Separa6on from Mother is NOTHING like the womb! Bright and loud - - PDF document

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Family-Centered Developmental Care: Suppor6ng A9achment in the NICU

Raylene Phillips, MD, FAAP, FABM, IBCLC Loma Linda University Children’s Hospital

I have no conflicts of interests and nothing to disclose

The NICU – while life-saving, is NOTHING like the womb!

— Bright and loud sounds — Frequent touch – often painful — IV line placements and blood draws — Intubation and suctioning — Gavage feeding tube insertions — X-rays, ultrasounds, and eye exams — Daily physical examinations — Frequent assessments of vital signs — Bathing and weighing — Separation from mother

Separa6on from Mother A Parent’s View of the NICU

“Where is my baby?”

“Where is my mother?”

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Parents are “Premature Parents”

— Who often feel guilty guilty, , usually helpless helpless and always terrified terrified for the life of their prematurely born baby

Mother-Infant Dyad A single psychobiological organism

— “There is no such thing as an infant. The infant and maternal care together form a unit.” Winnicott, 1965

Maternal Bonding

— “When a baby is born, a mother is born”

— Mother is totally focused on caring for baby to the exclusion of everything else

— “Primary maternal preoccupation” Winnicott

— Neuronal mechanisms regulate maternal behavior

— Medial preoptic area of the hypothalamus — Projections to the mesocorticolimbic dopaminergic

system

Diaz-Rossello NeoReviews 2008

A9achment Hormones

— Attachment is biological primed — Biochemical bonding/attachment activators in our neuronal reward circuitry

— Trigger maternal caregiving

— Increased by skin-to-skin contact

— Oxytocin — Vasopressin — Prolactin — Dopamine — Estrogen — Endogenous opiod peptides

Fetal brain development

From CONCEPTION CONCEPTION fetal brain growth is influenced by genes (the DNA) But from the beginning from the beginning, brain growth is an active process active process.

• N. Bergman

Fetal brain development

By 20 weeks gestational age all organ structures are formed Brain growth occurs by parallel development

• f structure

structure & function function (Hugo Lagercrantz 2004) Brain development depends on experiences experiences !!

• N. Bergman

(Shore, 2001)

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Fetal Brain Development

40 wks 28 wks 22 wks 14 wks 10 wks 32 wks

“Cri6cal Period”

Window of opportunity in early life when a child’s brain is exquisitely primed to receive sensory input in order to develop more advanced neural systems

Amygdala and Brain Development

— Areas of the amygdala...are in a critical period of maturation...in the first two months after birth

— Amygdala - Limbic System

— Emotional learning — Memory modulation — Activation of sympathetic

nervous system — Skin-to-skin contact activates the amydala via the

prefrontal-orbital pathway

Schore, Infant Mental Health Journal, 2001

Touch and Brain Development

— The fetus has well developed senses of:

— Touch, proprioception, smell

— These senses connect directly to the amygdala via the prefrontal-orbital pathway, the first and essential part of an efficiently regulated and

• rganized right brain.

Schore, Infant Mental Health Journal, 2001

Touch and Brain Development

• “In early postnatal life, maintenance of critical

levels of tactile input tactile input … is important for normal normal brain maturation. brain maturation. “

Schore 2001

— “... the baby must spend most of its time in its mother’s arms to get the full benefit of her sensory environment…”

White, Clinics in Perinatology, 2004

Face-to-face communication Eye-to-eye orientations Voice-ear interactions Hand/facial movements/touch Active Brain Development

( brain wiring)

Baby - Mother

Communication

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A newborn has a basic biological need for contact with mother

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A9achment and Regula6on

— “Attachment relationships are formative because they facilitate the development of the brain’s self-regulatory mechanism.”

Fonagy & Target, Psychoanalytic Inquiry, 2002

Neurologically Immature

At birth the human infant is the LEAST neurologically mature primate of all, and the most reliant on physiological regulation by the caregiver for the longest period of time.

McKenna

Mother is Baby’s Regulator

— “The dyadic interaction between the newborn and the mother constantly controls and modulates the newborn’s exposure to environmental stimuli and thereby serves as a regulator of the developing individual’s internal homeostasis.”

Ovt-scharoff , Neuroscience, 2001

A9achment and Brain Development

— “The regulatory function of the newborn-mother interaction may be an essential promoter to ensure the normal development and maintenance

• f synaptic connections during the establishment
• f functional brain circuits.”

Ovt-Scharoff , Neuroscience, 2001

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The Paren6ng Environment and Brain Development

— “There is now solid evidence that the parenting environment influences the neural connections that underlie infant behavior. “

Dawson 1994

Attachment and Brain Structure

“Early interpersonal events positively

and negatively impact the structural organization of the brain.”

“The brain is designed to be

sculpted into its final configuration by the effects of early experiences. These experiences are embedded in the attachment relationship. “

Schore, Infant Mental Health Journal, 2001

A9achment as Brain Organizer

— “If the attachment relationship is indeed a major

• rganizer of brain development… then the

determinants of attachment relationships are important far beyond the provision of a fundamental sense of safety or security.”

Fonagy, Attachment and Human Development, 2005.

What Can We Do in the NICU?

— To support infants — To support parents — To help support emotional connections — To help heal the wounds of mother-infant separation

Family-Centered Care

— An approach to An approach to planning, delivery planning, delivery, and , and evaluation evaluation o

• f

f healthcare healthcare that supports partnerships

partnerships among

patients, families, and healthcare team. — It is founded on the principle that the family plays a family plays a vital role vital role in ensuring the health and well-being of the infant. — Over time, the family has the greatest influence family has the greatest influence on an infant infant’s health and well-being s health and well-being. .

American Hospital Association Institute for Family Centered Care

Goals of Family-Centered Care

— To To reunite the family reunite the family — To To resume resume interrupted interrupted parent-infant bonding parent-infant bonding Ø To support parents To support parents in their role role as the most the most important caregivers important caregivers for their infant

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Family-Centered Care

— Four Guiding Principles Four Guiding Principles

— Dignity and respect — Information sharing — Participation — Collaboration

American Hospital Association Institute for Family Centered Care

Parents Parents are viewed not as “visitors” but WELCOMED as vital members vital members of

• f the

the caregiving team caregiving team and have 24-hr/day access to THEIR THEIR baby

Typical NICU Womb Rooms Womb Rooms

Parents Parents are encouraged to participate in participate in daily caregiving daily caregiving of THEIR THEIR baby

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Helping Parents COPE

— Creating Opportunities for Parent Empowerment

— Designed to make parent-infant interactions a more

positive experience

— Enhance parent mental health outcomes

— Parents report significantly less stress in the NICU — Less depression and anxiety — More positive interactions with infants — Infants had 3.8 days shorter NICU length of stay — VLBW infants (less than 1500 g at birth) had 8 days shorter length of stay

Melnyk BM,, Pediatrics 2006

Parent Support Organiza6ons Na6onal Perinatal Associa6on

— Interdisciplinary Recommendations for the Psychosocial Support of NICU Parents J of Perinatology, 2015 www.nationalperinatal.org

Suppor6ng Parents

— Welcome them daily to baby’s bedside — Acknowledge ambivalence of their feelings — Encourage time just to be with THEIR baby — Empower them to do daily cares – be a parent — Teach infant massage — Inform about risks for PTSD and depression — Provide resources for professional help and support

Suppor6ng Babies

Talking to Babies

Myriam Szejer, MD Telling babies their stories is healing

Suppor6ng Babies

Holding Babies

Holding with your heart Transport babies

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Suppor6ng Babies

Holding Babies

Holding with your eyes Charlie's baby

Suppor6ng Babies

Holding Babies

Holding with your hands Steven’s dads

Suppor6ng Babies

Holding Babies

Holding with your arms Daniel’s Mom

Suppor6ng Mothers and Babies Together

In Family-Centered Care In Family-Centered Care skin-to-skin contact is skin-to-skin contact is actively encouraged and facilitated facilitated

Natural Habitat for Newborns

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Natural Habitat for Newborns Natural Habitat for Newborns

The Natural Habitat for Human Newborn Mammals

Prof Peter Hartmann, UWA

Thermal Synchrony During Skin-to-Skin Contact

— Temperature of mother’s chest will increase by 2 degrees Celsius if baby is too cool. — Temperature of mother’s chest will decease by 1 degree Celsius if baby is too hot.

Individualized Thermal Synchrony

Each breast independently regulates baby’s temperature

Thermal Synchrony Challenge?

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History of Kangaroo Mother Care

(KMC)

LATE KMC Drs Rey & Martinez 1979 - Bogota, Colombia BIRTH KMC

• Dr. Nils Bergman, Agneta Jurisoo

1987 - Manama, South Africa

• N. Bergman

Manama, South Africa

Birth Weight: 1000 - 1500 g

Survival before KMC 10% Survival with KMC 50%

Weight gain per day 30 g/day Breastfeeding rate 100%

• N. Bergman

PERCENTAGE SURVIVAL BY BIRTH-WEIGHT

20 40 60 80 100

Birth weight intervals Percentage survived

KMC babies Pre-KMC babies

Manama, South Africa

• N. Bergman

Is KMC as safe as incubators for preterm infants immediately after birth?

First Randomized Controlled Trial

to compare KANGAROO MOTHER CARE KANGAROO MOTHER CARE and CONVENTIONAL CONVENTIONAL INCUBATOR CARE INCUBATOR CARE For preterm infants For preterm infants from birth to 6 hrs of life from birth to 6 hrs of life

Primary Hypothesis esis

Skin-to-skin contact with Kangaroo Mother Care (KMC) from birth is superior to conventional method of care with incubator (CMC) for low birthweight infants infants ONLY the ONLY the HABITAT HABITAT differed differed

KMC = K KMC = Kangaroo angaroo M Mother

• ther C

Care are CMC CMC = Conventional Conventional Method ethod of

• f Care

are

• N. Bergman

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( n = 34) KMC KMC CMC CMC Mean weight 1813 g 1866 g Mean GA 34.2 w 35.3 w Approp’ GA 65% 64% Male 60% 50%

• N. Bergman

SCRIP SCORE

2 1

Heart rate Regular Deceleration to 80-100 Rate <80 or >200 bpm Respiratory rate Regular Apnoea <10s,

• r periodic

breathing Apnoea >10s Tachypnoea >80 pm Oxygen saturation Regular >87% Any fall to 80 – 87% Any fall below 80%

Stability of Cardio-Respiratory system In Preterm Infants

Fischer et al, 1988

Score allocated for a five-minute period of continuous

• bservation with maximum score of 6 for each period
• N. Bergman

Randomized Controlled Trial Mother (KMC) vs. Incubators (CMC)

Kangaroo Mother Care (KMC) Stable at 6 hours of life Unstable at 6 hours of life Conventional Method of Care (CMC) Birth Weight 1200-2200 g

4 5 6

BIRTH RCT - SCRIP SCORES

KMC CMC

Bergman, Acta Paediatrica, 2004

Percent of Infants with 100% SCRIP Stability Scores

KMC KMC CMC CMC

1200 1200 g g to to 2 2200 g g

1- 6 hr 1- 6 hr

56% 56% 11% 11%

@ @ 6 6 hr hr

100% 100% 46% 46%

1200 1200 g g to to 1 1800 g g

1- 6 hr 1- 6 hr

44% 44% 0% 0%

@ @ 6 6 hr hr

100% 100% 25% 25%

Bergman Acta Paediatrica, 2004 Stabilisation first 6 hours, average hourly SCRIP score

5.1 5.2 5.3 5.4 5.5 5.6 5.7 5.8 5.9 6 6.1 2nd 3rd 4th 5th 6th KMC all KMC <1800 CMC all CMC <1800

INCUBATORS DE-STABILIZE Premature Newborns

• N. Bergman

CONCLUSION CONCLUSION

KMC started from birth is superior to incubator

for infants 1200 – 2199 g with respect to stabilization as defined by basic physiological parameters (HR, RR, Ox sats, apnea)

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KMC KMC is is safer! safer!

• N. Bergman

Mothers are Superior to Incubators

in stabilizing healthy preterm infants at birth

Bergman Acta Paediatrica, 2004

Skin-to-Skin Contact Promotes Normal Sleep Patterns

— STS contact increases

— Quiet sleep — REM sleep — Normal sleep cycles

Ludington-Hoe, Pediatrics 2006

Increases Weight Gain

— STS contact associated with increased weight gain

Sieratzi, Lancet, 1996, Charpak, Ruiz-Pelaez, & Figueroa, 2005, London, 2006

Decreased Length of Stay

— STS contact associated with shorter hospital stays

Sieratzi, Lancet, 1996, Charpak, Ruiz-Pelaez, & Figueroa, 2005, London, 2006

Increases Immune Protec6on

— STS contact increases antibodies in mother’s milk — Decreases incidence and severity of nosocomial infections

Hurst, Journal of Perinatology, 1997, Conde-Argudelo, Diaz- Rossello, & Belizan, 2003

9/8/16 14 Enteromammary Immune System

Lawrence & Lawrence, 5th ed, 1999, pg 166.

Increases Breastmilk

— STS contact increases breastmilk production by increasing prolactin levels

Ludington-Hoe, 1996, Mohrbacher & Stock, 2003

Increases BreasXeeding

— Preterm infants can practice breastfeeding anytime — Goal: Feeding at the breast before discharge

Prolongs BreasXeeding

— STS contact increases breastfeeding duration At Discharge After Discharge

Ludington-Hoe, 1996, Mohrbacher & Stock, 2003

Increases Parents’ Confidence

— STS contact increases parent’s confidence and sense of competence in handling tiny infant

Uvnas-Moberg, 2003, Tessier et al., 1998, Kirsten, Bergman, & Hann, 2001 Conde-Agudelo, Diaz-Rossello, & Belizan, 2003;

Con6nues “Gesta6on” Outside Womb

— STS contact brings babies back in contact with their mothers

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Helps Mothers Cope with Grief

— STS contact helps mothers cope with grief from loss of term pregnancy and normal term infant — Helps to “complete gestation”

Promotes Bonding and A9achment

Uvnas-Moberg, 2003, Tessier et al., 1998, Kirsten, Bergman, & Hann, 2001, Conde-Agudelo, Diaz-Rossello, & Belizan, 2003

Dads Need To Bond Too Even Future Dads

For premature infants… skin-to-skin contact is ESSENTIAL – not an op6onal ac6vity!

Skin-to-Skin Contact

• n Mechanical Ven6la6on

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Skin-to-Skin Contact

• n High Frequency Jet Ven6la6on

“JAKOB”

Photo story on www.kangaroomothercare.com/photo.htm Born 24 w EGA 593 g Continuous SSC since 25 w On VENTILATOR for BPD 1300 g at time

• f photo
• N. Bergman

“JAKOB”

Same technology NEW HABITAT

• N. Bergman

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25 3/7 w GA, 625 g – 5 days old High Frequency Jet Ven6la6on

“We’re in this together.”

A Familiar Heartbeat

Mommy is Here

9 Months Old

(6 months PMA)

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A new awakening ...

A “New” Paradigm” ...

• N. Bergman

Humanity AND Technology

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Humanity

AND Technology

Baby Stohm, 780g

• N. Bergman

Our NICU World

— Sometimes feels like a dark place

— Filled with tiny traumatized fetuses struggling to live — And anxious traumatized parents struggling to cope

Awareness Brings Light

— That all babies, no matter how small, know their mothers

— That supporting a baby’s emotional connection with mother (and father) makes a difference in short- and long-term

• utcomes

Shared Knowledge Inspires Courage

— It takes courage to initiate and sustain change — The support of others with shared knowledge inspires courage

Community Increases Strength

— Supporting each other as caregivers in the NICU, increases the strength and effectiveness of our efforts

Together we can make a difference

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Together we can change the world One baby and one family at a 6me!

Thank you

A person’s a person no matter how small

• Dr. Seuss