MATERNAL-INFANT BONDING AND THE MOTHER ́ S PARTICIPATION DURING VENIPUNCTURE : A PSYCHOANALYTIC PERSPECTIVE

La participación de la madre acompañante junto al niño durante la realización de procedimientos dolorosos es discutida por profesionales como una posibilidad de cuidado al binomio, pero no hay un consenso sobre este tema. Para contribuir con esta discusión, el texto trata de las necesidades del niño durante la realización de la punción venosa en un ambiente de hospital y la participación de la madre en el procedimiento, tomando como base autores del psicoanálisis y el vínculo madre y hijo.


INTRODUCTION
Since 1960, several studies have described the mother's participation in the hospitalization of a child as a fundamental support factor to the child (1)   .This is observed in hospitalization units through the mother's permanent presence by the child's side, especially regarding care in terms of feeding and cleaning, but unusual during procedures like venipuncture.However, several authors defend parents' participation during painful procedures because they believe that the presence of somebody significant to the child can offer support and security on these occasions as well (2)(3)(4)(5) .Some hospitals or pediatric units have standards that a priori establish the mother's participation during venipuncture, independently of the child's need or the mother's desire.Some mothers, in turn, choose not to participate or observe the venipuncture, even if the institution or professional agrees with her presence (6) .
Research shows that painful procedures in hospitalized child are one of the main sources of suffering for accompanying mothers (4)(5)(6)(7) .In addition, even mothers who recognize the benefit of venipuncture for the child's treatment suffer when watching the child's suffering and think about quitting hospitalization (6) .
This situation reveals that the care focus is not centered on hospitalized children and their family and also that there is a need for new discussions about this context in order to improve attendance to the child and mother's global needs when they are confronted with painful procedures.
Hence, analyzing issues involving the mother and child relationship in the hospitalization process has been considered fundamental in pediatric and neonatal nursing care, because they affect care quality (8) .
To support the discussion, we used nursing and psychology authors, especially from psychoanalysis.This discussion is focused on children between zero and 24 months old and their mothers.
The presence of older children's mothers is usually assured by the children themselves, who already possess a set of resources, such as verbalization, crying and movements to require this.This option does not intend to devalue the support of a significant person to older children since, just like their mothers, they also need support to pass through difficult experiences.
The reflections are also based on the conviction that mothers who are well attended are capable of helping the child in difficult situations and that their participation in the venipuncture process is fundamental for their children's psychic health.

THE MOTHER-INFANT RELATIONSHIP AND BONDING
An individual's personality is influenced by intrinsic and extrinsic factors.The former include genetic and hereditary factors, while the latter refer to factors related to the social and family environment, which can influence the constitution of a person's personality.Regarding to extrinsic factors, it is observed that some childhood events can deeply affect a person's development.Psychological tests make it possible to identify the marks left by these events, even if the person does not remember the impressions that caused them (9) .
People in general do not remember events from their early childhood, that is, up to six years old.This fact is due to a psychological phenomenon that can be explained through the understanding of the unconscious, called childhood amnesia (9) .Although, in childhood, we experience emotions and can receive and reproduce impressions, we are capable of retaining in our memory only intelligible and fragmented facts.
Therefore, the experiences children go through during hospitalization, even if they cannot remember them, can mark their personality.Any damages resulting from this experience will depend on how well it is addressed by people involved in the process.
It is known that, during the formation of children's personality, an adult, usually their mothers, represents their connection with the world.The mothers' importance in personality construction is because they are the children's reference point, in relation to the world and to themselves (10)(11) .
Breastfeeding infants are seen by human beings or with events of life (12) .Thus, if the child does not obtain the necessary support to bond with the mother since the first days of life, this situation will affect the child's capacity to develop satisfactory relationships.The affective connection between mother and child is established during the child's first 24 months of life of the child and results from the constant interactions between these two since birth.The mother is the person who answers or stimulates her child's manifestations such as a smiling, crying, babbling, feeling cold, hungry and pain (10)   .
In nursing, one of the more diffused theories is the Attachment Theory, which also affirms the importance of bonding between the developing child and the responsible.Attachment behavior is characterized by permanent physical contact between mother and child when the child is hungry, cold, afraid or anguished (12) .
The daily repetition of these interactions allows the child to elaborate a scheme of her mother or another caregiver.Thus, around the fourth or fifth month of life, the child already differentiates the mother from other people and does not allow others to rock or feed her (10,12)   .
According to Attachment Theory, between the ages of six and twenty-four months, the child goes through the attachment definition phase, starts to demonstrate fear of strangers and cries if can not have access to the mother; from the tenth to the eighteenth month, this feeling is intensified, in a critical period known as separation anxiety (12) .Thus, when the child is exposed to tense situations, like in the case of hospitalization which, besides the illness, also contains environmental changes, presence of strangers and painful procedures, the presence of a familiar person is fundamental to the child, especially in the first 24 months.This presence becomes essential, mainly while the child does not distinguish between her body and the existence of her body on the one hand and her mother's existence on the other.The child under stress seeks a way to reach the mother's presence, related to safety and comfort (11) .
After these 24 months, the child perceives the mother as an independent and, then, becomes capable of tolerating separation from the mother without suffering, if in a familiar place or receiving guarantees of her return (12)   .

THE MOTHER'S PARTICIPATION DURING VENIPUNCTURE OF THE HOSPITALIZED CHILD
In the venipunture process, if the mother is absent, it is observed that the child, until approximately two years old, cries continually, since the moment the mother leaves and even before the needle is introduced.The suffering the child shows is not caused just by the puncture itself, but also by the separation from the mother.This is due the fact that the mother, as the primary object of children's affective connection, has the condition to calm and protect them from fear when they go through an unknown situation (10)   .The mothers' capacity to alleviate their children's anxiety or fear is fundamental for growing attachment and necessary for them to learn how to separate from their mother without emotional damage, as their development improves (10,12) .
The experiences of our reality make an impression and are also influenced by the organism's integrity, by its transitory or permanent injuries and by physiological and visceral sensations (11) .In this sense, venipuncture, which frequently occurs during infant hospitalization, can be considered as a transitory injury to the organism.
Pain researchers report that children are capable of feeling pain from birth.Their early manifestations are crying and body movements.As nursing infants cannot express themselves verbally about their feelings, adults tend to devaluate or even ignore them.That does not mean that they do not express themselves in uncomfortable situations (13)(14) .
Crying, in response to discomfort or a strange event, is an ability children possess since the early moments of life.The mothers' proximity when children cry helps them to relax and to nest in the mother's arms (10)(11) .When children's request for attention is valued, even if their mother cannot provide the requested pleasure, this grants a highly compensatory human value and makes the children feel loved and acknowledge in their desire, strengthening motherinfant bonding (11) .
During the venipuncture, even if the mother cannot avoid the procedure, her presence assures comprehension and love to the child.When feeling assisted by the mother, children who go through a difficult experience will be better prepared to cope with anxiety on another occasion.When children feel Maternal-infant bonding... Pinto JP, Barbosa VL.
they are their mother's preferred object, manifestations of discomfort prevail, like crying in response to an aggression, because they feel safe to express their feelings (11) .Although limitations and corrections mothers may impose on children are necessary to form their personality, so is respect for their feelings.Thus, the children's feelings must be valued to avoid damage to their mental health.Not attending to children's manifested needs represents a limitation imposed by the mother.However, these limitations, which the individual goes through from childhood to adolescence, are humanizing because they favor the formation of adults responsible for their actions and capable of assuming their life (11) .
On the other hand, if the mother impedes, ignores or disdains the pain or fear manifested by the child in relation to the venipuncture, besides not feeling loved, the child can also understand that the mother wants her to go through that and, then, agrees with the procedure to satisfy the mother's desire.A situation that leads to the desire of reaching satisfaction through suffering, instead of through pleasure, is considered a perversion.Perversions are defined as pathogenic de-compensations that can originate masochist, hypochondriac, auto-destructive behaviors, among others (11)   .
Melanie Klein affirms that the positive relationship with the mother, that is, when she satisfies the child's need, allows the child to overcome anguish and frustration caused by the aggression and to increasingly believe in the possibilities of satisfying these needs (15) .
Like with illness, hospitalization and painful events can lead to a failure in narcissism.Narcissism is described as "the sameness of being", which gives rise to the human beings "notion of existence" and desire to live (11) .Children leave their routine during hospitalization, when anguishing factors are present and constantly frustrate the child's needs.The pain provoked by the venipuncture and the fact of not finding any answer to their needs in their mother causes anguish in children.
Anxiety is an unpleasant feeling that represents symptoms like contraction and respiratory symptoms.In normal life, contraction and relaxation alternate.An environment that keeps the child in a situation of contraction can lead to the loss of the ability to relax (15) .In healthy individuals, contraction and relaxation are balanced when they are free from internal tensions, hunger and other needs.For children up to two years old, the mother's constant presence is fundamental to maintain this balance.
When informed about venipuncture, in turn, mothers can turn this experience more familiar to their children.In view of the children's unknown and surprising perceptions, mothers usually intermediate their children's relation with the world and offer answers to the unknown fact.The mothers humanize everything surrounding the children through their words, manipulation and presence, granting a perception of safety to the children (11) .
During the period when children do not dissociate their body from their mothers', for the children, their mothers' absence during the venipuncture can mean that the mother cannot bear the situation, leading to the conclusion that they cannot either.Talking to the mother and explaining that her presence can contribute to minimize the children's suffering benefits the children not only at that moment but during their existence.
Some mothers have negative previous experiences, personally or involving their children, regarding hospitalization and venipuncture.This can make their participation in the procedure more difficult (6) .Given the existing mother-infant bond, if the mother has an increased perception of the pain caused by venipuncture, this feeling is sensed by the child.Although pain intensity cannot be measured, it can be influenced by the pain perception demonstrated by people the child trusts.
The nurse, by means of communication and/ or projective techniques, can explore the issue with the mother in order to strengthen her, so that she can decide about her participation in favor of the child.
Preliminary sessions with parents, without the child's presence, can by themselves improve the child's state.Parents, moved by personal anguish and not expressing them, provoke the children's reaction.
By talking, the mother elaborates her history and can find new ways to act towards her child (11) .
Not being able to decide about the best way to act is one of the most frequent causes of anguish (15) .
The child submitted to consecutive venipunctures, which may happen during hospitalization, and without adequate support, can get into a permanent state of anguish.
Offering conditions to the child and mother to deal with the anguish enables them to develop mechanisms to cope with the situation if they perceive it as aggression or to adapt to it, because they decide that this is the best way to continue treatment, despite the suffering.
The clarity the mother acquires about several aspects involved in a situation, can help her to decide whether to participate in the puncture or not without feeling guilty.Ambiguous behaviors, such as lying to the child that the procedure is not going to hurt and looking scared, by keeping her eyes wide open during the puncture moment, can also be avoided.The mother's ambivalence occurs even when, although she wants and is advised about the importance of being close to her child, acknowledges that she does not have the resources to help the child during the venipuncture.That is, she is not able to bear her own pain and that of her child.In this case, the mother's absence can be indicated, because she is at the risk of being ambiguous and sending contradictory messages to her child (10)   .
If the mother is absent during the venipunture without informing the child about her leave and about what is going to happen, this can make the child fantasize in order to explain this absence, understanding this absence as not being loved (10) .
Therefore, it is essential to inform the child, no matter at what age, and if possible by the mother.
In hospitalizations, it is also common for children to have one of their limbs immobilized for various days, due to the presence of an intravenous device.The language established between mother and child can prevent alterations in the child's body image provoked by organic injuries.In this case, the motive of this restriction, the normal past and possibilities of recovery must be explained to the child, no matter at what age (11) .The child feels respected as a person when the mother expresses her suffering, because words continue in the child's unconscious memory forever (10)(11) .
When in contact with the child who has care demands different from those presented in the home environment, the mother may not be able to attend about what is happening or will happen, they perceives signs that something different is happening, which generates expectations that something bad is coming.
Communicating with the child allows for emotions and affects shared with the environment to be understood by the child (11)   .
In addition, the difficulties children develop by the child do not originate from functional or physical injuries, but from what was not explained in time to them, even if she cannot exactly understand the words (11) .
The mother's eyes are another factor that facilitates any experience lived by the child.The adult's eyes authorize access to personal experiences and exploration of the world (10-11)   .The child can feel more secure in dealing with the puncture material if the mother is present and, thus, get accustomed to the procedure.
A friendly relationship between the mother and the nursing team is another factor that helps children to accept the procedures performed by professionals, because it is easier for them to accepting the care of a person who keeps a good relationship with their mother.
In the mother's absence, objects familiar to the child, such as toys named by the mother and persons with whom the mother communicates verbally arouse the mother's memorized presence in the child, together with the feeling of security and comfort associated to the mother figure (11)   .

FINAL CONSIDERATIONS
The referred authors made it possible to deepen a theme that has incited discussions about The nurse's role is to mediate between the child, the mother and the procedure.It is her task to provide the necessary explanations, adapted to their needs.This way, the nurse will be playing her role, facilitating the mother's and child's adaptation to the situation so that, despite the suffering, they can live the experience and strengthen their bond.The nurse's actions increase the possibility that the mother and child will be strengthened by the situation and apt to overcome new experiences that may threaten the child's physical and mental integrity.This experience, when well conducted, allows the child to continue exploring the world with confidence.
to the child's needs in new circumstances.The modification of the child's body scheme, due to partial immobilization of a limb, can create doubts about how to hold, feed or clean the child.This will probably demand a change in body scheme from the mother, so she can embrace and be recognized by her child as a person capable of identifying and attending to his/her needs.The mother's verbalization about what ishappening also avoids ambiguity.By talking openly with their children about the situation, the mothers can impede their children from fantasizing about the event.When the children are not clearly informed nursing care to children and their mothers during venipuncture.This reflection allowed us to consider the mother's participation as fundamental to give meaning to the experiences lived by the child.Her participation in the procedure is essential, since it is through the mother's presence that the child learns to recognize the other and acquires trust to establish other relationships.In summary, the nursing team must consider the mother's participation in painful procedures during hospitalization.This participation is presented in the sense that, even when not being present at the time Maternal-infant bonding... Pinto JP, Barbosa VL.Rev Latino-am Enfermagem 2007 janeiro-fevereiro; 15(1):150-5 www.eerp.usp.br/rlae of the puncture, the mother can help the child, based on their affective bond, making difficult moments familiar and bearable.