Pregnancy and Infant Loss Risk Factors and Treatment Issues

Foreign. I'd like to welcome everybody to today's presentation on pregnancy and infant loss, risk factors and treatment issues. This is actually Pregnancy and Infant Loss Awareness Month. So you know now you know where the inspiration for this presentation came from. Over the next hour, we're going to identify risk and protective factors for prematurity, miscarriage and stillbirth, as well as sudden infant death syndrome and explore treatment issues for the family. Miscarriages occur before 20 weeks. The prevalence of miscarriages is 10 to 25% of pregnancies or more. That's only the pregnancies that we know about. Obviously there's a lot of people on who may get pregnant and not realize they're pregnant and the pregnancy terminates before they even realize it. So just of the pregnancies we know up to 1/4 of them end in miscarriage. It's really important to know when we're working with clients who've experienced a miscarriage so we can help destigmatize, help normalize what's going on. We're not going to take away their pain. But when we get down to the mental health issues, there's often a lot of self blame when it comes to miscarriages. So helping people recognize that this happens. About 20% of those miscarriages happen in the first trial trimester and the other 1 to 5% of those miscarriages happen in THE second trimester. Once you get past, and if you've, I don't know, for about 20 years that's been known because I remember my OB telling me that when I was pregnant with my son, the first trimester is the riskiest time for miscarriage. But you know, 5% of miscarriages will still happen later in the pregnancy. Stillbirths are births or problems when the baby dies after 20 weeks. So up until 20 weeks before the fetus is considered viable is considered a miscarriage at 20 weeks. The fetus is theoretically considered viable at this point in time. So if the Fetus dies at 20 weeks or later, it's considered a still stillbirth. In developed countries, about 24,000 people every year experience a stillbirth. Okay, that's, that's a lot of people. It's not as uncommon as we would like to think. That's about one in every 100 births. Think about a busy labor and delivery floor. How many babies they deliver in a given week? Probably more than a hundred. Which means in any given week they probably have at least one stillbirth on that floor. You know, that's, let's, put it into perspective of how frequently this actually happens in less developed areas. You know, other countries, the stillbirth rate can be three out of every hundred or even higher. Why do we need to know the risk factors? We're mental health clinicians. Well, we need to know the risk factors because if we're going to help families, if we're going to help parents make sense of this, understand this, deal with their grief, we have to know, you know, potentially what caused it. And, and a lot of times there is no particular answer for any one woman. There isn't. It's really hard to draw causation and say this is exactly what caused the miscarriage, the stillbirth, the prematurity. There's a lot of guesswork. We know that there are significant correlations. Now remember, correlation doesn't mean causation. So not every person, for example, with uncontrolled diabetes is going to have a miscarriage. But we know that there is a strong correlation between, between uncontrolled diabetes, which is often, especially if it's coupled with obesity and miscarriages. One of the reasons they speculate for this is because the stress of the pregnancy on the body is perceived by the body as excessive. And in order to protect the, the host, the, the parent, the, the pregnancy is terminated, the miscarriage happens. So once they get the diabetes under control, and if they're able to control it throughout the pregnancy, then the body doesn't perceive it as a, a threat to itself. Imbalances in estrogen and progesterone. We know that there are significant mood issues associated with imbalances in the sex hormones, but imbalances in estrogen and progesterone can actually cause the, the uterus to not be able to sustain the pregnancy pose. Polycystic ovarian syndrome is one of those conditions that some women have that does cause a significant imbalance in the estrogen and progesterone ratio. Many people, if not most people with pcos have difficulty getting pregnant and maintaining pregnancy disease. Thyroid disease and autoimmune issues are also associated with miscarriage and stillbirth. Think how common these things are. I believe it's up to 12% of the population has thyroid imbalances and autoimmune issues. You know, when you start thinking fibromyalgia and Crohn's disease and, and those sorts of things, you know, a significant portion of the population has autoimmune issues and unfortunately they seem to women more than men. Why do our autoimmune issues a risk for miscarriage well, think about it. When you have a fetus that may be perceived by an overactive immune system as something that's not supposed to be there as a foreign invader. So the autoimmune issues may attack the, the pregnancy. Other hypotheses are that the stress of being pregnant, we know that stress increases the intensity of autoimmune issues. The stress of the pregnancy may cause a flare up of the autoimmune conditions where the body starts attacking itself. And as a result the body says I can't deal. Just like with uncontrolled diabetes, the body says I can't deal with this extra stressor, so it terminates the pregnancy. These are just hypotheses. You know, obviously we don't know exactly why it happens, but it is interesting to explore and also to recognize how many women or how many parents are at risk of developing complications or, or have risk factors for miscarriage. Which helps us understand why the rate of miscarriage is as high as 25%. Heart disease and hypertension goes along with the uncontrolled diabetes and the autoimmune issues. These are all situations in which the body system is not functioning optimally and it is already under stress. And the stress of the pregnancy may be more than the body can handle. STDs like chlamydia, gonorrhea and syphilis are associated with premature labor as well as miscarriage. Bacterial vaginosis, and I want to spend some time talking about this because some people mis classify bacterial vaginosis as an std. Now it can be, it can result from sex because bacterial vaginosis is the result. What results when the bacteria in the vagina becomes imbalanced. There's not enough lactobacilli type bacteria down there, so everything is sort of out of whack and it's not able to protect itself like it normally does. And this can happen for a variety of reasons. It's not just from sex. It can be just from the hormonal changes that result from pregnancy. It can be from working out too much and you know, starting to get some other sorts of infections. There are a lot of reasons, but bacterial vaginosis is strongly correlated with premature delivery with, with, with prematurity. So doctors often, well, doctors screen. The OBGYN is screening for you for bacterial vaginosis at every checkup, which is why prenatal care is so important, because you may not notice that you've got this going on. The doctor can tell when he or she does the, does the exam when you Go in for your monthly checkups or whatever it is. And if they think there's something wrong, they can do a slide. They can look, they can diagnose it, and they can give you medication for it. It is treatable. Not easily treatable, but it is treatable. But, you know, as I said, it is one of the most common correlations with premature delivery. Measles is, interestingly, it was kind of just thrown in there into the list of risk factors. Measles can cause miscarriage. Caffeine excess. When we drink too much caffeine, we put that HPA axis on, you know, overdrive, which, remember, HPA axis is our threat response system. So our body's perceiving a threat now, overdoing it on caffeine one day probably won't have. Won't cause a miscarriage. But people who are living on caffeine are at much greater risk of having a miscarriage. A weakened cervix is important to be aware of. And a lot of times the weakened cervix results from some sort of surgery that may have happened. They don't always know what causes it. But this is another one of those factors that has some relatively easy fixes to it. They figured out how to deal with incompetent cervixes for. To prevent prematurity. But if it's not caught in time, then it can cause, obviously, it can cause premature delivery. Even before the 20th week. Smoking, alcohol and opioid use were specifically mentioned in terms of causing miscarriage and stillbirth. Now, recognizing that, and we talked about this on Tuesday, nicotine exposure, alcohol exposure, these things can cause problems in the development of the fetus. And when the fetus. Fetus is having difficulty developing, sometimes the body will terminate the pregnancy, which can cause the miscarriage. We do know that children who are born to parents who smoke throughout the pregnancy tend to be much lower birth weight. Malnutrition and food poisoning, I kind of lumped those together because when we get food poisoning, if you've ever had salmonella or E. Coli, you, you know that you become malnourished for that, you know, week, two weeks until you get it back under control because everything just goes right through you. Unfortunately, this means that everything's going right through the parent and not getting to the fetus. The fetus starts to experience malnourishment. The body perceives it as a inopportune time to produce offspring and may terminate the pregnancy. Physical trauma, being hit, kicked, punched or in car accidents. And there are a lot of People who are in car accidents in, when they are in when they are pregnant and that any, any kind of assault to the abdomen can cause a miscarriage or a stillbirth. And age now age we can't fix, we can't be make ourselves any younger. Between the ages of 35 to 39, there's a 75% increase in the risk of miscarriage. Once you pass that age 40 there, the risk of miscarriage goes up 500%. There's a five fold increase. So do people get pregnant after 35 a lot more now? Yes they do. Do they have full term pregnancies now? Yes, they do. But the risk of miscarriage or stillbirth does go up significantly with age. Other things that can cause miscarriage and stillbirth include genetic issues in the fetus or genetic issues between the fetus and the, and the parent like RH positive, RH negative or if there are just genetic malformations where the fetus cannot actually develop will cause a miscarriage. Placental issues, this is usually. Well, I, I don't want to say that. A lot of times placental issues don't show up until after the 20th week, but they can show up sooner. You know, premature separation of the placenta. There's a lot of things that can happen. Remember the placenta is really important to feed the baby. And uterine issues such as fibroids. If a person had fibroids before they got pregnant, then they are at higher risk of miscarriage during a pregnancy. And if they have scar tissue, if you have scar tissue in your uterus, it can be from prior abortions, prior DNCs or even prior inter inter uterine birth control devices, especially the older ones used to have a bad risk, a high risk of causing scar tissue in the uterus, which unfortunately could lead to long term sterility. All of these are risk factors. Most of these aren't a direct one to one correlation. You know, we know that people, children are born that have certain genetic issues, that have certain special needs and obviously the body didn't terminate that pregnancy. But it is important to recognize that the more of these risk factors a parent has, the greater the risk of a miscarriage and the more things that they need to attend to. Some they will be able to address others like age. There's not much they can do about it. Prematurity impacts 1 in 10 births in the United States and prematurity is being born, gosh, I think it was before 36 weeks. I is they're still premature. It's irrelevant when A child is born before that 40 week period, a lot of times they're considered premature. 17% of preterm infants die. Now, what we do want to recognize here, if you're working with a family who has a premature infant, yes, there are complications. And the more premature the baby is, the greater the risk. A preterm infant that's born at 34 weeks has a much better shot than a preterm infant that is born at 22 weeks. And yes, there are infants that have been born at 22 weeks that have survived, and some of them even survive without major complications. One interesting thing, and I may have it on the next slide, is that when the body perceives that there is a hostile environment, I believe is what they called actually speeds up the development of the fear fetus. So I thought that was interesting and that played out with both of my children that, you know, my, my son was born at 29 weeks and didn't need to be on a ventilator at all, despite the fact that, you know, he really should have needed to be on a ventilator. And, you know, my daughter was, was born at 34 weeks and also didn't need to be on much. But it's interesting because a lot of times the, when I would go into the OB's office that they'd be like, are you sure you're only this far along? And I'm like, yeah, I'm sure. And because the baby seemed to be developing faster because evidently my body doesn't like being pregnant. But that can be comforting to some women to know or to some parents, families to know that if the birth environment is hostile, that the body may actually compensate and, you know, speed up that development. So, you know, it does produce a healthy baby. I thought that was kind of cool. Many times the cause of preterm labor is unknown, but the risk factors are similar to those for miscarriage, although the infant is born alive. Now, you may be saying, why are we talking about this? In a presentation on infant loss? We're also talking about pregnancy loss. And when a infant is born prematurely, the parent is deprived of that idealized pregnancy. With my son, I hadn't even gone to birthing classes yet, and he was here. And I was like, oh my gosh, what am I doing? The parents have to leave the hospital without baby. And that is devastating. It is gut wrenching to walk out of the hospital with nothing in your arms. And it's just like, okay, what just happened? There are both psychological and hormonal implications to that psychologically you know, you can imagine, but hormonally too, there are a lot of hormone changes and rebalancing that occur after birth, but also are contingent upon that skin to skin contact with the infant. Oxytocin, estrogen, progesterone. You know, you can start going down that list. And when the birth parent is not able to connect with, to contact, physically contact the infant, it does cause, can cause hormone imbalances. In some cases, when infants are born very, very early, they may not be able to be touched or even held for days or weeks. The only thing the parents can do is go and look at them in the incubator because they are so hypersensitive to touch and to stimulation that it overwhelms their sensory capacities. That's another one of those things that's agonizing just to sit there and wring your hands while you look at your, your child in the incubator. At a. Most parents who have a premature infant know that the statistics for complications and death are pretty significant. There are a lot of, you know, brain bleeds and, you know, lung problems that children can have. Again, the younger they are when they're born, the more likely they are to have complications because the more fragile they are. But, you know, we don't want to assume that just because a child is born at 34 or 35 weeks that they are completely out of the woods. Now, SIDS is sudden infant death syndrome. So obviously the baby has been born and has been at home with parents for some, you know, amount of time. The peak incidence of SIDS occurs between 1 and 4 months of age. 90% of the cases occur before 6 months of age. But babies continue to be at risk for SIDS for up to 12 months. We don't want people to start becoming complacent after a couple of months. A lot of times people start thinking, well, as soon as baby can roll over, then they're not at risk of suffocation. Well, suffocation is not the only cause of sids and it's important to recognize that they are at risk for up to 12 months. Now this is a chart I got off of one of the sites online and I can't remember which one right now. It's not relevant that that talks about the risk factors for sudden infant death syndrome. Now when you look at this, and it irritated me when I saw it, when you look at this, you see that 64% of SIDS deaths were associated with prenatal or postnatal smoke exposure. 60% age appro, inappropriate sleep service, 52% were found on their side or their stomach. Now, remember that children start rolling over, you know, early on. So by the time they're 12 months old, they're rolling over on their own bed, sharing bedding, related issues, put to sleep on their side or stomach. A recent, generally within four weeks, respiratory infection. Okay, so you're looking at these, and if you just look at this chart, you think, wow, most of these cases of SIDS were completely preventable, and that is a misnomer. That is not correct. And we're going to talk about some of the other risk factors in a minute. But I want you to think about what a parent who has a child that dies from SIDS would feel like if they're looking at this chart and saying, okay, one of these reasons must, must be why my child died. And all of these are preventable, so it must be my fault. Well, except for the no known risk factors, there are a lot of things that contribute to an increased risk of sids. And sometimes it's nothing the parent can do. Risk factors for an unhealthy pregnancy, drug exposure, low weight gain of the parent when she was pregnant, rem. And this can be if, if the parent had really bad morning sickness, like throughout the pregnancy, there may not be a significant weight gain. It may not be, you know, that the parent was dieting or something, but it. Or the parent may have just had difficulty gaining weight for some reason. Placental issues. Okay. There is nothing that a parent can do to prevent placental issues, to the best of my knowledge. So if the child, if the fetus experienced placental issues in utero, they are at greater risk for SIDS if the parent, birth parent, had a history of infections, including bacterial vaginosis, urinary tract infections, or STDs that has been linked to, to an increased risk of sids. You know, sometimes you can't prevent a urinary tract infection. And like I said, bacterial vaginosis sometimes just happens. So it's important to recognize that some of these things are not within the parent's control. If the child was premature, they are at a much greater risk for sids. When my son was in the hospital, the bar for him to get out was that he had to go an entire week without stopping breathing. Okay, let that sink in for a second. New mom taking home a baby going, oh, wow, he's gone a whole seven days without stopping breathing. I was terrified. I was scared witless. But it's important to recognize that premature infants, nervous systems are still premature and Sometimes it just stops. You know, the heart will stop, the breathing will stop, and a lot of times it's associate. Well, that's not true for my son. His, the times when his breathing would stop would be when he was nursing, taking a bottle or sucking on a pacifier, something about that sucking, he would forget to breathe and then because he forgot to breathe, his heart would stop. But other infants, you know, may just randomly, their heart may just randomly stop. So it's important to recognize that prematurity is a risk factor for sids. If the child had a upper respiratory infection within the past four weeks, they are at a greater risk of sids. We can't completely prevent our children from getting upper respiratory infections, especially once they, once they get older, once they're going to daycare, you know, you're not going to keep them in a bubble for the first 12 months. If the child had a low birth weight, and there are a lot of reasons for that, some may be due to behaviors of the birth parent, others may be due just to the child. And if they had siblings who died of sids, there can be a genetic component that, that is associated with sids, unfortunately. And the third set of risk factors are the sleep environments. Stomach or side sleeping is associated with increased risk of SIDS at any age, not just in little infants, but, you know, all the way up through that one year mark. Loose blankets or an inappropriate sleep surface like sleeping in a, in a playpen can be problematic. Loose blankets are especially problematic for a couple of reasons. Number one, the child can get wrapped up in them and asphyxiate itself. Um, the child can get too hot and you see down here, overheating is a significant risk factor for sids. Um, so being aware that the sleeping surface, the sleeping environment, that's why they have all those cute little onesies that, you know, cover the entire child so you don't have to put blankets on infants. Most of you have probably had children or been around children, so you know this. But you know, it's important to make sure that parents are educated, especially if you're work working with really young parents. Smoke exposure, secondhand smoke exposure greatly increases the risk of SIDS bed sharing, especially in a bed with more than one person, interestingly enough. But bed sharing can increase the risk of sids because think about it. Play, not playpens, but crib mattresses are pretty firm and they don't have any blankets on them. When baby comes into bed with parents, that mattress is probably not near as firm. And there are blankets and there's also the risk factor unfortunately of a parent rolling over on the, on the baby or close to the baby so the baby can't get enough oxygen. There's a lot of debate about bed sharing and I'm not going to get into that. Some people are fine with it, but it is one of those things that parents need to consider all the risk factors and benefits and then overheating is another one of those issues. So we know the risk factors. It's important to know those so we can help the parents deal with their grief after this event happens. So in the birth parent there is often complicated grief. Children are not supposed to die before their parents. That's just not the way we see things going in the world. So when it happens, it can be really devastating. When the child, when an infant dies, a lot of times the parents feel very guilty like they should have been able to prevent it. Now when we're talking about miscarriage or stillbirth, it's important to remember that the, the pregnant parent looks at the pregnancy as part of themselves. And when it's lost, there's an emptiness, searching and incompleteness. You know, you are growing this human being inside yourself where you're supposed to protect it, you're supposed to keep it safe and that's where it dies. And that is a hard thing for a lot of birth parents to come to terms with that, you know, there were, there was something that caused that environment to be unsafe. Depression occurs in up to 55% of people who experience pregnancy loss and an even greater number in parents who experience stillbirth, guilt and self anger. The birth parents are often going to look back and, and think, you know, what should I have done? I should have not drank so much caffeine, I should have done this. They will second guess. We know that hindsight is 2020 and in some cases, you know, like in, in prematurity or even miscarriages, the parent may have done everything right and it just wasn't a full term healthy birth, wasn't meant to be. And the parent may feel very inadequate because they weren't able to do something that is supposed to be a hundred percent natural. That, you know, every species gives birth and they weren't able to give birth to a healthy infant. So there's a lot of I didn't do it right. And feeling less than that may need to be addressed. Parents often have guilt for having happy feelings and you know, it may not be happiness about the loss of the child that's devastating. But they may have other children at home, they may have. They may see something that makes them smile, and then they feel guilty because they feel like they're being disingenuous or disrespectful to the lost child. They may feel relief, especially if it's an unplanned or a problematic pregnancy. And a lot of birth parents feel guilty talking about this, that, you know, they knew their child had multiple problems and, you know, even in utero and. And the pregnancy spontaneously miscarried and there was a sense of relief. Or maybe they didn't plan it and they didn't want to get an abortion, but when they ended up miscarrying, they felt conflicted. Thank you, Carolyn. They felt very conflicted about it. And it's important to be able to talk about that and ask the parents how they feel without. And even throw that out there. You know, was there some element of relief when it happened? And they may say yes, they may say no. You know, when you're talking to them, you're going to have an idea about whether there was a kernel of that in there or not. And you'll know when it's appropriate to ask. But, you know, sometimes there's a lot of guilt for feeling relief. And postpartum depression, you know, the body, when it goes through a pregnancy, does all kinds of changes and, you know, stuff, and then after the baby is born, it has to heal itself and hormones have to rebalance and things have to happen. And postpartum depression is very, very common. And it's important that we start talking about it before class. I put a link in the chat room to the video on the YouTube channel on postpartum depression because it is so important to understand. It's so important to understand the impact of these hormone changes on mood. And, you know, some women are more sensitive to it, some women have greater changes in hormones. And it's also important to recognize that postpartum depression also impacts the fathers. Also impacts, or I shouldn't say just fathers, the other partner, so the other caregiver in the household can experience postpartum depression complicating issues. As if miscarriage or prematurity was not enough, if the baby died in utero and the birth parent was required to go through the birthing process, that is extraordinarily traumatic, extraordinarily devastating. Devastating. Having to go through a DNC to clean out the uterine contents isn't any better. But I. I have worked with people who've had to go through the birth process. They had a stillbirth at, you know, eight and a half months and they had to actually birth the baby in order to terminate the pregnancy. Waiting for a natural miscarriage to occur after a fetus has died in utero can also be psychologically debilitating for parents. Sometimes the doctor, for whatever reason, will say, you just need to wait until your body goes through it. Sometimes it'll be a multiple pregnancy. And obviously the, the surviving, you know, twin or surviving babies can't be born early just to expel the fetus that died. So that's another issue that some families have to deal with. Having to go to the OB GYN's office for follow up after a miscarriage or a premature, or a premature delivery is agonizing because you're sitting in there with all of these women who are having allegedly healthy pregnancies or have newborns in their arms and there's a sense, a great sense of loss and grief and everything that can overwhelm a person. Anger, you know, well, kind of goes along with grief. Seeing other newborns in public can trigger a grief reaction, can trigger some anger can complicate things. If it was a multiple delivery and one baby survived and, or one or more babies survived, but at least one baby did not survive, that can be a complicating issue. Some, sometimes the families can resent the surviving child. Sometimes it can cause increased anxiety that the surviving child may die of sids. You know, it's important to ask the parents, you know, what their thoughts, thoughts are about it or if the pregnancy had complications and resulted in the parent becoming sterile, that can be another huge hit. Not only did their baby die in utero, but now they can't even try to have another one. In the other parent. There's also still complicated grief. There may be anger at the situation. A lot of times, just remember anger, denial, anger, bargaining, depression, acceptance immediately after the premature delivery, the miscarriage, the stillbirth. There's often a lot of anger at self, at others, at the ob, at, you know, anybody, because the parents are trying to make sense of it. They're trying to figure out who to blame in order to get some sort of closure to make it make sense. So there is a lot of anger. As we talked about before, there can be some issues of relief in the other parent. The issues of relief may be a little bit different. It could be because it was an unplanned pregnancy. It could be because that parent didn't want the pregnancy. It could be because, you know, now they don't have to worry about extra finances. There are a Lot of other things that can go on, but relief is one of those feelings that we do need to allow people to talk about. Sometimes the other parent may have difficulty understanding why the birth parent is taking it so hard. A when you're not carrying the child in your own body and feeling it kick and all that kind of stuff, you may not bond with it in the same way. And so sometimes it's hard for the non pregnant parent to understand the devastation of, of losing that child and you know, again, having lost it in what was supposed to be a safe environment of your own body. There may be anxiety in either parent about having another pregnancy, you know, thinking I can't go through this again or I don't want to have another miscarriage. And sometimes it's just the opposite. Parents may be determined to get pregnant as, again as quickly as possible. And that is very ill advised. Number one, the body needs time to rebalance, repair, restore itself. But number two, sometimes getting pregnant again too quickly prevents the parents from, or prevents the family from working through some of those grief issues that they need to. They just kind of put it on a back shelf and that trauma can come back later and cause problems. In the extended family. Grandma, grandpa, aunts, uncles, friends. There can be grief because they were so looking forward to having this grandbaby or nephew. So they may grieve on their own that that's not going to happen. They may have grief for the parents, you know, they feel bad, their heart breaks for the parents that, that lost the child. There can also be anger and blame. And again, when a traumatic event happens, we try to make sense of it so we want to be able to blame someone. We want to have a reason why something happened. So a lot of times, unfortunately there are passing, sometimes direct, but a lot of times passing snide remarks that can be made. You know, if you wouldn't have done this or you know, if you would have quit working when you were pregnant, this wouldn't have happened or what have you. There are a lot of old fashioned ideas about what may cause miscarriages or sids. And you know, with sids, remember that chart we looked at? If a parent just, or a grandparent or somebody just goes and looks at that chart, they're seeing it going, okay, well the parent should have been able to prevent this. And that's just not true. You know, we don't know. We know that, that you know, whatever it was, 60 some percent of the children were exposed to smoke, either in utero or secondhand smoke. But you know, that is a pretty wide period of time and they can't say exactly why it, it's related to sids. So we don't know that that was the cause. It could have been something, you know, within the child's nervous system in the siblings. Now this is interesting because a lot of times we don't think about the siblings in pregnancy loss and in prematurity. And it is so important to remember the impact. This is a family issue. A lot of times children don't understand what happened, especially younger children who don't. You know, you, your teenagers are going to have a better understanding. Your 5 year olds, not so much. Some siblings may feel relief because they didn't want to have to share mommy and daddy. Some siblings may experience disappointment because they were looking forward to a new playmate. Some children may resent that parents aren't instantly okay. It's like, okay, baby's gone, let's go to the park. They don't get it. They don't understand. And why should a 5 year old or even a 10 year old really understand? That's not something they should have to grasp. It's important to remember the developmental capacities of children, including egocentrism and making assumptions based on limited knowledge. You know, a five year old, if parents have a miscarriage, the five year old's like, okay, it's gone, you know, let's move on. And, and doesn't understand that same connection. Most times there are some exceptional five year olds, but at five, they understand the world as they experience it. They can't understand it from mom's perspective or dad's perspective. Younger children sometimes view a new sibling like a present and want to know why they're, they can't just get another one, okay, you lost that one, or didn't bring that one home from the store, let's go get another one. And it's important to help them understand that what's going on in a developmentally appropriate way. Surviving children may feel rejected or like they're not enough because parents are grieving the loss of this child that they never got to, the child that the siblings never got to see or interact with. So it's like, okay, this thing I never met is consuming you and I'm right here. What's, why don't you just pay more attention to me? It sounds selfish, but again, you have to remember the child's perspective. They don't understand the what, what parents are going through. But it's important because when they feel rejected, like they're not getting enough attention from their parents and they don't understand why. Generally that's going to result in some acting out behaviors. A lot of times it results in externalizing and that's often when parents end up showing up in counseling with, with junior children may fear that the parents will make them go away too and become very anxious. They don't understand what happened to the baby. And this is true with, with SIDS and even with miscarriages especially, especially stillbirths when the birth parent was clearly showing and then all of a sudden not and they'd been talking about this baby for months and now all of a sudden nobody talks about it. And, and they may fear that, you know, maybe that baby did something wrong and the parents made it go away. So now maybe they're in jeopardy of going away too. In the case of sids, you know, it's hard for children to understand. It's hard for adults to understand SIDS because like any of these things, sometimes there is just no one thing or two things that we can point out and go, this is what caused it. We may just not know. And so that can make younger siblings or surviving siblings anxious about going to sleep because baby went to sleep and then baby never woke up. And, and it's important to help them understand that they're safe and why they're safe partly because they're older and deal with any of those anxieties. Children may also surviving children may be happy because they have their parents all to themselves, which can cause friction with the grieving parents. Their so excited now it's mom's back. She's not on bed rest anymore. She's not sick all the time or you know, the baby in a Sid's case, you know, young infants, you know, need to be fed all the time. They require a lot of work in those first few months and older siblings can be resentful of that. And, and then if the baby dies, unfortunately of, of sids, the surviving siblings may have an element of happiness because you know, now they don't have to share the parent and re we've got to remember the child's developmental age and what's developmentally appropriate and what they can understand and, but even so we can cognitively understand what's going on with the child. But it can be frustrating to deal with sometimes as the, for the parents when they are still immersed in their grief. But also having to tend to tend to the surviving children. Interventions try to learn about what happened and implications for the future to help reduce guilt, blame and anxiety for everybody. Not just the birth parent, not just the partner, but everybody. We need to educate, you know, the family so they're not saying, well, you know, you should have or you could have just with, as with any grief process, we need to remind people that the grief process is not linear and it's not the same for any two people, even the same family. So one partner may start getting it over, getting over it faster than the other partner, or may deal with it in a different way. And sometimes this causes conflict and we want to help people communicate about how they're dealing with these things. Remember, like other losses, this grief will take time to process and may flare up for a year or more. It's important for the birth parents when they're ready to decide what to do with the maternity clothes and baby items. Always consider joining a support group or seeing a counselor and commemorating the child's life with a birthstone or even a scrapbook. It's important for the parents to practice self care. Recognizing that the body has gone through a trauma and pregnancy induced adaptations will take time to resolve. Giving themselves permission to grieve, but also to be happy. As we talked about earlier, it's also important to recognize that another pregnancy will, will not lessen the grief and may actually increase anxiety and depression for the partner. Listen, talk and process together. And with your own supports you can talk with one another, you can support one another, but sometimes there are things that one partner may not want to say to the other one and it's important like you know, feelings of relief for example, and, and it's still important for each person to be able to talk out their feelings without fear of hurting the other person, et cetera. So it's important for, for partners, for everybody to have their own people to talk with as well as to be able to support one another. Help eliminate triggers in the environment. If wanted, it is ill advised, although, you know, generally done with their heart in the right place for the non birth partner to go back to the house and completely strip everything out of the nursery. Like, you know, so the birth parent's not reminded of, of the loss that can be devastating to the birth parent. So it's important to decide as a team, as a family what to do with the triggers in the immediate environment. Do you move them to another room or when, whenever you're going to be ready to think about giving them away. You know, it's a process. Reaffirm the loss was not your partner's fault. This is really important remembering that most of the time we don't know what causes these things. And it's important for people not to continually blame themselves, help share the news with friends and family so the birth partner is not bombarded with questions, questions or sympathy constantly. And this is stuff that the family can do as well. If so, neither parent has to deal with the well wishes, you know, the, the heartfelt concern. Because sometimes that can just be like ripping the band aid off. And recognize the birth parent's body has to go through that postpartum process. Even though, you know, in miscarriage and stillbirth there is no baby to take care of, the body still has to recover. And it doesn't happen overnight. In the case of sids, you know, another time that the body readjusts is after the birth parent quits breastfeeding. So if the birth parent was breastfeeding and you know, the infant passes away or you know, whenever the parent stops breastfeeding, there is going to be another hormonal adjustment that has to take place and there are going to be some mood changes that may go along with that. Pregnancy and infant loss are devastating. Many times there's no clear explanation for why it happened, which flies in the face of what we want for closure. We want to have an understanding. I know after my son was born, I wanted to know why it happened so I could make sure it didn't happen again with the next pregnancy. And there was just, you know, we found two or three things that, you know, we were able to address in the next pregnancy. So, you know, as my husband lovingly says, she baked a little bit longer, but she was still born premature. Oftentimes, well meaning family and friends may probe for explanations and it may feel like they're blaming the birth parent. Parents may share some similar reactions, but they also may have very different reactions. So it's important not to assume that you know how either parent feels. Prematurity, miscarriage, stillbirth, and sudden infant death all have unique issues, but all represent a significant loss. Mimi points out that Chrissy Teigen and John Legend were sharing their infant loss last night. And you know, again, this is, I don't know when they lost their baby, if it was last night or if it was in the past. But this is Pregnancy and Infant Loss Awareness Month. So, you know, it's a great time for people to start becoming aware of how unfortunately common it is and what they can do to support the parents and the surviving siblings. And sometimes it is, well, a lot. Most times it is hard for the grieving parent to care for grieving children who are Fine. And it's really important for the parents to communicate about what is needed. Sometimes they need a little break. But we also have to recognize for the grieving child and however the grieving child's understanding this, you know, it's generally not in the best interest of the children to send them away because then they may feel like they're being rejected. So it's important to figure out how to navigate that as a family. The younger the children are, the harder it is to navigate sometimes because, you know, two year olds just aren't going to grasp what happened. And when a parent, Nancy brings up, you know, when we're talking about prematurity or birth of children who we know have been drug exposed, there may be guilt that the parent, anticipatory guilt that the parent is dealing with. And I shared with you on Tuesday how fascinating it was to me that, you know, of the, I don't know, dozens of women who went through our program, you know, they stayed for six to 10 months. So we didn't have a super high turnover rate. But for the dozens of women who went through our program in the time that I ran it, we really didn't see much in the way of developmental delays or birth defects, even though most of these women had been using quite heavily and a variety of different things throughout their pregnancy. So just because someone used or just because someone drank before they found out they were pregnant in the first trimester or even if they drank through their pregnancy doesn't guarantee a negative outcome. And it's important, I found working with that population, it was important to help them focus on what is going on right now, what do we know right now instead of anticipating the worst which would keep them from bonding with baby. And yes, there was also, you know, in when you're working with people who are in recovery from substance use, a lot of times they are going to go through labor and delivery drug free. And that can be terrifying for a lot of people. Some will get an epidural. You know, at the clinic I worked at, at the residential program I worked at, we didn't have a problem if they had epidural. We just didn't want them having like, you know, intravenous Dilaudid or something. But, you know, it is as a terrifying process for some people, especially if they're used to coping with physical or emotional pain through drugs. So there are a lot of unique issues that come out. But one of the unique issues, you other unique issues that came out when working with the MIST program was that, you know, there may be some anticipatory anxiety and grief or whatever. But then when they had their baby and, you know, baby was able to come home and, and all that stuff, a lot of those fears just kind of disappeared. And they were so much more able to be mindful and focus on the present moment, which I found to be interesting. Are there any questions? Obviously, I did not cover all of the possible or potential reactions or clinical issues that may face a family that is dealing with prematurity, pregnancy, prematurity, miscarriage, stillbirth, or sudden infant death syndrome. We didn't clearly have enough time to go do a deep dive on it. But, you know, now you're aware of, you know, some of the issues and hopefully some of the issues that you may not have even thought about before. So if you're working with a family dealing with this, even if they had the sudden infant death or the miscarriage five, 10 years ago, they may not have dealt with it yet. So some of these issues may still be important to process in order to help them heal from that trauma. If this podcast helps you help your clients or yourself, please support us by purchasing your ceus@allce.com or getting your agenc to sponsor an episode. 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