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.

What's an Ethologic Mom?

Definition of ETHOLOGY (from http://www.merriam-webster.com/dictionary/ethology)

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...

The First Decade of a Millenium

This post takes its cue from a post by Sarah over at One Starry Night about change. Sarah shared some intense life events over the last decade and that she fears change. If you don't follow Sarah, I definitely suggest that you go check out her blog. She is a truly authentic person and I think that's why her photography is so amazing!
Well, her post got me thinking about my own reactions to change. I tend to embrace change and am always looking forward to "what's next?" I'm not sure what that says about me, maybe that I should take time to enjoy the moment and perhaps be more reflective about what has passed. Since I'm in the midst of some big changes right now, looking back over the last decade seemed like a great idea!!

2001 - In June I gave birth to my first son. It was a dream come true, except for the c-section. Even that was sort of a blessing in disquise. I returned to work the week of September 11th. I mourned that my little boy would grow up in a world fundamentally different from the one I'd known. At work, I started on my APIB reliability (Assessment of Preterm Infant Behavior) and went to my first NIDCAP Trainers Meeting in Skamania, Washington.

2002 - A good year for my family. In August I became pregnant again. Trainers meeting was in Colonial Williamsburg, VA

2003 - I gave birth to my daughter on her brother's birthday by CBAC (cesarean birth after cesarean - a term used to describe a "failed" vaginal birth attempt after cesarean). Probably one of the worst years of my life but as with most things, it really did serve to make me a stronger person. Another mark on this year was the sudden onset of optic neuropathy experienced by my husband while we attended the NIDCAP meeting in Estes Park, CO. This is typically a "first strike" symptom of Multiple Sclerosis. *knock-on-wood* so far so good for the most part!

2004 - I achieved reliability on the APIB and continued my studies to train under Heidi Als, PhD to become a NIDCAP Trainer. Trainers meeting was in Oklahoma City that year. "I loved that world" my 3-yo son said as we left - Trainers meetings are great for my family who get to play while I'm working away!

2005 - Achieved reliability as a NIDCAP Trainer ! Also became pregnant with my second son. A great joy to me as I felt like I was really getting another chance to do better for myself and unborn child. (Trainers meeting was in Connecticut - my colleagues from Holland were amazed to hear of the barbaric birth culture here "don't most people give birth at home?" they asked)

2006 - Started off with a bang and had my son naturally on his due date at the end of January by vba2c. That's vaginal birth after two cesareans. Getting there wasn't easy, and I had to search and search for a provider to "allow" me to labor. (looking back I wish I'd done a home birth) I did find a provider - right down the hall from my office. Trainers meeting in Sun Valley, Idaho - hey these are the only vacations I get!

2007 - Had my first miscarriage that summer. Agonizing experience. Meeting was in Combrit, France. Went on a 2 week trip through Germany and France with hubby. Lots of fun! First time ever away from the kids. We missed them terribly.

2008 - Had my second miscarriage that summer. Even worse experience than the first and fell into a deep depression that I'm maybe even just now starting to recover from. Meeting was in Raleigh, NC where I met Nils Bergman http://www.kangaroomothercare.com/ - the main speaker for the conference I just recently put together.

2009 - The year of existence. My husband went on a freak out mission and did some really crappy things, which maybe someday I'll be able to write about. Planned and hosted the NIDCAP meeting in Chicago. Really enjoyed event planning, so soon after, I initiated the planning for the Skin to Skin care conference this year.

2010 - A big year of change for me. Here's a few: starting grad school in the fall, dropped my percentage at the med center (will continue on as a NIDCAP Trainer) and started working part-time at the Erikson Institute. Trainers meeting is in The Netherlands later this year! Still working on the marriage with my new motto: Love is the Only medicine.

I'm not just singing to the choir OR our best ain't good enough

I met 28-week Jasmine first, observed her powerful efforts to keep her tiny, one and a half pound body tucked, arms and legs folded in close for security as if trying to recreate her experience in the womb where she’d been just hours earlier. The sounds of the bright and busy intensive care nursery, the breathing apparatus, the lines and unwieldy diaper she wore, all weighed on her attempts to find a comfortable moment for rest. Her nurse that day generously responded to my suggestion to encourage Jasmine to quiet her movements by adjusting her blankets, rearranging her equipment, and quieting the room so that Jasmine could rest while being softly supported in a tucked posture. Jasmine grasped my finger tightly as her nurse gently adjusted her blankets, and then fell into a quiet, relaxed sleep. I headed down the hall to the post-partum unit to meet her parents. Tina and Jason greeted me hesitantly; their anxiety that I might bring unwelcome news of their newly born baby girl somewhat relieved as I introduced myself and congratulated them on the arrival of their amazingly strong and engaging baby. Tina, recovering from emergency surgery due to placental abruption, pre-eclampsia, and having not yet seen her baby, smiled weakly to my account of Jasmine’s behavior. As the days turned into weeks, Jasmine and her parents spent many hours together, somehow managing a bright attitude despite the lasting effects of pre-eclampsia damage to Tina’s body, the unexpected infection that put Jasmine on a breathing machine for a short time, and the difficulty of spending hours with little privacy or comfort. Along the way, I spent time with Jasmine and her family, guiding and encouraging them in their developing roles. I experienced satisfaction that Tina and Jason felt safe to share their worries, frustrations and hope during our times together. I managed effectively to advocate for a quieter room and a number of nurses invested in this family regularly cared for them. Despite these good efforts, I am left with the challenge of “was it good enough”? far too often. As typically occurs in so many instances, the earlier appreciation of the baby’s need for a supportive environment in which her abilities emerge, gives way to the hope that pushing the baby to “take a bottle” will result in an earlier transition to home. Despite what I felt had been a particularly successful process in providing this family the foundation to navigate past the typical obstacles, the forces of habit and NICU culture prevailed. Ultimately, Tina and Jason took Jasmine home healthy yet, breast-feeding abandoned. Furthermore, I know they experienced undo pain and plenty of conflicting messages as to their competency as parents along the way. The story of one family continues on long past "discharge"; the chapter of time when I get the privilege to walk along with them carries a great deal of joy yet also, the burden of always wanting and needing to do more with the little time that is given. Families who must endure the NICU deserve better. Evidence and logic demand it. While there are many who sing the same song, there is much work to be done.

*names and details have been changed to protect privacy*

I did it!

My stomach was "tied in rows" (as in one of my favorite songs, guess which one?)as I summoned up the courage to tell my colleague that I was planning my big move into a new job in addition to going to graduate school. It was a big suprise for her. I felt horrible that she was so overwhelmed and sad. It will be a difficult transition for us. On a brighter note, when I told my boss she was amazing! Very supportive and excited for me to pursue my degree. She's letting me keep a small percentage of my position so that I can still be a NIDCAP Trainer and help out on special projects as needed. This is GREAT news. One of the best aspects of my current job is when I get to share the amazing insights of how a tiny baby "speaks" to us with his/her behavior. Helping other NICU professionals use this knowledge to support families and babies in increasingly sensitive ways is a real joy!