Abstract
Does form follow function—or does function follow form? Nowhere is this question more pertinent than in the design of the care environment for the premature or sick neonate. In the early days of neonatology, the pediatric medical specialty focusing on neonates, the challenge was to reduce mortality, especially for infants born very prematurely. At that time, more than 90% of infants born weighing under 1 kilogram (kg) (2.2 pounds) did not survive. Because this challenge required frequent assessments of the infant at various times by physicians, nurses, respiratory therapists, and multitudes of other professionals and ancillary personnel, early neonatal intensive care units (NICUs) were most similar to post-anesthesia recovery areas: large, brightly lit, multipatient rooms bustling with activity throughout the day and night and accented by the sounds of monitor alarms, conversations, and equipment. As survival improved with advances in healthcare (currently about 90% survival is expected among babies born at < 1 kg birth weight), attention turned to the morbidities found in those survivors. Prominently noted were longer-term complications associated with the conditions being treated: chronic lung disease among infants afflicted with respiratory distress syndrome of prematurity or other lung diseases; growth retardation following feeding difficulties and/or intestinal complications such as necrotizing enterocolitis; and motor and cognitive impairments among infants encountering intracranial hemorrhages.
D. Kirk Hamilton, FAIA, FACHA, EDAC
However, some longer-term problems did not require a history of antecedent medical diseases or complications of prematurity; they evolved from prematurity itself—or at least we thought so! Perhaps first among these was retrolental fibroplasia, later renamed retinopathy of prematurity. This condition emerged among premature infants and initially was deemed to be multifactorial, but subsequently it was shown to be a complication of the excessive use of oxygen. When oxygen use was thereafter limited, the ocular complication was replaced by increased instances of cerebral palsy, a complication of hypoxemia.
Studies of survivors followed and showed both physical and cognitive dysfunction to be prominent among those survivors, even among those whose medical course had been “uncomplicated.” Could it be that function, or in this case dysfunction, was the result of adverse effects from the form, i.e., the environment, in which the extra-uterine fetus was forced to develop? Could innovations in the environment reduce or eliminate adverse effects and/or facilitate infants' adaptation to the unexpected extra-uterine world?
Developmental care for the neonate embodies the concept that understanding neurodevelopmental stages, interrelationships, and influences not only explains some adverse and unwanted outcomes, but it also can inform care processes themselves and help define the form of the care-giving environment, the NICU. Under the leadership of Stanley N. Graven, a multidisciplinary team began a rigorous exploration of the roles of the intensive care unit, of care-giving techniques, and of the social environment on infants' neurodevelopmental outcomes (Graven et al., 1992a; 1992b). Supplementing observations from the clinical world, this exploration sought a deeper understanding and did so by means of evidence from diverse sources: embryology, neurodevelopment, animal studies, physical sciences (light, sound, motion), sociology, psychology, up to and including molecular biology. From these diverse observations, the close interrelationship of human neurodevelopment with the environment has been uncovered, at least in part.
This book, edited by two leaders and innovators in the world of developmental care, gathers material from scientists and clinicians who have broken new ground in their fields of endeavor. Infant neurodevelopment in each field is shown to be intertwined with other systems' stages of development and with the supportive and noxious influences of the environment. Readers of this volume will gain an understanding of the developmental sequences and interrelationships among developing neurons and among persons, because infant development is also the acquisition of attachment and bonding among human beings.
How does form then follow function? It does so, in this case by supporting individual infants' current levels of development and by providing the requisite substrates for stages yet to come. Early developmentally supportive care-giving practices are supplemented by design features that allow for developmental progression, avoidance of disruptions, and nurturance of interpersonal bonding. Thus, the NICU has evolved into a network of individual care-giving sites, each enabling an optimal environment for infant and family. Design (form) must facilitate each of these functions. This book is an excellent summary of the current understanding of the elements of developmental care and of the care-giving setting. Each chapter discusses the best-practice environment according to current data and poses questions for further investigation. It should be read by everyone who cares for infants in intensive care, but it is essential for those charged with the design and construction of new facilities for providing that care.