The effects of preterm birth on mother-infant interaction and attachment during the infant's first two years

A self-comfort oriented pattern of regulatory behavior and avoidant attachment are more likely among infants born moderate-to-late preterm

Infants born preterm (<37 gestational weeks, GW) are at increased risk for regulatory difficulties and insecure attachment. However, the association between infants' regulatory behavior patterns and their later attachment organization is understudied in the preterm population. We addressed this gap by utilizing a Portuguese sample of 202 mother-infant dyads. Specifically, we compared the regulatory behavior patterns of 74 infants born moderate-to-late preterm (MLPT, 32-36 GW) to those of 128 infants born full-term (FT, 37-42 GW) and evaluated the associations of these regulatory patterns with later attachment. Infants' regulatory behavior patterns (Social-Positive Oriented, Distressed-Inconsolable, or Self-Comfort Oriented) were evaluated in the Face-to-Face-Still-Face paradigm at 3 months, and their attachment organization (secure, insecure-avoidant, or insecure-ambivalent) was evaluated in the Strange Situation at 12 months corrected age. In both samples, the Social-Positive-Oriented regulatory pattern was associated with secure attachment; the Distressed-Inconsolable pattern with insecure-ambivalent attachment; and the Self-Comfort-Oriented pattern with insecure-avoidant attachment. However, compared to FT infants, infants born MLPT were more likely to exhibit a Self-Comfort-Oriented pattern and avoidant attachment. Most perinatal and demographic variables were not related to infant outcomes. However, infants with a higher 1-min Apgar were more likely to exhibit the Social-Positive-Oriented regulatory pattern and secure attachment.

Preterm Birth Is Associated With Depression From Childhood to Early Adulthood

OBJECTIVE

There have been inconsistent findings on the associations among prematurity, poor fetal growth, and depression. We examined the associations among gestational age, poor fetal growth, and depression in individuals aged 5 to 25 years.

METHOD

We identified 37,682 case subjects based on International Classification of Diseases, Ninth Revision code 2961 and International Classification of Diseases, Tenth Revision codes F32.0-F32.9 and F33.0-F33.9 from the Care Register for Health Care, and 148,795 matched controls from the Finnish Central Population Register. Conditional logistic regression examined the associations between gestational age by each gestational week, poor fetal growth, and depression. The associations were adjusted for parental age and psychopathology, paternal immigrant status, maternal substance abuse, depression, number of previous births, marital status, socio-economic status, smoking during pregnancy, and the infant's birthplace.

RESULTS

In the adjusted models, increased risk of depression was found in children born ≤25 weeks (adjusted odds ratio [aOR] 1.89, 95% CI 1.08-3.31), at 26 weeks (aOR 2.62, 95% CI 1.49-4.61), at 27 weeks (aOR 1.93, 95% CI 1.05-3.53), and ≥42 weeks (aOR 1.11, 95% CI 1.05-1.19). In girls, extremely preterm birth was associated with depression diagnosed at 5 to 12 years (aOR 2.70, 95% CI 1.83-3.98) and 13 to 18 years (aOR 2.97, 95% CI 1.84-4.78). In boys, postterm birth (≥42 weeks) was associated with depression diagnosed at 19 to 25 years (aOR 1.28, 95% CI 1.07-1.54). Poor fetal growth was associated with an increased risk of depression in full-term infants (aOR 1.06, 95% CI 1.03-1.10) and postterm infants (aOR 1.24, 95% CI 1.08-1.43).

CONCLUSION

Preterm birth before 28 weeks of gestation appeared to play a role in the development of childhood depression. Smaller effects were also seen in postterm births, especially in boys.

Maternal speech decreases pain scores and increases oxytocin levels in preterm infants during painful procedures

Preterm infants undergo early separation from parents and are exposed to frequent painful clinical procedures, with resultant short- and long-term effects on their neurodevelopment. We aimed to establish whether the mother's voice could provide an effective and safe analgesia for preterm infants and whether endogenous oxytocin (OXT) could be linked to pain modulation. Twenty preterm infants were exposed to three conditions-mother's live voice (speaking or singing) and standard care-in random order during a painful procedure. OXT levels (pg/mL) in saliva and plasma cortisol levels were quantified, and the Premature Infant Pain Profile (PIPP) was blindly coded by trained psychologists. During the mother's live voice, PIPP scores significantly decreased, with a concomitant increase in OXT levels over baseline. The effect on pain perception was marginally significant for singing. No effects on cortisol levels were found. The mother's live voice modulated preterm infants' pain indicators. Endogenous OXT released during vocal contact is a promising protective mechanism during early painful interventions in at-risk populations.

A Study of Maternal Competence in Preterm Birth Condition, during the Transition from Hospital to Home: An Early Intervention Program's Proposal

The study was conducted with 104 mothers (average age 32.5 years, SD 6.1) of preterm infants (very and moderately preterm but still healthy) to monitor the perceived maternal role competence from the time of hospitalisation to post-discharge, in order to define an intervention program to support mothers during this transition. A targeted Q-Sort tool (Maternal Competence Q-Sort in preterm birth) was applied at two different times as a self-observation tool for parenting competence in neonatology. A tendency towards dysregulation of the maternal role competence was detected, mainly in terms of low self-assessment and was found to worsen during post-discharge, particularly with regard to caregiving ability. This study suggests the importance of accompanying parenting competence in preterm birth conditions, not only during hospitalisation in the Neonatal Intensive Care Unit (NICU) but also following discharge in order to promote the development of premature infants. This paper reports in the last part a specific integrated psychoeducational intervention program (psychologist and nurses), which we defined precisely in light of the suggestions offered by the study data on perceived maternal competence created with the Q-sort.

Associations of Maternal-Infant Bonding with Maternal Mental Health, Infant's Characteristics and Socio-Demographical Variables in the Early Postpartum Period: A Cross-Sectional Study

(1) Background: There is a continuing discussion concerning the impact of preterm birth on Maternal-Infant bonding with inconsistent results. The large burden of preterm births calls for research to evaluate the impact of it on material psychological outcome in the early postpartum period. Thus, the aim of this study was to evaluate the relationship between maternal postpartum bonding with maternal mental health, socio-demographical factors, and child's characteristics. (2) Methods: A cross-sectional study design was used. In total, 72 women (a mean age of 31.44 years old) of preterm infants (mean gestational age = 33.54; range 24-36) filled out socio-demographic questionnaires, Postpartum Bonding Questionnaire (PBQ), Edinburgh Postpartum Depression Scale (EPDS), Postpartum Depression Screening Scale (PDSS), Generalized Anxiety Disorder Assessment (GAD-7), and Parental Stress Scale (PSS) 1-3 days post-delivery; (3) Results: The results analyses have shown positive correlations between the overall result of maternal postpartum bonding with stress (p < 0.01), maternal educational level (p < 0.01), maternal age (p < 0.05) and the number of children (p < 0.01). However, there were no significant relationships between other investigated variables. The results of linear regression have revelated the important role of the overall scores in experience of stress among mothers (explaining 49% of the variability). The mediating role of maternal stress on maternal postpartum bonding was not found. That relationship of maternal postpartum bonding and maternal stress was not moderated through socio-demographic variables. (4) Conclusions: In this study mothers of prematurely born children had a good level of Maternal-Infant bonding. Maternal stress was found to be a predictor of maternal postpartum bonding among the tested variables. Surprisingly, the study results did not show significant relationships between maternal postpartum bonding and maternal mental health (depression and anxiety).

NICU music therapy effects on maternal mental health and preterm infant's emotional arousal

In recent decades, music therapy in the Neonatal Intensive Care Unit (NICU) has been shown to regulate preterm infant's physiological responses and improve maternal mental health. This study investigated the effects of the music therapy intervention for the mother-preterm infant dyad (MUSIP) for maternal anxiety, postnatal depression, and stress, and preterm infants' weight gain, length of hospitalization, heart rate (HR), and oxygen saturation (So₂ ). A pre-experimental design was used with 33 mother-preterm infant dyads in a Brazilian NICU: 16 dyads in the Music Therapy Group (MTG) and 17 dyads in the Control Group (CG). The MTG took part in the MUSIP, aimed at supporting maternal singing with the preterm baby. Infants' HR and So₂ were recorded at each minute from 10 min before to 10 min after sessions 1, 3, and 6. Before infants' discharge, maternal anxiety and depression scores were lower in the MTG compared to the CG. Anxiety, depression, and stress levels decreased significantly after the intervention in the MTG. With regard to infants, HR and So₂ ranges were higher during music therapy, compared to before and after sessions. MUSIP improved maternal mental health and affected preterm infants' emotional arousal, with positive trends in decreasing HR, stabilizing So₂ , and reducing length of hospitalization.

Longitudinal Study of Music Therapy's Effectiveness for Premature Infants and Their Caregivers (LongSTEP): Feasibility Study With a Norwegian Cohort

Premature infants and their parents experience significant stress during the perinatal period. Music therapy (MT) may support maternal-infant bonding during this critical period, but studies measuring impact across the infant's first year are lacking. This nonrandomized feasibility study used quantitative and qualitative methods within a critical realist perspective to evaluate the feasibility, acceptability, and suitability of the treatment arm of the Longitudinal Study of music Therapy's Effectiveness for Premature infants and their caregivers (LongSTEP) (NCT03564184) trial with a Norwegian cohort (N = 3). Families were offered MT emphasizing parent-led infant-directed singing during neonatal intensive care unit (NICU) hospitalization and across 3 months post-discharge. We used inductive thematic analysis of semi-structured interviews with parents at discharge from NICU and at 3 months and analyzed quantitative variables descriptively. Findings indicate that: (1) parents of premature infants are willing to participate in MT research where parental voice is a main means of musical interaction; (2) parents are generally willing to engage in MT in NICU and post-discharge phases, finding it particularly interesting to note infant responsiveness and interaction over time; (3) parents seek information about the aims and specific processes involved in MT; (4) the selected self-reports are reasonable to complete; and (5) the Postpartum Bonding Questionnaire appears to be a suitable measure of impaired maternal-infant bonding. Parents reported that they were able to transfer resources honed during MT to parent-infant interactions outside MT and recognized parental voice as a central means of building relation with their infants. Results inform the implementation of a subsequent multinational trial that will address an important gap in knowledge.

Exploring Perinatal Indicators of Infant Social-Emotional Development: A Review of the Replicated Evidence

The importance of infant social-emotional development for outcomes across the lifecourse has been amply demonstrated. Despite this, most screening measures of social-emotional development are designed for children 18 months of age and over, with a clear gap in earlier infancy. No systematic review has yet harvested the evidence for candidate indicators in the perinatal window. This paper examines modifiable risk and protective factors for two seminal early markers of social-emotional development: attachment security and behavioral regulation mid-infancy. We searched meta-analytic and longitudinal studies of developmental relationships between modifiable exposures in the perinatal window (pregnancy to 10 months postpartum) and attachment and behavioral regulation status measured between 12 and 18 months. Six electronic databases were used: ERIC, PsycINFO, Medline Complete, Informit, Embase, and Scopus. Twelve meta-analytic reviews and 38 original studies found replicated evidence for 12 indicators across infant, caregiving, and contextual domains predictive of infant behavioral regulation and attachment status between 12 and 18 months. Key among these were caregiving responsiveness, maternal mental health, couple relationship, and SES as a contextual factor. Perinatal factors most proximal to the infant had the strongest associations with social-emotional status. Beyond very low birthweight and medical risk, evidence for infant-specific factors was weaker. Risk and protective relationships were related but not always inverse. Findings from this review have the potential to inform the development of reliable tools for early screening of infant social-emotional development for application in primary care and population health contexts.

Music therapy enhances preterm infant's signs of engagement and sustains maternal singing in the NICU

Hospitalized preterm infants are exposed to stressful stimuli and early parental separation, which can undermine their long-term development and mother-infant bonding. Family-centered music therapy can enable positive mother-infant interactions, mediated by maternal infant-directed singing. This study aimed to investigate the effects of music therapy on preterm infant's signs of engagement, namely Eye Opening (EO) and Smiling (SM), and maternal vocalizations. Participants were 30 mother-preterm infant dyads in a Brazilian Neonatal Intensive Care Unit (NICU), divided into a Music Therapy Group (MTG) and a Comparison Group (CG). The MTG participated in 6 sessions of the Music Therapy Intervention for the Mother-Preterm Infant Dyad (MUSIP), with the aim of supporting maternal singing with the infant. Prior to discharge, all mothers were filmed during a Non-singing (NS) and Singing (S) interactional condition; in the S condition, mothers were explicitly asked to address their infants by singing. Results of video and audio analysis showed that infants in the MTG displayed greater Eye Opening (EO) frequency compared to CG, but only when they were in an initial awake state at test, suggesting that music therapy can potentialize infants' alertness, by increasing their disposition and chances of being engaged in the interaction with the mother. Non-religious mothers appeared to sing significantly more in the MTG than in the CG. These preliminary findings indicate that music therapy in the NICU could promote infant's signs of engagement during interactions and can sustain maternal singing, especially with non-religious mothers in Brazil.

Parent-child bonding and attachment during pregnancy and early childhood following congenital heart disease diagnosis

Diagnosis and treatment of congenital heart disease (CHD) can present challenges to the developing parent-child relationship due to periods of infant hospitalization and intensive medical care, parent-infant separations, child neurodevelopmental delay and feeding problems, and significant parent and child distress and trauma. Yet, the ways in which CHD may affect the parent-child relationship are not well-understood. We systematically reviewed the evidence on parental bonding, parent-child interaction, and child attachment following CHD diagnosis, according to a pre-registered protocol (CRD42019135687). Six electronic databases were searched for English-language studies comparing a cardiac sample (i.e., expectant parents or parents and their child aged 0-5 years with CHD) with a healthy comparison group on relational outcomes. Of 22 unique studies, most used parent-report measures (73%) and yielded mixed results for parental bonding and parent-child interaction quality. Observational results also varied, although most studies (4 of 6) found difficulties in parent-child interaction on one or more affective or behavioural domains (e.g., lower maternal sensitivity, lower infant responsiveness). Research on parental-fetal bonding, father-child relationships, and child attachment behaviour was lacking. Stronger evidence is needed to determine the nature, prevalence, and predictors of relational disruptions following CHD diagnosis, and to inform targeted screening, prevention, and early intervention programs for at-risk dyads.

[Questionnaires for the Assessment of Bonding During Pregnancy and after Birth (Part 3 of a series on psychological assessment during the peripartum period)]

Bonding of (expectant) parents with their child is of great importance for the psychological well-being of both the parents and the child. This is especially true if parents suffer from mental health problems like depression. Furthermore, attachment experiences during early childhood can affect both the child's mental health as well as later relationships. However, typical assessment methods like the Strange Situation Test are not very suitable in clinical practice in neonatology and obstetrics, especially since the focus here is primarily on the child's attachment behavior. In addition, bonding with the unborn child cannot be assessed in this way. Therefore, questionnaires represent a more feasible method for the assessment of parental bonding. Instruments have been developed for the time during pregnancy and after birth, but most of them were developed for women. Also, there is a need for further methodological development of these questionnaires. Cut-offs and norm values are highly relevant for clinical practice, but still need to be established in some cases. Assessment of parental bonding using questionnaires can potentially be beneficial and will most likely help to initiate timely supportive interventions.

Self-reinforcement: Coping strategies of Iranian mothers with preterm neonate during maternal role attainment in NICU; A qualitative study

INTRODUCTION

Having a preterm neonate in the neonatal intensive care unit (NICU) is one of the most stressful experience for parents. In facing these stressors, mothers need to find ways to adapt and control resources to maintain stability. The aim of this paper is to report coping strategies of mothers with preterm neonate during maternal role attainment in NICU.

METHODS

This paper reports a part of the findings of a grounded theory study that investigated how the mothers of preterm neonates go through maternal role attainment. The data were collected through in-depth semi-structured interviews with 12 mothers with preterm neonate admitted to the NICU and 5 nurses working in NICU. Data were analyzed according to Corbin and Strauss's (2015) approach using constant comparative analysis technique.

FINDINGS

Four themes, emerged from experiences of the participants, formed the concept of "Self-reinforcement" as the prominent strategy of mothers: "support seeking", "Spiritual getting in the mood", "Hope creation" and "Getting energy from the baby".

CONCLUSION

These findings showed that mothers use strategies to calm and support themselves and their neonates, and recognize that their lives had changed and need to adjust to their new circumstances.

Relationship between prenatal and maternal attachment: a longitudinal study from Turkey

The healthy development of the attachment which starts in the prenatal period and continues after the birth strengthens, positively supports the newborn care and contributes to raising healthy individuals in the future. This study was carried out to determine the effect of mother-fetus attachment that develops during pregnancy on mother-infant attachment in the postpartum period. This descriptive, correlational and longitudinal study was conducted with 150 volunteer mothers who could be reached again within 1-4 months after birth. Data were collected by the Questionnaire Form, the Prenatal Attachment Inventory (PAI) and the Maternal Attachment Scale (MAS). When the relationship between participants' PAI (41.20 ± 11.35) and MAS (26.05 ± 5.13) point averages was examined, it was observed that there was a weak, positive and statistically significant relationship between the two scales (r = 0.304, p=.000). It was observed that there was a relationship between the attachment between pregnant woman and developing fetus and the maternal attachment in the postnatal period.Impact statementWhat is already known on this subject? Attachment is a process which is formed by an interaction between the mother and the infant that is satisfying and enjoyed by both sides. It provides a basis for the establishment of relationships of the infant with the outside world and for the psychological development of the infant.What the results of this study add? This study has shown that a strong and healthy establishment of attachment in the prenatal period will positively contribute to the mother-infant attachment process in the postnatal period. A strong and healthy establishment of attachment in the prenatal period will positively contribute to the mother-infant attachment process in the postnatal period.What the implications are of these findings for clinical practice and/or further research? Mother-infant attachment can be strengthened just before the baby is born by determining the prenatal attachment and providing the appropriate approach to those who identify the problems in this regard, and thus, the risk of neglect and exploitation of the baby can be reduced and also the problems such as breastfeeding of the baby after birth, receiving proper care, and postnatal depression in the mother can even be reduced.

Comparison of mother’s therapeutic touch and voice stimulus in reduce pain in premature infants undergoing invasive procedures

Invasive procedures commonly cause recurring pain in preterm infants. Noninvasive pain management is an essential part of nursing intervention in the Neonatal Intensive Care Unit (NICU). The study’s aim is to identify the impact of touch therapy on pain in premature infants undergoing invasive treatments. The method was a quasi- experiment with 63 premature infants. The premature infants were classified into four groups: i) Mother’s touch Therapy (MTT), ii) Mother’s Voice Stimulus (MVS), iii) a combination of MTT and MVS, and iv) routine care. The observed infants’ pain scores were determined through a multiple regression model using the Generalized Estimating Equation (GEE) method. The GEE test showed that the combination of touch and sound therapy significantly reduced pain in premature infants undergoing invasive measures (p<0.05). A combined application of MTT and MVS is the most effective in reducing pain scores in infants undergoing invasive procedures and thus, can used safely as part of nursing intervention in the NICU.

Promoting infant mental health in the neonatal intensive care unit (NICU): A review of nurturing factors and interventions for NICU infant-parent relationships

Premature and medically vulnerable infants experience early and sometimes prolonged separation from their parents, intrusive and unnatural environments, painful and distressing procedures, difficulties with physiological regulation, increased biological and neurological vulnerabilities, and grow up to have higher rates of neurocognitive and psychosocial difficulties. Parents of infants born prematurely or with medical vulnerabilities, in turn, experience significant distress and are a psychiatrically vulnerable population, with very high rates of depression, anxiety, and posttraumatic stress disorder. The combination of these factors cause significant challenges for some of these infants and parents in developing an early optimal relationship and connection. Given the critical importance of early relationships with main caregivers for infant mental health and long-term developmental outcomes, we review various targets of intervention to promote healthy infant and parent mental health and bonding thereby facilitating an optimal infant-parent relationship in the NICU population.

The burden of early life stress on the nociceptive system development and pain responses

For a long time, the capacity of the newborn infant to feel pain was denied. Today it is clear that the nociceptive system, even if still immature, is functional enough in the newborn infant to elicit pain responses. Unfortunately, pain is often present in the neonatal period, in particular in the case of premature infants which are subjected to a high number of painful procedures during care. These are accompanied by a variety of environmental stressors, which could impact the maturation of the nociceptive system. Therefore, the question of the long-term consequences of early life stress is a critical question. Early stressful experience, both painful and non-painful, can imprint the nociceptive system and induce long-term alteration in brain function and nociceptive behavior, often leading to an increase sensitivity and higher susceptibility to chronic pain. Different animal models have been developed to understand the mechanisms underlying the long-term effects of different early life stressful procedures, including pain and maternal separation. This review will focus on the clinical and preclinical data about early life stress and its consequence on the nociceptive system.

War trauma and infant motor, cognitive, and socioemotional development: Maternal mental health and dyadic interaction as explanatory processes

BACKGROUND

Taking care of infants in conditions of war is highly demanding and a few studies reveal the negative impact of war trauma on maternal and infant well-being. Yet, little is known regarding the influence of trauma on infant development and the potential explanatory mechanisms. First, the present study examines how mothers' prenatal exposure to traumatic war events is associated with infant cognitive, motor, and socioemotional development. Second, it analyses the mediating roles of maternal postpartum mental health problems, quality of dyadic mother-infant interaction, and earlier infant development (at six months) in the association between prenatal traumatic war events and infants' developmental skills at 18 months.

METHOD

This prospective three-wave study involved 502 Palestinian pregnant females in their first trimester during the 2014 Gaza War and participated at delivery (T1) and when the child was six (T2;N = 392) and eighteen (T3; N = 386) months of age. Mothers reported their exposure to traumatic war events (human and material losses, horrors, and threat to life) at T1 and T2, and researchers photo-documented the extent of destruction at T1. Mothers reported infants' language, fine- and gross-motor, and socioemotional skills at T2 and researchers tested infants' motor, cognitive-language and socioemotional skills using the Bayley Scales of Infant development (BSID-II) at T3. Mothers reported their mental health problems (symptoms of post-traumatic stress disorder [PTSD], depression and somatization) at T2 and T3 as well as dyadic interaction quality (the emotional availability self-report, [EA-SR] brief) at T2.

RESULTS

First, the structural equation model (SEM) on direct effects indicated, in contrast to our hypotheses, that maternal prenatal exposure to traumatic war events did not associate with infants' developmental skills at T2 and predicted higher level of developmental skills at T3. Second, as hypothesized, we found two negative underlying mechanisms (paths) between high exposure and low levels of motor, cognitive-language, and socioemotional skills at T3: (1) through increased maternal mental health problems at T2, which then were associated with problems at T3, and (2) through increased maternal mental health problems at T2, which then were associated with a low quality of mother-infant-interaction and low level of infant developmental skills at T2.

CONCLUSION

Improving maternal mental health and encouraging close and positive dyadic interaction can be critical for infant sensorimotor, cognitive, and socioemotional development in war conditions.

Defining Attachment and Bonding: Overlaps, Differences and Implications for Music Therapy Clinical Practice and Research in the Neonatal Intensive Care Unit (NICU)

Preterm birth and the subsequent hospitalization in the Neonatal Intensive Care Unit (NICU) is a challenging life event for parents and babies. Stress, anxiety, and depressive symptoms, limitations in holding or touching the baby, and medical complications during the NICU stay can negatively affect parental mental health. This can threaten the developing parent-infant relationship and might adversely impact child development. Music therapy in the NICU is an internationally growing field of clinical practice and research and is increasingly applied to promote relationship building between parents and babies. The two most commonly used concepts describing the early parent-infant relationship are 'attachment' and 'bonding'. While frequently used interchangeably in the literature, they are actually not the same and describe distinctive processes of the early relationship formation. Thus, it is important to discuss the overlaps and differences between attachment and bonding and the implications for music therapy clinical practice and research. Whereas providing examples and possible scenarios for music therapists working on either bonding or attachment, the distinction between both concepts is relevant for many health care professionals concerned with early parenting interventions in the NICU. This will hopefully lead to a more precise use of theory, and ultimately, to a more informed clinical practice and research.

Anxiety and Depressive Disorders in Children Born Preterm: A Meta-Analysis

OBJECTIVE

Preterm birth is associated with a high prevalence of psychiatric disorders including internalizing problems. However, there is a lack of consensus on the risk for depression and on specific diagnostic profiles. This meta-analysis investigates the independent pooled odds of Diagnostic and Statistical Manual of Mental Disorders Fourth Edition anxiety and depressive disorders in children between 3 and 19 years of age born preterm compared with their term-born peers.

METHOD

PubMed/MEDLINE, PsycINFO, and Cumulative Index to Nursing and Allied Health Literature electronic databases were searched (last updated in September 2019) using population ("child"), exposure ("preterm birth"), and outcome ("anxiety") terms for English peer-reviewed publications. Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines were followed with the risk of bias assessed using the Newcastle-Ottawa Quality Assessment Scale. Pooled odds ratio (OR) with 95% confidence intervals (CIs) was estimated using fixed-effects models.

RESULTS

Eleven independent studies met the inclusion criteria. The pooled sample comprised 1294 preterm and 1274 term-born children with anxiety outcomes and 777 preterm and 784 term-born children with depressive outcomes between 3 and 19 years of age. Children born preterm had significantly greater odds for anxiety (OR: 2.17; 95% CI, 1.43-3.29), generalized anxiety (OR: 2.20; 95% CI, 1.26-3.84), and specific phobia (OR: 1.93; 95% CI, 1.05-3.52) relative to their term-born peers. There were no significant between-group differences for reported depressive disorders.

CONCLUSION

Preterm birth is associated with a higher prevalence of anxiety, but not depressive disorders, from 3 to 19 years of age, suggesting distinct etiological pathways in this high-risk population. The findings support variation in the rates of specific anxiety diagnoses, indicating the need to extend neurodevelopmental surveillance to encompass a holistic emotional screening approach.

Mothers' experiences of parenting and everyday life of children born at 23 weeks of gestation - a qualitative descriptive study

BACKGROUND

Surviving children born at 23 gestational weeks are a growing population. As many of these children face developmental challenges during childhood and adolescence, more knowledge is needed about the everyday life of this group. The parental perspective is important, as developmental problems often pose a challenge for the parents. The aim of this qualitative study was to explore mothers' experiences of parenting children born at 23 gestational weeks and of the children's everyday lives.

METHODS

This was a qualitative descriptive study conducted with mothers of children born at 23 weeks of gestation. These purposively sampled eight mothers were interviewed using a semi-structured interview. Thematic analysis was used to analyse the interviews.

RESULTS

Seven themes were formed on the basis of the interview data and they are presented in three dimensions: 1) the child seen from maternal perspective included themes 'emphasizing strengths in the midst of challenges', 'relations with peers and siblings', and 'emotional well-being and active life'; 2) the parenting experience included themes 'intensive mothering' and 'gratitude'; 3) the support included themes 'support from the social network' and 'support from society'.

CONCLUSIONS

The mothers described how the lives of their children were active and rich. The mothers were dedicated to motherhood and they also expressed feelings of gratitude. Mothers received support from social networks and from society. This qualitative study provided an important complementary perspective to the discussion on extremely premature children's quality of life. It also highlighted the importance of parental perspectives in assessing neonatal care and its outcomes.

Social Behavior as a Transdiagnostic Marker of Resilience

The recent shift from psychopathology to resilience and from diagnosis to functioning requires the construction of transdiagnostic markers of adaptation. This review describes a model of resilience that is based on the neurobiology of affiliation and the initial condition of mammals that mature in the context of the mother's body and social behavior. The model proposes three tenets of resilience-plasticity, sociality, and meaning-and argues that coordinated social behavior stands at the core sustaining resilience. Two lines in the maturation of coordinated social behavior are charted, across animal evolution and throughout human development, culminating in the mature human reciprocity of empathy, mutuality, and perspective-taking. Cumulative evidence across ages and clinical conditions and based on our behavioral coding system demonstrates that social reciprocity, defined by plasticity at the individual, dyadic, and group levels, denotes resilience, whereas the two poles of disengagement/avoidance and intrusion/rigidity characterize specific psychopathologies, each with a distinct behavioral signature. Attention to developmentally sensitive markers and to the dimension of meaning in human sociality may open new, behavior-based pathways to resilience.

Premature Birth and Developmental Programming: Mechanisms of Resilience and Vulnerability

The third trimester of pregnancy represents a sensitive phase for infant brain plasticity when a series of fast-developing cellular events (synaptogenesis, neuronal migration, and myelination) regulates the development of neural circuits. Throughout this dynamic period of growth and development, the human brain is susceptible to stress. Preterm infants are born with an immature brain and are, while admitted to the neonatal intensive care unit, precociously exposed to stressful procedures. Postnatal stress may contribute to altered programming of the brain, including key systems such as the hypothalamic-pituitary-adrenal axis and the autonomic nervous system. These neurobiological systems are promising markers for the etiology of several affective and social psychopathologies. As preterm birth interferes with early development of stress-regulatory systems, early interventions might strengthen resilience factors and might help reduce the detrimental effects of chronic stress exposure. Here we will review the impact of stress following premature birth on the programming of neurobiological systems and discuss possible stress-related neural circuits and pathways involved in resilience and vulnerability. Finally, we discuss opportunities for early intervention and future studies.

Longitudinal changes in attachment patterns of preterm infants born in a non-Western country

Unexpected early birth of an infant may affect the attachment formation of mother-child dyads. This longitudinal study aimed to explore mother-infant attachment patterns of very preterm (VPT) and preterm (PT) infants compared to their term-born peers in a non-Western country. Neurodevelopmental outcomes of infants, maternal anxiety and depressive symptoms, and sociodemographic features were evaluated to explore their effects on attachment. Eighteen VPT, 11 PT, 11 term infants and their mothers participated. Observations of attachment patterns and neurodevelopmental assessments were performed at 18 and 24 months of corrected age. This study identified a change in attachment patterns of VPT infants over time such that VPT infants tended to have less insecure attachment patterns with their mothers at the end of the infancy period. While motor and language development scores were associated with attachment patterns at 18 months, models predicting attachment patterns were no longer significant at 24 months. Therefore, change in VPT infants' developmental outcomes and attachment patterns over time suggests that preterm birth itself is not necessarily a risk factor for developing insecure attachment patterns; yet, developmental delays may account for insecure attachment patterns. It is suggested that efforts to promote developmental outcomes of preterm infants may improve mother-child attachment.

Parents' Experiences of the First Year at Home with an Infant Born Extremely Preterm with and without Post-Discharge Intervention: Ambivalence, Loneliness, and Relationship Impact

With increasing survival rates of children born extremely preterm (EPT), before gestational week 28, the post-discharge life of these families has gained significant research interest. Quantitative studies of parental experiences post-discharge have previously reported elevated levels depressive symptoms, posttraumatic stress-disorder and anxiety among the parents. The current investigation aims to qualitatively explore the situation for parents of children born EPT in Sweden during the first year at home. Semi-structured interviews were performed with 17 parents of 14 children born EPT; eight parents were from an early intervention group and nine parents from a group that received treatment as usual, with extended follow-up procedures. Three main themes were identified using a thematic analytic approach: child-related concerns, the inner state of the parent, and changed family dynamics. Parents in the intervention group also expressed themes related to the intervention, as a sense of security and knowledgeable interventionists. The results are discussed in relation to different concepts of health, parent-child interaction and attachment, and models of the recovery processes. In conclusion, parents describe the first year at home as a time of prolonged parental worries for the child as well as concerns regarding the parent's own emotional state.

Experiences of the mothers of infants hospitalized in the neonatal intensive care unit (NICU)

BACKGROUND

The mother-newborn relationship is more important in neonates hospitalized in the NICU than in healthy neonates. This study was conducted to explore the experiences of the mothers of infants hospitalized in the NICU.

MATERIALS AND METHODS

This qualitative study was done in 2016 by adopting a conventional content analysis approach. Thirty-five mothers in the NICUs, Imam Hossein Hospital and Fatemieh Hospital were selected. Their experiences were assessed using in-depth individual semi-structured interviews. Sampling was purposive and was continued until reaching data saturation.

RESULTS

Two hundred and nine primary codes were extracted. After removing duplicates and overlaps, 95 primary codes were categorized in 8 subcategories, 2 accessory categories and 1 main category based on their appropriateness, agreement, and similarity. The accessory categories of "mothers' worries" and "mothers' hopes" were merged into a more general, abstract category named "dual feelings about the baby".

CONCLUSIONS

The nurses' awareness of the mothers' experiences can help design interventions to promote the quality of care for mothers and infants in the critical period of the NICU admission.

Parenting Behavior at 18 Months Predicts Internalizing and Externalizing Problems at 6 Years in Moderately Preterm and Full Term Children

Moderately preterm born children (MPT) are at increased risk for behavior problems compared to full term born (FT) children. MPT children may receive less optimal parenting, and in response, may develop behavior problems. Our aims were to examine whether parenting behavior and mother–child interaction quality mediate the association between birth status and child behavior problems. Participants were 120 MPT children and 100 FT children. At 18 months of age, mothers reported on their parenting behavior (support and structure), and mother–child interaction (sensitivity and limit-setting) was observed. At 6 years of age, mothers reported on children’s behavior problems. Using structural equation modeling, birth status was found to predict attention problems, but not internalizing and externalizing problems. Mothers of MPT children set less appropriate limits than mothers of FT children at 18 months of age. More maternal structure at 18 months predicted fewer internalizing and externalizing problems, but not attention problems, at 6 years. These associations between parenting behavior, mother–child interaction quality, and child behavior problems were similar for MPT and FT children. Our findings indicate that maternal structure in toddlerhood is an important predictor of later internalizing and externalizing problems for both MPT and FT children.

Association between hyperemesis gravidarum and psychological symptoms, psychosocial outcomes and infant bonding: a two-point prospective case-control multicentre survey study in an inner city setting

OBJECTIVES

To assess if there is any association between hyperemesis gravidarum (HG), psychological morbidity and infant bonding and to quantify any psychosocial consequences of HG.

DESIGN

Two-point prospective case-control, multicentre survey study with antenatal and postnatal data collection.

SETTING

Three London hospitals.

PARTICIPANTS

Pregnant women at ≤12 completed weeks gestation recruited consecutively over 2 years. Women with HG were recruited at the time of admission; controls recruited from a low risk antenatal clinic. 106 women were recruited to the case group and 108 to the control. Response rates at antenatal data collection were 87% and 85% in the case and control groups, respectively. Postnatally, the response rate was 90% in both groups.

PRIMARY AND SECONDARY OUTCOME MEASURES

Primary outcomes were psychological morbidity in the antenatal and postnatal periods, infant bonding in the postnatal period and psychosocial implications of HG. Secondary outcomes were the effects of severity and longevity of HG and assessment of correlation between Edinburgh Postnatal Depression Scale scores and maternal-to-infant bonding scores.

RESULTS

Antenatally, 49% of cases had probable depression compared with 6% of controls (OR 14.4 (5.29 to 39.44)). Postnatally, 29% of cases had probable depression versus 7% of controls (OR 5.2 (1.65 to 17.21)). There was no direct association between HG and infant bonding. 53% of women in the HG group reported needing four or more weeks of sick leave compared with 2% in the control group (OR 60.5 (95% CI 8.4 to 2535.6)).

CONCLUSIONS

Long-lasting psychological morbidity associated with HG was evident. Significantly more women in the case group sought help for mental health symptoms in the antenatal period, however very few were diagnosed with or treated for depression in pregnancy or referred to specialist perinatal mental health services. HG did not directly affect infant bonding. Women in the case group required long periods off work, highlighting the socioeconomic impact of HG.

Parents' experiences of emotional closeness to their infants in the neonatal unit: A meta-ethnography

BACKGROUND

Physical and emotional parent-infant closeness activate important neurobiological mechanisms involved in parenting. In a neonatal care context, most research focuses on physical (parental presence, skin-to-skin contact) aspects; insights into emotional closeness can be masked by findings that overemphasise the barriers or challenges to parenting an infant during neonatal care.

AIM

To explore existing qualitative research to identify what facilitates and enables parents' experiences of emotional closeness to their infants while cared for in a neonatal unit.

STUDY DESIGN

A systematic review using meta-ethnographic methods. Search strategy involved searches on six databases, author runs, and backward and forward chaining. Reciprocal translation was used to identify and compare key concepts of parent-infant emotional closeness.

RESULTS

Searches identified 6992 hits, and 34 studies from 17 countries that involved 670 parents were included. Three overarching themes and associated sub-themes were developed. 'Embodied connections' describes how emotional closeness was facilitated by reciprocal parent-infant interactions, spending time as a family, and methods for parents to feel connected while physically separated. 'Inner knowing' concerns how knowledge about infant and maternal health and understanding the norms of neonatal care facilitated emotional closeness. 'Evolving parental role' relates to how emotional closeness was intertwined with parental identities of contributing to infant health, providing direct care, and being acknowledged as a parent.

CONCLUSION

Parent-infant closeness evolves and is facilitated by multifaceted biopsychosocial factors. Practice implications include creating private and uninterrupted family time, strategies for parents to maintain an emotional connection to their infant when separated, and neurobiology education for staff.

Trajectories of Overprotective Parenting and Hyperactivity-Impulsivity and Inattention Among Moderate-Late Preterm Children: A Population-Based Study

Parents of preterm children are more likely to adopt non-optimal parenting behaviors than parents of full-term (FT) children. However, there is a lack of studies on parents of children born moderate to late preterm (MLP; 32-36 gestational weeks). In this study, we aimed to examine: (1) the association between MLP birth status and the trajectory of parental overprotection throughout preschool years, and (2) the role of parental overprotection, MLP birth status, and their interaction in the prediction of the trajectories of hyperactivity-impulsivity and inattention throughout childhood. Data comes from a Canadian representative population-based cohort including 2028 FT, 100 MLP children, and their parents. Overprotective parenting was measured when children were 5, 17, and 29 months old. Hyperactivity-impulsivity and inattention symptoms were measured repeatedly from 4 to 8 years of age. Trajectories of parents' overprotectiveness and children's hyperactivity-impulsivity and inattention were modeled. MLP birth status was associated with an increase in parental overprotectiveness across the preschool period. MLP birth status and parental overprotection were both found to be associated with higher levels of hyperactivity-impulsivity symptoms across childhood. No interaction was found between birth status and parental overprotection. The results suggest that parents of MLP children become more overprotective across time compared to parents of FT children and that children born MLP and/or exposed to higher levels of parental overprotection demonstrated higher levels of hyperactivity-impulsivity symptoms across childhood.

The effect of cognitive-behavioral therapy on psychological distress in the mothers of preterm infants: a systematic review and meta-analysis

Introduction: The birth of a preterm infant has the potential to cause stress, anxiety, depression and Post-Traumatic Stress Disorder (PTSD) in mothers. Numerous interventions have been developed for the parents of preterm infants to deal with these problems. Cognitive-Behavioral Therapy (CBT) is a client-centered intervention for improving mental health and alleviating psychological distress by transforming unconstructive thoughts and behaviors. The present systematic review was conducted to evaluate the effect of CBT on anxiety, depression and PTSD (the primary outcomes) and stress (the secondary outcome) in the mothers of preterm infants.Methods: A search was carried out of all the articles published by 30 Sep. 2018 in English and Persian databases including Medline (via PubMed), Scopus, Embase (via Ovid), Web of Science, Psycinfo, Google Scholar, SID, Magiran and Iran Medex. The risk of bias was assessed for the studies based on the Cochrane Handbook. The meta-analysis results were reported as Standardized Mean Difference (SMD). The heterogeneity of the studies was examined using I², T² and Chi².Results: Four clinical trials on 455 mothers with preterm infants were systematically reviewed. The meta-analysis results revealed a lower mean depression score in the CBT group compared to the controls (SMD = -0.45; 95% CI: -0.98 to 0.08), but this difference was not statistically significant (p = .09). The mean scores of PTSD (MD = -11.69; 95% CI: -19.45 to -3.94; p = .003) and anxiety (SMD = -0.38; 95% CI: -0.61 to -0.15; p = .001) were significantly lower in the CBT group too.Conclusion: CBT was effective in decreasing the level of PTSD and anxiety in the mothers of preterm infants. Due to the small number of included studies and the small sample size, clinical trials with large sample sizes and a low risk of bias are recommended to provide evidence for the implementation of interventions affecting psychological distress in the mothers of preterm infants in clinical settings.

Preterm birth and maternal sensitivity: Findings from a non-western country

INTRODUCTION

Although there are several studies on maternal sensitivity of preterm-born children conducted in Western countries, the factors affecting the sensitivity of mothers of preterm infants have not been investigated outside the Western context.

OBJECTIVES

This study aimed to compare maternal sensitivity of preterm children at 18 months of corrected age with their healthy term-born peers and explore the factors associated with maternal sensitivity in a middle-income non-Western country. Moreover, the associations of maternal sensitivity with socio-demographic factors, maternal depression, and social-emotional competency and behavior problems of infants were investigated.

METHODS

In total, 70 (40 preterm-born and 30 term-born) mother-child dyads participated in this study. An observation-based measurement tool, Maternal Sensitivity Scale, was used to assess maternal sensitivity. Social-emotional competency and behavior problems of infants were evaluated via The Turkish version of the Brief Infant-Toddler Social Emotional Assessment. Maternal depressive symptoms were assessed via the Beck Depression Inventory. In addition, a demographic information form was filled out by the mothers.

RESULTS

Maternal sensitivity scores of preterm infants were significantly lower compared to term infants. Depressive symptoms scores and employment status of mothers, socio-economic status (SES), gestational age, breastfeeding duration, and behavior problems of children were the factors related to maternal sensitivity scores. In hierarchical regression analysis, SES and gestational age were the strongest predictors of maternal sensitivity. After controlling SES and gestational age, maternal depressive symptoms scores negatively predicted maternal sensitivity scores.

CONCLUSION

This study pointed out the factors associated with the maternal sensitivity of preterm infants outside the Western context. Interventions to improve sensitive parenting behaviors of preterm infants are needed, especially in socio-economically disadvantaged groups.

Family nurture intervention in the NICU increases autonomic regulation in mothers and children at 4-5 years of age: Follow-up results from a randomized controlled trial

Background

Maturation of multiple neurobehavioral systems, including autonomic regulation, is altered by preterm birth. The purpose of this study was to determine the long-term effects of Family Nurture Intervention (FNI) in the NICU on autonomic regulation of preterm infants and their mothers.

Method

A subset of infants and mothers (48% of infants, 51% of mothers) randomly assigned to either standard are (SC), or SC plus the FNI in the NICU in a prior RCT (ClincalTrials.gov; NCT01439269) returned for follow-up assessments when the children were 4 to 5 years corrected age (CA). ECGs were collected for 10 minutes in mothers and their children while children were in their mothers’ laps. Heart rate, standard deviation for heart rate, respiratory sinus arrhythmia (RSA)–an index of parasympathetic regulation, and a measure of vagal efficiency were quantified.

Results

Both children and mothers in the FNI group had significantly greater levels of RSA compared to the SC group (child: mean difference = 0.60, 95% CI 0.17 to 1.03, p = 0.008; mother: mean difference = 0.64, 95% CI 0.07 to 1.21, p = 0.031). In addition, RSA increased more rapidly in FNI children between infancy and the 4 to 5-year follow-up time point (SC = +3.11±0.16 log_e msec^2, +3.67±0.19 log_e msec² for FNI, p<0.05). These results show that the rate of increase in RSA from infancy to childhood is more rapid in FNI subjects.

Conclusion

Although these preliminary follow-up results are based on approximately half of subjects originally enrolled in the RCT, they suggest that FNI-NICU led to healthier autonomic regulation in both mother and child, when measured during a brief face-to-face socioemotional interaction. A Pavlovian autonomic co-conditioning mechanism may underly these findings that can be exploited therapeutically.

A Randomized Trial of Continuous Versus Intermittent Skin-to-Skin Contact After Premature Birth and the Effects on Mother-Infant Interaction

BACKGROUND

Premature birth affects opportunities for interaction between infants and mothers. Skin-to-skin contact (SSC) is standard care in neonatal care but has not been sufficiently studied regarding the effects on interaction between preterm infant and mothers.

PURPOSE

The purpose of this study was to compare interaction between preterm infants and their mothers after continuous versus intermittent SSC from birth to discharge. A secondary aim was to study a potential dose-response effect between time in SSC and quality of interaction.

METHODS

Families were randomly assigned to either continuous (n = 17) or intermittent (n = 14) SSC before delivery. Interaction was measured from videotapes of a Still-Face Paradigm collected at 4 months' corrected age. Face-to-face interaction was coded according to Ainsworth's Maternal Sensitivity Scales and the Maternal Sensitivity and Responsivity Scales-R. Dose-response correlations were calculated between mean time spent in SSC and each of the interaction scales.

RESULTS

There were no statistically significant differences between groups in maternal interactive behavior toward their infants regarding sensitivity, interference, availability, acceptance, withdrawal, or intrusivity. There was no correlation between mean time in SSC and quality of interaction.

IMPLICATIONS FOR PRACTICE

Continuous SSC from birth to discharge was not superior to intermittent SSC concerning mother-infant interaction between preterm infants and their mothers at 4 months' corrected age. However, compared with other studies, mean time in SSC was also high in the intermittent group.

IMPLICATIONS FOR RESEARCH

Further studies are needed to find out how interaction between parents and preterm infants can be improved, supported, and facilitated in the neonatal intensive care unit (NICU) and whether there is an optimal dose for SSC.

Maternal pre and perinatal experiences with their full-term, preterm and very preterm newborns

Background

Mothers’ reports about pregnancy, maternity and their experiences during the perinatal period have been associated with infants’ later quality of attachment and development. Yet, there has been little research with mothers of very preterm newborns. This study aimed to explore mothers’ experiences related to pregnancy, premature birth, relationship with the newborn, and future perspectives, and to compare them in the context of distinct infants’ at-birth-risk conditions.

Methods

A semi-structured interview was conducted with women after birth, within the first 72 h of the newborn’s life. A total of 150 women participated and were divided in three groups: (1) 50 mothers of full-term newborns (Gestational Age (GA) ≥ 37 weeks; FT), (2) 50 mothers of preterm newborns (GA 32–36 weeks; PT) and (3) 50 mothers of very preterm newborns (GA < 32 weeks; VPT).

Results

Mothers of full-term infants responded more often that their children were calm and that they did not expect difficulties in taking care of and providing for the baby. Mothers of preterm newborns although having planned and accepted well the pregnancy (with no mixed or ambivalent feelings about it) and while being optimistic about their competence to take care of the baby, mentioned feeling frightened because of the unexpected occurrence of a premature birth and its associated risks. Mothers of very preterm newborns reported more negative and distressful feelings while showing more difficulties in anticipating the experience of caring for their babies.

Conclusion

The results indicate that Health Care Systems and Neonatal Care Policy should provide differentiated psychological support and responses to mothers, babies and families, taking into account the newborns’ GA and neonatal risk factors.

Developmental Dimensions in Preterm Infants During the 1st Year of Life: The Influence of Severity of Prematurity and Maternal Generalized Anxiety

BACKGROUND

The literature has recognized premature birth as a risk factor for infant development and maternal anxiety. This study investigated the impact of the severity of birth weight, as well as of maternal anxiety at 3 months of infants' corrected age, on infants' outcomes during the 1st year postpartum. Moreover, it described the longitudinal trajectories of developmental outcomes, additionally exploring the impact of anxiety.

METHODS

The study compared 147 mothers and their 147 newborns, differentiated in 25 Extremely Low Birth Weight (ELBW), 41 Very Low Birth Weight (VLBW), and 81 Full-Term (FT) infants. At 3, 9, and 12 months (corrected age in the case of preterm infants) the level of infants' development was investigated according to the 5 quotients (Locomotor, Personal and Social, Hearing and Language, Eye-hand Co-ordination and Performance) of the Griffiths Mental Development Scales (GMDS-R). During the assessment of 3 months, mothers fulfilled Penn State Worry Questionnaire (PSWQ) to evaluate the presence of generalized anxiety.

RESULTS

Among the 5 GMDS-R quotients, significant effect of severity of birth weight emerged only for Performance quotient: preterm infants (ELBW at 3 months; VLBW at 12 months) showed lower scores than FT ones. Moreover, this quotient decreased from 3 to 9 and to 12 months for VLBW and FT infants, while it was stable for ELBW ones. A significant interaction between severity of birth weight and maternal anxiety emerged for Hearing and Language and Locomotor quotients. In the first case, scores for ELBW infants, independently from maternal anxiety, decreased from 9 to 12 months. The same results emerged for VLBW infants, in the case of non-anxious mothers. Regarding Locomotor quotient, mean scores decreased from 3 to 9 and to 12 months for all groups in the case of non-anxious mothers. Conversely, when mothers were anxious, this decrease emerged only for VLBW infants. Lastly, ELBW, VLBW and FT showed difference in the growth and slope of the trajectories of different quotients.

CONCLUSION

The severity of birth weight for preterm infants, also in interaction with maternal anxiety, had significant and specific impact on different dimensions of infants' development. Clinical implications of these results underline the need for individualized interventions.

The body comes first. Embodied reparation and the co-creation of infant bodily-self

During infancy relational experiences of body-to-body exchanges (i.e., embodied interactions) contribute to the infant's bodily perception. Early embodied interactions are based on countless multimodal reciprocal exchanges, in which mother and infant contribute to interpersonal rhythmic cycles of co-regulation (i.e., attunement). However, it remains unclear how infants and their mothers actually accomplish attunement in their exchanges. Interactions between mothers and their infants typically fluctuate between attuned and misattuned states and recovery attunement states by a process called 'reparation'. Here, we discuss recent neuroscientific evidence that provides insight into the mechanisms underpinning the concepts of attunement and misattunement in early embodied interactions. We propose that a process of embodied reparation might be achieved within the dyad through tactile contact behaviors (e.g., skin-to-skin, affectionate touch) and maternal interoceptive sensitivity (i.e., ability to perceive internal input about the state of one's own body). We describe how these elements that mothers provide during embodied interactions with their infants, might contribute not only to bodily attunement, but also to co-create the infant bodily-self.

Do developmental and temperamental characteristics mediate the association between preterm birth and the quality of mother-child interaction?

BACKGROUND

The current study aims to evaluate the association between preterm birth and the quality of mother-child interaction of very preterm-, moderate preterm-, and full-term-born children at 18 and 36 months and to determine whether developmental and behavioral characteristics mediate the association between preterm birth and the quality of mother-child interaction.

METHOD

Participants included 110 preterm-born children and 39 full-term-born children assessed at ages 18 and 36 months. Mother-child free play interactions, the Mullen Scales of Early Learning, the Infant Behavior Questionnaire, and the Early Childhood Behavior Questionnaire were administered.

RESULTS

Significant associations between preterm birth and the quality of mother-child interaction were found at 18 and 36 months. The mother-child interaction quality was less optimal for the preterm-born children compared with the full-term-born children, mainly so for the very preterm-born children. Unlike behavioral characteristics, cognitive development was found to mediate the association between the gestational age-based group and the quality of mother-child interaction.

CONCLUSIONS

Intervention programs for preterm-born children and their families, should consider maternal and children's behaviors during mother-child interactions, in addition to cognitive, language, motor and emotional regulation abilities, and particularly so with very preterm-born children, who exhibit slower cognitive development.

What Do We Know About the Preterm Behavioral Phenotype? A Narrative Review

Preterm birth is associated with a significantly increased risk for childhood and adolescent psychopathology relative to full-term birth, with an inverse relationship between gestational age at birth and later risk for psychopathology. The manifestation of symptomatology and comorbidity profiles of emotional and behavioral adjustment problems in this high-risk group have been shown to be distinct from the broader pediatric population. Acknowledging these differences, a preterm behavioral phenotype has been proposed and increasingly recognized, highlighting the unique, frequent co-occurrence of symptomatology associated with attention-deficit/hyperactivity disorder, autism spectrum disorder, and anxiety disorders. The current state-of-the-art review provides a comprehensive characterization of this phenotype to date and further highlights key knowledge gaps primarily regarding the evolution of symptoms, co-occurrence of disorders and/or symptomatology within the phenotype, and associations of the phenotype with chronological age and degree of prematurity.

Out-of-home care placements of children and adolescents born preterm: A register-based cohort study

BACKGROUND

Preterm birth predisposes to child protection action in the form out-of-home care. The impact of the degree of preterm birth on the likelihood for OHC placement(s) and their timing is unknown.

METHODS

This population-based register-linkage study assessed the likelihood of OHC placement in different gestational age groups using multivariable Cox regression models. All 193 033 traceable singleton (8324 preterm, 4.3%) liveborn in Finland (January 1987-September 1990), as the first index child of each mother within the cohort period, were followed up until their 18th birthday.

RESULTS

A total of 6562 children (3.4%) experienced OHC. In comparison with full-term children (39-41 weeks), those born at 23-33 completed weeks were predisposed to OHC (hazard ratio [HR] 2.11, 95% confidence interval [CI] 1.74, 2.56). For those born late preterm (34-36 weeks) and early term (37-38 weeks), the HR were 1.54 (95% CI 1.37, 1.73) and 1.19 (95% CI 1.12, 1.26), respectively. Adjustment for parental and child characteristics attenuated the HRs: 23-33 weeks: 1.31 (95% CI 1.07, 1.59), 34-36 weeks: 1.17 (95% CI 1.04, 1.31), and 37-38 weeks: 1.08 (95% CI 1.02, 1.16). However, the adjusted HRs for first OHC entries at 0-5 years of age were higher: 23-33 weeks 2.29 (95% CI 1.72, 3.05), 34-36 weeks 1.76 (95% CI 1.46, 2.13), and 37-38 weeks 1.40 (95% CI 1.25, 1.56). Among those born preterm or early term, in comparison with their term born peers, no excess risk for OHC was seen after 5 years.

CONCLUSIONS

A dose-response relationship exists between the level of preterm birth and OHC placement risk. OHC placements are more common among early and late preterm, and early term children, compared with those born full term, and occur at younger age. Perinatal and postnatal adverse circumstances appear to explain the phenomenon only partly.

Feasibility of Live-Performed Music Therapy for Extremely and Very Preterm Infants in a Tertiary NICU

Objective: We aimed to investigate the feasibility of live-performed music therapy for extremely and very preterm infants admitted to the neonatal intensive care unit (NICU), and their parents, starting the 1st-2nd week after birth. They may benefit from live-performed music therapy as comforting non-pharmacological intervention. Study Design: We included infants born before 30 weeks' gestation in a single center NICU study. Live-performed music therapy was provided three times per week, tailored to the infant's medical condition. Parents were actively involved. Feasibility was determined as a combination of participation, drop-out, overstimulation (based on COMFORT-Neo scores), and evaluations of the intervention by parents and nurses (using a questionnaire on perceived effects on the parent, their infant and the NICU sound environment). Results: We included 18 infants (90% participation rate), with a gestational age of median 27 weeks (IQR 26-28 weeks), 61% males. One infant (5.6%) dropped-out. Differences of COMFORT-Neo scores during and after sessions compared with before sessions were non-significant; overstimulation by music therapy did not occur. Parents reported high satisfaction (highest score possible of 7) with the interventions and reported improvements in both infant and their own respiratory rates. Nurses also reported high satisfaction with the intervention and perceived a quieter NICU sound environment during and after sessions. Conclusion: Live-performed music therapy for extremely and very preterm infants is feasible and well-tolerated, and is experienced as an added value to developmental care. Future studies should assess both short-term and long-term effects, to determine whether this intervention should be part of routine care at the NICU and whether it is most beneficial to start shortly after birth.

Interdisciplinary assessment

Interdisciplinary assessment (IA) is defined as the integration of clinical contributions by healthcare professionals from distinct disciplines into a comprehensive diagnostic and prognostic evaluation. This process requires the professionals to independently and simultaneously consider and gage clinical information collected via a variety of methods and from a variety of informants. A shared perception of the clinical situation is progressively achieved via team meetings. IA helps clinicians to overcome the many challenges posed in today's context for assessment and treatment planning in the field of neurodevelopmental disorders. Most national and international guidelines recommend the inclusion of IA in the diagnostic workup for complex cases (e.g., autism spectrum and attention deficit hyperactivity disorder). Hence, IA should always be part of the neurodevelopmental disorder diagnostic process in children in general and preterm infants in particular.

Early environment and long-term outcomes of preterm infants

Prematurity is associated with an increased risk of long-term health and neurodevelopmental problems. Key perinatal and neonatal factors that affect these outcomes have long been studied. However, more recently, there has been an appreciation of the importance of environmental factors in long-term outcomes of preterm babies, particularly in light of the rapid maturation of the brain during these babies' early days of life. Breastmilk and breastfeeding is the gold standard for infant feeding, including preterm babies. The benefits are well established in regard to protection from serious complications like necrotising enterocolitis. Although theoretically plausible, the benefits for neurodevelopment are less clear. Noise, pain and the environment of the neonatal intensive care can also affect infant neurodevelopment. It is established that noise and pain have deleterious effects. However, the benefits of single-room vs open-bay neonatal units remain under debate. Developmental care practices, of which there are many, are increasingly embraced worldwide. There are benefits both for the parents and the baby, however, the evidence is difficult to pool due to the heterogeneity of studies and study populations. Finally, it is important to remember the importance of the role of parents in shaping long-term neurodevelopment of the high-risk preterm newborn. Increasingly, positive parenting and parents' mental health are shown to have long lasting advantages for preterm infants. A deeper understanding of early environmental factors is key to developing future interventions to optimise outcomes of preterm newborns.

The contribution of maternal executive functions and active coping to dyadic affective dynamics: Children with autism spectrum disorder and their mothers

Parenting is a cognitive, emotional, and behavioral endeavor, where parents' control capacities, including executive functions and active control coping, help parents to guide and regulate interactions with their children; yet limited research investigates how these capacities are associated with parent-child affective regulation processes during parent-child interactions. This study examined whether maternal executive functions (sustained attention, interference inhibitory control, working memory) and active engaged coping were related to dyadic affective flexibility and positive mutual affective interactions between mothers and their young children with autism spectrum disorders (N = 40). Dyadic flexibility and mutual positive affect were measured using dynamic systems-based modeling of second-by-second affective patterns during a mother-child interaction. The results showed that higher levels of maternal sustained attention and inhibitory control were related to increased dyadic affective flexibility. In addition, higher levels of maternal sustained attention and higher use of engaged coping were related to dyadic mutual positive affect. The findings highlight the importance of maternal cognitive control capacity in promoting adaptive parent-child dyadic regulatory processes.

Interactive sequences between fathers and preterm infants in the neonatal intensive care unit

AIMS

The first purpose of the study was to examine fathers' spontaneous communicative behavior with their preterm infants in the neonatal intensive care unit, and how father's and infant's behaviors affected each other. The second purpose was to examine any possible association between the fathers' and/or infants' characteristics and the quality of fathers' behaviors with their infants.

STUDY DESIGN/SUBJECTS/OUTCOME MEASURES

Father-preterm infant dyads (n=20) were assessed at 34-36 weeks postmenstrual age, during a spontaneous face-to-face communication with the infant placed in a heated cot in the NICU, and coded according to the Parent-Preterm Infant Coding System.

RESULTS

The presence of the father's Affiliative Behavior increased the occurrences of infant Gazing at the parent's face. In turn, infant gazing increased the occurrence of paternal Affiliative Behavior. The likelihood of infant's Gazing at the father's face was also significantly elicited by infrequent occurrences of paternal Affectionate Talk, co-occurring with Gazing at infant with Positive Facial Affect (but no Touch). With regard to the predictors of quality in father-infant interactions, we found a significant positive correlation between fathers' level of depressive symptomatology and fathers' Affiliative Behavior.

CONCLUSION

Our results show the of bidirectional sequential patterns of communication between fathers and preterm infants at 35 weeks postmenstrual age, and provide important information about the quality and modalities of paternal communication and their influence on infant behavioral states. From a clinical perspective, these results suggest that father-specific interventions designed to improve and sustain fathers' positive engagement with infants in the NICU should be pursued.

Depressive symptoms and maternal psychological distress during early infancy: A pilot study in preterm as compared with term mother-infant dyads

BACKGROUND

Preterm birth does not only affect infants but also represents an unexpected and traumatic event for parents. There are few reports on parenting stress during early infancy comparing preterm and term mothers, with the results being somewhat inconsistent.

METHODS

As part of a longitudinal study, preterm mother-infant and term mother-infant dyads were enrolled. Dyads were assessed twice: during hospitalisation in the neonatal intensive care unit (NICU) and at 3 months of infant age (corrected age for preterm). Each mother completed a self-report set of psychological questionnaire in both time points. All the children underwent a neurological examination at 40 weeks post conceptional age and at 3 months (corrected age for preterm).

RESULTS

20 preterm and 20 term dyads were included. NICU mothers reported elevated postnatal depressive symptoms and high stress level, even if the preterm infants were with low perinatal risk and normal neurological examination. Comparing preterm infant with low perinatal risk and normal neurological examination with term-born children at 3 months, we found higher parental stress in term mothers than in preterm mothers.

LIMITATIONS

This study was limited by a relatively small sample size; findings are preliminary and warrant further investigation in larger-scale study.

CONCLUSIONS

Findings confirm that becoming a mother of a preterm infant is an event associated with emotional distress. These symptoms may resolve with time, and sometimes are independent of the infant's clinical severity. Assessing parental sources of stress and subsequent follow-up is essential to promote parental support, both for preterm and term mothers.