A Neurobehavioral Intervention Incorporated into a State Early Intervention Program is Associated with Higher Perceived Quality of Care Among Parents of High-Risk Newborns

The newborn behavioural observations system: A relationship-building intervention to support families in the neonatal intensive care unit

AIM

Relationship-based interventions for neonatal intensive care unit families have potential to improve parent and infant outcomes; yet, their implementation has been modest within systems of care for high-risk newborns. The purpose of this paper is to describe a relationship-building intervention, the newborn behavioural observation system, summarise the evidence supporting its use, and address its clinical application for high-risk parent-infant dyads in the neonatal intensive care unit.

METHODS

We summarise the extant literature describing the use of the newborn behavioural observation system in high-risk populations.

RESULTS

While the body of literature supporting the use of the newborn behavioural observation system is modest, several randomised controlled studies have highlighted statistically significant and clinically meaningful gains in infant development and parental mental health. In these studies, the intervention was often integrated into existing systems of care and included high-risk parent-infant dyads.

CONCLUSION

The newborn behavioural observation system is a promising intervention designed to support the early challenges of high-risk infants and their parents. Future research should examine its effects in diverse neonatal intensive care unit populations and professionals, strive for continuity of care from inpatient to post-discharge follow-up and developmental support services, and include more longitudinal studies.

Home-visiting programs based on the Brazelton approach: a scoping review

This review maps and summarizes the quantitative studies on the main outcomes associated with home visiting (HV) programs using Brazelton methods aimed at supporting expectant and new parents. One hundred thirty-seven records were identified, and 19 records were selected. The design of our study was based on the methodological framework for conducting scoping reviews. Quality was assessed through the Jadad scale. Studies were coded for participant characteristics (number, mean age, and risk status), methodology (recruitment, home visit frequency, age of the child, Brazelton method, and research design), and intervention outcomes (on infants, parents, and home visitors). The studies mostly focused on the impact of Brazelton HV programs on infant development, the mother's psychological well-being, mother-infant interaction, and home visitor satisfaction. Experimental and quasi-experimental studies consistently have shown that parents receiving the intervention have greater knowledge of their children. Results are less conclusive regarding the intervention's impact on other domains of child development, mothers' psychological well-being, and mothers' sensitivity to the relationship with the child. Overall, the results suggest that the improvements associated with the intervention are mainly influenced by the risk status of families. Further research is needed to better understand the benefits of HV based on the Brazelton approach and the target population that may benefit most from this intervention.

CONCLUSION

 Although the impact of the Brazelton home visiting intervention is not yet fully understood, there is promising evidence of its positive effects on child development, maternal well-being, and parental knowledge. Further research with consistent methodologies and larger sample sizes is needed to strengthen our understanding. However, existing findings in the literature underscore the importance of preventive interventions such as the Brazelton program in improving family well-being, with potential long-term benefits.

WHAT IS KNOWN

• Home visiting programs based on the Brazelton approach aim to increase parents' knowledge and sensitivity to their children. • There is no clear picture in the literature of the effectiveness of these programs.

WHAT IS NEW

• Existing studies consistently show the effectiveness of these programs to improve parents' knowledge of their children. • Findings on the impact of these programs on child development, mothers' psychological well-being and sensitivity to their child are inconclusive and may be influenced by the risk status.

Use of the Newborn Behavioral Observations System as an early intervention for infants and their parents: A scoping review

BACKGROUND

The Newborn Behavioral Observations (NBO) system is an infant-focused, family-centered, relationship-based tool designed to help parents become aware of their baby's abilities and to promote a positive parent-child relationship from the very beginning of birth.

AIMS

The aim of this scoping review was to provide an overview of the key characteristics of the research and evidence accumulated over the past 17 years on the early NBO intervention for infants and their parents to identify the existing research gaps and to inform the future direction of research on the NBO System.

STUDY DESIGN

A scoping review guided by Arksey and O'Malley's methodological framework and the PRISMA-ScR Checklist was conducted. This review used six databases (PubMed, CINAHL, MEDLINE, Google Scholar, Ichushi-Web, and CiNii) and was limited to English and Japanese language articles from January 2006, when the NBO was developed, to September 2022. Reference lists were also hand-searched to further identify relevant articles from the NBO site.

RESULTS

A total of 29 articles were selected. Through the analysis of included articles, four overarching themes were identified: (1) usage pattern of the NBO; (2) participants, setting, duration, and frequency of the NBO intervention; (3) outcome measures and effects of the NBO intervention; and (4) findings from a qualitative perspective. The review suggested that early NBO intervention had a positive impact on maternal mental health and sensitivity to the infant, confidence and knowledge of practitioners, and infant development.

CONCLUSIONS

This scoping review shows that the early NBO intervention has been implemented in a variety of cultures and settings and by professionals of various disciplines. However, research to evaluate the long-term effects of this intervention on a wider range of subjects is needed.

Effectiveness of The Newborn Behavioral Observation (NBO) System in Improving Mother and Infant Interaction

The interaction of mother and infant is a fundamental basis for the development of the infant. It can also determine the success of the baby in the future. About 4 out of 10 infants experience problems interacting with their parents. The NBO system was created to sensitize parents on their infant’s competencies to help them understand their infant’s behavior, and promote positive interactions between parents and their new infant. This study aimed to evaluate the effectiveness of the NBO system to improve mother-infant interactions and find out the mothers’ knowledge about their infant’s behavior when participating in this observation. This study was a cross-sectional study consisting of all the newborns and their mothers admitted to the Dr. Soetomo General Academic Hospital Surabaya from May 2019 to January 2020 who met the inclusion criteria. Mothers and infants participated in the NBO within 1-3 days after delivering their infants and one month postpartum for the second NBO. The NBO was carried out with 35 mothers and infants. The mothers’ age was on average 28.5±5.98 years old, multiparous mothers accounted for 71.4%, most infants were male (65.7%), the median gestational age was 38 weeks with the median birth weight 2900 grams. The median score of mothers’ knowledge about their infants before the NBO session was 2 (1-6). After the session, these median scores increased to 7 (5–10) significantly (p<0.001). The NBO system was significant to strengthen mother-infant interaction and increased the mothers’ knowledge about their infants’ behavior.

A Pilot Validation Study of the Newborn Behavioral Observations System: Associations with Salivary Cortisol and Temperament

OBJECTIVE

There are few standardized neonatal neurobehavioral instruments available for longitudinal child development research. We adapted an established clinical tool, the Newborn Behavioral Observations (NBO) system, for research by standardizing the administration protocol and expanding the 3-point coding scale to 5 points.

METHODS

We administered the 5-point NBO to 144 racially/ethnically diverse late preterm or term infants born to low-income women (average age 5 weeks). Cronbach's alphas were calculated to determine internal consistency reliability of Autonomic, Motor, Organization of State, and Responsivity subscales. We examined concurrent validity using subscale associations with infant salivary cortisol reactivity to the NBO and maternally reported infant temperament.

RESULTS

Two of the 4 NBO subscales, Organization of State and Responsivity, had excellent (0.91) and good (0.76) reliability, respectively, and were retained for further analyses. Infants with higher Organization of State scores (more optimal regulation) demonstrated lower cortisol reactivity (r = -0.30, p < 0.01) and temperamental negativity (r = -0.16, p < 0.05). Responsivity was unrelated to cortisol reactivity or temperament.

CONCLUSIONS

State regulation, as measured by the 5-point NBO, was associated with a biologic marker of infant stress response to the NBO administration and reported temperament. Poor reliability of the NBO's 3-item Autonomic and 7-item Motor subscales suggests that further psychometric research in other samples and likely refinement are needed. Given the paucity of neurobehavioral assessment tools for infants, these findings justify such research as next steps in the incremental progression toward the development of a practical, reliable, and predictive measure of early neurobehavioral development.

Mental health of Urban Mothers (MUM) study: a multicentre randomised controlled trial, study protocol

INTRODUCTION

Mental health disorders are common during pregnancy and the postnatal period and can have serious adverse effects on women and their children. The consequences for global mental health due to COVID-19 are likely to be significant and may have a long-term impact on the global burden of disease. Besides physical vulnerability, pregnant women are at increased risk of mental health problems such as anxiety, depression and post-traumatic stress disorder due to the consequences of social distancing. It can result in altered healthcare routines, less support from the family and friends, and in some cases, partners not being allowed to be present during prenatal visits, labour and delivery. Higher than expected, rates of perinatal anxiety and depression have been already reported during the pandemic. Pregnant women may also feel insecure and worried about the effects of COVID-19 on their unborn child if they get infected during pregnancy. Today, young urban women are used to using internet services frequently and efficiently. Therefore, providing mental health support to pregnant women via internet may be effective in ameliorating their anxiety/depression, reducing the risk of serious mental health disorders, and lead to improved maternal and perinatal outcomes.

OVERARCHING AIM

Our aim is to explore the effectiveness of a web-based psychosocial peer-to-peer support intervention in reducing the risk and severity of perinatal mental health disorders and preventing adverse pregnancy outcomes among pregnant women living in metropolitan urban settings.

METHODS AND ANALYSIS

We plan to conduct a multicentre prospective randomised controlled trial, Mental health of Urban Mothers trial. Pregnant women living in large metropolitan cities will be recruited using internet-based application through non-profit organisations' websites. The women who consent will be randomised to receive a web-based peer-to-peer support intervention or usual care. Data will be analysed to identify the effects of intervention on Edinburgh Postnatal Depression Score and Generalised Anxiety Disorder 7 scores as well as pregnancy outcomes. The impact of COVID-19 pandemic on maternal stress will be assesed using Impact Event Scale-R. Any differences in outcomes between cities will be addressed in subgroup analyses.

ETHICS AND DISSEMINATION

The study will be conducted according to the principles of Good Clinical Practice and will follow the ethical principles of the Declaration of Helsinki. The study protocol has been approved by the ethical review board of Chinese University of Hong Kong (IRB number 2019-8170) and Shanghai Center for Women's and Children's Health (international review board (IRB) number 2020-F001-12). The results will be disseminated at national and international scientific conferences, published in peer-reviewed medical journals and spread to the public through social media, news outlets and podcasts.

TRIAL REGISTRATION NUMBER

NCT04363177; Trial sponsor Karolinska Institute, CLINTEC, Stockholm, Sweden.

What are the effects of supporting early parenting by newborn behavioral observations (NBO)? A cluster randomised trial

BACKGROUND

Professional support to enhance the early parent-infant relationship in the first months after birth is recommended, but little is known about the effect of universal interventions. The objective was to investigate the effect of health visitors' use of the Newborn Behavioral Observations system in new families.

METHODS

A cluster-randomised study was conducted in four Danish municipalities. Health visitors' geographical districts constituted the units for randomisation (n = 17). In the intervention group, 1332 families received NBO from 3 weeks after birth; in the comparison group, 1234 received usual care. Self-administered questionnaires were collected at baseline one to two weeks after birth, and at follow-up three and nine months postpartum. The outcomes were change over time measured by The Karitane Parenting Confidence Scale (KPCS), The Major Depression Inventory (MDI), The Ages and Stages Questionnaire: social-emotional (ASQ:SE) and The Mother and Baby Interaction Scale (MABIC). Data were analysed with mixed-effects linear regression using the intention-to-treat approach.

RESULTS

At baseline, no significant differences between the two groups were seen regarding maternal and infant factors. At follow-up three and nine months after birth, the change in maternal confidence and mood, infant's socio-emotional behaviour, and early parent-infant relationship moved in a slightly more positive direction in the intervention group than in the comparison group, though not statistically significant. The only significant effect was that the intervention mothers reported higher level of knowledge about infant's communication skills, response to cues, and how to sooth and establish a relation with the infant, compared to the comparison group.

CONCLUSIONS

We found no effect of the NBO system delivered in a universal context to all families in a community setting. The only significant difference between groups was a higher maternal degree of knowledge regarding early parenting in the intervention group.

TRIAL REGISTRATION

ClinicalTrials.gov ID: NCT03070652 . Registrated February 22, 2017.

The effects of the Newborn Behavioral Observations (NBO) system in early intervention: A multisite randomized controlled trial

The purpose of this pilot study was to evaluate the effect of an infant mental health intervention, the Newborn Behavioral Observations system (NBO), versus usual care (UC) on infant neurodevelopment and maternal depressive symptoms in early intervention (EI). This multisite randomized trial enrolled newborns into the NBO (n = 16) or UC group (n = 22) and followed them for 6 months. Outcome measures included the Battelle Developmental Inventory (BDI-2), Bayley Scales of Infants Development (BSID-III), and Center for Epidemiologic Studies Depression Scale (CES-D). The CES-D and BSID-III were collected at 3- and 6-months post EI entry and the BDI-2 was collected at EI entry and 6-months post-EI entry. We estimated group differences [95% CI], adjusting for program characteristics. At 6 months, the NBO group had greater gains in Communication (b = 1.0 [0.2, 1.8]), Self-Care (b = 2.0 [0.1, 3.9]), Perception and Concepts (b = 2.0 [0.4, 3.6]), and Attention and Memory (b = 3.0 [0.4, 6.0]) than the UC group. The NBO group also had greater decline in maternal postnatal depressive symptoms (b = -2.0 [-3.7, -0.3]) than the UC group. Infants receiving the NBO infant mental health intervention had greater gains in cognitive and adaptive functions at 6 months than infants receiving UC. Caregivers receiving NBO care had greater improvements in maternal depressive symptoms than caregivers receiving UC.

Neurodevelopmental assessment of infants with congenital heart disease in the early postoperative period

OBJECTIVE

Mortality rates for children with congenital heart disease (CHD) have significantly declined, resulting in a growing population with associated neurodevelopmental disabilities. American Heart Association guidelines recommend systematic developmental screening for children with CHD. The present study describes results of inpatient newborn neurodevelopmental assessment of infants after open heart surgery.

OUTCOME MEASURES

We evaluated the neurodevelopment of a convenience sample of high-risk infants following cardiac surgery but before hospital discharge using an adaptation of the Newborn Behavioral Observation. Factor analysis examined relationships among assessment items and consolidated them into domains of development.

RESULTS

We assessed 237 infants at a median of 11 days (interquartile range [IQR]: 7-19 days) after cardiac surgery and median corrected age of 21 days (IQR: 13-33 days). Autonomic regulation was minimally stressed or well organized in 14% of infants. Upper and lower muscle tone was appropriate in 33% and 35%, respectively. Appropriate response to social stimulation ranged between 7% and 12% depending on task, and state regulation was well organized in 14%. The vast majority (87%) required enhanced examiner facilitation for participation. Factor analyses of assessment items aligned into four domains of development (autonomic, motor, oral motor, and attention organization).

CONCLUSION

At discharge, postoperative infants with CHD had impairments in autonomic, motor, attention, and state regulation following cardiac surgery. Findings highlight the challenges faced by children with CHD relative to healthy peers, suggesting that neurodevelopmental follow-up and intervention should begin early in infancy.

What are the effects of supporting early parenting by enhancing parents' understanding of the infant? Study protocol for a cluster-randomized community-based trial of the Newborn Behavioral Observation (NBO) method

Background

Support to strengthen the early parent-infant relationship is recommended to ensure the infant’s future health and development. Little is known about the universal approaches taken by health visitor to support this early relationship. The aim of this study is to investigate the effects of health visitors’ use of the Newborn Behavioral Observation (NBO) method among new parents.

Methods

This is a cluster-randomised community-based study implemented in four Danish municipalities. Health visitors will conduct the trial, and the geographical districts they work in will constitute the clusters as units of randomisation. The participants will be approximately 2800 new families, randomised into an intervention or a comparison group according to their health visitor. The families are recruited at the first postpartum home visit. Parents in both groups receive care as usual: parents in the intervention group also receive the standardised NBO method in home visits performed from 3 weeks to 3 months postpartum. Data consist of self-reported parent questionnaires and video recordings of a selected group of vulnerable first-time mothers recorded 4 months postpartum. The self-reported data are obtained: at baseline 1 week postpartum and then at follow-up 3, 9 and 18 months postpartum. Data will be analysed using the intention-to-treat method and the analyses will include comparison of change in the primary variables across time supplemented by multiple regression analysis. The primary study outcomes are measured by the following factors: parental confidence, infants’ socio-emotional development and mother-infant relationship. Other measures include parental mood and stress, breastfeeding duration and utility of the health visitor services. Data collection among the health visitors in both groups will serve to monitor any change in practice regarding the work with early parent-infant interactions.

Discussion

This protocol describes an evaluation of the NBO method used universally in health visiting practice. The intervention seeks to support early parenting by increasing parents’ understanding of their infants’ cues. The NBO is currently implemented in Denmark even though an evaluation of the NBO has yet to be made in a community setting in Denmark and internationally. The study may contribute to building an increasingly evidence-based practice for health visitors.

Trial registration

ClinicalTrials.gov ID: NCT03070652. Registered February 22, 2017.

The Neonatal Behavioral Assessment Scale (NBAS) and Newborn Behavioral Observations (NBO) system for supporting caregivers and improving outcomes in caregivers and their infants

BACKGROUND

The first three years of a child's life are a key period of physical, physiological, cognitive and social development, and the caregiver-infant relationship in early infancy plays an important role in influencing these aspects of development. Specifically, caregiver attunement facilitates the move from coregulation to self-regulation; a parent's ability to understand their infant's behaviour as communication is a key part of this process. Early, brief interventions such as the Neonatal Behavioral Assessment Scale (NBAS) or Neonatal Behavioral Observation (NBO) system are potential methods of improving outcomes for both infant and caregiver.

OBJECTIVES

To assess the effects of the NBAS and NBO system for improving caregiver-infant interaction and related outcomes in caregivers and newborn babies. Secondary objectives were to determine whether the NBAS and NBO are more effective for particular groups of infants or parents, and to identify the factors associated with increased effectiveness (e.g. timing, duration, etc.).

SEARCH METHODS

In September 2017 we searched CENTRAL, MEDLINE, Embase, PsycINFO, 12 other databases and four trials registers. We also handsearched reference lists of included studies and relevant systematic reviews, and we contacted the Brazelton Institute and searched its websites to identify any ongoing and unpublished studies.

SELECTION CRITERIA

We included randomised controlled trials (RCTs) and quasi-RCTs that had used at least one standardised measure to assess the effects of the NBAS or NBO versus inactive control for improving outcomes for caregivers and their infants.

DATA COLLECTION AND ANALYSIS

Two reviewer authors independently assessed the records retrieved from the search. One reviewer extracted data, and a second checked them for accuracy. We presented the results for each outcome in each study as standardised mean differences (SMDs) or as risk ratios (RR) with 95% confidence intervals (CIs). When appropriate, we combined the results in a meta-analysis using standard methodological procedures expected by Cochrane. We used the GRADE approach to assess the overall quality of the body of evidence for each outcome.

MAIN RESULTS

We identified and included 16 RCTs in this review: 13 assessing the NBAS and 3 the NBO for improving outcomes in 851 randomised participants, including parents and their premature or newborn (aged 4 to 12 weeks) infants. All studies took place in the USA, and we judged all of them to be at high risk of bias.Seven studies involving 304 participants contributed data to one meta-analysis of the impact of the NBAS or NBO for caregiver-infant interaction, and the results suggest a significant, medium-sized difference between intervention and control groups (SMD -0.53, 95% CI -0.90 to -0.17; very low-quality evidence), with moderate heterogeneity (I² = 51%). Subgroup analysis comparing the two types of programmes (i.e. NBAS and NBO) found a medium but non-significant effect for the NBAS (-0.49, 95% CI -0.99 to 0.00, 5 studies), with high levels of heterogeneity (I² = 61%), compared with a significant, large effect size for the NBO (-0.69, 95% CI -1.18 to -0.20, 2 studies), with no heterogeneity (I² = 0.0%). A test for subgroup differences between the two models, however, was not significant. One study found a significant impact on the secondary outcome of caregiver knowledge (SMD -1.30, 95% CI -2.16 to -0.44; very low-quality evidence). There was no evidence of an impact on maternal depression. We did not identify any adverse effects.

AUTHORS' CONCLUSIONS

There is currently only very low-quality evidence for the effectiveness of the NBAS and NBO in terms of improving parent-infant interaction for mostly low-risk, first-time caregivers and their infants. Further research is underway regarding the effectiveness of the NBO and is necessary to corroborate these results.

Protocol for the Northern babies longitudinal study: predicting postpartum depression and improving parent-infant interaction with The Newborn Behavioral Observation

INTRODUCTION

Postpartum depression (PPD) is a prevalent disorder. Studying the factors related to PPD will help to identify families at risk and provide preventive interventions. This can in turn improve the developmental trajectories for the children. Several previous studies have investigated risk factors for PPD. However, few studies have focused on cognitive vulnerability factors. The first aim of the present study is to explore a range of protective and risk factors, including cognitive factors, for PPD, parent-infant interactions and child development. The second aim of the study is to evaluate the effectiveness of The Newborn Behavioral Observation (NBO) as a universal preventive intervention delivered in routine practice. The NBO is a brief relationship-enhancing intervention that may reduce depressive symptomatology in mothers.

METHODS

The study is a longitudinal observational study with an intervention. The observational study uses a prospective cohort design, whereas the intervention study has a non-randomised cluster-controlled design comparing a group receiving NBO with a group receiving standard care. The intervention group will receive three NBO sessions within the first 4 weeks postdelivery. Between 2015 and 2018, approximately 200 families will be recruited in the municipality of Tromsø, Norway. Parents are recruited during pregnancy, and assessments will be performed during gestational weeks 16-22, 24-30 and 31, and at 6 weeks, 4 months and 6 months postdelivery. Predictor variables include several cognitive vulnerability factors including early maladaptive schemas, implicit attitudes and cognitive processing of emotionally valenced infant facial information.

ETHICS AND DISSEMINATION

The Regional Committee for Medical and Health Research Ethics in Northern Norway has approved the project. The research team has collaboration with local health services and can assist participants who need more extensive follow-up. Results from the project will be disseminated in international and national peer-reviewed journals, and at courses and conferences.

TRIALS REGISTRATION NUMBER

NCT02538497; Pre-results.

Assessment: The Newborn

Neonatal neurobehavioral assessment has become a standardized component of clinical care provided to newborn infants, guiding neonatal clinical care and subsequent access to early interventions and services. Links between neonatal assessment and neurosensory and motor impairments in high-risk infants have been relatively well established. In contrast, the extent to which newborn neurobehavioral assessment might also facilitate the early identification of infants susceptible to socioemotional impairments in early childhood is less well documented. This review examines longitudinal links between the neonatal neurobehavioral assessment, temperament, and socioemotional outcomes in early childhood.

Prolactin, a potential mediator of reduced social interactive behavior in newborn infants following maternal perinatal depressive symptoms

BACKGROUND

The hormone prolactin (PRL) plays a crucial role for the initiation and maintenance of maternal behavior, and is also associated with the etiology of mood disorders in women, especially for depression. The present study aimed to determine whether maternal peripheral prolactin would be associated with newborn behavior disorders following maternal perinatal depressive symptoms, and further to explore the efficacy of the Newborn Behavioral Observations (NBO) in improving newborn social interactive behavior.

METHODS

Interview and the 24-item Hamilton Rating Scale for Depression (HAMD) were used to assess the hospitalized pregnant women waiting for delivery at 37-42weeks of gestation. A total of 255 subjects were recruited, diagnosed with depression (n=135), and control group (n=120). Within 2 weeks postpartum, mothers were asked to fill with Maternal Attachment Inventory (MAI) to measure maternal care. Neonatal Behavioral Assessment Scale (NBAS) were used to evaluate newborn behavior. The depressed mother-newborns dyad was randomly assigned to NBO intervention and control group. Serum prolaction in mothers and cortisol in mothers and newborns were measured.

RESULTS

The newborns of mothers exposed to maternal perinatal depressive symptoms displayed the reduced newborn social interactive behavior accompanied by decreased maternal serum PRL as well as increased maternal and neonatal serum cortisol. The NBO could be an effective intervention tool.

LIMITATIONS

Our study could not be double-blind. The mothers knew which group their infant were in.

CONCLUSIONS

Maternal peripheral PRL had the potential to be a mediator in reduced social interactive behavior in newborn infants following maternal perinatal depressive symptoms.