Monday, July 28, 2008

The Newborn

THE NEWBORN

John Olsson, Kliegman : Nelson Textbook of Pediatrics, 18th ed.

The newborn (neonatal) period begins at birth and includes the 1st mo of life. During this time, marked physiologic transitions occur in all organ systems and the infant learns to respond to many forms of external stimuli. Infants thrive physically and psychologically only in the context of their social relationships. Therefore, any description of the newborn's developmental status has to include consideration of the parents' role as well.

PARENTAL ROLE IN MATERNAL-INFANT ATTACHMENT

Parenting a newborn infant requires dedication because a newborn's needs are urgent, continuous, and often unclear. Parents must attend to an infant's signals and respond empathically. Many factors influence parents' ability to assume this role.

Prenatal Factors

Pregnancy is a period of psychologic preparation for the profound demands of parenting. Women may experience ambivalence, particularly (but not exclusively) if the pregnancy was unplanned. If financial worries, physical illness, prior miscarriages or stillbirths, or other crises interfere with psychologic preparation, the neonate may not be welcomed. For adolescent mothers, the demand that they relinquish their own developmental agenda, such as an active social life, may be especially burdensome.

The early experience of being mothered may establish unconsciously held expectations about nurturing relationships that permit mothers to “tune in” to their infants. These expectations are linked with the quality of later infant-parent interactions. Mothers whose early childhoods were marked by traumatic separations, abuse, or neglect may find it especially difficult to provide consistent, responsive care. Instead, they may reenact their childhood experiences with their own infants as if unable to conceive of the mother-child relationship in any other way. Bonding may be adversely affected by several risk factors during pregnancy and in the postpartum period, which undermine the mother-child relationship and may threaten the infant's cognitive and emotional development ( Table 1 ).


TABLE 1 -- Prenatal Risk Factors for Attachment


Recent death of a loved one



Previous loss of or serious illness in another child



Prior removal of a child



History of depression or serious mental illness



History of infertility or pregnancy loss



Troubled relationship with parents



Financial stress or job loss



Marital discord or poor relationship with the other parent



Recent move or no community ties



No friends or social network



Unwanted pregnancy



No good parenting model



Experience of poor parenting



Drug and/or alcohol abuse



Extreme immaturity

From Dixon SD, Stein MT: Encounters with Children: Pediatric Behavior and Development, 3rd ed. St. Louis, Mosby, 2000, p 74.

Social support during pregnancy, particularly support from the father and close family members, is also important. Conversely, conflict with or abandonment by the father during pregnancy may diminish the mother's ability to become absorbed with her infant. Anticipation of an early return to work may make some women reluctant to fall in love with their babies due to anticipated separation. Returning to work should be delayed at least until after 6 wk, when feeding and basic behavioral adjustments have been established.

Many decisions have to be made by parents in anticipation of the birth of their child. The most important choice is that of how the infant will be nourished. Among the important benefits of breast-feeding is the role of promoting bonding. Providing breast-feeding education for the parents at the prenatal visit by the pediatrician and by the obstetrician during prenatal care can increase maternal confidence in breast-feeding after delivery and reduce stress during the newborn period.

PERIPARTUM AND POSTPARTUM INFLUENCES.

The continuous presence during labor of a woman trained to offer friendly support and encouragement (a doula) results in shorter labor, fewer obstetric complications (including cesarean section), and reduced postpartum hospital stays. Early skin-to-skin contact between mothers and infants immediately after birth may correlate with an increased rate and longer duration of breast-feeding. Most new parents value even a brief period of uninterrupted time in which to get to know their new infant, and increased mother-infant contact over the first days of life may improve long-term mother-child interactions. Nonetheless, early separation, although predictably very stressful, does not inevitably impair a mother's ability to bond with her infant. Early discharge home from the maternity ward may undermine bonding, particularly when a new mother is required to resume full responsibility for a busy household.

THE INFANT'S ROLE IN MATERNAL-INFANT ATTACHMENT

The in utero environment contributes greatly but not completely to the future growth and development of the fetus. Abnormalities in maternal-fetal placental circulation and maternal glucose metabolism or the presence of maternal infection can result in abnormal fetal growth. Infants may be small or large for gestational age as a result. These abnormal growth patterns not only predispose infants to an increased requirement for medical intervention but also may affect their ability to respond behaviorally to their parents.

Physical Examination

Examination of the newborn should include an evaluation of growth and an observation of behavior. The average term newborn weighs approximately 3.4 kg (7½ lb); boys are slightly heavier than girls are. The average length and head circumference are about 50 cm (20 in) and 35 cm (14 in), respectively, in term infants. Each newborn's growth parameters should be plotted on growth curves specific for that infant's gestational age to determine the appropriateness of size. The infant's response to being examined may be useful in assessing its vigor, alertness, and tone. Observing how the parents handle their infant, their comfort and affection, is also important. The order of the physical examination should be from the least to the most intrusive maneuver. Assessing visual tracking and response to sound and noting changes of tone with level of activity and alertness are very helpful. Performing this examination and sharing impression with parents is an important opportunity to facilitate bonding.

Interactional Abilities

Soon after birth, neonates are alert and ready to interact and nurse. This first alert-awake period may be affected by maternal analgesics and anesthetics or fetal hypoxia. Nearsighted neonates have a fixed focal length of 8–12 in, approximately the distance from the breast to the mother's face, as well as an inborn visual preference for faces. Hearing is well developed, and infants preferentially turn toward a female voice. These innate abilities and predilections increase the likelihood that when a mother gazes at her newborn, the baby will gaze back. The initial period of social interaction, usually lasting about 40 min, is followed by a period of somnolence. After that, briefer periods of alertness or excitation alternate with sleep. If a mother misses her baby's first alert-awake period, she may not experience as long a period of social interaction for several days.

Modulation Of Arousal

Adaptation to extrauterine life requires rapid and profound physiologic changes, including aeration of the lungs, rerouting of the circulation, and activation of the intestinal tract. The necessary behavioral changes are no less profound. To obtain nourishment, to avoid hypo- and hyperthermia, and to ensure safety, neonates must react appropriately to an expanded range of sensory stimuli. Infants must become aroused in response to stimulation, but not so overaroused that their behavior becomes disorganized. Underaroused infants are not able to feed and interact; overaroused infants show signs of autonomic instability, including flushing or mottling, perioral pallor, hiccupping, vomiting, uncontrolled limb movements, and inconsolable crying.

Behavioural States

The organization of infant behavior into discrete behavioral states may reflect an infant's inborn ability to regulate arousal. Six states have been described: quiet sleep, active sleep, drowsy, alert, fussy, and crying. In the alert state, infants visually fixate on objects or faces and follow them horizontally and (within a month) vertically; they also reliably turn toward a novel sound, as if searching for its source. When overstimulated, they may calm themselves by looking away, yawning, or sucking on their lips or hands, thereby increasing parasympathetic activity and reducing sympathetic nervous activity. The behavioral state determines an infant's muscle tone, spontaneous movement, electroencephalogram pattern, and response to stimuli. In active sleep, an infant may show progressively less reaction to a repeated heel stick (habituation), whereas in the drowsy state, the same stimulus may push a child into fussing or crying.

Mutual Regulation

Parents actively participate in an infant's state regulation, alternately stimulating and soothing. In turn, they are regulated by the infant's signals, responding to cries of hunger with a letdown of milk (or with a bottle). Such interactions constitute a system directed toward furthering the infant's physiologic homeostasis and physical growth. At the same time, they form the basis for the emerging psychologic relationship between parent and child. Infants come to associate the presence of the parent with the pleasurable reduction of tension (as in feeding) and show this preference by calming more quickly for their mother than for a stranger. This response, in turn, strengthens a mother's sense of efficacy and her connection with her baby.

IMPLICATIONS FOR THE PEDIATRICIAN

The pediatrician can support healthy newborn development in several ways.

Optimal Practices

A prenatal pediatric visit allows pediatricians to assess potential threats to bonding (a tense spousal relationship) and sources of social support. Supportive hospital policies include the use of birthing rooms rather than operating suites and delivery rooms; encouragement for the father or a trusted relative or friend to remain with the mother during labor or the provision of a professional doula; the practice of giving the newborn infant to the mother immediately after drying and a brief assessment; placement of the newborn in the mother's room rather than in a central nursery; and avoiding in-hospital distribution of infant formula. Such policies (Baby Friendly Hospital) have been shown to significantly increase breast-feeding rates. After discharge, home visits by nurses and lactation counselors can reduce early feeding problems and identify emerging medical conditions in either mother or baby. Infants requiring transport to another hospital should be brought to see the mother first, if at all possible. On discharge home, fathers can shield mothers from unnecessary visits and calls and take over household duties, allowing mothers and infants time to get to know each other without distractions. The first office visit should occur during the first 2 wk after discharge to determine how smoothly the mother and infant are making the transition to life at home. Babies who are discharged early, those who are breast-feeding, and those who are at risk for jaundice should be seen 2 to 5 days after discharge.

Assessing Parent-Infant Interactions

During a feeding or when infants are alert and face-to-face with their parents, it is normal for them to appear absorbed in one another. Infants who become overstimulated by the mother's voice or activity may turn away or close their eyes, leading to a premature termination of the encounter. Alternatively, the infant may be ready to interact, whereas the mother may appear preoccupied. Asking a new mother about her own emotional state, and inquiring specifically about a history of depression, facilitates referral for therapy, which may provide long-term benefits to the child. Pediatricians may detect postpartum depression using the Edinburgh Postnatal Depression Scale (EPDS) at well child visits during the first year ( Table 2 ).


TABLE 2 -- Edinburgh Postnatal Depression Scale

INSTRUCTIONS FOR USERS


1.

The mother is asked to underline the response that comes closest to how she has been feeling in the previous 7 days.


2.

All 10 items must be completed.


3.

Care should be taken to avoid the possibility of the mother discussing her answers with others.


4.

The mother should complete the scale herself, unless she has limited English or has difficulty with reading.


5.

The Edinburgh Postnatal Depression Scale may be used at 6–8 weeks to screen postnatal women. The child health clinic, a postnatal checkup, or a home visit may provide a suitable opportunity for its completion.



Edinburgh Postnatal Depression Scale



Name:



Address:



Baby's age:

Because you have recently had a baby, we would like to know how you are feeling. Please underline the answer that comes closest to how you have felt in the past 7 days, not just how you feel today.

Here is an example, already completed.



I have felt happy:



Yes, all the time



Yes, most of the time



No, not very often



No, not at all

This would mean: “I have felt happy most of the time” during the past week. Please complete the other questions in the same way.

In the past 7 days:


1.

I have been able to laugh and see the funny side of things



As much as I always could



Not quite so much now



Definitely not so much now



Not at all


2.

I have looked forward with enjoyment to things



As much as I ever did



Rather less than I used to



Definitely less than I used to



Hardly at all


*3.

I have blamed myself unnecessarily when things went wrong



Yes, most of the time



Yes, some of the time



Not very often



No, never


4.

I have been anxious or worried for no good reason



No, not at all



Hardly ever



Yes, sometimes



Yes, very often


*5.

I have felt scared or panicky for no very good reason



Yes, quite a lot



Yes, sometimes



No, not much



No, not at all


*6.

Things have been getting on top of me



Yes, most of the time I haven't been able to cope at all



Yes, sometimes I haven't been coping as well as usual



No, most of the time I have coped quite well



No, I have been coping as well as ever


*7.

I have been so unhappy that I have had difficulty sleeping



Yes, most of the time



Yes, sometimes



Not very often



No, not at all


*8.

I have felt sad or miserable



Yes, most of the time



Yes, quite often



Not very often



No, not at all


*9.

I have been so unhappy that I have been crying



Yes, most of the time



Yes, quite often



Only occasionally



No, never


*10.

The thought of harming myself has occurred to me



Yes, quite often



Sometimes



Hardly ever



Never

From Currie ML, Rademacher R: The pediatrician's role in recognizing and intervening in postpartum depression. Pediatr Clin North Am 2004;51:785–801.

Response categories are scored 0, 1, 2, and 3 according to increased severity of the symptom. Items marked with an asterisk (*) are reverse scored (i.e., 3, 2, 1, and 0). The total score is calculated by adding the scores for each of the 10 items. Users may reproduce the scale without further permission providing they respect copyright (which remains with the British Journal of Psychiatry) by quoting the names of the authors, the title, and the source of the paper in all reproduced copies.


Teaching About Individual Competencies

The Newborn Behavior Assessment Scale (NBAS) provides a formal measure of an infant's neurodevelopmental competencies, including state control, autonomic reactivity, reflexes, habituation, and orientation toward auditory and visual stimuli. This examination can also be used to demonstrate to parents an infant's capabilities and vulnerabilities. Parents might learn that they need to undress their infant to increase the level of arousal or to swaddle the infant to reduce overstimulation by containing random arm movements. The NBAS can be used to support the development of positive early parent-infant relationships. Demonstration of the NBAS to parents in the 1st wk of life has been shown to correlate with improvements in the caretaking environment months later.

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