Kate CP - posted on 03/03/2011 ( 2 moms have responded )
Kinda long but worth the read. :)
This was not the baby that Grace Miller* had imagined.
An athletic, 29-year-old advertising executive with auburn hair and hazel eyes, Grace had daydreamed throughout her pregnancy that she and her newborn daughter would cuddle happily together, like all the other new families she’d known. Everyone told her that having a child would feel wonderful. Why then, the day after becoming a mother, did she feel despair?
The doctors had assured her that her baby, Jennifer, although underweight, was healthy and normal. Yet Jennifer cried incessantly, she had trouble eating, and everything her new parents did to comfort her only seemed to make matters worse. Grace had never been bad at anything in life, but only one day into the experience she already felt like a failure at motherhood, which was supposed to be so basic and innate. She looked at squalling
Jennifer and thought, I can’t seem to manage her. She pushes me away. I don’t think she likes me.
Most maternity-ward veterans would consider this mother-child disconnect to be a worrying sign, a flashing yellow light warning of trouble ahead. According to the American Psychiatric Association, “baby blues”—a mild form of postpartum depression characterized by days of parental sadness, crying spells, and anxiety—afflicts up to 70 percent of all new mothers. Scientists now know that the children of depressed mothers have lower rates of positive behavior and higher rates of childhood aggression. Attachment, that initial bond between parents and their baby, turns out to be crucial to a child’s brain development and sense of self-worth.
Until remarkably recently, however, psychiatrists and pediatricians couldn’t do much to help mothers like Grace and babies like Jennifer find their way to each other. That changes for Grace and Jennifer when Kevin Nugent walks into their room at Brigham and Women’s
Hospital in Boston. A gracious, smiling, 67-year-old native of Ireland, Nugent is, on this day, training a group of medical residents and interns in a new procedure called the Newborn Behavioral Observations, or NBO. With his black eyebrows, philosophical musings, and lilting accent, Nugent might impress you as a character from a novel—the country priest, perhaps, bringing comfort to the sick. In fact, he is a pediatric psychologist who teaches at the University of Massachusetts and the Harvard Medical School, and directs the Brazelton Institute, which is among the country’s leading centers of infant knowledge. But first and foremost, Nugent is someone who believes in the healing power of babies.
Born in Mullingar, a small town west of Dublin, Nugent grew up more interested in soccer than infantile behavior. He says he found his true calling in 1977, at age 34, when as a doctoral candidate at Boston College he first saw the renowned pediatrician and author T. Berry Brazelton examine a newborn. He watched Brazelton hold a tiny, swaddled girl in his arms while her mother looked on. When Brazelton cooed the baby’s name—“Sarah”—the infant locked onto his face, and as Brazelton moved his head from side to side, Sarah followed with her eyes, causing Sarah’s mother to weep with amazement. Seeing this sparked an epiphany for Nugent. “I was very moved,” he says. “At that moment, my life changed.”
Nugent says his strong response to the scene was in large part due to an “echo” from his own past. When he was just shy of his 11th birthday, his own mother died. “I was utterly bereft,” he remembers. “Uncomprehending. Lost. The world looked very dark to me.” What saved him, he says, was the caretaking of his baby brother. Nugent began to feed him, to change his diapers, and push him in a buggy around Mullingar. “Taking care of my brother lifted the blackness in my life,” he says. “I recovered my hope thanks to him. So I knew from then on the capacity of babies to change our lives.”
Watching Brazelton examine a newborn moved Nugent for another reason: It proved that the experts were wrong. In the 1970s, textbooks taught us that babies were blank slates, “subcortical” blobs, functioning only at the brain-stem level, roughly the biological equivalent of a flatworm. They could breath, eat, excrete, and circulate blood, the experts said, but they couldn’t see, hear, or think. And they certainly couldn’t communicate.
A decade earlier, however, a few pioneering researchers began to document the contrary: that babies could indeed see and hear, recognize their mother’s voice, delight in the human face, and even communicate their likes and dislikes. One of the leaders of this effort was Brazelton. In order to conduct better studies of newborns, researchers needed data, and to create that data they needed an assessment scale. So Brazelton developed and published one—some call it “the Brazelton.” Its official name is the Neonatal Behavioral Assessment Scale, or NBAS, and it evaluates 46 of a newborn’s capacities, from following a red rubber ball with her eyes to grasping the examiner’s finger with her hand. Now in its fourth edition, its co-authors are Brazelton and Nugent.
The NBAS made possible a wave of research, revealing, for instance, that newborns are social and responsive from birth: They want to speak to us, if we only knew how to listen. It never became a staple of the maternity ward, though, mostly because it takes half an hour to administer and another half an hour to score—time most busy practitioners can’t afford. As a result, Nugent and his colleagues decided to develop a more simplified, parent-friendly version of the NBAS, called the NBO. The NBO doesn’t try to measure anything. Its goal is not to assess so much as to build relationships between parents, babies, and medical professionals. It takes less than half an hour and looks deceptively simple. “The NBO isn’t a magic show,” Nugent says, “but if you’re open to it, it can actually change you.”
when nugent walks into the pastel pink room on the 10th floor of Brigham and Women’s Hospital and meets Grace Miller, her husband Michael, and her baby Jennifer, he radiates compassion. His voice soft and low, Nugent explains that the NBO isn’t something he is going to do to Jennifer, and that it isn’t a test. “Let’s look at your baby together, shall we?” he says. “Let’s see what little Jennifer can tell us about herself.” The parents agree.
Nugent bends over Jennifer and admires her wisps of black hair and her tiny fingers. “You’re such a beautiful baby, Jennifer,” he says as she cries. “I’m so lucky to meet you.” He asks Grace and Michael how they’d chosen her name, and marvels at their answers. Coming from another person, this might seem pandering or saccharine; from Nugent, it is remarkably soothing. Later he’ll say, “I never lose sight of the fact that I have been allowed into the life of this baby just a day or two after its birth, and that this is a tremendous privilege.”
In a perfect world, Nugent would examine babies who are asleep and halfway between feedings. He would start by looking at something called “habituation.” To do this he shines a little flashlight into the baby’s closed eye for a second, then moves it away. The baby usually startles, waving an arm or fussing a bit, then goes back to sleep. He waits five seconds and repeats it, up to 10 times, until the baby no longer responds at all. He then does something similar with a rattle beside the baby’s ear.
A baby who can block out and ignore the light or sound entirely after three or four flashes is good at what Nugent calls “protecting sleep.” Stray stimulus probably won’t bother her; she’s likely to be an easy sleeper. A baby who’s still agitated by the light after eight or nine flashes will likely be a sensitive little person, requiring more help from his parents, such as a dark, quiet room for sleeping.
Because Jennifer is awake and fussing, Nugent can’t observe her habituation. Instead he puts her on her back, asks Grace’s permission to unwrap the baby’s blankets and examine her “tone.” He extends her feet and arms, and notices how quickly she retracts them into the fetal position. He comments to her parents that Jennifer is strong. He puts his pinky in her tiny palm, and compliments her on her healthy grasp. Her parents seem exhausted, but also pleased.
Now Nugent strokes the side of Jennifer’s mouth and notes how quickly she turns her head towards his finger, an indication of her tendency to “root,” or seek out the breast. “She’s got a very clear-cut root, doesn’t
she?” he says to her parents, suggesting that she ought to feed well. Her suck, which he notes by putting a gloved finger to the roof of her mouth, also feels strong. Already, though, he notices something that concerns him: Besides the constant, ragged cry, Jennifer’s responses strike him as unusually intense.
Ordinarily Nugent would now pick up the baby and see how she responds to his face, his voice, the red ball. When he picks up Jennifer, however, she stiffens dramatically and cries even louder. NBO examiners like crying; they say it tells them a lot. Once a baby starts to cry, they sometimes leave him alone for a bit to see how he “self-soothes.” Some babies can calm themselves simply by altering their posture or putting a hand to their mouth. Many babies can be calmed just by an adult hand on their belly. Even the slightest touch, however, causes Jennifer to tense up. Nugent goes through his usual repertoire of soothing maneuvers, from tucking her tiny limbs back into the fetal position to presenting his face for her to view, but she remains stiff and rigid, arms out, fingers splayed, eyes tightly shut, crying.
Nugent says softly, “Are you okay, Jennifer?”
He puts her down, swaddles her tightly, which he says alleviates a newborn’s need to control her limbs. He holds her against his shoulder and rocks her gently. After 30 years of working with babies—he’s also had two of his own—Nugent generally knows how to calm them. Jennifer remains stiff, pushing her feet into Nugent’s white dress-shirt. She is saying to him, he later explains, “Leave me alone!”
“She’s very, very upset, isn’t she?” Nugent says to Grace, who lies in a white terrycloth bathrobe on the hospital bed.
“She’s been like that from the very beginning,” Grace responds. “She keeps pushing me away.”
“I can’t help her, either,” Michael says. “It’s as if she doesn’t want to be with us.”
Grace seems about to cry. “I think she doesn’t love me.”
“It may be her nature,” Nugent says.
Grace and Michael brighten a bit. Grace asks him what they should do.
Nugent isn’t entirely sure. Birth is a wildly traumatic experience for babies; sometimes they’re recovered and happier by day two. Sometimes they’ve simply had a difficult feeding. He says to them, “As of now, she’s definitely having a hard time, but we can’t say it’ll be the same tomorrow.”
“Can we see you again?” Grace asks.
“Of course,” Nugent says. “Why don’t I visit you at your house.”
Nugent leaves the Millers’ room concerned about the intensity he’s seen in Jennifer’s responses, but also confident in the restorative nature of the NBO. Although it has only been in use for six years, studies already show that it helps parents to understand their babies. It increases their confidence in themselves, allays their fears, increases interaction, and makes them better observers of their baby’s behavior. As one nurse who works with newborns put it, “A lot of the parents I deal with, especially the young ones, view their baby almost as a doll. The NBO helps to show parents that their baby is a little, thinking person.”
NBO practitioners recognize dozens of subtle signs. A baby’s growing stress might manifest itself in color changes, sneezes, yawns, clenched fists, furrowed brows. Jerky movements might actually say, “Swaddle me. Cuddle me. I want to be contained.” Rooting—jerking her head side to side—says, “I’m hungry.” On the flip side, wide eyes and relaxed toes can mean, “I’m happy and fascinated,” and a tiny sleep smile, “I’m at ease, please don’t disturb me.” A baby’s reflex to pull her hand to her mouth isn’t merely for the purpose of pacification. The calm it inspires allows the newborn to get to important work: the alert exploration of the new world around her.
Nugent has further distilled and made accessible to all parents his knowledge of infant behavior and expressions in the just-published Your Baby Is Speaking To You, a revelatory read for anyone who has struggled with and/or delighted in interpreting the surprisingly sophisticated and direct signals that newborns send us. In a passage from the book, titled “The Language of Babies,” Nugent writes that “the word ‘infant’ derives from the Latin infans, meaning unable to speak.”
Newborns and their thrillingly active minds may not have mastered the King’s English (yet), but that doesn’t mean they’re not telling us something, and, in doing so, feeding vexed and often distressed parents the cues and clarity they desperately need.
When, three days after their hospital visit, Nugent arrives at the Millers’ house in suburban Boston, Grace looks gloomy. She says that Jennifer’s eating has improved some and she is sleeping better, but when she is awake she continues to fuss and cry. “If anything,” Grace says, “it’s worse.”
Nugent finds Jennifer asleep in her room. This is good; it allows him to observe her habituation. “Shall we look at how Jennifer protects her sleep?” he says.
When he shines his little flashlight in her eyes, Jennifer startles and her hands extend, but she stays asleep. It takes quite a few flashes with the light—eight—but she eventually stops reacting. Eight is a fairly high number for habituation. Yes, this is a very sensitive little girl.
They wake Jennifer, and again Nugent looks at her muscle tone, all the while conversing with Grace about what he sees. Her rooting and sucking are still strong, and less intense than the first visit. When he picks her up, however, she is still “absolutely stiff as a board.” She kicks at him again, pushing away from him with her feet. She cries. She is far too cranky for him to attempt the red ball or the moving face.
Nugent is a placid man, but “my anxiety level was quite high,” he’ll say later; he desperately wants to find something positive to give this mother.
He puts Jennifer back down in her crib and asks Grace what she has done to soothe her.
Grace had swaddled her tightly. That helped some.
Nugent does the same, then holds Jennifer up in front of himself, rocks her, and silently waits.
One eye opens. He waits some more. Then the other.
Two tiny lights have appeared at the end of the tunnel.
Slowly, he moves his face to one side. Jennifer follows with her eyes. He moves to the other side. She is still with him. When he speaks to her in a soft voice, however, she looks away.
It’s called “gaze aversion.” Most of us would miss it entirely, or assume that the baby had spotted something fascinating in the distance. Nugent knows better.
“See that?” he whispers to Grace. “She just disengaged. She’d had enough, so she decided to shut me out.” This baby’s tolerance for stimuli is so low that looking at a face is all she can handle; adding a voice pushes her over her edge. Nugent explains that it is Jennifer’s way of saying, “You’re beginning to overwhelm me.” It isn’t quite a cry, but it is an early warning that she is headed in that direction.
Jennifer has been an extremely hard case, but now Nugent understands what to do: only one stimulus at a time. He hands Jennifer to Grace, who sits down on a couch in a dark corner of the living room and holds Jennifer on her shoulder, tightly wrapped, and rocks her at her chest. Jennifer doesn’t protest. Grace holds her a foot from her face, and smiles at her. Jennifer opens her eyes for a second.
This gets Grace excited. She coos too energetically, “Jennifer!”
The baby looks away, furrows her brow, extends her tongue, and develops a faint bluish cast around her small, soft lips.
“Do you see that?” Nugent says, pointing out these behaviors. “Do you think maybe she’s telling you it’s too much for her? That this takes so much out of her, that she has to take a break? Let’s wait until her color gets back to normal.”
Grace does. Without speaking or even looking at her baby, she waits. Gradually the blue tinge around Jennifer’s mouth fades away, her forehead smoothes, her tongue relaxes.
Nugent compliments Grace, hoping she’ll recognize her competence as a mother. “See? You really helped her when you gave her that break. Her developing mind needs those little moments.”
Grace continues to quietly hold Jennifer. She smiles at her, but doesn’t say a word. After a while Jennifer opens her eyes, looks up into her mother’s face, and for the first time in this family’s young life, holds her gaze.
Grace is ecstatic. “She sees me!”
As Nugent will say later, “The veil had been lifted.”
To Grace he says, “The more you do that, recognizing when to pull back and let Jennifer recover, the more Jennifer will realize, ‘somebody here understands me.’”
He talks to Grace about ways to help her baby—low light, minimal sounds and stimuli—and assures her that as the habituation observation has shown, Jennifer will gradually learn to react less.
“There are ghosts in the nursery,” Nugent likes to tell his students, “legacies from our own past, and fantasies about what our babies should be.”
He feels assured, however, when Grace says to him, “I guess this is who Jennifer is, and I just have to get used to that.”
Nugent smiles compassionately. “It’s a lifelong endeavor,” he says, “learning to accept our children as they really are.”
Nathaniel Reade wishes he’d met Kevin Nugent before he had two little babies of his own.
*Patients names and some physical details have been changed to protect their privacy