Family Nurture Intervention
What is the Family Nurture Intervention?
The Family Nurture Intervention study, developed by Nurture Science Program co-director Martha G. Welch, MD, is a controlled clinical trial conducted by Columbia University Medical Center's Nurture Science Program in the NICU at New York Presbyterian/Morgan Stanley Children's Hospital. The recently published results suggest hospital-based family nurture is a powerful force in helping prevent or overcome emotional, behavioral and developmental problems in prematurely born infants.
The Family Nurture utilizes this calming cycle that is as old as the human species itself. Many decades of research show that mammalian developmental systems are highly dependent on the interactive behavior of both the mother and the infant, as well as on hormonal and other physiological mechanisms. We also know that variations in maternal nurturing can affect the response to stress throughout life.
FNI restores activities between the mother and infant that are critical to development. It does so by means of what we call a mother-infant calming cycle routine. These calming sessions are central to FNI.
One in eight babies in the United States is born prematurely, which is only a portion of a growing international figure. Advances in modern medicine have made it possible for more of these children to survive, but it is often necessary to physically separate the mother and infant in order to administer specialized treatments in the neonatal intensive care unit. This separation interrupts several natural processes between mother and child.
Mother and infant are highly reliant upon one another during gestation and after birth. Physical contact between the two involves a complex mixture of mutual stimulation, emotional communication, and interactions that impact physiological, endocrinological and behavioral mechanisms in both mother and infant.
Separation can have a traumatic effect on the autonomic nervous systems that can lead to a visceral response to stress. Theoretically, the trauma conditions an uncontrolled emotional response between mother and infant that can have a devastating impact on development. The separation trauma results in what neuroscientists call a general state of toxic stress.
Through her research, Dr. Welch developed the Calming Cycle—repeated and regular calming sessions between mother and infant.
The goal of the calming cycle is to restore a state of co-regulation between mother and infant. Co-regulation allows the two to become mutually attuned to one another’s emotional, physiological, and behavioral cues. This process bolsters the mother’s confidence in her ability to fully care for her preterm infant and enhances her maternal behavior.
The intervention takes place over the course of a preterm infant’s stay in the NICU. It enables mothers to engage in nurturing interactions as early as possible, within the constraints of the NICU environment.
This is how it's done.
- The first interactions begin while the infant is confined to an incubator. Incubators in the NICU were designed to keep babies warm in a moist, clean environment and help to protect the baby from noise, drafts, infection, and excess handling. FNI gives the mother an active role in the care of the infant at this stage of treatment. Interactions include odor-cloth exchange, firm sustained touch, vocal soothing, and eye contact.
- As soon as the infant can leave the incubator and be held and fed by the mother, interactions include holding and calming session activities.
- During a calming session, the mother is instructed to hold her infant safely and securely skin-to-skin and chest-to-chest, between her breasts and under her clothes. Clothed holding is facilitated if the mother does not want to engage in skin-to-skin holding. This is done in an upright position while seated in a reclining chair. The infant’s head is tilted up to ensure the airway is not constricted and a blanket is placed over the infant’s back to help maintain temperature. Once initiated, the mother is encouraged to engage in the calming activity for a minimum of one hour, but longer if possible.
- As calming sessions proceed, the mother learns to identify four phases through which mothers and infants cycle: 1) separate mother and infant discomfort/distress; 2) mutually shared distress; 3) mutual resolution of discomfort/distress; 4) mutual calm that may include periods of eye-to-eye contact and/or sleep.
Theoretically, over time the repeated calming interactions will lead to an emotional engagement and increased attraction between mother and infant. This process leads to more rapid reductions of discomfort and distress in both the mother and the infant. Ultimately, the repeated process leads to the establishment of a calming cycle routine that can continue at home, after leaving the NICU, and give the mother an important parenting tool with which she can calm her infant when distressed.
The intervention can include sessions with additional family members whenever possible, including the father and grandparents. These sessions provide the family with strategies to support the mother as she continues these interactions with her infant within the NICU and at home.
The Purpose of Family Nurture Intervention
The implications are exciting. Results from our first randomized controlled trial suggest that the negative effects of the stress and trauma of preterm birth are not necessarily permanent. The results also show that a small dose of the intervention can lead to relatively large effects that are sustained throughout the critical 18-month stage following discharge.
Future studies will test whether implementing FNI in another institution can replicate our findings. In another study we hope to test whether FNI can be implemented by NICU staff and incorporated into standard care.
Results of Family Nurture Intervention Study
The results show that babies receiving Family Nurture Intervention had robust increases in infant brain activity (by electroencephalographic power) when the infants reached full term age.
Increases up to 36% were observed in the frontal polar region in the intervention group, as compared to the control group. The electroencephalographic findings in the Family Nurture Intervention study are highly significant because other researchers have reported preterm infants to have deficits related to frontal polar function.
In addition, still others have found that infants with greater power in this region have improved cognitive function, language, and attention to regulate and manage emotions at older ages.
Periods of eye contact increased mutual calm and improved sleep.
Evidence that the negative effects of the stress and trauma of preterm birth are not necessarily permanent.
A small dose of Family Nurture Intervention can lead to relatively large effects that are sustained throughout the critical 18-month stage following discharge from the NICU.
Implementing Family Nurture Intervention in Hospitals and Medical Practices
Multi-site replication studies are currently being set up at Morgan Stanley Children’s Hospital in New York City and Children’s Hospital at the University of Texas Health Science Center San Antonio. These studies will be followed by effectiveness trials in the same hospitals to determine if this intervention can be effectively applied to all babies in NICUs within the next few years.
Our hope is that three to four years from now the Nurture Science Program will be ready to promote Family Nurture Intervention in NICUs around the country and help more children and families.
Replicating the Family Nurture Intervention NICU Study
The Family Nurture Intervention NICU research carries with it the promise that mothers have the power to promote healthy future learning and relating while their baby is still in the hospital. Results suggest that mothers can mitigate and even repair some of deficits that can accompany premature birth.
These studies will be followed by effectiveness trials in the same hospitals to determine if this intervention can be effectively applied to all babies in NICUs within the next few years.
Other Family Nurture Intervention Studies
- A study to test the effects of Family Nurture Intervention (FNI) in a group setting of pre-school aged children and their mothers is being set up through the Norwalk Housing Authority in Connecticut. This study is a randomized control trial and we will recruit 80 mother-child test pairs. They will be randomized to either FNI or a play and nutrition group. Mother-child pairs will come in weekly for sessions for six months. Assessments will occur at three time points (3, 6, and 12 months post-enrollment). Behavioral and physiological data will be collected at enrollment and at the three following assessments.
- A Family Nurture Intervention brain imaging study is also being planned at the Women’s Hospital of British Columbia (WHBC) and University of British Columbia (UBC) This randomized control trial will examine whether FNI improves brain maturation, compared to standard care, using state-of-the-art MRI to measure changes in brain development from shortly after a premature birth to term equivalent age. The study is expected to begin in the fall of 2017.