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Madalynn Neu, PhD, RN JoAnn Robinson, PhD

Effect of Holding on Mother-infant Co-Regulation and Infant Development. Madalynn Neu, PhD, RN JoAnn Robinson, PhD Mark Laudenslager, PhD University of Connecticut Sarah Schmiege, PhD Nick Hazel, PhD University of Colorado Research supported by K23HD40892 from the

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Madalynn Neu, PhD, RN JoAnn Robinson, PhD

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  1. Effect of Holding on Mother-infant Co-Regulation and Infant Development Madalynn Neu, PhD, RN JoAnn Robinson, PhD Mark Laudenslager, PhD University of Connecticut Sarah Schmiege, PhD Nick Hazel, PhD University of Colorado Research supported by K23HD40892 from the National Institute of Child Health and Human Development; and MO1-RR00069, General Clinical Research Centers Program, NCRR, NIH.

  2. Preterm Hospitalization & Stress (Healthy Preterms) • Pain & Discomfort • Heelsticks • IV Insertion • Weighing • Assessments • Nasogastric feedings • Immature Neurological System • Hyperresponsive stress response

  3. Co-Regulation • High quality maternal interaction associated with development of self-regulation, cognitive development, positive sense of self, and secure attachment • Co-regulation is a form of high quality interaction • Dyad functions as integrated unit to regulate each other’s behavior (Fogel, 2000) • Dyad co-creates and responds to new information that was not available to them before current interaction

  4. Kangaroo Holding Kangaroo holding is associated with enhanced mother-infant Interaction, physiologic stability, positive affect, alertness suggesting That it promotes co-regulation BUT • Additional research needed to: • Explore underlying dyadic physiology • Compare kangaroo holding and blanket holding • Measure, and compare the support and attention received by mothers • Define “Standard Care” condition

  5. Purpose Compare the effects of two 8 week nurse-supported infant holding interventions and a control condition on co-regulated responses of mothers and their preterm infants after 2 weeks, and at 2, 6, and 12 months of kangaroo holding.

  6. Hypotheses When compared to dyads supported in blanket holding or the control group , mother-infant dyads supported in kangaroo holding will show: • More co-regulated salivary cortisol levels from baseline to 2 months • More co-regulated mother-infant interaction at 6 months Infants experiencing kangaroo holding will show: • Better developmental scores at 2 months • Greater infant vitality in re-engaging mother at 6 months

  7. Design Multisite, randomized 8-week controlled trial – 3 groups 1) Nurse-supported kangaroo holding – 1 hour per day 2) Nurse supported blanket holding - 1 hr per day 3) Choice of holding – no holding constraints

  8. Sample Criteria • Recruited from NICUs at 5 hospitals in Denver • 32 through 35 weeks gestational age at birth • Enrolled within 1-3 weeks after birth • No umbilical lines, physical anomalies, surgery, or more than ½ L oxygen requirement • Mothers fluent in English or Spanish • Mothers without chronic illness

  9. Procedure Nurse-supported kangaroo and blanket holding groups received weekly visits from RN lasting 45-60 minutes with agenda: • Relaxation techniques • Benefits of assigned holding • Encouragement to hold at least one hour per day • Recognition and response to infant cues • General early growth and development Control group received weekly social visit lasting 10-20 minutes • Two types of holding explained but no encouragement to hold

  10. Procedure • Most visits were conducted in the infant’s home • All mothers completed a daily holding diary for 8 weeks • Length of holding • How baby held • Who held baby

  11. Findings

  12. Consented & Randomized n = 87 Allocated to Kangaroo Holding n = 31 Allocated to Blanket Holding n = 29 Allocated to Control n = 27 Withdrew n = 2 Reasons: Too busy, n = 1 Disliked group, n = 1 Withdrew n = 3 Reasons: Too busy, n = 3 Withdrew n = 3 Reasons: Too busy, n = 1 Disliked group, n = 1 Study Week 8 N = 24 Study Week 8 N = 26 Study week 8 n = 29

  13. Demographics of Sample (n = 87) M • Gestational Age : 31-35 wks (33.3wks) • Birth Weight: 1100-3127 g (1948g) • Illness score (SNAP): 0-16 (4.0) • Maternal Age: 15-43 yrs (26.0 yrs) • Paternal age: 15-43 yrs (27.7 yrs) • Hollingshead SES: 13-66 (37.9) • 50% Male • 48% Caucasian

  14. * P = .027; ** p = .000

  15. Hypotheses When compared to dyads supported in blanket holding or the control group , mother-infant dyads supported in kangaroo holding will show: • More co-regulated salivary cortisol levels from baseline to 2 months

  16. HPA Axis & Cortisol • Perception of stress or emotional arousal activates HPA axis • Early experiences influence later responses to stress

  17. Physiologic Co-regulation (Mother-Infant Cortisol Levels) Conceptualized as: • Decreasing stress in • infants Mother-infant • levels close at the end • of an observation than • at the beginning

  18. Maternal-infant Physiologic Co-regulation in cortisolConceptualized as similar slopes:

  19. Holding Observations • 60-minute holding observations at baseline, and after 2 & 8 weeks of holding • Mother’s sat in comfortable chair • Control group held their typical style • Infant diaper changed before holding • Saliva collected with filter paper from mother and infant • Before holding and diaper change • After 30 minutes of holding • After 60 minutes of holding

  20. Saliva Collection & Assay • Filter paper • Folder in half lengthwise • Placed on infant’s or mother’s tongue directed toward side of mouth • Left in place for ~2 minutes until about 1 in. saturated (mothers 20 seconds) • Dried by hanging wet-end down • Stored at room temperature • Cortisol extracted in lab and assayed using ELISA technique

  21. Data Analysis (ANOVA models) • Outcome variables: • Coregulation, 0-60 minute score: Difference between mother and infant scores at 0 and 60 minutes over time. • Also segmented 0 – 30 minutes and 30-60 minutes • Mixed model analysis

  22. Mother –infant Cortisol Co-regulation During Holding • Maternal-infant salivary cortisol difference from 0 to 60 minutes at baseline, 2 weeks and 8 weeks: • No differences among groups • Maternal-infant salivary cortisol difference from 30 to 60 minutes at baseline, 2 weeks and 8 weeks: • No differences among groups

  23. Mother –infant Cortisol Co-regulation During Holding • Maternal-infant salivary cortisol difference from 0 to 30 minutes at baseline, 2 weeks and 8 weeks: • p = .07 with kangaroo group becoming increasingly in sync between showing more synchronous levels between baseline and 30 minutes

  24. Baseline Week 2 Week 8

  25. Hypotheses When compared to infants supported in blanket holding or the control group Infants experiencing kangaroo holding will show: • Better developmental scores at 2 months

  26. Procedure • Two developmental exams conducted 2 days apart at week 8 • Infants were 40-45 weeks postconceptual age (M = 42.5 weeks) • Exams were conducted in the homes of the infants by certified examiners

  27. Assessment of Preterm Infant Behavior APIB (Als et al., 1981) • Adapted for preterm infants from NBAS (Brazelton, 1984) • Assesses subsystem functioning (physiologic, motor, state organization, attention, self-regulation, examiner facilitation) • From NBAS assesses cluster scores: newborn habituation, orientation, motor quality, state regulation and arousal, and reflexes

  28. Analysis • Subsytem scores were highly correlated so analyzed only Physiologic and Attention • NBAS cluster scores: Motor, Social, Autonomc, State Regulation, Ability to arouse to vigorous crying/regulate, State Stability • Analyzed scores from best exam • Covaried sex and examiner in ANCOVA

  29. Group Differences: Robust Crying

  30. Preterm Sample Compared to Infants Born at Term (Subsystems) Term infants scored higher in Attention, p = .017

  31. Preterm Sample Compared to Infants Born at Term (Cluster Scores) **P <.01

  32. Hypotheses When compared to dyads supported in blanket holding or the control group , mother-infant dyads supported in kangaroo holding will show: • More co-regulated mother-infant interaction at 6 months Infants experiencing kangaroo holding will show: • Greater infant vitality in re-engaging mother at 6 months

  33. 6 Months • Mothers notified when infants were 26 weeks of age (4.9 months corrected age) to schedule a Still Face Observation. • Most visits were conducted in the infant’s home

  34. Dyads Lost to Study at 6 Months (Sample = 65)

  35. Still Face Observation (Tronick et al, 1978) • Assesses mother-infant interaction and infant responses to sudden, unexpected change in maternal emotional expressions • Three 2-minute phases • Face-to-face maternal-infant social interaction • Maternal neutral face • Reunion face-to-face mother-infant social interaction • Widely used and well validated tool for infants 2 to 9 months of age

  36. Still Face Observation

  37. Scoring for Co-regulation During Face-to-Face Play • Mother-Infant (Fogel, 1994) • Dyad is considered a unit with interactive patterns continuously and jointly co-created • Scoring of the dyad done second by second • Validity for infants less than 6 months of age documented • Categories • Symmetrical - Optimal • Asymmetrical • Unilateral • Disruptive • Disengaged Co-Regulated Interaction

  38. Data for Analysis • Disruptive and disengaged rarely observed so no included in analysis • Agreement between scorers was .94.

  39. Scoring for Infant Vitality During Neutral Face Phase (Weinberg & Tronick, 1996) • Infant positive bids for mother’s attention • Happy expression • Laughing or cooing • Reaching for mother • Lean forward toward mother • Infant negative bids for mother’s attention • Crying or fussing • Grimace or frowning

  40. Findings

  41. Percent of Observation of Mother-infant Co-regulation (Depression and infant sex used as covariates) Mother-Infant Co-Regulation Post Neutral Face Mother-Infant Co-Regulation Pre Neutral Face Asymmetrical

  42. Percent of Observation of Infant Vitality Behaviors Infant Behavior During Neutral Face Infant Positive Behavior During Reunion Phase (Post Neutral Face)

  43. Limitations • Difficult recruitment resulting in smaller sample than 44/group required by power analysis • 60% of those approached refused • When differences were not found, group means were very close • Small effect sizes • Most mothers did not begin kangaroo holding until infants were ~ 2 weeks of age. • Attrition of 9.2% at 2 months; 21% at 6 & 12 months • Withdrawals evenly split between groups and similar to remaining sample.

  44. Strengths of This Study • Kangaroo holding was compared to blanket holding when mothers received carefully monitored and identical amounts of attention and guidance • Control group received brief visits and recorded holding time • Very similar holding times and demographics to traditional holding group BUT • Did not receive home visiting intervention

  45. Conclusions (General) • Mothers are more likely to practice kangaroo holding in a supportive atmosphere

  46. Conclusions Maternal and infant cortisol levels in dyads who practiced kangaroo holding seem to become more in sync during eight weeks of holding cortisol levels in dyads who practiced blanket holding. • Kangaroo holding may not influence dyad interaction during low stress situations • Kangaroo holding seems to enhance self-regulation of infants to allow them to contribute more effectively to interaction in higher stress situations • Dyads practicing kangaroo holding may be better able to adapt to mismatches and novelty in interaction

  47. Conclusions (Infant Development) • In a randomized sample when compared to nurse supported blanket holding, extended kangaroo holding provides similar developmental benefits to healthy preterm infants born at 32 to 35 weeks postconceptional age. • Increased holding time may provide benefits to infants born preterm • The home visiting intervention, not holding style, seemed to support energy for vigorous crying.

  48. Future Research • Examine the maternal-infant cortisol patterns in dyads in which the infant has very low or very high cortisol levels. • Examine the optimal duration of time for practice of kangaroo holding • Examine longitudinal benefits of kangaroo holding past 12 months • Continue to compare holding styles, not kangaroo holding to lying in bed

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