Are Parenting Interventions Effective in Improving Therelationship Between Mothers and Their Preterm...

Infant Behavior & Development 37 (2014) 131154

Contents lists available at ScienceDirect

Infant Behavior and Development

Are parrelation

Tracey EPaul Colda Queensland CThe University b School of Psyc Perinatal Resd The Universite Parenting an

a r t i c l

Article history:Received 2 JulReceived in re27 November Accepted 29 DAvailable onlin

Keywords:MotherinfanAttachmentParenting intePreterm infanPrematurity

1. Introdu

1.1. Preterm

Globallycan generat(Goutaudieassociated wa greater hecan include& Brooks-G

CorresponHerston, QLD

E-mail add

0163-6383/$ http://dx.doi.oenting interventions effective in improving theship between mothers and their preterm infants?

vansa,b,c,, Koa Whittinghama,b, Matthew Sanderse,itzc,d, Roslyn N. Boyda

erebral Palsy and Rehabilitation Research Centre, The School of Medicine, Faculty of Health Sciences,of Queensland, Australiachology, Faculty of Social and Behavioral Sciences, The University of Queensland, Australiaearch Centre, Royal Brisbane and Womens Hospital, Brisbane, Australiay of Queensland Centre for Clinical Research, Royal Brisbane and Womens Hospital, Brisbane, Australiad Family Support Centre, The University of Queensland, Australia

e i n f o

y 2013vised form2013ecember 2013e 11 February 2014

t relationship

rventiont

a b s t r a c t

Aim: To systematically review the efcacy of parenting interventions in improving thequality of the relationship between mothers and preterm infants.Method: Randomized or quasi-randomized controlled trials (RCT) of parenting interven-tions for mothers of preterm infants where motherinfant relationship quality outcomeswere reported. Databases searched: The Cochrane Library, PubMed, CINAHL, PsycINFO andWeb of Science.Results: Seventeen studies met the inclusion criteria, 14 with strong methodological quality.Eight parenting interventions were found to improve the quality of the motherpreterminfant relationship.Conclusions: Heterogeneity of the interventions calls for an integrated new parenting pro-gram focusing on cue-based, responsive care from the mother to her preterm infant toimprove the quality of the relationship for these motherpreterm infant dyads.

2014 Elsevier Inc. All rights reserved.

ction

birth

, the average preterm birth rate is approximately 11% (Blencowe et al., 2012). For mothers, the preterm birthe feelings of guilt, helplessness, grief at the loss of the pregnancy, and anxiety and fear for their infants futurer, Lopez, Sjourn, Denis, & Chabrol, 2011; Whittingham, Boyd, Sanders, & Colditz, 2013). Preterm birth is alsoith signicant mortality and short and long term morbidity for the child, with increased prematurity leading to

alth risk (Clark, Woodward, Horwood, & Moor, 2008; Greco et al., 2005; Laws & Hilder, 2008). Medical concerns lung dysfunction, chronic respiratory disease, seizure disorders, cerebral palsy (McCormick, McCarton, Tonascia,unn, 1993), deafness and blindness (Lorenz, Wooliever, Jetton, & Paneth, 1998).

ding author at: Perinatal Research Centre, The University of Queensland, Level 6, Ned Hanlon Building, Royal Brisbane & Womens Hospital,4029, Australia. Tel.: +61 7 3636 1655.ress: [email protected] (T. Evans).

see front matter 2014 Elsevier Inc. All rights reserved.rg/10.1016/j.infbeh.2013.12.009

Andi PuentesNota adhesivaMarked definida por Andi Puentes

132 T. Evans et al. / Infant Behavior & Development 37 (2014) 131154

The medical condition of the infant can lead to the absence of close physical contact between the mother and the infant(Amankwaa, Pickler, & Boonmee, 2007). It may also nd the mother withdrawing from her critically ill preterm infant toprotect herself from disappointment, guilt and hurt (Miles, Holditch-Davis, & Burchinal, 1999). This can increase mater-nal depression and anxiety, and decrease maternal responsiveness (Amankwaa et al., 2007; Borghini et al., 2006; Fiese,Poehlmannrelationshipties can leadFor motherabout the d

1.2. Mother

Motheret al., 2006of motherscompared tfull-term ininfant when2006). For assessed by

Other stclassicatiodiffer betwcluded simhowever, aptional behaneurologicapostnatal efound socio& HeinemaWhittingharelationship

A meta-tion of pre& Frenkel, attachmentteenage moHarris, & Pers of pretClements, &2009) followinfant attacpopulationsment.

1.3. Parent

Effective(Bakermansdegree to wenvironmenhas been foNewnham,

1.4. Infant

Improvi(Beckwith quality predGuex et al.,, Irwin, Gordon, & Curry-Bleggi, 2001; Poehlmann & Fiese, 2001) increasing the risk for motherpreterm infant difculties (Amankwaa et al., 2007; George & Solomon, 2008; Korja et al., 2008; Miles et al., 1999). These difcul-

to both short-term (Borghini et al., 2006) and long-term problems (Tideman, Nilsson, Smith, & Stjernqvist, 2002).preterm infant dyads at the 9- and 18-year follow-ups, there were more feelings of anxiety and uncertaintyyad, and anxiety and separation difculties, respectively (Tideman et al., 2002).

preterm infant relationship difculties

preterm infant dyads can be at higher risk of relationship difculties than motherfull-term dyads (Borghini; Forcada-Guex, Pierrehumbert, Borghini, Moessinger, & Muller-Nix, 2006; Wille, 1991). Only 20 and then 30%

of preterm infants had secure attachment representations at 6 and 12 months respectively following the birtho 53 and 57% in a term comparison group (Borghini et al., 2006). They were also less likely than mothers withfants to have a cooperative dyadic pattern of interaction and demonstrate balanced representations of their

assessed with a videotaped play session and the Working Model of the Child Interview (Forcada-Guex et al.,preterm infants, only 44% were securely attached at 12 months ca compared to 83% of full term infants when

the Strange Situation task (Wille, 1991).udies have found the distribution of maternal attachment classications (Korja et al., 2009), infant attachmentns (Pederson & Moran, 1996) and motherinfant attachment relationships (Pederson & Moran, 1995) did noteen preterm and full-term groups. (Borghini et al., 2006; Forcada-Guex et al., 2006). A systematic review con-ilar results for all three categories (Korja, Latva, & Lehtonen, 2012). Of the 29 studies included in the reviewproximately half found maternal attachment representation difculties, insecure infant attachment, or interac-

vior and affect differences for the motherpreterm infant dyads. Variables such as socioeconomic status, infantl impairment, and altered maternal representations due to the contrast between prenatal expectations andxperience were cited as possible reasons for the disparity (Korja et al., 2012). Several other studies have alsoeconomic status (Borghini et al., 2006; Wille, 1991), infant neurological impairment (Brisch, Bechinger, Betzler,nn, 2003) and the contrast between prenatal expectations and postnatal experience (Borghini et al., 2006; Evans,m, & Boyd, 2012; Korja et al., 2009) to have a negative impact on the quality of the motherpreterm infant.analysis using the standardized Strange Situation task to assess infant attachment, also found the distribu-term attachment classications to be similar to that of normal samples (IJzendoorn, Goldberg, Kroonenberg,1992). In contrast, there was a decrease in secure attachment and an increase in insecure ambivalent

for children whose mothers had maternal problems, including mental illness, maltreatment and being ather (IJzendoorn et al., 1992). Interestingly, mental illness (Brandon et al., 2011), maltreatment (Noll, Trickett,utnam, 2009) and being a teenage mother (Chen et al., 2010), have been found to be higher in moth-erm births compared to mothers of term births. Other maternal factors including unresolved grief (Shah,

Poehlmann, 2011) and decreased maternal responsiveness (Fuertes, Lopes-dos-Santos, Beeghly, & Tronick,ing a preterm birth have also been related to insecure infantmother attachment. This evidence suggests that

hment maybe affected by maternal rather than infant problems, and difculties could be higher in preterm where these maternal problems exist. Focusing on maternal problems may therefore help improve attach-

ing interventions

parenting interventions can increase maternal sensitivity which can increase infant attachment security-Kranenburg, Van Ijzendoorn, & Juffer, 2003). This can be explained through the transactional model, where thehich the preterm infants biological problems impacts upon development depend upon the infants caregivingt (Sameroff & Chandler, 1975). Improving the infants caregiving environment through parenting interventionsund to improve attachment and relationship outcomes for motherpreterm infant dyads (Kang et al., 1995;Milgrom, & Skouteris, 2009; Pridham et al., 2005)

development

ng the quality of the motherpreterm infant relationship can have consequences for the infants later development& Rodning, 1996; Forcada-Guex et al., 2006; Wijnroks, 1998). Decreased motherpreterm infant relationshipicted increased behavioral problems and decreased personal-social development at 18 months-of-age (Forcada-

2006). Alternatively, increased levels of maternal involvement predicted improved cognitive status at both 12

T. Evans et al. / Infant Behavior & Development 37 (2014) 131154 133

and 24 months as assessed by the Bayley Scales of Infant Development (Wijnroks, 1998) and increased language skills at 3years and problem solving at 5 years (Beckwith & Rodning, 1996).

1.5. Aims

In the lapreterm infinterventioaim of this prelationshipassessmentparenting in

2. Method

2.1. Literatu

This sysCollaboratioLibrary (19of Science (

(1) preterm(2) and par(3) and atta

infant in

2.2. Selectio

Studies h

(i) random(ii) preter(iii) studie(iv) studie(v) studie(vi) studie(vii) article

Studies w

(i) parenti(ii) infants(iii) non-ra(iv) articles(v) studies(vi) studies

accessi

The resuNote: Re

from the pe

2.3. Validity

Methodo(PEDro) Sca

2.4. Data ex

The infodelivery locst 50 years, a decrease in preterm infant mortality has led to an increase in the number of mothers and theirants who will be exposed to these attachment and relationship difculties (Goldenberg & Rouse, 1998). Examiningns which are effective in reducing these difculties may lead to improved outcomes for these dyads. The primaryaper was to systematically review the literature to determine the efcacy of parenting interventions in improving

outcomes between mothers and their preterm infants. The secondary aim was to identify at the post intervention, if the delivery location, content, intensity, duration or delivery mode of these interventions determined whichterventions are most effective in improving relationship outcomes between mothers and their preterm infants.

re search strategy

tematic review followed the guidelines of the Cochrane Review Group search strategy (Higgins, Green, &n, 2008). The following databases were comprehensively searched by two reviewers (TE and KW in the: Cochrane

96April 2013), PubMed (1951April 2013), CINAHL (1982April 2013), PsycINFO (1966April 2013) and Web1900April 2013). The search strategy comprised the following MESH headings or key words:

infant or prematurity;enting intervention OR parent education OR intervention OR parent intervention;chment OR motherinfant interaction OR mother infant interaction OR parentinfant interaction OR parentteraction.

n criteria

ad to meet the following inclusion criteria:

ized control trials (RCT) or quasi-RCT;m infants born 37 weeks gestation;ndomized studies, single case studies, observational studies;

not addressing interventions or without a clear explanation of the intervention; that did not have a control group; without available means and standard deviations, standardized outcome measures or outcome measures notng attachment and/or the motherinfant relationship.

lt of the screening process to identify relevant articles is presented in Fig. 1.lationships can be measured in three ways, either as a dyad where the mother and the infant are assessed, orrspective of the mother, or from the perspective of the infant. All three have been included in this review.

assessment

logical quality assessment of included studies is reported according to the Physiotherapy Evidence Databasele (Verhagen et al., 1998) (see Table 1). The scale assesses internal and external validity across 11 criteria.

traction

rmation extracted from the studies included population characteristics and methods of included studies. Theation, content, intensity, duration and delivery mode of the intervention programs were tabulated. The variables


Table 1Methodological quality assessment of included studies PEDro Scale.

Study 1 2 3 4 5 6 7 8 9 10 11 Total

Brisch et al. (2003) 1 1 0 1 0 0 1 0 1 1 1 7Browne and Talmi (2005) 1 0 0 0 1 0 1 1 0 1 1 6Bustan and Sagi (1984) 1 0 0 0 0 0 1 0 0 1 1 4Cho et al. (2Glazebrook Kaaresen et Kang et al. (1Meijssen et Meijssen et Melnyk et alMeyer et al.Neu and RobNewnham eParker-LoewSchroeder aRavn et al. (2Zahr et al. (1

Key: Scale of concealed alloof at least oneand measures

and characttain variablextracted fo

2.5. Quanti

All studand standaence betweparenting idard deviat2010). The square testlyzed.

It was ththe methodGlazebrookcombinatiofor each grThe discretparticipant

3. Results

Sevente987 in the have a highof 1817 parinterventio

3.1. Particip

Two tria& Sagi, 198excluded trrandomizedthree studie013) 1 0 0 1 0 0 0 0 0 1 1 4et al. (2007) 1 1 0 0 0 0 1 1 0 1 1 6al. (2006) 1 1 1 0 1 0 0 1 1 1 1 8995) 1 1 1 0 0 0 1 1 0 1 1 7

al. (2010) 1 1 1 0 0 0 1 0 0 1 1 6al. (2011) 1 1 0 0 0 0 1 1 0 1 1 6. (2006) 1 1 1 0 0 0 1 1 1 1 1 8

(1994) 1 1 0 0 0 0 1 1 0 1 1 6inson (2010) 1 1 1 0 0 0 1 0 1 1 1 7t al. (2009) 1 1 0 0 0 0 1 1 0 1 1 6en and Lytton (1987) 1 1 0 1 0 0 1 1 0 1 1 7

nd Pridham (2006) 1 1 0 1 0 0 1 1 1 1 1 8011) 1 1 1 0 0 0 1 0 1 1 1 7992) 1 0 0 0 0 0 1 0 0 1 1 4

item score 0 = absent/unclear, 1 = present. The PEDro scale criteria are: (1) specication of eligibility criteria; (2) random allocation; (3)cation; (4) prognostic similarity at baseline; (5) subject blinding; (6) therapist blinding; (7) assessor blinding; (8) greater than 85% follow up

key outcome; (9) intention to treat analysis; (10) between group statistical comparison for at least one key outcome; (11) point estimates of variability provided for at least one key outcome.

eristics were extracted by the rst author and checked by the second author. The authors discussed any uncer-es and characteristics to reach agreement on included and excluded data. Means and standard deviations werer continuous variables and the number of occurrences was extracted for categorical variables.

tative data synthesis

ies reported results for the control and experimental groups. For continuous variables, the reported meansrd deviations for both groups were used to perform a t test to determine if there was a signicant differ-en the groups who received the parenting intervention compared to the control groups. For studies with twonterventions, each intervention group was compared to the control group, using each groups mean, stan-ion and sample size to calculate a t test value (Browne & Talmi, 2005; Kang et al., 1995; Neu & Robinson,mean difference, condence intervals and effect sizes were also calculated. For categorical variables, a chi

was performed. If studies reported data for more than one time-point, only post-intervention data was ana-

e original intention of this review to conduct a meta-analysis of all the data using RevMan 5. The diversity ofs used to measure outcomes meant a meta-analysis was only possible for three studies (Browne & Talmi, 2005;

et al., 2007; Kang et al., 1995). Measures used included observation, self-report questionnaire, interview or an of these. Some of the measures using continuous variables provided an overall mean and standard deviationoup, while others reported a mean and standard deviation for each discrete mother and/or infant behavior.

e behaviors measured varied between studies. Measures using a categorical variable reported the number ofs for each outcome. Studies using the same assessment measure, reported assessment times that varied.

en RCTs (11) or quasi-RCTs (6) met the inclusion criteria. Results were calculated on a total of 1940 participants,experimental groups and 953 in the control groups (see Table 2). Fourteen of the 17 RCTs were considered to

methodological rating with a PEDro score of 6 and were included in the nal reporting. This included a totalticipants, 927 in the experimental groups and 890 in the control groups. Of the 14 RCTs, 14 different parentingns were identied, eight nding an improvement in the quality of the motherpreterm infant relationship.

ants

ls recruited only singleton births (Cho et al., 2013; Melnyk et al., 2006), two included rst born infants (Bustan4; Neu & Robinson, 2010), one included only rst born infants of the pregnancy (Brisch et al., 2003), and threeiplets (Kaaresen, Ronning, Ulvund, & Dahl, 2006; Meijssen et al., 2011; Newnham et al., 2009). Mothers who were

to the intervention group received a parenting program. All studies included preterm infants


Table 2Population characteristics and methods of included studies.

Study Methods No. of sites GA (wks) Group allocation

Treated (n) Control (n)

Brisch et al. (2003) RCT 1 2435 43 44Browne andBustan and SCho et al. (20Glazebrook Kaaresen et Kang et al. (1Meijssen et Meijssen et Melnyk et alMeyer et al. Neu and RobNewnham eParker-LoewSchroeder anRavn et al. (2Zahr et al. (1

Total includ

GA: gestationaa Method ofb Number oc Number o

3.2. Aim of

The 17 Rand deliverin three diftwo differenparenting in

3.3. Measur

Within twere the Nuet al., 1995)Most measuSynchrony from the moEnvironmenet al., 2006)Interview (Pridham, 20

3.4. Outcom

3.4.1. MothThree stu

(see Table 4the intervesmall, 0.38 symmetricaattention (1on cue-baseand includeprogram wagrief. Talmi (2005) Quasi-RCT 1 36 59 25agi (1984) Quasi-RCT b

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Table 3Structure and content of intervention and control programs.

Study Content of intervention program Intensity Duration Delivery mode Content of control program Intensity Duration

Brisch et al. (2003) Preventative Psychotherapeutic Intervention: NICU nurse andpsychotherapistled sessions

Infant health; handling andcaring procedures.

Daily In hospital

a) Parent group: emotional coping 5 sessions In hospitalb) Individual psychotherapy: formerattachment

5 sessions In hospital

c) Home visit: self-competence, coping, infantcare

1 visit 1 week pd

d) Sensitivity training: infant cues 1 visit 3 mths ca

Browne and Talmi(2005)

Demonstration and interaction Group:Assessment of Preterm Infant Behavior (APIB):infant reexes, attention-interaction, motorcapabilities, sleep-wake states, MothersAssessment of the Behavior of her Infant(MABI)

45 mins 1 week ptd Examinerdemonstrated andexplained infantsbehavioralresponses

Clothing, infants names,bathing infant, importance ofimmunisations

45 mins 1 week ptd

Education Group: Infant strengths and skills,feelings of parents during pregnancy, earlydelivery, NICU experience and interpersonalrelationships

45 mins 1 week ptd Mothers viewededucational slidesand videos; given 2baby informationbooks

Bustan and Sagi(1984)

Standardized individualized intervention:

Infants condition, mothers feelings, infantbehaviors demonstration, medical explanation

Day 1 Birth todischarge

Psychologist leddiscussion

General condition of infantencouraged to visit NICU andask questions

As required In hospital

Crying, sleeping, optimal stimulation, mothersfeelings on leaving hospital without baby,prematurity manual

Day 3 Psychologist leddiscussionBook for mother

Anticipated problems at home, babystimulation and contact, demonstrations andmodelling of interactive behaviors

Day ofdischarge

Psychologist leddiscussions anddemonstrations

Cho et al. (2013) Japanese Infant Mental Health Program: 1 session 1 week ptd Nurse/publichealthnurse/clinicalpsychologist

Ordinary care and clinicalguidance

Daily In hospital

Motherinfant interaction, subjectiveexperiences of mother and infant, infant cues,characteristics, strengths and development

5 sessions 1, 3, 5 mthspd, 9 and12 mths ca

Nurse, publichealth nurse andclinicalpsychologist gaveinformation andfeedback

Health and developmentalcheck-up

3 home visits 3 mths pd,9 and 12mths ca

Glazebrook et al.(2007)

The Parent Baby Interaction Program (PBIP):Tactile, discussion, verbal, and observationactivities to enhance mothers observations ofbaby and sensitivity to babys cues.

Weekly 60minssessions

Birth to 6weeks pd

Neonatal nursesled activities anddemonstrations

Normal care As required In hospital

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Table 3 (Continued)


Kaaresen et al.(2006)

Motherinfant Transaction Program (MITP):Infants characteristics, development potentialand temperament, infant cues, responding tothe infant, sensitivity and responsiveness ineveryday tasks, enhancing mothers enjoymentof her infant, discuss hospital stay experienceand feelings of grief, active participation inevaluating infants and their cues

1 session60 minsdailysessions for7 days, 4home visits

1 week ptd 90 dayspd

Neonatal nursesmodelled skills,provided directdemonstration,verbal instruction,emotional supportand reinforcedmothers initiative

Infant examination, training ininfant massage, clinicalexamination, dischargeconsultation with doctor

NS In hospital

Kang et al. (1995) State Modulation (SM): infant states ofconsciousness, interaction cues, arousing andsoothing infants during feeding.

60 minsession

Inhospital/athome

Public healthnurses usedwritteninformation anddemonstration

Car seat instructional program:improve positioning of infantin car seat

60 minsession

Inhospital/athomeNS

Nursing Systems Towards EffectiveParenting-Preterm (NSTEP-P): 4 topicsSM: sleep-wake states of infants, behavioralcues, arousing and soothing infants duringfeeding. Infant Behavioral Responsiveness andInfant Stimulation: infant communication,stimulation activities. Infant health concerns:e.g. feeding, health concerns. Family andCommunity Resources: assessing communityservices to cope with stress

9 homevisits

Home 5mths

Public healthnurses discussedthe information

Standard public health nursing:infant health problems andfamily needs

At home

Meijssen et al.(2010, 2011)

Infant Behavioral Assessment and InterventionProgram (IBAIP): Visits to paediatric clinic,babys responses to sensory information,infants self-regulatory efforts, adjustingenvironment to match infantsneurobehavioral needs, supporting infantsexplorations and self-regulatory competence

68, 1-hhome visits

Pd to 6mths ca

Paediatric physicaltherapistsadministeredInfant BehavioralAssessment todemonstrate infantresponses and gaveweekly report

Visits to paediatric clinic NS Postdischarge

Melnyk et al.(2006)

Creating Opportunities for ParentEmpowerment (COPE):4 phases: infant behavior and development,parent role, infant states, transition fromhospital to home, parentinfant relationship,cognitive developmentActivities: keep milestone record, identifyinfant characteristics, stress and interactioncues, foster cognitive development

NS 24 days paday 48 pa14 daysptd1 week pd

Research assistantprovidedaudiotape,information and aparent activity

Hospital services, dischargeand immunisation information

NS 24 days paday 48 pa14 daysptd1 week pd

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Table 3 (Continued)


Meyer et al. (1994) An individualized family-based intervention:Infant behavior and characteristics, familyorganisation and functioning, caregivingenvironment (modifying sensory environment,parentinfant interaction), home dischargeand community resources intervention basedon questionnaire and interview responses

6090 minsfor 317sessions

28 weeks Paediatric,psychology,nursing andphysical therapycliniciansdevelopedindividualizedintervention usinginformation anddemonstration

Medical and nursing treatmentfor infant, assignment of socialworker

NS NS

Neu and Robinson(2010)

Kangaroo Holding: relaxation during holding,infant development, recognition and responseto cues, Kangaroo holding 60 consecutiveminutes at least once/dayTraditional Holding: relaxation during holding,early development, infant cues, blanketholding 60 consecutive minutes at leastonce/day

4560 mins Twice aweek for 2weeksWeeklyvisits for 6weeks

Registered nurseprovidededucation,information andholding techniqueencouragement

Complete study forms, generalhealth of mother and infant

1020 mins NS

Newnham et al.(2009)

Motherinfant Transaction Program (MITP):MITP program, kangaroo care and massageinformation, bath session (between 7 and 8)

7 3060-min

In hospital Psychologist usedverbal and writteninformation, infantobservation,modelling andpracticalexperience

Interview, standard hospitalcare

NS NS

Mutual enjoyment through play 3060 mins 1 mth pd:home

Infant temperamental characteristics 3060 mins 3 mths pd:hospital

Parker-Loewen andLytton (1987)

Interaction Coaching: Identied infantbehaviors and alternative maternal responses.Increase mothers imitation, infantizing,gameplaying and pausing during gaze aversion.

8 40min 1215weeks

Psychologistvideotaped 1st playsession, thenwatched remainingsessions offeringfacilitativesuggestions

Offered toys for their baby NS NS

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Table 3 (Continued)


Ravn et al. (2011) Motherinfant Transaction Program (MITP) 7 60min4 60min

Hospital:week ptdHome: 3mths pd

Neonatal nurses NS NS NS

Schroeder andPridham (2006)

Guided participation (GP): Developingrelationship competency by learning how tocare for the infant: changing diaper,temperature taking, dressing the infant,observing signs of illness, holding the infant,feeding the infant

6 45 minweeklysessions

3036weeks pca

Research nurseguides the motherthroughparticipating inactivities

Infant caregiving, preterminfant information

6 45 minweeklysessions

3036weeks pca

Zahr et al. (1992) An individualized developmental plan: formother: infants visual and auditory attention,consoling infant, voice and discuss concernsand ideas, preterm infant behavior anddevelopment

34 weeklysessions for6090 mins

In hospital,pd

Developmentalspecialist discussedindividualizeddevelopmentalplan with motherbased onAssessment ofInfant Behaviorscale

Received standardnursing/physician feedback

NS In hospital

NS: not specied; ca: corrected age; NICU: Neonatal Intensive Care Unit; pca: post-conceptional age; pd: post discharge; pa: post admission; ptd: prior to discharge; pts: prior to sessions; mins: minute.

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Table 4Independent observation of motherinfant dyadic outcomes comparing the motherpreterm infant group and a control group.

Study Assessmentmeasure

Age assessed Treatment Control p value Mean diff (95% CI) Effect size

n Mean (SD) n Mean (SD)


Motherinfantinteractionobservation

3 mths 1week

8 Coordinated stimulus2.48 (0.88)

8 Coordinated stimulus2.27 (1.5)

t(14) = 0.34, p = 0.738 0.21 (1.11 to 1.53) 0.17

Uncoordinatedstimulus 0.0 (0.0)

Uncoordinatedstimulus 2.88 (3.76)

t(14) = 2.16, p = 0.048 2.88 (5.73 to 0.03 1.08

Verbal stimulation28.25 (10.82)

Verbal stimulation 14.0(12.13)

t(14) = 2.48, p = 0.027 14.25 (1.92 to 26.58) 1.24

Minimal body contact2.50 (2.27)

Minimal body contact18.50 (18.06)

t(14) = 2.49, p = 0.026 16.00 (29.80 to 2.20 1.24

Much body contact4.13 (4.73)

Much body contact 1.5(3.51)

t(14) = 1.26, p = 0.227 2.63 (1.84 to 7.10) 0.63

Sounds andvocalisations 19.75(15.06)

Sounds andvocalisations 11.0(10.68)

t(14) = 1.34, p = 0.201 8.75 (5.25 to 22.75) 0.67

Cho et al. (2013) NCAFS 12 mths ca 23 63.17 (4.78) 20 61.60 (7.10) t(41) = 0.86, p = 0.395 1.57 (2.12 to 5.23) 0.26Kang et al. (1995) NCAFS 1.5 mths ca 64 HE-SM: 63.2 (9.8) 70 HE-CS: 60.1 (9.5) t(132) = 1.86, p = 0.065 3.10 (0.20 to 6.40) 0.32

67 LE-SM-PHN 60.4 (9.0) 49 LE-CS-PHN: 54.6 (10.8) t(114) = 3.15, p = 0.002 5.80 (2.15 to 9.45) 0.5966 LE-SM-NSTEP-P 58.5

(10.0)49 LE-CS-PHN:54.6 (10.8) t(113) = 2.00, p = 0.048 3.90 (0.03 to 7.77) 0.38

Kang et al. (1995 NCATS 5 mths ca 64 HE-SM 58.1 (7.0) 70 HE-CS 53.7 (7.5) t(132) = 3.50, p = 0.001 4.40 (1.91 to 6.89) 0.6167 LE-SM-PHN 51.1 (8.4) 49 LE-CS-PHN 47.5 (10.4) t(114) = 2.06, p = 0.042 3.60 (0.14 to 7.06) 0.3966 LE-SM-NSTEP-P

54.7(9.1)49 LE-CS-PHN 47.5 (10.4) t(113) = 3.95, p < 0.001 7.20 (3.59 to 10.81) 0.74


Fogel ScoringSystem

26 weekspost-natalage

22 1) Kangaroo: 20

Symmetricalcoregulation 35.73(4.87)


t(40) = 8.80, p < 0.001 13.45 (10.36 to 16.54) 2.72

Asymmetricalcoregulation: 32.63(5.45)

Asymmetricalcoregulation 48.22(5.64)

t(40) = 9.11, p < 0.001 15.59 (19.05 to 12.13) 2.81

Unilateral regulation:31.58 (5.89)

Unilateral regulation:26.87 (6.09)

t(40) = 2.55, p = 0.015 4.71 (0.97 to 8.45) 0.79

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Table 4 (Continued)





Fogel ScoringSystem

26 weekspostnatal age

22 2) Traditional: 20



t(40) = 1.97, p = 0.056 2.93 (5.94 to 0.08) 0.61

Asymmetricalcoregulation 50.94(5.17)

Asymmetricalcoregulation: 48.225.64)

t(40) = 1.63, p = 0.111 2.72 (0.65 to 6.09) 0.50

Unilateral regulation29.46 (5.58)

Unilateral regulation26.87 (6.09)

t(40) = 1.44, p = 0.158 2.59 (1.05 to 6.23) 0.44

Newnham et al.(2009

SynchronyScale

6 mths ca 32 Mutual attention 0.45(0.08)

31 Mutual attention 0.24(0.13)

t(61 = 7.75, p < 0.001 0.21 (0.16 to 0.26) 1.95

ca: corrected age; mths: months; HE: High Education; LE: Low Education; SM: State Modulation; NSTEP-P: Nursing System Towards Effective Parenting Preterm; CS: Car Seat; PHN: Public Health Nursing;NCAFS: Nursing Child Assessment Feeding Scale; NCATS: Nursing Child Assessment Teaching Scale; IRSS: Infant Regulatory Scoring System.


Potentially relevant RCTs or quasi-RCTs identified and screened by title and abstract (n=536)

3.4.2. MateEleven s

measures w2011). Seveinterventiowere foundPridham, 20Preterm) SM2006) and during care

Three ofet al., 2007;included astions in theincluded asgroup. Thistiple compatreatment einterventioincluded asprogram], 2more favou

3.4.3. InfanSeven st

vention waimprovemegroup (Kanwere foundRCTs and quasi RCTs retrieved for more detailed examination (n=64)

RCTs and quasi RCTs included (n= 30). This included 29 different studies (Table 1). These studies were reviewed again to determine which were appropriate for inclusion in a meta-analysis

RCTs excluded (n= 472) Not RCT or quasi-RCT, inappropriate intervention, no intervention, inappropriate outcomes or population.

RCTs excluded (n= 34) Not RCT or quasi-RCT, no intervention, not preterm infants

RCTs with usable information by outcome and included in systematic review (n= 17)

RCTs and quasi RCTs excluded from systematic review (n= 13) Appropriate data not available

Fig. 1. Included and excluded studies.

rnal relationship outcomestudies reported maternal results on 12 parenting interventions; 11 observational, 2 questionnaire and 2 interview

ere used (see Table 5). One intervention was trialled in two separate RCTs (Kaaresen et al., 2006; Ravn et al.,n of the interventions found an improvement in the quality of the motherinfant relationship for mothers in then group compared to the control group. The effect sizes ranged from small, 0.39 to large, 2.09. Large effect sizes

for Guided Participation (GP) with both an observation (2.09) and an interview measure (1.20) (Schroeder &06) and for low education mothers who received (State Modulation Nursing Systems for Effective Parenting--NSTEP-P (0.86) (Kang et al., 1995). Both the 4-hour hospital delivered GP program (Schroeder & Pridham,

the 9 home-visit SM-NSTEP-P program (Kang et al., 1995) included information on responding to infant cues activities and were delivered by nurses.

the studies had data that was able to be pooled into the rst meta-analysis (Browne & Talmi, 2005; Glazebrook Kang et al., 1995) (see Fig. 2). For Browne and Talmi (2005) only the Demonstration and Interaction group was

this intervention included both education and demonstration, and was therefore more similar to the interven- remaining two studies (Glazebrook et al., 2007; Kang et al., 1995). The Education intervention group was not

comparing this group to the control group would have been double-counting the participants in the control would have created a unit-of-analysis error due to the correlation of intervention effects generated from mul-risons (Review Manager (RevMan) [Computer program], 2012). The meta-analysis did not reveal a signicantffect (95% CI: 0.34 to 0.41; p = 0.85). The second meta-analysis included data from the State Modulation (SM)n for both the low and high education groups (Kang et al., 1995) (see Fig. 3). The SM-NSTEP intervention was not

again the control group participants would have been double-counted (Review Manager (RevMan) [Computer012). The analysis revealed a treatment effect (95% C1: 1.19 to 4.14; p < 0.001) such that higher scores indicatedrable outcomes.

t relationship outcomesudies reported infant results on nine interventions, all using observational measures (see Table 6). One inter-s trialled in two separate RCTs (Newnham et al., 2009; Ravn et al., 2011). Four of the interventions found annt in the quality of the motherinfant relationship for infants in the intervention group compared to the controlg et al., 1995; Neu & Robinson, 2010). The effect sizes ranged from small, 0.35 to large, 1.60. Large effect sizes

for the Kangaroo Holding program for total protest (1.60) and total positive bids (0.85) and the Traditional

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Table 5Comparing the effects between the motherpreterm infant group and a control group of the maternal reporting of the relationship between the mother and the infant.




ObservationBrowne andTalmi (2005)

NCAFS ptd 31 Group 1:Demonstration andinteraction 45.65 (6.20)

28 48.88 (7.41) t(57) = 1.82, p = 0.074 3.23 (6.78 to 0.32) 0.47

25 Group 2: Education47.43 (7.36)

28 48.88 (7.41) t(51) = 0.71, p = 0.479 1.45 (5.53 to 2.63) 0.20


Motherinfantinteractionobserva-tion

3 mths 1week

8 Enface 9.63 (6.65) 8 Enface11.25 (8.49) t(14) = 0.42, p = 0.677 1.62 (9.80 to 6.56) 0.21

Close body contact20.38 (19.92)

Close body contact 6.88(11.13)

t(14) = 1.67, p = 0.116 13.50 (3.80 to 30.80) 0.84

Instrumental contact:0.71 (0.86)

Instrumental contact:2.33 (1.73)

t(14) = 2.37, p = 0.033 1.62 (3.09 to 0.16) 1.19

Patting 18.25 (17.03) Patting 6.75 (5.01) t(14) = 1.83, p = 0.088 11.50 (1.96 to 24.96) 0.92Kissing 4.50 (4.66) Kissing 1.50 (2.62) t(14) = 1.59, p = 0.135 3.00 (1.05 to 7.05) 0.79Smile 35.25 (18.78) Smile 22.00 (17.7) t(14) = 1.45, p = 0.169 13.25 (6.31 to 32.82) 0.73Laugh16.5 (11.98) Laugh 8.38 (3.7) t(14) = 1.83, p = 0.088 8.12 (1.39 to 17.63) 0.92Positive verbalisation64.5 (40.78)

Positive verbalisation52.13 (25.79)

t(14) = 0.73, p = 0.480 12.37 (24.22 to 48.96) 0.36

Negative verbalisations1.5 (3.12)

Negative verbalisations2.0 (3.67)

t(14) = 0.29, p = 0.773 0.50 (4.15 to 3.15) 0.15

Cho et al. (2013) NCAFS 12 mths ca 23 42.44 (2.95) 20 41.50 (3.55) t(41) = 0.95, p = 0.349 0.94 (1.06 to 2.94) 0.29Glazebrook et al.(2007)

NCATS 3 mths ca 93 37.4 (4.8) 106 38.3 (5.2) t(197) = 1.26, p = 0.208 0.90 (2.31 to 0.51) 0.18

Kang et al. (1995) NCAFS 1.5 mths ca 64 HE-SM 43.3 (5.7) 70 HE-CS 41.9 (6.3) t(132) = 1.34, p = 0.181 1.40 (0.66 to 3.46) 0.2367 LE-SM-PHN 41.9 (5.2) 49 LE-CS-PHN 39.2 (5.9) t(114) = 2.61, p = 0.010 2.70 (0.65 to 4.75) 0.4966 LE-SM-NSTEP-P 40.4

(7.0)49 LE-CS-PHN 39.2 (5.9) t(113) = 0.97, p = 0.334 1.20 (1.25 to 3.65) 0.18

Kang et al. (1995) NCATS 5 mths ca 64 HE-SM 42.3 (5.1) 70 HE-CS 39.6 (6.0) t(132) = 2.79, p = 0.006 2.70 (0.79 to 4.61) 0.4867 LE-SM-PHN 37.1 (6.1) 49 LE-CS-PHN 34.5 (6.7) t(114) = 2.18, p = 0.032 2.60 (0.23 to 4.97) 0.4166 LE-SM-NSTEP-P 40.1

(6.4)49 LE-CS-PHN 34.5 (6.7) t(113) = 4.55, p < 001 5.60 (3.16 to 8.04) 0.86

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Table 5 (Continued)




Meijssen et al.(2010)

ICEP 6 mths ca 57 Play 55 Play

Negative 0.1 (0.67) Negative 0 (0) t(110) = 1.11, p = 0.271 0.10 (0.08 to 0.28) 0.21Non-infant focused:0.2(0.73)

Non-infant focused 0.2(0.69)

t(110) = 0.00, p = 1.000 0.00 (0.27 to 0.27) 0.00

Social monitor/nvc58.2 (20.1)


t(110) = 0.80, p = 0.428 3.30 (4.92 to 11.52) 0.15

Social monitor/pvc24.5 (20.4)


t(110) = 0.96, p = 0.338 4.10 (12.56 to 4.35) 0.18

Social positiveengagement 3.9 (4)

Social positiveengagement 2.5 (3)

t(110) = 2.09, p = 0.039 1.40 (0.07 to 2.73) 0.39

Reunion: Reunion:Negative 0.1(0.51) Negative 0 (0) t(110) = 1.45, p = 0.149 0.10 (0.04 to 0.24) 0.27Non-infant focused 0.2(0.78)

Non-infant focused: 0.2(1.1)

t(110) = 0.00, p = 1.000 0.00 (0.36 to 0.36) 0.00



t(110) = 0.15, p = 0.884 0.70 (8.20 to 10.22) 0.03



t(110) = 0.23, p = 0.818 1.10 (10.54 to 8.34) 0.04

Social positiveengagement 3.5 (3.7)

Social positiveengagement 2.7 (3.2)

t(110) = 1.22, p = 0.224 0.80 (0.50 to 2.10) 0.23

Meijssen et al.(2010)

MSRS 6 mths ca 53 Sensitivity: 4.13 (0.78) 56 Sensitivity: 3.91 (0.84) t(107) = 1.41, p = 0.160 0.22 (0.09 to 0.53) 0.27

Overcontrol/intrusiveness:1.75 (0.87)

Overcontrol/intrusiveness:2.04 (0.93)

t(107) = 1.68, p = 0.096 0.29 (0.63 to 0.05) 0.32

Undercontrol/withdrawn:1.32 (0.55)

Undercontrol/withdrawn:1.38 (0.68)

t(107) = 0.50, p = 0.615 0.06 (0.30 to 0.18) 0.10

Melnyk et al.(2006)

IPB 10 days pb 116 9.10 (3.52) 95 8.38 (3.53) t(209) = 1.48, p = 0.141 0.72 (0.24 to 1.68) 0.20

Melnyk et al.(2006)

VAS-I 10 days pb 115 67.84 (22.48) 94 63.20 (22.52) t(207) = 1.48, p = 0.140 4.64 (1.53 to 10.81) 0.21

Melnyk et al.(2006)

VAS-S 10 days pb 112 81.63 (18.41) 87 78.85 (18.42) t(197) = 1.06, p = 0.292 2.78 (2.41 to 7.97) 0.15

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Table 5 (Continued)




Meyer et al.(1994)

Motherinfantfeedingbehavioralinteraction

Pre-dis-charge

15 Smiles (yes/no) 15/0 15 Smiles (yes/no) 9/6 2(1, N = 30) = 5.21,p = 0.022

0.50

Vocalisation (yes/no)13/2

Vocalisation (yes/no)10/5

2(1, N = 30) = 0.75,p = 0.388

0.24

Sensitivity to infantsfeeding behavior(neg/pos) 1/14

Sensitivity to infantsfeeding behavior(neg/pos) 5/10

2(1, N = 30) = 1.88,p = 0.171

0.33

Quality of physicalcontact (neg/pos) 1/14

Quality of physicalcontact (neg/pos) 5/10

2(1, N = 30) = 1.88,p = 0.171

0.33

Positive affect(neg/pos) 2/13

Positive affect(neg/pos) 6/9

2(1, N = 30) = 1.53,p = 0.215

0.30

Parker-Loewenand Lytton(1987)

IRS Postintervention

18 Non-feeding variables: 17 Non-feeding variables:

MNFIRS: 2.46 (0.22) MNFIRS: 2.38 (0.16) t(33) = 0.86, p = 0.395 0.08 (0.05 to 0.21) 0.412 mths postintervention

18 TPNF: 0.25 (0.06) 17 TPNF: 0.28 (0.08) t(33) = 1.26, p = 0.217 0.03 (0.08 to 0.02) 0.43

Feeding variables: Feeding variables:MFIRS: 2.50 (0.24) MFIRS: 2.55 (0.14) t(33) = 0.75, p = 0.460 0.05 (0.19 to 0.09) 0.25TPF: 0.13 (0.13) TPF: 0.14 (0.13) t(33) = 0.23, p = 0.822 0.01 (0.01 to 0.08) 0.08Non-feeding variables: Non-feeding variables:MNFIRS: 2.53 (0.26) MNFIRS: 2.39 (0.26) t(33) = 1.59, p = 0.121 0.14 (0.04 to 0.32) 0.54TPNF: 0.22 (0.08) TPNF: 0.21 (0.08) t(33) = 0.37, p = 0.714 0.01 (0.05 to 0.07) 0.13Feeding variables: Feeding variables:MFIRS: 2.39 (0.29) MFIRS: 2.56 (0.22) t(33) = 1.95, p = 0.060 0.17 (0.35 to 0.01) 0.66TPF: 0.16 (0.15) TPF: 0.12 (0.01) t(33) = 1.10, p = 0.281 0.04 (0.03 to 0.11) 0.37

Ravn et al. (2011) QualitativeRatings forParent-ChildInteraction

12 mths ca 46 Sensitivity/responsiveness 47 Sensitivity/responsiveness 2(1, N = 93) = 3.90,p = 0.048

0.28

Intrusiveness Intrusiveness 2(1, N = 93) = 3.54,p = 0.060

0.20

Stimulation Stimulation 2(1, N = 93) = 0.04,p = 0.849

0.17

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Table 5 (Continued)





RCA 36 wks pca 8 26.00 (1.31) 8 18.00 (5.25) t(14) = 4.18, p = 0.001 8.00 (3.90 to 12.10) 2.09

Zahr et al. (1992) Feeding andPlay

4 mths pb Affective behavior Affective behavior

12 1500: 5.61 (0.81) t(21) = 1.16, p = 0.261 0.37 (1.04 to 0.30) 0.49

8 mths pb Affective behavior Affective behavior12 1500: 5.06 t(21) = 0.21, p = 0.833 0.05 (0.44 to 0.54) 0.09

QnnaireGlazebrook et al.(2007)

MaternalResponsivity-HOME)

3 mths ca 93 8.8 (1.1) 106 9.1 (1.5) t(197) = 1.59, p = 0.114 0.30 (0.67 to 0.07) 0.23

Kaaresen et al.(2006)

Attach ment(PSI)

6 mths 69 10.6 (2.7) 65 12.3 (2.7) t(132) = 3.64, p < 0.001 1.70 (2.62 to 0.78) 0.63

InterviewMeijssen et al.(2011)

WMCI 18 mths ca 41 Balanced: 29 (71%) 37 Balanced: 25 (67%) 2(2, N = 78) = 0.26,p = 0.878

0.06

Disengaged: 6 (15%) Disengaged: 7 (19%)Distorted: 6 (15%) Distorted: 5 (13%)


WMRB 36 wks pca 8 10.13 (1.36) 8 8.25 (1.75) t(14) = 2.40, p = 0.031 1.88 (0.20 to 3.56) 1.20

ca: corrected age; mths: months; pca: post conceptional age; ptd: prior to discharge; pb: post-birth; HE: High Education; LE: Low Education; SM: State Modulation; NSTEP-P: Nursing System Towards EffectiveParenting: Preterm; CS: Car Seat; PHN: Public Health Nursing; nvc: no/neutral vocalizations; pvc: positive vocalizations; MNFIRS: Mothers non-feeding Interaction Rating Scale; TPNF: Mothers responsivity tothe infants positive signalling during non-feeding interactions; MFIRS: Mothers Feeding Interaction Rating Scale; TPF: mothers responsivity to the infants positive signalling during feeding interactions; NCAFS:Nursing Child Assessment Feeding Scale; NCATS: Nursing Child Assessment Teaching Scale; ICEP: Infant and Caregiver Engagement Phases; MSRS: Maternal Sensitivity and Responsivity Scales; IPB: Index ofParent Behavior; VAS-I: Interaction With Infant; VAS-S: Sensitivity to Needs of Infant; IRS: Interaction Rating Scale; RCA: Relationship Competencies Assessment; HOME: Home Observation for Measurement ofthe Environment; PSI: Parenting Stress Index; WMCI: Working Model of the Child Interview; WMRB: Internal Working Model of Relating to the Baby.

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Fig. 2. Meta-analysis including NCAFS prior to discharge for the Demonstration and Interaction intervention (Browne & Talmi, 2005) and at 1.5 months ca for low and high education mothers receiving the SMintervention (Kang et al., 1995), and the NCATS at 3 months ca for the PBIP intervention (Glazebrook et al., 2007).

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Fig. 3. Meta-analysis including NCATS at 5 months ca for low and high education mothers receiving the SM intervention.

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Table 6Comparing the effects between the motherpreterm infant group and the control group of the motherinfant interaction on the infant.




ObservationBrisch et al.(2003)

StrangeSituationProcedure

14 mths ca 32 A = 31.3% 36 A = 8.3% 2(1, N = 68) = 2.69,p = 0.101

0.20

B = 59.4% B = 77.8%C = 9.4% C = 13.9%


Motherinfantinteraction

3 mths 1week

8 Smile 5.63 (5.26) 8 Smile 7.13 (7.51) t(14) = 0.46, p = 0.651 1.50 (8.45 to 5.45) 0.23

Laugh 2.38 (4.24) Laugh 3.7 (5.01) t(14) = 0.57, p = 0.579 1.32 (6.30 to 3.66) 0.28Cry 2.88 (3.44) Cry 13.00 (11.09) t(14) = 2.47, p = 0.027 10.12 (18.92 to 1.32) 1.23Vocalisations 17.5 (11.03) Vocalisations 8.13

(6.29)t(14) = 2.09, p = 0.056 9.37 (0.26 to 19.00) 1.04

Cho et al. (2013 NCAFS 12 mths ca 23 20.96 (3.23) 20 20.10 (3.17) t(41) = 0.88, p = 0.385 0.86 (1.12 to 2.84) 0.27Kang et al. (1995 NCAFS 1.5 mths ca 64 HE-SM 19.9 (4.8) 70 HE-CS 18.2 (4.8) t(132) = 2.05, p = 0.043 1.70 (0.06 to 3.34) 0.35

67 LE-SM-PHN 18.5 (4.6) 49 LE-CS-PHN 15.4 (6.0) t(114) = 3.15, p = 0.002 3.10 (1.15 to 5.05) 0.5966 LE-SM-NSTEP-P: 18.1 (4.5) 49 LE-CS-PHN 15.4 (6.0) t(113) = 2.76, p = 0.007 2.70 (0.76 to 4.64) 0.52

Kang et al. (1995 NCATS 5 mths ca 64 HE-SM 15.8 (3.9) 70 HE-CS 14.0 (4.1) t(132) = 2.60, p = 0.010 1.80 (0.43 to 3.17) 0.4567 LE-SM-PHN 14.0 (4.3) 49 LE-CS-PHN 12.9 (4.6) t(114) = 1.32, p = 0.189 1.10 (0.55 to 2.75) 0.2566 LE-SM-NSTEP-P 14.6 (4.2) 49 LE-CS-PHN 12.9 (4.6) t(113) = 2.06, p = 0.042 1.70 (0.07 to 3.33) 0.39

Meijssen et al.(2010

ICEP 6 mths ca 57 Normal play: 55 Normal play:

Positive smiles: 4.7 (6.3) Positive smiles: 8.1(14)

t(110) = 1.67, p = 0.098 3.40 (7.44 to 0.64) 0.32

Mother focused: 24.4(16.8)


t(110) = 0.27, p = 0.789 0.80 (6.70 to 5.10) 0.05

Environment focused: 66.5(23)

Environment focused:63.4 (20.5)

t(110) = 15.31, p < 0.001 63.10 (54.93 to 71.27) 0.14

Negative: 2.8 (9.1) Negative: 1.6 (5.2) t(110) = 0.85, p = 0.396 1.20 (1.59 to 3.99) 0.16Stress: 0 Stress: 0.02 (0.14) t(110) = 1.08, p = 0.283 0.02 (0.06 to 0.02) 0.20Oral self-comfort: 5.4 (13) Oral self-comfort: 5.6

(10.5)t(110) = 0.09, p = 0.929 0.20 (4.63 to 4.23) 0.02

Still-face: Still-face:Positive smiles: 1.1 (2.4) Positive smiles: 1.6

(4.3)t(110) = 0.76, p = 0.447 0.50 (1.80 to 0.80) 0.14



t(110) = 1.39, p = 0.167 4.50 (1.90 to 10.90) 0.26

Environment focused: 71.5(21.7)

Environment focused:74.9 (24)

t(110) = 0.79, p = 0.433 3.40 (11.96 to 5.16) 0.15

Negative: 4.7 (15.2) Negative: 3.2 (10.2) t(110) = 0.61, p = 0.543 1.50 (3.37 to 6.37) 0.12Stress: 0.2 (1.2) Stress: 0.3 (1.5) t(110) = 0.39, p = 0.697 0.10 (0.61 to 0.41) 0.07

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Table 6 (Continued)




Oral self-comfort: 9.8(14.9)

Oral self-comfort: 10.3(17)

t(110) = 0.17, p = 0.869 0.50 (6.48 to 5.48) 0.03

Reunion: Reunion:Positive smiles: 4.7 (6.8) Positive smiles: 7.1

(14.4)t(110) = 1.13, p = 0.259 2.40 (6.59 to 1.79) 0.21

Mother focused: 24 (18) Mother focused: 23.1(17.1)

t(110) = 0.27, p = 0.787 0.90 (5.68 to 7.48) 0.05

Environment focused: 61.7(24.8)

Environment focused:58.8 (26)

t(110) = 0.60, p = 0.547 2.90 (6.61 to 12.41) 0.11

Negative: 9.3 (22.0) Negative: 9 (20.6) t(110) = 0.07, p = 0.940 0.30 (7.69 to 8.29) 0.01Stress: 0.4 (2) Stress: 0.1 (0.6) t(110) = 1.07, p = 0.288 0.30 (0.26 to 0.86) 0.20Oral self-comfort: 6.9(11.9)

Oral self-comfort: 9.2(16.3)

t(110) = 0.86, p = 0.394 2.30 (7.63 to 3.03) 0.16

Neu andRobinson (2010)

IRSS 26 weeks 22 1) Kangaroo condition: 20

Total protest 28.07 (6.90) Total protest 39.25(7.12)

t(40) = 5.17, p < 0.001 11.18 (15.55 to 6.81) 1.60

Total positive bids19.17(3.89)

Total positive bids15.81 (4.02)

t(40) = 2.75, p = 0.009 3.36 (0.89 to 5.83) 0.85

Neu andRobinson (2010)

IRSS 26 weeks 22 2) Traditional condition: 20

Total protest 33.35 (6.53) Total protest 39.25(7.12)

t(40) = 2.80, p = 0.008 5.90 (10.16 to 1.64) 0.87

Total positive bids 13.22(3.68)

Total positive bids15.81 (4.02)

t(40) = 2.180, p = 0.035 2.59 (4.99 to 0.19) 0.67

Newnham et al.(2009)

SynchronyScale 6 mths ca 32 Alert: 1.94 (0.25) 31 Alert: 1.82 (0.72) t(61) = 0.89, p = 0.377 0.12 (0.15 to 0.39) 0.22

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Table 6 (Continued)




Parker-Loewenand Lytton(1987)

IRS Postintervention

18 Non-feeding variables: 17 Non-feeding variables:

INFIRS: 2.27 (0.22) INFIRS: 2.12 (0.30) t(33) = 1.69, p = 0.100 0.15 (0.03 to 0.33) 0.572 mths postintervention

18 DURNF: 0.35 (0.18) 17 DURNF: 0.33 (0.17) t(33) = 0.34, p = 0.738 0.02 (0.10 to 0.14) 0.11

Feeding variables: Feeding variables:IFIRS: 2.08 (0.47) IFIRS: 2.43 (0.50) t(33) = 2.13, p = 0.040 0.35 (0.68 to 0.02) 0.72DURF: 0.32 (0.27) DURF: 0.55 (0.31) t(33) = 0.32, p = 0.753 0.23 (0.43 to 0.03) 0.79Non-feeding variables: Non-feeding variables:INFIRS: 2.27 (0.23) INFIRS: 2.13 (0.33) t(33) = 0.15, p = 0.153 0.14 (0.05 to 0.33) 0.49DURNF: 0.34 (0.16) DURNF: 0.27 (0.17) t(33) = 1.26, p = 0.218 0.07 (0.04 to 0.18) 0.42Feeding variables: Feeding variables:IFIRS: 2.25 (0.49) IFIRS: 2.14 (0.55) t(33) = 0.63, p = 0.536 0.11 (0.25 to 0.47) 0.21DURF: 0.34 (0.31) DURF: 0.42 (0.26) t(33) = 0.82, p = 0.416 0.08 (0.28 to 0.12) 0.28

Ravn et al. (2011)Qualitativeratings forparentchildinteraction

12 months ca 46 Positive mood 47 Positive mood 2 (1, N = 93) = 3.33,p = 0.068

0.22

Negative mood Negative mood 2 (1, N = 93) = 2.21,p = 0.137

0.17

Dyadic mutuality Dyadic mutuality 2 (1, N = 93) = 3.44,p = 0.064

0.26

Zahr et al. (1992) Feeding andPlayObservationScales

4 mths pb Babys social behavior: Babys social behavior:

12 1500: 5.48 (0.93) t(21) = 0.63, p = 0.534 0.18 (0.77 to 0.41) 0.27

8 mths pb Babys social behavior: Babys social behavior:12 1500: 5.63 (0.96) t(21) = 0.31, p = 0.764 0.11 (0.86 to 0.64) 0.13

ca: corrected age; HE: High Education; LE: Low Education; SM: State Modulation; NSTEP-P: Nursing System Towards Effective Parenting Preterm; CS: Car Seat; PHN: Public Health Nursing; INFIRS: InfantsNon-Feeding Interaction Rating Scale; DURNF: Duration of the Infants Positive Signalling During Non-Feeding Interactions; IFIRS: Infants Feeding Interaction Rating Scale; DURF: Duration of Infants PositiveSignalling During Feeding Interactions; NCAFS: Nursing Child Assessment Feeding Scale; NCATS: Nursing Child Assessment Teaching Scale; ICEP: Infant and Caregiver Engagement Phases; IRSS: Infant RegulatoryScoring System; IRS: Interaction Rating Scale.


Holding program for total protest (0.87) (Neu & Robinson, 2010). The Kangaroo Holding and Traditional Holding programswere the same as outlined above for motherinfant dyadic outcomes, except mothers were encouraged to use blanketholding with their infants in the Traditional Holding group (Neu & Robinson, 2010). Three interventions found a negativeeffect on the motherinfant relationship for infants (Meijssen et al., 2010; Neu & Robinson, 2010; Parker-Loewen & Lytton,1987).

4. Discussi

To the authe relationof the approused. ThereHolding, TrMeijssen etPridham, 20

The mos710 houet al., 2009et al., 1995Blanket Hodelivery, whome (Kangin response(Bowlby, 19

The metmonths ca, of these infto implemethe improvSM-NSTEP-

The negLytton, 198focussing omothers weInterventioread their i

The hetesignicant manner, buthe quality are assessedassess the r(Biringen, 2

Some met al., 2006;rst year of1978). Theswith the infwith attachcare, improSchroeder &et al., 2006;

This reving results streamlinedinfants. Thically. As boet al., 2006;preterm birthe interverelationshipon

thors knowledge, this is the rst systematic review to assess the efcacy of parenting interventions for improvingship quality between mothers and their preterm infants. The current literature is limited by the heterogeneityaches with regards not only to the structural framework of the interventions but also the assessment measures

is evidence for the efcacy of eight different parenting interventions: MITP, SM, NSTEP-P, IBAIP, GP, Kangarooaditional Holding, and an individualized family-based intervention (Kaaresen et al., 2006; Kang et al., 1995;

al., 2010; Meyer et al., 1994; Neu & Robinson, 2010; Newnham et al., 2009; Ravn et al., 2011; Schroeder &06).t effective interventions showing large effect sizes were very similar in intensity and duration of sessions;rs over 8 weeks (Neu & Robinson, 2010), 49 hours from hospital stay to three months post discharge (Newnham), 4 hours during the hospital stay (Schroeder & Pridham, 2006) and 9 home visits to 5 months-of-age (Kang). All these interventions except the MITP (Newnham et al., 2009) were delivered by nurses. The Kangaroo andlding (Neu & Robinson, 2010) and the MITP (Newnham et al., 2009) interventions combined hospital and homehile the GP intervention was delivered in hospital (Schroeder & Pridham, 2006) and the N-STEP-P program at

et al., 1995). All these interventions promoted cue-based care, that is, maternal care that is given to the infant to the infants behavioral cues, and sensitive responsive mothering. This is consistent with attachment theory88).a-analysis revealed the SM program had a benecial effect for both high and low education mothers at vehowever this effect did not extend to the infants in the low education group (Kang et al., 1995). Perhaps mothersants require more than a 1-hour intervention to reinforce the information sufciently to be able to continuent responsive cue-based care to their infants past the initial 1.5-month assessment period. This could explained infant relationship quality at ve months ca after the low education mothers had received the more intenseP program (Kang et al., 1995).ative relationship effects found for infants were for orientation and signalling to the mother (Parker-Loewen &7), the vitality in the infants positive bids for the mothers attention (Neu & Robinson, 2010), and the infantsn the environment instead of focussing on the mother (Meijssen et al., 2010). This could indicate that interventionre overstimulating their infants, causing the infants to turn away or to have less involvement in the relationship.ns focusing on cue-based care could enhance the infants relationship with the mother by helping the mothersnfants cues and responding to signals of overstimulation.rogeneity of the outcome measures made it difcult to compare the results of the interventions and this is aaw of the existing research. As interaction between mothers and infants is not achieved in a simple unidirectionalt through a complex process of synchrony (Osofsky & Connors, 1979), it is important for future research to assessof the motherpreterm infant relationship using an observational measure where both the mother and the infant

simultaneously. The measure should rate the quality of the interaction rather than discrete counts of behavior toelationship, as the number of times a behavior occurs does not represent the sensitivity of the mothers response008).otherpreterm infant dyads are at risk for developing relationship difculties (Borghini et al., 2006; Forcada-Guex

Wille, 1991). Mothers can enhance the relationship, as mothers who respond sensitively to their infants in the life, are more likely to have children that develop secure attachments to them (Ainsworth, Blehar, Waters, & Wall,e attachment relationships can be enhanced by responding sensitively during caregiving activities and interactionant, which not only enhances their relationship and but also her caregiving capabilities (Bowlby, 1988). Consistentment theory, this systematic literature review identied that interventions promoting cue-based, responsiveves the motherpreterm infant relationship (Kang et al., 1995; Neu & Robinson, 2010; Newnham et al., 2009;

Pridham, 2006) which may enhance the infants later development (Beckwith & Rodning, 1996; Forcada-Guex Wijnroks, 1998).iew has identied the wide variety of existing parenting interventions for mothers of preterm infants with vary-on improving the quality of their relationship. Future research should take a unied approach to develop one, minimally sufcient parenting intervention to enhance the relationship between mothers and their preterm

s program should combine the common elements of existing effective programs and be easy to implement clini-th maternal and infant variables have been found to inuence the motherpreterm infant relationship (Borghini

Brisch et al., 2003; Evans et al., 2012; Korja et al., 2009; Wille, 1991), these variables could be assessed after theth in the NICU. After assessment, mothers of at-risk dyads could receive the parenting intervention. Assessingntion in an RCT would help to determine if there was a direct effect on enhancing the motherpreterm infant. This RCT should be longitudinal in nature as there is not only a lack of long-term relationship quality evidence


for motherpreterm infant dyads, but also for the effectiveness of parenting interventions for this population. Maternal psy-chological symptoms and maternal responsiveness outcomes could also be assessed to determine the interventions indirecteffect on the quality of the motherpreterm infant relationship.

Some limitations of the current research were small sample sizes, changes to the intended delivery mode of the inter-vention, unFuture reseand potenti

5. Conclus

With anthe numberimportant tmotherpre

Acknowled

NationalDoctoral Fe

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Health and Medical Research Council (NHMRC) Career Development Fellowship 1037220 (RB), NHMRC Post-llow 631712 (KW), Prem Baby Triple P Project Grant 1024345.

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Are parenting interventions effective in improving the relationship between mothers and their preterm infants?1 Introduction1.1 Preterm birth1.2 Motherpreterm infant relationship difficulties1.3 Parenting interventions1.4 Infant development1.5 Aims

2 Method2.1 Literature search strategy2.2 Selection criteria2.3 Validity assessment2.4 Data extraction2.5 Quantitative data synthesis

3 Results3.1 Participants3.2 Aim of Interventions3.3 Measures3.4 Outcomes3.4.1 Motherinfant dyadic outcomes3.4.2 Maternal relationship outcomes3.4.3 Infant relationship outcomes

4 Discussion5 ConclusionAcknowledgementsReferences

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