Duke Fetal Bonding ProgramDr. Jay Campbell, Dr. Piers Barker, and Madden Brewster

Duke Pediatric Cardiology, Duke University Medical Center

Abstract:

The object of the following clinical study is to evaluate the success of the

Duke Cardiology Fetal Bonding Protocol in standard risk CHD patients as well as

examine APGAR scores and weights of patients who did and did not have successful

bonding and finally, to discuss the maternal and infant benefits of the program.

Chart review and statistical analysis of a population of 98 patients was used to

determine a 62% (n=49) successful bonding rate in those who planned bonding

(n=79). Additionally, those where successful bonding did not successfully occur,

lower APGAR scores and birth weights were presented. Mother-infant bonding is

said to promote strong and lasting emotional ties, between mother and child,

provide physiological stability and autonomic maturity, benefit infant emotional

complexes, and allow for breastfeeding if the mother chooses to do so. Overall, the

study provides a comprehensive look at the success as well as the maternal and

infant benefits of the Duke Fetal Bonding Program.

Background and Significance:

Echocardiography (cardiac echo) is a technology that uses Doppler

ultrasound (sound waves) to create two and three-dimensional images of the heart.

Echocardiography is especially useful in determining congenital heart disease (CHD)

in fetuses with a high level of accuracy. (Connolly and Oh, 2011). Currently, many

hospitals use fetal cardiac echo technology to determine CHD in babies prior to birth

to determine where the infant will be transferred to directly after birth (i.e.

operating room, pediatric cardiac intensive care unit (PCICU), neonatal intensive

care unit (NICU), or nursery care) (“Congenital heart disease and defects,” n.d.). The

removal of infants from mothers directly after birth causes forfeiture of invaluable

mother-infant bonding time.

Many studies have indicated that mother-infant bonding is important in

developing strong emotional ties between mother and child (O’Higgins et al., 2013).

Additionally, the already stressful process of pregnancy is bombarded with more

undue stress when the mother of a child with CHD is told that she will not get to

engage in the typical mother-infant bonding period because her baby will be

transferred to the PCICU, NICU, nursery care, or even the operating room directly

after birth. This excessive prenatal stress has been linked to have effects on infant

neurodevelopment. (Schneider et al., 1999, Coe et al., 2001, and Chapillon et al.,

2001).

In another 2012 study by Moore et al. early skin-to-skin contact (SSC) during

initial bonding periods is discussed and suggests that it may play an important role

in physiological and emotional complexes in the infant by benefiting breastfeeding

habits, cardio-respiratory stability, and a reducing infant crying. During initial

bonding, the mother is encouraged to breastfeed her newborn. This initial and later

continuation of maternal breastfeeding time has been shown to produce a higher

quality relationship between mother and child at 1 year compared to non-maternal

bottle-feeding groups (Else-Quest et al, 2003).

A recent 2014 study by Feldman et al. showed that preterm infants, who

engage in Kangaroo Care (KC) intervention, where mother and infant maintain close

skin to skin contact, showed better autonomic functioning, sleep efficiency, and

executive function. Prior studies suggest that KC intervention also encourages

neuromaturation. (Feldman et al., 2014).

Duke Pediatric Cardiology and OB/GYN departments, have joined together to

create the Fetal Bonding Program at Duke, which allows mother-infant bonding time

and consequently permits potential emotional and physical benefits to both mother

and child.

Literature suggests that the ductus arteriosus (figure 1) in babies does not

close until 12-24 hours after birth on average (Lim et al., 1992 and Reller et al.,

1988). Many congenital heart diseases, like hypoplastic left heart syndrome for

example, do not present themselves and/or cause life-threatening complications

until after the closure of the ductus arteriosus. The ductus arteriosus is a canal,

which connects the pulmonary artery to the descending aorta so that the already

oxygen-rich blood from the placenta can bypass the fluid filled lungs and be

distributed directly to the body. Often times, 12 hours after birth, before the ductus

closes, all babies will experience the pumping of some “blue blood” (deoxygenated

blood), which escapes through the still open ductus, to the body in coalescence with

the “red blood” (oxygenated blood), which passes through the lungs and out of the

aorta. Once the ductus closes, healthy babies will see the distribution of oxygen rich

blood only, because blue blood can no longer escape through the now closed ductus.

(“Congenital heart disease and defects,” n.d.).

Figure 1: Shows the ductus arteriosis and basic fetal circulation. Source: https://encrypted-tbn0.gstatic.com/images?q=tbn:ANd9GcTe314OzsM_3sH5-CZg6t3soAj0VE_HxxOpdyVYyqz9w1O8oPlV

There are both right and left sided obstructive congenital heart disease,

which rely on the presence of the ductus arteriosis for survival. For example, a

common left sided obstructive heart disease, hypoplastic left heart syndrome

(HLHS), displays a small aorta and left ventricle/atrium. Because of this, the minimal

amount of red blood that passes through the aorta will primarily go towards the

head. The blue blood from the pulmonary artery will be able to connect to the

descending aorta to distribute blood to the lower body through the ductus. While

this blood is not well oxygenated, it allows for short-term function. This, however,

can become life threatening as the ductus arteriosis closes because there will no

longer be that connection between the pulmonary artery and the descending aorta

and therefore there will be little to no blood flow down to the lower body. HLHS will

present major problems after the ductus closes. (See figure 2). (“Facts about HLHS,”

2012)

Figure 2: This is an example of the anatomy of hypoplastic left heart syndrome (HLHS) versus a normal heart. As you can see in the HLHS heart, the left side of the heart as well as the aorta is very small. The HLHS figure also contains a “patent ductus arteriosis” which is what allows infants to survive before it closes. Source: http://umm.edu/~/media/UMM/Images/Centers%20and%20Services/Childrens%20Hospital/hypoplastic%20left%20heart%20synd.ashx

Another example of when the presence of the ductus arteriosis allows for

short-term survival is in pulmonary atresia, which is a right-sided obstructive heart

disease. In pulmonary atresia, the pulmonary valve is not formed and therefore

deoxygenated blood is unable to go to the lungs to gain oxygen. The ductus

arteriosis as well as the atrial septal defect (hole in the atrial wall of the heart that

separates the left and right atrium) that all fetuses have in order for blood to bypass

the lungs and go directly to the left ventricle is important for blood flow the body in

a patient with pulmonary atresia. The ductus allows blue blood to enter the aorta,

but go back to the pulmonary artery to gain oxygen before returning to the left

ventricle to be pumped out to the body. The blood that goes to the body is “mixed”

(a mixture of red and blue—oxygenated and deoxygenated blood), but allows for

short-term function. Once the ductus arteriosis closes, pulmonary atresia becomes

fatal if it is not corrected because all blood going to the body will be deoxygenated.

(See figure 3). (“Pulmonary Atresia,” n.d.)

Figure 3: This is a diagram which shows the anatomy of pulmonary atresia in a fetus/new born who still has the ductus arteriosis. Source: http://www.heart.org/idc/groups/heart-public/@wcm/@private/@hcm/documents/image/ucm_307329@z_extracted~1/medium.jpg

With the use of echocardiograph technology we can predict many congenital

heart diseases prior to birth. Additionally, with the presence of the ductus arteriosis

for 12-24 hours after birth, many of these CHD’s don’t present themselves until after

that period. Because of this, we are able to allow valuable mother-infant bonding

time, thus reducing prenatal stress, potential neurodevelopment and behavioral

issues, and other negative outcomes that are suggested affects caused by lack of

bonding.

Methods:

Patient charts were reviewed to gather data for this clinical study.

Information such as triage number, “was bonding planned?,” “did bonding actually

occur?,” APGAR scores, and infant birth weights were recorded in an excel

spreadsheet. Statistics software was used to complete univariate comparisons and

statistical analysis of the data.

Figure 4: This is the protocol followed by the Duke Fetal Bonding Program to determine whether CHD infants are healthy enough to be allotted mother-infant bonding time. Source: Duke Hospital

Results:

The sample consisted of 135 mothers and their prenatally diagnosed CHD

infants who qualified for and wished to participate in the Duke Fetal Bonding

Program. Of those, 37 were excluded due to termination of pregnancy (n=4), fetal

demise (n=2), or a delivery that occurred outside of Duke at another hospital

(n=31). Each subject within the remaining population (n=98) had a delivery plan

based on triage status. A triage status above a 2 did not plan bonding after the

delivery (n=19). When bonding wasn’t planned due to a high triage status, it

typically indicated a severe CHD, high risk for mother and/or baby, or other non-

cardiovascular related issues. Those where bonding was planned (n=79) continued

to follow the Heart for Bonding Initiative protocol (see figure 4). While bonding was

planned for many, it may not have been carried out for a variety of usually common,

unexpected birthing complications (n=30). The subjects who completed bonding

successfully (planned, occurred, and without complication) had a population of 49.

This gave a successful bonding rate of 62% in the population. (See Figure 5).

Figure 5: Displays breakdown of data analysis to determine bonding success in the Duke Fetal Bonding Program.

Fetal Bonding Program

population (n=135)

Excluded (n=37; 27%):

Termination (n=4)

Fetal Demise (n=2)

Not delivered at Duke (n=31)

Fetal Bonding Program population

with exclusions (n=98; 73%)

Bonding Planned (n=79; 80%)

Bonding Occurred (n=49;

62%)

APGAR scores and birth weights were analyzed in both successful bonding

and unsuccessful bonding populations. As shown in figure 6, the mean birth weight

for those who did not have successful bonding (no) is lower (weight=2.62kg) than

those who did have successful bonding (yes) (weight=3.25kg). This result is

statistically significant (p=0.0026).

Figure 6: The above box and whiskers plot displays mean infant weights in those who had successful bonding (Yes) and those who did not (No). (p=0.0026).

APGAR (see figure 7) scores at 1 minute and 5 minutes were also examined

in successful and unsuccessful bonding populations. Figure 8 displays APGAR scores

at 1 minute. It is evident that scores are higher in a majority of those who had

successful bonding (89.80% in 7-10 range) whereas the APGAR scores in those who

did not have successful bonding had a spread out range of scores. This analysis was

statistically significant (p=0.000).

Figure 7: Apgar scoring system for newborn infants. Source: http://r2.cygnuspub.com/files/cygnus/image/EMSR/2012/JAN/600x400/apgar_10616033.jpg

Figure 8: This table displays the frequency and percentage of those who had 1-minute APGAR scores within ranges 0-3, 4-6, and 7-10 in populations who did (yes) and did not (no) have successful bonding. (p=0.000).

APGAR scores at 5 minutes were a slightly more similar between successful

and unsuccessful bonding groups. Figure 9 shows both successful (yes) and

unsuccessful (no) bonding groups had a majority in the 7-10 range at 5 minutes,

however, all but one in the successful bonding group were in the 7-10 range

whereas the unsuccessful bonding group was a little bit more spread out. This is

statistically significant (p=0.011).

Figure 9: This table displays the frequency and percentage of those who had 5-minute APGAR scores within ranges 0-3, 4-6, and 7-10 in populations who did (yes) and did not (no) have successful bonding. (p=0.011).

Discussion:

Statistical analysis supports our hypothesis that bonding can be completed

successfully in a majority of standard risk CHD patients. While 62% seems like a

rather low percentage for those to successfully complete bonding, it is a huge

improvement from typical prenatally diagnosed CHD patient success rate. Because

most hospitals do not allow mother-infant bonding in CHD patients, our program

essentially allows for the transition from a 0% to 62% successful bonding rate.

Improving emotional and physiological complexes, mother-infant long-term

relationship, and breastfeeding ability are potential benefits that may occur in those

who successfully completed bonding in the Duke Fetal Bonding Program (O’Higgins

et al., 2013, Else-Quest et al, 2003, Feldman et al., 2014). Additionally, the success

rate of bonding in our study may ensure mothers that they will be able to bond with

their prenatally diagnosed CHD babies and reduce the hazardous prenatal stress

presented at initial diagnosis (Schneider et al., 1999, Coe et al., 2001, and Chapillon

et al., 2001).

Our hypothesis that those who did not have successful bonding would

present lower APGAR scored and birth weights was supported. This result was

intuitive and expected. APGAR scores are given at 1 and 5 minutes to determine the

health of the baby and if intervention is needed. Babies with dangerously low or

borderline dangerously low scores were most likely flagged by the caregiver and

transported elsewhere to be taken care of—ultimately forgoing initial mother-infant

bonding time. Non-cardiovascular problems or cardiovascular issues that weren’t

prenatally diagnosed would also contribute to lower APGAR scores and

consequently would not be allowed to bond in some cases. (“What Is The Apgar

Score?” n.d.)

Average birth weights in infants were lower in those who did not have

successful bonding, which also supported our hypothesis. The average birth weight

for a healthy baby is about 3.4 kg and while those who successfully bonded had an

average birth weight lower than that (3.25 kg), those who unsuccessfully bonded

had a birth weight far below the normal average (2.62 kg) (“Infant,” 2014). This low

birth weight most likely contributed to lower APGAR scores and decreased

autonomic function, which ultimately reduced the likelihood of successful bonding.

Additionally, premature babies tend to have lower birth weights and additional

health risks which may also explain why those who did not bond successfully had

lower birth rates, however additional analysis involving gestational age would have

to be assessed to support this notion (“A Primer on Preemies,” 2014).

This specific study provides a platform for safe methods and protocols to

allow successful bonding in standard risk congenital heart disease patients. Some

things worth further examining in this study is gestational age between the two

groups as well as diagnosis patterns. Gestational ages may allows us to predict the

likelihood of premature babies to bond. Diagnosis patterns will also allow us to

prenatally predict the likelihood of bonding in those with certain CHD. Finally, the

ultimate goal of this study was to prove that is has no adverse affects and encourage

other hospitals to adopt similar programs.

Conclusion:

Through the safety of the Duke Mother-infant Bonding Program as well as

the benefits of mother-infant bonding and possible reduction of prenatal stress we

hope to encourage other hospitals to use echocardiograph technology to prenatally

diagnose CHD so that a similar protocol to the Duke Fetal Bonding Program is

implemented so that infants with CHD are able to bond with their mothers directly

after birth and do not develop potential deficits due to lack of bonding. Overall, we

would like to see more babies born with CHD able to engage in mother-infant

bonding so that neurodevelopmental and emotional issues do not ensue.

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