| Model Essays in EN 202 |
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Touch:
The Foundation of Infant Growth and Bonding A premature infant is defined by Whaley & Wong’s Nursing Care of Infants and Children as "any infant born before completion of 37 weeks of gestation, regardless of birth weight." (Wong, p. 1999, p.392) Many premature infants are also considered high risk neonates because the major activities of life, including thermoregulation, respiration and digestion, cannot fully function at their time of birth. This poses a problem for both the health professionals and the parents of the infant. The health professionals must closely monitor this vulnerable infant and, in most situations, assist the infant in thermoregulation, respiration, and feeding while the cautious, nervous parents look on, concerned about their child’s progress. The parent or parents often feel removed from their child’s care as another adult cares for their child’s every need. Infant stimulation can be as subtle and slight as touch of the infant’s arm or as much as skin to skin contact through holding. Touch actively involves the parents in the their child’s care and has proven to be beneficial for improving the vulnerable, tiny infant’s condition. Parents, as well as medical professionals, should be encouraged to touch these vulnerable tiny infants as much as, if not more than, they would touch a full term infant. Despite their low birth weight, tiny size and vulnerable condition, these infants should be held, caressed and cuddled with as often as possible. The experience of birth for a mother of a premature infant varies drastically from the birth of a normal full term infant because of the lack of infant stimulation or even sight of her newly born child. Peggy, a mother of newly born premature infant states "I imagined that Bob would be smiling through teary eyes, as we cuddled with our newborn for the first time and waved to the home video camera. Well I found out right away that if your baby comes early, it’s just not like that." (Manginello, 1991, p.23) Peggy’s experience is quite similar to experiences of other mothers after the birth of their premature infant. Is there nothing more painful than not holding the baby you carried and grew with for nearly nine months? Because of their infant’s vulnerable state, he or she must be immediately evaluated and receive the intensive care necessary to preserve its life. There is little or no time for holding, cuddling and caressing the newest addition to the family, a loss for both the baby and the mother and the father. However, despite the mother’s medical needs, some mothers do receive an opportunity to see their baby and touch it minimally before it is rushed off for evaluation. Peggy, in Your Premature Baby, further describes her experience by saying, "The doctor folded down the flap of the blanket and let me have a fast look. This at least gave me a picture to hold in my mind. It was my only concrete proof that I did have a baby. It sounds silly, but that one-second peek gave me a lot of comfort until I could finally see Jason again." (Manginello, 1999, p. 28) Jason was then rushed off to the Neonatal Intensive Care Unit (NICU). Often times, if the father is present at the child’s birth, he will accompany his new son or daughter to the NICU and there receive more of an opportunity to touch him or her. It is to the baby’s advantage to receive the immediate care it needs. A premature infant is delivered into an environment it is not yet ready to handle. "Inside a well-functioning uterine environment, these infants would likely continue to thrive toward normal outcome at term. Delivered to the extrauterine world of a hospital intensive care nursery, they are helpless to sustain their own basic life support systems." (Gorski, Huntington, & Lewkowicz, 1987, p. 43) Therefore, he or she often needs assistance with the basic activities of life, a frustrating experience for the parents because contact with their infant is reduced. There are several tests and observances made within the first few minutes a premature infant is born while the infant is out of sight of the parents. These observances help determine how effectively the infant is adjusting to the extrauterine world. One such test is the Apgar scoring system. It evaluates the infant’s heart rate, respiratory effort, muscle tone, reflex irritability and color (appearance). These are individually rated on a score of 0,1, or 2 with 0 being the worst and 2 being the best. A score of 0 to 3 represents severe distress, 4 to 6 moderate difficulty and 7 to 10 no difficulty in adjusting to the environment. (Wong, 1999, p.307) The reflex irritability indicates a baby’s response to annoying stimuli such as a tap or finger flick. The color is used to indicate whether the baby is receiving significant amount of oxygen to all its tissues. A baby’s heart rate should be above 100 beats/min. (Manginello, 1991, pp.25-26) Once the concept of Apgar scoring is explained to the parents and they understand the importance of each subdivision, it can provide relief. In my interview with Lynne Jones, who gave birth to a 31 gestational week infant, she said, "Madeline received an 8 on her Apgar score. The doctors were quite surprised by her high Apgar score despite her prematurity and low birth weight. It gave my husband and I a sense of relief that, despite her prematurity, she was healthy." Lynne and Madeline’s doctor attributed her high score to steroids Lynne received while quite ill with an infection the two weeks before Madeline’s birth. The steroids probably helped rapidly increase Madeline’s growth rate and lung deveolpment in the two weeks. One major concern about many premature infants is their low birth weight. This is often associated with "little body fat to help regulate his or her body temperature, and with too little muscle strength to generate heat by shivering, his body temperature is artificially regulated." ( Manginello, 1991, p. 24) The infant’s body temperature is regulated by a radiant warmer over an incubator and monitored with a temperature sensor on the infant’s abdomen. This was true for Lynne’s daughter Madeline. Another concern of premature infants is monitoring and maintaining an infant’s respiration. The assistance necessary varies depending upon the infant’s ability to do so on its own. The degree of breathing rate irregularity in premature infants varies the kind of assistance it may need to oxygenate more effectively. An infant may need treatment as drastic as a ventilator, which actually breathes for the infant to varying degrees, to as simple as a peripheral oxygen sensor placed on an infant’s foot to monitor the amount of oxygen being delivered to the skin. How developed the infant’s lungs are controls the respiration assistance the infant will require, in other words, the more premature an infant is, the more assistance it will need. It often scares parents to see that a machine must make sure their infant is receiving an adequate amount of oxygen and reduces the parents’ desire to interact with their son or daughter, afraid they will disrupt all the wires and monitors attached to their infant. All of these are necessary to monitor heart rate, oxygen saturation, temperature and respiratory rate. "It is frightening to learn that he has difficulty breathing or that he cannot maintain his body temperature without mechanical assistance. Machines, and not you, have become the controlling influence during the first few days or weeks of your child’s life." (Ludington-Hoe, 1993, p. 5) What can be done to counteract this? What can be done to reduce the parent’s feeling of helplessness? Touch and stimulation can be both positive and negative, and it can affect the infant’s temperature, heart rate, and breathing rate positively or negatively as a result. Negative or harmful touch and stimulation is often associated with medical touch. "Medical touch compromises up to 90% of the touching a baby receives. The nurse may turn your baby’s head, move his leg, or stick his foot. It’s intermittent. Babies, especially small ones, react to this type of touch with a decrease of oxygen in the blood." (Ludington-Hoe, 1993, p. 101) Health professionals should try to comfort the infant as much as possible in order to counteract the negative touch. They should treat each infant they care for as if it was their own, not wanting to see the infant flinching every time you touch him or her. The positive effects of infant stimulation benefit both the infant and the parents. It enhances the parent child bonding and may begin with the simple act of touching the baby’s arm through the incubator porthole, a small opening in the side of the closed incubator. The simple act of softly stroking the child’s arm can make the mother feel more secure as she finally touches the baby she carried for nearly nine months. The simple act can calm the infant and make her or him feel more secure. This infant was just pulled out of his snug, safe, calming in utero environment into a world of lights and noises. The mother is the only familiar thing the infant recognizes. Dr. Frank P. Manginello , in Your Premature Infant, expresses the importance of touch by saying, "All babies need human touch to enhance their mental and physical development, all parents need to touch their babies to foster emotional attachment. It’s the perfect way to establish a warm, positive, parent-child relationship with your preemie even when you can’t hold him." (1991, p.209) As the infant’s condition stabilizes other methods of infant stimulation can be, and should be, implemented if the parents are willing to participate. One method is holding the infant as you would a full term infant, close to your body, wrapped tightly in a soft blanket. (Manginello, 1991, p. 211-212) This has proven to benefit the parents greatly. Dr. Manginello says, "For the time that your baby is in your arms, it doesn’t matter how small he is, or how sick he is, or how funny he looks to others; he’s yours, and you love him, and nothing else matters." (Manginello, 1991, p.212). It establishes for the parent that, under all the wires and monitors, lies her child. Another method of infant stimulation has recently become more popular and has also proven to be beneficial, like other well known forms. Kangaroo care, also known as skin to skin contact, involves placing the premature infant, wearing only a diaper, hat and booties, on the mother or father's bare chest. It has incredible results. Kangaroo Care: The Best You Can Do to Help Your Preterm Infant, discusses the benefits of kangaroo care at great lengths and avidly supports it. This book defines kangaroo care as a "simple, natural, low-tech form of care for high tech babies" (Ludington-Hoe, 1993, p.7) and this is exactly what it is. It is natural for the mother because it is a normal desire for her to want to hold her infant. In order to comfort the infant and foster its growth, it only seems logical for the infant to be in contact with the sounds he or she is most familiar with, the sounds of the mother’s heartbeat and muffled voice. These are the natural sounds the infant heard in utero. It is low tech because it requires only a comfortable chair, a button down shirt for the parent, privacy, time to "kangaroo" and most importantly, love and affection. Kangaroo care has incredible benefits for the preterm infant. Those noted in Kangaroo Care: The Best You Can Do to Help Your Preterm Infant include "a stable heart rate, more regular breathing, improved dispersion of oxygen throughout the body, prevention of cold stress, longer periods of sleeping, more rapid weight gain, reduction in purposeless activity, decreased crying, earlier bonding and increased likelihood of being discharged from the hospital sooner." (Ludington-Hoe, 1993, pp. 6-7) The list goes on and on. Based on this it seems as though kangaroo care counteracts all the problems associated with premature birth. Who wouldn’t avidly support this based on this incredible evidence of the benefits for the infant? Kangaroo care has incredible benefits for the parents as well. For the mother it is an opportunity to hold the infant that was so close inside her for nearly nine months. Also it is an important way to reduce the mother’s feeling of removal from her child’s care. It offers an opportunity to positively influence her young child and foster its growth. A story of an infant, Steven, born at 24 gestational weeks is described in Kangaroo Care: The Best you Can Do to Help your Preterm Infant. Steven’s experience with kangaroo care is quite amazing. The story begins with Steven’s blood values dropping and unable to properly oxygenate himself due to his underdeveloped lungs. His mother expressed her wish to hold him for what she thought would be the last time before he passed away. The nurses of course granted her wish. The mother undressed him and instinctively placed him on her bare chest and laid a blanket over his back. After two hours the nurses returned to check Steven’s vital signs, expecting them to have dropped further below normal, but amazingly they had greatly improved. Over the course of three days the mother and her husband held Steven constantly and his condition consistently improved. (Ludington-Hoe, 1993) Because of the mother’s instinctive kangaroo care and her persistence Steven lived. This is just one of many amazing stories that shows the positive benefits of kangaroo care. Lynne Jones reflected on her experience of kangaroo care with her daughter Madeline in her interview with me. She avidly supported kangaroo care by saying "It helped Madeline better maintain her body temperature, stabilized her heart rate and increased her oxygen saturation levels. One time in particular I remember Madeline’s oxygen saturation level was 93% before I began to kangaroo with her. Then as I held her it gradually increased to a normal level of 97%. It was just amazing." Lynne also believes it helped increase the bond between herself and her daughter. Based on my research and interview I believe there is considerable evidence that touch, holding and kangaroo care do help the child develop and grow more quickly. Young children, as well as adults, seek touch and human contact to some degree. So it only seems natural for a vulnerable premature infant to desire and require this as well. Parents need, and want, to be actively involved in their child’s care, growth and development. Contrary to this, though, is the parent’s anxious, nervous and scared feelings. Through education and interaction, medical professionals need to calm the parents and encourage interaction with their child. What better way is there for interaction than touch?
References Manginello M.D., Frank P., & Foy DiGeronimo M.D., Theresa. (1991). Your Premature Baby New York: John Wiley & Sons, Inc. Gorski M.D., Peter, & Huntington Ph.D., Lee & Lewkowicz Ph.D., David J. (1987). Handling Preterm Infants in Hospitals: Stimulating Controversy about Timing Stimulation. In Infant Stimulation For Whom, What Kind, When and How Much? (pp. 43-51) (no place of publication): Johnson & Johnson Baby Products. Co. Wong, Donna L. (1999). Whaley and Wong’s Nursing Care of Infants and Children. St. Louis: Mosby, Inc. Ludington-Hoe Ph.D., Susan M., & Golant, Susan K. (1993). Kangaroo Care: The Best You Can Do to Help Your Preterm Infant. New York: Bantam Books, Inc.
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