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The Newborn in the Intensive Care Unit

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This book is all about the emotional experience of the baby who has not had enough of one type of life to be able to transfer its emotional allegiances to the new one. The approach to this problem, as it is illustrated here, involves a philosophy that goes far beyond the humane attitude of alleviating suffering which operates in hospital medicine.

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1 - Work with the Parents

ePub

The post-partum days of a pregnancy are critical for the mother psychologically as well as: in reviewing the experience of giving birth, from the original phantasies of conception and pregnancy to the relationship with the newborn infant. During this stage the feelings and expectations that once focused on the future baby become blurred owing to the emergence of infantile parts of the self; these ask to be contained and comforted, in order that the woman's natural maternal instinct can express itself in her relationship with the baby. The baby needs to be fed, supported, and comforted by its mother in order to begin its new existence. This is a very critical time for the woman, who is in a fragile condition: “that very special condition which is similar to an illness even though it's perfectly normal”, as Winnicott (1958) has described it. This state should gradually disappear after a few days or weeks, thanks also to the relationship that is established between the mother and the newborn (“breast relationship” and “holding”) and to their mutual adjustment.

 

CHAPTER ONE Work with the parents

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CHAPTER ONE

Work with the parents

T

he post-partum days of a pregnancy are critical for the mother psychologically as well as: in reviewing the experience of giving birth, from the original phantasies of conception and pregnancy to the relationship with the newborn infant. During this stage the feelings and expectations that once focused on the future baby become blurred owing to the emergence of infantile parts of the self; these ask to be contained and comforted, in order that the woman’s natural maternal instinct can express itself in her relationship with the baby. The baby needs to be fed, supported, and comforted by its mother in order to begin its new existence. This is a very critical time for the woman, who is in a fragile condition: “that very special condition which is similar to an illness even though it’s perfectly normal”, as Winnicott (1958) has described it.

This state should gradually disappear after a few days or weeks, thanks also to the relationship that is established between the mother and the newborn (“breast relationship” and “holding”) and to their mutual adjustment.

 

CHAPTER TWO The death of the newborn

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CHAPTER TWO

The death of the newborn

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n the previous edition of this book (Negri, 1998), I did not deal very much with the issues concerning the death of the newborn. I was immediately aware of this omission also because, having had a great deal of experience in this kind of department, I realized the importance of such an occurrence, which I had shared with parents and staff on many occasions. The problem surfaced to a certain degree in the chapter devoted to working with nursing staff, and where the difficulties experienced by medical teams in facing this type of grievous event were easily recognized. It was also clear how this obstacle led to the defensive processes I described. I realized that dealing in any depth with issues regarding the death of a newborn required exhaustive investigation and reflection, involving not only time, but above all an inner receptiveness which would allow me to tackle sensitive issues, matters which were particularly complex and distressing, deriving from early existential experiences.

 

2 - The Death of the Newborn

ePub

In the previous edition of this book (Negri, 1998), I did not deal very much with the issues concerning the death of the newborn. I was immediately aware of this omission also because, having had a great deal of experience in this kind of department, I realized the importance of such an occurrence, which I had shared with parents and staff on many occasions. The problem surfaced to a certain degree in the chapter devoted to working with nursing staff, and where the difficulties experienced by medical teams in facing this type of grievous event were easily recognized. It was also clear how this obstacle led to the defensive processes I described. I realized that dealing in any depth with issues regarding the death of a newborn required exhaustive investigation and reflection, involving not only time, but above all an inner receptiveness which would allow me to tackle sensitive issues, matters which were particularly complex and distressing, deriving from early existential experiences.

 

CHAPTER THREE Work with the staff

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CHAPTER THREE

Work with the staff

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he work programme in our department gave me the opportunity to organize meetings with the medical and non-medical staff. I was aware of the intense emotional stress experienced by the staff in the neonatal intensive care unit. I also felt it was important for the staff to be more fully involved in the emotional aspects concerning both parents and newborns. In addition, I became aware of the interest that my role in the department aroused among the staff.

The existing literature (De Caro, Orzalesi, & Pola, 1986;

Marshall & Kasman, 1980) stresses the discomfort, fatigue, and tension in the context of nursing work, which often lead to the so-called “burn-out syndrome”. It is not surprising that this might be prevalent in our department when one considers that it deals with children who are at the beginning of their lives but under constant threat of death. This in itself is difficult to tolerate; but it is not all. In this unit, the medical and nursing staff deal with newborn infants who, by themselves – as the Kleinian school has already pointed out – are a source of very strong and violent emotions. Martha Harris, in particular, has highlighted

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3 - Work with the Staff

ePub

The work programme in our department gave me the opportunity to organize meetings with the medical and non-medical staff. I was aware of the intense emotional stress experienced by the staff in the neonatal intensive care unit. I also felt it was important for the staff to be more fully involved in the emotional aspects concerning both parents and newborns. In addition, I became aware of the interest that my role in the department aroused among the staff.

The existing literature (De Caro, Orzalesi, & Pola, 1986; Marshall & Kasman, 1980) stresses the discomfort, fatigue, and tension in the context of nursing work, which often lead to the so-called “burn-out syndrome”. It is not surprising that this might be prevalent in our department when one considers that it deals with children who are at the beginning of their lives but under constant threat of death. This in itself is difficult to tolerate; but it is not all. In this unit, the medical and nursing staff deal with newborn infants who, by themselves – as the Kleinian school has already pointed out – are a source of very strong and violent emotions. Martha Harris, in particular, has highlighted the extreme complexity of the task of caring for newborns – usually both strong and vulnerable at the same time – owing to the intense and deep emotions that they arouse. Therefore, if the hospital staff cannot or do not receive any help in understanding the deep emotional stress aroused by these factors, they will be more susceptible to the tiring and stressful aspects of their work, which can ultimately lead to burn-out.

 

CHAPTER FOUR Infant observation

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CHAPTER FOUR

Infant observation

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his observation study of preterm newborns in the incubator from the first moments of their hospitalization was started in 1982. It was intended primarily as research for a medical university degree thesis, and also to improve the care of these infants. When starting this observation work, I believed that the recognition of extremely early mental mechanisms would provide a better understanding of the baby’s distress and needs (Benedetti, 1984). It would enable more appropriate provision to be made of the various

“direct preventive actions” I have identified, to improve the infant’s mental and physical condition during and after its stay in the incubator (as illustrated in Table 2, page 9).

Yet the initial approach to the early mental processes of a newborn who was so seriously premature and in such great distress soon brought into contact obscure aspects of the observer’s mentality and more generally of all the people involved with the child. Our thoughts often tended to be fragmented and abortive. We felt strongly and painfully that parts of ourselves found it difficult to be psychologically born and to find their identity.

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4 - Infant Observation

ePub

This observation study of preterm newborns in the incubator from the first moments of their hospitalization was started in 1982. It was intended primarily as research for a medical university degree thesis, and also to improve the care of these infants. When starting this observation work, I believed that the recognition of extremely early mental mechanisms would provide a better understanding of the baby's distress and needs (Benedetti, 1984). It would enable more appropriate provision to be made of the various “direct preventive actions” I have identified, to improve the infant's mental and physical condition during and after its stay in the incubator (as illustrated in Table 2, page 9).

Yet the initial approach to the early mental processes of a newborn who was so seriously premature and in such great distress soon brought into contact obscure aspects of the observer's mentality and more generally of all the people involved with the child. Our thoughts often tended to be fragmented and abortive. We felt strongly and painfully that parts of ourselves found it difficult to be psychologically born and to find their identity.

 

CHAPTER FIVE The neuropsychological screening of the infant before discharge from hospital

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CHAPTER FIVE

The neuropsychological screening of the infant before discharge from hospital

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he neuropsychological screening of the infant, in addition to a neurological examination, is carried out only when the infant is in the lower-dependency room, or when it has reached term and its discharge is imminent. During the earlier phases of hospitalization (for reasons explained in

Chapter 4 and in particular in Box 5), the assessment of neurological maturation and of possible nervous system distress is performed through infant observation. The clinical examination is compared with the functional activities of the nervous system and morphological elements resulting from examinations such as the EEG and ultrasound, performed on the newborn in the standard manner (Couchard, De Bethmann,

& Sciot, 1982).

The neuropsychological screening of the preterm newborn and of newborn infants generally, especially during the first stage – is based on observation, as outlined and illustrated in this chapter. This approach is in line with indications given at present by the major European and American schools (Cioni & Prechtl,

 

5 - The Neuropsychological Screening of the Infant before Discharge from Hospital

ePub

The neuropsychological screening of the infant, in addition to a neurological examination, is carried out only when the infant is in the lower-dependency room, or when it has reached term and its discharge is imminent. During the earlier phases of hospitalization (for reasons explained in Chapter 4 and in particular in Box 5), the assessment of neurological maturation and of possible nervous system distress is performed through infant observation. The clinical examination is compared with the functional activities of the nervous system and morphological elements resulting from examinations such as the EEG and ultrasound, performed on the newborn in the standard manner (Couchard, De Bethmann, & Sciot, 1982).

The neuropsychological screening of the preterm newborn and of newborn infants generally, especially during the first stage – is based on observation, as outlined and illustrated in this chapter. This approach is in line with indications given at present by the major European and American schools (Cioni & Prechtl, 1988; Korner et al., 1987; Milani Comparetti. 1982b; Prechtl, 1984; Touwen, 1990). The above-mentioned researchers attach great importance to the newborn's variabllity of movement and its spontaneous motility (on which depends its “propositional competence”). Echographic (ultrasound) studies of foetal motility have influenced researchers considerably, especially those with a neurological background (Cioni & Prechtl, 1988; Cioni et al., 1988; Milani Comparetti, 1982a; Prechtl, 1984; Touwen, 1990), by attaching greater importance to observation in studies of the newborn. Findings based on echographic observations have notably reduced the significance given to the role of the archaic reflexology, which used to predominate in infant screening before echography was discovered (Peiper, 1961; Saint-Anne Dargassles, 1974; Thomas & Autgaerden, 1966; Vojta, 1974).

 

6 - Follow-Up after Discharge from Hospital

ePub

In the light of our current knowledge in the field of neurobiology, follow-up of the child after discharge from hospital takes on a particularly important role. It shapes intervention right from the very early part of the child’s life. At this age it is vital that the typical features of development and the functioning of the central nervous system (CNS) be examined. “Cellular multiplication, migration, differentiation and connexion” are the foundation of the child’s development and functionality (Boncinelli, 2008, p. 48). However, after birth, development and functionality are greatly dependent on environmental issues.

Neurobiological premise

At birth the brain is made up only of a number of neurons, varying from between 10 to 13 and 100 billion, but they are not yet part of the functional connective system: the brain is far from being complete. Its first task after birth is to create the necessary connections and reinforce them so they become permanent. From this time on connections are formed determining the enlargement of the cerebral cortex, which during the first year of life, triples in thickness. This process is greatly affected by environmental experiences. The caregiving environment has a specific impact on a growing brain, so much so that it automatically creates neuronal networks which reflect the experience.

 

CHAPTER SIX Follow-up after discharge from hospital

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CHAPTER SIX

Follow-up after discharge from hospital

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n the light of our current knowledge in the field of neurobiology, follow-up of the child after discharge from hospital takes on a particularly important role. It shapes intervention right from the very early part of the child’s life. At this age it is vital that the typical features of development and the functioning of the central nervous system (CNS) be examined. “Cellular multiplication, migration, differentiation and connexion” are the foundation of the child’s development and functionality (Boncinelli, 2008, p. 48). However, after birth, development and functionality are greatly dependent on environmental issues.

Neurobiological premise

At birth the brain is made up only of a number of neurons, varying from between 10 to 13 and 100 billion, but they are not yet part of the functional connective system: the brain is far from being complete. Its first task after birth is to create the necessary connections and reinforce them so they become permanent.

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7 - Psychopathological Risks

ePub

As already stressed in Chapter 4, the early life of the seriously preterm newborn or of the pathological newborn is characterized on the one hand, by hyperstimulation, and on the other, by serious sensorial and affective deficiencies. According to Meltzer (1992), this condition can invite the onset of claustrophobic anxieties as well as of major psychopathological states.

Claustrophobic anxieties

Isolation and the absence of contact can correspond for the newborn to the claustrophobic anxiety of being thrown out or thrown away; while the physical hyperstimulation can correspond to the equally painful experience of being closeted in a very narrow environment, from which the newborn derives no comfort and which it does not understand but feels as constraining, crushing, and oppressive. According to Meltzer (1992), the appearance of claustrophobic anxieties – dreadful experiences which can lead to a delusional system – is a risk both for newborns inside the incubator and for adopted children, even if they are just a few weeks old.

 

CHAPTER SEVEN Psychopathological risks

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CHAPTER SEVEN

Psychopathological risks

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s already stressed in Chapter 4, the early life of the seriously preterm newborn or of the pathological newborn is characterized on the one hand, by hyperstimulation, and on the other, by serious sensorial and affective deficiencies. According to Meltzer (1992), this condition can invite the onset of claustrophobic anxieties as well as of major psychopathological states.

Claustrophobic anxieties

Isolation and the absence of contact can correspond for the newborn to the claustrophobic anxiety of being thrown out or thrown away; while the physical hyperstimulation can correspond to the equally painful experience of being closeted in a very narrow environment, from which the newborn derives no comfort and which it does not understand but feels as constraining, crushing, and oppressive. According to Meltzer (1992), the appearance of claustrophobic anxieties – dreadful experiences

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THE NEWBORN IN THE INTENSIVE CARE UNIT

 

8 - Treatment of Cases at Psychopathological Risk

ePub

The post-discharge follow-up of the newborn at risk has a therapeutic significance, and so the methodology employed there is similar to that adopted in cases requiring actual treatment. In these cases, changes are introduced in response to the clinical picture (as illustrated in greater detail below). During the examination it is very important to think about the degree of weakening of the life instinct which all newborns at risk undergo, both on account of possible brain damage and because of the traumatic therapeutic procedures. It must also be borne in mind that the newborn tends to believe that these seriously persecutory situations originate in the mother. Given its specific mental apparatus, it is in fact very perceptive of its mother's anxiety, which, especially at the beginning, hinders the adequacy of her response to the child's complex communications (Salzberger-Wittenberg, 1990). Therefore the mother's anxiety is experienced by the child as extremely threatening and imminent, and this aggravates the child's emotional difficulties.

 

CHAPTER EIGHT Treatment of cases at psychopathological risk

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CHAPTER EIGHT

Treatment of cases at psychopathological risk

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he post-discharge follow-up of the newborn at risk has a therapeutic significance, and so the methodology employed there is similar to that adopted in cases requiring actual treatment. In these cases, changes are introduced in response to the clinical picture (as illustrated in greater detail below). During the examination it is very important to think about the degree of weakening of the life instinct which all newborns at risk undergo, both on account of possible brain damage and because of the traumatic therapeutic procedures. It must also be borne in mind that the newborn tends to believe that these seriously persecutory situations originate in the mother.

Given its specific mental apparatus, it is in fact very perceptive of its mother’s anxiety, which, especially at the beginning, hinders the adequacy of her response to the child’s complex communications (Salzberger-Wittenberg, 1990). Therefore the mother’s anxiety is experienced by the child as extremely threatening and imminent, and this aggravates the child’s emotional difficulties.

 

9 - The Problems of the Siblings

ePub

In the previous edition of this book, (Negri, 1994), I talked about the problems of the siblings of preterm newborns, with particular reference to those parents who seek separate meetings in order to discuss the problem of the elder brother or sister's jealousy. I had thought that when having to face such as traumatic experience as the birth of a very premature baby, for whom the risk of survival was small, the parents would not be able to find the resources to face simultaneously both this dramatic event and the problems emerging in the older sibling or siblings. I thought that as a defensive measure they would choose deliberately not to focus directly on the more serious problem, that is, that of the newborn baby, but instead would concentrate on the jealousy of the older child or children.

Perhaps this aspect may emerge in some cases and be of some importance. However, the pressing demand of a couple to have me examine in person the emotional state of the older child, by bringing him for consultancy, has allowed me to reflect at greater depth on the problems of the siblings of very premature newborns and, in particular, of those who are likely to develop a pathology of cerebral palsy or serious psychological disorders.

 

CHAPTER NINE The problems of the siblings

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CHAPTER NINE

The problems of the siblings

I

n the previous edition of this book, (Negri, 1994),

I talked about the problems of the siblings of preterm newborns, with particular reference to those parents who seek separate meetings in order to discuss the problem of the elder brother or sister’s jealousy. I had thought that when having to face such as traumatic experience as the birth of a very premature baby, for whom the risk of survival was small, the parents would not be able to find the resources to face simultaneously both this dramatic event and the problems emerging in the older sibling or siblings. I thought that as a defensive measure they would choose deliberately not to focus directly on the more serious problem, that is, that of the newborn baby, but instead would concentrate on the jealousy of the older child or children.

Perhaps this aspect may emerge in some cases and be of some importance. However, the pressing demand of a couple to have me examine in person the emotional state of the older child, by bringing him for consultancy, has allowed me to reflect at greater depth on the problems of the siblings of very premature newborns and, in particular, of those who

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