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

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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

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Symmetrical UnilateralAsymmetrical

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KangarooBlanketControl

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Mother-Infant Co-Regulation Pre Neutral Face

Mother-Infant Co-Regulation Post Neutral Face

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Postive Bids Negative Bids0

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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