Post on 15-Jan-2016
description
Madalynn Neu, PhD, RN JoAnn Robinson, PhDMark Laudenslager, PhD University of ConnecticutSarah Schmiege, PhDNick 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.
Effect of Holding on Mother-infant Co-Regulation and Infant
Development
Pain & Discomfort◦Heelsticks◦IV Insertion◦Weighing◦Assessments◦Nasogastric feedings
Immature Neurological System Hyperresponsive stress response
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
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
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.
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
Multisite, randomized 8-week controlled trial – 3 groups
1) Nurse-supported kangaroo holding – 1 hour per day2) Nurse supported blanket holding - 1 hr per day
3) Choice of holding – no holding constraints
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
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
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
Consented & Randomized n = 87
Allocated to Kangaroo Holding n = 31
Allocated to Blanket Holding n = 29
Allocated to Control n = 27
Withdrew n = 2Reasons:Too busy, n = 1Disliked group, n = 1
Withdrew n = 3Reasons: Too busy, n = 3
Withdrew n = 3Reasons:Too busy, n = 1Disliked group, n = 1
Study week 8n = 29
Study Week 8N = 26
Study Week 8N = 24
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
Kangaroo Holding n = 29
Traditional Holding n = 26
Control n = 24
Maternal Characteristics Mean (SD) Mean (SD) Mean (SD) Age 25.8 (6.8) 25.9 (7.3) 26.6 (5.9) Hollingshead Score 38.3 (15.9) 36.7 (14.4) 38.6 (14.5) Daily Hours Maternal Holding
2.6 (1.1) 2.4 (0.9) 2.5 (1.6)
Daily Holding Hours (Total) 4.8 (2.1) 4.5 (1.3) 4.8 (1.6)
Depression Score (CES-D) 13.8 (6.8) 10.1 (7.3) 9.1 (9.0) Anxiety Trait (STAI)* 36.8 (7.6) 31.7 (7.2) 31.8 (6.8) Anxiety State (STAI) 34.9 (11.6) 30.6 (11.0) 29.3 (8.1) Days Breast Fed 32.4 (29.8) 36.8 (33.1) 38.7 (31.2) Hours of Home Visiting** 6.6 (0.8) 6.3 (1.0) 2.1 (1.2)Infant Characteristics Gestational Age, Birth (wks) 33.1 (1.1) 33.4 (0.9) 33.4 (0.9) Birth Weight (kg) 2.0 (0.5) 1.9 (0.3) 2.0 (0.4) Illness Score, Birth 4.0 (2.9) 3.1 (2.7) 4.8 (3.7) APGAR 1 minute 7.2 (1.7) 7.1 (1.7) 6.5 (1.9) APGAR 5 minutes 8.7 (0.5) 8.6 (0.9) 8.0 (1.5) Days Hospitalized 21.7 (10.9) 23.5 (8.2) 19.1 (6.4) Days on Oxygen 8.1 (14.6) 7.1 (17.0) 13.7 (20.5) Postnatal Days Baseline Holding 2 weeks Holding 8 weeks Holding
14.0 (6.7) 30.1 (6.6) 70.9 (8.2)
15.0 (4.9) 28.8 (4.8) 72.1 (17.5)
16.1 (5.7) 30.1 (5.5) 74.1 (8.4)
* P = .027; ** p = .000
Kangaroo Holding n = 29
Traditional Holding n = 26
Control
n = 24
Male 18 (62.1) 12 (46.1) 9 (37.5)
Ethnicity
White, Non Hispanic Hispanic African American Mixed Race
14 (48.3) 7 (24.1) 2 (6.9) 6 (20.7)
12 (46.1) 6 (23.1) 4 (15.4) 4 (15.4)
13 (54.2) 4 (16.7) 3 (12.5) 4 (16.7)
Feeding Type
Breast Feeding Breast and Bottle Bottle Feeding
3 (10.3)14 (48.3) 12 (41.4)
2 (7.7) 12 (46.1) 12 (46.1)
1 (4.2) 11 (45.8) 12 (50.0)
Marital Status Married
23 (79.3) 19 (73.1) 20 (83.3)
Private Hospital 19 (65.5) 20 (76.9) 16 (66.7)
Number of home visits ** 8 7 6
22 (75.9) 6 (20.7) 1 (3.4)
22 (84.6) 4 (15.4) 0 (0.0)
0 (0.0) 10 (41.7) 14 (58.3)
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
Perception of stress or emotional arousal activates HPA axis
Early experiences influence later responses to stress
• Decreasing stress in infants Mother-infant levels close at the end of an observation than at the beginning
0
2
4
6
8
10
Time 1 Time 2 Time 3
Baby
Mother
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
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
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
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
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
When compared to infants supported in blanket holding or the control group Infants experiencing kangaroo holding will show:
◦ Better developmental scores at 2 months
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
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
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
Term infants scored higher in Attention, p = .017
**P <.01
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
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
Kangaroo Traditional Control
Enrolled 31 29 27
Week 8: Withdrew
2 (Too Busy; Disliked group assignment)
3 (Too Busy) 4 (Too Busy; Disliked Group Assignment)
Sample at Week 8
29 26 24
6 Months: Lost 4 2 2
6 MonthsTechnical Difficulties
3 1 2
Sample at 6 Months
22 23 20
Assesses mother-infant interaction and infant responses to sudden, unexpected change in maternal emotional expressions
Three 2-minute phases1. Face-to-face maternal-infant social
interaction2. Maternal neutral face3. Reunion face-to-face mother-infant social
interaction Widely used and well validated tool for
infants 2 to 9 months of age
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
Disruptive and disengaged rarely observed so no included in analysis
Agreement between scorers was .94.
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
0
10
20
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60
Symmetrical UnilateralAsymmetrical
0
10
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60
Symmetrical Unilateral
KangarooBlanketControl
Asymmetrical
Mother-Infant Co-Regulation Pre Neutral Face
Mother-Infant Co-Regulation Post Neutral Face
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40
Postive Bids Negative Bids0
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Postive Behavior
KangarooBlanketControl
Infant Behavior During Neutral Face
Infant Positive Behavior During Reunion Phase (Post Neutral Face)
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.
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
Mothers are more likely to practice kangaroo holding in a supportive atmosphere
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
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.
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