Excerpted from Chapter 5 of Understanding Newborn Behavior and Early Relationships: The Newborn Behavioral Observations (NBO) System Handbook, by J. Kevin Nugent, Ph.D., Constance H. Keefer, M.D., Susan Minear, M.D., Lise C. Johnson, M.D., Yvette Blanchard, Sc.D., PT, with invited contributors.
Copyright © 2007 by Paul H. Brookes Publishing Co. All rights reserved. No part of this excerpt may be reproduced or reprinted without permission in writing from the publisher.
Use of the NBO During Common Pediatric Encounters in the Early Newborn Period
For convenience, the role of the NBO for clinicians in the early newborn period is outlined somewhat chronologically. Although every interaction differs, common themes do emerge from one family to the next, providing a framework for discussion. Although this is to some extent an artificial organization of concepts, the following themes are discussed as a “rounding” pediatrician or nurse practitioner might encounter them:
Day 1: The first encounter—strengths and needs within the family system
Day 1/Day 2: Feeding support and easing transition
Day 2/Day 3: Crying and soothability
Day 2 and beyond: Individualized caregiving guidelines
The reader will see how concepts from one theme weave throughout other themes and how the NBO adapts itself to a variety of professionals. As is discussed in the latter part of this chapter, the NBO is most powerful when it is used by all of the clinicians the family encounters; it helps if everyone is using the same language.
Day 1: First Encounter—Strengths and Needs within the Family System
The first pediatric physical assessment often is the first meeting between the clinician and the family. The pretext of the visit is to complete the physical examination of the infant and discuss newborn health maintenance issues. Its richness, however, comes from clinician and parents looking together at the new infant as a person. Therefore, as discussed earlier, this examination should be done, whenever possible, in the presence of the family. Although each provider builds relationships in his or her own style and there are cultural differences in the ways in which such an introduction may be presented, a useful first question is, “How did you choose his name?” Most parents care deeply about the name they have chosen for their infant; usually much thought has gone into their decision. There often are stories that spring from the parents as they begin to recount their story of the infant’s name. Listening carefully to the answer, the clinician can elicit important social and family history without asking uncomfortable or intrusive questions (e.g., the father’s involvement, key support people who participated in choosing the name, religious and cultural traditions, hopes and dreams for the new infant). Using the infant’s name throughout the subsequent examination gives parents one of their first opportunities to hear their infant addressed by his or her name—an intimate joy to share.
Early in this first encounter, the clinician can invite the parents to bring their concerns to the fore: “What questions do you have about your infant so far?” Typical concerns may revolve around unresolved worries or fears from the pregnancy, prenatal testing findings, medication exposure, effects of maternal illness on the infant, delivery room events, transitional difficulties that the infant may have experienced, or physical findings that were noticed by a parent or other family member. Many of these issues, of course, may not be raised at first. Nevertheless, the question should be posed at the start of the visit as a standing invitation for parents to raise concerns when they feel comfortable doing so. Indeed, in a study by Wolke, Dave, Hayes, Townsend, & Tomlin (2002), the opportunity to discuss health care issues during a newborn’s routine physical examination was found to be related significantly to mothers’ satisfaction with the clinician who was performing the examination.
The only question on the minds of many parents at first is, “Is my infant healthy?” Even if the clinician narrates every item of the examination for families,—“Her heart sounds normal, her belly feels fine . . ." —if he or she forgets to end it with a summary pronouncement of health, someone in the room is likely to ask for it. The importance of this opportunity presented by the simple physical examination of a typical child must not be underestimated. “This looks like a healthy infant to me,” is just what each parent has hoped to hear after the many months of pregnancy. Even when the clinician finds a medical problem, such as a clavicle fracture or a dislocated hip, he or she has the opportunity to frame these findings more easily when sharing the examination with the family at each step.
Conducting the physical examination in the presence of the parents can be both a way of communicating with them and a means of gathering important information about the family (Kennell & Rolnick, 1960). The examination, when infused with the principles and spirit of the NBO, offers an opportunity to draw in those who are present in the room. Siblings may be invited to stand beside the bassinet. A perhaps reticent father can be invited to feel the fontanels or, if culturally appropriate, to calm his infant during the examination by helping the child to suck on his or her hand or even on the father’s finger. Commenting on the infant’s tone or level of activity may prompt a question about what he or she was like in utero, thereby honoring some of the mother’s already developed intimate expertise on her infant. Noticing aloud how the infant calms in response to the familiar voice of the mother or father acknowledges the uniqueness of the parents’ roles in this particular newborn’s life. In so many ways, the clinician’s openness to the family while looking together at the newborn provides opportunities to support and recognize the parents’ competence and expertise, often even before they are aware of these things themselves. Furthermore, observing the family’s responses to the examination—indifference, joy, anxiety, surprise, conflict—can begin to help the clinician understand where some of the strengths and vulnerabilities in this family system may be. Moreover, the very experience of focusing on the infant together provides an environment of trust and often will prompt families to offer unsolicited information about their strengths and needs. Of course, this is not the time to draw firm conclusions but rather to begin to gather information that will help guide future interactions. Finally, honestly enjoying the infant—tiny fingers, searching eyes, even a cry—signals to this family that the clinician truly cares, really does see how special this individual is, and sincerely wants to help them succeed in their parenting.
Day 1/Day 2: Feeding Support and Easing Transition
In the first 24 to 48 hours of their newborn’s life, many parents observe an array of state changes in their infant as he or she makes the transition to a new, extrauterine environment. They experience their infant’s erratic early feeding behaviors and may have trouble making any sense of it all. The NBO is ideally suited to helping guide families through this early, confusing time. Here, the critical concept is that of state and organization of state. The pediatric care clinician can share aloud observations of the newborn’s states and how he or she moves through them. Many parents can identify easily the common quiet alert state in the first few hours of life, often followed by a prolonged sleepier period, and are comforted to know that this is a normal pattern. Sometimes, transient medical complications that require separation of mother and infant occur in the first few hours after birth. These families, having missed that initial alert period, may need more reassurance about the subsequent sleepiness. All infants are individuals, of course, and may have a variety of behavioral patterns. Some parents may report that their infant has been very wakeful, wishing to be held constantly. Perhaps the clinician notices that an infant has difficulty habituating to light or sound and/or moves jaggedly from crying to sleeping. The skilled clinician will share his or her observations with parents in a way that helps them make sense of their experience and guides caregiving choices while avoiding labeling and prediction. There is a world of difference between being told, “I notice that she is disturbed quite easily when asleep. Protecting sleep is a skill that each infant learns at his or her own pace. We’ll have to keep an eye on this with her,” and, “You sure have a fussy infant on your hands!” Observations should be made in the spirit of “what is being seen together on this day, at this time.” Parents then are given the tools to make their own observations, confirmatory or otherwise, as they move forward. The critical goal is not to hand the family a complete understanding of who this infant is and what his or her individual personality is like, but to look together and help to identify what to look for and a developmental context in which to place it.
For example, the NBO is used frequently as a way to help parents of nearterm newborns understand their infant’s less mature state organization.
One mother was working very hard in the first days to help her infant of 36 weeks’ gestation learn to breast-feed. Although the infant had a mature suck and swallow, her feeding was inconsistent. While observing the mother attempt breast feeding, the postpartum nurse noticed that the infant alternated between crying and sleepy staring. The nurse talked to the mother about feeding cues and infant states and reinforced the idea that breast feeding typically takes some time to be established. This made sense to the mother and alleviated her anxiety. Although initially perplexing to the mother, when it was explained that the infant’s ability to regulate her state still was immature, that it was still developing, the infant’s behavior—and what to do about it—made sense to her. The next day, the mother reported, “She did that same crying–staring thing again last night, so I just let her rest on my chest for a while and she was able to feed better a little later.” This mother understood the concept of state regulation in the context of her infant and was using it to adapt her caregiving; the result was successful breast feeding.
Behavioral state also is a central concept when helping parents make sense of early feeding behaviors of mature, term newborns (Hughes, Townsend, & Branvin, 1988; Kennell & McGrath, 2003). Before meeting their infant, crying may be the only feeding cue that many parents recognize or know. Crying is a late feeding cue and often results in an infant who is too disorganized to calm and latch onto the breast, a situation that will be frustrating for all involved. Observing rooting, sucking, and hand-to-mouth behaviors and distinguishing between deep and light sleep all serve to help teach parents the “sign language” of feeding readiness (Gill, White, & Anderson, 1984). Although each infant may differ in feeding skills at birth, helping parents to identify their infant’s states and sense of his or her state organization as well as early feeding cues will go a long way toward making the most of each unique situation (Karl, 2004).
Day 2/Day 3: Crying and Soothability
Listening to their infant cry presents a challenge for many parents, especially when the reasons for the cry are unexplainable (Barr, St. James-Roberts, Keefe, 2001; Brazelton, 1962; Donovan, Perlstein, Atherton, & Kotagal, 2000; St. James-Roberts, 2001). Told that they would recognize their infant’s different cries— hunger, dirty diaper, pain—they more often stare with panic, wondering which one is which and why they do not seem to know the language. They fear that the crying is unpredictable, that they are incompetent to stop it, and that they will be unable to help their infant in need. Although some newborns may cry even the first day, crying periods may lengthen after the infant emerges from the postbirth sleepy period. Crying may be related to feeding cues or it may be unrelated to hunger. A common scenario is to arrive at the hospital room on the second, third, or fourth day and be greeted by a tired mother who says, “I think something is wrong with him. He kept me up all night crying.” Most typical, the infant now, of course, is asleep either next to the mother or in the bassinet. Concepts from the NBO can be very helpful in these situations. For example, in an earlier encounter, the clinician may have heard the infant’s cry and commented on its strength and vigor, what seemed to trigger it, and what seemed to calm him or her. In other words, the clinician can value crying, not that the infant should not be consoled, but that it is a typical thing that infants do.
By expressing interest in the infant’s crying, the clinician can talk with the mother about variations in crying and response to consoling measures. The parent and the clinician then can look together at this infant to examine these issues. In these encounters, the clinician hopes to see the infant cry. This can be stated explicitly to the parent, “Maybe we will have a chance to see Sarah crying together now while I am examining her. What have you noticed that sets her off? What have you noticed so far that works to calm her?” Most often, even if they had not yet realized this themselves, parents will be able to describe patterns that they have already noticed: “Well, she really likes it if Hakim [father] holds and sings to her. It’s just that we can’t put her down!” The clinician watches how and when the infant cries in his or her own hands as well as the stepwise series of consoling maneuvers, which the clinician can narrate as he or she moves through them, remembering also to notice the infant’s attempts at self-consoling. This may be an opportunity, for example, to affirm the parents’ awareness of their infant’s preferences. Parents also may have the validating experience of seeing their infant crying and being difficult to console in a professional’s arms (“She’s really crying all out. What a strong cry she has, although I can see what a challenge it is for her to calm down!”). Many times, once the clinician hands the inconsolably crying infant back to mother, everyone will have the opportunity to see the infant calm promptly in those familiar arms, with that familiar voice and scent. In summary, the goals are 1) to focus on the crying, placing it the context of the infant’s individual pattern of state regulation and soothability; 2) to help parents identify and extend their own emerging expertise in reading their infant’s behavior; 3) to empathize with the difficulty of coping with a crying infant; 4) to identify efforts at the infant’s self-consoling, even if not yet fully successful; and 5) to normalize the sometimes surprising amount of external support that some infants may need and to place it in a developmental context.
Day 2 and Beyond: Caregiving Guidelines and Anticipatory Guidance
As the time for discharge from the hospital approaches and during the first days and weeks at home, parents are able to turn their attention from the issues of early transition to the concerns of caring for their infant at home. Pediatric clinicians often have laundry lists of topics to discuss with new parents before discharge. Meanwhile, parents, exhausted and overwhelmed, have their own sets of questions that may or may not overlap with a clinician’s agenda. Providing guidance in the context of the NBO allows clinicians to give advice that is individualized and presented in a collaborative style. For a clinician who is conducting a discharge examination, for example, the NBO may take the form of a combined physical and behavioral examination, similar to that outlined as an adaptation of the Neonatal Behavioral Assessment Scale (NBAS; Keefer, 1995). What follows is a template for such an encounter, based on a discharge pediatric hospital visit. Ideally, this visit will be at least the second or third time the clinician and family have met so that the clinician can refer to and build on earlier discussions.
As already discussed, parents must be invited genuinely to share their concerns and to influence the agenda. Therefore, many an encounter will not “fit the mold.” It is not necessary to have every topic on the clinician’s mental list addressed if the encounter was informative and meaningful from the parents’ point of view. In fact, a thorough discussion of every topic outlined next probably would exhaust everyone!
As the clinician approaches the infant, he or she may begin with skin inspection. This is an ideal time to look for jaundice and to discuss this topic and any necessary follow-up with families. The heart and lungs can be auscultated at this point. If the infant is still sleeping and has not been disturbed, then habituation items may be administered, prompting discussions such as where the infant will sleep at home, maturity of state regulation, or sibling adjustment (because it may be the sibling who disrupts the infant’s sleep). As the infant is unwrapped a bit and placed on his or her back, a good opportunity is presented to discuss sudden infant death syndrome prevention while demonstrating proper sleep conditions and positioning (American Academy of Pediatrics Task Force on Sudden Infant Death Syndrome, 2005; Hauck et al., 2003).
The clinician may take this moment to inspect and show the parents the healing cord and guidelines for its care and surveillance; to examine and show the healing circumcision site, if applicable, and review circumcision care or notice the umbilical cord; to check for robust femoral pulses; and to perform a hip examination. The undiapered, supine infant also provides an opportune time to talk about temperature taking as well as infection prevention at home. Often, the infant will have cried by this point in the examination, prompting discussion about the parents’ experience thus far with the infant’s crying, soothability, and predictability. The clinician may have noted some rooting or sucking or may have found urine or stool in the diaper, all of which make for good opportunities to talk about feeding guidelines. The clinician then may look together with the parents at the infant’s muscle tone and pull him or her to sit, allowing for a conversation about robustness as well as the level of head support that the infant seems to need at this point. Putting the newborn in the prone position naturally prompts a discussion of “tummy time” for encouraging extensor muscle development.
Many parents are surprised and delighted by their infant’s neck strength or mention having seen this neck strength themselves while holding their infant on their chest. If the infant comes to a reasonably quiet alert state during this time, the clinician may take the opportunity to observe the infant’s ability to respond to visual and/or auditory stimulation, inanimate and animate. This is an ideal time to discuss issues around social readiness, stress cues or signs of possible over stimulation, and decision making around exposure of the new infant to the family’s social world. Finally, if the opportunity presents, there can be no nicer way to end the encounter than by asking one of the parents to call the infant’s name and watching the infant turn to his or her mom or dad and then returning the infant to their arms.
Sometimes patient encounters are not so straightforward and not at all what the clinician is expecting. A mother’s hidden fears may express themselves in seemingly surprising worries or concerns. On such occasions, the relationship-building power of the NBO can be invaluable. The following vignette describes such an encounter, showing how newborn behavioral observation also can be used to great advantage as a way of discovering, prioritizing, and addressing parent concerns. Here, the Lopes twins, born at 38 weeks and 7 pounds each, have been thriving in their first days and are ready to be discharged. Their mother is recovering well from her cesarean section and has multiple family members supporting her. Nurses have found her to be coping well with her infants, although a bit nervous.
Upon entering the room, Dr. Zhu sees that Ms. Lopes is anxious about taking her newborn twins home. Dr. Zhu puts aside her discharge teaching “agenda” to explore Ms. Lopes’s anxieties. Ms. Lopes expresses her concern that maybe her twins are not ready to go home. Dr. Zhu is perplexed because, looking at the medical record, the infants are healthy, term infants who have transitioned well and are medically stable for hospital discharge after 4 days of life. Rather than explain the medical reasons for why the infants are ready to go home, Dr. Zhu listens. She proposes to Ms. Lopes that they unwrap the infants and look at them together. Immediately, Dr. Zhu senses Ms. Lopes’s anxiety decrease as she perceives that her concerns are being heard. Dr. Zhu uses the language and structure of the NBO to share with Ms. Lopes, with her own infants, the aspects of their examinations that are healthy and typical. The two also look at those important areas of the infants’ physical and developmental stage that will require extra care, such as attention to head control and careful bundling of small newborns. At the end of this brief encounter of shared observation, Ms. Lopes is visibly more open to Dr. Zhu’s opinion regarding safety for discharge. Recognizing Dr. Zhu’s genuine interest in her and her infants, Ms. Lopes volunteers her fear: She describes a friend whose infant died at home. Dr. Zhu acknowledges the mother’s fear and does not meet it with superficial assurances that these infants are typical. Instead, she proposes another option: a visiting nurse to check on mother and infants after discharge. Having been reassured, Ms. Lopes now is mentally available to take in important anticipatory guidance. Having been shown through her own infants aspects of their health, she is less likely to be anxious at home and to convey that anxiety to her infants. Moreover, in the brief minutes that Dr. Zhu spent during this encounter, her relationship with this mother has been strengthened and a key trust has been established.