September is #NICUAwareness Month
Preterm birth is defined by the World Health Organization (WHO) as delivery before 37 completed weeks of gestation (2016). There are 15 million preterm births worldwide with the United States alone responsible for over 517 thousand preterm births ranking the U.S. sixth in the world (Blencowe et al., 2013). Despite much attention and intervention, preterm births in the U.S. have continued to rise in the last 20 years and have been consistently high in comparison with other high-income countries (WHO, 2016). While 90% of babies born before 28 weeks gestation will survive in the U.S., complications due to preterm births are the second leading cause of death in children younger than 5 years of age (Blencowe et al., 2013). Moreover, babies born to vulnerable minority groups are at higher risk for preterm birth and infant mortality (MacDorman & Gregory, 2015).
Families experiencing neonatal intensive care unit (NICU) admissions are at high risk for stress, anxiety, depression, and somewhere between 15-25% will experience symptoms of post-traumatic stress disorder. NICU stays can undermine parental confidence, in turn, negatively affecting attachment between child and caregivers (Guralnik, 2012; Vanderbilt et al., 2009). Kangaroo care (KC) can increase parental confidence. A study of fathers participating in STS care revealed enhanced sensitivity and caring behaviors and facilitation of paternal role attainment (Shorey, 2016). The benefits of KC can extend even to adulthood. A longitudinal study found that infants receiving KC had lower mortality rates and lower socio-deviant conduct facilitating positive familial relationships 20 years later (Charpak et al., 2017).
While Kangaroo Care has long been established as evidence-based practice for the last 30 years and should be the standard of care, it’s implementation in NICUs continues to be problematic. The reasons are multi-factorial including availability of caregivers, hospital staff support, short-staffing in NICUs, hospital policies requiring a physician’s order for Kangaroo Care, and complicated medical equipment that may make Kangaroo Care improbable. While these issues may not be within our realm of influence, something can be done to help NICU families mitigate the ongoing risks of their NICU stay after they go home.
Babywearing is the practice of using a baby carrier to hold a child close to a caregiver’s torso. Scholarly research on babywearing is limited. The research that does exist focuses on improved breastfeeding success and the bonds of attachment (Anisfeld et al., 1990; Pisacane, et al., 2012). Because babywearing has strong similarities to skin-to-skin (STS) care, it is theorized to have similar benefits as STS (Reynolds-Miller, 2016). The unique characteristics of preterm children require caregivers to continually adjust parenting behaviors creating stressors for social parent-child transactions (Guralnick, 2012). If babywearing can be used as a tool to facilitate transition from NICU to home and operate as a type of scaffolding to ease the work of parenting, there is potential for improvement of the behavioral and cognitive risks of preterm birth.
Synactive Theory of Newborn Behavioral Organization and Development
Individualized care is the supporting framework for Heidelise Als’ theory of neonatal and preterm neonatal development. The goal of this theory is to mimic the conditions of the womb in the neonatal intensive care unit (NICU) in order to prevent or blunt iatrogenic harm from the hospital environment. The Synactive Theory can help identify signs of stress in the neonate and guide practitioners and family to work to lessen its effects (Als & McAnulty, 2011).
The importance of skin-to-skin contact is highlighted by Als through embryology. The ectoderm is the outermost germ layer and forms both the skin and nervous system (Spruill, 2015). This helps elucidate why skin-to-skin contact is so important to the neurodevelopment of infants.
Promoting babywearing as an extension of kangaroo care after hospital discharge is a unstudied area but one that babywearing educators and healthcare professionals could help caregivers explore. Expectations are that babywearing can improve parental confidence, decrease stress and anxiety, promote resilience and positive outlook toward preterm infants. As a result, facilitation of positive health trajectories is expected for discharged NICU families.
Als, H., & McAnulty, G. B. (2011). The Newborn Individualized Developmental Care and Assessment Program (NIDCAP) with Kangaroo Mother Care (KMC): Comprehensive care for preterm infants. Current Women’s Health Reviews, 7(3), 288-301. doi:10.2174/157340411796355216
Anisfeld, E., Casper, V., Nozyce, M., & Cunningham, N. (1990). Does infant carrying promote attachment? An experimental study of the effects of increased physical contact on the development of attachment. Child Development, 61(5), 1617-1627. doi:10.2307/1130769
Charpak, N., Tessier, R., Ruiz, J., Hernandez, J. T., Uriza, F., Villegas, J. . . . Maldonado, D. (2017). Twenty-year follow-up of Kangaroo Mother Care versus traditional care. Pediatrics, 139(1).
Guralnick, M. J. (2012). Preventive interventions for preterm children. Journal of Developmental & Behavioral Pediatrics, 33(4), 352-364. doi:10.1097/dbp.0b013e31824eaa3c
Kim, W. J., Lee, E., Kim, K. R., Namkoong, K., Park, E. S., & Rha, D. (2015). Progress of PTSD symptoms following birth: A prospective study in mothers of high-risk infants. Journal of Perinatology, 35(8), 575-579. doi:10.1038/jp.2015.9
Ludington-Hoe, S. (2011). Thirty years of kangaroo care science and practice. Neonatal Network, 30(5), 357-362
MacDorman, M. F., & Gregory, E. C. (2015). Fetal and Perinatal Mortality: United States, 2013. National Vital Statistics Reports, 64(8), 1-23. Retrieved from http://www.cdc.gov/nchs/data/nvsr/nvsr64/nvsr64_08.pdf
Nyqvist, K., Anderson, G., Bergman, N., Cattaneo, A., Charpak, N., Davanzo, R., . . .Widström, A. (2010). Towards universal Kangaroo Mother Care: Recommendations and report from the first European conference and seventh international workshop on Kangaroo Mother Care. Acta Paediatrica, 99(6), 820–826. http://dx.doi.org/10.1111/j.1651-2227.2010.01787.x
Pisacane, A., Continisio, P., Filosa, C., Tagliamonte, V., & Continisio, G. I. (2012). Use of baby carriers to increase breastfeeding duration among term infants: The effects of an educational intervention in Italy. Acta Paediatrica, 101(10), E434-E438.
Reynolds-Miller, R. L. (2016). Potential therapeutic benefits of babywearing. Creative Nursing, 22(1), 17-23. doi:10.1891/1078-45188.8.131.52
Shorey, S., Hong-Gu, H., & Mőrelius, E. (2016). Skin-to-skin contact by fathers and the impact on infant and paternal outcomes: An integrative review. Midwifery, 40, 207-217.
Spruill, C. T. (2015). Developmental Support. In M. T. Verklan & M. Walden (Authors), Core curriculum for neonatal intensive care nursing (5th ed., pp. 193-215). St. Louis, MO: Elsevier Saunders.
Sweeney, S., Rothstein, Ra., Visintainer, P., Rothstein, Ro., & Singh, R. (2016). Impact of kangaroo care on parental anxiety level and parenting skills for preterm infants in the neonatal intensive care unit. Journal of Neonatal Nursing. doi:10.1016/j.jnn.2016.09.003
Tahirkheli, N., Cherry, A., Tackett, A., Mccaffree, M., & Gillaspy, S. (2014). Postpartum depression on the neonatal intensive care unit: Current perspectives. International Journal of Women’s Health, 6, 975-987.
Vanderbilt, D., Bushley, T., Young, R., & Frank, D. A. (2009). Acute posttraumatic stress symptoms among urban mothers with newborns in the neonatal intensive care unit: A preliminary study. Journal of Developmental & Behavioral Pediatrics, 30(1), 50-56. doi:10.1097/dbp.0b013e318196b0de