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ADAPTATION OF BROTHERS AND SISTERS IN NEONATALOGY

Welcoming a new family member can be difficult for children who have to adapt to their new role as brother or sister. When a premature newborn is hospitalized in the neonatal intensive care unit (NICU), it becomes even more difficult for children and their parents. For most families, premature birth is an unexpected event and can be really stressful.

Hospitalization of a premature newborn in the NICU can cause emotional as well as behavioral changes in your children. Your children may be affected by the new situation or by your own reactions to the hospitalization. They can be greatly influenced by the changes caused by the premature newborn’s hospitalization in the NICU.

This website has been created to help you better understand how siblings adapt to their new role, but also to the stressful situation that is the hospitalization of the premature newborn in the NICU. You will find information and intervention tips to help you better support your children going through this situation.

This website has been developed by a nurse completing her Masters of Science in nursing at Université de Montreal in collaboration with the Montreal Jewish General Hospital.

Beavis, A. G. (2007). What about brothers and sisters? Helping siblings cope with a new baby brother or sister in the NICU. Infant , 3, 239-242.
 Bliss, (2014). Publications. Family Handbook, Retrieved from http://www.bliss.org.uk/Shop/bliss-family-handbook.
Rozdilsky, J. R. (2005). Enhancing sibling presence in pediatric ICU. Critical Care Nursing Clinics of North America , 17, 451-461.
Taylor, L. S. (2008). A rites of passage analysis of the families’ experience of premature birth. Journal of Neonatal Nursing , 14, 56-60.
Volling, B. L. (2012). Family transitions following the birth of a sibling: An empirical review of changes in the firstborn’s adjustment. Psychological Bulletin, 138, 497-528.

Changes your children may go through

The changes brought by the premature birth have a direct impact on your children, their feelings and their behaviors. Every child adjusts to new situations differently depending on, for example, past experiences, gender, age, family cohesion, and social support. As parents, you have to pay attention to the subtle changes that your children may show.

You may observe these changes in your children’s emotions:
  • Sadness
  • Anger
  • Guilt
  • Vulnerability
  • Despair
  • Loneliness
  • Feeling of abandonment
You may observe these changes in your children’s behaviors:
  • Tantrums
  • Guilt outburst
  • Childish behaviors
  • Wetting the bed
  • Thumb sucking
  • Needing a stuffed animal or a blanket
  • Difficulty sleeping or falling asleep
  • No appetite, does not want to eat
  • Lacking concentration in school
  • Spending less time with friends
For some children, having a premature brother or sister in the NICU may have positive impacts:
  • Help become more mature
  • Help their self-esteem
  • Develop their social competencies (i.e. : communication, making friends, outgoing, less shy)
  • Improve the way they interact
  • Develop ability to be compassionate
  • Help family cohesion

Remember that everything is not all black or white. Changes brothers and sisters go through are perceived and lived differently and represent how they adjust to the situation. It is essential that you pay attention, that you have a nonjudgmental approach, that you be patient, and that you reassure your children.

Beavis, A. G. (2007). What about brothers and sisters? Helping siblings cope with a new baby brother or sister in the NICU. Infant , 3, 239-242.
Camhi, C. (2005). Siblings of premature babies: Thinking about their experience. Infant Observation: International Journal of Infant Observation and Its Application , 8, 209-233.
 Despars, J., Jaunin, L., Monnier, M., Wannaz, M., Vernez, S. B., Tolsa, J.-F. et al. (2013). Un groupe d’accueil pour la fratrie lors d’une naissance à risque dans un service de néonatalogie. Devenir , 25, 233-243.
 Kramer, L. et Ramsburg, D., (2002). Advice to parents on welcoming a second child: a critical review. Family Relations51, 2-14.
 Volling, B. L. (2012). Family transitions following the birth of a sibling: An empirical review of changes in the firstborn’s adjustment. Psychological Bulletin , 138, 497-528.

Family systems nursing

When is a family assessment needed?
  • When a family is experiencing emotional, physical, or spiritual suffering or disruption caused by a family crisis
  • When a child is hospitalized
The genogram and the ecomap tells us:
  • who is in this family system
  • how the family system is affected, as a whole and individually
Factors that may hinder family systems approach: 
  • Family readiness
  • Nurse’s lack of knowledge about family systems approach and ability to translate into practice **or theory-practice gap: theory lacks relevance to practice
  • Lack of time, unit’s routine, restrictions on family visiting and care
Five important therapeutic questions
  1. What are you most concerned about today?
  2. Who, in your family, is reacting the most to the preterm birth of your newborn and the hospitalization? How?
  3. What has challenged you the most since the beginning of the hospitalization of your newborn?
  4. If you were asking your child what worries him the most, what do you think he would respond?
  5. When your child has regressive or unusual behaviours, what do you say/ do/ feel?

Getting to know the NICU

The NICU environment can be quite stressful for anybody the first time they walk into it. As parents, it is important that you prepare your children for the NICU environment. Health care professionals are there to guide you and to answer your questions. It is important to answer your children’s questions and to talk about the visit with your children once you get back home. Insist on the fact that the visit was a moment for brothers and sisters and that you spend time with them.

The NICU is a noisy place

There can be a lot of noises. There are many babies requiring special care.

There are often alarms ringing to inform nurses, respiratory therapists, and doctors that a baby requires attention. Often, many monitors ring at the same time, which increases the amount of noise. Health care professionals are trained to recognize each alarm. If you listen to the noises at the bottom of the page, you will be able to hear the difference. You can listen to them with your children to them to prepare them for their visit to the NICU.

There are many new smells

You and your children will be exposed to new smells that are often strong. For example, the smell of the hand sanitizer, of the alcohol swabs or the strong smells of the cleaning products could be disturbing. You can warn your children that there will be new and strong smells during their visit to the NICU.

Members of the team your children could meet in the NICU

Many professionals are part of the medical team taking care of your newborn. The number of people present in the NICU will vary according to the time of the day and the day of the week. Seeing many strangers could be distressing for your children. Professionals usually introduce themselves when they meet families. You can always ask them their name and what their role is.

Here is a list of the professionals that could be present in the NICU :

  • Nurses
  • Neonatologists
  • Respiratory therapists
  • Pharmacists
  • Nutritionists/dieticians
  • Radiology technicians
  • Social workers
  • Medical residents
Beavis, A. G. (2007). What about brothers and sisters? Helping siblings cope with a new baby brother or sister in the NICU. Infant , 3, 239-242.
Latva, R., Lehtonen, L. et Tamminen , T. (2006). Visits by the family to the neonatal intensive care unit. Acta Paediatrica , 96, 215-220.
Levick, J., Quinn, M., Holder, A., Nyberg, A., Beaumont, E. et Munch, S. (2010). Support for siblings of NICU patients: An interdisciplinary approach. Social Work in Health Care , 49, 919-933.

How you can help your children adapt

Here are a few intervention tips you may find helpful in supporting your children in their adaptation to the hospitalization of your premature newborn in the NICU :

Encourage your children to share their feelings

Some children may react to hospitalization of the newborn according to your own reactions and those of others surrounding them. Every child is unique. Talk about the situation with them. Ask them what they know and understand about the situation.

Be honest with your children

Your children need to know and understand the newborn’s hospitalization to make sure they don’t create false explanations for the situation.

Talk with your children

No matter how old they are, talk about the situation with your children. Give them clear explanations regarding why the newborn is not home. Ask them what they have understood from your explanations. If it is difficult for you to find the right words, you may ask one of the health care professionals to help you.

Reassure your children that they are not responsible for the premature birth and the hospitalization.

Sometimes, younger children might think their whishes or ideas have caused everything to happen. Communicating with your children will prevent them from feeling guilty.

Be aware of the changes in your children’s behaviors

Children might have unusual behaviors like tantrums or have difficulty concentring in school. They may have childish behaviors such as wetting their bed or needing help for actions they were able to accomplish before. They may be more solitary and stay away from their usual group of friends. On the contrary, they may also want to spend all their time with their friends.

Share the situation with your children’s day care educators and teachers to make them aware of what is going on so they can understand any changes that may occur in your children’s behaviors.

Try to preserve the family routine as much as possible

Keeping a routine makes your children feel safe. When you have to leave the house, ask people your children trust and know well to take care of them. Also, when you know you will be absent, tell your children when, where, and for how long you will be gone in order to prepare them. Tell them in advance who will babysit them. Make sure to dedicate time to spend with your children for them to feel they still hold a place in the family and that you love them.

Introduce your children to the new member of the family. Visit the NICU with them

Visiting their sibling in the NICU may help your children in becoming a big brother or big sister. It will promote attachment and bonding between your children and your newborn. In a way, your children will know their place in the family is still there and the newborn is now a new member.

Bringing your children to visit the newborn in the NICU is a way to involve them during the hospitalization. Before bringing them, you can evaluate their wish to visit the newborn by asking them :

  • Do you want to visit (name of the newborn) today?
  • How are you feeling about going to visit (name of the newborn) today?
  • Do you feel scared, happy, angry (suggest feelings) about going to visit (name of the newborn)?

However, if your children are not ready yet, do not force them. It is important to find other ways to include them in the hospitalization of your newborn in the NICU.

Here are a few suggestions that may help your children feel more involved and prepare them for a future visit:

  • Take pictures and videos of your newborn
  • Show them how small the newborn is compared to your hand or a toy 
  • Ask your children to draw a picture or write a message that will be hung at the newborn’s bedside

As soon as your children are ready to go to the NICU, speak with the health care team to choose the best time for their first visit.

Save time for each of your children

Your children need attention from you. Create ‘special moments’ for you and your children to share. Take this opportunity to do activities you were usually doing before the hospitalization of the newborn.

These intervention tips serve as a guide to help you attend to your children’s unique needs. If you feel the situation is overwhelming and that your family might need more support, do not hesitate to consult professional resources in the NICU. They will be able to help you or to refer you to other resources. You may want to consult the page Available resources for you.

Bliss, (2011). Publications. Family Handbook, Retrieved from http://www.bliss.org.uk/Shop/bliss-family-handbook.
Kramer, L. et Ramsburg, D., (2002). Advice to parents on welcoming a second child: a critical review. Family Relations51, 2-14.
Montgomery, L. A., Kleiber, C., Nicholson, A. et Craft-Rosenberg, M. (1997). A research-based sibling visitation program for the neonatal ICU. Critical Care Nurse , 17, 29-40.
Munch, S. et Levick, J. (2001). “I’m special too”: Promoting sibling adjustment in the neonatal intensive care unit. Health et Social Work , 26, 58-64.
Rozdilsky, J. R. (2005). Enhancing sibling presence in pediatric ICU. Critical Care Nursing Clinics of North America , 17, 451-461.
Sibling support project (2013). What siblings would like parents and service providers to know. Retrieved from http://www.siblingsupport.org/publications/what-siblings-would-like-parents-and-service-providers-to-know

Your children’s needs

Your children’s needs can be divided into three categories : the need for attention, the need for communication and the need for social support.

 The need for attention

Family relationships may change with the hospitalization of your premature newborn. Your multiple absences may have a great impact on your children. They need to spend time with you. No matter how long, time spent with you is special to them. Therefore, it is important to plan time alone with your children for them to feel that they are still part of the family.

The need for communication

Children have a need to communicate; they need to receive information, but also to share their feelings and how they are experiencing the situation. You may think that your children do not need to be informed or to talk about the hospitalization of your newborn. You may also be scared that the truth about the situation will have a negative impact on the other children in your family. In fact, your children need to be informed of what happens Information that you and health care professionals share with your children will help them adapt.

The need for social support

During the hospitalization of your newborn in the NICU, parents are preoccupied and often away from home. Even when you are at home, you may be distracted and stressed out. Your children may feel a temporary loss of their parents. Despite your preoccupations, try to keep the family routine. It is important to include other family members that your children are close to (grand-parents, aunts, uncles, close friends) when possible. When there is a good social support system, children seem to develop less behavioural difficulties.

Alderfer, M. A., Long, K. A., Lown, A. E., Marsland, A. L., Ostrwoski, N. L., Hock, J. M. et al. (2010). Psychosocial adjustment of siblings of children with cancer: a systematic review. Psycho-Oncology , 19, 789-805.

Beavis, A. G. (2007). What about brothers and sisters? Helping siblings cope with a new baby brother or sister in the NICU. Infant , 3, 239-242.

Camhi, C. (2005). Siblings of premature babies: Thinking about their experience. Infant Observation: International Journal of Infant Observation and Its Application , 8, 209-233.

Kilmer, R. P., Cook, J. R., Munsell, E. P. et Salvador, S. K. (2010). Factors associated with positive adjusmtent in siblings of children with severe emotional disturbance: Role of family resources and community life. American Journal of Orthopsychiatry , 80, 473-481.

Malone, A. et Price, J. (2012). The significant effects of childhood cancer on siblings. Cancer Nursing Practice , 11, 26-31.

Credits 

Original idea and development: Phoukim Savanh, RN, B.ScN, M.Sc

Director of Master: Marilyn Aita, RN, PhD, Nursing faculty, Université de Montréal

Co-director of Master: Marjolaine Héon, RN, PhD,  Nursing faculty, Université de Montréal

Clinical resource person: Lyne Charbonneau, RN, M.Sc, Head nurse, Neonatal intensive care unit, Jewish General Hospital

Readibility: Francesca Frati, Medical Librarian, Jewish General Hospital

Multimedia: Fabrice Baro, Team leader of the Jewish General Hospital Web and Multimedia team

Copyright © 2015 Phoukim Savanh