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by Mary E. Coughlin, MS, NNP, RNC-E,
Mitigating the iatrogenic psychological effects of medical care in the NICU and beyond is a moral and ethical imperative for quality healthcare delivery. The American Academy of Pediatrics issued a technical report and policy statement outlining the lifelong effects of early childhood adversity, toxic stress and the role of pediatric clinicians (Garner et al., 2012; Shonkoff et al., 2012). Provenzi & Montirosso (2015) confirm that preterm birth is an early adverse experience characterized by exposure to toxic stress and reduced access to the buffering effects of maternal care. Understanding the concepts of infant medical traumatic stress and its association with alterations in brain growth and development highlights the biologic relevance of a trauma informed developmental approach to care in the NICU and beyond (D’Agata et al., 2016; Montirosso et al., 2017; Coughlin, 2021).
Early life adversity is most often mediated by the infant’s relationship with adult caregivers and is also referred to as interpersonal trauma. Early life stress and interpersonal trauma is associated with attachment disturbances and has been linked to posttraumatic stress disorder (PTSD) and developmental trauma disorder (DTD) in survivors (Spinazzola et al., 2018; Pervanidou et al., 2020). Adversity during infancy is associated with significantly poorer health outcomes, risky health behaviors and socioeconomic challenges (Crouch et al., 2019; Merrick et al., 2019).
During sensitive and critical periods of development, the experiences associated with critical illness and hospitalization take on new meaning as they direct and disrupt biological processes in the wake of the associated toxic stress. These biological processes, mediated by epigenetic mechanisms, have lifelong implications for an individual’s physiologic and psychologic health and wellbeing (Coughlin, 2020). Maternal separation is the most significant trauma experienced by all newborn mammals. Preterm and critically ill newborns are by all means no exception to this reality. Early maternal separation jeopardizes the physical and behavioral health of the newborn (Csaszar-Nagy & Bokkon, 2017). Separation of mother and baby at 2-days of age for 1-hour revealed a 176% increase in autonomic activity and an 86% reduction in quiet sleep (Morgan et al., 2011). The experience of maternal separation in the NICU and beyond becomes a foundation for cumulative toxic stress exposures that range from inappropriate sensory stimuli to hazardous rituals and routines that do not honor the personhood of the infant (Weber & Harrison, 2019). All of these experiences have a graded-dose effect on the developing infant who endures the early life adversity associated with newborn intensive care (Sanders & Hall, 2018; Weber & Harrison, 2019).
Separation also has profound implications on the parent as well leading to depression, anxiety, and post-traumatic stress. The capacity for mothers and families of critically ill infants to partner with clinicians in the care of their infant is influenced by a myriad of factors. Physical and emotional health, economic and social resources, culture, medical establishments, social policy and structural injustice impact parenting behaviors in the NICU and more broadly the individual’s health trajectory over the lifespan (Pineda et al., 2018; Krieger, 2020). Understanding these factors and how they play out in the life of the family in crisis is critical to co-create compassionate, collaborative, and supportive relationships with infants, families and clinicians in the NICU.
A trauma informed approach realizes the pervasiveness of trauma in everyday life; recognizes the signs and symptoms of trauma in patients, families, colleagues and self; responds to trauma by integrating knowledge and evidence-based best practices that mitigate and prevent trauma into policies, procedures, and language; and resists re-traumatization by ensuring consistency and compassion in service delivery. The principles and values of trauma informed care ensure safety, choice, collaboration, empowerment and trustworthiness. These principles underpin parent-clinician interactions and partnerships. Parent-based interventions support operationalization of these principles and lead to a reduction in the infant’s experience of toxic stress, improvement in parental mental well-being, and validation of parental role identity while insuring the delivery of safe quality care for the infant-family dyad (Ottosen et al., 2019).
The buffering effects of parental care cannot be understated (Condon et al., 2018). Alterations in bonding-related early life experiences within the context of the NICU impairs hormonal, epigenetic and neuronal development in preterm infants (Kommers et al., 2015).
Hospitalized infants are at risk for socio-emotional deficits, disturbed executive function, cognitive and language delays and psychiatric disorders (Beebe et al., 2018; Porges et al., 2019). The paucity of mother-infant face-to-face communication in the NICU contributes to these deficits (Margolis et al., 2019).
Social relationships early in life are mediated by the neuropeptide hormone oxytocin. Oxytocin plays a critical role in early life nurturing, social bonding and attachment (Filippa et al., 2019; Scatliffe et al., 2019). Skin-to-skin care increases oxytocin levels in both mothers and fathers and is an effective neuroprotective strategy for the immature brain of the critically ill hospitalized infant (Zinni et al., 2018; Filippa et al., 2019). When parents take on the role of primary caregiver for their infant in the NICU, they experience significantly lower stress, anxiety, and depression (Welch et al., 2015; O’Brien et al., 2018).
The value proposition of a trauma informed approach to care in the NICU is reflected in figure 1. Identifying primary preventative strategies and earlier opportunities for intervention has the potential to significantly reduce the short term and long term physical, emotional and spiritual morbidity associated with NICU hospitalization for infants, families and clinicians.
The use of a parent-based intervention in the NICU mitigates and minimizes the trauma experience of the infant and family. Examples of tools that support family-based interventions are represented by The Zaky from Nurtured by Design. The Zaky line includes The Zaky HUG and The Zaky ZAK, The Zaky ZEN, and The Zaky mobile application. The Zaky HUG is comprised of two cylindrical devices shaped like human forearms and hands, made of an incredibly soft and warm fabric filled with weighted beads and has the capacity to absorb the parents’ scent. The Zaky ZAK is a cloth holding device to support the infant for safe skin-to-skin care practice and is made of a stretchable, form fitting fabric that is attached to itself by an adjustable zipper that allows it to wrap comfortably around the circumference of the infant-parent dyad during the skin-to-skin encounter. The Zaky ZEN provides organic and natural products for skin care and wellness line for infants to adults; while The Zaky mobile application educates and tracks activities such as kangaroo care, journals, and sharing the account with others. The simplicity and elegance of The Zaky make it effective in reducing human errors and safety risks, while streamlining the entire supply chain ensuring consistency, reliability, and care based on family and clinical evidence for every patient and around the clock.
In a randomized, controlled trial by Russell et al., (2015), use of The Zaky HUG device, in both scented and unscented intervention groups, resulted in a decrease in observed stress behaviors and fewer episodes of apnea and bradycardia when compared to the control group and an alternative scented nesting device. In several studies evaluating The Zaky ZAK, results demonstrate its safety in the use of preterm infants as well as infants hospitalized with congenital cardiac defects. The use of The Zaky ZAK to facilitate skin-to-skin care encounters resulted in an increase in the frequency of skin-to-skin care encounters, enhanced parental confidence and competence in providing skin-to-skin care, while promoting staff confidence in the safety and reliability of the device which resulted in the facilitation of even more skin-to-skin care experiences for the patients and families (Coughlin, 2015).
Examining The Zaky through the lens of trauma informed care begins with an understanding of the disease independent needs of the infant and family in crisis. The five core measures for trauma informed developmental care represent disease independent domains of human caring that have been endorsed by the National Association of Neonatal Nurses (NANN), the Canadian Association of Neonatal Nurses (CANN), and the Council of International Neonatal Nurses (COINN) (Fig 2) (Coughlin et al., 2009; Coughlin, 2011; Coughlin, 2014; Coughlin, 2016; Coughlin 2021).
Figure 2. Core Measures for Trauma Informed Developmental Care. Photo of family during Kangaroo Care using The Zaky ZAK.
Beginning with the HEALING ENVIRONMENT, the use of The Zaky ensures that the parent-infant dyad is fully supported within a soothing, aesthetically pleasing healing milieu. The HEALING ENVIRONMENT includes the physical, human and organizational components of the clinical setting. The Zaky supports the infant’s physical and human environments by providing a safe vehicle to facilitate frequent and sustained skin-to-skin experiences while The Zaky HUG supports the infant’s physical environment through containment and proprioceptive input and providing familiar comforting olfactory stimulation, similar to what the infant experienced in the womb (Benoist et al., 2004). With regard to the organizational environment, the adoption of a standardized approach to facilitating skin-to-skin care encounters and ensuring consistent postural support reduces variability in the patient’s experience, the parent’s expectations and the clinician’s practice and performance.
PROTECTED SLEEP is a combination of assessing sleep-wake state and using that information to determine whether or not to proceed with non-emergent care; supporting sleep through skin-to-skin care encounters, optimal postural alignment and a quiet milieu; and, ensuring that the infant is safe during sleep (Coughlin, 2021). The Zaky supports PROTECTED SLEEP through the promotion of quality safe skin-to-skin care experiences and comfortable, restorative sleep epochs as demonstrated by the work of Russell et al., (2015). The latest consensus standards for developmental care recommend that parents are encouraged and supported to provide early, and frequent skin-to-skin contact with their hospitalized infant and that parents should be allowed to sleep during these encounters when skin-to-skin care safety measures are in place (Phillips et al., 2020). The Zaky HUG is the only device on the market that can meet these safety parameters. In a recent cross-sectional, exploratory and descriptive survey of clinician use of skin-to-skin care devices and ranking of the various device features, The Zaky ZAK features met and exceeded device needs and preferences across all survey indicators (Weber & Jackson, 2020). The primary features identified as critical for a kangaroo care device readily provided by The Zaky ZAK included the safe support of the infant’s position in skin-to-skin contact even if the parent falls asleep or needs to use his/her hands; immediate and effective access to the infant; and washability of the device (Weber & Jackson, 2020).
The PAIN & STRESS PREVENTION AND MANAGEMENT core measure is comprised first and foremost by those activities aimed at preventing pain; secondarily, the assessment, management and reassessment of the infant for the presence of pain and/or stress, and finally, the role of the parent in the prevention and management of pain and/or stress (Coughlin, 2021). The Zaky supports effective non-pharmacologic pain and stress prevention and management that incorporates the role of the parent. Whether it is supporting an infant in skin-to-skin care during a procedure (e.g., heel stick, feeding tube insertion, immunization, etc.) or providing containment with proprioceptive and olfactory input during two-person care, these devices are important adjuncts to the management and prevention of the pain and stress endured by infants in the NICU that empower parents and validate their role identity in providing confident comfort for their baby during their hospital course (Coughlin, 2016; Johnston et al., 2017; Coughlin, 2021).
ACTIVITIES OF DAILY LIVING core measure includes posture and play; eating and nourishment; skin care and hygiene (Coughlin 2021). The Zaky ZAK supports optimal postural alignment in the skin-to-skin position and in doing so enables the infant to become familiar with the maternal chest landscape, facilitating early pre-feeding activities while also enriching the infants skin microbiome during the skin-on-skin contact with their parent (Doucet et al., 2007; Hendricks-Munoz et al., 2015). The Zaky HUG supports postural alignment without restricting spontaneous movement. The flexibility of this device enables it to uniquely support the infant in various positions while ensuring maximal comfort both physically and sensorially. The Zaky HUG also guides the clinician away from employing the prone position which has shown to impede cardiac output and increase systemic vascular resistance (Ma et al., 2015).
Finally, the COMPASSIONATE FAMILY COLLABORATIVE CARE core measure, comprised of parental emotional well-being, self-efficacy and compassionate communication (Coughlin 2021) is fully reflected in The Zaky product line. Skin-to-skin care supports, protects and promotes parental emotional well-being and parental self-efficacy. Empowering parents as primary caregivers in the hospital setting validates their role identity, cultivates attachment and enables them to stand in their power as parents and advocate for their family. Whether the parent is physically present or not, The Zaky HUG provides a vehicle for the infant to enjoy the sensorial presence of their parent which reduces stress behaviors and promotes autonomic stability (Russel et al., 2015).
Awareness of the experience of trauma in the NICU for babies and families is a first step to transform and humanize this fragile, yet critical care environment. Trauma informed care is an effective, compassionate and evidence based strategy. Through the use of parent-based interventions, such as The Zaky HUG when they are apart, and The Zaky ZAK for safe and prolonged skin to skin contact, clinicians are able to actively buffer trauma experienced by the babies and families they serve in the NICU and beyond. By providing a holistic approach to care and predictable ergonomic surroundings for the patient and families, The Zaky became an unmatched and important tool that mitigates suffering, while empowering NICU healthcare team to provide neuroprotective care based on evidence to prevent separation from the parents, many physical malformations and other deficiencies. The ability to transform the experience of intensive care for vulnerable infants, families in crisis and themselves is possible with The Zaky.
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