Relationship care in premature babies, a thread to (re) build

Step by step, Italian neonatology is undergoing a revolution in the care offered to premature babies and their families. If Italy is one of the most advanced countries in the world from the point of view of clinical care, much remains to be done at the level, also fundamental, of the relationship. “It’s not philosophy, it’s not poetry, but it’s strong scientific evidence: just as we give oxygen or an antibiotic, we have to create an environment conducive to the development of the child’s brain involving parents as much as possible.”

Gina Ancora, neonatologist, director of the Neonatal Intensive Care of Rimini and the NIDCAP Center, specializes in the individualized care of the newborn in collaboration with the family. Dra. Ancora leads the working group recently created by the Italian Society of Neonatology (SIN) for the dissemination and application of European standards of care for the health of the newborn, a collection of recommendations on the best modalities of care for premature births and their families, assessed in the light of the most advanced scientific evidence. In the Standards, the health of the newborn is addressed in 360 degrees, embracing a new model of care aimed not only at treating diseases, but at ensuring the well-being, health and development of the child in a global sense, combining technology with care of relationships.

The Standards project was born from the European Foundation for Newborn Care (EFCNI), thanks to cooperation between families and professionals from all over Europe, including neonatologists, nurses, physiotherapists, psychologists and Italian family associations. Italy immediately embraced the standards with enthusiasm and translated them in a few months, thanks to the synergy between SIN and Vivere Onlus, the national coordination of neonatology associations.

“In the last 10-20-30 years we have evolved mainly from a technological point of view, to allow the survival of children,” says Ancora. “Now the real innovation is to ensure the survival of the highest possible quality, not only in terms of the ability to walk and move, but to give children a future in which the incidence of autism and other disorders is reduced. We know that premature infants have a high incidence of autism spectrum disorders (7-10 times higher than that of non-at-risk children) and other problems such as school difficulties and emotional disorders. The aim of these Standards is precisely to ensure a better quality of life and, therefore, better social skills. The other aspect concerns parents, because when a premature baby is admitted to intensive care, the parents are also born premature with the baby: very often, after admission to the neonatal intensive care unit (NICU), they suffer from post-traumatic stress disorder. . .stress, have a higher incidence of anxiety and depression and are more separated. In addition to the initial health difficulties, families also create social difficulties: all this has an impact on the relational development and progress that these families and children can make in society ”.

The path of the Standards, the result of years of work and international collaborations, starts from a premise: the care of premature babies must comply, first of all, with the rules of technological safety, but together with this we must do do everything possible to help the development of a brain that is making a huge effort. The last weeks of pregnancy are when brain development runs faster to prepare for delivery; it is clear that if a child, for whatever reason, leaves earlier, he will have to readjust to a new environment. The closer this environment is to the one designed for millions of years to allow this development – the body of the mother and the family – the more the risks are reduced that something could go wrong, revealing itself even years later. . Clearly, parents, in this endeavor, can only play a central role.

“Premature babies are children in some way disadvantaged: their physiological development is suddenly interrupted by premature birth and then they are forced to continue growing in an environment completely different from the mother’s uterus, and this, unfortunately, it can also cause problems in the future ”, explains Luigi Orfeo, president of the Italian Society of Neonatology. “Clinical progress has allowed us to reduce the percentage of major motor and brain disabilities, while increasing those disorders – which we call minor but which have a significant impact on the lives of children and their families – which are behavioral disorders.” language. In our non-ideal environment, with our behaviors and our organization, we must try to recreate an environment, especially sensory, as close as possible to what the baby would have been during fetal life, We can do this thanks to the constant presence of parents close to the child, who can provide a whole series of sensory stimuli (caressing, talking, singing a song, helping him to develop your brain and his personality in the most correct way). possible) “.


One of the Task Force’s goals is to co-build criteria to define a friendly hospital with the premature and his family, involving “zero separation” between babies and parents, the 24-hour opening of the neonatal center. intensive care, care based on the most advanced scientific evidence, collaboration with parents in care, the promotion of skin-to-skin contact and breastfeeding, the multidisciplinary approach of the newborn and, to the extent of possible, structuring a departmental environment capable of minimizing the stress of infants, families, and staff.

Toxic stress for the newborn is an issue that worries Dr. Ancora a lot. “Toxic stress arises when the newborn is living in difficult conditions without the cushioning system of parental protection. If the newborn feels the separation, his brain records that the external environment is a dangerous environment and implements survival strategies. , such as the production of cortisol, which impair their ability to develop.It is something we must avoid: we can no longer see children locked in incubators alone, without the presence of someone who can reassure them and recreate the physiological environment “.

The problem, in Italy, is anything but marginal. According to research conducted by SIN in the two-year period 2019-2020, about 40% of neonatal intensive care units still do not allow parents to run out of time limitations. There are big differences at the territorial level: in principle, this attention is more present in the north, less in the south, but there are also significant inhomogeneities at the regional level. A situation that does not allow the equal treatment that should be due to each newborn and each family. Despite the steady decline in births, we are not talking about small numbers: according to the latest data, 30,000 premature babies are born each year in Italy (about 7% of births), which is projected in the school year from kindergarten to in the middle. school means more than 400,000 people starting, somehow, at a disadvantage.

Obviously, the degree of prematurity affects the incidence of developmental disorders. If the preterm birth includes all those born before the 37th week of gestational age, children born below the 28th week of gestational age are considered severely premature. “There are cases of babies surviving at 22 weeks, but it is usually from week 23 to 24 that babies have some hope of survival,” Orfeo explains. “What interests us more and more is a survival free of distant results.”

That is why it is important to achieve the presence of families within the Can as elements of care: as a drug, as oxygen, as any medicine for brain development. It is a mission that guides the commitment of the numerous parent associations that make up Vivere Onlus, the national coordination of neonatology associations. Monica Ceccatelli, vice president of Vivere onlus and president of Piccino Piciò. “My son was born at 29 weeks plus two days, now 28 years ago. They let us in an hour and a half a day and a half an hour in the evening, as long as there were no emergencies, but we were in the hallway. I’ve always defined our generation as that of runner parents: he spent much more time outside than with the child.Unfortunately, this was repeated during the Covid period, when the Cans were closed although this was not the indication of the SIN. first time it was imposed, and it could have been, but unfortunately some departments have not returned to full performance with the schedule or have kept limits on the entry of both parents.I relived all this and realized that many injuries they have healed, but they still hurt me ”.

According to Dr. Ancora, “Italy is one of the most remote in Europe due to the presence of parents in the wards. And Covid didn’t help: if we had taken a step forward, he made us take three steps back. Often after discharge we hear parents recounting very painful experiences of separation from their children, and that comes at no cost, because we have changed the developmental trajectory of a brain. ”

The benefits of a broader approach to care, on the other hand, are evident. It is about turning the perspective upside down and seeing the presence of parents in the Tin not as a concession, but as a necessity: a real partnership, with parents becoming an active part of the care. “Clearly this is not immediately accessible, we need a foster path for intensive care parents,” Ancora stresses. “The first step, which is very powerful and also stimulates the production of breastfeeding, is the skin-to-skin contact with mother and father, which can also be done with premature babies with mechanical ventilation.”

It is the oldest practice in the world, known as Kangaroo mother care (KMC). “Making a kangaroo means putting the baby skin to skin on the mother’s breast,” says Ceccatelli. “There are incontrovertible scientific results: it has been understood that the kangaroo stabilizes the child, helping him to breathe and his heartbeat. It is a practice that was discovered almost by chance in Bogota, Colombia, where the lack of resources had to sharpen the ingenuity: it was observed that in this way the children get sick much less and also the mothers were calmer. the. Since then the Kangaroo has been exported worldwide with a document signed by authorized scientific societies. “

This approach is good for children, but also for parents, because it is clear that premature birth and separation from the child’s mother -with all that follows- are a trauma that not only the boy or girl suffers but also Parents .. Encouraging parental involvement in the care and development of their child ensures a better and calmer return home and therefore better mental health for all. “We’ve had serious news from mothers who didn’t get it, after this kind of trauma,” Orfeo recalls. “Needless to say, sending a healthy child home to an upset family is not a great success of care: we need to be able to send home a family that has somehow managed to restore the normal dynamic of affection that is it would occur if there had been a birth out. ”It is about healing wounds with patience and love, combining scientific progress with a sensitivity that is time to rediscover.

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