Interactions of parents and nurses with high-risk preterm infants

Losing touch

The need for human touch is universal among critical care patients and is an important component of the nurse-patient relationship. However, multiple barriers to human touch exist in the critical care environment. With little research to guide practice, we argue for the importance of human touch in the provision of holistic nursing care.

Comparing the effects of minimal handling protocols on the physiological parameters of preterm infants receiving exogenous surfactant therapy

BACKGROUND

The practice of minimal handling is recommended for preterm infants (PTIs). However, few studies have investigated the effects of this practice among these infants or the time needed to ensure greater physiological stability, especially after exogenous surfactant treatments.

OBJECTIVE

The current study compared the effects of two protocols of minimal handling on the physiological variables of PTIs after surfactant therapy.

METHOD

An exploratory prospective observational study was performed with 40 PTIs weighing less than 1,500 g. The infants were divided into two groups and monitored for 72 hours. One group received the standard minimal handling procedure during the first 12 hours after surfactant therapy; the other group (i.e., the modified group) received minimal handling within 72 hours after surfactant therapy. Infant heart rate (HR), oxygen saturation, body temperature, and the adverse events associated with changes to these variables were monitored every 10 minutes.

RESULTS

Significant between-group differences were not found with regard to the occurrence of the adverse events associated with physiological changes (p>0.05).

CONCLUSION

The practice of minimal handling among very low birth weight infants did not alter their physiological stability when performed either 12 or 72 hours after surfactant therapy.

Prem Baby Triple P a new parenting intervention for parents of infants born very preterm: acceptability and barriers

Over 10% of preterm infants develop major disabilities, 50% develop behavioural problems and 40% need special education (Huddy et al., 2001; Webster, 2003). Prem Baby Triple P is a new variant of the Positive Parenting Program (Triple P) adapted specifically for parents of very preterm infants. The aim of this study is to assess the acceptability of Prem Baby Triple P to parents of infants born preterm and to test whether parental attributions and parental perception of infant health/developmental status are barriers to intervention acceptability. One hundred and twenty-three parents of preterm infants participated, 83 parents of very preterm infants and 40 parents of preterm infants. In addition, 32 parents of term infants participated as a comparison group. The acceptability of Prem Baby Triple P was moderately high and did not differ significantly across the three groups. Parental attributions were not found to be barriers to intervention acceptability and parental perceptions that their infant is less healthy/developmentally delayed facilitated Prem Baby Triple P acceptance in parents of infants born very preterm. This suggests that the planned Prem Baby Triple P content is acceptable to parents of infants born very preterm and sensitised to medical and developmental issues. These findings, as social validation data, will contribute towards the further development of Prem Baby Triple P and a future randomised controlled trial.

Parental caregiving and developmental outcomes of infants of mothers with HIV

BACKGROUND

All infants exposed to human immunodeficiency virus (HIV) prenatally, even those who do not become infected, are at risk for developmental problems because of poverty, prenatal substance abuse, and maternal illness.

OBJECTIVES

The purpose was to describe the development of infants of mothers with HIV and to determine, using hierarchical linear models, the longitudinal effects of child characteristics, parental caregiver characteristics, family characteristics, and parenting quality on development.

METHODS

Eighty-one infants born to women with HIV and their primary parental caregivers were followed-up until 18 to 24 months of age; 53 infants were always cared for by their biologic mothers, 16 were always cared for by kin or foster parents, and 12 had primary caregiver changes. Predictor variables and developmental outcomes were obtained at enrollment and 6, 12, 18, and 24 months.

RESULTS

Mental development and adaptive behavior scores decreased over age. Infants with changes in their primary caregiver had lower motor and adaptive behavior scores than infants remaining with consistent caregivers. Higher mental, motor, and adaptive behavior scores were associated with more positive attention and more negative control, whereas better language abilities were associated only with more positive attention. Child, maternal, and family characteristics had lesser effects. HIV-infected infants and infants of mothers with more education had lower mental, motor, and adaptive behavior scores. Male gender and more family conflict were associated with lower motor and adaptive behavior scores. Infants from smaller families had lower mental scores.

CONCLUSIONS

Because both parenting quality and consistency of the primary caregiver influenced developmental outcomes, interventions with the mothers of these infants need to focus both on improving the quality of parenting and reducing the frequency of primary caregiver changes.

The Mother-Infant Feeding Relationship Across the First Year and the Development of Feeding Difficulties in Low-Risk Premature Infants

Although feeding problems are common during infancy and are typically accompanied by relational difficulties, little research observed the mother-infant feeding relationship across the first year as an antecedent to the development of feeding difficulties. We followed 76 low-risk premature infants and their mothers from the transition to oral feeding in the neonatal period to the end of the first year. Prior to hospital discharge, microlevel patterns of maternal touch and gaze were coded during feeding and nonfeeding interactions, global patterns of maternal adaptation were assessed, and infants' neurobehavioral status was tested. Psychomotor development was evaluated at 4 months. At 1 year, feeding difficulties were determined on the basis of maternal interview and direct observations of feeding interactions. Mothers of infants who exhibited feeding difficulties at 1 year showed less affectionate touch and gaze during nonfeeding interactions and more gaze aversion and lower adaptability during feeding interactions already in the neonatal period. Infants with feeding difficulties demonstrated poorer psychomotor performance at 4 months. Feeding interactions of infants with feeding difficulties at 1 year were characterized by higher maternal intrusiveness, lower infant involvement, and greater infant withdrawal. Less maternal affectionate touch and lower maternal adaptation in the neonatal period, poor infant psychomotor skills, and higher maternal intrusiveness and lower infant involvement at 1 year predicted feeding difficulties. The findings underscore the role of the relational components across the first year in the development of feeding difficulties.

Parent-infant synchrony and the construction of shared timing; physiological precursors, developmental outcomes, and risk conditions

Synchrony, a construct used across multiple fields to denote the temporal relationship between events, is applied to the study of parent-infant interactions and suggested as a model for intersubjectivity. Three types of timed relationships between the parent and child's affective behavior are assessed: concurrent, sequential, and organized in an ongoing patterned format, and the development of each is charted across the first year. Viewed as a formative experience for the maturation of the social brain, synchrony impacts the development of self-regulation, symbol use, and empathy across childhood and adolescence. Different patterns of synchrony with mother, father, and the family and across cultures describe relationship-specific modes of coordination. The capacity to engage in temporally-matched interactions is based on physiological mechanisms, in particular oscillator systems, such as the biological clock and cardiac pacemaker, and attachment-related hormones, such as oxytocin. Specific patterns of synchrony are described in a range of child-, parent- and context-related risk conditions, pointing to its ecological relevance and usefulness for the study of developmental psychopathology. A perspective that underscores the organization of discrete relational behaviors into emergent patterns and considers time a central parameter of emotion and communication systems may be useful to the study of interpersonal intimacy and its potential for personal transformation across the lifespan.

Maternal postpartum behavior and the emergence of infant–mother and infant–father synchrony in preterm and full-term infants: The role of neonatal vagal tone

Relations between maternal postpartum behavior and the emergence of parent-infant relatedness as a function of infant autonomic maturity were examined in 56 premature infants (birthweight = 1000-1500 g) and 52 full-term infants. Maternal behavior, mother depressive symptoms, and infant cardiac vagal tone were assessed in the neonatal period. Infant-mother and infant-father synchrony, maternal and paternal affectionate touch, and the home environment were observed at 3 months. Premature birth was associated with higher maternal depression, less maternal behaviors, decreased infant alertness, and lower coordination of maternal behavior with infant alertness in the neonatal period. At 3 months, interactions between premature infants with their mothers and fathers were less synchronous. Interaction effects of premature birth and autonomic maturity indicated that preterm infants with low vagal tone received the lowest amounts of maternal behavior in the postpartum and the least maternal touch at 3 months. Infant-mother and infant-father synchrony were each predicted by cardiac vagal tone and maternal postpartum behavior in both the preterm and full-term groups. Among preterm infants, additional predictors of parent-infant synchrony were maternal depression (mother only) and the home environment (mother and father). Findings are consistent with evolutionary perspectives on the higher susceptibility of dysregulated infants to rearing contexts and underscore the compensatory mechanisms required for social-emotional growth under risk conditions for parent-infant bonding.

Mother-Child touch patterns in infant feeding disorders: relation to maternal, child, and environmental factors

OBJECTIVE

To examine mother and child's touch patterns in infant feeding disorders within a transactional framework.

METHOD

Infants (aged 9-34 months) referred to a community-based clinic were diagnosed with feeding disorders (n = 20) or other primary disorder (n = 27) and were case matched with nonreferred controls (n = 47). Mother-child play and feeding were observed and the home environment was assessed. Microcoding detected touch patterns, response to partner's touch, and proximity at play. Relational behaviors were coded during feeding.

RESULTS

Compared with infants with other primary disorder and case-matched controls, less maternal affectionate, proprioceptive, and unintentional touch was observed in those with feeding disorders. Children with feeding disorders displayed less affectionate touch, more negative touch, and more rejection of the mother's touch. More practical and rejecting maternal responses to the child's touch were observed, and children were positioned more often out of reach of the mothers' arms. Children with feeding disorders exhibited more withdrawal during feeding and the home environment was less optimal. Feeding efficacy was predicted by mother-child touch, reduced maternal depression and intrusiveness, easy infant temperament, and less child withdrawal, controlling for group membership.

CONCLUSIONS

Proximity and touch are especially disturbed in feeding disorders, suggesting fundamental relationship difficulties. Mothers provide less touch that supports growth, and children demonstrate signs of touch aversion. Touch patterns may serve as risk indicators of potential growth failure.

Direct and indirect effects of breast milk on the neurobehavioral and cognitive development of premature infants

Eighty-six premature infants were tested to examine the effects of maternal breast milk on infant development. Infants were classified by breast-milk consumption during the hospitalization period (M = 57.4 days) into three groups: those receiving minimal (<25% of nutrition), intermediate (25-75%), and substantial (>75%) amounts of breast milk. Infants in the three groups were matched for birth weight, gestational age (GA), medical risk, and family demographics. At 37 weeks GA, mother-infant interaction was videotaped, maternal depression self-reported, and neurobehavioral maturation assessed by the Neonatal Behavior Assessment Seale (Brazelton, 1973). At 6 months corrected age, infants were tested with the Bayley II (Bayley, 1993). Infants receiving substantial amounts of breast milk showed better neurobehavioral profiles-in particular, motor maturity and range of state. These infants also were more alert during social interactions, and their mothers provided more affectionate touch. Higher maternal depression scores were associated with lower quantities of breast milk, longer latencies to the first breast-milk feeding, reduced maternal affectionate touch, and lower infant cognitive skills. Maternal affectionate touch moderated the relations between breast milk and cognitive development, with infants receiving a substantial amount of breast milk and frequent touch scoring the highest. In addition to its nutritional value, breast milk may be related to improved maternal mood and interactive behaviors, thereby indirectly contributing to development in premature infants.

Testing a family intervention hypothesis: the contribution of mother-infant skin-to-skin contact (kangaroo care) to family interaction, proximity, and touch

The provision of maternal-infant body contact during a period of maternal separation was examined for its effects on parent-infant and triadic interactions. Participants were 146 three-month-old preterm infants and their parents, half of whom received skin-to-skin contact, or kangaroo care (KC), in the neonatal nursery. Global relational style and micro-patterns of proximity and touch were coded. Following KC, mothers and fathers were more sensitive and less intrusive, infants showed less negative affect, and family style was more cohesive. Among KC families, maternal and paternal affectionate touch of infant and spouse was more frequent, spouses remained in closer proximity, and infant proximity position was conducive to mutual gaze and touch during triadic play. The role of touch as a constituent of the co-regulatory parent-infant and triadic systems and the effects of maternal contact on mothering, co-parenting, and family processes are discussed.

Temperament characteristics of premature infants in the first year of life

Parenting preterm infants in the first months after hospital discharge is challenging. Although preterm infants are considered to be difficult, preterm temperament at less than 3 months is unknown empirically. The purpose of this analysis was to investigate the 6-week temperament characteristics of preterm infants in comparison with standardized norms of full-term infants. The sample of 74 infants with gestational ages at birth between 24 and 32 weeks were enrolled in a study of preterm infant neurobehavioral outcomes. Mothers rated temperament at 6 weeks, 6 months, and 12 months of age (adjusted for prematurity). At 6 weeks the premature infants were significantly less rhythmic (regular), more distractible (soothable), less approaching (more withdrawing), and less intense than standardized norms for full-term infants. From these data we conclude that premature infants may be initially more challenging to parent. Temperament moderated over time but remained significantly lower in persistence at 12 months. Considerable change in temperament in the first 12 months of life may be influenced by biological and environmental factors common to the premature birth experience.

Infant handling in the NICU: does developmental care make a difference? An evaluative review of the literature

Infant handling and disruptions in the neonatal intensive care unit are environmental stressors over which nurses have the most control. Two of the major goals of developmental care are individualizing care by decreasing infant disruptions and handling by caregivers, and modulating or attenuating infant responses to the care they receive. However, it has yet to be established to what extent these goals have been achieved. This article will provide a comparative review of selected literature to ascertain what effect, if any, the introduction of developmental care has had on infant handling or disruption in the neonatal intensive care unit.

Nursing care and the development of sleeping and waking behaviors in preterm infants

The relationship between nursing care and the development of sleep-wake behaviors of 71 medically high-risk preterms was examined. The development of preterm infants' sleep-wake states, jitteriness, and negative facial expressions were influenced not only by the presence of the nurse, but also by the type of caregiving the nurse provided. The infant was awake more often when with caregivers than when alone. Waking states increased over time only when the infant was with caregivers, whereas quiet sleep increased only when the infant was alone. Infant behaviors and sleep-wake development were related to the intrusiveness of care. For example, negative facial expressions and sleep-wake transitions increased over time during the most intrusive caregiving. The development of sleeping and waking in preterm infants appears to depend not only on biological maturation but also nursing stimulation. As long-term developmental effects of nurse caregiving are unknown, additional research is needed.

Effect of standard rest periods on convalescent preterm infants

OBJECTIVE

To examine the effects of standardized rest periods on the sleep-wake states of preterm infants who were convalescing.

DESIGN

A randomized experimental study conducted from time of infants' entry into intermediate care until their discharge from the hospital. Because subjects' time in this study varied, data were analyzed cross-sectionally using the observation made between 5-11 days of the study and longitudinally over 3 weeks using a subset of subjects.

SETTING

The intermediate care nursery of a tertiary care hospital.

SUBJECTS

Forty-six preterm infants (23 matched pairs). A subset of 12 pairs, in which infants in the experimental and the control groups were in the study for 3 weeks, was analyzed longitudinally.

INTERVENTIONS

Four standardized rest periods each day.

MAIN OUTCOME MEASURES

Infants were observed once a week between noon and 8 p.m. Three sleep-wake states--quiet awake, active, and sleep--were measured as percentages of the naps and total observation.

RESULTS

Within 5 days, infants in the experimental group exhibited more sleep (F[1,44] = 2.37, p < 0.05) and less active states (F[1,44] = 3.06, p < 0.01) during nap time. Infants receiving the intervention for 3 weeks had more sleep (F[1,22] = 4.63, p < 0.05) and less quiet waking states (F[1,22] = 13.85, p < 0.01) during naps. State patterns over the entire observation did not differ between the groups at 5 days, but by 3 weeks, infants in the experimental group had less quiet waking (F[1,22] = 17.44, p < 0.001) and longer uninterrupted sleep bouts (F[1,22] = 5.19, p < 0.05).

CONCLUSIONS

A simple modification of nursing care had an impact on the sleeping and waking states of preterm infants.