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

9/8/16 Family-Centered Developmental Care: I have no conflicts of interests Suppor6ng A9achment and nothing to disclose in the NICU Raylene Phillips, MD, FAAP, FABM, IBCLC Loma Linda University Children’s Hospital The NICU – while life-saving, Separa6on from Mother 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 “Where is my mother?” A Parent ’ s View of the NICU “ Where is my baby? ” 1

9/8/16 Mother-Infant Dyad Parents are “ Premature Parents ” A single psychobiological organism — Who often feel guilty guilty, , usually helpless helpless and always terrified terrified for the life of their prematurely born baby — “ There is no such thing as an infant. The infant and maternal care together form a unit. ” Winnicott, 1965 Maternal Bonding A9achment Hormones — Attachment is biological primed — “ When a baby is born, a mother is born ” — Biochemical bonding/attachment activators in our neuronal reward circuitry — Mother is totally focused on caring for baby to the exclusion of everything else — Trigger maternal caregiving — “ Primary maternal preoccupation ” Winnicott — Increased by skin-to-skin contact — Oxytocin — Neuronal mechanisms regulate maternal behavior — Vasopressin — Medial preoptic area of the hypothalamus — Prolactin — Projections to the mesocorticolimbic dopaminergic — Dopamine system — Estrogen Diaz-Rossello NeoReviews 2008 — Endogenous opiod peptides Fetal brain development Fetal brain development By 20 weeks gestational age all organ structures are formed From CONCEPTION CONCEPTION fetal brain growth Brain growth occurs is influenced by by parallel development genes (the DNA) of structure structure & function function (Hugo Lagercrantz 2004) But from the beginning from the beginning, brain growth Brain development is an active process active process. depends on experiences experiences !! ( Shore, 2001 ) N. Bergman N. Bergman 2

9/8/16 “ Cri6cal Period ” Fetal Brain Development Window of opportunity in early life when a child ’ s brain is exquisitely primed to receive sensory input in order to develop more advanced 10 wks 14 wks 22 wks 28 wks neural systems 32 wks 40 wks Touch and Brain Development Amygdala and Brain Development — The fetus has well developed senses of: — Areas of the amygdala...are in a critical period of — Touch, proprioception, smell maturation...in the first two months after birth — Amygdala - Limbic System — These senses connect directly — Emotional learning to the amygdala via the — Memory modulation prefrontal-orbital pathway, — Activation of sympathetic the first and essential part of nervous system an efficiently regulated and — Skin-to-skin contact activates the amydala via the organized right brain. prefrontal-orbital pathway Schore, Infant Mental Health Journal , 2001 Schore, Infant Mental Health Journal , 2001 Baby - Mother Touch and Brain Development Communication “ 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 Face-to-face communication mother ’ s arms to get the full benefit of her Active Brain Eye-to-eye orientations sensory environment… ” Development Voice-ear interactions ( brain wiring) White, Clinics in Perinatology , 2004 Hand/facial movements/touch 3

9/8/16 A newborn has a basic biological need for contact with mother 4

9/8/16 Neurologically Immature A9achment and Regula6on At birth the human infant is the LEAST — “ Attachment relationships are formative because neurologically mature primate of all, and the they facilitate the development of the brain ’ s most reliant on physiological regulation by self-regulatory mechanism. ” the caregiver for the longest period of time. McKenna Fonagy & Target, Psychoanalytic Inquiry, 2002 A9achment Mother is Baby ’ s Regulator and Brain Development — “ The dyadic interaction between — “ The regulatory function of the newborn-mother the newborn and the mother interaction may be an essential promoter to ensure constantly controls and the normal development and maintenance modulates the newborn ’ s of synaptic connections during the establishment exposure to environmental of functional brain circuits. ” stimuli and thereby serves as a regulator of the developing individual ’ s internal homeostasis. ” Ovt-scharoff , Neuroscience , 2001 Ovt-Scharoff , Neuroscience, 2001 5

9/8/16 The Paren6ng Environment Attachment and Brain Structure and Brain Development “ Early interpersonal events positively and negatively impact the — “There is now solid evidence that the parenting structural organization of the brain. ” environment influences the neural connections that underlie infant behavior. “ “ The brain is designed to be sculpted into its final configuration Dawson 1994 by the effects of early experiences. These experiences are embedded in the attachment relationship. “ Schore, Infant Mental Health Journal , 2001 A9achment as Brain Organizer What Can We Do in the NICU? — To support infants — “ If the attachment relationship is indeed a major — To support parents organizer of brain development… then the determinants of attachment relationships are — To help support emotional connections important far beyond the provision of a — To help heal the wounds of mother-infant separation fundamental sense of safety or security. ” Fonagy, Attachment and Human Development , 2005 . Goals of Family-Centered Care Family-Centered Care — An approach to An approach to planning, delivery planning, delivery, and , and evaluation evaluation o of f — To To reunite the family reunite the family healthcare that supports partnerships partnerships among healthcare — To To resume resume interrupted interrupted parent-infant bonding parent-infant bonding patients, families, and healthcare team. Ø To support parents To support parents in their role role as the most the most important caregivers important caregivers for their infant — It is founded on the principle that the family plays a family plays a vital role in ensuring the health and well-being of the vital role infant. — Over time, the family has the greatest influence family has the greatest influence on an infant ’ s health and well-being infant s health and well-being. . American Hospital Association Institute for Family Centered Care 6

9/8/16 Family-Centered Care Parents are viewed not as “ visitors ” Parents but WELCOMED — Four Guiding Principles Four Guiding Principles as vital members vital members of of the the caregiving team caregiving team and have 24-hr/day access to THEIR THEIR baby — Dignity and respect — Information sharing — Participation — Collaboration American Hospital Association Institute for Family Centered Care Womb Rooms Typical NICU Womb Rooms Parents Parents are encouraged to participate in participate in daily caregiving daily caregiving of THEIR THEIR baby 7

9/8/16 Parent Support Organiza6ons 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 Suppor6ng Parents Na6onal Perinatal Associa6on — Welcome them daily to baby ’ s bedside — Interdisciplinary Recommendations for the Psychosocial Support of NICU Parents — Acknowledge ambivalence of their feelings J of Perinatology, 2015 — 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 www.nationalperinatal.org — Provide resources for professional help and support Suppor6ng Babies Suppor6ng Babies Holding Babies Talking to Babies Holding with your heart Myriam Szejer, MD Transport babies Telling babies their stories is healing 8

9/8/16 Suppor6ng Babies Suppor6ng Babies Holding Babies Holding Babies Holding with your eyes Holding with your hands Charlie's baby Steven ’ s dads Suppor6ng Mothers and Babies Suppor6ng Babies Together Holding Babies Holding with your arms Daniel ’ s Mom In Family-Centered Care In Family-Centered Care Natural Habitat for Newborns skin-to-skin contact is skin-to-skin contact is actively encouraged and facilitated facilitated 9

9/8/16 Natural Habitat for Newborns Natural Habitat for Newborns The Natural Habitat Thermal Synchrony for Human Newborn Mammals 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. Prof Peter Hartmann, UWA Individualized Thermal Synchrony Thermal Synchrony Challenge? Each breast independently regulates baby ’ s temperature 10