Kangaroo Mother Care Method

1. < Kangaroo Mother Care Method SOCIAL AND EMOTIONAL ASPECTS MODULE 6

2. SOCIAL AND EMOTIONAL ASPECTS OF THE KANGAROO MOTHER METHOD • GLOSSARY • ‘Secure’ attachment: secure attachment refers to the specific and special bond that forms between the mother or the permanent substitute mother and the baby. The child experiences a sensation of safety, security and protection with this person. • Contingent social responsiveness: refers to the mother´s interpretation of her child´s behavior as intention to communicate, her sensitivity towards his attempts to initiate interactions and her responsiveness to these behaviors. • Emotions can be ‘contained´ in different ways; sometimes, the sole presence of the baby and his mother creates a scenario that ´contains´ emotion. • Contained words, contained emotions: the emotional state of mothers and babiesisimplicit inwords. This is why it becomes important to talk to babies and maintain a dialogue with mothers.

3. SOCIAL AND EMOTIONAL ASPECTS OF THE KANGAROO MOTHER METHOD (2) • GLOSSARY • Unbearable impact:the baby´s capacity to deal with external reality is probably limitedgiven his physical and emotional immaturity. • Every physical or psychological impact will be unbearable in principle; the baby will need external help from the mother or caregiver to avoid feelings of helplessness and loneliness. • Stimulus from other humans: it refers to any message or communicative act from the baby´s parents or caretakers. All of them can be perceived by the baby as positive or negative impact, making an imprint, a mnemonic link that will make up the emotional history of the baby. • Mnemonic links: a mnemonic link is when an image and sounds are associated with words or phrases, which in turn are linked to their own meaning. They finally connect with a particular emotion circuit.

4. SOCIAL AND EMOTIONAL ASPECTS OF THE KANGAROO MOTHER METHOD (3) • GLOSSARY • ´Haunting´procedures: are all those stimuli received, which cause discomfort, pain, fear and instability in the baby. Due to his immaturity, he is unable to deal with these stimuli and perceives them as something that haunts and harasses him, generating stress. • Premature mother: is the name given to the mother of a premature child. The experience of motherhood during pregnancy completes a natural cycle which is arrested by a physical or emotional event. It is essential that the mother also receives special care or support, in order for her to carry out this experience successfully. • Mothering (maternage): a word generally used to describe the exercise of motherhood in a wider context. It entails the focused dedication and concern of the mother for the well-being of her baby. She needs support from her surroundings: the child´s father, a relative or the health care team.

5. SOCIAL AND EMOTIONAL ASPECTS OF THE KANGAROO MOTHER METHOD (4) • GLOSSARY • Fathering (paternage): a word generally used to describe the exercise of fatherhood in a wider context. Fathering refers to the role of the mother´s partner in child care. • Fathering describes the permanent, physical and emotional presence of the father, needed by mother and child in order to strengthen the primary bond and to prepare the child´s confident entry into the world • Feelings of fragmentation: from the psychoanalytical point of view, this is understood to be the primary state of the baby, where there are only sensations, the body has no precise boundaries in his mind or his experience. • These boundaries will later be provided by the touch, voice, gaze and cradling of the mother or her permanent substitute. While these boundaries are established in the baby´s mind, any uncomfortable or unbearable experience will trigger in him a sensation of being torn in pieces that need to be put together. The containing function of the mother will serve this purpose.

6. SOCIAL AND EMOTIONAL ASPECTS OF THE KANGAROO MOTHER METHOD (5) • GLOSSARY • Cognitive reorganization: it refers to the task carried out by the mother during her child´s first days of life, where all her affection, ideas and fantasies adjust in order to modify her priorities and focus on her baby´s needs. J • Just as the mother´s hormonal system must reorganize, her new emotions must also be refined and understood and her intellectual or reasoning functions complete a new process of accommodation and organization.   • ´The symbolic´: it refers to the process that must take place in adolescent fathers or mothers as they are no longer sons or a daughters, and become ´fathers´ or ´mothers´. • A process of intellectual, emotional and mental maturation must take place in order for this parental function to have symbolic´ value and for parenthood to become relevant.

7. MATERNAL INFANT BONDING: AFFECTIVE BOND • Affective bond: The relationship of the mother’s early interest and commitment to her child. • The infant and young child should experience a warm, intimate, and continuous relationship with his mother (or permanent mother substitute) in which both find satisfaction and enjoyment”. • The affective bonding process promotes a permanent affective tie and has long term effects. • This process begins at the time the pregnancy is planned, materializing and becoming real with the birth of the baby.

9. MATERNAL INFANT BONDING: AFFECTIVE BOND (2) • The affective bond or bonding is expressed in four dimensions in permanent interaction: biological, behavioral, affective and imaginary. • Biological dimension: mother and baby are prepared to interact with each other from the moment of birth; there is a predictable pattern of sensory and neuroendocrine events that binds them. • Behavioral dimension: real and observable interactions between mother and child. These interactions may be expressed through the following interrelated areas. • Bodily: is the way mother and baby hold, manipulate and touch each other. • Visual: it refers to the visual encounter of mother and child. • Vocal: it refers to all communicative actions that translate the needs and wishes of both members of the dyad; it includes the newborn’s crying and other vocalizations and the words and verbal expressions of the mother. • Social: it refers to the strategies used by the mother in order to encourage her baby to socially express his feelings and to stimulate him to interact with her.

11. MATERNAL INFANT BONDING: AFFECTIVE BOND (3) • Affective dimension: the mother and her child interact and communicate through their feelings. They must identify and figure out the emotion and feeling behind each other´s behavior. • Imaginary dimension: the mother interacts with the baby in front of her but also with the unconscious image she has of her child. In some cases, she may relive unresolved conflicts from her past. For instance, since the baby looks so much like her father, in her mind the baby is also going to leave her, just like her father did when she was a child.

12. MATERNAL INFANT BONDING: AFFECTIVE BOND (4) • Klaus and Kennel (1986) point out how both mother and newborn are prepared to interact from the moment of birth.

14. MATERNAL INFANT BONDING: AFFECTIVE BOND (5) • If the mother infant dyad is not reunited after delivery, these interactions will take place at a later time, once mother and child are together, in intimacy, for a considerable period of time. • There is a unique sensitive period where there is greater probability to develop attachment behaviors in the mother for her child. • This period extends through the first month and requires parents to have early and prolonged contact with their newborn as well as emotional support from the health care staff. • The quality of the affective bond, in a process of consolidation, must be assessed during kangaroo adaptation. This can be done through observation of daily interactions such as nursing and diaper change, or through direct questions to the mother and the family.

15. MATERNAL INFANT BONDING: AFFECTIVE BOND (6) • This quality is observed in the degree of mutual acceptance, the affective ‘tone’ of interactions and by the compliance with the laws of attachment (the observable expression of the bond): symmetry, synchrony, contingency and consistency. • Synchrony:it refers to the mother’s behavioral adjustments to fit her baby’s rhythm; she learns his language and controls her own motor behavior. • Symmetry:it is the way in which both members of the pair contribute, give, receive, maintain and initiate interactions. • Contingency: defined as the mother’s accurate interpretation of her child’s signals (for example, crying) and adequately (starts breast feeding). • Consistency: refers to the mother’s similar response to the same stimulus from her baby.

16. MATERNAL INFANT BONDING: AFFECTIVE BOND (7) • The following conditions pose a risk for a failure in mother-infant bonding: • The mother looks tense, anxious, as if unhappy • Her behavior show feelings of incompetence to hold, care for and breastfeed her child • She can't communicate with her child • She can't interpret the child’s signals or doesn’t seem to respond to them • Is overly protective or negligent. In some cases, may even seem aggressive • She doesn’t understand her baby’s temperament and assigns negative connotations to his behavior • Doesn’t ask or seeks information about the baby’s clinical evolution or care needs • The baby may in turn exhibit the following behaviors • Is irritable and sleepy • Averts his gaze • Does not quiet down in his mother’s arms • His feeding and sleeping cycles are disrupted; exhibits vomit and frequent colic • Shows excessive, uncontrollable crying • Exhibits gestures and behaviors of discomfort and stress (e.g. frowning, tongue thrust, clenched fists drawn to the chest, etc.)

17. THE EMOTIONAL RESPONSE OF PARENTS • The neuroscience perspective • The relationship between a mother and her child is an expression of a communion, a delicate and vulnerable arrangement. • Just as the baby requires of his mother’s presence, her attention and focus around him, the mother also needs her baby. • For her physical and emotional reorganization, she needs the baby’s sound, his scent, his gaze.

19. THE EMOTIONAL RESPONSE OF PARENTS (2) • The neuroscience perspective • The loving and inclusive presence of the mother’s partner is essential to reassure motherhood as an emotional experience that strengthens the nest that the baby requires in order to find protection and security. • There is evidence to support the fact that even though babies cannot talk about it, they are fully aware of such emotionally stimulating contexts, or at least can react to them. • The organs of perception and action for conscious communication with others are formed in the fetus body and brain and there is evidence to show that fetal expression and senses are activated before birth. • During childhood we learn to manage our emotions, organizing our experiences and affecting our ability to do and to think. • A precariously nestled, held and contained child develops a reactive stress response and biochemical patterns which are different from those of a well-contained child. • Our emotional responses are not brought out by our biological urges, but rather by the patterns of emotional experiences with other people, deeply rooted in infancy. • These patterns are not immutable; but much like habit, once established they are difficult to break.

20. PREMATURE MOTHERS – PREMATURE BABIES • Premature babies during their first minutes of life are separated from their mothers. The baby experiences mistreatment, loneliness, deprivation and insecurity that the "subconscious is populated". • Affective bonds and safe attachment are sacrificed, particularly in countries where health care services restrict the mother’s presence in the Neonatal Wards. • The approach of the Kangaroo Mother Program of promoting a close and intense relationship between mother and child through skin-to-skin contact is a ‘care’ intervention that also fosters an essential aspect for survival, such as this socio-emotional relationship, paired with the social development of the brain.

22. PREMATURE MOTHERS – PREMATURE BABIES (2) • Prematurity presents to us a mother who is psychologically fragile, in need of containment and support, with elements of her motherhood still ‘entangled’ in her fears related to pregnancy and deliveryand unbearable feeling of guilt.   • We must be aware of the fact that parents, and particularly mothers, are grieving for the healthy full-term child they do not have. Parents must reconcile with this reality, with this baby, who is not ideal, but real. • Each and every one of the aspects mentioned above can now be addressed with the baby in skin-to-skin contact with his mother. • The social relationship is established, brain connections are established within this enabling environment, since emotions are contained, and they obtain a response that matches the baby’s need. • The ‘Kangaroo’ Mother-Baby Method proposes a physical and a mental uterus to in which to nestle the baby, recuing in this loving nest, the child’s physical and emotional lives as well as the strength of affective bonds.

23. PREMATURE MOTHERS – PREMATURE BABIES (3) • Every time the baby is to be placed in kangaroo position whether it is from the incubator to the caregiver’s chest or from one caregiver to another, the action (touching him, caressing him, massaging him, dressing him, prepare him for breastfeeding or for being picked up) must be accompanied by verbal language. • Once in skin-to-skin contact, verbalizations must continue until a relaxed and secure position of the baby is achieved. The mother’s gaze, her heart beat and rhythmic breathing will guide the baby while he settles to the mother’s chest. • The mother’s arms will provide the initial support for the adjustment of the baby’s body. Later, they will be replaced by a Lycra girdle to keep him in position, against to the mother’s body. • Once the baby has been placed in position, following this small ritual that will become a habit for mother and baby, it is utterly important for the mother to get some rest. • Just as her premature infant, the premature mother needs special care, since she also requires containment from her environment, in adult form in order for her to cope with the physical and emotional demands of this new experience.

24. PREMATURE MOTHERS – PREMATURE BABIES (4) • The sooner the child adapts to his mother’s chest, the stronger the possibilities of attaining a strong bond between them. • Nature and nurture join forces to offer the best opportunities to this emerging mother-child relationship. • The strength of this bond will generate a basic feeling of security, which is required by the infant in his journey to adulthood. • This bond it is important in order to face successive separation experiences in the future.

25. FEAR AND ANXIETY BEFORE EARLY DISCHARGE • The birth of a premature or low birth weight infant is an unexpected event for which no one is prepared. • It causes an emotional crisis in the mother, understood as a temporary, non-pathological situation that makes the mother feel sad, distraught, guilty, with low self-esteem, impotent, isolated and misunderstood. • It is necessary to identify any signs of crisis in the parents, hopefully from the time of birth, since these could have a negative effect on the development of the affective bond, the adaptation of the family and the development of the child. • In case a member of the health care staff detects one such sign, the necessary emotional support must be given to the parents and their family so that it can be overcome it as soon as possible.  

27. FEAR AND ANXIETY BEFORE EARLY DISCHARGE (2) • The Kangaroo Mother Program has implemented some measures to help parents overcome their crises. • Hold individual or group support sessions where the mother, the father and other family members who give support to the parents may express their fears, anxieties, doubts and complaints about their child or the experience of having a premature or low birth weight baby. • The aims of this intervention are : • Removing guilt: premature birth is not caused by anything anyone has done or failed to do. It is the conjunction of several circumstances related to the mother’s health, environmental factors, and prenatal care, which made premature delivery difficult to control. • Normalization: ambivalent feelings and lack of knowledge about the baby and his care are common in parents of premature babies. Expressing and sharing these, the sensation of failure is alleviated. • Empowering:parents gain control and mastery over the lives of their children through access to information; they participate and take responsibility for their child and his care. • Redefine: the role of the father and other family members as active participants in caring emotionally and physically for the mother and the child.

28. FEAR AND ANXIETY BEFORE EARLY DISCHARGE (3) • Clarify: the role of the KMP and its health care team as the parents’ guide and companion (coach) and not as their replacement in getting information, making decisions and caring for the needs of their child. • Promote the creation of informal mother groups: Mothers are a source of mutual support and teaching and are better able to normalize their feelings and behavior. • Inform parents about the abilities and limitations of their premature child: show them how to identify his signals and how to respond to them appropriately; help them see what they can do as parents to help their child. • Promote, from the NICU, the early and constant participation of the parents, grandparents and siblings in the care of the premature infant and in keeping the health care staff informed about his health and development. • Facilitate opportunities for them to see, touch, hold and interact with the baby to develop their sensitivity and ability to respond appropriately to the child. • Be attentive and ready to identify and intervene in case other relatives are taking the place of parents as primary caregivers (it is the parents role to care for, protect, stimulate and bring the child to consultation). If this happens, parents will not develop their parental abilities and independence. If the crisis experienced by the parents or the family does not resolve easily, it could be the origin of destabilizing situations of the family dynamics and of the optimal development of the premature or low birth weight child.

29. EMOTIONAL RISK INDICATORS • High risk Indicators: these indicators determine the significant difficulty or impossibility of establishing the affective bond. • Death of the mother • Significant postpartum illness of the mother, where she must remain in the ICU more than three days. • Postpartum depression (clinically diagnosed major depression). • Severe neonatal illness (respiratory dysfunction, surgery, low gestational age, congenital malformations, intrauterine growth retardation, and ROP, among others). • Mother with a record of mental illness or disorder (mental retardation, psychosis, among others). • Suicide attempt during pregnancy. • Grieving situation in the mother (separation from partner, death of a relative or a close or significant person, transfer to another city, physical or psychological neglect from the spouse). • Alcoholism and/or drug abuse in the mother

30. EMOTIONAL RISK INDICATORS (2) • High risk Indicators: these indicators determine the significant difficulty or impossibility of establishing the affective bond. • Pregnancy as product of incest or rape • Inabilty to establish verbal and affective contact with the baby (even from pregnancy). • Great fear of touching the baby. • Excessive preoccupation about the baby’s health (fantasies of damage or illness) • Evident rejection or discomfort towards the pregnancy or the child (the mother is incapable of perceiving her pregnancy and fetal movements and to construct a mental image of her baby; does not follow a prenatal care program or adopts behaviors to care for herself or her pregnancy). • Inadequate responses to her child’s signals. • Excessive preoccupation with her appearance following birth. Self-image disorders. • Reiterative and recent miscarriage or abortions, • Substance or alcohol abuse in one of the members of the couple.

31. EMOTIONAL RISK INDICATORS (3) • Average risk: factors affecting establishing the bond • Miscarriage or perinatal death immediately before the current birth. • A weak support network, riddled with conflict (extended family or partner). • Dissatisfaction with the baby’s gender or appearance, in one of the members of the couple. • Abortion attempt during pregnancy. • Significant financial distress. • Disinterest in attending medical check-ups or in following care instructions received. • Underage mother or over 35. • Fertility disorders in one of the members of the couple. • Hospitalization of mother or child longer than two weeks. • Signs of extreme mental or physical exhaustion during ambulatory kangaroo care. • Children with psychological or significant cognitive disorders. • Birth of twins, triplets or others. • Management issues with other school aged or adolescent children. • Serious difficulties to nurse the baby. • Prejudice or beliefs against skin-to-skin contact, exposure of body to others or any other resistance associated with the KMM. • Antecedents of sexual or physical abuse in the mother. • Twins separated by illness in one of them • Antecedents in the mother of failure to bond

32. EMOTIONAL RISK INDICATORS (4) • Low risk • Unemployment or financial difficulties of father or mother • Low or no schooling in the mother • First time mother • Threatened miscarriage • Initial difficulties to accept the pregnancy • Conflict or dissatisfaction in the couple’s relationship

33. THE ADOLESCENT MOTHER • Adolescence is a critical period since it is a time for resolving psychological or physical-psychological situations. It is a period of conflict in which the adolescent seeks to defend himself through the use of defense mechanisms. • Every psychological and biological change is experienced as a conflict, if it entails development, change or consolidation. • The changes occurring in the body of the adolescent are directly related to the sex drive and the species mandate: reproduction. It is an organic process, expressed through hormonal pressures; the adolescent seems to have no choice but to experience the sexual act as an intense mandate. • The young teenage girl standing before the misunderstanding of her search for adulthood as she goes directly into motherhood faces great bewilderment as she holds this very real infant in her arms. • An adolescent pregnancy is in itself a high-risk pregnancy and is when the baby is born prematurely the resulting mental scenario is one of utter chaos. • The presence of more organized and watchful minds is imperative; someone who can use special containment qualities to show motherhood and fatherhood models to these new parents, so they in turn can identify themselves with them and become parents for their babies

35. THE ADOLESCENT MOTHER (2) • The adolescent mother in KMCP requires the following sources of external support. • Become acquainted with the psychological realities of adolescent pregnancy, delivery and postpartum. • In experiencing her motherhood this adolescent must have someone who displays this quality of care. • She needs to be helped to use language and creative actions as opportunities to engage in direct contact with the baby in her womb. • The premature baby, once in the KMCP, becomes a real being for the teenage mother. The permanent presence of the baby’s grandmother, close to the new mother is necessary not as a mother substitute, but as an identification figure. • The teenage mother must not be alone with her baby; she needs a special containment force. The health care service has an enormous responsibility in this task. • The specialized care required by the adolescent mother is of a psychological nature, as she must go from thought to action in her motherly role. • Promotion of breastfeeding must be intense. It is an opportunity to form and strengthen the mother-infant bond. This ‘communion’ will impose the ‘commitment’ needed for the deployment of motherhood. • Every bit of information given to a premature mother, and particularly to an adolescent premature mother, must be relayed more intensely to her companion, and with special care to the mother. She is a process of emotional but also cognitive reorganization.

36. THE ADOLESCENT MOTHER (3) • The adolescent mother is in a situation of greater emotional vulnerability due to her own psychological, mental and emotional state, characteristic of adolescence. • The professional specializing in emotional care, and aware of this psycho-emotional and social reality of teenage pregnancy, must first approach this mother using appropriate register. • When questions arise as to whether the adolescents are capable of forming a family, the real and overwhelming answer is that it the familial and social spheres that must rise to help the adolescent create an adequate scenario for this reality. • This shaping of a family or of the affective bonds that strengthen family relations may be placed at risk if the adolescent is stripped of his or her parental functions. Therefore, they require a social and familial motherhood or fatherhood that shelters the mother in her relationship with her infant and the father in his fatherly role.

37. NURSING, A BONDING EXPERIENCE • The experience of nursing a child follows such forceful plans that fundamental nature and nurture law becomes evident.

38. NURSING, A BONDING EXPERIENCE (2) • If all goes well, in the intimate communion of mother and child, the infant sends signals to his mother (e.g. he is hungry) she perceives this signal and responds accordingly (by offering the breast to her child). • This way, the mother-infant dyad synchronizes their responses, stimulating each other as active participants of the interaction. • Nursing is the only act which is exclusive of the mother towards her child which helps her reinforce her self-esteem and her maternal role. • The mother’s state of mind and her intent are read by the baby, who in turn emits signals to provide feedback to the mother and make her feel as a good mother: nursing is not only offering milk, it is essentially nurturing the bonds of life. • This maternal predisposition, present from pregnancy, is indicative of her ability or inability to nurse that child. • The mother needs to be free from the stress resulting from the grief and possibly the guilt she feels from what she considers being a failure in her maternity. • The baby’s permanence on her mother’s chest in skin-to-skin contact, and an environment that is stimulating and positive towards her motherly role, favors the connection necessary for nursing.

40. NURSING, A BONDING EXPERIENCE (3) •  Arms to cradle: very small babies in the Kangaroo Mother Program must be placed in safe contact with the mother’s body. She will use her arms, to put her child in the desired position.  • Voice that rock: placing the baby, connecting with him. The entire breastfeeding experience must be paired with words that guide the baby.  • Breathing that sets the pace: the slow pace of the mother’s breathing, the exact distance at which the baby is held, cradled in his mother’s arms promotes stress management in the child. • Encompassing gaze: the baby perceives and registers the way in which his mother’s gaze conveys her ‘intent’. Mother and child are the minimal loving, communicative unit that the human brain can metabolize.

42. NURSING, A BONDING EXPERIENCE (4) • Listening to decipher: each baby has a specific suction pattern and also a peculiar sounds, which arise from those heard while in the mother’s womb: the mother’s voice and register, for example.   • A non-anxious mother can recognize this tone and cadence in her baby and decipher those codes, filled with emotional significance; these signals are obviously sent by the baby in order to get a response, to construct a dialog of mutual understanding. • Mind that contains: all this physical and emotional exercise of the mother as she cradles her baby in nursing, with each one of her senses connected in this idyllic act, generates a state of mind of emotional ‘commitment’ with her baby. • Love that integrates: this emotion, of such a biological, social and cultural importance seems to be called upon to be the primordial nucleus of survival, procreation and the formation of the affective bond. It is a physiological need. This feeling is an organizer of the cognitive-emotional development of the infant and ensures what has been called the infallible glue to seal the affective bonds towards joy and mental growth.   • A story of loss and recovery of that loved object begins with that first nursing experience. If this takes place in a satisfactory manner, it develops adequate ability to relate and to separate. • In ‘kangaroo’ mother-infant couples, the above task must be guided, closely followed by a health care team and a close and containing family, who has been sensitized to the emotional meanings of this first postnatal stage.

43. SUPPORT NETWORK: GRANDPARENTS AND SIBLINGS Grandparents • Grandparents are vital since their life experience can contribute physical and emotional tools to the new parents so that in being ‘contained’ they can extend the essence of maternal and paternal care to their newborn. • Grandparents not only relive their own past parenting experience, but have elements to exercise a role of care and support. • This support is fundamental in the Neonatal Unit, their support is unrivaled. • These grandparent ‘visits’, may be individual or in group. • The methodology of group sessions consists of a first reception of the group of grandparents, where they can verbalize their impressions on this experience. • The parents of the premature infants will receive the grandparents and introduce the babies. It may be the child’s first family reunion in the hospital. The health care staff will be available during the visit, to give instructions, answer questions or monitor the groups in case there is an inadequate, careless or clumsy behavior, or perhaps due to lack of awareness.  

45. SUPPORT NETWORK: GRANDPARENTS AND SIBLINGS (2) Grandparents • Once the visit is over, grandparents reunite with the group to comment on the experience and share it, reinforcing their own containing role. • Intensive and frequent work is done with grandmothers who are mothers of adolescents in order to help them give their daughters or sons the special care needed by this new parent without the required maturity for their new role. • Siblings, grandparents and other relatives who have been protagonists of stories told to the babies by the health care staff and product of the contained word and the construction of reality will have a real contact with their babies. • There are two modalities of visits from grandparents and other relatives: a guided group visit and an individual visit; they will be conducted according to the circumstances and will show the flexibility of the health care team and the directives.

46. SUPPORT NETWORK: GRANDPARENTS AND SIBLINGS (3) Siblings • A special program will be followed every time there is a visit from the baby’s siblings. It may also be a guided group visit and at the discretion of the medical, nursing and psychology staff, may be individual. In both cases, without exception, the psychologist must identify anxieties and expectations in the babies’ siblings. • An explanation of all medical care procedures to which the baby is subjected is immediate: a member of the nursing staff begins a conversation with them and teaches them how they will find their hospitalized baby brother or sister. A baby doll will be used to simulate the baby’s situation, the cables connected to his tiny body and the monitors. • This initial contact and explanation diminishes their anxiety and familiarizes them with the Unit’s environment. • Once hygiene regulations, required by the local authorities for the control of infection are fulfilled (hand washing, use of a robe and mask) siblings can go in the Unit, accompanied by a member of the health care staff, who will take them to their parents, who will be waiting for them to introduce them to their baby brother or sister.   • The psychologist and/or health care staff must encourage the baby’s siblings to talk to the baby, touch him, sing to him, ask him questions, in other words, to promote a family dialogue. This is part of sharing the experience as a family. • It is expected for the siblings’ anxiety to diminish, forming a brotherly bond. The parents may also be better able to reach these children when they have been helped to build bridges to reach their newborn baby brother and sister, who up until now only existed as an imaginary one.

48. SUPPORT NETWORK: GRANDPARENTS AND SIBLINGS (4) Siblings • Once the visit to the different Neonatal Wards is over, the siblings are welcomed by the psychology staff. Through close dialogue, they relay their stories on what they saw, felt and understood; their perception of the baby. • The psychologist will acknowledge their anxieties. All siblings will then be invited to make a picture, write a letter or something they want to leave for the baby, as a present. • Mothers and fathers who are present as long as they can, sometimes 24 hours a day; grandparents and siblings as directly involved in the experience of receiving a new baby, fulfill a welcoming function, one of rooting and belonging. • Once the infant is discharged from hospital, his arrival generates big changes in the life of the family, demanding important adaptation from every member of the family. • A small child who up until now, reigned on the household, was expecting a brother or sister-playmate, of his same size while still being the center of attention and family interest. However, his baby brother or sister is born before time and the mother must be away for a few days and focus all her energy on the new member of the family. • The child feels displaced, threatened, disconcerted, insecure, lonely and furious. This is known as sibling rivalry and could generate on the one hand, changes in his behavior and family and school performance, and on the other, alter the interaction that must exist between the small child, his parents and the premature baby.

49. SUPPORT NETWORK: GRANDPARENTS AND SIBLINGS (5) Siblings • If parents refer family problems due to any of the following behaviors of their child, listen to them and offer the necessary support and guidance: • i) defiance or misbehavior, • ii) constantly asks who will be caring for him and whether they still love him • iii) begin to behave in immature ways or exhibits regressions • iv) is aggressive towards the baby or wishes the baby to leave or return to the hospital • v) is socially isolated or his school performance deteriorates. Parents feel disgusted, overwhelmed and guilty. • The members of the KMP health care staff must not ignore or dismiss these complaints and feelings; on the contrary, they must understand them and take measures to help parents overcome them, through actions such as the following. • If at all possible, siblings must be encouraged to visit their baby brothers and sisters in the NU in order to meet him and begin interacting with the premature infant. • In KMP ambulatory follow up, when parents come for control visits with their babies, it is necessary to allow the visit of siblings. they may ask and get to know the setting and participate in routine care activities such as diaper change, massage and breastfeeding; • If they’re older than six years, they can be allowed and accompanied in the experience of holding the baby in skin-to-skin contact with the infant, for short periods of time.