Birth & Beyond California: Breastfeeding Training & QI Project With funding from the federal Title V Block Grant 1

2 The Science of Attachment Birth & Beyond California: Breastfeeding Training & QI Project

3 Objectives Describe how the hospital staff can use therapeutic touch as an intervention modality Define attachment Identify three ways hospital staff can promote proximity of the mother/baby dyad

4 What Does Attachment Mean to You? Discuss with your neighbor Let’s talk about your thoughts…

5 Attachment: Importance of Touch DVD: Touch in Labor and Infancy: Clinical Implications Marshall Klaus, MD Stephen Suomi, MD

6 Attachment: Importance of Touch “Touch or patterns of touch early in life can have long-term consequences for normal physical growth, physiological functioning, and even combating disease process.” Suomi, Touch in Labor and Infancy: Clinical Implications

Attachment: Importance of Touch Preterm infant massage therapy –Increases infant vagal activity & gastric motility that are associated with greater weight gain –Increases infant temperature –Reduces infant stress behaviors & activity –Reduces mothers’ depressed mood & anxiety levels Diego, Acta Paediatrica, 2007 Diego, Infant Behavior & Development, 2007 Hernandez-Reif, Infant Behavior & Development, 2007 Feijo, Infant Behavior & Development,

8 Touch as an Intervention Modality Promoting comfort in a caring situation has significance on many levels –Physical –Emotional –Social –Spiritual Chang, J Adv Nursing, 2001

9 Definition of Attachment/Bonding When the mother/father view their needs as secondary to the needs of the infant A desire to be together A feeling of emotional connection The complex process in which a baby learns to trust and depend on other human beings, especially his mother Bowlby, Attachment and Loss, 1969

10 Physiology of Attachment The attachment felt between mother and infant may be biochemically modulated through oxytocin. Klaus, Your Amazing Newborn, 1998 Feldman, Psychological Science, 2007

11 How Can We Increase Attachment?

12 What Elements Increase Attachment? Consistent, predictable and appropriate responses to the baby’s needs Lively, positive interaction (play) First 7 months of life are the most important Bowlby, Fifty Years of Attachment Theory, 2004

13 Attachment DVD Six Core Strengths for Healthy Childhood Development Bruce Perry, MD, PhD

14 Attachment Theory Began in the 1950s: Bowlby, Ainsworth, Kennell, and Klaus The belief that the mother-child bond is the essential & primary force in infant development Forms the basis of coping, negotiation of relationships & personality development Forms a secure base: behaviorally and emotionally

15 What If: Altering the way we care for mothers and babies could conclusively change their lives?

16 Sensitive Periods Sensitive periods in biologic phenomena are times when events can alter later behaviors Lawrence, Breastfeeding: A Guide for the Medical Professional, 2005

17 Sensitive Period Study Design Mothers are given extra contact: –One hour of contact in the first 3 hours –5 extra hours in the first 3 days Siegel, Pediatrics, 1980

18 Sensitive Period: Results Mothers in the extra contact group showed significantly different behavior that persisted for at least two years

19 Sensitive Period: Results at One Month More soothing More fondling More eye-to-eye exchange

20 Sensitive Period: Results at One Year Soothed their baby more during the stress of a pediatric visit

21 Sensitive Period: Results at Two Years Fewer commands More questions More elaborate, descriptive vocabulary

22 Conclusions There is a “Sensitive Period” for maternal attachment during the first hours and days after delivery Siegel, Pediatrics, 1980

23 Sensitive Period Right after birth, within the 1 st hour of life, normal infants have a prolonged period of quiet alertness…during which they look directly at their mother’s and father’s face and eyes and can respond to voices. It is as though the newborn had rehearsed the perfect approach to the 1 st meeting with their parents Klaus, Your Amazing Newborn, 1998

24 Self Regulation DVD Six Core Strengths for Healthy Childhood Development Bruce Perry, MD, PhD

25 Responsiveness When a mother responds within 1.5 minutes of beginning to cry Infants stopped crying almost immediately Thoman, Aberrant Development in Infancy, 1975

26 Non-Responsiveness When infants are allowed to cry longer They cry more over time Thoman, Aberrant Development in Infancy, 1975

27 Brain Development Infants are born with the capacity for feeling deep emotions The caregiver assists the infant to regulate his emotions The infant’s brain is “sculpted” as the neural connections for the capacity to form attachments are employed or pruned Schore, Infant Mental Health Journal, 2001 Spangler, Development Psychology, 1994

28 The “Baby Dance” is Relational Following baby's cues Babies have their own spontaneous expressions of themselves When a mother pays attention to these expressions, she communicates that she understands what the baby is doing, feeling, and even thinking Feldman, Journal of Applied Developmental Psychology, 1996

29 The “Baby Dance” is Relational The mother tunes to her baby's internal states She responds to the baby’s cues This produces a response in the baby Which further fuels this synchronized system Schore, Infant Mental Health Journal, 2001

30 Cultural Conflicts Happy Healthy Myth Sleepy baby is good Children need to be independent Mom needs to rest, take baby to nursery Mothers bond and breastfeed Happy Healthy Reality Sleepy baby becomes dehydrated, jaundiced Children are dependent Moms are designed to rest with baby, baby elicits maternal sleep Babies elicit bonding behaviors and are responsible for establishing breastfeeding

31 What Can We Do?

32 A Relational Approach to Perinatal Nursing Attachment is of critical importance Nurses are responsible for facilitating and protecting this relationship –All staff in contact with the mother/baby dyad need to keep this concept as a priority Nurses can “fan the fire of love” or can limit its development Karl, MCN, 2006

33 The Nurse/Mother Relationship Often parallels the mother/infant relationship “Mothering the Mother” creates trust and credibility that allows the nurse to support the attachment process Every encounter a nurse has with the mother/baby dyad is an opportunity to enhance a secure attachment Kennell, Acta Paediatrica, 2005

34 Promoting Proximity Maximize physical contact –Rooming in –Skin-to-skin –Breastfeeding –Infant massage Share information and observations that instruct the mother of the value of keeping baby close Martell, JOGNN, 2003

35 Promoting Proximity Rooming in increases maternal attachment –Increased positive interactions Looking Touching Talking to their babies –Decreased avoidance behaviors Watching TV Talking on the phone Prodromidis, Birth, 1995

36 Supporting Maternal Responsiveness Encourage mother’s observations Describe baby’s thoughts Reframe perceptions –From: He’s demanding To: He knows what he needs –From: She doesn’t want to breastfeed To: She needs to spend some time with you first Karl, MCN, 2006

37 Supporting Maternal Responsiveness Model responding to infant cues in all clinical tasks, i.e. bathing, feeding, newborn assessment Nurses have the unique opportunity to make a positive difference in the beginning of the relationship between a mother and her newborn Karl, MCN, 2006

38 Nurse as a Doer Making sure baby is bathed, diapered, fed –Your baby is sucking on his hands –He’s hungry –I’ll go feed him

39 Nurse as a Teacher Educating the mother –Your baby is crying –Have you been able to breastfeed? –He’s probably hungry –I’ll go over breastfeeding so you can get him on –I know you’re tired, but feeding him will make you feel better –We’ll make sure you know how to do it before you go home

40 Nurse as an Attacher Relational Process –Your baby is crying –What do you think is happening? –How do you usually calm him? –…Yes, picking him up usually works, why don’t you try it? –Another way to quiet down babies is by remembering “repetition to soothe” – such as patting or swinging –Babies can take up to 20 minutes to change their state, so don’t think you’re not doing it right! –…As the baby quiets down, do you think he could be hungry? Would you like some help breastfeeding lying down?

41 Attachment: Nursing Plan of Care Attachment is relational: establish a responsive, nurturing relationship with the mother that mimics the mother/infant relationship Infants are proximity seeking: help the mother/baby maintain contact Attachment depends on maternal responsiveness: ally with mothers to facilitate their availability and responsiveness to their infants

42 Outcomes When a Nurse Attacher Has Helped a Mother/Baby Pair Mother has demonstrated ability to care for her infant Mother is confident she can problem- solve The nurse has observed the emotional connection between mother and baby

43 Nurses are Wise Women Nurses have amazing power to influence mothering Nurses help parents get to know their baby Nurses help parents meet the needs of their babies by teaching them to respond appropriately to the baby’s cues

44 Power of Early Contact The single most important duty of care givers at this time is to allow these natural abilities to blossom, and not to interfere. Klaus, Your Amazing Newborn, 1998