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Family-CenteredDevelopmentalCare:Suppor6ngA9achment

intheNICU

Raylene Phillips, MD, FAAP, FABM, IBCLC

Loma Linda University Children’s Hospital

I have no conflicts of interests

and nothing to disclose

TheNICU–whilelife-saving,isNOTHINGlikethewomb!

�  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

Separa6onfromMother

AParent’sViewoftheNICU“Where is my baby?”

“Whereismymother?”

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Parentsare“PrematureParents”� Who often feel guilty, usually helpless and

always terrified for the life of their prematurely born baby

Mother-InfantDyad

Asinglepsychobiologicalorganism

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

� 

MaternalBonding�  “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

A9achmentHormones� 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 fetal brain growth is influenced by genes (the DNA) But from the beginning, brain growth

is an active process.

N. Bergman

Fetal brain development By 20 weeks gestational age all organ structures are formed Brain growth occurs

by parallel development of structure & function (Hugo Lagercrantz 2004)

Brain development depends on experiences !!

N. Bergman

(Shore, 2001)

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Fetal Brain Development

40 wks

28 wks 22 wks 14 wks 10 wks

32 wks

“Cri6calPeriod” 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

AmygdalaandBrainDevelopment� 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

TouchandBrainDevelopment

� 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

organized right brain.

Schore, Infant Mental Health Journal, 2001

TouchandBrainDevelopment

•  “In early postnatal life, maintenance of critical levels of tactile input … is important for normal 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,ClinicsinPerinatology,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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A9achmentandRegula6on

� “Attachment relationships are formative because they facilitate the development of the brain’s

self-regulatory mechanism.”

Fonagy & Target, Psychoanalytic Inquiry, 2002

NeurologicallyImmatureAt 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

MotherisBaby’sRegulator�  “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

A9achmentandBrainDevelopment

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

of synaptic connections during the establishment

of functional brain circuits.”

Ovt-Scharoff , Neuroscience, 2001

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TheParen6ngEnvironmentandBrainDevelopment

�  “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

A9achmentasBrainOrganizer� “If the attachment relationship is indeed a major

organizer 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-CenteredCare� An approach to planning, delivery, and evaluation of

healthcare that supports partnerships among patients, families, and healthcare team.

� It is founded on the principle that the family plays a

vital role in ensuring the health and well-being of the infant.

� Over time, the family has the greatest influence on an infant’s health and well-being.

American Hospital Association Institute for Family Centered Care

GoalsofFamily-CenteredCare

� To reunite the family � To resume interrupted parent-infant bonding

Ø To support parents in their role as the most important caregivers for their infant

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Family-CenteredCare

�  Four Guiding Principles � Dignity and respect

�  Information sharing

� Participation

� Collaboration AmericanHospitalAssociation InstituteforFamilyCenteredCare

Parents are viewed not as “visitors” but WELCOMED

as vital members of the caregiving team

and have 24-hr/day access to THEIR baby

TypicalNICU WombRooms

WombRoomsParents are encouraged to participate in

daily caregiving of THEIR baby

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HelpingParentsCOPE� 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

ParentSupportOrganiza6ons

Na6onalPerinatalAssocia6on�  InterdisciplinaryRecommendationsforthePsychosocialSupportofNICUParents

JofPerinatology,2015

www.nationalperinatal.org

Suppor6ngParents

� 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

Suppor6ngBabiesTalking to Babies

Myriam Szejer, MD

Telling babies their stories is healing

Suppor6ngBabiesHolding Babies

Holding with your heart

Transport babies

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Suppor6ngBabiesHolding Babies

Holding with your eyes

Charlie's baby

Suppor6ngBabiesHolding Babies

Holding with your hands

Steven’s dads

Suppor6ngBabiesHolding Babies

Holding with your arms

Daniel’s Mom

Suppor6ngMothersandBabiesTogether

In Family-Centered Care skin-to-skin contact is

actively encouraged and facilitated

Natural Habitat for Newborns

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Natural Habitat for Newborns Natural Habitat for Newborns

TheNaturalHabitatforHumanNewbornMammals

Prof Peter Hartmann, UWA

ThermalSynchronyDuringSkin-to-SkinContact

� 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.

IndividualizedThermalSynchrony

Each breast independently regulates baby’s temperature

ThermalSynchronyChallenge?

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HistoryofKangarooMotherCare

(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

0

20

40

60

80

100

<1000g 1000g 1100g 1200g 1300g 1400g 1500g 1600g 1700g 1800g 1900g

Birth weight intervals

Pe

rce

nta

ge

su

rviv

ed

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

and CONVENTIONAL

INCUBATOR CARE

For preterm infants from birth to 6 hrs of life

Primary Hypothesis 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 ONLY the HABITAT differed KMC = Kangaroo Mother Care CMC = Conventional Method of Care

N. Bergman

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Subjects ( n = 34) KMC 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 0 Heart rate

Regular

Deceleration

to 80-100

Rate <80 or >200 bpm

Respiratory rate

Regular

Apnoea <10s, or 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 observation with maximum score of 6 for each period

N. Bergman

RandomizedControlledTrialMother(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

60min 90min 120min 150min 180min 210min 240min 270min 300min 315min 330min 345min 360min

BIRTH RCT - SCRIP SCORES

KMC CMC

Bergman, Acta Paediatrica, 2004

Percent of Infants with 100% SCRIP Stability Scores

KMC CMC 1200 g to 2200 g

1- 6 hr 56% 11%

@ 6 hr 100% 46%

1200 g to 1800 g

1- 6 hr 44% 0%

@ 6 hr 100% 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 allKMC <1800CMC allCMC <1800

INCUBATORS DE-STABILIZE Premature Newborns

N. Bergman

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 is

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

IncreasesWeightGain� STS contact associated with increased weight gain

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

DecreasedLengthofStay� STS contact associated with shorter hospital stays

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

IncreasesImmuneProtec6on� 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

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Enteromammary Immune System

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

IncreasesBreastmilk� STS contact increases breastmilk production by

increasing prolactin levels

Ludington-Hoe, 1996, Mohrbacher & Stock, 2003

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

ProlongsBreasXeeding� STS contact increases breastfeeding duration

At Discharge After Discharge

Ludington-Hoe, 1996, Mohrbacher & Stock, 2003

IncreasesParents’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”OutsideWomb

� STS contact brings babies back in contact with their mothers

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HelpsMothersCopewithGrief� STS contact helps mothers cope with grief from loss of

term pregnancy and normal term infant

� Helps to “complete gestation”

PromotesBondingandA9achment

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

DadsNeedToBondToo EvenFutureDads

Forprematureinfants…skin-to-skincontactisESSENTIAL

–notanop6onalac6vity!

Skin-to-SkinContactonMechanicalVen6la6on

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Skin-to-SkinContactonHighFrequencyJetVen6la6on

“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 of photo

N. Bergman

N. Bergman

“JAKOB”

Same technology NEW HABITAT

N. Bergman

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253/7wGA,625g–5daysoldHighFrequencyJetVen6la6on “We’reinthistogether.”

AFamiliarHeartbeatMommyisHere

9MonthsOld(6monthsPMA)

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A new awakening ...

A “New” Paradigm” ...

N. Bergman

Humanity

ANDTechnology

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Humanity

ANDTechnology

Baby Stohm, 780g

N. Bergman

OurNICUWorld� Sometimes feels like a dark place

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

AwarenessBringsLight

� 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 outcomes

SharedKnowledgeInspiresCourage

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

courage

CommunityIncreasesStrength� Supporting each other as caregivers in the NICU,

increases the strength and effectiveness of our efforts

Togetherwecanmakeadifference

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TogetherwecanchangetheworldOnebabyandonefamilyata6me!

Thankyou

A person’s a person no matter how small

Dr. Seuss