Dr. Welch and Dr. Dumitriu discuss the surprises and opportunities the COMBO initiative has presented.
The Nurture Science Program (NSP) is proud to share that since March of 2020, we have been partnering with the COVID-19 Mother-Baby Outcomes (COMBO) Initiative to study how COVID is affecting parents and babies during the critical first year of life, and beyond.
As part of COMBO’s multidisciplinary study, they are using some of NSP’s core tools and practices: both to measure how COVID is impacting mother-infant emotional connection, and to protect and repair it.
COMBO’s recently published papers include data on low rates of vertical transmission (passing COVID from mother to baby), newborn outcomes, and racial/ethnic disparities in the sleep health of mothers and babies. While many results have yet to be published, we’re excited to share with you what COMBO founder Dani Dumitriu MD, PhD and NSP Director Martha G. Welch MD—have to say about COMBO’s discoveries so far, and what comes next.
How Was the COMBO Study Born?
Dr. Dumitriu: When Dr. Welch and I met, we found that we had the same ultimate goal: to bring about a whole different world view, and to do it through the avenue of pediatrics. We both work with moms and babies—Dr. Welch specializes in building emotional connection, and I specialize in building resilience, which are interrelated but not exactly the same.
Dr. Welch: For over a decade, NSP has been studying an intervention called Family Nurture Intervention (FNI), which emotionally connects preterm babies and their mothers in the NICU, with excellent results. Dr. Dumitriu and I wanted to bring the intervention into the well-baby nursery to help full-term babies and parents.
Dr. Dumitriu: But when the pandemic hit, we pivoted toward what was most urgent. I became the designated COVID attending physician in the nursery, and as I was there taking care of these moms and babies for ten, twelve, fourteen hours a day, I started having a lot of questions. And out of those questions evolved what is currently COMBO: Covid-19 Mother-Baby Outcomes Initiative at Columbia University.
It started with just a few of us pediatricians in the nursery, calling up our former patients and asking them how their babies were doing. But then it evolved into a very large multidisciplinary initiative, now involving almost a hundred physicians, researchers, students, and staff. There was no funding to start this, so we all redirected our time, attention, effort, and resources towards this.
What Aspects of Mother-Baby Health is the COMBO Study Looking At?
Dr. Dumitriu: We are measuring a lot of different things in moms and babies. Let’s start with moms:
We’re measuring their depression, anxiety, and post-traumatic stress from COVID. We’re measuring their social support and trying to include what happened before the pandemic—their prior lives and childhoods. We’re evaluating maternal olfaction (or mom’s sense of smell), which plays a big role in mother-baby emotional connection and potentially maternal mental health.
And then we’re measuring a lot of different things in the babies:
Neurodevelopment is, of course, one of the most important aspects we’re looking at. The babies born at the height of the pandemic are just now turning one, so we’re starting to look at the long term neurodevelopmental effects of mom having had COVID during pregnancy and of pandemic practices on infants (for example: are masks impacting babies’ development?).
Moving forward, we’re going to try to get some data on brain function. There are these very cool devices we’re using right now called Epilogs, which can measure the brain function of both mom and baby simultaneously. We’re also measuring socioemotional function, sleep, smell, and heart function, which are all important to mom-baby connection and health. So we will get an incredible amount of data.
And of course, most importantly, we’re asking: can we mitigate any negative effects with Family Nurture Intervention?
What Has the COMBO Study Found?
Dr. Dumitriu: COMBO has already begun to see some really good news, and some not-so-good news.
The good news is that vertical transmission (the passing of COVID-19 from mother to baby) is very, very low. In pediatrics, and in particular in newborn medicine, we worry a lot about sick moms. Lots of bugs that are in the mom get transmitted to the baby while the mom is still pregnant. What we’ve found with COVID, luckily, is that transmission is extremely rare. And even when it happens, it does not tend to cause severe disease in the infant.
But after that, we started noticing some other disturbing trends. In some populations, breastfeeding rates have gone down during the pandemic, whether mom had COVID or not. There is absolutely nothing that matches the long-term benefits for an infant, and also for a mom, as breastfeeding. Anything the mom has ever been exposed to, any vaccine the mom has ever gotten (including the COVID-19 vaccine)—those antibodies go into the breast milk and protect the baby. And breastfeeding is so important for emotional connection between mother and baby.
Dr. Welch, do you want to talk about mom-baby emotional connection and the screen you developed to very rapidly measure it?
Dr. Welch: Yes. Emotional connection is a necessary component of infant development and maternal health. We’ve found that since the start of the pandemic, the rate of emotional connection between mothers and babies has dropped about 50% by the time the baby is four months old. We had a pre-pandemic sample that showed a little more than 40% were connected. That wasn’t exactly good news, because that’s too few. But during the pandemic, it’s gone down to 20%, and it doesn’t matter whether the mother was COVID-positive or COVID-negative. That level of emotional disconnect is an emergency.
We have a screen called the Welch Emotional Connection Screen (which we call the WECS), that measures the vital signs of relational health, using four parameters:
- Attraction (do mom and baby show approach behaviors toward each other?)
- Vocal exchange (is their vocal exchange warm?)
- Facial communication (are they making sustained eye contact?)
- Reciprocity(is there a give and take in their interactions?)
If those scores are all good, baby and mom are connected. You don’t have to worry about them. If the scores are low, we know how to reconnect them, and that’s Family Nurture Intervention.
When reciprocal mother-baby interactions suffer, it has validated implications for both of them. Babies are at risk for slower development of brain activity and nervous system regulation, as well as difficulty with future social relatedness, attention, thinking and learning, and language skills. Moms are at risk of postpartum anxiety and depression, and less responsiveness when caring for their infants. FNI decreases all of these risks.
What Might Be Causing This Crisis of Connection?
Dr. Welch: Reciprocity sounds odd to talk about with a newborn, but believe me, it’s there. It should be there. It naturally occurs if birthing goes undisturbed. Now, of course, birthing has been greatly disturbed by COVID: at first, not even the partner was allowed in the delivery room. Then, once they were, they had to leave immediately after the birth. And mothers were being separated from their babies in the hospital. So, the family was highly disrupted.
We thought, “Okay. This birth was disrupted, but they’ll go home and they’ll get together.” But no. At four months, they had not. Those of us doing the rating on the WECS were astonished. Because the kind of interactions we saw after birthing during the pandemic, we haven’t seen in other mothers—even other mothers who aren’t connected to their babies. So now we know: we have an epidemic of disconnect, or lack of emotional connection.
Dr. Dumitriu: You brought up something very interesting, which is that in addition to the sample you had from pre-pandemic times, we had also enrolled a few moms who had given birth right before the pandemic, in February. Despite the fact that these moms and babies had undergone a lot of the stress of the pandemic starting when the baby was around one month old, those mom-baby pairs actually had the higher, pre-pandemic-era emotional connection score.
So, we’re really talking about that moment in time—birth and the very early postnatal period between mom and baby—being absolutely critical.
What’s exciting is that we’re finally collecting data on this connection. We’re saying, “How are mom and baby’s brains, as well as mom and baby’s hearts—how are those responding to each other?” We’re recording the activity of the frontal brain region of both mom and baby, as well as their heart rates, at the same time. And even cooler, we’re doing it during the intervention (FNI).
It’s early. We can’t really talk about results, but we do have some evidence that as we are working on that connection—as we’re seeing that connection between mom and baby happening in real time—we can see their actual hearts starting to be in sync with each other.
Dr. Welch: So now, we’re back on track with Family Nurture Intervention in the well-baby nursery, and being part of COMBO, we’re going to have a huge amount of information. It will be very important to see how many of the effects being measured have been mitigated by FNI.
Actually, doing the intervention remotely has been very interesting. I had to do it by Zoom. I was probably the last person in the world to think you could do an intimate interaction, such as this work of emotional connection, over Zoom! And I found, to my astonishment, that you really could.
The mother put her phone on a pillow next to her and the baby, so they were maybe 18 inches from the camera. And I was less than 18 inches from my camera. So it was just as if we were together, and it worked very, very well. I didn’t think it could have gone better. We’re studying how well it works and will have data on this population, and others, soon.
That was a really great learning experience. Not only is that good for the times of COVID, but the success of doing FNI remotely is good for scalability. That would make it accessible to all mothers everywhere.
How Can FNI Address Issues Moms and Babies Are Facing Because of the Pandemic?
Dr. Welch: There are a couple of things we should mention. Our intervention includes a scent cloth exchange. We use this in the NICU with preterm babies to very good effect—giving the mother a scent cloth from the baby, and giving the baby a scent cloth from the mother.
Now, this is very important, because one of the cues for connecting is scent. And it’s widely known that smell is affected by COVID. We don’t know yet what effect that might be having in the emotional connection problems we’re seeing in the mothers who’ve had this coronavirus.
Dr. Dumitriu: Oh, absolutely. Not only is it widely-known, but in our own data, we have found that about 70% of the moms who’ve had COVID during pregnancy—even if they didn’t have any other symptoms—reported loss of smell and taste.
There’s data from other sources that some people might actually have prolonged olfaction (smell) deficits. Which of course would be incredibly detrimental to the mom-baby connection, not just over the period of time that the mom is infected, but long term. Those results are still a little bit too preliminary. We’re just at the beginning of that work, and we’re partnering with the incredible Monell Center to hopefully get some answers.
Dr. Welch: And then there’s reciprocal facial interaction, which has been disrupted by the pandemic. In COMBO, we’re studying how masks disrupt mother-baby interactions.
Dr. Dumitriu: Just like the WECS scoring, it’s really painful to watch how badly these babies respond to masks. They start crying, they start vocalizing, and they start arching their backs. From a public health perspective, this is of huge, huge relevance. Because all of these babies have been seeing masks for the whole first year of their lives now.
To be clear, we definitely believe in safety first and wearing masks! But until we have better technology (like clear masks), we have to actively do things to mitigate the effects of not seeing each other’s faces.
Dr. Welch: And the other phenomenon is, of course, all of us are using computers and phones to make contact with other people. And having the mother drop out of an interaction to text or look at her phone may be having exactly the same effect. FNI promotes face-to-face interaction and emotional exchange, which can help heal disconnect caused by mask-wearing and overuse of screens.
Dr. Dumitriu: Yeah. So, how are we gonna fix this connection problem, Dr. Welch?
Dr. Welch: If our intervention works by meeting virtually, we have a good chance to scale this to a very high order. And when we can get back to doing it safely in person, it’s relatively scalable as well. So it’s a matter of just doing it, however we can.
How Has the Pandemic Affected Family Support, When Moms and Babies Go Home from the Hospital?
Dr. Dumitriu: It’s a really interesting question. I don’t have any hard data for you right now, but anecdotally speaking, from talking to many of these families, support has definitely gotten more problematic. One of the most common questions my patients ask the day they leave the hospital is, “Can my family come over?”
As a physician, it breaks my heart to have to advise new parents to maintain certain limits that I wouldn’t necessarily advise normally. Of course, it’s important to protect the whole family, but I’m really worried about the parents. Because if babies get COVID, they tend to have a pretty mild course. But if the parents are not healthy, they cannot care for the baby, and their risk is greater.
So there is definitely less support, in terms of having family members like grandparents come and help with the babies. Which can be so hard for families. And there’s also the loss of employment for many people around the world, which places an incredible burden on new parents.
Dr. Welch: There are so many disruptions, especially right now. It’s unrealistic to think that you could meet everybody’s needs all of the time. What you need to be able to do is meet them as much as you can, and then repair any disruptions that cause the lack of emotional connection. Being emotionally connected is a state we can move in and out of. We expect it to get disrupted! But we have to be able to repair—it’s constant repair. It’s easy to do when we do it often. And it’s so, so important.
What’s next for you two at NSP and COMBO?
Dr. Dumitriu: Lots of really, really awesome things. So, of course the clinical trial of FNI in the well-baby nursery is critical. NICU work is really important—babies born prematurely or with medical complications can have all kinds of issues. But really, our dream is to bring this intervention to all populations. 90% of babies born in the U.S. go to the nursery, not the NICU. And as we’ve just been talking about, that very early postnatal time immediately after birth, and the first few days after birth, are absolutely critical to the connection between mom and baby.
We are also really interested in being able to bring FNI very broadly to the community. A lot of the birthing process has indeed been disrupted, not just by COVID, but just in general by our society. There’s a lot of medicalization of birth. That has definitely done some good stuff, in terms of saving numerous babies from dying or from having really bad outcomes. But it has also disrupted the more subtle, but still crucial, things.
Science has not really caught up to this: in the process of saving lives, we also have to save the emotional connection between mom and baby.
Dr. Welch: And now we have a way to measure it, which is the WECS. It’s very important, in looking at our work with COMBO and NSP, to understand how aligned Dr. Dumitriu and I are on what’s important and how to communicate it to everyone who might be affected by this work.
Dr. Dumitriu: Absolutely. We have to do the research because there’s a need for rigorous data on all of these things. We worked really hard to mobilize at a time of absolute crisis and we’re starting to generate that data.
We have all these individuals who have contributed to both NSP and COMBO in the last year, really because of their dedication to the ultimate goal of protecting moms and babies—protecting the emotional connection, building an empathic society, and recovering from COVID. Because we all know that COVID not only will still be with us for a while, but also will have tremendous repercussions on long-term functioning within our society.
And that is why we’ve worked so hard in the past year. Because we are trying to rapidly generate the knowledge of what is happening with moms and babies due to COVID, and how we can protect them.
Dr. Welch: Emotional connection is how we get through times like these. It’s how mothers and babies have survived since the very beginning.