birth & beyond california: breastfeeding training & qi project with funding from the federal...
TRANSCRIPT
Birth & Beyond California: Breastfeeding Training & QI
Project
With funding from the federal Title V Block Grant
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Objectives
• Describe how the hospital staff can use therapeutic touch as an intervention modality
• Define attachment• Identify three ways hospital staff
can promote proximity of the mother/baby dyad
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Attachment: Importance of Touch
DVD: Touch in Labor and Infancy:
Clinical Implications
Marshall Klaus, MD Stephen Suomi, MD
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Attachment: Importance of Touch
“Touch or patterns of touch early in life canhave long-term consequences for normal
physical growth, physiological functioning, and even combating disease process.”
Suomi, Touch in Labor and Infancy: Clinical Implications
Attachment: Importance of Touch
• Preterm infant massage therapy– Increases infant vagal activity & gastric
motility that are associated with greater weight gain
– Increases infant temperature– Reduces infant stress behaviors &
activity– Reduces mothers’ depressed mood &
anxiety levels
Diego, Acta Paediatrica, 2007Diego, Infant Behavior & Development, 2007
Hernandez-Reif, Infant Behavior & Development, 2007Feijo, Infant Behavior & Development, 2006
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Touch as an Intervention Modality
• Promoting comfort in a caring situation has significance on many levels
–Physical–Emotional–Social–Spiritual
Chang, J Adv Nursing, 2001
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Definition of Attachment/Bonding
• When the mother/father view their needs as secondary to the needs of the infant
• A desire to be together
• A feeling of emotional connection
• The complex process in which a baby learns to trust and depend on other human beings, especially his mother
Bowlby, Attachment and Loss, 1969
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Physiology of Attachment
• The attachment felt between mother and infant may be biochemically modulated through oxytocin.
Klaus, Your Amazing Newborn, 1998
Feldman, Psychological Science, 2007
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What Elements Increase Attachment?
• Consistent, predictable and appropriate responses to the baby’s needs
• Lively, positive interaction (play)
• First 7 months of life are the most important
Bowlby, Fifty Years of Attachment Theory, 2004
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Attachment Theory
• Began in the 1950s: Bowlby, Ainsworth, Kennell, and Klaus
• The belief that the mother-child bond is the essential & primary force in infant development
• Forms the basis of coping, negotiation of relationships & personality development
• Forms a secure base: behaviorally and emotionally
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What If:
• Altering the way we care for mothers and babies could conclusively change their lives?
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Sensitive Periods
• Sensitive periods in biologic phenomena are times when events can alter later behaviors
Lawrence, Breastfeeding: A Guide for the Medical Professional, 2005
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Sensitive Period Study Design
• Mothers are given extra contact:– One hour of contact in the first 3 hours– 5 extra hours in the first 3 days
Siegel, Pediatrics, 1980
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Sensitive Period: Results
• Mothers in the extra contact group showed significantly different behavior that persisted for at least two years
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Sensitive Period: Results at One Month
• More soothing
• More fondling
• More eye-to-eye exchange
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Sensitive Period: Results at One Year
• Soothed their baby more during the stress of a pediatric visit
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Sensitive Period: Results at Two Years
• Fewer commands
• More questions
• More elaborate, descriptive vocabulary
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Conclusions
• There is a “Sensitive Period” for maternal attachment during the first hours and days after delivery
Siegel, Pediatrics, 1980
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Sensitive Period
• Right after birth, within the 1st hour of life, normal infants have a prolonged period of quiet alertness…during which they look directly at their mother’s and father’s face and eyes and can respond to voices. It is as though the newborn had rehearsed the perfect approach to the 1st meeting with their parents
Klaus, Your Amazing Newborn, 1998
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Responsiveness
• When a mother responds within 1.5 minutes of beginning to cry
• Infants stopped crying almost immediately
Thoman, Aberrant Development in Infancy, 1975
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Non-Responsiveness
• When infants are allowed to cry longer
• They cry more over time
Thoman, Aberrant Development in Infancy, 1975
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Brain Development
• Infants are born with the capacity for feeling deep emotions
• The caregiver assists the infant to regulate his emotions
• The infant’s brain is “sculpted” as the neural connections for the capacity to form attachments are employed or pruned
Schore, Infant Mental Health Journal, 2001Spangler, Development Psychology, 1994
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The “Baby Dance” is Relational
• Following baby's cues• Babies have their own spontaneous
expressions of themselves• When a mother pays attention to these
expressions, she communicates that she understands what the baby is doing, feeling, and even thinking
Feldman, Journal of Applied Developmental Psychology, 1996
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The “Baby Dance” is Relational
• The mother tunes to her baby's internal states • She responds to the baby’s cues• This produces a response in the baby• Which further fuels this synchronized system
Schore, Infant Mental Health Journal, 2001
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Cultural ConflictsHappy Healthy Myth
• Sleepy baby is good
• Children need to be independent
• Mom needs to rest, take baby to nursery
• Mothers bond and breastfeed
Happy Healthy Reality
• Sleepy baby becomes dehydrated, jaundiced
• Children are dependent• Moms are designed to
rest with baby, baby elicits maternal sleep
• Babies elicit bonding behaviors and are responsible for establishing breastfeeding
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A Relational Approach to Perinatal Nursing
• Attachment is of critical importance• Nurses are responsible for facilitating and
protecting this relationship – All staff in contact with the mother/baby dyad
need to keep this concept as a priority• Nurses can “fan the fire of love” or can limit
its development
Karl, MCN, 2006
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The Nurse/Mother Relationship
• Often parallels the mother/infant relationship• “Mothering the Mother” creates trust and
credibility that allows the nurse to support the attachment process
• Every encounter a nurse has with the mother/baby dyad is an opportunity to enhance a secure attachment
Kennell, Acta Paediatrica, 2005
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Promoting Proximity
• Maximize physical contact– Rooming in– Skin-to-skin– Breastfeeding– Infant massage
• Share information and observations that instruct the mother of the value of keeping baby close
Martell, JOGNN, 2003
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Promoting Proximity
• Rooming in increases maternal attachment– Increased positive interactions
• Looking • Touching• Talking to their babies
– Decreased avoidance behaviors • Watching TV • Talking on the phone
Prodromidis, Birth, 1995
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Supporting Maternal Responsiveness
• Encourage mother’s observations
• Describe baby’s thoughts
• Reframe perceptions– From: He’s demanding
• To: He knows what he needs– From: She doesn’t want to breastfeed
• To: She needs to spend some time with you first
Karl, MCN, 2006
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Supporting Maternal Responsiveness
• Model responding to infant cues in all clinical tasks, i.e. bathing, feeding, newborn assessment
• Nurses have the unique opportunity to make a positive difference in the beginning of the relationship between a mother and her newborn
Karl, MCN, 2006
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Nurse as a Doer
• Making sure baby is bathed, diapered, fed– Your baby is sucking on his hands – He’s hungry– I’ll go feed him
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Nurse as a Teacher
• Educating the mother– Your baby is crying – Have you been able to breastfeed?– He’s probably hungry– I’ll go over breastfeeding so you can get
him on– I know you’re tired, but feeding him will
make you feel better– We’ll make sure you know how to do it
before you go home
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Nurse as an Attacher
• Relational Process– Your baby is crying– What do you think is happening?– How do you usually calm him?– …Yes, picking him up usually works, why don’t you
try it?– Another way to quiet down babies is by remembering
“repetition to soothe” – such as patting or swinging – Babies can take up to 20 minutes to change their
state, so don’t think you’re not doing it right!– …As the baby quiets down, do you think he could be
hungry? Would you like some help breastfeeding lying down?
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Attachment: Nursing Plan of Care
• Attachment is relational: establish a responsive, nurturing relationship with the mother that mimics the mother/infant relationship
• Infants are proximity seeking: help the mother/baby maintain contact
• Attachment depends on maternal responsiveness: ally with mothers to facilitate their availability and responsiveness to their infants
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Outcomes When a Nurse Attacher Has Helped a Mother/Baby Pair
• Mother has demonstrated ability to care for her infant
• Mother is confident she can problem-solve
• The nurse has observed the emotional connection between mother and baby
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Nurses are Wise Women
• Nurses have amazing power to influence mothering
• Nurses help parents get to know their baby
• Nurses help parents meet the needs of their babies by teaching them to respond appropriately to the baby’s cues