Interventions in early infancy

Infant Mental Health Journal, Vol. 13. No. 4. Winter 1992

Interventions in Early Infancy

TIFFANY FIELD Touch Research Institute

University of Miami Medical School

ABSTRACT: Infants of high-risk pregnancies and deliveries may need early intervention to facilitate attachment both to and from their caregivers. Three early interventions are described: ( I ) giving high-risk pregnant women video feedback during prenatal ultrasound, which reduced maternal anxiety, obstetric complications, and fetal activity and improved neonatal outcome (increased weight gain, better performance on the Brazelton. and decreased irritability); (2) providing preterm neonates nonnutritive sucking opportunities to reduce stress during heelsticks and gavage feedings; and (3) providing preterm neonates and preterm cocaineaposed neonates massage therapy, which facilitated weight gain and better performance on the Brazelton scale. Following improved neonatal behavior, infants would be expected to have better interactions with their caregivers.

RfiSUMf? I1 se pcut que les nourrissons de grossesscs et d'accouchcments P haut risque aient besoin d'une intervention prbcoce pour faciliter l'attachement A et de leurs modes de soin. Trois interventions prkoces sont dtcrites: ( I ) donner aux meres enceintes P haut risque un feedback vidCo pendant I'ultrason prbnatal. ce qui a rCduit l'anxittt matcmellc, les complications obstCtricales et I'activitC du foetus. et qui a amCliorC le rhultat nbnatal (augmentation de la prise de poids, mcilleure rCussite P I'khelle Brazelton et diminution de I'irritabilitt); (2) offrir aux nouveau-n& prCmaturCs des occasions de succion non nutritif de facon P riduire le stress pendant le gavage; et (3) offrir aux nouveau-nCs prCmaturts et aux nouvcau-nts exposCs P la coca'inc une thCrapie de massage qui a facilitC la prise de poids et une meillcure rtussite P 1'Echelle Brazelton. Les nouveau-nCs dont le comportement a ainsi Ctt amCliorC devraient avoir de meilleurs interactions avec lcurs modes de soin.

RESUMEN: Los infantes de un embarazo o parto de alto riesgo pudieran necesitar una interveci6n temprana para facilitar el afecto que le o f r m n a y reciben de quienes les dispensan cuidado. En este ensayo se describen tres de esas intervenciona tempranas: (1) proveerles a las mujeres que sufren de un embaram de alto riesgo de infonnaa6n en video durante el examen de ultasonido prenatal. lo cual rcduciria la ansicdad maternal, las complicaciones obstetricas y la actividad del feto. y mejorarfa el resultado del parto (incremento en el peso, mejor resultado en la Escala Bratelton y menos irritabilidad); (2) proveerles a 10s infantes nacides antes de 10s nueve mesa dc oportunidades de mamar no nutritivas para reducia la tensi6n durantc el sangrado del tal6n y la alimentaci6n por t u b s ; y (3) proveerla a 10s infants nacidos antes de 10s nueve mews y a aquellos que han a t ado expuestos al us0 de la cocaina con una tcrapia de masajes, la c u d facilitaria el aumento de peso y un mejor resultado en la Escala Brazclton. DespucS del mejoramiento de la conduaa neonatal. se espera que 10s infanta tengan mejores interacciones con quienes les cuidan.

Address correspondence to the author at the Touch Research Institute, University of Miami Medical School, P.O. Box 016820, Miami, FL 33101.

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for Infant Mental Health

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Although most early interventions target the more sophisticated member of the parent-infant dyad, several recent intervention efforts have focused on improving the infant. While not saying so directly, they have tried to make the infant more like a “Gerber baby” in order to facilitate the parents’ attachment to the infant and thereby enhance their developing relationship. This approach is particularly important in the case of high-risk or potentially at-risk infants who are often less appealing babies. In this paper, data are reviewed on a prenatal intervention to improve the neonate’s growth and developmental outcome and on neonatal interventions to reduce stress and to increase weight gain and behavioral responsibility. In all cases, the interventions improved the status of the infant, and by doing so, would be expected to enhance parent-infant interactions and later attachments/relationships.

PRENA TAL INTER VENTIONS

Because the fetus is subject to the first stresses in life, the fetus should be the target of interventions during the prenatal period. The rat model suggests that prenatal stressors can cause considerable fetal damage, and the literature on anxiety in human pregnancies is replete with stories about mothers feeling stressed by their insecurity about the development of the fetus. Invariably this stress would affect the fetus unless it could be alleviated by a very simple intervention that reassured mothers that the fetus was developing normally.

A large number of high-risk mothers have prenatal ultrasound, and during these sessions there is an opportunity to “talk” the mothers through the procedure. The ultrasonographer simply thinks aloud throughout the session. Face-on views of the fetus can be obtained and shared with the parents and thus facilitate the attachment process. To explore the effect of this, a study was conducted in which one group of mothers viewed the ultrasound on a television screen and another group were simply told at the end of the session that their baby was developing normally (Field, Sand- berg, Quetel, Garcia, & Rosario, 1985). A state anxiety scale was given to both groups. The mothers who received the untrasound feedback had lower anxiety than the mothers who did not get feedback. When the feedback mothers recorded the minutes of fetal movement prior to sleep, the fetus was less active. Activity in the fetus is curvilinear in terms of being optimal. Reduced activity and excessive activity are nonoptimal and lead to irritability and to lower birthweight in the neonate. The mothers in the feedback group slept 2 hours more on average per night, probably because the fetus was less active. Somewhat surprising was the fact that there were fewer obstetric complications in the feedback group and the birthweight was significantly greater. Finally, scores on the Brazelton Neonatal Behavioral Assessment

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Scale (1973), including habituation, motor activity, and range of state, were better for the feedback group.

This was a very inexpensive intervention inasmuch as it does not cost very much for an ultrasonographer to “think out loud.” Most attempts to reduce stress in the fetus and in the neonate have focused on interventions that are inexpensive, that is, adding something onto existing procedures.

STRESS IN THE NEONATAL INTENSIVE CARE UNIT

In the intensive care unit, babies are in very stressful environments, wired up to apparatus that monitor several functions and sustain life. Attachment to a “wired-up” creature is very difficult to achieve. How do you touch and relate to a baby who is wired up and is in a very fragile condition and may not survive? In some hospitals in the United States, early attachments are discouraged until the baby is out of medical jeopardy, at which point parents are encouraged to visit. In one low socioeconomic status hospital, for example, the average number of parent visits to the hospital during a 2-week period was 1.2 (Scafidi et al., 1986). Much of the early relating to the baby has to be provided by nursing staff who are actively encouraged to become at- tached to these babies so that they have a primary caregiver during their hospital stay.

Many procedures used to keep preterm NICU babies alive are very stressful. One paradoxical stressor is weaning from the incubator. Of course it makes sense that infants might go through a stressful period because they have been very dependent upon the oxygen provided. Cortisol levels (an index of stress in the baby) are elevated until around day five following weaning from incubators. Similarly, administering something as simple as the Brazelton Neonatal Behavioral Assessment is stressful. Here the baby is simply held and enjoyed in ways that elicit reflex behaviors thought to be only a little more stressful than ordinary social maneuvers. However, when the Brazelton is given, growth hormone dramatically decreases. Growth hormone typically increases in children and adults who are stressed, but in babies who are stressed, it decreases.

PA CZFIERS

One of the infant’s own resources for reducing stress is sucking. Sucking has been used to reduce stress associated with heelsticks. The heelstick is typically used for obtaining small amounts of blood for analysis. Premature babies may have up to 20 of these heelsticks a day to monitor their blood gasses and biochemistry. Because they cry during heelstick maneuvers and because sucking is incompatible with crying, smaller pacifiers were developed for these babies’ use (Field & Goldson, 1984). The percentage of time crying when the preemies had pacifiers was significantly reduced. It is important to note that respiration rate and heart rate were also decreased. Thus, a very simple procedure (i.e., having the blood technician provide a pacifier) reduced the physiological stress for these babies.

Another procedure that is somewhat stressful is tube or gavage feeding. When preemies were given a pacifier during tube feedings, their later bottle feedings were easier (Field et al., 1982). The nurses had to look at them less, talk to them less,

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and do less jiggling of the bottle and less repositioning to elicit feeding. There were also fewer days of tube feeding, a greater daily weight gain, and shorter hospital stays leading to significant hospital cost savings ($3,000 per baby). Again, a very simple intervention reduced stress and was cost effective. Initially these findings were not easily accepted because the underlying mechanism for sucking and weight gain was not understood. However, a neonatologist demonstrated that if you passed carmine dye though the gastrointestinal system, the use of the pacifier led to reduced transit time (Birnbaum & Jou, 1990). Being able to establish a mechanism was more con- vincing to neonatalogists and has led to increased acceptance of the intervention.

INFANT MASSA GE

A more active approach to calming babies and making them less stressed was in- troduced by a nurse (Jay, 1982). who simply placed her hands on the backs of babies for 10 minutes a day and documented significant decreases in the percent of oxygen needed by the infants. A simpler measure of the response to this treatment was the reduction in the nonstartle and startle responses over the period of the 10 days of her study. These were very dramatic findings, published, unfortunately, in a very obscure journal. Subsequently, several investigators gave preterm infants what they called tactile kinesthetic stimulation which was later called “massage.” Massage was probably a better term because the only tactile stimulation that was effective involved pressure rather than light touch. If you stroke these babies lightly (which is what you think of doing instinctively because they are very fragile), the infants find it aversive and they do not gain weight (Scaiidi et al., 1990). The most successful techniques involved taking very slow strokes (approximately 10 strokes per minute) from the top of the head down to the nape of the neck and then back up again, and then the shoulder region, the back region, and down and up the arms and legs. The chest and stomach region are not massaged because babies find it very aversive, possibly because invasive procedures are typically performed on the chest and abdomen and they have learned a conditioned association with negative touch in these regions. The conditioned aversive response in that region is typically a startle response and crying. The massage procedure typically lasts 5 minutes with the infants lying in a prone posi- tion. Then, with the infants lying on their backs, the therapist performs 5 minutes of flexion and extension movements of the upper and lower limbs. After this, the infants are turned on their stomachs, and the massage procedure is repeated. In the preemie weight gain studies, massage was given three times a day for a total of 45 minutes per day for a 10-day period.,

Before conducting these studies, it was necessary to demonstrate that massage was not a dangerous procedure. Lucey, a pediatrician, and his colleagues, had published some data (Long, Philip, & Luccy, 1980) showing that even if you handle babies just for diaper changes and then reposition them, they experience a decrease in T,P02, a physiological reaction that indicates stress. The pediatric community interpreted this study as a “do not touch” story. In other words, they generalized it to all touch including what Lucey subsequently called “tender loving touch.” Lucey now qualifies this, stating that when “tender loving touch” is given, these babies do not show a decrease in T,P02 but an increase.

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To establish that massage was not stressful, Morrow et al. (1991) compared T,POz during massage versus the heelstick procedure. During heelsticks, TcPOz typically decreased about 14 to 16 millimeters followed by a return to baseline after the procedure. With massage there was negligible change, suggesting that it was a safe procedure. The effects of massage were then explored using a number of measures (Field et al., 1986). Preemies who were massaged showed fewer stress behaviors (mouthing, facial grimaces, and clenched fists). They also showed better performance on the Brkelton habituation, orientation, motor, and range of state items. Finally, they gained weight more rapidly (47% more weight than the control group). This was important because after they were out of medical jeopardy they needed simply to gain weight to be discharged from the hospital. The hospital cost savings associated with massage were approximately $3,000 per infant. The weight gain effects only emerged around day six, suggesting that you have to provide massage for at least six days before you can show the effect.

Despite the increase in weight gain, there was no change in their food intake. Although the infants were expected to be less active and thereby save calories, instead they spent more time awake and more time being active than the control group. These data were interpreted in the context of a literature on rats (Mittleman & Valenstein, 1984), which suggested that if you exercise rats they gain more weight independent of food intake. Studies of malnourished children (Torva, Schutz, & Viteri. 1979) also showed that exercise without any additional foodstuffs resulted in greater weight gain.

At 8 months, the preemies continued to show a weight advantage and at this time they also showed superior performance on the Bayley (1969) mental and motor scales (Field et al., 1987). The authors did not interpret this as a direct effect of massage, but rather suggested that the massage had made the babies more like “Gerber babies”; they were more responsive on the Brazelton, gained more weight, went home earlier, and their parents in turn found it easier to respond and to relate to their babies. In a kind of a snowball effect, this probably gave them more positive stimulation, and more positive stimulation in turn resulted in better development.

Despite replication of these data, the mechanism for the massage/weight gain effect was still not known. Again the rat model was investigated as a model for infant growth. One of the experiments that is typically conducted with rats is to remove the baby rats from their mother. Invariably there are major changes in growth. Ornithine decar- boxylase (ODC) is a measure of tissue growth, and if infant rats are separated from their mothers there are dramatic reductions in ODC in the brain, heart, and liver (Butler, Suskind, & Schanberg, 1978) and there is a similar drop in growth hormone (Kuhn, Butler, & Schanberg, 1978).

Schanberg and his co-workers (cf. Schanberg & Field, 1987, for a review) found that the mother rat provides several different forms of stimulation. She pinches the tails of the rat pups, lightly strokes them, and carries them around. The question was what was missing when the mother is separated from the rat pups for them to have lowered levels of growth hormone and ODC. One of Schanberg’s students observed that the rat mothers were spending most of their time tongue-licking these rat pups (they have to be tongue-licked in order to void and excrete). The student then simulated this tongue licking with a wet paint brush, and this heavy stroking brought the ODC levels back to normal in the brain, heart, and liver. Similarly, growth

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hormone returned to baseline following heavy stroking with the paint brush. Strok- ing was contrasted with kinesthetic and vestibular stimulation. That is, the limbs of the rat pups were moved rhythmically for kinesthetic stimulation, and for vestibular stimulation the pups were spun around on a merry-go-round platform. Neither kinesthetic nor vestibular spinning was effective in raising ODC and growth hormone to normal levels.

In the second replication of the preemie study, growth hormone and catecholamines were assayed. The weight gain effect was again present, with the treatment group gaining more weight.

Sleep behavior was also studied. Indeterminant sleep (a disorganized sleep state) decreased dramatically. This was significant because Sigman and Parmelee (1989) reported that the only neonatal variable that predicted IQ at 12 years was sleep behavior, with less indeterminate sleep being related to higher IQ.

Growth hormone and cortisol were also measured, and no differences were noted between the control and the massaged groups, suggesting that the rat model differed from the human model. Dramatic increases were noted, however, in catecholamines (Kuhn et al., 1991). It is interesting to note that the neonatologists interpreted this as an indication that the infants were being stressed because catecholamines (norepinephrine and epinephrine) generally increase when an adult is stressed. However, an alternative interpretation was made by the neuroscientists who claimed that the normal neonatal increase in these catecholamines was being facilitated by the massage.

In the interim a Swedish study (Uvnas-Moberg, Widstrom, Marchini, & Winberg, 1987) suggested another possible mechanism. These investigators studied the baby’s sucking behavior and the mother’s breast-feeding behavior. In their study, vagal tone increased with a consequent slowing of heart rate during feeding. Vagal tone also increases during massage. The Swedish study showed that when the mammary gland or the oral lining of the baby’s mouth is stimulated, vagal tone increases, catecholamines increase, and gastrointestinal food absorption hormones are released such as insulin, gastrin, glucose, and cholecystokinin. A preliminary analysis suggested that insulin levels also increased during infant massage (this may provide an explanation for the underlying mechanism for the massage/weight gain relationship); namely, if you provide stimulation to the mouth, to the mammary gland, or to other parts of the body, vagal tone increases which in turn increases the release of insulin and other food absorption hormones that facilitate weight gain.

THE COCAINE BABY

A relative newcomer to neonatal intensive care nurseries is the cocaine baby. Many cocaine babies appear normal and alert, unlike the methadone and heroin babies who are irritable and difficult to console. Cocaine babies show diminished head cir- cumference and an increase in obstetric complications in most studies, but most people who have looked at neonatal behavior have noted very few differences except slightly more withdrawal symptoms. A regression analysis on withdrawal symptoms in cocaine-exposed newborns suggested that it was alcohol, not cocaine, that contributed

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to these symptoms. Approximately 95% of the so-called cocaine babies were polydrug babies, typically cocaine, alcohol, marijuana, and cigarettes. In the Eisen et al. (1991) sample, for example, there were more drinkers and more cigarette smokers in the cocaine group. The mothers were also more often single parents. Thus, there were many confounding factors that contributed to the undesirable outcomes of cocaine- exposed infants.

On the Brazelton, there were basically no differences except diminished performance on the habituation items. This was of interest because, again using the rat model, if you introduce cocaine to the rat, dopaminergic function changes. Dopamine levels increase and then decrease and habituation (an inability to shut out stimulation) is negatively affected. The cocaine babies similarly had both elevated dopamine levels and habituation problems.

Because massage facilitated habituation in preterm infants, massage was also used with cocaine babies (Wheeden, Scafidi, Field, Ironson, & Valdeon, in review). Preliminary data analysis suggests that their habituation scores approached normal once they received massage, and their weight gain was greater than the control group. They also showed elevations in catecholamines, mainly norepinephrine and dopamine. This intervention may be a relevant prevention of later habituation problems. Older grade school children who were cocaine-exposed in utero seem to have habituation problems and difficulty closing out stimulation (i.e., they are stimulus seekers and often provoke fights seemingly for more stimulation).

How any of these interventions relate to'later development is unclear. Developmen- tal follow-up studies will be needed to trace any long-term effects. However, because of the reciprocal-nature of early infant-parent interactions, the improvement of one member of the dyad would presumably improve early interactions and thereby facilitate later attachment relationships.

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Interventions in early infancy