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The emotional connection between a mother and her infant is normally present at birth, and vocal soothing, touching, comforting, holding, and making eye contact—behaviors commonly associated with “nurture” — have a profound impact on development and behavior. Studies have shown that they can help a child become more resilient to a broad range of mental, behavioral, and physical disorders, and that they play a role in the mother’s wellbeing, too.
Recent trials reviewed here find positive effects of a variety of family-related interventions focused on parental guidance. These interventions target prescribed physical activities with infants, parents’ stress, and the parents’ ability to recognize their positive and negative behaviors with their infants. Beneficial effects include reductions in parenting stress, maternal anxiety, and depression.
Advances in prenatal and neonatal care have led to increased survival of preterm infants (Hack, Klein, & Taylor, 1995). However, infants born prematurely continue to be at risk for a broad range of adverse short- and long-term outcomes (Bhutta, Cleves, Casey, Cradock, & Anand, 2002; Moster, Lie, & Markestad, 2008).
Vocalizations can be markers of emotional social communication. Maternal potentiation was originally described as an increased rate of vocalization by isolated rat pups following an interaction with their mothers, but not with other social companions. Here we asked if potentiation in prairie voles, a species with pair-bonding and bi-parental rearing, is parent-specific.
Premature infants, loosely defined as babies born before 34 weeks gestation, arrive in a state of arrested development. The lungs, the heart, the digestive system, the eyes, the ears—and the brain—may not have reached their full potential when a preemie comes into the world. Lacking proper brain development, premature infants are at elevated risk for problems with learning, communication, emotional regulation, and social bonding.
Infants born prematurely show alterations in the structure and function of their brain circuits — findings that hint at why they are at increased risk for autism. Researchers presented the unpublished results, from two independent long-term studies, at the 2015 Society for Neuroscience annual meeting in Chicago.
Via Williams College:
On any given day in associate professor of psychology Amie Hane’s Early Experience and Physiology lab, students are gathered around a TV monitor, reviewing video of mothers and tiny infants. They stop the recording every few seconds to take note of the slightest change in glance, touch, or tone of voice....
The first RCT of FNI was conducted over a four-year period from 2008 to 2012, with randomization of infants between FNI and Standard Care (SC). One hundred fifteen (115) families and one hundred fifty (150) infants 26-34 wk GA were included. This trial was conducted in a level IV NICU at Morgan Stanley Children’s Hospital of New York at Columbia University Medical Center. FNI was delivered during the NICU stay and the cohort is being followed and assessed for a period of 5 years (1). Exclusion criteria included major congenital defects; birth weight below the third percentile; maternal age of less than 18 years; mother not fluent in English; mother reporting current or previous severe mental illness, addiction or substance abuse; mother did not have at least 1 supportive adult in her home.
For our primary outcome measure, length of stay, we showed that the average length of Nurture Specialist-supervised intervention was 7 weeks (2). The average amount of facilitated interaction between the mothers and infants was 6 hours per week. Analyses showed no significant difference in the overall length of stay between groups.
Further data analyses, however, showed that while still in the NICU, at approximately 36 wks GA, FNI mothers displayed significantly greater sensitivity in measures of maternal care giving, when compared to SC mothers (3).
When the infants were at or near term age (~40 weeks), analyses of brain electroencephalograph (EEG) revealed that infants in the FNI group had extremely robust increases in power (p=.003 to p=.00003) in the prefrontal cortical region (4), as compared to SC infants. Effects were independent of gestational age, weight at birth, gender, twin status, or discharge status when assessed. Such region and frequency-specific increases have been shown by others to correlate with better neurodevelopment at later ages. Further analyses were conducted on the cohort at or near term age to determine EEG coherence, a measure of the maturation of cortical function. These revealed that FNI infants showed significantly lower levels of coherence (1 to 18 Hz), largely within and between frontal regions (p less than .01 to p=.000013) (5). These results suggest that FNI infants displayed accelerated brain maturation, particularly in frontal brain regions shown by other to be invovled in regulation of attention, cognition and emotion regulation.
To determine the impact of FNI on maternal depressive and anxiety symptoms following premature delivery, self-report measures were gathered from mothers when their infants were 4 months corrected age (CA). Analyses showed that FNI mothers had significantly lower levels in both anxiety symptoms (p=.004) and depressive symptoms (p=.038) (6). These results suggest that the psychological well-being of the mother may be tied more closely to mother-infant emotional connectedness than previously thought.
In December of 2014, the cohort passed the 18-month corrected age (CA) mark. Results showed that FNI infants’ neurodevelopment was significantly better than SC infants in two areas, as measured by the Bayley III (7). The FNI infant scores were better on cognition (p=.039) and better on language (p=.008). FNI infants at 18 months had fewer attention problems on the CBCL (p less than .02). FNI infants also displayed better scores in the area of social-emotional development. As measured by the MCHAT, FNI showed significantly less overall risk for autism (p less than 0.02). 76% of SC infants failed at least one of the M-CHAT items, compared to 27% of FNI infants (p less than .001). In addition, 36% of SC infants failed at least one social-relatedness M-CHAT item versus none (0%) of FNI infants (p less than .001).
In summary, we believe that published findings support the feasibility and efficacy of nurture in the NICU. While FNI incorporates some activities that are part of other nurture-based interventions, such as skin-to-skin care and infant touch, this study provides support for integrating these activities into a program of standard NICU care focused on mother-infant connectedness. This is the first NICU RCT to show improvement across multiple domains in preterm infants at 18 months CA. The positive effect of FNI on behavioral problems, social-relatedness, and cognitive and language performance suggests that this intervention may protect against a broad range of developmental delays and disorders.
- Welch MG, Hofer MA, Brunelli SA, Stark RI, Andrews HF, Austin J, et al. Family nurture intervention (FNI): methods and treatment protocol of a randomized controlled trial in the NICU. BMC pediatrics. 2012; 12:14
- Welch MG, Hofer MA, Stark RI, Andrews HF, Austin J, Glickstein SB, et al. Randomized controlled trial of Family Nurture Intervention in the NICU: assessments of length of stay, feasibility and safety. BMC pediatrics. 2013; 13:148
- Hane AA, Myers MM, Hofer MA, Ludwig RJ, Halperin MS, Austin J, et al. Family Nurture Intervention Improves the Quality of Maternal Caregiving in the Neonatal Intensive Care Unit: Evidence from a Randomized Controlled Trial. Journal of developmental and behavioral pediatrics : JDBP. 2015; Apr;36(3):188-96.
- Welch MG, Myers MM, Grieve PG, Isler JR, Fifer WP, Sahni R, et al. Electroencephalographic activity of preterm infants is increased by Family Nurture Intervention: a randomized controlled trial in the NICU. Clinical neurophysiology : official journal of the International Federation of Clinical Neurophysiology. 2014; 125:675-84
- Myers MM, Grieve PG, Stark RI, Isler JR, Hofer MA, Yang J, Ludwig RJ, Welch MG. Family Nurture Intervention in preterm infants alters frontal cortical functional connectivity assessed by EEG coherence. Acta Paediatr. 2015 Mar 14. doi: 10.1111/apa.13007. [Epub ahead of print]
- Welch MG, Halperin MS, Austin J, Stark RI, Hofer MA, Hane AA, Myers MM. Depression and anxiety symptoms of mothers of preterm infants are decreased at 4 months corrected age with Family Nurture Intervention in the NICU. Arch Womens Ment Health. 2015 Mar 1. [Epub ahead of print]
- Welch MG, Firestein MR, Austin J, Hane AA, Stark RI, Hofer MA, Garland M, Glickstein SB, Brunelli SA, Ludwig RJ, Myers MM. Family Nurture Intervention in the Neonatal Intensive Care Unit improves social-relatedness, attention, and neurodevelopment of preterm infants at 18 months in a randomized controlled trial. J Child Psychol Psychiatry. 2015 Mar 11. doi: 10.1111/jcpp.12405. [Epub ahead of print]
This study assessed the impact of Family Nurture Intervention (FNI) on the quality of maternal caregiving behavior (MCB) while in the neonatal intensive care unit (NICU). FNI is a randomized controlled trial conducted in a high-acuity NICU to facilitate an emotional connection between mothers and their premature infants. FNI begins shortly after birth, continues until discharge, and involves mother/infant calming sessions that include scent cloth exchange, vocal soothing and emotion expression, eye contact, skin-to-skin and clothed holding, and family-based support sessions. Methods: Maternal caregiving behavior was coded during a single holding and feeding session (;30 min) in the NICU before discharge at approxi- mately 36 weeks gestational age (GA). Sixty-five mothers and their premature infants (34 male, 31 female; 26–34 wk GA) were included in these analyses (FNI, n 5 35; standard care [SC], n 5 30). Results: Relative to mothers in the SC condition, those in the FNI group showed significantly higher quality MCB, which remained significant when controlling for birth order, twin status, maternal depression, and maternal anxiety. Conclusion: This is the first study to demonstrate that in-unit MCB can be enhanced by a hospital-based intervention. FNI provides a new rationale for integrating nurture-based interventions into standard NICU care.
Family Nurture Intervention is a NICU-based intervention designed to establish emotional connection between mothers and preterm infants. Infants born at 26–34 weeks postmenstrual age (PMA) were divided into two groups, standard care (SC, N = 49) and FNI (FNI, N = 56). Infants had EEG recordings of ~one hour duration with 124 lead nets between 37 and 44 weeks PMA. Coherence was measured between all pairs of electrodes in ten frequency bands. Data were summarised both within and between 12 regions during two sleep states (active, quiet).
Coherence levels were negatively correlated with PMA age in both groups. As compared to SC infants, FNI infants showed significantly lower levels of EEG coherence (1–18 Hz) largely within and between frontal regions.
Coherence in FNI infants was decreased in regions where we previously found robust increases in EEG power. As coherence decreases with age, results suggest that FNI may accelerate brain maturation particularly in frontal brain regions, which have been shown in research by others to be involved in regulation of attention, cognition and emotion regulation; domains deficient in preterm infants.
Preterm delivery can precipitate maternal psychological morbidities. Family Nurture Intervention (FNI) was designed to minimize these by facilitating the emotional connection between mother and infant, beginning early in the infant’s neonatal intensive care unit (NICU) stay. We examined depression and anxiety symptoms of mothers of preterm infants at 4 months infant corrected age (CA). One hundred fifteen mothers who delivered between 26 and 34 weeks gestational age were randomized to receive standard care (SC) or standard care plus FNI. Mothers’ self-reported depressive symptoms (Center for Epidemiologic Studies Depression Scale: CES-D) and state anxiety (Spielberger State-Trait Anx- iety Inventory: STAI) symptoms were assessed at enrollment, near to term age, and 4 months (CA). At 4 months CA, mean CES-D and STAI scores were significantly lower in FNI mothers compared to SC mothers. Effectiveness of FNI can only be evaluated as an integrated intervention strategy as it was not possible to control all aspects of FNI activities. Although there was considerable loss to follow-up, analyses suggest that resulting biases could have masked rather than inflated the measured effect size for depressive symptoms. FNI may be a feasible and practicable way to diminish the impact of premature delivery on maternal depressive and anxiety symptoms.
Preterm infants are at high risk for adverse neurodevelopmental and behavioral outcomes. Family Nurture Intervention (FNI) in the Neonatal Intensive Care Unit (NICU) is designed to counteract adverse effects of separation of mothers and their preterm infants. Here, we evaluate effects of FNI on neurobehavioral outcomes.
The objective of the study was to assess the impact of Family Nurture Intervention (FNI) on electroencephalogram (EEG) activity in preterm infants (26–34 weeks gestation). Our results show that FNI leads to increased frontal brain activity during sleep, which other investigators find predictive of better neurobehavioral outcomes. FNI may be a practicable means of improving outcomes in preterm infants.
The stress that results from preterm birth, requisite acute care and prolonged physical separation in the Neonatal Intensive Care Unit (NICU) can have adverse physiological/psychological effects on both the infant and the mother. In particular, the experience compromises the establishment and maintenance of optimal mother-infant relationship, the subsequent development of the infant, and the mother's emotional well-being. These findings highlight the importance of investigating early interventions that are designed to overcome or reduce the effects of these environmental insults and challenges. The Family Nurture Intervention (FNI) is designed to increase biologically important activities and behaviors that enhance maternally-mediated sensory experiences of preterm infants, as well as infant-mediated sensory experiences of the mother.