Ab Initio International | NBO: Medically Necessary

by Nancy Deacon D.O., F.A.A.P.,
Shore Touch Pediatrics, Toms River, New Jersey, USA

I had been practicing as a general pediatrician in a busy two-office practice for eight years, when I became trained to use the NBO. I was eager to incorporate the NBO into my newborn evaluation in the hospital but aware that it would mean a major change in my practice routine. The hospital where I was working had a large nursery where the routine had been in place for many years. The babies were gathered up from their mothers before the night shift went home at 7 am. The babies then remained in the nursery until they were evaluated by their nurse and pediatrician. They were then returned to their mothers, usually by 9:30- 10:00 am the next morning. As I was scheduled to be in my office by 9:30 am, seeing the babies with their mothers during my rounding hours would require a major change in the nurses’ routine. It was not unusual for me to have 10-12 babies to see in the hospital, and I was not sure I could manage that many bedside exams in the few hours I had available! I waited to use the NBO until there were just 3 babies on my list. It was such a good experience for me and the parents, that before long I was attempting to see all the babies with their mothers and often fathers as well. As you can imagine, the nurses considered it a major inconvenience, to get these babies assessed and ready for me to take out to the rooms. I persisted, however, because I found it to be the best and most efficient way to assess these babies, understand and address the parental concerns, and remember the encounters with them. I found myself unable to comfortably do it any other way. It was medically necessary for me to practice this way as the following vignette illustrates.

One Saturday, a 3-week old baby boy was brought by his parents to my office with the concern that he was no longer holding his right elbow in flexion. Instead, he was keeping his right arm straight by his side. He was otherwise fine, breastfeeding and sleeping well. When the parents had noticed this the night before, the on-call pediatrician told them that most likely the baby had  been doing this all along and had a fractured clavicle and/or Erb’s palsy from birth trauma, which had not been appreciated in the initial exams. “Dr. Deacon,” Mom said, “I know this is new because I remember you showing us how strong he was and how he flexed both arms after you straightened them when you examined him in the hospital with us.” I remembered it too because despite having to examine 11 other newborns that day, I had examined each one with their parents and incorporated the NBO in my physical exams. For first-time parents, this exam is particularly exciting, and because of the passion they display, more memorable for me. This baby’s parents had been so excited to watch how strong their baby was! As a pediatrician, I would like to think that I would never miss a physical finding such as a fractured clavicle or Erb’s Palsy, but examining 12 babies in a noisy, distracting nursery and recalling each one probably would have had me doubting myself. In this case, however, the parents and I were sure that this was a new finding. Further evaluation revealed a paraspinal tumor. While this is a rare occurrence, a newborn’s condition can often change in the few days from her discharge until she is seen in the office. I believe that it is our responsibility as pediatricians to send parents home knowing their babies as well as they possibly can so that changes in their baby’s condition can be recognized as soon as possible. I have found the NBO an effective tool for doing this.

NBO- Helping Mother and Baby Reconnect

I have found using the NBO with newborns and their parents to be a powerful opportunity to elicit the connection newborns have with their parents that began before birth. I remember one case in particular when I was able to use the NBO to help a mother and her baby reconnect. This baby boy was born with an unexpected cardiac defect and was transferred very soon after birth to a tertiary care hospital in order to undergo cardiac surgery. His father went with him but unfortunately his mother had to stay behind, recovering from her C-section. While she was in the hospital, I visited her each day and could see how difficult it was for her to not be with her baby at such a critical time in his life. I wondered how this was going to affect her relationship with her baby. Three weeks later, I found out. When I entered the exam room, Mom was sitting in a chair away from the exam table looking sad and was very quiet. Dad was holding the baby and proceeded to tell me how the baby was doing. My asked  Mom  what she thought of her baby, and she answered with a shrug of her shoulders. I said to Mom, “This is the first time I am seeing your baby. Why don’t we look at him together?” Dad eagerly pulled a chair beside the exam table and helped his wife sit down. I proceeded with the exam incorporating the NBO. The baby was a willing and able participant and turned to his mother’s voice on cue. “You know your Mom’s voice," I said. At that, her face softened and she reached out arms to hold him. The gaze mother and baby shared at that moment was intense as if they were drinking each other in. She then smiled and started speaking to him softly. The NBO had enabled me to help this Mom and her baby find their way back to each other.

The number of stories I could tell about how the NBO has enabled me to provide better support to the families of newborns is endless. Parents “know” their babies better. Together, parent and practitioner can see how connected the baby is to her parents, and parents are able to share their newfound expertise of their baby. This leads me to one last story. Just yesterday, a first-time mother shared with me that she had not slept well, thinking about how she was taking the baby home today. She felt very nervous about her ability to care for her baby. After first discussing what supports she had available at home, I then began my exam of her baby. As I went along, I found out from her what was working to soothe her baby. She told me how she was feeding her and what she had learned to minimize her spitting. She told me, and herself, just how much she had already learned about caring for her baby. By the time I finished, she looked visibly less anxious and said that she was ready to take her home! The NBO helps me support parental confidence.