Interaction between mothers and infants born at risk during the first six months of corrected age

Abstract The effects of preterm birth and the perinatal infant health condition on mother-infant interactions were analysed in 278 mother-infant pairs, divided into four groups according to infants' gestational age at birth: group 1. 23–31 weeks; group 2,32–36 weeks; group 3, 37–42 weeks; and group 4, a control group of healthy full-term infants. The methodological approach was based on observation of the pairs at 2,4 and 6 months of infants" corrected age (± 1 week) during undressing of the infant and face-to-face interaction. It was found that mother-infant pairs with preterm infants (groups 1 and 2) did not differ in interactional variables from those of the control group. On the other hand, the birth of a full-term infant in need of neonatal intensive care (group 3) affected maternal and infant interactive behaviour. Additionally, infants from group 3 did not show stability in their interactive behaviour between any ages of measurement. This result suggests that interactive behaviour of full-term infants in need of neonatal intensive care are rather unpredictable during their first 6 months of life, which might have contributed to the less optimal interactive pattern observed for their mothers compared with mothers of the control group.     

The impact of very premature birth on the psychological health of mothers

BACKGROUND: The birth of a very premature infant is a critical event in the life of a family and studies have shown that mothers of these infants are at greater risk of psychological distress than mothers of full-term infants. STUDY DESIGN: A total population study of mothers of preterm infants born at less than 32-week gestation at a tertiary referral hospital. SUBJECTS AND METHODS: Sixty-two mothers of very preterm infants (<32 weeks) participated in the present study which examines correlates of maternal depressive symptomatology at 1 month following very premature birth. Information was obtained from structured questionnaires completed by mothers at 1 month after infant admission to neonatal intensive care. RESULTS: Forty percent of the mothers reported significant depressive symptoms on the Edinburgh Postpartum Depression Scale (EPDS). Logistic regression analysis indicated that high maternal stress resulted in an increased likelihood of depressive symptoms (OR 1.15, CI 1.04-1.26, p<0.01). Higher levels of maternal education (p<0.05), and increased perception of support from nursing staff (OR 1.06, CI 0.88-1.00, p<0.05) resulted in decreased likelihood of depressive symptoms. CONCLUSIONS: The birth and subsequent hospitalisation of a very premature infant evokes considerable psychological distress in mothers. These results have implications for policy development in order to enhance family centred care in the neonatal intensive care.     

Incorporating nutrition into delivery care: delivery care practices that affect child nutrition and maternal health

Delayed umbilical cord clamping, early skin-to-skin contact and early initiation of exclusive breastfeeding are three simple and inexpensive delivery care practices which have the potential to improve short-term and long-term nutrition and health outcomes in mothers and infants. In preterm infants, delayed clamping prevents intraventricular haemorrhage and improves haematological status, and in full-term infants, delayed clamping improves iron status through 6 months of age. Early skin-to-skin contact, in addition to regulating neonatal temperature, improves early breastfeeding behaviours, which has important implications for long-term infant nutrition and health. Finally, early exclusive breastfeeding prevents neonatal mortality and morbidity and provides numerous health and nutritional benefits to the infant, throughout infancy and beyond, as well as to the mother. Though each practice has been the subject of controlled trials and systematic reviews, with evidence of benefit from their implementation, these practices are not common in many delivery settings, nor are their long-term effects on infant and maternal nutrition and health status adequately recognized. We discuss the immediate and long-term health and nutrition benefits of each practice, and identify the policy and programme changes needed for integration and implementation of these practices into standard delivery care.     

Room for improvement in breast milk feeding after very preterm birth in Europe: Results from the EPICE cohort

Breast milk feeding (BMF) is associated with lower neonatal morbidity in the very preterm infant (<32 weeks gestation) and breastfeeding is beneficial for maternal health. Previous studies show large variations in BMF after very preterm birth and recognize the need for targeted breastfeeding support in the neonatal intensive care units (NICU). In a European collaboration project about evidence‐based practices after very preterm birth, we examined the association between maternal, obstetric, and infant clinical factors; neonatal and maternal care unit policies; and BMF at discharge from the NICU. In multivariable analyses, covariates associated with feeding at discharge were first investigated as predictors of any BMF and in further analysis as predictors of exclusive or partial BMF. Overall, 58% (3,826/6,592) of the infants received any BMF at discharge, but there were large variations between regions (range 36–80%). Primiparity, administration of antenatal corticosteroids, first enteral feed <24 hr after birth, and mother's own milk at first enteral feed were predictors positively associated with any BMF at discharge. Vaginal delivery, singleton birth, and receiving mother's own milk at first enteral feed were associated with exclusive BMF at discharge. Units with a Baby Friendly Hospital accreditation improved any BMF at discharge; units with protocols for BMF and units using donor milk had higher rates of exclusive BMF at discharge. This study suggests that there is a high potential for improving BMF through policies and support in the NICU.     

Co-bedding as a Comfort measure For Twins undergoing painful procedures (CComForT Trial)

Background  

Co-bedding, a developmental care strategy, is the practice of caring for diaper clad twins in one incubator (versus separating and caring for each infant in separate incubators), thus creating the opportunity for skin-to-skin contact and touch between the twins. In studies of mothers and their infants, maternal skin-to-skin contact has been shown to decrease procedural pain response according to both behavioral and physiological indicators in very preterm neonates. It is uncertain if this comfort is derived solely from maternal presence or from stabilization of regulatory processes from direct skin contact. The intent of this study is to compare the comfort effect of co-bedding (between twin infants who are co-bedding and those who are not) on infant pain response and physiologic stability during a tissue breaking procedure (heelstick).     

The impact of newborn bathing on the prevalence of neonatal hypothermia in Uganda: a randomized, controlled trial

AIM: To elucidate the impact of bathing on the prevalence of hypothermia among newborn babies exposed to the skin-to-skin (STS) care technique before and after bathing. METHODS: Non-asphyxiated newborns after vaginal delivery (n = 249) in a Ugandan referral hospital were consecutively enrolled and randomized either to bathing at 60 min postpartum (n = 126) or no bathing (n = 123). All mothers practised skin-to-skin care of their newborns. Four rectal and tympanic registrations of newborn temperatures were carried out in both groups directly after drying at birth, and at 60, 70 and 90 min postpartum. RESULTS: Bathing of newborns in the first hour after delivery resulted in a significantly increased prevalence of hypothermia, defined as temperature <36.5 degrees C, at 70 and at 90 min postpartum despite the use of warmed water and the application of the STS method. There was no neonatal mortality. Aside from the bathing procedure, no background factor potentially predisposing the newborns to hypothermia was identified. CONCLUSION: Bathing newborn babies shortly after birth increased the risk of hypothermia despite the use of warm water and STS care for thermal protection of the newborn.     

Parental perceptions of infant vulnerability in a preterm sample: prediction from maternal adaptation to parenthood during the neonatal period

The present longitudinal study of African-American mothers of preterm infants tested the hypothesis that the quality of maternal adaptation to parenthood before infant discharge from the hospital is predictive of maternal perceptions of infant vulnerability later in the infant's first year. As hypothesized, perceptions of infant vulnerability at 3 to 4 months of infant corrected age were predicted by two theoretically relevant measures of maternal adaptation in the neonatal period: mothers' perceptions of their neonates as lethargic and unresponsive to mothers' bids and by low maternal self-efficacy beliefs about feeding the infant. Neonatally obtained maternal self-inefficacy beliefs about their ability to feed the infant in particular proved to be quite robust in predicting mothers' later perceptions of infant vulnerability. Findings collectively suggest that careful attention to the manner in which mothers of preterm infants adapt to parenthood, even before infant hospital discharge, can help clinicians identify mothers at particularly high risk of developing perceptions of infant vulnerability later in the infant's first year. Implications for intervention are discussed.     

Towards universal Kangaroo Mother Care: recommendations and report from the First European conference and Seventh International Workshop on Kangaroo Mother Care

The hallmark of Kangaroo Mother Care (KMC) is the kangaroo position: the infant is cared for skin‐to‐skin vertically between the mother’s breasts and below her clothes, 24 h/day, with father/substitute(s) participating as KMC providers. Intermittent KMC (for short periods once or a few times per day, for a variable number of days) is commonly employed in high‐tech neonatal intensive care units. These two modalities should be regarded as a progressive adaptation of the mother‐infant dyad, ideally towards continuous KMC, starting gradually and progressively with intermittent KMC. The other components in KMC are exclusive breastfeeding (ideally) and early discharge in kangaroo position with strict follow‐up. Current evidence allows the following general statements about KMC in affluent and low‐income settings: KMC enhances bonding and attachment; reduces maternal postpartum depression symptoms; enhances infant physiologic stability and reduces pain, increases parental sensitivity to infant cues; contributes to the establishment and longer duration of breastfeeding and has positive effects on infant development and infant/parent interaction. Therefore, intrapartum and postnatal care in all types of settings should adhere to a paradigm of nonseparation of infants and their mothers/families. Preterm/low‐birth‐weight infants should be regarded as extero‐gestational foetuses needing skin‐to‐skin contact to promote maturation. Conclusion: Kangaroo Mother Care should begin as soon as possible after birth, be applied as continuous skin‐to‐skin contact to the extent that this is possible and appropriate and continue for as long as appropriate.     

Consequences for the family of a very preterm birth two months after discharge. Results of the EPIPAGE qualitative study.]

OBJECTIVES: To assess mothers' and fathers' psychological health 2 months after discharge of a very preterm infant. To describe the problems encountered with the child, the quality of the marital relationship, the organization of the family and to compare the answers made by mothers and fathers. POPULATION: Mothers having delivered before 33 weeks in two maternity units in Paris and in Rouen were contacted. Among the 38 mothers who were eligible, 21 accepted to participate. Their children were born between 26 weeks and 32 weeks and weighted from 630 to 2100 g. METHOD: A semi-structured interview was conducted at home by a psychologist with each member of the couple. It lasted approximately 1 h. Each interview was tape-recorded and fully transcribed. The analysis allowed to discover the main themes emerging from the interviews and to search for the role of factors. RESULTS: Two months after discharge, mothers expressed anxiety and feelings of depression. Fathers noted considerable fatigue and both parents expressed concerns about the child's health and development. Marital dissatisfaction and behavioural symptoms in siblings were also noted. Mothers' difficulties were not linked to the degree of prematurity or length of stay in neonatal unit but with the baby's present health state, his rehospitalizations and maternal characteristics such as isolation, lack of support and previous perinatal loss. The mother's psychological organisation modifies the role of objective factors. Fathers seemed more able to cope with and overcome the traumatic event caused by the very preterm birth. They insisted on their role of support for the mother and the mother-child relationship. CONCLUSION: The consequences of a very preterm birth are important and concern the whole family. After hospital discharge, the follow-up care of the very preterm baby should take the family social and psychological situation into account.     

Short-term effects of early suckling and touch of the nipple on maternal behaviour

The objective was to evaluate the effects of suckling within 30 min after birth when skin-to-skin body contact for mothers and infants was held constant in both cases (n = 32) and control groups (n = 25). Mother-infant interaction during breast-feeding, infants' time spent in nursery and different aspects of breast-feeding were evaluated. Prolactin and gastrin were measured in maternal serum before and after breast-feeding on day 4 post partum. The aim to evaluate effects of early post delivery suckling failed since only six of the 32 case infants did suck at this time. In spite of this, we found three significant differences among cases and controls. In the case group where all infants had touched or licked the areola and nipple, the mothers left the infants in the nursery for a significantly shorter time and significantly more mothers talked to their infants during the short breast-feeding observation. Median gastrin levels were significantly lower in cases than in controls both before (P less than 0.01) and after (P less than 0.03) breast-feeding. In conclusion, the infant's early touch of the mother's areola and nipple seemed to have positively influenced the mother/infant relationship during the first four days after birth. It was also associated with lower maternal gastrin levels which suggests that maternal neuroendocrine functions were also influenced. Ten months after birth, we found no differences between cases and controls.     

Maternal depression is associated with mother-infant interaction in preterm infants.

AIM: The purpose of this study was to assess the prevalence and the background factors of maternal depressive symptoms and their relation to the quality of mother-infant interaction in a group of preterm infants and their mothers. METHODS: The signs of maternal depression were evaluated in 125 mothers of very preterm infants (birth weight < or = 1500 g or < 32 gestational weeks) at 6 months of infant's corrected age using Edinburgh Postnatal Depression Scale (EPDS). The association between maternal depressive symptoms and the quality of mother-infant interaction as assessed by the parent child early relational assessment method (PCERA) method was studied at 6 and 12 months of corrected age in 32 preterm infants who were their mothers' firstborn infants and singletons. RESULTS: The prevalence of depression assessed by EPDS in mothers of very preterm infants was 12.6%. Most interestingly, the number of postnatal signs of depression associated negatively with the quality of the maternal interaction behaviour with their preterm infants. CONCLUSIONS: This study suggests that maternal depression may be a risk factor in the development of the mother-infant relationship between preterm infants and their mothers. Therefore, it would be important to identify signs of depression in mothers of preterm infants to offer early support.     

Closeness and separation in neonatal intensive care

In this paper, we highlight the need for acknowledging the importance and impact of both physical and emotional closeness between the preterm infant and parent in the neonatal intensive care unit. Physical closeness refers to being spatially close and emotional closeness to parental feelings of being emotionally connected to the infant (experiencing feelings of love, warmth and affection). Through consideration of the literature in this area, we outline some of the reasons why physical closeness and emotional closeness are crucial to the physical, emotional and social well-being of both the infant and the parent. These include positive effects on infant brain development, parent psychological well-being and on the parent-infant relationship. The influence of the neonatal unit environment and culture on physical and emotional closeness is also discussed. Conclusions: Culturally sensitive care practices, procedures and the physical environment need to be considered to facilitate parent-infant closeness, such as through early and prolonged skin-to-skin contact, family-centred care, increased visiting hours, family rooms and optimization of the space on the units. Further research is required to explore factors that facilitate both physical and emotional closeness to ensure that parent-infant closeness is a priority within neonatal care.     

Survival of very preterm infants: Epipage, a population based cohort study

OBJECTIVE: To evaluate the outcome for all infants born before 33 weeks gestation until discharge from hospital. DESIGN: A prospective observational population based study. SETTING: Nine regions of France in 1997. PATIENTS: All births or late terminations of pregnancy for fetal or maternal reasons between 22 and 32 weeks gestation. MAIN OUTCOME MEASURE: Life status: stillbirth, live birth, death in delivery room, death in intensive care, decision to limit intensive care, survival to discharge. RESULTS: A total of 722 late terminations, 772 stillbirths, and 2901 live births were recorded. The incidence of very preterm births was 1.3 per 100 live births and stillbirths. The survival rate for births between 22 and 32 weeks was 67% of all births (including stillbirths), 85% of live births, and 89% of infants admitted to neonatal intensive care units. Survival increased with gestational age: 31% of all infants born alive at 24 weeks survived to discharge, 78% at 28 weeks, and 97% at 32 weeks. Survival among live births was lower for small for gestational age infants, multiple births, and boys. Overall, 50% of deaths after birth followed decisions to withhold or withdraw intensive care: 66% of deaths in the delivery room, decreasing with increasing gestational age; 44% of deaths in the neonatal intensive care unit, with little variation with gestational age. CONCLUSION: Among very preterm babies, chances of survival varies greatly according to the length of gestation. At all gestational ages, a large proportion of deaths are associated with a decision to limit intensive care.     

Parents as practitioners in preterm care

The very preterm birth of an infant is physiologically traumatic for the infant and physiologically and psychologically traumatic for the parents. The manner of care delivery in the first few days and weeks of the infant's life plays a large role in determining the impact of that trauma. For optimal outcomes parents need to be integrated into the care process as the primary practitioners of their infant's care in the neonatal intensive care unit. Supporting and enabling parents to be central to the care process establishes a consistent care environment where parents are in control and able to support their infant's physiological and psychological needs, thereby improving infant outcomes and reducing parent stress and anxiety. This article reviews the role of parents in the optimal development of preterm neonates, and discusses the elements crucial to promoting parent involvement in the neonatal intensive care unit and supporting parents following discharge.     

Early discharge of preterm infants followed by domiciliary nursing care: parents'' anxiety, assessment of infant health and breastfeeding

The aim of this study was to evaluate the effect of early discharge of preterm infants, followed by domiciliary nursing care, on the parents' anxiety, their assessment of infant health and breastfeeding. Seventy-five families including 88 preterm infants who were physiologically stable but in need of further special care, such as gavage feeding, were allocated to an early discharge group (EDG) that was offered home visits (n = 40), or to a control group offered standard neonatal care (CG) (n = 35). Seventy families (37 in the EDG and 33 in the CG) completed the study to the 1-y follow-up. Data were collected by means of questionnaires on three occasions: in the EDG, at hospital discharge, on completion of the domiciliary care programme and after 1 y, and in the CG at the corresponding points in time, which were during hospitalization, at hospital discharge and after 1 y. No statistical differences were observed between the groups in emotional well-being, except that mothers in the EDG had a lower level of situational anxiety at the time of hospital discharge compared with CG mothers whose infants remained in hospital. One year after the birth, the EDG mothers said they had felt better prepared to take responsibility for the care of their babies after completion of the domiciliary care programme, in contrast to CG mothers. However, no statistical differences were observed in the recollection of anxiety, confidence in handling the baby and periods of mental imbalance. No statistical difference was observed in breastfeeding rates between the groups. Fathers in the EDG group tended to perceive their babies as being healthier, compared with CG fathers. CONCLUSION: Early discharge of preterm infants followed by domiciliary nursing care did not seem to have any major effect on the parents' anxiety and their assessment of infant health.     

Community neonatal practices and its association with skilled birth attendance in rural Haryana,India

Aim: The study aimed to document home-based neonatal care practices and their association with type of birth attendance. Methods: This study was conducted in rural Haryana on mothers who had delivered a live baby one to 2 months prior to interview. The study instrument, administered through home visits, had questions related to cord care, breastfeeding, thermal care, baby handling and healthcare seeking. Logistic regression was performed to test for association [OR; 95% CI] of key newborn care practices with skilled birth attendance. Results: Of the 415 mothers interviewed, 26.7% applied nothing on umbilicus; 15% were kept in skin-to-skin contact with mother; 20.2% were exclusively breastfed in first month. Seeking care in private sector and cost incurred in the treatment for a neonatal illness was significantly higher for male babies. Delivery by skilled birth attendant (68.5%) was associated with applying nothing on the cord [1.8; 1.01–3.25], in skin-to-skin contact with mother for ≥6 h a day [2.21; 1.18–4.13], bathing the baby after third day [14.63; 6.85–31.21] and exclusive breastfeeding [8.84; 3.42–22.8]. Conclusion: The results of this study call for not only upscaling skilled birth attendance but also improving the quality of care currently provided.     

LONG-TERM EFFECT ON MOTHER-INFANT BEHAVIOUR OF EXTRA CONTACT DURING THE FIRST HOUR POST PARTUM I. First Observations at 36 hours

Abstract The immediate post partum period may be particularly important for the developing relationship between mother and infant; little is as yet known, however, of the long-term effects of hospital practice during this period. This study examines the effect of extra contact during the first hour following delivery. An extra skin to skin contact and suckling contact was given to 22 primiparous mothers and their infants. One control group of 20 primiparous mothers and infants and a second one of 20 multiparous mothers and infants was given routine care immediately after birth. All mothers and infants were healthy with normal pregnancies and deliveries. At 36 hours a first observation was made of maternal and infant behaviour during breast feeding in all three groups. At this stage primiparae with extra contact showed behaviour much more like the behaviour of multiparae with routine care. Infants of primiparae with routine care cried most frequently. The behaviour of mothers of boys differed more from group to group than did that of mothers of girls.     

The thrombopoietin level in the cord blood in premature infants born to mothers with pregnancy-induced hypertension

OBJECTIVE: To investigate the level of thrombopoietin in the cord blood of preterm infants, and its relationship with neonatal platelet count and pregnancy-induced hypertension. STUDY METHOD: Thrombopoietin levels in the cord blood of preterm neonates, with or without maternal pregnancy-induced hypertension, were measured by enzmye-linked immunosorbent assay. RESULTS: The platelet count was significantly lower in very low birth weight infants, infants with maternal pregnancy-induced hypertension, and infants with maternal thrombocytopenia. Neonatal thrombocytopenia was associated with maternal pregnancy-induced hypertension and very low birth weight. The neonatal platelet count was correlated significantly with the birth weight and the maternal platelet count. There was no difference in the cord blood level of thrombopoietin between infants born to mothers with pregnancy-induced hypertension and those without. No correlation was found between the thrombopoietin level and the neonatal platelet count. A positive correlation between the cord blood thrombopoietin and the maternal platelet count was identified. CONCLUSIONS: Maternal pregnancy-induced hypertension and very low birth weight were significantly associated with thrombocytopenia in premature infants, which cannot be explained by decreased thrombopoietin level.     

Immediate maternal thermal response to skin-to-skin care of newborn

AIM: To elucidate the immediate maternal thermal skin response when placing the neonate on the mothers' chest, skin-to-skin (STS). METHODS: Ugandan mothers with non-asphyxiated newborns after vaginal delivery (n = 39) were studied. Maternal skin and axillary temperatures were measured immediately before STS contact, then every 2 min for 20 min and finally 10 min after removing the neonate. Neonatal axillary/forehead temperatures were measured immediately before STS contact, and twice after initiating STS, followed by a measurement 10 min after the newborn had been removed. RESULTS: A rapid thermal response was demonstrated in maternal breast skin immediately after STS contact. It rose by 0.5 degrees C (p < 0.0001) on average the first 2 min after STS contact and fell by 0.5 degrees C 10 min after we had removed the neonate (p < 0.0001). Maternal axillary temperature also rose 2 min after initiation of STS (p < 0.0001) but stayed constant 10 min after removal of the newborn from the STS position. CONCLUSION: The findings indicate that there is a rapid maternal, thermal response to the positioning of the newborn STS. The tactile contact may elicit a maternal adaptation enhancing the warming of the newborn. Possible mechanisms include maternal autonomic nerve-mediated skin vasodilatation.