Wow, so I thought when I started this blog that I would have so much to write about.  Well that is true, but graduate school, full time work, 3 children and a decidedly undomesticated husband have left little time to write about it! I've finished two of the three years of my program in child development and the next two semesters will be for my internship only! Can't wait.  I am really blessed to have been granted approval to spend the next year working on the validation and piloting of a behaviorally based feeding assessment for preterm infants that I developed several years back but had not, until now, any time to properly research.  I'd promise to write a whole post about it soon but, well, you know how unlikely that is from my history!  But I will try to take time soon.  It is a great project and definitely would fill a gap that exists in practice and the literature.  NICU's don't know how to support an infant's emerging feeding abilities, they want to measure things like how many milliliters the baby took, regardless of what it cost the baby behaviorally to do so.  So I'm giving them a way to measure what matters, the infant's own capacity and threshold for challenges. 5ml taken well with regulated body movements, breathing, etc... is way better in the short and long term than forcing a baby to take an entire bottle after which he is exhausted and limp, or worse, telling a mother that the nurse will supplement her breastfeeding effort "just in case". My feeding assessment also provides a meaningful measure of how regulating breast feeding in tiny babies is (not hard work at all!) and provides support for the notion that the infant is an active participant in his own nurturance - when a NICU forgets this, babies and parents suffer.  Wish me luck!!!

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...

Can't we ask the "right" questions?

Humpf. I'll just say it. I'm frustrated. Can I get my PhD and several huge research grants, like, tomorrow? Humpf. Or better yet, yesterday.

The source of my angst? I'm just very, very tired of seeing actual scientists/researchers continuing to ask the wrong questions as it relates to the care of preterm infants, newborns and mothers. Why are we doing research that asks if doing A or B is better based on the flawed paradigms within which the ENTIRE medical community works?

Can't we find ways to look at how basic paradigms are sustained despite effective research to the contrary? Shouldn't there be some lithmus test for research proposals that sounds the "uh-huh" alarm when the scientific question is based on the failed paradigm? Yes says me. Et tu?

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*