11 minute read
Understanding newborn behavior
Explore how Newborn Behavior Observation nurtures early relationships by helping parents learn to appreciate what babies have to tell them.
When Theresa Shanahan, MD, tries to explain the Newborn Behavior Observation system, or NBO for short, she likes to give an example of doing a routine exam on the Mother-Baby Unit.
As a pediatric hospitalist at Newton-Wellesley, she’s done it thousands of times over.
For newborns, it’s a brand-new thing. They’re on high alert. As she talks through the exam with the parents, saying what she’s checking and why, babies likely are crying. “But if dad or mom says something, baby stops and turns to find their voice,” she says.
“They’re reassured that even in this whole new situation that familiar voice is with them and has them safe,” she explains. “If I simply point that out to parents while it’s happening, boy, do they feel empowered.”
Often the dad comes over and puts his hand on the baby and speaks a few comforting words. “You can feel the baby’s heart rate calming down and the baby’s muscles relax,” she notes. “So there’s real power there.”
“The birth of the relationship”
Growing evidence shows the first 100 to 1,000 days of life have a profound impact on how a child goes on to develop emotionally, socially, and cognitively. In 2021 the American Academy of Pediatrics issued a new policy emphasizing the need to focus on safe, nurturing early relationships.
Some people call the first 100 days of a baby’s life the “fourth trimester,” Dr. Shanahan notes. To her, “it’s the birth of the relationship.”
“The NBO is a tool to help us support early relational health,” she explains. “It’s not just a theoretical idea. It’s concrete. And it’s super easy to teach to the parents,” she adds. “It’s also very individualized and applies across cultures, and it empowers both the staff and the parents.”
In simple terms, she describes it as a series of shared observations helping parents understand how the baby uses their behavior to communicate their individual preferences, strengths, and vulnerability—how they protect sleep or respond when awake, what settles them when they cry, and so much more.
The NBO encourages parents to be curious about the baby’s signals and learn what their baby may be feeling and need. The parents’ touch and attention provide great comfort in a newborn’s world. These interactive responses give both the parents and the newborn security now and in the future.
Bringing the NBO to Newton-Wellesley
Dr. Shanahan first trained in the NBO system in a special workshop on neurobehavioral observations designed for use from birth to three months at the Brazelton Institute. Based at Boston Children’s Hospital, the Institute builds on the legacy of T. Berry Brazelton, MD, whose insights on parenting and child development revolutionized infant care. The NBO was first developed at the Institute in 2001. Since then, both interest in the approach and the evidence of its effectiveness have continued to grow with now a dozen affiliated training sites worldwide.
“I came back completely transformed,” she says, “and I integrated the skills and tools I learned going forward in every interaction I have with a family.”
Two years ago, she approached hospital leaders about bringing NBO to a wider team at Newton-Wellesley. “I thought we could do a better job caring for our families and supporting them if more people had this training,” she says. With their support, she reached out to Lise Johnson, MD, director of the Brazelton Institute and newborn hospitalist at Brigham and Women’s Hospital. “They train people around the world, and I invited them come across the city and do a multidisciplinary training here,” she says.
Success of initial training
To introduce the idea, Dr. Johnson spoke to hospital providers about early relational health and the role of the NBO. “To this day it’s the highest attended grand rounds ever in pediatrics,” Dr. Shanahan notes.
Two workshops followed in 2024, drawing 62 staff and community members from multiple disciplines. While together the participants had 2,000 years of combined experience in working with infants and families, surveys before and after captured how new the framework was.
The NBO’s multidisciplinary nature is part of its power. From the start, everyone from OBGYNs to child psychologists, nurses to social workers took part in training. Bringing staff together nurtured collaborative bonding and expanded their shared sense of team.
Philanthropy played a key role making it happen. Inspired by the potential impact on both providers and families, the Maternity Services Council and The Resilience Project of NWH’s Community Collaborative helped to fund the training.
“I can’t think of another program where it can work so well across settings,” Dr. Shanahan adds. “Once you have the basic tools and language, you just apply it to what you’re already doing, and that’s the beauty of it.”
A shared language
Rachel Carpenter, OT, sees the Special Care Nursery as where she’s meant to be. “I’m one of those people whose dream in life was to become a mom,” she says. While her own kids are now in college and beyond, “I have such a fulfilling job in that I still get to be with babies every day while supporting their families.”
Since being trained in the NBO, the certified neonatal therapist has become one of its champions. Together with neonatologist Francheyska Silfa Mazara, MD, she’s working to train all staff on their unit so they share a basic understanding of its tools.
To Rachel, “when I’m working with families, they’re just as much of my patient as the baby is.” Being in the SCN can be stressful time, and she knows how critical it is to support them emotionally and facilitate bonding.
While babies’ medical needs may be front of mind for parents, she finds the NBO helps them see their infants’ strengths. “They’re more able to appreciate their baby as a whole little person and enjoy these early precious moments,” she senses.
She shares an example from the day before, working with a nurse who’s passionate about her own growing NBO skills. As a mom was holding her baby on her chest, the nurse pointed out how strong he was and how intently he was looking at her.
When it comes to early relational health, “the more we’re all talking about it, using the same language, it brings the significance of the bonding relationship into focus,” Rachel adds. “It’s important to take every moment we can to support that bond,” she adds. “So I love it when I see us all using that lens.”
“Your baby’s talking to you”
When Dr. Mazara uses the NBO with parents, she’ll focus on what they’ve come to know about their baby. “I’ll ask them to tell me, when do you think that your baby is happiest? Or what are things that make your baby comfortable?” As they talk together, the baby becomes their focus.
At end of the NBO, “parents know that they’re their baby’s experts, and they know what to do,” she says. “And they know that they have the biggest tool, which is the love that they have for their baby.”
She wants parents to see this as a natural process: your baby is talking to you and you’re listening, and you’re talking to your baby and your baby is listening.
Reflecting on the team’s aim for cultural sensitivity, Dr. Mazara recounts having the privilege to administer the NBO with a family in Spanish. “The power of providing this therapy in the family’s first language was incredible,” she says.
The NBO doesn’t apply only to parents, she adds. She’s seen how it opens the eyes of grandparents and others in the parents’ support system.
“We have all of these intrinsic abilities and the NBO allows you to recognize them,” Dr. Mazara explains. “It’s just observing your baby and picking up on the baby’s and your own cues of how you’re doing to relate with each other. And that’s the beautiful part.”
Scaling opportunities for training
When Marissa Troy, RN, took part in the initial NBO training at NWH, “I immediately saw the value of bringing the principles to our unit,” says the postpartum nurse educator.
Now, as part of a collaborative team of educators, she leads NBO skill stations for nurses across Maternity Services: "Even those who haven't done a full systematic training are learning to apply it," she notes.
“I think anyone that has experienced it on any level sees how amazing a tool it can be,” she adds. “My goal is to get it to more of our staff.”
Dr. Shanahan echoes her point. She sees so many possibilities for expanding training opportunities in a way that’s streamlined and scalable. “We’d like any family, wherever they’re encountered in the system to have this type of informed care— from prenatal visits through their pediatricians’ offices.”
The Brazelton Institute sees in NWH’s success a potential model, she notes, and they continue to partner with the hospital team in exploring ways to widen the reach of NBO.
Knowing your newborn
Dr. Shanahan spends much of her day in the newborn nursery, taking care of families before they head home. For 25 years, she’s has been there for babies and parents. The hospital has also been there for her, not only as her professional home but also as the place where she gave birth to her own children.
When she reflects on the future of Newborn Behavior Observation, she imagines its profound impact on the triad of baby, parents, and provider.
For parents and providers alike, the more they experience it, the more it simply makes sense. Across the community, “we have such a huge educational opportunity,” she believes. “People just need to know about it.”
“Every single time I do this with a family, you actually see a connection they’re making with their baby,” she reflects. “The light bulb goes on and they wonder, how come we didn’t know about this?”
As a case in point, she recounts its impact on a family who just had their fifth baby. She integrated the principles of NBO into their admission and care, as she now does with every family. “And at the end the mom said, ‘You know, this is our fifth baby, and I don’t think I knew who a newborn was until today.’”
"Exactly what our little family needed"
Everyone struggles at times with the initial adjustment to parenthood. “This little amazing creature in front of you dictates your life and it’s beautiful in a lot of ways,” reflects Marissa Troy, RN, “but it’s also a huge adjustment.”
While working with colleagues on bringing NBO principles to NWH, she was expecting her own first baby. She gladly took Lise Johnson, MD, up on her offer to do an NBO with the family.
When the director of the Brazelton Institute visited her, her husband, and baby Oliver, Marissa vividly remembers how observant and thoughtful Dr. Johnson was. “She kept commenting on all these things about Oliver, like, ‘oh, he’s remarkably calm and look how alert he is and how curious he is about the world. Look at how he looks at you.’”
She showed them how well he responded to faces, voices, and toys. “And Oliver, he’s a very physical kid. He still is. And she’d say, look at that head control, look how strong he is.”
“She would find that any baby will have amazing attributes,” Marissa explains. “The whole point is finding those and highlighting them.”
From Marissa’s perspective, she did a great job validating and reassuring her husband. Understanding his tentativeness, she noted how everyone becomes a parent in their own way. She observed how he held Oliver gently, how he looked into his eyes, how he smiled when looking at him.
In her own practice, Marissa always loves pointing out the impact of even a parent’s smallest actions. “It’s amazing how just from holding your baby, they relax. And they feel so much safer. You’re their safe place. And how amazing is it that babies already know that? And they’re only 24 hours old.”
“That’s part of the power of the NBO,” says Marissa. “It helps the family come together and helps the parents see the amazing qualities in their baby. It was exactly what our little family needed.”
