Albion Reisid Ltd. Sales manager, Source Breath therapist, Birth supporter, Rannametsa, mother of threeHäädemeeste vald, Pärnumaa Estonia

Argo Schneider , Tteacher MA, Albion Reisid Ltd. managing director, Breath therapist, father of threeRannametsa, Häädemeeste vald, Pärnumaa Estonia

Dr Yuliya Shcherbakova, Resident and laboratory assistantDepartment of Pediatrics and Neonatology, Penza Regional Institute of Improvement of DoctorsMinistry of Public Health of the Russian Federation, Penza Russia

Dr. Roberto Shimabuku Pediatria-NeonatólogoInstituto Nacional de Salud del Niño Profesor Principal de la Universidad Nacional Mayor de San Marcos Lima Perú

Dr Dina Shlyaposhnikova, Intern, Department of Pediatrics and Neonatology, Penza Regional Institute of Improvement of doctorsMinistry of Public Health of the Russian Federation, Penza

Russia

Dr Margarita Taipe Silva.Pediatra. IBCLC.Hospital "San Juan Bautista" de Huaral Lima Perú

Professor Villoriy Strukov, Head, Department of Pediatrics and Neonatology, Penza Regional Institute of Improvement of Doctors of Ministry of Public Health of the Russian Federation, Penza Russia

Vilma Suárez, Registered nurse and IBCLC Lima Perú

Moonika Tammel  OÜ Gravidos Midwife, Breath therapist, Source Birth supporter, mother of twoRapla Estonia

Dr Gladys Rosa Cruz TapiaPediatraProfesora Asociada de PediatríaFacultad de Medicina "San Fernando"Universidad Nacional Mayor de San MarcosLima Perú

Dr Vallo Tillmann, MD, PhD Professor of Paediatrics Chairman Children’s Clinic of Tartu University Hospital Tartu Estonia

Dr Liis Toome, MDPresident of the Estonian Pediatric AssociationHead of the Department of Newborns and Infants,Tallinn Children's Hospital, Tallinn Estonia

Prof. Dominique TurckGastroenterology & NutritionDepartment of Paediatrics

Jeanne de Flandre Children's Hospital, Lille University HospitalsFaculty of Medicine, University of Lille, Lille France

Ere Uibu, MSc, RNUniversity of TartuFaculty of MedicineDepartment of Nursing ScienceTartuEstonia

Gerli Usberg, RNBoard member, Estonian Nurses UnionTartuEstonia

Ken-Marti Vaher,Minister of the InteriorMember of Estonian Government Estonia

Dr Heili Varendi, MD, PhD Associate professor of paediatrics University of Tartu Estonia

Triin Värnik Source Breath therapist, mother of two Tallinn Estonia

Lic. Carmen Villarreal VerdeNutricionista Docente-Ex Directora y Miembro del Comité Asesor de laEscuela Académico Profesional de Nutrición y Miembro Investigador del Instituto Nacional de Biología Andina Universidad Nacional Mayor de San Marcos Miembro de la Sociedad Peruana de Nutrición (SOPENUT)Lima Perú

Dr Matias Viera, MDPaediatricianPast Prsident Punta Arenaas Pediatric Society,Subsidiary of Sociedad Chilena de PediatriaFormer Head Pediatric Dept, Hospital Arenas Punta Arenas, Chile

Dr Rosa María Valle VillónEnfermera Especialista en Salud Publica          Ministerio de SaludLima Perú

Dr Ylia Espinoza Vivas MD, PhDPediatra NeonatólogaProfesora de Pediatría Universidad Nacional Mayor de San MarcosLima Perú

Dr Ekaterina Volkonitina, Intern, Department of Pediatrics and Neonatology, Penza Regional Institute of Improvement of doctorsMinistry of Public Health of the Russian Federation, Penza Russia

Dr Julie Ware, MD, MPH, IBCLC, FAAP, FABMAll Better Pediatrics, Breastfeeding MedicineChair, Shelby County Breastfeeding CoalitionTN AAP Co-Chapter Breastfeeding CoordinatorUSA

Dr  Nancy E. Wight MD, IBCLC, FABM, FAAP Attending Neonatologist, Sharp Mary Birch Hospital for Women Medical Director, Sharp HealthCare Lactation Service San Diego, California USA

Dr Anna Yarkina, Intern, Department of Pediatrics and Neonatology, Penza Regional Institute of Improvement of doctorsMinistry of Public Health of the Russian Federation, Penza Russia

Dr Rosa Victoria Saona YarmasEnfermera de Salud Pública con Especialidad en Crecimiento/Desarrollo del Niño/FamiliaConsejera Nacional de Lactancia MaternaAsesora en el Área Madre-Niño, Colegio de Enfermeros del Perú Consejera Domiciliaria de Lactancia Materna y Cuidado Humano del Recién NacidoPeru

Dr Irena Zakarija-Grkovic, MD, FRACGP, IBCLC, PhDABM member Croatia

Dr Héctor Pereyra ZaldívarMédico Pediatra y SalubristaPast-Coordinador del Capítulo de Pediatría Social - Sociedad Peruana de PediatríaCoordinador del Departamento Académico de Medicina Preventiva y Salud PúblicaFacultad de Medicina - Universidad Nacional Mayor de San MarcosLima Perú

Dr Ledda Zelada Enfermera-Especialista en NeonatologíaJefe del Departamento de Enfermería del Hospital Santa RosaProfesora- Coordinadora General de Post Grado de la Segunda Especialidad de Enfermería de la Universidad Nacional Federico Villarreal. Lima Perú

Dr Vladislav Zhiganov, Intern, Department of Pediatrics and Neonatology, Penza Regional Institute of Improvement of doctorsMinistry of Public Health of the Russian Federation, Penza Russia

References:

1. Klaus HM, Kennel JH. Parent-infant bonding. 2nd ed. St Louis: CV Mosby, 1982

2. Levin A. Where are you going, neonatal medicine? (Letter to the Editor). News and views from Estonia. Initiative Crit Care Nurs 1995; 11: 49-52.

3. Chalmers, B. The Baby Friendly Hospital Initiative: Where Next? British Journal of Obstetrics and Gynaecology, 2004, 111(3), 198-199.

4. Levin A. The Mother-Infant Unit at Tallinn Children’s Hospital, Estonia: A.Truly Baby-Friendly Unit. Birth 1994;21: 39-44.

5. Harrison L and.Klaus M, Commentary: A Lesson from Eastern Europe“ Birth 21:1 March 1994;45-6.

6. Levin A., von Mühlendahl KE Familienfreundlichkeit von Kinderkrankenhäusern in Estland und Deutschland. Internationale Sozialpädiatrie 1994;16(7): 430-431.

7. Levin A. Humane Neonatal Care Initiative. Viewpoint. Acta Paediatrica 1999; 88: 353-355.

8. Kennell JH . The Humane Neonatal Care Initiative Acta Pædiatrica 1999; 88: 367 -370.

9. Chalmers B, Levin A. Humane Perinatal Care. TEA Publishers, Tallinn, 2000 .

10. Medical-Psychological Work with Mothers in Neonatal Unit. VI Jornada Chileno - Argentina de Pediatria: Cuidados Humanos en la Pediatria del III Mileno. Coyhaique, Chile. 17-19.April 2000.

11. Tecnicas de Humanizacion en el Manejo del Prematuro. XLI Congreso Chileno de Pediatria. Pucon (Chile) 28 de Noviembre al 1 de Deciembre 2001. Pucon Declaration 28.11.2001 Pucon Chile.

12. Levin.A Letter to Editor Are NICUs Baby-Friendly or Breastfeeding-Friendly? Birth, 2013; 40(2) 152-153.

13. O’Brien K, Bracht M, MacDonnell K, McBride T, Robson K, O’Leary L, Christie K, Galarza M, Dicky T, Levin A, Lee SK. A pilot cohort analytic study of Family Integrated Care in a Canadian neonatal intensive care unit. BMC Pregnancy and Childbirth 2013, 13 (Suppl 1):S12 doi:10.1186/1471-2393-13-S1-S12.

14. Wolf H, Charrondiere R, Helsing E. First "baby-friendly" hospital in Europe. Lancet 1993, 341: 440.

15. The BFHI Initiative in Neonatal Units. Proposal from a Nordic and Quebec working group. Three guiding principles and ten steps supporting Breastfeeding and Family/centered care. Draft for the 1st International conference and workshop on the expansion of the Baby Friendly Hospital Initiative in Neonatal Units. 14 th-16th September 2011 in Uppsala, Sweden

PUCON DECLARATIONXLI Chilean Paediatric Congress. Pueõn, Chile, November 28, 2001

The Chilean Society of Paediatrics is committed to promote the"HUMANIZATION OF PERINATAL PAEDIATRICS". This commitment means to put emphasis on maternaI involvement in the care of thenewborn and preterm infant as well as on the protection of the rights to be breastfed,to develop a sound mother-child bonding and to get a good care in everycircumstance, including the hospitalization in intensive care units.

This Society wishes to acknowledge the extreme value and positive consequences of the" Baby Friendly Hospitals" initiative and states its recognition to PAHO/WHO,UNICEF and other international organizations working to spread these ideas whichhave been planted in our and other countries.

Our commitment goes beyond the protection of breastfeeding for a minimun of sixmonths and extends to maternaI involvement and inclusion of the mother as an active-not passive- protagonist of child care ideally with the longest possible contact with her ehiId, namely during the 24 hours of the day.

Furthermore, points to the highest rationalization of laboratory tests and treatments to diminish or eliminate physical and psychological pain and to support skin contactbetween mother and ehiId.

In accordance with these statements during the XLI Chilean Paediatric Congress inPucon, Chile, this society and all its members, in the presence of Professor AdikLevin subscribe and endorse the 11 points of the Tallin Hospital, Estonia,methodology: "The Humane Neonatal Care Initiative" aimed to the humanization ofnewborn care.

To accomplish this goal our institution invites all the Paediatric Societies of theworld to subscribe to this declaration and asks for support from all the internationalorganizations working for the health, well being and rights of Man and Child.