Birth & Beyond California: Breastfeeding Training & QI

Project

With funding from the federal Title V Block Grant

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The Science of Attachment

Birth & Beyond California:

Breastfeeding Training & QI

Project

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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

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What Does Attachment Mean to You?

• Discuss with your neighbor

• Let’s talk about your thoughts…

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Attachment: Importance of Touch

DVD: Touch in Labor and Infancy:

Clinical Implications

Marshall Klaus, MD Stephen Suomi, MD

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Attachment: Importance of Touch

“Touch or patterns of touch early in life canhave 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, 2007Diego, Infant Behavior & Development, 2007

Hernandez-Reif, Infant Behavior & Development, 2007Feijo, Infant Behavior & Development, 2006

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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

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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

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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

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How Can We Increase Attachment?

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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

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Attachment

DVD

Six Core Strengths for

Healthy Childhood Development

Bruce Perry, MD, PhD

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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

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What If:

• Altering the way we care for mothers and babies could conclusively change their lives?

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Sensitive Periods

• Sensitive periods in biologic phenomena are times when events can alter later behaviors

Lawrence, Breastfeeding: A Guide for the Medical Professional, 2005

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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

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Sensitive Period: Results

• Mothers in the extra contact group showed significantly different behavior that persisted for at least two years

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Sensitive Period: Results at One Month

• More soothing

• More fondling

• More eye-to-eye exchange

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Sensitive Period: Results at One Year

• Soothed their baby more during the stress of a pediatric visit

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Sensitive Period: Results at Two Years

• Fewer commands

• More questions

• More elaborate, descriptive vocabulary

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Conclusions

• There is a “Sensitive Period” for maternal attachment during the first hours and days after delivery

Siegel, Pediatrics, 1980

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Sensitive Period

• Right after birth, within the 1st 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 1st meeting with their parents

Klaus, Your Amazing Newborn, 1998

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Self Regulation

DVD

Six Core Strengths for

Healthy Childhood Development

Bruce Perry, MD, PhD

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Responsiveness

• When a mother responds within 1.5 minutes of beginning to cry

• Infants stopped crying almost immediately

Thoman, Aberrant Development in Infancy, 1975

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Non-Responsiveness

• When infants are allowed to cry longer

• They cry more over time

Thoman, Aberrant Development in Infancy, 1975

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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, 2001Spangler, Development Psychology, 1994

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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

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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

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Cultural ConflictsHappy 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

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What Can We Do?

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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

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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

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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

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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

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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

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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

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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

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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

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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?

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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

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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

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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

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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