Friday, June 12, 2015

Forging Bonds in the NICU: Parenting and Maternal Sensitivity

By: Lydia Furman, MD,  Assistant Editor
      As a Case Western Reserve Universisty medical student, I and many others spent long and rewarding hours watching and coding videotape of mothers feeding their term and preterm infants as part of  Dr. John Kennell’s research elective which was a perennial favorite among students. Kennell, along with Dr. Marshall Klaus of “Bonding” fame are widely credited with bringing humane, sensitive, and parent-friendly practices to the Neonatal Intensive Care Unit. They also brought all of us, trainees and colleagues, along with them: there was no way to deny the importance of maternal sensitive touch while watching Dr. Kennell help a new mother connect with her premature infant. 
     After a very protracted birthing process, measures of parenting and maternal sensitivity have finally become accepted by many as mainstream and scientifically valuable research outcomes. Doctors Bilgin and Wolke (doi: 10.1542/peds.2014-3570) have done a great service in systematically examining the literature on this topic to compare mothers of preterm and term infants- is there a difference in sensitivity in how they respond to their infants? Fortunately, we are well past the question of whether this matters! 
     In this meta-analysis, the authors found that study heterogeneity was high, despite clear criteria for study selection, e.g.  the study must have used an observational instrument, must have included both term and preterm comparison groups, and was required to use a defined construct for the outcome (“…maternal sensitivity …defined as mother's ability to perceive and infer the meaning behind her infant's behavioral signals, and to respond to them promptly and appropriately; “maternal responsiveness”, such as providing stimulation to the infant or “maternal facilitation” such as positive regard and respect for the child’s autonomy...”). I note that the mean gestational age and birthweight of the studied “preterm” infants were 30.4 weeks and 1374 grams respectively, babies who would be considered relatively mature and stable in today’s NICU.
      In general, the results of the meta-analysis are both reassuring and intriguing. Of interest, half (exactly 50%) of the studies that could be included used a single “snap shot” observation period, rather than multiple measurements. This led me to wonder whether multiple measurements for hospitalized infants, for example weekly measures, might be a way to prospectively identify parents who are either doing very well in connecting with their infant, or more importantly, those in need of additional support and assistance. We have just learned from authors Bilgin and Wolke that gestational age and neonatal morbidity alone cannot guide us in finding parents at risk, and yet maternal sensitivity and responsiveness are linked to positive developmental outcomes (Magill-Evans et al. Child Health Care 2001).   We really need to find a way to identify those parents who need help, Just as growth and chemistry profiles are routinely measured and monitored, maybe it’s time to begin to have the same level of vigilance about parenting behaviors and skills?

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