Find out more about this survey published on the Cercle Psy website.

Over the past fifteen years, neonatal units have made enormous strides in limiting the stress experienced by babies born prematurely. However, they cannot match the living and development conditions of the intrauterine environment.

« The noise from the machine that helped Melina breathe was very loud, a bit like a washing machine in spin mode! We put a kind of construction helmet over her ears to limit the discomfort. And then, every three hours, she needed to be cared for: eyewash, feeding, blood pressure check, diaper change… This sensory hyperstimulation, although compulsory, was stressful. But in the end, what bothered us most was the voice of some of the nurses during care, at decibels far too high for this little baby! » recalls Aline, mother of Mélina, a little girl born in a Paris hospital at 26 weeks’ gestation, weighing 640 grams and measuring 32 centimetres. Like Mélina, children classified as « very premature » (born between 26 and 30 weeks of pregnancy[i]) are unfortunately exposed to multiple stress factors during their first weeks of life. Their little bodies, barely out of their mothers’ wombs, are subjected daily to painful and invasive care procedures for which they are unprepared. The sensory environment is aggressive: machines rumble and beep, lights dazzle and flash, voices carry, metal materials clash. The noise, which causes the child to jump, flinch or extend his or her limbs in response, is a major source of energy.

Early-life stress has a long-term impact on the individual

Over the last ten years or so, scientific research has highlighted the likelihood of early exposure to stress having an impact on long-term psychological development[1]. To better understand this mechanism, we need to take a detour into the fibers of a baby’s brain. Faced with stress, the hypothalamus begins to secrete the stress hormone cortisol. From as early as 30 weeks of pregnancy, this hormonal response to stress is functional, which means that the majority of premature babies secrete as much cortisol as an older child. While this cortisol secretion is useful for mobilizing energy episodically, it becomes toxic to the brains of these babies when secreted in high doses. These large cortisol discharges can alter certain structures in their tiny brains and the body’s neurobiological responses to stress. Numerous studies have highlighted the correlation between maternal stress, cortisol levels in children and their psychological development trajectories. We now know that early sensory experience influences neuronal organization, modulating the child’s brain. While some neurons mature autonomously, others need to be stimulated. Based on electroencephalogram (EEG) measurements, it was found that babies who had more physical activity in the first few hours of life showed better brain growth. Similarly, babies who grow up in a mechanical environment tend to develop less well than babies who grow up in a human environment with adults. So much so that, in the long term, for multifactorial reasons, we can observe emotional and cognitive disorders in children born very prematurely, as well as problems with attention, memory and learning during childhood and adolescence. And yet… Until the 1970s, teams operated on newborns and babies without anesthesia. Given the estimated low level of « consciousness » and feeling of these little patients, this procedure was considered superfluous…

Play music, dim lights

Over the past thirty years, a 180-degree shift has taken place. Research into the emotions of premature babies has given rise to a common desire among neonatal units: to limit the stress and pain of these featherweight babies and increase their well-being. To get as close as possible to intra-uterine living conditions by reconstituting a kind of cocoon. The rumble of machines (which tends to increase the heart rate) is reduced in favor of music and the mother’s voice, which is particularly relaxing. We try to limit painful treatments, bright lights, sudden loud noises and excessive temperature variations. A circadian day-night cycle can be created, while all care tends to be grouped together at the same time. « Mélina’s needs were a priority. One of the nurses drew up a chart with the ‘likes’ (having my foot stroked, the smell of Mum…) and the ‘dislikes’ (noise, being spoken to too loudly…) » recalls Aline. In 1996[2], Lynda Harrisson, a nursing researcher at the University of Alabama at Birmingham, developed Gentle Human Touch. This soothing technique involves placing one hand on the child’s head and the other on one of its limbs, for several minutes. The child can also be offered light massages, caresses and non-nutritive sucking. In the 1980s, Colombia developed the famous « kangaroo method », which has helped many developing countries to increase the chances of survival for very premature babies. The technique consists in reproducing, in human babies, the type of ectopic growth observed in kangaroo babies. The baby is placed on its mother’s stomach, head up, skin to skin. This method is full of benefits: it provides the child with heat-regulating properties similar to those of an incubator, reduces the pain induced by caregiving and crying, improves the closeness and relationship between parents and baby, and is more inclusive of the father (since he too can take over from the mother and practice skin-to-skin with his child). While all neonatal units are working towards this goal, not all have the same commitment or the same resources. Helping caregivers to change their practices is a difficult task requiring regular training, effective management, evaluation and questioning. Often, actions taken over a period of time have only temporary effects.

Excellent NIDCAP certification

Some teams go one step further and aim for the excellent NIDCAP[3] certification(Newborn Individualized Developmental Care and AssessmentProgram ). Behind this acronym lies a series of rigorous developmental care strategies to be applied as early as possible, in an individualized manner centered on the child and his or her family. The baby is seen as a player in his or her own right. The service is organized around the baby and his or her family. All care needs to be revisited and transformed. The baby’s entire environment is called into question: noise, light, sleeping arrangements, care, hygiene and feeding. It may be advisable, for example, to use a water mattress for babies of very low weight, to keep the child at a distance from exchanges between caregivers, especially during changeover time, to handle cupboard doors and dustbins meticulously during cleaning to avoid metallic impact noises, position a scented comforter close to the child’s face as soon as the central line is removed, and warm all materials that come into contact with the child’s skin, such as thermometers, liniment, physiological saline, etc. One of NIDCAP’s major assets is that it is based on scientific evidence. Its benefits have been measured time and again. In 2014, a meta-analysis of clinical trials conducted at the Centre Hospitalier Universitaire de Caen[4] confirmed the benefits of NIDCAP on the development of premature infants in the first 24 months of life. It has also been found that this developmental care reduces children’s length of stay. In 2012, research conducted in Boston[5] confirmed the positive impact of NIDCAP on the brain development of children with intrauterine growth retardation, born between 27 and 33 weeks. Research from 2013[6] underlines that allowing parents to sleep on the ward and participate in their baby’s care encourages their prolonged presence. As parents are perceived in NIDCAP as natural co-regulators for their child, it is important to encourage them to stay with their baby. The aim of the NIDCAP International Federation (NFI), an international non-profit organization, is to support the development of this practice in hospitals worldwide. Currently, NIDCAP training is provided by 19 centers, nine of which are located in the USA, nine in Europe and one in South America. However, as both the level of requirements and the costs involved are high, NIDCAP certification is not easily accessible to all teams wishing to do so.

The end of the stay on the ward marks the beginning of a delicate adventure, that of returning home. Parents leave the hospital cocoon to find themselves alone, in the privacy of their own home, in the presence of a vulnerable little being they have only just tamed. Not all units accompany families as they take their first steps in the home. Aline tells us that, in the unit where her daughter was cared for, a monthly meeting was organized to raise parents’ awareness of how to care for a baby born prematurely.  » A good initiative that enabled us to take care of her without overprotecting her, » she says. But these meetings don’t seem to be enough. Aline confides to us that she and her partner felt like they had been « left to their own devices ». « Between the joy and anxiety of returning home, we had no follow-up at home. I would have liked to have had a midwife the first week to reassure me. I told myself that we had to trust each other and that we had to trust ourselves. Aline continues:  » The hospital environment gave us a certain level of comfort, we were focused, the scopes reflected our daughter’s emotions… ».

This concern for the quality of developmental care provided to premature babies is linked to major ethical questions. How far should we push back the frontiers of viability? Should we increase morphine prescriptions to relieve babies, despite the possible negative impact of this analgesic on the body? Should we keep babies alive at all costs, even if they are expected to suffer serious developmental sequelae?

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Parents stunned and distraught

At the baby’s side, parents are often overwhelmed and devastated. The too-early birth of their child puts an abrupt end to a large number of daydreams. They are forced to mourn the loss of a rewarding, ideal baby. Some parents haven’t had time to make the final preparations for their child’s arrival. The room isn’t ready, and the first bodysuits haven’t always been bought. They haven’t received the flowers, gifts, cheerful visits and congratulations they’d imagined. This baby, which we don’t want people to know about, is sometimes associated with shame, leaving parents feeling ambivalent and painfully guilty. What to say to family and friends who want to meet the child? To whom should the rest of the siblings be entrusted? How should day-to-day life be organized? Should I reduce my working hours to spend more time with my child?

The heart is not in creating an announcement. Their anxious preoccupations revolve mainly around organizational constraints, their baby’s somatic condition and, sometimes, even his or her survival. In this highly medicalized and mechanical environment, parents may find it difficult to find their place as parents, and to adjust and interact with their baby. The first meeting may be marked by a certain ambivalence, far from what they had imagined during pregnancy: « 48 hours after giving birth, I’m still in recovery, my condition stabilizing. Between perfusions, oxygen goggles and a urinary catheter, I’m invited to meet Mélina in her wheelchair, accompanied by Ludovic. That’s it, I’m in her room: a dark room with an incubator at the back. I lift the sheet on top. When I see her, I collapse with both joy and sadness. After informing me of my daughter’s condition, the nursery nurse leaves the three of us. I couldn’t hold her, but I could at least put my hand on her… ». says Aline. The psychological state of the parents of premature babies can in itself require support. It is not uncommon for mothers to suffer from psychological disorders. Depression is estimated at 35%, and anxiety at 75%. 35% of mothers suffer from Post-Traumatic Stress Disorder (PTSD), with nightmares, parasitic thoughts, hypervigilance, startle reactions and flashbacks. All these psychic problems are part of a human context with irregular support. This is because many of the professionals who work with children are not trained in empathy and family relations (although they are excellent technicians in their own right).

Aline testifies: « On July 10, my prognosis was life-threatening. I was told I had to have an emergency Caesarean section under general anaesthetic. I was surrounded by resuscitators, pediatricians and an obstetrician who told me that it would be right away. Up until then, I’d remained strong. But now I’m cracking up. I refuse because it’s too early, I cry, I scream, but nobody channels me. I’m alone in front of all these professionals focused on my clinical condition ». To complement the quality of care provided to children, family support is essential. All too often, the psychological takes a back seat to the physiological, the urgent and the vital.

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Here’s an account[7] of the birth of a baby born (most probably) prematurely, on February 26, 1802. You know this baby, who became one of the greatest legends of French literature. His name was Victor Hugo.

« Then in Besançon, an old Spanish town,
Thrown like seed to the whim of the flying air,
Born of Breton and Lorraine blood at once
A child without color, without look and without voice;
So debilitated as he was, like a chimera,
Abandoned by all, except his mother,
And that his neck bent like a frail reed
Made his beer and his cradle at the same time.
This child whom life erased from its book,
And who didn’t even have a tomorrow to live,
That’s me. »

[1] Habersaat, S. and Borghini, A. (2010). Study of perinatal stress on the development of premature infants: biological, psychological factors and management programs. Enfances et Psy. Vol 4, n°49, 130-137. DOI : 10.3917/ep.049.0130

[2] Harrisson, L. and al. (1996). Effects of gentle human touch on preterm infants: pilot study results. Neonatal Netw. 15(2):35-42.

[3] The NIDCAP France association offers explanations and documentation for professionals http://www.nidcapfrance.fr/

[4] Fazilleau, L. and al. (2014). NIDCAP in preterm infants and the neurodevelopmental effect in the first 2 years. Archives of Disease in Childhood. Fetal and Neonatal Edition. doi: 10.1136/archdischild-2012-303508.

[5] Als, H. (2012). NIDCAP improves brain function and structure in preterm infants with severe intrauterine growth restriction. Journal of Perinatology. 32(10), 797-803. doi: 10.1038/jp.2011.201.

[6] Heinemann, AB. (2013). Factors affecting parents’ presence with their extremely preterm infants in a neonatal intensive care room. Acta Paediatrica. 102(7), 695-702. doi: 10.1111/apa.12267.

[7] Excerpt from « This century was two years old ».

[i] A full-term birth occurs between the ^35th and ^39th week of pregnancy.