Best practice guidelinesPromoting infant mental health in the neonatal intensive care unit (NICU): A review of nurturing factors and interventions for NICU infant-parent relationships
Introduction
The circumstances of early life in the Neonatal Intensive Care Unit (NICU) may have serious negative consequences on the emotional wellbeing and relationship quality of infants and parents. NICU infants have higher rates of behavioral and self-regulatory problems in early childhood, and grow up to have higher rates of academic, cognitive, emotional, and physical problems later in life [1,2]. Therefore, identifying timely and effective interventions that can mitigate early adversity, increase resilience, improve outcomes, and support their optimal development and mental health are of significant importance.
The prenatal period and infancy are sensitive developmental stages - with significant impacts on the child's physical, mental, and social emotional trajectory - during which a complex interplay between genetic, biological, and environmental factors occurs [3,4]. This is particularly true for premature or medically vulnerable infants, who are neurologically more vulnerable and therefore more susceptible to positive and negative environmental factors [3]. The quality of the relationship with primary caregivers is one of the most important environmental factors in infancy, with the potential to be a mitigating or aggravating factor that deeply affects developmental trajectories.
NICU infants face a completely different environment compared to most healthy full-term infants. Admission to the NICU creates unique issues, such as: early parental separation, unnatural environments with loud noises and bright lights, isolation and lack of contact for long periods of time, numerous painful and intrusive procedures, and increased parental stress and mental health challenges [5,6]. Additionally, a NICU admission significantly alters parental proximity, reciprocity, and responsibility, which have all been described as antecedents to optimal infant-parent attachment [7]. The NICU infant-parent relationship has been studied from various lenses and there has been a consensus that NICU infants and parents face many challenges that can hinder the early formation of a close emotional connection. For example, one review of 18 studies comparing maternal-infant interaction in preterm and term infants found that the majority of studies showed some degree of impairment in the quality of early interactions in the preterm group [8]. Hence, there is a need to better identify struggling parents and infants to implement early and effective interventions.
Over the past few decades there has been a significant growth in formal programs that aim to decrease stress in NICU infants and parents and improve NICU infants' outcomes. Most of these programs fall within the broader range of Family Centered Developmental Care programs - with the goal of reducing infant stress and pain, increasing targeted exposures or sensory interventions to promote neuronal connectivity and microbiome assembly, and improving healthy infant-parent relationships. There has also been an increasing attention to provide mental health support for NICU parents. However, fewer programs primarily address the infant-parent relationship during or after NICU admission, or assess the results of the intervention on the infant-parent relationship. More importantly, most of these programs require time consuming and often expensive training which might be prohibitive for many NICUs.
In this article, we first present a review of the factors affecting NICU infants and parents that can facilitate or hinder their relationship, and secondly present a review of published interventions to positively address these factors. It is important to note that many of these factors directly or indirectly affect each other and are often very interconnected (see Fig. 1). Some of these factors have been studied more extensively, and some require better understanding and assessment. Nevertheless, the following factors can be potential and more easily accessible areas of intervention when considering ways to optimize and facilitate the NICU infant-parent relationship.
Section snippets
The parental representational mind
A main part of the infant-parent relationship and an important target for intervention is the unobservable mental and emotional entity of the relationship. Parental mental representations - the ways in which the parents make meaning of their infant, themselves as parents, and the relationship they have with their infant - start forming prenatally, and it has been hypothesized that preterm birth, which is often traumatic, can disrupt this process [7]. Parental representations can affect how
Formalized interventions for factors affecting NICU infant-parent relationships
Below we present a brief summary of some of the main formalized interventions addressing NICU infant-parent relationships. These interventions are also summarized in Table 1.
Conclusion
NICU infants and their parents face many challenges that can adversely impact the formation of an optimal relationship, with long-term implications for infant and parental mental health and infant development. Research and clinical care should focus on better identifying vulnerable parents and infants, and developing strategies to support these early and critical relationships in ways that are more easily replicable in various NICUs. Interventions should ideally start as soon as at risk
Declaration of competing interest
The authors declare that they have no relevant conflicts of interest to disclose.
References (87)
- et al.
Early life adversity: lasting consequences for emotional learning
Neurobiol Stress.
(2017 Feb) - et al.
Scoping review of the mental health of parents of infants in the NICU
J. Obstet. Gynecol. Neonatal Nurs. JOGNN.
(2017 Aug) - et al.
Maternal and paternal infant representations: a comparison between parents of term and preterm infants
Infant Behav. Dev.
(2014 Aug) - et al.
Prematurity, maternal posttraumatic stress and consequences on the mother-infant relationship
Early Hum. Dev.
(2011 Jan) - et al.
Maternal attachment representations after very preterm birth and the effect of early intervention
Infant Behav. Dev.
(2011 Feb) - et al.
The early social environment of premature and fullterm infants
Early Hum. Dev.
(1988 Sep) - et al.
Parent-infant interaction as a mediator of the relation between neonatal risk status and 12-month cognitive development
Infant Behav. Dev.
(2001 Feb) - et al.
Effects of maternal depressive symptoms and infant gender on the interactions between mothers and their medically at-risk infants
J. Obstet. Gynecol. Neonatal. Nurs.
(2008 Jan) - et al.
Early communication in preterm infants following intervention in the NICU
Early Hum. Dev.
(2013 Sep) - et al.
Parent participation in the neonatal intensive care unit: predictors and relationships to neurobehavior and developmental outcomes
Early Hum. Dev.
(2018)
Maternal holding of preterm infants during the early weeks after birth and dyad interaction at six months
J. Obstet. Gynecol. Neonatal. Nurs.
The effects of kangaroo Care in the Neonatal Intensive Care Unit on the physiological functions of preterm infants, maternal–infant attachment, and maternal stress
J. Pediatr. Nurs.
The effectiveness of a parent participation improvement program for parents on partnership, attachment infant growth in a neonatal intensive care unit: a randomized controlled trial
Int. J. Nurs. Stud.
Postpartum depression: etiology, treatment and consequences for maternal care
Horm. Behav.
Human interaction in the NICU and its association with outcomes on the brief infant-toddler social and emotional assessment (BITSEA)
Early Hum. Dev.
Rideau Batista Novais a. [single-family rooms for neonatal intensive care units impacts on preterm newborns, families, and health-care staff. A systematic literature review]
Arch Pediatr Organe Off Soc Francaise Pediatr.
Integrative review of technology to support communication with parents of infants in the NICU
J. Obstet. Gynecol. Neonatal. Nurs.
The impact of web-cameras on parent-infant attachment in the neonatal intensive care unit
J. Pediatr. Nurs.
Effect of early intervention on social interaction between mothers and preterm infants at 12 months of age: a randomized controlled trial
Infant Behav. Dev.
Effect of an early intervention programme on development of moderate and late preterm infants at 36 months: a randomized controlled study
Infant Behav. Dev.
A randomized controlled trial of an early intervention program in low birth weight children: outcome at 2 years
Early Hum. Dev.
Effectiveness of a modified mother-infant transaction program on outcomes for preterm infants from 3 to 24 months of age
Infant Behav. Dev.
Decrease of premature mothers’ stress levels in the intensive care unit
Enferm Intensiva.
Developmental outcome, child behaviour and mother-child interaction at 3 years of age following newborn individualized developmental care and intervention program (NIDCAP) intervention
Early Hum. Dev.
Cognitive and behavioral outcomes of school-aged children who were born preterm: a meta-analysis
JAMA.
Biological embedding of early life adversity
JAMA Pediatr.
Recognizing the potential effect of stress and trauma on premature infants in the NICU: how are outcomes affected?
J. Perinatol. Off. J. Calif. Perinat. Assoc.
The effects of preterm birth on mother-infant interaction and attachment during the infant’s first two years: preterm birth and mother-infant relationship
Acta Obstet. Gynecol. Scand.
Clinical interview for high-risk parents of premature infants (CLIP) as a predictor of early disruptions in the mother-infant relationship at the nursery
Infant Ment. Health J.
Mothers’ depression, anxiety, and mental representations after preterm birth: a study during the Infant’s hospitalization in a neonatal intensive care unit
Front. Public Health
Stress levels and depressive symptoms in NICU mothers in the early postpartum period
J Matern-Fetal Neonatal Med Off J Eur Assoc Perinat Med Fed Asia Ocean Perinat Soc Int Soc Perinat Obstet.
Mothers’ perceptions of quality of family-centered care and environmental stressors in neonatal intensive care units: predictors of and relationships with psycho-emotional outcomes and postpartum attachment
Matern. Child Health J.
Facilitation of parenting the premature infant within the newborn intensive care unit
J Perinat Neonatal Nurs.
Family-based intervention to enhance infant–parent relationships in the neonatal intensive care unit
J. Pediatr. Psychol.
Parents’ expectations of staff in the early bonding process with their premature babies in the intensive care setting: a qualitative multicenter study with 60 parents
BMC Pediatr.
Mother-child interactions in the NICU: relevance and implications for later parenting
J. Pediatr. Psychol.
Parenting behavior is associated with the early neurobehavioral development of very preterm children
Pediatrics.
Premature birth: complexities and difficulties in building the mother-child relationship
J Reprod Infant Psychol.
Effects of infant risk status and maternal psychological distress on maternal-infant interactions during the first year of life
J Dev Behav Pediatr.
Maternal depression is associated with mother–infant interaction in preterm infants
Acta Paediatr.
Nurturing the Premature Infant: Developmental Interventions in the Neonatal Intensive Care Nursery
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