Sunday, January 15, 2012

Bonding in the NICU

In Dr. Sears The Attachment Parenting Book, he talks about Birth Bonding. There are 8 "steps" he gives and I know that personally, I would have loved to more than anything to be able to do these immediately after birth with my babies but it wasn't possible. They were rushed to the NICU immediately after I briefly got to lay eyes on them. However, that doesn't mean you can't still have the experience of bonding with your baby and attaching to each other. I'm going to go through each "step" or tip that Dr. Sears gives and talk about how you could still do these while having a baby in the NICU. His suggestions are meant for the first hour after birth and while this generally isn't possible with preemies, these tips can still be incredibly helpful as you struggle to get to know your baby and bond with him/her while you're in the crazy world of the NICU. Some of these tips that Dr. Sears offers are nearly impossible to do with a preemie that is rushed to the NICU, but I will offer possible alternatives or suggestions that can still help.

Dr. Sears *does* talk about premature babies and I highly recommend checking out his book The Premature Baby Book.

1. Hold your baby skin-to-skin immediately after birth.
Dr. Sears says: "The needs of your newborn after birth are...:peace, quiet, warmth and the arms of someone who cares. This is not just good psychology, this is good medicine. Draping baby over the mother allows natural heat transfer from other to infant that is at least as effective as putting baby in an artificial warmer. Skin to skin contact also soothes the newborn."

In the NICU, this is known as Kangaroo Care (from here on out, I'll refer to this as K-care). The benefits of K-care are plentiful.

For baby, they include:
Stabilization of the baby's heart rate 
Improved (more regular) breathing pattern/ less episodes of apnea (75% decrease!)
Improved oxygen saturation levels (an indicator of how well oxygen is being delivered to all the infants organs and tissues)
Gain in sleep time
More rapid weight gain
Decreased crying
More successful breastfeeding episodes
Earlier hospital discharge

For mom:
Improved bonding, feelings of closeness with their babies
Increased breast milk supply
Increased confidence in ability to care for their babies
Increased confidence that their babies are well cared for
Increased sense of control

All of these benefits have been proven time and time again by research. In fact, in countries without as many medical resources, this is often the only option for many premature babies to be kept warm. While preemie parents are often unable to have baby placed upon them immediately after birth, you can usually start K-care very soon after your baby is born. There are some instances when baby is too ill to be taken out of their incubator. These instances are much less than some NICU's would have us know but if this is truly the case, you can lay your hand firmly, but gently on your baby's body so that they can experience your touch at the very least. If mom isn't available right away, dad can and should do skin on skin with baby as soon as possible!
For more resources on K-care, see the end of this article. (Note: If you're having a difficult time getting your NICU to allow K-care, these resources are research based and supported. Bring them to the NICU and fight for your and your baby's rights!)

2. Notice baby's state of quiet alertness.
Dr. Sears says: "Within minutes after birth, the newborn enters a state of quiet alertness, the state in which, researchers have discovered, a baby is most able to interact with her environment. it's almost as if she is so enthralled by what she sees, hears, and feels that she doesn't want to waste any energy squirming. During this alert stage, the baby looks directly at the mother's eyes and snuggles at the mother's breasts....The quiet, alert phase lasts only an hour or so, and then the baby contentedly drifts into a deep sleep. You'll see this state again in the days to come, but for shorter periods of time."

At first, preemies spend only very brief periods of time with their eyes open, and do not focus on anything. Assuming your preemie does not have any eyesight issues like ROP, your preemie will only have a few periods a day, for possibly only a few seconds, when they are in a quiet alert state (The Essential Guide for Parents of Premature Infants). When your preemie is in this quiet alert stage, bring her about 8 inches away from your face, and interact with her. Smile, talk softly, change your expression often and allow her to enjoy this time with you. Do not let anything that isn't vitally important inturrupt these moments. If a procedure or medication needs to be done but it can be held off for a few minutes, do so and use your preemie's quiet alert time to interact with her. If for some reason you are unable to hold your preemie, get close to the incubator and put your face level with hers. Open the door to the incubator, place your hand on her and talk softly.

*NOTE: Even if your baby has eyesight issues, you should obviously still do these kinds of things with your baby! :)

3. Touch your baby.
Dr. Sears says: "Gently stroke your baby, touching her whole body. Besides feeling good, stroking has medical benefits. The skin is the largest organ of the human body, and it is very rich in nerve endings. At a crucial transition time in a baby's entry into the world, when breathing patterns are often very irregular, stroking stimulates the newly born baby to breath more rhythmically."

This is one of the things that almost ALL preemie parents can do with their preemies. There may be times when your preemie is too delicate or too sick to hold, but you can almost always touch them. Depending on their gestational age and health, there are different types of touch that should be utilized.
Still Touch is exactly what it sounds like. You lay a hand gently, but firmly on your preemie and do not move it around. Some preemies are very sensitive to being stroked and with the very earliest preemies, stroking their skin can cause damage. It is important to pay attention to your preemie and notice their reactions as you're touching them. It's also important to talk to your nurse about the condition of their skin and what is and isn't safe. If you feel your NICU nurse is not receptive to your needs and wants as a parent, ask to speak to the charge nurse.
Containment provides your preemie with a secure and nurturing human-boundary. Use your hands to provide containment by holding baby's arms and legs in a flexed position. This method of providing stability and predictability enables parents to gain confidence, especially during the early days in the NICU. Containment is useful for preemies who are medically unstable, fretful, or recovering from surgery. It can also be used during procedures where your prem needs support and comfort.
Movement: If you have an older preemie or as your preemie gets older and can tolerate movement, try a firm stroking on the bottoms of their feet or palm of their hands. If they are tolerating that well, you can try other movements. You can also try patting their butts. Keep a very close eye on them to see how they tolerate the movement. If they don't like it, stop and try again later.

4. Gaze at your baby
Dr. Sears says: "Your newborn can see best at a distance of about ten inches, which, incidentally, is the approximate distance from a mother's nipple to her eyes. During the first hour after birth, a baby's eyes are wide open, as if wanting to relate to his new world."

Once they start getting quiet alert times, gaze at them often. Direct eye contact with them so they can see you and learn your face. Even if they're asleep, which preemies sleep far more than regular newborns, it is comforting for mother and father/partner to gaze at their newborn. As soon as you can get up to the NICU after your baby is born, spend time just looking at them. It can be difficult to see past all of the monitors and wires hooked up to your baby so look at their face. Absorb their tiny eyes and nose, see their ears, their sweet baby cheeks. Breathe deeply and just gaze at your baby.

5. Talk to your newborn.
Dr. Sears says: "Studies have shown that newborns can distinguish their mother's voice from that of everytong else very early in life. Baby can also recognize Dad's voice, as well as siblings'. Mother's voice comforts her baby and helps baby feel at home in the world."

Your baby has heard your voice from the time their ears were developed in utereo. They know your voice, as well as their fathers voice. Talk to your preemie all the time. Read to them. Sing them songs. Tell them about your day. Tell them what their big sister or brother is doing. Tell them how much you love them and how proud you are of them for being so strong and brave. They will be comforted by your voice.

6. Delay routine procedures.
Dr. Sears says: "Often times the attending nurse takes care of routines first, such as measuring the baby, cleaning him up, giving him vitamin K and putting ointment on his eyes...Ask the nurse ahead of time to delay these procedures for an hour or so, until you and your new baby have enjoyed the initial bonding period."

Procedures that are done on preemies right after they are born can almost never be delayed. Many times they are life saving things such as providing oxygen etc. However, you can ask that the blanket or towel they use to clean your baby off be given to you. The smells from the womb will help stimulate the mother's milk production. Also, speak to the nurses and doctors ahead of time and impress upon them how vital it is for you as a new mother to be able to at least briefly touch and look at your baby after they are born. Depending on how well they are breathing on their own, you may be able to spend time gazing into their face. Of course, this may not be an option but let your medical team know how important it is to you if it IS possible.

7. Breastfeed your baby in the first hour after delivery.
Dr. Sears says: "The baby's sucking and licking of the nipple releases the hormone Oxytocin into the mother's bloodstream. Oxytocin causes the uterus to contract and lessens postpartum bleeding. It also produces feelings of affection. Your baby's first sucking experience should take place at the breast. Newborns need to breastfeed early and often in order to learn correct sucking based on the sucking instincts they are born with."

Most preemies cannot be brought to breast right away. If they can, great! But in almost all instances, this simply isn't possible. What you can do however is start pumping as soon as possible. If you know ahead of time that you're going to deliver, have a pump brought in your room. If not, have a nurse bring you a hospital grade breast pump right away. You should start pumping as soon as you can, preferably within 3 hours after your baby's birth. Even if you get nothing at first, keep pumping to stimulate your breasts. It is imperative that you pump often, at least 8-10 times in a 24 hour period. If you're not responding well to the breast pump, try hand expression. Many moms respond to hand expression far better than they do to a breast pump. In fact, there is very new research that demonstrated that mothers who followed each electric pumping session with hands-on compressions of the breast extracted more milk and boosted their long-term milk production.

Human milk is far easier on a premature baby's digestive system. It contains lipase, a hormone that helps with fat digestion, which allows babies to be able to use more of the calories available in the milk. In fact, studies have shown that the milk of mothers who deliver a premature infant is higher in protein, fat, and other nutrients for catch-up growth. (Dr. Sears)

By 32-34 weeks gestation, most preemies can start attempting to breastfeed. That doesn't mean they'll catch on and start breastfeeding immediately (although some may!!), it just means that their suck/swallow/breathe reflex is usually mature enough to start trying to breastfeed. They may just nuzzle or fall asleep but keep trying! And I STRONGLY recommend not giving preemies any bottle feedings until breastfeeding is established. If the NICU insists on mouth feedings, you can try alternate feeding methods.

8. Ask for privacy.
Dr. Sears says: "This first hour after birth should be a quiet one in which Mother and Father/Partner focus on their new baby. Ask that you be left alone as much as possible during this time, so that your attention is not diverted from your baby by the hustle and bustle of nurses and other hospital personnel."

Again, this is something that you probably will not be able to have with your preemie. Most preemies have to go to the NICU right away, even if it's just for observation. However, once you can get to your preemie, unless your baby is having procedures done, there is no reason why you cannot have privacy. Even if you're in a NICU where there are multiple beds in one room, there are usually curtains or room separators that are offered for your baby and you can ask for privacy. Spend time with your preemie and try to focus on them as opposed to the machines and wires. It can be difficult to celebrate the birth of a baby if they are premature and sick but remember, you just had your baby and try to enjoy and celebrate the birth of your baby.

Kangaroo Care Resources and Articles
Midwifery Today: Kangaroo Care
Kangaroo Care Benefits
U of Michigan: Kangaroo Care

Pumping Resources
Pumping for your Preemie
More Nutritious Breastmilk for Preemies
Breastmilk for Preemies

Other Preemie Resources
Bonding with your Preemie
"The Premature Baby Book" by Dr. Sears
Ella's Halo

Works Cited:
"PREEMIES: The Essential Guide for Parents with Premature Babies" By Dana Wechsler Linden, Mia Wechsler Doron, Emma Trenti Paroli

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