Thursday, May 26, 2011

An open letter to NICUs about feeding

I am often asked by NICUs, "how can we get our babies to feed better and earlier"? The question regarding feeding early (<32 weeks) depends a lot on a unit's definition of "feeding". Does the unit have a philosophy that supports feeding as an emergent developmental skill? Or does the unit practice in a way that expects babies to feed at a certain age regardless of their gestational age or hospital course? Do the therapists come in to "fix" those babies that don't meet the deadline, so to speak? I say this because many units struggle with the idea that we can "teach" infants to eat by starting earlier, offering more often, etc... That philosophy is mistakenly adapted from the rehabilitation model, a model that is not appropriate when applied to the premature, developing infant. Adding to that is the very real pressure to get the baby home and often, "feeding" is the last hurdle - it is understandable to want to hurry that along! But by continuing to operate from this model, NICUs have actually made the transition to full feeding more difficult for most families.

If feeding then is an emergent, developmental skill, how do we best support the process? The best practice is to start early by ensuring as much regulation as possible with gentle, slow and responsive care and by promoting early and on-going skin-to-skin holding. Mothers can gradually transition some of that skin to skin time to holding the baby near her nipples so that the baby can nuzzle, lick and taste without there being any expectation of intake. Some babies may very well have the baseline regulation of breathing, posture, and state to begin to taste milk as early as 27-28 weeks, but again this is not what I would call "feeding". I liken it to the early signs of readiness to stand when a baby reaches up in sitting and pulls their bottom up an inch or two before plopping down. We don't expect an infant to learn to walk suddenly and then increase the distance they walk immediately rather, the infant works for weeks and months on steadying and regulating the underlying capacities that allow that first step to "emerge", first wobbly and uncoordinated and gradually with more skill. The infant initiates the early activities and parents respond, support, and let the baby try more skills when he is ready to do so. When we talk about introducing feedings, breast or bottle, we should be very confident that the baby has had the same sort of early capacity-building experiences, support and respect for the infant's own emerging abilities.

NICUs are getting better at understanding the importance of reading cues to direct feeding. Yet in a protocolized, medical environment, that can be a very tall task to implement. Units ask me often to clarify what the cues might "look like", without first overhauling their general rehabilitation-oriented philosophy. Without seeing feeding as a continuum of how an infant is cared for, it is very difficult to truly use the infants cues as a way to progress towards feeding competency. Caregivers must trust that the behavioral cues of the baby are real and meaningful. "Let's try a bit more" or "he's 35 weeks, he needs to do this" are actually quite harmful and although we may see a short term outcome (full oral intake) the long term effects on nutrition, growth, development and parental confidence are significant.

On the unit where I work, we try to address the underlying values and myths that surround feeding development and spend time helping clinicians reflect on the challenges of changing one's paradigm. We promote skin-to-skin care and the early "tastes" at mom's breast. When the staff and family feel like the baby can try to latch on or try a bottle, we ask that they ensure the baby is alert, well-supported by his own parent (for us this means cradled, swaddled in mom's/nurse's arms - not held out on laps!), and has steady vital signs. The expectation is to do this when the baby shows the ability to alert before or with care and is not overwhelmed by his care alone. Then the baby is offered a few tastes with the slow-flow nipple or at the mother's breast. The expectation is that this should be pleasant and that intake is not the goal. The baby may or may not take a measurable amount. In fact, measuring intake at any point is counterproductive - overall wellness, hydration and behavior are accurate clinical signs, weight gain is secondary even. This "practice" should end with the baby still comfortable, awake or drowsy (not shut down) with good tone and posture and within a reasonable range in heart beat and breathing rate from baseline. The goal is to support the baby to be "ready" for these experiences by not overwhelming him. This means he may wake up for 3 feeding times initially and take 3-5cc, then wake up for 4 feedings and may take a bit more, etc... The emphasis is on supporting the arousal, readiness and regulation, rather than the intake. Intake will come assuredly if the baby can alert, stay regulated and take in milk without being overwhelmed. Protocols that call for offering one full feeding a day, then progressing to two, etc... once the baby can do a full feeding, do not support well enough the baby's actual cues and do not assure the flexibility that all humans need for success.

So the answer to the original question? To help ensure the nurturance and growth of premature babies, support the baby to be regulated from birth so that his naturally occurring developmental skills can emerge in the context of a safe, secure environment that ideally is supported within the arms of his mother. The goal should always be to feed "better" rather than faster or earlier.

Tuesday, March 15, 2011

What's an Ethologic Mom?

Definition of ETHOLOGY (from

1: a branch of knowledge dealing with human character and with its formation and evolution
2: the scientific and objective study of mammalian behavior especially under natural conditions

I thought that I'd say a few words about why I chose to be the "Ethologic Mom". Ethology is a more recent discipline devoted to studying behavior and social organization through a biological lens. I am not officially an "ethologist" yet I appreciate the theories and the implications for my work (and as a mother of 3 little ones!) In my work as a developmental specialist and NIDCAP Trainer in the Newborn Intensive Care Nursery (NICU), I spend a lot of time formally observing small infants in under the conditions in which they find themselves (albeit not so natural but alas, they are here...). I am fascinated by how well a tiny, premature infant is capable of communicating about his or her need for social interaction, comfort and support to do the hard work of development while outside the womb too soon and in the often overwhelming atmosphere of the NICU. The baby's success in meeting his biologic, social and emotional goals depends on how well his caregivers see and "hear" the message she gives. Parents read the message of the baby intuitively most of the time, so in some ways my role is to be a cultural broker and interpreter between baby/family and the NICU staff. Parents benefit from seeing how the baby communicates differently and exquisitely but differently than the full term infant. And staff benefit from seeing the baby as a unique individual with his own personality, strengths and preferences. The only way to do this sensitively and without adding to the baby's stress is through behavioral observation. Almost universally when I spend time with a new trainee who is learning the NIDCAP method of observation, they are amazed at how much there is to see. Inevitably someone says, "I always wondered what you were looking at for all that time! Now I know, this tiny baby is amazing and at the same time, I feel so bad for all of the times I didn't realize what a baby was trying to tell me and he experienced overwhelming stress." That sort of attunement is what I hope for all babies, all parents, all NICU workers and it begins by standing and watching...

Monday, February 14, 2011

Life is a Valentine

Well, it's Valentine's night and all is well with the world. My lovely husband did not get me anything "material", that's fine because we are broke and I would have been mad if he had spent any money. ("Honey, I love you and got you this gift that we can't afford...isn't that romantic?") Although, I DID get him a soup ladle since he's been bemoaning the lack of one in the house... I know, I'm a pretty awesome gift giver, I come by it naturally. What my darling did give me was unsolicited sweet, loving "googly" eyes (my favorite), tender hugs, kisses and, the best, generously performed vacuuming, laundry folding and dish cleaning while I studied tonight. I'm so blessed!

Thursday, February 3, 2011

Snowpocalypse 2011

Snowpocalypse 2011 lived up to the hype! My first big Chicago snowstorm was the one in 1999 and it was good, but we lived in an apartment building off a main road. The buses never stopped running, so that was "no big deal". But this one! 500 cars stranded on Lake Shore Drive! Awesome. (unless one of them was yours of course) 4 foot drifts! Great! Plus, this time we have children and they loved it, especially the snow days. Snow days simply don't happen for anything less than 17 inches of snow in Chicago. Serious. Well, I love looking at all of the photos others have been sharing, so here's some more...