Running head: Interventions for Maternal-Infant Bonding
The Effects of Evidence Based Interventions on Maternal Infant Bonding
Emily Frank and Laura Wiegand
Arizona State University
1
Interventions for Maternal-Infant Bonding
The Effects of Evidence Based Interventions on Maternal Infant Bonding
One of the most critical events following birth is the development of
attachment/bond between mother and infant. This early connection creates a foundation
for their relationship and fosters the future interactions between mother and child. Nurses
are in a prime position to assess and facilitate this relationship. Nurses assess the
maternal-infant bonding by observing whether the mother is sensitive to the child’s cues,
responding to the child’s distress, fostering the child’s social emotional growth, and
fostering the child’s cognitive growth (Hockenberry &Wilson, 2001). The assessment of
mother-infant bonding is less concrete than the physical assessment of a newborn and
requires more observational and interviewing skills. Due to the importance of this early
relationship, it is important to review the evidence aimed at facilitating the maternalinfant bond.
In the following studies, the term “bonding” refers to the development of
emotional ties from the mother to the infant while the term “attachment” refers to the
emotional ties from the infant to the mother (Hockenberry & Wilson, 2011).
We chose two appropriate questions in order to respond to this clinical issue. The
first question aims to appraise the efficacy of kangaroo care when used to improve
maternal-infant bonding/attachment. In mothers and newborn infants, how does kangaroo
care compared to standard care affect the bonding/attachment between mother and
infant?
Kangaroo care is a technique that includes the nurse placing the bare-skinned
infant directly on the parent’s bare chest and covering them with a warmed blanket
(Lowdermilk & Perry, 2007). Evidence suggests that, not only does kangaroo care
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Interventions for Maternal-Infant Bonding
physiologically assist the thermoregulation of the infant, but that it fosters
neurobehavioral development factors such as bonding between the infant and parent
(Lowdermilk & Perry, 2007).
The second question aims to appraise the effectiveness of infant massage when
used to improve maternal-infant bonding. In mothers and newborn infants, how does
infant massage compared to no intervention affect maternal-infant bonding?
“Touch is an intrinsic part of caring for an infant that establishes powerful
physical and emotional connections between the caregiver and the baby, and plays a
pervasive role in communication and affect regulation” (Underdown, Barlow, & StewartBrown, 2008, p. 11). Infant massage can be defined as the purposeful tactile stimulation
of infants. Many benefits have been attributed to infant massage, including: greater
relaxation and body awareness, strengthened circulatory, hormonal, and digestive system;
and improved muscle tone and sleep patterns (Lappin & Kretschmer, 2005, p. 355).
Summary of Kangaroo Care Articles
For the first article, infants were allocated to the kangaroo care group or the
control group. The mother-infant dyads were observed before discharge, at three months,
and at six months. Before discharge, the dyads were examined for mother-infant
interaction as well as maternal perceptions. At three months corrected age, the infants and
their mothers were examined in their home environment. At six months corrected age, the
infants were evaluated to measure mother-infant interactions as well as infant cognitive
development. The mean reliability of the tool was determined to be 93% in a group of 15
mother-infant dyads. The validity of this study was not given in the article.
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Interventions for Maternal-Infant Bonding
In the second article, neonates were randomly allocated into kangaroo mother care
group and a control group for a 16-month time period. The randomization of the subjects
occurred while using the random number table. Each infant in the kangaroo mother care
group was given at least six hours of skin-to-skin contact every day while an infant in the
control group received traditional incubator care. The reliability and the validity of the
tool used to measure the interactions were not given in the article.
In the third article, the required baseline characteristics for eligibility included
infants weighing less than 2001 grams. These infants were eligible to be subjects in the
randomized control trial used to test the efficacy of kangaroo mother care. The design of
this study permits precise observation of the timing and duration of mother–infant
contact. This study design takes into account the infant’s health status at birth as well as
the socioeconomic status of the parents. The validity and reliability of the tools were not
provided in this article.
Summary of Infant Massage Articles
The first article was a systematic review of 23 randomized control trials.
According to the article infant massage is becoming more popular in the community for
the low-risk babies and their primary care givers. Some early research suggests that infant
massage provides benefits for sleep, respiration, elimination and the reduction of colic
and wind. It is also thought that infant massage may reduce infant stress and promote
positive parent-infant interactions. This study aimed to appraise the current evidence
regarding the benefits of infant massage in healthy infants less than 6 months old.
Study Design: Systematic Review
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Interventions for Maternal-Infant Bonding
5
The second article was a systematic review and meta-analysis, which involved a
search of multiple databases that had addressed the effectiveness of tactile stimulation in
physically healthy infants. Included studies must have utilized standardized outcome
measures of infant mental or physical development.
The third article was a correlational predictive study that aimed to evaluate the
response of 32 preterm infants, who were hospitalized in the NICU, to stimulation
provided during regular parent visits. Heart rates and oxygen saturation were measured
in response to tactile stimulation. Furthermore, the amount of handling provided to the
infant during the two hours preceding the parent visit, the amount of handling provided
during the visits, the severity of the infant’s medical condition, and the infant’s
gestational age were all measured by both the researcher and an assistant using separate
measurement tools.
Conclusion
There is evidence to suggest the efficacy of both kangaroo care and infant
massage in relation to maternal-infant bonding. While appraising the evidence,
discrepancies were noted in reliability, validity, applicability, and feasibility. Therefore,
not all of the appraised articles served to support this evidence. Specific gaps in these
studies include the lack of quantitative data related to maternal-infant bonding and the
absence reliable tools used to measure outcomes. In conclusion, more research is needed
before kangaroo care and infant massage can be implemented as known therapies for
maternal-infant bonding.
Interventions for Maternal-Infant Bonding
6
References
Feldman, R., Eidelman, A. I., Sirota, L., & Weller, A. (2002). Comparison of skin-to-skin
(kangaroo) and traditional care: parenting outcomes and preterm infant
development. Pediatrics, 110, 16-26. Retrieved from
http://pediatrics.aappublications.org/content/110/1/16.full.html
Gathwala, G., Singh, B., & Balhara, B. (2008). KMC facilitates mother baby attachment
in low birth weight infants. Indian Journal of Pediatrics, 75, 43-47. Retrieved
from www.kmc.com
Law Harrison, L., Leeper, J., Yoon, M., Lobo, M. L., & Harrison, M. J. (1991). Preterm
infant’s physiologic responses to early parent touch . Western Journal of Nursing ,
13, 698-713. doi:10.1177/019394599101300603
Lowdermilk, D. L., Perry, S. E., Cashion, K., & Alden, K. R. (2012). Maternity &
women’s health care (10 ed.). St. Louis, MO: Elsevier Mosby.
Melnyk, B. M., & Fineout-Overholt, E. (2011). In Evidence-based practice in nursing &
healthcare (2 ed., pp. 571-583). Philadelphia, PA: Lippincott Williams &
Wilkins.
Tessier, R., Cristo, M., Velez, S., Giron, M., W, S., Figueroa de Calume, Z.,...Charpak,
N. (1998). Kangaroo mother care and the bonding hypothesis. Pediatrics, 102, 18. Retrieved from http://pediatrics.aappublications.org/content/102/2/e17.full.html
Underdown, A., Barlow, J., Chung, V., & Stewart-Brown, S. (2009). Massage
intervention for promoting mental and physical health in infants aged six months
(review). The Cochrane Library , 1-38.
Interventions for Maternal-Infant Bonding
Underdown, A., Barlow, J., & Stewart-Brown, S. (2010). Tactile stimulation in
physically haelth infants: results of a systematic review . Journal of Reproductive
and Infant Psychology , 28(1), 11-29.
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Interventions for Maternal-Infant Bonding
8
Rubric #2
Search for Related Evidence 12%
Dimension
3
2
1
0
Score
Search and
Sources
 Must Search
both AHRQ and
Cochrane Library
results. Include
searches from
two other
databases
pertinent to the
problem area,
such as
CINAHL,
MEDLINE,
ERIC,
PSYCINFO, or
others.
 Identify the
databases
searched
 Each of the
search histories is
included in the
appendices in a
table format.
Each summary
includes
keywords, limits,
numbers found,
and criteria used
to include or
exclude studies.
 Include search
results for
systematic
reviews, metaanalyses, clinical
guidelines, preappraised
literature, and
raw evidence
The search
demonstrates
appropriate
sources of
evidence and
thorough search
strategies.
Elements of the
search strategy
are clearly
identified and
accurate. The
tables/flow
charts of the
search
strategies are
clear and reflect
appropriate
keywords.
The outcome of
the search in
terms of
number of
papers found is
clearly
summarized
and includes
how you
narrowed the
search to
identify article
chosen.
Search is
complete for
at least 3 of
the databases
required. The
search
histories are
summarized in
the table and
included in the
appendices.
Each summary
includes
keywords,
limits,
numbers
found, and
criteria used to
include or
exclude
studies but
only identified
how you
narrowed the
search for 2
articles.
Search is
complete for
at least 2
databases.
The search
histories are
summarized in
the table and
included in the
appendices.
Each summary
includes
keywords,
limits,
numbers
found, and
criteria used to
include or
exclude
studies but
only identified
how you
narrowed the
search for one
article.
Search is
complete for
0-1 database.
The search
process is
superficial,
vague,
incomplete, or
is irrelevant to
the issue.
Lacks
summaries of
the search
strategies or
other required
elements.
Presentation
reflects lack of
knowledge of
searching.
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Interventions for Maternal-Infant Bonding
related to your
PICO question,
including when
evidence is not
found.
Critical
Appraisal of
Evidence
 Narrow down
the search to 6
evidence sources
that fit your
criteria (3 for
each student.)
 Review each
article or
abstract, identify
the type of
evidence, then
complete the
appropriate
Rapid Critical
Appraisal form
for each article
copy and paste
the abstract on
the form. Rapid
Critical appraisal
forms located in
the assignment
folder. Include
the appraisal
forms in the
appendices
5 to 6 evidence
sources
included with
complete
citations and
pasted-in
verbatim
abstract. The
critical
appraisal
process is
evident.
At least 3 to 4
of the evidence
sources
included have
complete
citations and
pasted-in
verbatim
abstracts.
Appraisal form
for at least 2
articles is
chosen
Appraisal form correctly to
for each article best fit the type
of study and
is chosen
correctly to best completed
accurately.
fit the type of
Includes
study and
written
completed
explanations of
accurately.
Includes written most of the
explanations of questions on
the questions on the form. If
cannot be
the form. If
answered in the
cannot be
answered in the way they are
asked gives
way they are
asked include a mostly yes or
no answers.
discussion of
why they
cannot be
answered more Inconsistencies
are recognized.
than yes or no
Obvious gaps
answer.
and
Discussion
controversies
reflects the
inconsistencies are noted.
across studies,
Tables are
major
clear, easy to
conclusions
9
At least 1 to 2
of the evidence
sources
included has
complete
citations and
pasted-in
verbatim
abstracts.
Appraisal form
for at least 1
article is
chosen
correctly to
best fit the type
of study and
completed
accurately.
Includes
minimal
written
explanations
when the
questions on
the form cannot
be answered in
the way they
are asked.
Inconsistencies,
gaps, and
controversies
are not clearly
noted.
Information is
accurate.
Citation,
abstracts, and
appraisals not
complete from
any of the
evidence
sources.
The critical
appraisal
process is
unclear or not
identified.
Tables or
presentation of
evaluation of
evidence and
synthesis of
evidence are
unorganized,
lacking
information or
inaccurate.
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Interventions for Maternal-Infant Bonding
drawn across
studies, clinical
implications of
findings across
studies;
Discusses gaps
(what is
unknown and
needs to be
researched) and
controversies
that might exist
in the literature
Tables are
clear, easy to
read and
demonstrate
key elements
for appraisal
and synthesis.
Information is
accurate.
The summary
Summary of
and
Best Evidence
conclusions
and
about the
Conclusions
evidence
about the
evidence.
addresses
information
from both
Synthesize and
write a summary PICO searches.
The relevance
of the evidence
for clinical
and your
decisionconclusions
making is
about that
clearly stated
evidence, (not
and flows from
those presented
the evidence.
by the authors in
The level of
each of the
papers reviewed). evidence is
correct for 5-6
articles.
Include a
Each source is
summary of the
available
overall findings
online from the
from the
ASU Library
combined
10
read and
contain major
elements
needed for
appraisal and
synthesis.
Information is
accurate.
The summary
and
conclusions
about the
evidence is
clear but may
lack depth.
The level of
evidence is
correctly
identified for at
least 3 to 4
articles.
Each source is
available
online from the
ASU Library
or a pasted
electronic copy
of the article/
electronic link
to the
article/evidence
is provided.
The summary
and conclusion
about the
evidence is not
clear and lacks
depth.
The level of
evidence is
correctly
identified for at
least 1 to 2
articles.
Each source is
available online
from the ASU
Library or a
pasted
electronic copy
of the article/
electronic link
to the
article/evidence
is provided.
The summary
and conclusion
about the
evidence is
brief,
superficial or
incomplete and
lacks logical
deduction of
the evidence,
or the evidence
is a repeat of
the study
authors’
findings.
No credit will
be given for
articles that
cannot be
verified or for
summaries that
are plagiarized.
Sources are not
__3___
Interventions for Maternal-Infant Bonding
searches that
includes a
combination of
the evidence and
how that
information
might guide
practice.
11
or a pasted
.
electronic copy
of the article/
electronic link
to the
article/evidence
is provided.
available
online from the
ASU Library
and a pasted
electronic copy
of the article/
electronic link
to the
article/evidence
is not provided.
The level of
evidence is not
correctly
identified for
articles.
Include the level
of evidence of
the findings
If you chose any
articles not
available online
from the ASU
Library databases
or on the
Internet, include
an electronic link
to each of those
articles or sites in
the citation on
the reference
page.
Organization,
Content,
Mechanics and
Style
 Introduction
 Conclusion
Content
 Topic
Statement
Well-developed
introduction
engages the
reader and
creates interest.
The
introduction
states the main
topic, and
previews the
structure of the
paper.
Details are
placed in a
logical order
and the way
they are
presented
effectively
keeps the
Introduction
creates interest.
The
introduction
clearly states
the
main topic and
previews the
structure
of the paper,
but it is not
particularly
inviting to the
reader.
Details are
placed in
a logical order,
but
the way they
are
The
introduction
states the main
topic,
but does not
adequately
preview
the structure of
the
paper nor is it
particularly
inviting to the
reader.
Introduction
adequately
explains the
background,
but may lack
detail.
Some details
There is no
clear
introduction of
the main topic
or structure of
the paper.
Background
details are a
random
collection of
information,
unclear, or not
related to the
topic.
Many details
are not
in a logical or
expected order.
There is little
sense that the
__3___
Interventions for Maternal-Infant Bonding
interest of the
reader.
Conclusion
effectively
wraps up and
goes beyond
restating the
thesis
Mechanics
 Spelling,
 Punctuation,
 Capitalization Topic statement
is clear, states
 Grammar
the issue and
significance is
Style
well developed
 Sentence
and guides the
flow
reader through
 Sentence
the paper.
structure
 Sentence
Has few, if any,
variety
spelling,
 Word choice
punctuation,
 Transitions
grammar or
APA formatting
 Title page,
headings,
margins, etc
References and
presented
sometimes
makes the
writing less
interesting.
Conclusion
effectively
summarizes
topics.
12
are not in a
logical or
expected order,
and this
distracts the
reader.
Conclusion is
recognizable
and ties up
almost all loose
ends.
writing is
organized.
Conclusion
does not
summarize
main points.
Topic
statement is
missing.
Topic
Has more than
statement is
five mechanics
somewhat
Topic
errors.
clear, attempts statement is
Writer uses a
to state the
vague and does limited
issue and
not state the
vocabulary,
significance
issue or
which does not
but not well
significance
Communicate
developed not
does not guide strongly or
clear what the
the reader.
capture the
paper is about.
reader's
Has two or
Has four or five interest.
usage errors.
three
mechanics
Jargon or
Writer uses
mechanics
errors.
clichés may be
vivid words and errors.
Writer uses
present and
phrases that
Writer uses
words that
detract from
linger or draw
vivid words
communicate
the meaning.
pictures in the
and phrases
clearly, but the The sentences
reader's mind,
that linger or
writing lacks
are difficult to
and the choice
draw pictures
variety, punch, read aloud
and placement
in the reader's
or flair.
because they
of the words
mind, but
Most sentences sound
seems accurate, occasionally
sound natural
awkward, are
natural, and not the words are
and are easy
Distractingly
forced
used
on-the-ear
repetitive, or
All sentences
inaccurately or when read
difficult to
sound natural
seem overdone. aloud, but
understand.
and are easy
Almost all
several are
on-the-ear
sentences
awkward or
when read
sound natural
difficult to
aloud. Each
and are easyunderstand.
Has five or
sentence is
on-the-ear
more APA
clear and has an when read
formatting
obvious
aloud, but 1 or
errors
emphasis.
2are awkward
Does not credit
or difficult to
appropriately
Interventions for Maternal-Infant Bonding
Citations
Appendices
Self-assessment:
Rubric is
completed by
students
Rubric Total
Score
understand.
or does not
Has one or two Has three or
adhere to APA
APA
four APA
No appendices
formatting
formatting
are included
errors.
errors.
Paper is 3
Almost all
More than 2
pages shorter
citations and
citations or
or longer than
references
references do
required
reflect APA
not reflect APA
style
style
Required
Missing one or
appendices are more of the
present with
required
some
appendices or
components
components
not
Paper is 2
appropriately
pages shorter
completed
or longer than
Paper is 1 page required
shorter or
longer than
required
Rubric is not completed and submitted after reference(s) page of the
paper
(-1 point for assignment)
13
Has no APA
formatting
errors
All citations
and references
reflect APA
style.
Required
appendices are
present with all
components
appropriately
included
Paper meets the
length
requirements
Grading: Both authors receive the same score.
Comments:
12
Total
Score
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Interventions for Maternal-Infant Bonding
14
Appendix A
Search Strategy
Developed by: Laura Wiegand
Database: AHRQ
Type of search
Website search
Website search
Website search
Website search
Website search
Website search
Database: Cochrane
Type of search
Keywords
Keywords
Database: CINAHL
Type of search
Search terms
“kangaroo care”
“bonding”
“bonding and attachment”
“maternal-infant bonding”
“skin-to-skin”
“skin-to-skin bonding”
Search terms
“kangaroo care”
“kangaroo care and bonding”
Search terms
Number of Results
0
33
16
8
4
1
Number of Relevant Articles
0
0
0
0
0
0
Number of Results
Number of Relevant Articles
6
3
3
1
Number of Results
Number of Relevant Articles
Select a field
Select a field
Select a field
“bonding”
“kangaroo care”
“bonding” AND “kangaroo care”
3479
415
49
15
8
5
Select a field
“maternal-infant”
314
4
Interventions for Maternal-Infant Bonding
Select a field
“maternal-infant” AND “bonding” AND
“kangaroo care”
Database: PubMed
Type of search
Search terms
15
4
3
Number of Results
Number of Relevant Articles
Database search
“kangaroo care”
380
38
Database search
“kangaroo care” AND “randomized control
trial”
“kangaroo care” AND “bonding” AND
“randomized control trial”
48
8
6
2
Database search
Interventions for Maternal-Infant Bonding
16
Appendix B
Rapid Critical Appraisal: Randomized Clinical Trials (RCTs)
Prepared by: Laura Wiegand
Citation: Feldman, R., Eidelman, A. I., Sirota, L., & Weller, A. (2002). Comparison of skin-toskin (kangaroo) and traditional care: parenting outcomes and preterm infant development.
Pediatrics, 110, 16-26. Retrieved from
http://pediatrics.aappublications.org/content/110/1/16.full.html
Abstract:
Objective. To examine whether the kangaroo care (KC) intervention in premature infants affects
parent–child interactions and infant development.
Methods. Seventy-three preterm infants who received KC in the neonatal intensive care unit were
matched with 73 control infants who received standard incubator care for birth weight, gestational
age (GA), medical severity, and demographics. At 37 weeks’ GA, mother–infant interaction,
maternal depression, and mother perceptions were examined. At 3 months’ corrected age, infant
temperament, maternal and paternal sensitivity, and the home environment (with the Home
Observation for Measurement of the Environment[HOME]) were observed. At 6 months’ corrected
age, cognitive development was measured with the Bayley-II and mother–infant interaction was
filmed. Seven clusters of outcomes were examined at 3 time periods: at 37 weeks’ GA, mother
infant interaction and maternal perceptions; at 3-month, HOME mothers, HOME fathers, and infant
temperament; at 6 months, cognitive development and mother–infant interaction
Results. After KC, interactions were more positive at 37 weeks’ GA: mothers showed more
positive affect, touch, and adaptation to infant cues, and infants showed more alertness and less
gaze aversion. Mothers reported less depression and perceived infants as less abnormal. At 3
months, mothers and fathers of KC infants were more sensitive and provided a better home
environment. At 6 months, KC mothers were more sensitive and infants scored higher on the
Bayley Mental Developmental Index (KC: mean: 96.39; controls: mean: 91.81) and the
Psychomotor Developmental Index (KC: mean: 85.47; controls: mean: 80.53).
Conclusions. KC had a significant positive impact on the infant’s perceptual-cognitive and motor
development and on the parenting process. We speculate that KC has both a direct impact on infant
development by contributing to neurophysiological organization and an indirect effect by
improving parental mood, perceptions, and interactive behavior.
1. Are the Results of the Study Valid? (Using the following sub-questions [ai], determine if the results of the study are valid and indicate your decision in
the column to the right.) In the sub questions below include notes (brief 2-3
Yes
sentences, not sections of article pasted in document) to explain your choice
and help you remember the information for later use. Use this model for all
of the sections.
Were the subjects randomly assigned to the experimental and control
group?
Comparison was done between infants who were matched to each other. Each
a.
No
group of infants was born in the same year and in the same hospital. Each
infant shared similar birth weight, gestational age, and family demographic.
One infant was provided kangaroo care while the other infant was provided
Interventions for Maternal-Infant Bonding
b.
c.
d.
e.
f.
g.
h.
i.
standard care. Mothers who matched the study criteria and who delivered in
one of the two hospitals were asked to enroll in either the kangaroo care
group or the control group as soon as their infant would become eligible.
Was random assignment concealed from the individuals who were first
enrolling subjects into the study?
The comparison was performed between matched infants cared for in a
hospital where they were provided kangaroo care and in another hospital
where they were given standard care.
Were the subjects and providers blind to the study group?
The trained psychologist who assessed for infant cognitive development at
the six month laboratory visit was blind to the group assignment. However,
the subjects involved were not blind to the study group to which they were
placed.
Were reasons given to explain why subjects did not complete the study?
Six of the mothers who were asked to participate in the control group
declined for the reason of time constraints. Other reasons were not given.
Were the follow-up assessments conducted long enough to fully study the
effects of the intervention?
In order to determine the efficacy of kangaroo care, the adequate duration of
the follow-up assessments were an essential part of the study. Mother-infant
interactions were studied pre-discharge at 37 weeks’ gestational age, again at
three months during a home visit, and again at six months during a
developmental laboratory visit.
Were the subjects analyzed in the group to which they were randomly
assigned?
Each mother-infant dyad was analyzed individually. First, they were assessed
while interacting in a separate room next to the NICU. Next, they were
separately analyzed at their home after 3 months. Then, the dyad was
analyzed in a laboratory setting separate from the group to which they were
assigned.
Was the control group appropriate?
The control group consisted of an equal number of participants as the
intervention group. Clinical characteristics and demographics of the subjects
were compared to the listed baseline characteristics to determine eligibility.
Were the instruments used to measure the outcomes valid and reliable?
The Mother-Newborn Coding System was used to code each videotaped
sequence of maternal-infant interaction. The five categories being tested were
maternal gaze, maternal affect, maternal talk, maternal touch, and infant state.
Then, a mother-infant interaction was rated on a 5-point scale for Maternal
Adaptation and Maternal Intrusiveness. Reliability was tested on 15 motherinfant dyads. The mean reliability was 93%. The validity was not reported.
Were the subjects in each of the groups similar on demographic and
baseline clinical variables?
Infants were matched depending on their gender, birth-weight, gestational
age, and medical risk. Major health conditions excluded certain infants from
the study. Each family involved was middle-class, representing the majority
17
No
Yes
Yes
Yes
No
Yes
Yes
Yes
Interventions for Maternal-Infant Bonding
18
of young families of that population. Families of the two infants who were
matched also shared the same education level, average age, parity, and
maternal employment. Mothers included in the study reported no substance
abuse during pregnancy.
2. What are the Results?
How large is the intervention or treatment effect (NNT, NNH, effect size, level of
significance)?
Each of the 7 clusters of outcome measures was studied with a separate multivariate
examination of variance with intervention.
Univariate analysis followed main effects of findings. In some mother-infant dyads, the innate
longing to bond with each other is lost due to multiple causes. During these instances, nursing
interventions are essential.
The 7 clusters of outcomes were obtained as follows:
1) Before discharge= mother–infant interaction
a.
2) Before discharge= maternal perceptions
3) 3 months at home= mothers
4) 3 months at home= infant temperament
5) 6 months in lab= infant cognitive development
6) 6 months in lab= mother–infant interaction
Two graded multiple regression models were calculated to predict infants’ scores by the 5
clusters of outcome variables across the first 6 months.
The NNT, NNH, overall effect size, or the level of significance were not provided in this
article.
How precise is the intervention or treatment (CI)?
b. The precise confidence intervals for the overall treatment outcomes were not given in this
article. The overall clinical decision was not clear in the article describing this study.
3. Will the Results Help Me in Caring for my patients?
a.
b.
c.
d.
Yes
Were all clinically important outcomes measured?
Clinical outcomes that were measured in this study included emotional and verbal
Yes
responsiveness from the infants. Acceptability of the intervention was also
measured.
What are the risks and benefits of the treatment?
For this intervention, risks include the inability for mothers to continue this type of one-on-one
care. Benefits include the increase of cognitive and physical development of the child. The
benefits are linked together. When the mother receives skin-to-skin contact with her newborn,
she becomes more comfortable with the newborns cues of distress. In turn, becoming
comfortable with her newborn will create an ability to emotionally bond.
Is the treatment feasible in my clinical setting?
The intervention will be feasible in my clinical setting because I will be working
Yes
with a population that will include laboring mothers and newborns. Parts of my
interventions will involve the bonding and interactions between these dyads.
What are my patients/family’s values and expectations for the outcome that is trying to be
prevented and the treatment itself?
I believe that this intervention will be accepted within my patient population. Since it is cost
Interventions for Maternal-Infant Bonding
19
effective, patients will be more willing to listen to the technique that’s being explained to them.
Since it is simple to understand, the mothers should not become defensive or discouraged about
their ability to accomplish this technique on their own.
Summary Paragraph: Write a 1-2 paragraph summary, synthesizing the information from the
questions to support your decision regarding the usefulness of the evidence in your practice.
The strict baseline characteristics that determined the eligibility provides a detailed outline of the
population that will benefit from the intervention being studied. Therefore, knowing the validity
and reliability of a study provides information about the effectiveness of kangaroo care on these
specific populations. However, I find that this evidence is not strong due to the lack of
randomization or blindness implemented throughout the study.
Interventions for Maternal-Infant Bonding
20
Appendix C
Rapid Critical Appraisal: Randomized Clinical Trials (RCTs)
Prepared by: Laura Wiegand
Citation:
Gathwala, G., Singh, B., & Balhara, B. (2008). KMC facilitates mother baby attachment in low birth
weight infants. Indian Journal of Pediatrics, 75, 43-47. Retrieved from www.kmc.com
Abstract:
Objective. To determine whether Kangaroo mother care (KMC) facilitates mother baby attachment in
low birth weight infants.
Methods. Over 16 month period 110 neonates were randomized into kangaroo mother care group and
control group using a random number table. The kangaroo group was subjected to Kangaroo mother care
for at least 6 hours per day. The babies also received kangaroo care after shifting out from NICU and at
home. The control group received standard care (incubator or open care system). After 3 months followup, structured maternal interview was conducted to assess attachment between mothers and their babies.
Results. Mean birth weight was 1.69 ± 0.11 Kg in KMC group compared to 1.690 ± 0.12 Kg in control
group (p>0.05). Mean gestational age was 35.48 ± 1.20 week in KMC group and 35.04±1.09 week in the
control group (p>0.05). KMC was initiated at a mean age of 1.72±0.45 days. The duration of KMC in
first month was 10.21±1.50 hour, in the 2nd month was 10.03±1.57 hour and in the 3rd month was
8.97±1.37 hours. The duration of hospital stay was significantly shorter in the KMC group (3.56±0.57
days) compared to control group (6.80±1.30 days). The total attachment score (24.46±1.64) in the KMC
group was significantly higher than that obtained in control group (18.22±1.79, p<0.001). In KMC group,
mother was more often the main caretaker of the baby. Mothers were significantly more involved in care
taking activities like bathing, diapering, sleeping with their babies and spent more time beyond usual care
taking. They went out without their babies less often and only for unavoidable reasons. They derived
greater pleasure from their babies.
Conclusion. KMC facilitates mother baby attachment in low birth weight infants.
1. Are the Results of the Study Valid? (Using the following subquestions [a-i], determine if the results of the study are valid and
indicate your decision in the column to the right.) In the sub
questions below include notes (brief 2-3 sentences, not sections of
Yes
article pasted in document) to explain your choice and help you
remember the information for later use. Use this model for all of the
sections.
Were the subjects randomly assigned to the experimental and
control group?
Each neonate enrolled in the study was placed in the kangaroo
a.
Yes
mother care group or the control group. This allocation was done by
using a random number table as well as a written consent forms
signed by the infants’ mothers.
Was random assignment concealed from the individuals who
were first enrolling subjects into the study?
b.
Yes
The infants were allocated to either the kangaroo mother care group,
also known as the KMC group, or the control group. Informed
Interventions for Maternal-Infant Bonding
c.
d.
e.
f.
g.
h.
i.
consent was signed by each of the infants’ mothers. There were fifty
infants assigned to each group by using a random number table.
Were the subjects and providers blind to the study group?
The mothers of the infants knew to which group their child was
placed. They were the primary caregivers during this time that
provided the kangaroo care or traditional care for their child.
Were reasons given to explain why subjects did not complete
the study?
The only reasons given were reasons that excluded certain infants or
mothers from participating initially. For example, babies who were
sick, unstable or had major congenital malformations were omitted.
Mothers who were ill or unable to come were excluded. Mothers
who refused to sign the consent forms were disqualified.
Were the follow-up assessments conducted long enough to fully
study the effects of the intervention?
All infants in the KMC group as well as the control group were
followed up after discharge. They were assessed in the neonatal
follow up clinic on a weekly basis until the age of three months. A
structured maternal interview was conducted to measure attachment
between mother and child.
Were the subjects analyzed in the group to which they were
randomly assigned?
Each baby was assessed individually. First, they were assessed with
their mothers at the hospital then at the neonatal follow up clinic.
The three month follow-up was an adequate amount of time to
assess the efficacy of kangaroo care on mother-infant attachment.
Was the control group appropriate?
The control group was provided standard care. This indicates that
the infants in the standard care group were under a warmer or
incubator. When compared to the size of the intervention group, an
equal number of infants were allocated to the control group.
Were the instruments used to measure the outcomes valid and
reliable?
The maternal interview that was conducted at 3 months is a valid
instrument used to measure the outcomes of the kangaroo care
intervention. It was a structured interview which consisted of nine
specific questions asked in the same order. It is unknown whether
this is a reliable instrument.
Were the subjects in each of the groups similar on demographic
and baseline clinical variables?
When comparing socio-economic status between the intervention
group and the control group, the difference is less than 10%. For
example, 22% of the intervention group was upper-middle class
when compared to 26% of the control group.
21
No
No
Yes
No
Yes
Unknown
Yes
Interventions for Maternal-Infant Bonding
22
2. What are the Results?
How large is the intervention or treatment effect (NNT, NNH, effect size, level of
significance)?
a.
b.
The p values remained below .05 proving that the results had a high enough level of significance.
The overall effect size was not provided in the article. The NNT and NNH were not given in the
study’s results. The attachment score (24.46±1.64) in the KMC group was significantly higher
than that obtained in control group (18.22±1.79, p<0.001). In KMC group, the mothers of the
infants were the main caretakers.
How precise is the intervention or treatment (CI)?
The confidence interval was not provided in the study’s results. Mothers who were placed in the
kangaroo care group were significantly more involved in care taking activities like bathing,
diapering, sleeping with their babies. They also reported spending more time beyond typical care
taking. They went out without their babies less often than those in the traditional care group. The
KMC group only went out without their infants for reasons that cannot be avoided.
3. Will the Results Help Me in Caring for my patients?
Yes
Were all clinically important outcomes measured?
The clinically important outcomes were measured through the use
a.
of a standardized attachment scoring tool. Standardized questions
Yes
were asked of mothers in each group. Feelings of attachment were
assessed at different time intervals.
What are the risks and benefits of the treatment?
The risks of using the intervention include the mothers refusing to continue participating, inability
b.
to keep in contact after discharge, as well as the inability for healthcare professionals to monitor
the dyads at all times. This nursing intervention is an affordable technique to aid the progression
of mother-infant interaction.
Is the treatment feasible in my clinical setting?
c.
The treatment of kangaroo care can be easily taught at the level of
Yes
nursing care. It is cost effective, easy to understand, and comforting.
What are my patients/family’s values and expectations for the outcome that is trying to be
prevented and the treatment itself?
Inadequate bonding is the outcome that the healthcare system is trying to prevent. By
d.
implementing initial kangaroo care, I believe that the feeling of connection that is achieved
through the use of kangaroo care will increase maternal competence. As her competence
increases, her ability to bond with her baby should increase.
Summary Paragraph: Write a 1-2 paragraph summary, synthesizing the information from the questions
to support your decision regarding the usefulness of the evidence in your practice.
The effect sizes and the levels of significance that were provided by this study will prove useful in my
clinical practice. Structured maternal interviews regarding maternal-infant attachment provided evidence
that influences my decision on the feasibility of the intervention. The baseline characteristics required for
eligibility may be similar to the baseline characteristics seen in the patients that I care for in the future.
Interventions for Maternal-Infant Bonding
23
The baseline characteristics are relevant to the population to which I will be treating. These
characteristics include the mothers’ education levels, the delivery modes, socio-economic status, and
neonatal problems.
Consistent, valid, and reliable attachment scores suggest that the intervention may be feasible in practice.
Therefore, kangaroo care would be an intervention that I would feel comfortable implementing in my
nursing practice. I will be able to teach and encourage the use of this technique with valid evidence to
back-up the information that I’m giving to the mothers.
Interventions for Maternal-Infant Bonding
24
Appendix D
Rapid Critical Appraisal: Randomized Clinical Trials (RCTs)
Prepared by: Laura Wiegand
Citation: Tessier, R., Cristo, M., Velez, S., Giron, M., W, S., Figueroa de Calume, Z.,...Charpak, N. (1998).
Kangaroo mother care and the bonding hypothesis. Pediatrics, 102, 1-8. Retrieved from
http://pediatrics.aappublications.org/content/102/2/e17.full.html
Abstract:
Background. Based on the general bonding hypothesis, it is suggested that kangaroo mother care (KMC)
creates a climate in the family whereby parents become prone to sensitive caregiving. The general
hypothesis is that skin-to-skin contact in the KMC group will build up a positive perception in the
mothers and a state of readiness to detect and respond to infant’s cues.
Method. The randomized controlled trial was conductedon a set of 488 infants weighing <2001 g, with
246 in the KMC group and 242 in the traditional care (TC) group. The design allows precise observation
of the timing and duration of mother–infant contact, and takes into account the infant’s health status at
birth and the socioeconomic status of the parents.
Bonding Assessment. Two series of outcomes are assessed as manifestations of a mother’s attachment
behavior. The first is the mother’s feelings and perceptions of her premature birth experience, including
her sense of competence, feelings of worry and stress, and perception of social support. The second
outcome is derived from observations of the mother and child’s responsivity to each other during
breastfeeding at 41 weeks of gestationalage.
Interventions. KMC has three components. The first is the kangaroo position. Once the premature infant
has adapted to extra-uterine life and is able to breastfeed, he is positioned on the mother’s chest, in a
upright position, with direct skin-to-skin contact. The second component is kangaroo nutrition. Although
breastfeeding is the prime source of nutrition, infants also may receive preterm formula whenever
necessary and vitamin supplements. The third component is the clinical control; infants are monitored on
a regular basis, daily until they are gaining at least 20 g per day. Afterward, weekly clinic visits are
scheduled until term, which constitutes the ambulatory minimal neonatal care. In the TC group, infants
are kept in incubators until they are able to self-regulate their temperature and are thriving (ie, have an
appropriate weight gain). Infants are discharged according to current hospital practice, usually not before
their weight is ;1700 g. Afterward, as with the KMC group, weekly clinic visits are scheduled until
term.
Results. We observed a change in the mothers’ perception of her child, attributable to the skin-to-skin
contact in the kangaroo-carrying position. This effect is related to a subjective “bonding effect” that may
be understood readily by the empowering nature of the KMC intervention. Moreover, in stressful
situations when the infant has to remain in the hospital longer, mothers practicing KMC feel more
competent than do mothers in the TC group. This is what we call a resilience effect. In these stressful
situations we also found a negative effect on the feelings of received support of mothers practicing KMC.
We interpret this as an isolation effect. To thwart this deleterious effect, we would suggest adding social
support as an integral component of KMC. The observations of the mothers’ sensitive behavior did not
show a definite bonding effect, but rather a resilience effect. This is attributable to the KMC intervention;
mothers practicing KMC were more responsive to an at-risk infant whose development has been
threatened by a longer hospital stay. Otherwise, we observed that the mothers (in both the KMC group
and the TC group) had behavioral patterns that were adapted to the child’s at-risk health status and to the
precarious condition of some premature infants requiring intensive care. We conclude that the infant’s
Interventions for Maternal-Infant Bonding
25
health status may be a more prominent factor in explaining a mother’s more sensitive behavior, which
overshadows the kangaroo-carrying effect.
Conclusion. These results suggest that KMC should be promoted actively and that mothers should be
encouraged to use it as soon as possible during the intensive care period up to the 40 weeks of gestational
age. Thus, KMC should be viewed as a means of humanizing the process of giving birth in a context of
prematurity. This finding confirms the conclusions of the 1996 Trieste workshop suggesting that KMC
should be promoted both in hospitals and after early discharge.
1. Are the Results of the Study Valid? (Using the following subquestions [a-i], determine if the results of the study are valid and
indicate your decision in the column to the right.) In the sub
questions below include notes (brief 2-3 sentences, not sections of
Yes
article pasted in document) to explain your choice and help you
remember the information for later use. Use this model for all of the
sections.
Were the subjects randomly assigned to the experimental and
control group?
A stratified block randomization procedure was prepared prior to
the conduction of the study. The procedure was used to randomize
a.
Yes
and allocate the eligible mother-infant dyads into two groups.
Mothers in the kangaroo mother care group practiced 24-hour-a-day
skin-to-skin contact. While mothers in the traditional care group
kept their infants in incubators at a minimal care unit.
Was random assignment concealed from the individuals who
were first enrolling subjects into the study?
The participants of the two randomized groups were distributed
prior to signing consent. The parents of the infants assigned to the
traditional care group were not given consent forms to sign. This
b.
Yes
procedure was accepted by the ethics committee for the reason of it
being usual care provided to those participants who were in the
traditional care group. Reasons for this procedure include the fact
that parents, if given the option, would likely choose to be involved
in the KMC group because of the appeal of possible early discharge.
Were the subjects and providers blind to the study group?
It was impossible to perform the entire study under completely
c.
blind conditions. The psychologists who participated were involved
No
in multiple aspects of the study. However, most of the study was
conducted under quasi-blind conditions.
Were reasons given to explain why subjects did not complete
the study?
Of the group that initially began the study, 20.1% were lost because
of technological issues, 2.3% died between the age of eligibility and
d.
Yes
41 weeks of gestational age, and 8.2% abandoned the study for
unknown reasons. Also, 3.6% of the mothers in the KMC group did
not follow the instructions on how to properly carry the infant.
Interventions for Maternal-Infant Bonding
e.
f.
g.
h.
i.
Were the follow-up assessments conducted long enough to fully
study the effects of the intervention?
The follow-up assessments were conducted for an adequate amount
of time in order to study the effects of the intervention. All infants
involved in the study were evaluated at birth. The infants were also
evaluated at the time of eligibility as well as at term by several
healthcare providers such as pediatricians, nurses, and
psychologists. Social workers also evaluated each child at term. Due
to their increasing age, the data would not be applicable to infant
outcomes if the follow-up assessment would have been prolonged
past the first year of life.
Were the subjects analyzed in the group to which they were
randomly assigned?
Each subject was evaluated individually. There were no group
evaluations during this study. However, the reported outcomes were
adjoined to evaluate the efficacy of the intervention.
Was the control group appropriate?
Many control variables were introduced throughout the study. For
example the gestational age at birth, gender, weight, and height
were documented at birth. These documentations were compared to
the baseline characteristics in order to identify eligibility.
Were the instruments used to measure the outcomes valid and
reliable?
The Nursing Child Assessment Feeding Scale was used to measure
the emotional bond between a mother and her child. The four
subscales of the measurement tool included the mother’s behavior
toward her infant. Her sensitivity to the infant, her response to the
infant’s distress, as well as her behaviors to the socio-emotional
stimulation of the infant was recorded. Of the six total subscales, the
two remaining included measurements of the infant’s response to
the mother. The responses that were assessed included the clarity of
the infant’s cues as well as their overall responsiveness to the
mother.
Were the subjects in each of the groups similar on demographic
and baseline clinical variables?
Of the 1084 infants tested for eligibility, 746 weighed less than
2001 grams and were born in the same year. The infant and mother
remained eligible if the mother was willing and able to follow
instructions. The infant remained eligible if it had overcome all
major adaptation problems with extra-uterine life. The infant
remained eligible if it demonstrated positive weight gain and ability
to suckle properly.
2. What are the Results?
26
Yes
No
Yes
Unknown
Yes
Interventions for Maternal-Infant Bonding
a.
b.
27
How large is the intervention or treatment effect (NNT, NNH, effect size, level of significance)?
In this article, the overall treatment effect size and level of significance were not provided. The
values for NNT and NNH were not provided within the study’s results.
How precise is the intervention or treatment (CI)?
This study’s design allowed for precise observation. Precise observation was done for the timing
and duration of mother–infant contact. The study’s design also took into account the infant’ health
status at birth and the socioeconomic status of their parents. The confidence intervals were not
listed in this article.
3. Will the Results Help Me in Caring for my patients?
Yes
Were all clinically important outcomes measured?
Clinically important outcomes that are included in KMC are as
follows: the mother’s sense of competence in motherhood, feelings
of support, and feelings of stress. In order to evaluate the
a.
Yes
effectiveness of the intervention and the ability of the intervention
to be accepted in the patient population, the maternal feelings
needed to be measured. Maternal feelings and infant cues were
evaluated throughout the time intervals used in the study.
What are the risks and benefits of the treatment?
Kangaroo mother care assists in the development of maternal-infant bonding experience.
Understanding the effects that maternal stress has on the maternal-infant bonding experience is
vital to the role of the nurse. The nurse and the family must realize the connections between skinb.
to-skin contact and the emotional/physical bond between a mother and her infant. A benefit for
the use of this treatment is the fact that it does not cost anything. Another benefit is the ease of
understanding the technique of kangaroo care. It is a simple technique that can be easily described
by the nurse to the patient.
Is the treatment feasible in my clinical setting?
The treatment of Kangaroo Care in a hospital setting is feasible.
Nurses are able to assist and teach mothers who are willing to learn
c.
Yes
about kangaroo care. Mothers who provide kangaroo care
immediately after birth are usually able to discharge their infant
earlier than those who provide standard care.
What are my patients/family’s values and expectations for the outcome that is trying to be
prevented and the treatment itself?
The outcome that is trying to be prevented is the possibility of longer stay at the hospital due to
d.
the delay of the maternal-infant bonding experience. This creates extra stress, discomfort, and
unreliability for the mother and her newborn child. I believe that this will decrease the amount of
time that they are able to bond with each other. In turn, this will diminish their physical and
emotional attachment to each other.
Summary Paragraph: Write a 1-2 paragraph summary, synthesizing the information from the questions
to support your decision regarding the usefulness of the evidence in your practice.
Based on the results of this study, the intervention of Kangaroo care has been proven to have risks and
benefits in the clinical setting. This intervention has been proven to be feasible as evidence by the valid
measurements of important clinical outcomes such as mothers’ perception, mothers’ sensitivity, and the
child’s responsivity.
Interventions for Maternal-Infant Bonding
28
The study’s results are reliable as evidence by effect sizes and the level of significance of each
measurement. This evidence will be useful throughout my nursing practice as a labor and delivery nurse.
This evidence provides valid and reliable information for me to relay to the patients that I care for.
Interventions for Maternal-Infant Bonding
29
Appendix E
Evaluation Table
Developed by: Laura Wiegand
Source 1
Feldman, R.,
Citation:
Eidelman, A. I., Sirota,
L., & Weller, A.
(2002). Comparison of
skin-to-skin
(kangaroo) and
traditional care:
parenting outcomes
and preterm infant
development.
Pediatrics, 110, 16-26.
Retrieved from
http://pediatrics.aappu
blications.org/content/
110/1/16.full.html
Infants were allocated
Design/Method:
Indicate design
to the kangaroo care
Briefly state what was
group or the control
done
group. The infants and
in study
their mothers were
observed at the time of
pre-discharge, at three
months, and at six
months. At predischarge, the dyads
were examined for
mother-infant
interaction and
maternal perceptions.
At three months
corrected age, the
infants and their
mothers were
examined in their
home environment. At
six months corrected
age, the infants were
assessed to measure
interaction and
cognitive
Date: 6/18/12
Source 2
Source 3
Gathwala, G., Singh,
Tessier, R., Cristo, M.,
B., & Balhara, B.
Velez, S., Giron, M.,
(2008). KMC facilitates W, S., Figueroa de
mother baby
Calume, Z.,...Charpak,
attachment in low birth N. (1998). Kangaroo
weight infants. Indian
mother care and the
Journal of Pediatrics,
bonding hypothesis.
75, 43-47. Retrieved
Pediatrics, 102, 1-8.
from www.kmc.com
Retrieved from
http://pediatrics.aappub
lications.org/content/10
2/2/e17.full.html
Within a 16 month
period, neonates were
randomized and
allocated into
kangaroo mother care
group and a control
group. This
randomization
occurred while using
the random number
table. Each subject in
the kangaroo mother
group was given at
least six hours of skinto-skin contact every
day. The control group
received traditional
incubator care.
Infants weighing less
than 2001 grams were
subjects of a
randomized controlled
trial used to test the
effectiveness of
kangaroo mother care,
or KMC.
The design allows
precise observation of
the timing
and duration of
mother–infant contact,
and takes into
account the infant’s
health status at birth
and the socioeconomic
status of the parents.
Interventions for Maternal-Infant Bonding
Sample & Setting:
Number, characteristics
Attrition rate & why
Variables &
Definitions:
IV
DV
development.
The study included 73
infants receiving
kangaroo care and 73
infants receiving
standard care. Infants
given standard
incubator care at one
hospital were matched
to infants receiving
skin-to-skin contact
with their mothers at
another hospital during
the same time period.
Six of the mothers
who were asked to
participate in the
control group declined
for the reason of time
constraints. Other
reasons were not
given.
Independent variables:
New born infants born
to middle-class
families with matched
gender, birth weight,
gestational age, and
medical risk.
Dependent variables:
Maternal gaze, affect,
talk, and touch. Infant
state of fussiness, cry,
alertness, gaze
aversion, and sleep.
30
At the beginning of the
study, 110 neonates
were included. After
the loss of 10 neonates
during follow-up,
there were 100 to be
distributed to the two
groups. Fifty neonates
went to the kangaroo
mother care group
while fifty neonates
went to the traditional
care group. The only
reasons given were
reasons that excluded
certain infants or
mothers from
participating initially.
For example, babies
who were sick,
unstable or had major
congenital
malformations were
omitted. Mothers who
were ill or unable to
come were excluded.
Mothers who refused
to sign the consent
forms were
disqualified.
Independent variables:
Baseline
characteristics such as
maternal education,
mode of delivery,
socio-economic status,
and neonatal
problems.
Dependent variables:
Maternal and infant
response to the
varying degrees of
care. Attachment
scores indicate the
The KMC group
consisted of 246
newborns and 242
newborns were
allocated to the
traditional care (TC)
group. Of the group
that initially began the
study, 20.1% were lost
because of
technological problems,
2.3% died between the
age of eligibility and 41
weeks of gestational
age, and 8.2%
abandoned the study.
Also, 3.6% of the
mothers in the KMC
group did not follow
the instructions on how
to properly carry the
infant.
Independent variables:
Infants weighing less
than 2001 grams.
Health status of the
infant at birth was taken
into account.
Socioeconomic status
of the parents was a
baseline characteristic
used to determine
eligibility.
Dependent variable:
Change in the mother’s
perception of her child
Interventions for Maternal-Infant Bonding
31
efficacy of the
intervention being
examined.
Measurement:
What scales were used
to measure the
outcome variables
(e.g. name of scale,
author, and reliability
info (e.g., Cronbach
alphas)
Bayley-II scale:
The reliability of this
scale was not given.
The Mother-Newborn
Coding System was
used to code each
videotaped sequence
of maternal-infant
interaction. The five
categories being tested
were maternal gaze,
maternal affect,
maternal talk, maternal
touch, and infant state.
Then, a mother-infant
interaction was rated
on a 5-point scale for
Maternal Adaptation
and Maternal
Intrusiveness.
Reliability was tested
on 15 mother-infant
dyads and 93% was
the mean reliability.
After three months of
follow up, the
structured maternal
interview process was
conducted. The name
of the author of this
interview process was
not provided. It was a
structured interview
which consisted of
nine specific questions
asked in the same
order. This process
was used to assess the
attachment between
mothers and their
infants. This is
considered a reliable
instrument. P values
remained below .05
which means that it is
it has a high enough
level of significance to
be considered reliable
and valid.
and the overall bonding
and attachment between
them. Mother’s sense of
competence, feelings of
stress or worry, and the
perception of social
support was observed.
Also, assessments were
done on the mother and
child’s responsivity to
each other.
The Nursing Child
Assessment Feeding
Scale was used to
measure the emotional
bond between a mother
and her child.
The four subscales of
the measurement tool
included the mother’s
behavior toward her
infant. Her sensitivity
to the infant, her
response to the infant’s
distress, as well as her
behaviors to the socioemotional stimulation
of the infant was
recorded.
The measurements of
the infant’s response to
the mother were
involved in the
remaining two
subgroups. The
responses that were
assessed included the
clarity of the infant’s
cues as well as their
responsiveness to the
mother.
Interventions for Maternal-Infant Bonding
Data Analysis:
Statistical significance
Missing data
Clinical importance
Findings:
Statistical findings or
qualitative findings
Each of the 7 clusters
of outcome measures
was inspected with
a separate multivariate
investigation of
variance (MANOVA)
with intervention.
Univariate analysis
followed main effects
of findings. In some
mother-infant dyads,
the innate longing to
bond with each other
is lost through
multiple causes.
During these
instances,
interventions by the
nurse such as
explaining kangaroo
care is essential.
The 7 clusters
of outcomes were
obtained as follows:
1) mother–infant
interaction
2) maternal
perceptions
3) mothers at home
4) infant temperament
at home
32
The attachment score
(24.46±1.64) in the
KMC group was
significantly higher
than that obtained in
control group
(18.22±1.79, p<0.001).
In KMC group, the
mothers of the infants
were the main
caretakers.
The interrater
reliability of the
individual scales was
not reported for this
study.
Mothers who were
placed in the kangaroo
care group were
significantly more
involved in care taking
activities like bathing,
diapering, sleeping
with their babies. They
also reported spending
more time beyond
The kangaroo care
positioning changed the
perception that the
mothers had of their
newborns. This effect is
related to a subjective
“bonding effect”. This
may be explained
by the empowering
nature of the KMC
intervention. Moreover,
in stressful situations
mothers practicing
KMC feel more
competent than do
mothers in the TC
group. This is called the
resilience effect of the
kangaroo care
intervention. Longer
length of hospital stays
may contribute to the
stress of the dyads. In
these stressful
situations, there are
negative feelings of
received support of
mothers practicing
KMC. This is called the
isolation effect.
The interrater reliability
of the individual scales
was not reported for
this study.
The observations of the
mothers’ sensitive
behavior focused on the
resilience effect of the
bonding experience.
An attributable part of
the KMC intervention
includes the fact that
the mothers
practicing KMC were
Interventions for Maternal-Infant Bonding
5) infant cognitive
development
7) mother–infant
interaction in lab
Appraisal - Worth to
Practice:
Strengths/Limitations
Risk/harm
Feasibility for my
practice
Impact on My Practice
Two hierarchical
multiple regression
models were computed
to predict infants’
MDI and PDI scores
by the 5 clusters of
outcome variables
across the first 6
months.
Limitations for this
study include the fact
that they did not
randomly assign the
subjects into groups.
The subjects involved
were not blind to the
intervention. The
reliability of the tools
used contributed to the
strength of the study.
For this intervention,
risks include the
mothers not being
willing to give
adequate one-on-one
care to their infants.
Kangaroo care
increases the cognitive
and physical
development of the
child. The benefits are
linked together. When
the mother practices
skin-to-skin contact
with her newborn, she
becomes more
comfortable with the
newborns cues. This
would make her more
comfortable with her
33
typical care taking.
They went out without
their babies less often
than those in the
traditional care group.
The KMC group only
went out without their
infants for reasons that
cannot be avoided.
Those in the KMC
group also derived
greater pleasure from
their infants.
more responsive to an
infant whose
development has been
threatened by a longer
hospital stay.
The clinically
important outcomes
were measured
through the use of a
standardized
attachment scoring
tool. Standardized
questions were asked
of mothers in each
group. Feelings of
attachment were
assessed at different
time intervals.
Clinically important
outcomes include the
mother’s sense of
competence and
feelings of stress.
Kangaroo mother care
assists in the
development of
maternal-infant
bonding experience.
It’s important for
nurses to understand
the effects that maternal
stress has on the
maternal-infant
bonding experience.
The nurse should
realize the connections
between skin-to-skin
contact and the
emotional/physical
bond between a mother
and her infant.
The risks of using the
intervention include
the mothers refusing to
continue participating,
inability to keep in
contact after
discharge, as well as
the inability for
healthcare
professionals to
monitor the dyads at
all times. This nursing
intervention is an
affordable technique to
aid the progression of
mother-infant
interaction.
The treatment of
Kangaroo Care in a
hospital setting is very
feasible. Nurses are
able to assist and teach
mothers who are
willing to learn about
kangaroo care. Mothers
Interventions for Maternal-Infant Bonding
Confidence to Act:
Level of evidence
Quality of evidence
Strength of evidence
Decision:
Keep for use
Background only
Discard
34
infant and will
generate an
opportunity to
emotionally bond.
I will be working with
populations described
who share the same
baseline
characteristics. My
nursing interventions
will involve the
bonding and
interactions between
these mother-infant
relationships.
Level II: Randomized
Control Trial
The treatment of
kangaroo care can be
easily taught at the
level of nursing care.
It is cost effective,
easy to understand,
and comforting to both
patients involved.
who provide kangaroo
care immediately after
birth are usually able to
discharge their infant
earlier than those who
provide standard care.
Level II: Randomized
Control Trial
Level II: Randomized
Control Trial
The quality of the
evidence concluded
from this study is
undecided. The
reliability of the tools
used was proven.
The evidence is not
strong because the
infants were matched
based on which
hospital they were
born at. They were not
randomly assigned to
the KMC or the TC
group so, therefore,
the evidence is not
strong.
The quality of the
evidence depended on
the amount of
quantitative data. The
p-values given in the
article suggested a
high level of
significance. Strength
of the evidence
depended on the
validity and the
reliability of the tools
used. Since I found the
evidence to be valid
and reliable, I believe
that the strength of the
evidence is solid.
I will keep the
background
information that I’ve
received on kangaroo
care for use in my
future career as a labor
and delivery nurse.
I believe that it will be
beneficial for me to
keep this evidencebased information with
me so that I can use it
for my practice as a
labor and delivery
nurse.
The quality of the
evidence depends on
the amount of data
provided by the studies
outcomes. Since the p
values remained below
.05, the level of
significance of each
data collected remains
high. Strength of the
evidence depended on
the validity and the
reliability of the tools
that were used. Due to
the evidence being
valid and reliable, the
strength of the evidence
is concrete.
I believe, due to the
validity and reliability
of the study, that I can
use this information in
my future career as a
labor and delivery
nurse. I will find it
easier to teach about a
concept for which I
have a solid
Interventions for Maternal-Infant Bonding
35
knowledge-base.
Interventions for Maternal-Infant Bonding
36
Appendix F
Search Strategy
Developed by: Emily Frank
Database
Key words
Limits
Results
Cochrane
“Infant Attachment”
N/A
7
Cochrane
“Infant Massage”
N/A
8
Cochrane
“Maternal Bonding”
N/A
3
Cochrane
“Bonding”
N/A
23
Cochrane
“Infant Bonding”
N/A
6
Cochrane
“Massage”
N/A
7,296
Cochrane
“Parental Attachment”
N/A
674,312
AHRQ
“Infant Attachment”
N/A
34
AHRQ
“Infant Massage”
N/A
70
AHRQ
“Maternal Bonding”
N/A
68
AHRQ
“ Bonding”
N/A
234
AHRQ
“Infant Bonding”
N/A
96
AHRQ
“Massage”
N/A
147
AHRQ
“Parental Attachment”
N/A
141
Date: June 16, 2012
Valid Articles: Include DM Patients, Support Group, blood
glucose.
Massage Intervention for Promoting Mental and Physical
Health in Infants Aged Under Six Months
Massage Intervention for Promoting Mental and Physical
Health in Infants Aged Under Six Months
Interventions for Maternal-Infant Bonding
CINAHL
CINAHL
MH "Parent-Infant Attachment
(Iowa NOC)" OR "Infant
attachment"
“Infant Massage”
37
N/A
152
N/A
82
Building infant-mother attachment: the relationship between
attachment style, socio-emotional well-being and maternal
representations.
Interventions to support early relationships: mechanisms
identified within infant massage programmes.
Tactile stimulation in physically healthy infants: results of a
systematic review.
Preterm infant massage therapy research: a review.
Infant massage as a component of developmental care: past,
present, and future.
Clinical update. Enhancing early parent-infant interaction:
Part 4: infant massage.
CINAHL
CINAHL
CINAHL
CINAHL
MH "Parent-Infant Attachment
(Iowa NOC)" OR "Infant
attachment", AND “Infant
Massage”
MH "Parent-Infant Bonding"
N/A
1
N/A
714
MH "Parent-Infant Attachment
(Iowa NOC)" OR "Infant
attachment", AND MH
“Parent-Infant Bonding”
N/A
13
"attachment" OR (MH
N/A
"Attachment Promotion (Iowa
NIC)") OR (MH "Parent-Infant
The benefits of infant massage: a critical review.
Massage Intervention for Promoting Mental and Physical
Health in Infants Aged Under Six Months
Better beginnings through nurturing touch.
Infant massage: building relationships through touch.
Infant massage promotes bonding, relaxation.
15
Intimacy and attachment in massage therapy.
Applying infant massage practices: a qualitative study.
Interventions for Maternal-Infant Bonding
38
Attachment (Iowa NOC)")
AND (MH "Massage")
Tactile stimulation in physically healthy infants: results of a
systematic review.
Parent delivered infant massage: are we truly ready for
implementation?
Massage intervention for promoting mental and physical
health in infants aged under six months.
CINAHL
(MH "Parent-Infant Bonding")
N/A
714
CINAHL
N/A
256
N/A
4
Individualized touch and massage options: a
neurobehavioral, family-centered approach for high risk
infants.
N/A
3
Tactile stimulation in physically healthy infants: results of a
systematic review.
PubMed
(MH "Infant Stimulation") OR
"tactile stimulation”
(MH "Parent-Infant Bonding")
AND (MH "Infant
Stimulation") OR "tactile
stimulation"
"attachment" OR (MH
"Attachment Promotion (Iowa
NIC)") OR (MH "Parent-Infant
Attachment (Iowa NOC)")
(MH "Infant Stimulation") OR
"tactile stimulation"
“Infant Attachment”
N/A
4100
PubMed
“Maternal Infant Attachment”
N/A
1633
PubMed
“Infant Massage”
N/A
765
PubMed
“Infant Massage” and
“Attachment”
N/A
25
CINAHL
CINAHL
Preterm infants' physiologic responses to early parent touch.
Touch with respect. A loving way to interact with babies and
children with massage
The effects of infant massage on weight, height, and motherinfant interaction.
The effects of infant massage on weight, height, and mother-
Interventions for Maternal-Infant Bonding
39
infant interaction.
Baby massage--a chance for a careful encounter between
parents and child
PubMed
“Maternal Bonding”
N/A
2394
PubMed
“Bonding”
N/A
4165
PubMed
“Infant Bonding”
N/A
2977
Interventions for Maternal-Infant Bonding
40
Appendix G
Rapid Critical Appraisal: Systematic Reviews of Clinical Interventions/Treatments
Prepared by: Emily Frank
Citation:
Underdown, A., Barlow, J., Chung, V., & Stewart-Brown, S. (2009). Massage intervention for
promoting mental and physical health in infants aged six months (review). The Cochrane
Library , 1-38.
Abstract:
Background
Infant massage is increasingly being used in the community for low-risk babies and their primary care givers. Anecdotal
claims suggest benefits for sleep, respiration, elimination and the reduction of colic and wind. Infant massage is also
thought to reduce infant stress and promote positive parent-infant interaction.
Objectives
The aim of this review was to assess the effectiveness of infant massage in promoting infant physical and mental health in
population samples.
Search methods
Searches were undertaken of CENTRAL 2005 (Issue 3), MEDLINE (1970 to 2005), PsycINFO (1970 to 2005), CINAHL
(1982 to 2005), EMBASE (1980 to 2005), and a number of other Western and Chinese databases.
Selection criteria
Studies in which babies under the age of six months were randomized to an infant massage or a no-treatment control group,
and utilizing a standardized outcome measuring infant mental or physical development.
Data collection and analysis
Weighted and standardized mean differences and 95% confidence intervals are presented. Where appropriate the results
have been combined in a meta-analysis using a random effects model.
Main results
Twenty-three studies were included in the review. One was a follow-up study and thirteen were included in a separate
analysis due to concerns about the uniformly significant results and the lack of dropout. The results of nine studies
providing primary data suggest that infant massage has no effect on growth, but provides some evidence suggestive of
improved mother-infant interaction, sleep and relaxation, reduced crying and a beneficial impact on a number of hormones
controlling stress. Results showing a significant impact on
1. Are the Results of the Study Valid? (Using the following sub-questions [a-e],
determine if the results of the study are valid and indicate your decision in the column to the right.) In the sub
questions below include notes (brief 2-3 sentences, not sections of article pasted in document) to explain your
choice and help you remember the information for later use. Use this model for all of the sections.
a.
b.
c.
Are the studies contained in the review randomized controlled
trials?
Yes, a total of 23 randomized controlled trials were included.
Does the review include a detailed description of the search
strategy to find all relevant studies?
Yes, two separate reviewers searched electronic databases for article
titles that included the inclusion criteria. If the abstracts did not
meet the inclusion criteria, they were not included.
Does the review describe how validity of the individual studies
was assessed (e.g., methodological quality, including the use of
random assignment to study groups and complete follow-up of
the subjects)?
Yes, the review only included studies in which participants had
Yes
Yes
Yes
Yes
Interventions for Maternal-Infant Bonding
d.
41
been randomized to either an infant massage group or a control
group that had no intervention.
Were the results consistent across studies?
No, the results were not consistent and the article admits this. 13 of
the trials were deemed bias and were therefore analyzed separately.
One study only reported follow up data. The remaining trials were
able to be combined, but only a small number of outcomes were
compared.
Were individual patient data or aggregate data used in the
analysis?
The results included aggregate data from every study
2. What are the Results?
e.
No
Yes
How large is the intervention or treatment effect (OR, RR, effect size, level of significance)?
a.
The treatment effect was reported as a mean difference of -0.76. The OR, RR, and level of
significance was not reported.
How precise is the intervention or treatment (CI)?
b.
There was a 95% confidence interval indicating that the researchers were 95% confident that the
true value of their research falls within the reported range.
3. Will the Results Assist Me in Caring for my Patients?
a.
b.
c.
d.
Are my patients similar to the ones included in the review?
Yes, the patients included in the study were babies under the age of
6 months. My patients will be newborns, therefore, my patients are
similar to the ones included in the review.
Is it feasible to implement the findings in my practice setting?
While there was some indication that infant massage positively
affected maternal-infant relationships, the exact efficacy could not
be proven. Due to this fact, it would not be feasible to implement
the findings of this review.
Were all clinically important outcomes considered, including
risks and benefits of the treatment?
Yes, both risks and benefits were considered. The review described
previously discovered benefits of infant massage such as weight
gain, increased activity levels, and decreased length of hospital
stays. The author concluded that more research was needed in order
to determine potential risks to other population groups but currently,
there is little risk to this intervention.
What is my clinical assessment of the patient and are there any
contradictions or circumstances that would inhibit me from
Yes
Yes
No
Yes
Yes
Interventions for Maternal-Infant Bonding
42
implementing the treatment?
Infant massage, as described in the article, is suitable for healthy
full-term infants. My patients would be healthy newborns. While
infant massage could prove beneficial to newborns with health
needs, this review only provides evidence of efficacy towards
healthy full-term infants.
What are my patient’s and his or her family’s preference and
values about the treatment that is under consideration?
This would have to be determined on a case-by-case basis. Infant
e.
Yes
massage is non-invasive and relatively safe when performed
correctly. Touch can be viewed as a very intimate therapy that some
parents may not want implemented with their newborn.
Summary Paragraph: Write a 1-2 paragraph summary, synthesizing the information from the
questions to support your decision regarding the usefulness of the evidence in your practice.
This systematic review included 23 randomized control trials from at least five separate databases. The
articles were chosen using certain inclusion criteria including: physically stable infants who were 6
months old or less, interventions that could be defined as tactile stimulation by human hands, and
infants that appeared to have no apparent physical health conditions. The review included a detailed
description of the search strategy and each trial was reviewed for it’s individual validity. One negative
aspect of the review was the fact that the results were not consistent across of all the studies. Overall, I
believe the review is still valid due to the fact that it took these consistencies into account in the data
analysis.
The results indicate there is a sizeable difference between the reported means of each intervention;
therefore, the results are inconsistent between each report. This also leads me to conclude that the
intervention is invalid.
While the findings are invalid, infant massage could still prove to be efficacious in the hospital setting.
If research can prove infant massage to be beneficial, it could easily and inexpensively taught to RN’s
in the post-partum setting. Implementing infant massage would need to be done on a case-by-case basis
as parental values regarding touch differ, but due to the relatively low risks, infant massage could still
be proven a beneficial intervention in newborns.
Modified from: © Fineout-Overholt & Melnyk, 2005. This form may be used for educational, practice change & research
purposes without permission.
Interventions for Maternal-Infant Bonding
43
Appendix H
Rapid Critical Appraisal: Systematic Reviews of Clinical Interventions/Treatments
Prepared by: Emily Frank
Citation:
Underdown, A., Barlow, J., & Stewart-Brown, S. (2010). Tactile stimulation in physically haelth
infants: results of a systematic review . Journal of Reproductive and Infant Psychology , 28(1),
11-29.
Abstract: Touch establishes powerful physical and emotional connections between infants and their
caregivers, and plays an essential role in development. The objective of this systematic review was to
identify published research to ascertain whether tactile stimulation is an effective intervention to
support mental and physical health in physically healthy infants. Twenty-two studies of healthy infants
with a median age of six months or less met our inclusion criteria. The limited evidence suggests that
infant massage may have beneficial effects on sleeping and crying patterns, infants’ physiological
responses to stress (including reductions in serum levels of norepinephrine and epinephrine, and
urinary cortisol levels), establishing circadian rhythms through an increase in the secretion of
melatonin, improving interaction between mother-infant dyads in which the mother is postnatally
depressed, and promoting growth and reducing illness for limited populations (i.e. infants in an
orphanage where routine tactile stimulation is low). The only other evidence of a significant impact of
massage on growth in infants living in families was obtained from a group of studies regarded to be at
high risk of bias which we have reported separately. There is no evidence of a beneficial effect on
infant temperament, attachment or cognitive development. There is, therefore, some evidence of
benefits on mother-infant interaction, sleeping and crying, and on hormones influencing stress levels.
In the absence of evidence of harm, these findings support the use of infant massage in the community,
particularly in contexts where infant stimulation is poor. Further research is needed, however, before it
will be possible to recommend universal provision.
1. Are the Results of the Study Valid? (Using the following sub-questions [a-e],
determine if the results of the study are valid and indicate your decision in the column to the right.) In the sub
No
questions below include notes (brief 2-3 sentences, not sections of article pasted in document) to explain your
choice and help you remember the information for later use. Use this model for all of the sections.
a.
b.
c.
Are the studies contained in the review randomized controlled
trials?
Studies were only included if infants were randomized into either a
tactile stimulation group or a control group that received no
intervention.
Does the review include a detailed description of the search
strategy to find all relevant studies?
A minimum of 5 separate databases was searched. Studies must
have matched certain inclusion criteria. These include: only healthy
full-term infants, infants age 6 moths or less, and infant message
defined as “systematic tactile stimulation by human hands”
Does the review describe how validity of the individual studies
was assessed (e.g., methodological quality, including the use of
random assignment to study groups and complete follow-up of
the subjects)?
Yes
Yes
No
Interventions for Maternal-Infant Bonding
While the article does describe how the studies were all randomized
control trials, it does not describe how the trials were randomized
nor does it include a complete follow up of the subjects.
Were the results consistent across studies?
No, the review states that the results are not consistent across all of
d. the studies. The article states “This variation, however, makes it
very difficult to identify the core components of effective massage
intervention.”
Were individual patient data or aggregate data used in the
e. analysis?
Aggregate data of all the studies were used in the analysis
2. What are the Results?
44
No
Yes
How large is the intervention or treatment effect (OR, RR, effect size, level of significance)?
a.
The review showed improvements in the intervention group based on three aspects of infant
interaction (attentiveness, liveliness, and happiness). The standardized mean difference was
reported for each aspect to represent the standard deviation between the sizes of each intervention
effect. They were reported as -1.31, -1.30, and -0.95 respectively. All three aspects were reported
with a 95% confidence interval. The OR, RR, and level of significance was not reported.
How precise is the intervention or treatment (CI)?
This review looked at three aspects of infant interaction including attentiveness, liveliness, and
happiness. The study showed a significant improvement in mother-infant interaction by using
coded video-recordings, the amount of warmth, and intrusiveness of maternal interactions in the
b. massage group.
The CI of attentiveness was -2.26 to -0.37, liveliness was -2.24-0.36, and happiness was -1.850.06.
The CI of coded video-recordings was documented as -2.27 to -0.38. Warmth and intrusiveness
was recorded as -3.27 to -1.07 and -1.87 to -0.08 respectively.
3. Will the Results Assist Me in Caring for my Patients?
Yes
a.
b.
c.
Are my patients similar to the ones included in the review?
Yes, the patients included in the review are younger than 6 months.
My patients will include mostly newborns, but this still fits within
the included patients.
Is it feasible to implement the findings in my practice setting?
Infant massage requires little training, no outside specialists, and is
relatively cost effective if it is included in the RN’s tasks.
Were all clinically important outcomes considered, including
risks and benefits of the treatment?
Yes, while infant massage has fairly few risks, the main risk
identified was that of experimental bias. Biased trials were
identified and eliminated as deemed appropriate. Trials were
assigned a quality category based on a standardized checklist. If
trials were found to have bias, they were not included in the review.
Yes
Yes
Yes
Interventions for Maternal-Infant Bonding
45
What is my clinical assessment of the patient and are there any
contradictions or circumstances that would inhibit me from
implementing the treatment?
Infant massage, as described in the article, is suitable for healthy
d.
Yes
full-term infants. My patients would be healthy newborns. While
infant massage could prove beneficial to newborns with health
needs, this review only provides evidence of efficacy towards
healthy full-term infants.
What are my patient’s and his or her family’s preference and
values about the treatment that is under consideration?
This would have to be determined on a case-by-case basis. Infant
e.
Unknown
massage is non-invasive and relatively safe when performed
correctly. Touch can be viewed as a very intimate therapy that some
parents may not want implemented with their newborn.
Summary Paragraph: Write a 1-2 paragraph summary, synthesizing the information from the
questions to support your decision regarding the usefulness of the evidence in your practice.
This article was also a systematic review of 23 randomized control trials regarding tactile stimulation
in health infants. While all of the studies were hand selected using certain inclusion and exclusion
criteria, there were a few aspects that lead to me to conclude the results were not valid. The review did
not mention the validity of the individual studies thus making it difficult to determine the validity of
the review in general. Furthermore, the results were not consistent across the 23 studies. Due to these
facts, I could not conclude that the intervention was valid.
The standard mean deviation (SMD) is simply the average of the means divided by one standard
deviation. These values are used to interpret the average standard deviation between the interventions.
Because the SMD’s are so close, it can be assumed that the results are objectively reliable.
Overall, the review did target my specific patient population and considered both risks and benefits to
this patient population. Infant massage is fairly easy and relatively inexpensive to practice in the
hospital setting. Although there were many strengths to this review, the lack of individual validity of
the 23 trials leads me to conclude that this review was not valid.
Modified from: © Fineout-Overholt & Melnyk, 2005. This form may be used for educational, practice change & research
purposes without permission.
Interventions for Maternal-Infant Bonding
46
Appendix I
Rapid Critical Appraisal: Descriptive Study (Exploratory, Comparative Survey, & Correlational)
Quantitative Study
Prepared by: Emily Frank
Citation:
Law Harrison, L., Leeper, J., Yoon, M., Lobo, M. L., & Harrison, M. J. (1991). Preterm infant’s
physiologic responses to early parent touch . Western Journal of Nursing , 13, 698-713.
doi:10.1177/019394599101300603
Abstract: Nurses working in neonatal intensive care units (NICUs) are concerned with promoting
parent-infant attachment and generally acknowledge the importance of encouraging parents to hold and
touch their infants. However, as a result of recent studies indicating that excessive handling may cause
hypoxia in preterm infants, many nurses are reluctant to encourage parents to touch their infants in the
NICU. Yet no previous studies have examined the specific effects of early parent touch on young
preterm infants’ physiologic responses to parental touch during NICU visits are influenced by their
gestational age, birth weight, gender, behavioral state, or morbidity status, by the use of supplemental
oxygen, by the amounts of tactile stimulation during the 2 hours preceding parent visits, or by the
amount of parent and nurse touch during visits. This study was part o a larger research project designed
to (a) describe the physical characteristics of touch use by parents in touching their preterm infants and
(b) determine the effects of parent touch on the heart rates and arterial oxygen saturation levels or
preterm infants. Other results from the larger study are reported elsewhere.
1. Are the Results of the Study Valid and Reliable? (Using the following subquestions [a-h], determine if the results of the study are valid and reliable and indicate your decision in the
column to the right.) In the sub questions below include notes (brief 2-3 sentences, not sections of article
pasted in document) to explain your choice and help you remember the information for later use. Use this
model for all of the sections.
a.
Is the research design appropriate for the research question/purpose
of the study?
According to Melnyk & Fineout-Overholt, “the purpose of descriptive
studies is to describe, observe, or document a phenomenon that can serve
as a foundation for developing hypotheses or testing theory.” (2011, p.
412). Due to this, I would say that this research design is appropriate
because the research aims to observe and document the “specific effects
of early parent touch on young preterm infants.”
No
Yes
Were the sampling methods suitable?
b.
The sampling method was not identified in the article.
Unknown
Was the sample size adequate?
c.
Because there is no power analysis to help determine the effective
sample size, I cannot make an assumption about the adequacy of the
sample size.
Unknown
Interventions for Maternal-Infant Bonding
d.
Was the setting(s) appropriate for the study?
Yes, the study was conducted in the NICU which housed the
infants.
Were the research variables operational defined?
Yes, the research variables were defined. These variables included: heart
e. rates, the amount of handling provided to the infant during the tow hours
preceding the parent visits, the amount of handling provided during the
visits, the severity of the infant’s medical complications, and the infant’s
gestational age.
1. Were the instrument(s) used to measure the outcomes valid and
reliable?
f.
Yes, this study utilized the six-category measure described by
Brazelton in order to assess the infant’s behavioral state. The
interrater reliability between the researcher and research assistant
was 100% when utilizing this tool.
The amount of handling provided to the infant during the 2 hours
preceding the parent visit was assess using the Quantity of Tactile
Stimulation Rating Scale (QTSRS) which was developed by the
researcher. Infants are rated on a 28 item scale and are given one
point every time they receive tactile stimulation. Interrater
reliability of the QTSRS was assessed periodically and ranged from
75% to 100%, with a mean of 87%.
The severity of the infant’s medical complications was assessed
with a revised version of the Neonatal Morbidity Scale (NMS). The
scale and it’s content validity was confirmed by two neonatologists,
two perinatal clinical nurse specialists, and one neonatal nurse
practitioner. The revised NMS consisted of 18 items, which were
rated on a three point scale. Higher scores indicated more serious
complications. Interrater reliability of the revised NMS ranged from
83% to 100% with an average of 98%.
Neonatologists in the study NICU assessed the infant’s gestational
age using the Ballard Assessment tool.
g.
Were the statistics appropriate?
Yes, the instruments measured heart rate and O2 saturation in response to
tactile stimulation
h.
Were the study limitations identified and discussed?
Yes, the study limitations were identified. For the purpose of the study,
O2 saturations levels less than 90% and heart rates less than 100 or greater
than 200 beats per minute were considered abnormal
47
Yes
Yes
Yes
Yes
Yes
2. What are the Results?
a.
Are the results logical, consistent, and easy to follow?
Yes, the results were logical and followed an easy to read structure.
All findings were appropriately defined and elaborated on.
Yes
Interventions for Maternal-Infant Bonding
48
Was the interpretation/analysis of the results accurate?
b.
c.
Yes, the article acknowledges the statistical findings under the context
that extraneous variables were present and may have had undue influence
on the results. The author’s concluded that only 7 of the 9 variables of
infant response were reliable and/or significant for interpretation.
Are the conclusion/implications logically presented?
Yes, each variable is described in succession in order to adequately and
logically make a conclusion upon each.
Yes
Yes
3. How are the results applicable to your patients?
1. Are my patients similar to the ones included in this study?
a.
No, the patients in study were all preterm infants being cared for in
the NICU. My target patient population would be healthy newborn
infants.
No
2. Are the results applicable to my patients?
b.
Due to all the variable conditions that could accompany preterm
infants, the information presented in the article could not be
assumed to pertain to healthy infants without further study.
No
3. Are the conclusions appropriate to my patient population?
c.
Further studies about the implications of tactile stimulation in
healthy newborn infants would be necessary in order to apply the
information to my patient population.
No
4. Do the results inform my practice to improve patient, provider
and/or system outcomes?
d.
The results inform me about current evidence towards the efficacy
Yes
of tactile stimulation with pre-term infants and inform my practice
towards this population, but this information cannot be applied to
my current patient population.
Summary paragraph: Write a 1-2 paragraph summary, synthesizing the information from the questions
to support your decision regarding the usefulness of the evidence in your practice.
I cannot conclude this review to be valid and/or reliable due to the amount of information that was
undisclosed in the article. While the research design and setting was appropriate, the sample size and
sample method was poorly described. The research variables were defined and the measurement tools
were defined and supported by reliability statistics.
The major problem with utilizing this evidence was due to the fact that my target population is
significantly different than the population recognized in the review. This study focused on 32 preterm
infants who ranged from 25 to 33 weeks gestation. Preterm infants have many extraneous variables that
could affect the outcome of this trial. Due to this fact, I am hesitant to apply this information in practice
with healthy term newborn infants.
Interventions for Maternal-Infant Bonding
49
Overall, this article does not provide enough clarity regarding the validity and reliability of the tools
utilized or the statistics presented. Secondly, the patient population does not closely match the target
population. Due to these aspects, I would not be compelled to apply this evidence to my practice.
Interventions for Maternal-Infant Bonding
50
Appendix J
Evaluation Table
Developed by: Emily Frank
Source 1
Underdown, A.,
Citation:
Barlow, J., Chung, V.,
& Stewart-Brown, S.
(2009). Massage
intervention for
promoting mental and
physical health in
infants aged six
months (review). The
Cochrane Library , 138.
Design/Method:
Indicate design
Briefly state what was
done
in study
Study Design:
Systematic Review
“A systematic review
is a compilation of
similar studies that
address a specific
clinical question”
(Melnyk & FineoutOverholt, 2011, p.
121).
Summary: 23 studies
were included in this
review. According to
the article infant
massage is becoming
more popular in the
community for the
low-risk babies and
their primary care
givers. Some early
research suggests that
infant massage
provides benefits for
sleep, respiration,
elimination and the
reduction of colic and
wind. It is also thought
that infant massage
may reduce infant
stress and promote
Source 2
Underdown, A.,
Barlow, J., & StewartBrown, S. (2010).
Tactile stimulation in
physically health
infants: results of a
systematic review .
Journal of
Reproductive and
Infant Psychology ,
28(1), 11-29.
Source 3
Law Harrison, L.,
Leeper, J., Yoon, M.,
Lobo, M. L., &
Harrison, M. J. (1991).
Preterm infant’s
physiologic responses
to early parent touch .
Western Journal of
Nursing , 13, 698-713.
doi:10.1177/019394599
101300603
Study Design:
Systematic Review
Study Design:
Correlational Predictive
Study
The purpose of a
correlation predictive
study is to examine the
relationship between
two or more variables
when the independent
variable cannot be
manipulated (Melnyk &
Fineout-Overholt,
2011, p. 405).
Summary: This study
aimed to evaluate the
response of 32 preterm
infants, who were
hospitalized in the
NICU, to stimulation
provided during regular
parent visits. Heart
rates and oxygen
saturation were
measured in response to
tactile stimulation.
Furthermore, the
amount of handling
provided to the infant
during the two hours
preceding the parent
Summary: A
systematic review and
meta-analysis, which
involved a search of
multiple databases that
had addressed the
effectiveness of tactile
stimulation in
physically healthy
infants. Included
studies must have
utilized standardized
outcome measure of
infant mental or
physical development.
Researchers reviewed
titles and abstracts for
eligibility.
Interventions for Maternal-Infant Bonding
51
positive parent-infant
interactions. This
study aimed to
appraise the current
evidence regarding the
benefits of infant
massage in healthy
infants less than 6
months old.
Sample & Setting:
Number, characteristics
Attrition rate & why
Sample:
Approximately 17
databases were
searched with certain
inclusion criteria in
order to obtain the
articles included in
this systematic review.
There were 23 studies
included in total.
Studies were included
if participants had
been randomized to
either an infant
massage group or a
control group that
received no
intervention. The
review also included
quasi-randomized
study designs. Only
studies that focused on
healthy infants aged 6
months or less were
included. Any studies
that include preterm or
low birth-weight
babies were excluded
from the review.
Several studies
reported no dropout or
attrition. The
remaining studies all
reported some
dropout.
Sample: 23
randomized control
trials appraising the
effects of infant
massage. Studies of
stable infants with a
median age of 6
months or less were
included. Infant
massage was defined
as “systematic tactile
stimulation by human
hands.”
Attrition Rate:
Attrition rates were
available through the
individual trial
sources, but not the
systematic review
itself.
visit, the amount of
handling provided
during the visits, the
severity of the infant’s
medical condition, and
the infant’s gestational
age were all measured
by both the researcher
and an assistant using
separate measurement
tools.
Sample: 32 preterm
infants and their
parents. Infants ranged
from 25 to 33 weeks
gestational age at birth
and their birth weights
ranged from 752 to
2080 grams. The
sample included 14
male and 18 females. 9
infants were white and
23 were black.
Setting: an undisclosed
NICU in the southern
United States
Attrition Rate: An exact
attrition rate was not
given but the article did
state that due to
scheduling conflicts, of
the infant sample, 18
infants were videotaped
during three visits, five
were taped during two
visits, and nine were
videotaped during only
one visit. Thus the data
were collected on 73
different visits to the 32
infants.
Interventions for Maternal-Infant Bonding
52
Variables &
Definitions:
IV
DV
Independent variables:
Healthy full term
infants aged 6 months
or less
Dependent variables:
infant-adult
interaction, growth
monitoring, infant
mental health
Independent variables:
Physically stable
infants with a median
age of 6 months or less
Dependent variables:
weight, sleep, crying,
hormones
Measurement:
What scales were used
to measure the
outcome variables
(e.g. name of scale,
author, and reliability
info (e.g., Cronbach
alphas)
Scales:
Trials were assigned a
quality category based
on allocation
concealment because
of the potential for
bias where allocation
was not concealed.
Categories were
defined according to
the Cochrane
Collaboration
Handbook.
One study measured
impact of massage on
mother-infantinteraction using
global ratings of
interactions and
indicated a significant
difference favoring the
intervention group.
Another study utilized
the Bayley Scale of
Infant Development to
evaluate the impact of
infant massage on
psychomotor
development.
One study measured
infant attachment at 1year sing the
Scales:
Trials were assigned a
quality category based
on allocation
concealment. A
modified version of
the Critical Appraisal
Skills Program was
used as a checklist to
assess the quality of
other aspects of the
study that may cause
bias. These aspects
include: sample size,
number of infants lost
to follow up, the
method of dealing
with attrition/drop out,
use of blinding to
assess outcomes, and
whether there was any
assessment of the
distribution of
confounders.
Independent variables:
Preterm infants
Dependent variables:
heart rate, oxygen
saturation, the amount
of handling provided to
the infant during the
two hours preceding the
parent visits, the
amount of handling
provided during the
visits, and the severity
of the infant’s medical
complications.
Scales:
Quantity of Tactile
Stimulation Rating
Scale (QTSRS)- This
scale was developed by
the researcher and
consists of 28 tactile
stimuli items. There
was a reported
interrater reliability of
100%.
Neonatal Morbidity
Scale (NMS)- This
study utilized a revised
version of this scale
originally written by
Minde, Whitelaw,
Brown, & Fitzhardinge.
Two neonatologists,
two perinatal clinical
nurse specialists, and
one neonatal nurse
practitioner confirmed
the content validity.
The tool consisted of 18
items that are rated on a
three-point scale. The
interrater reliability was
reported as a range of
83% to 100% with an
average of 98%.
The Ballard Gestational
Interventions for Maternal-Infant Bonding
53
attachment Q-set.
The review did not
define/describe an of
the measurement tools
nor did it give
interrater reliability for
any of the scales.
Data Analysis:
Statistical significance
Clinical importance
Findings:
Statistical findings or
qualitative findings
Weighted and
standardized mean
differences and a 95%
confidence interval
were reported.
Clinical importanceInfant massage is
increasingly apparent
in the community
health setting. It has
been suggested that
infant massage
promote positive
mother-infant
relationships.
The results of this
review suggest that
infant massage may
have beneficial effects
but findings were
obtained from a very
small number of
Tool was also utilized
but no further
information was given.
Statistical significance:
For continuous
variables, the review
reports a weighted
mean difference with
95% confidence
intervals. In cases were
data scales are
incompatible, the
review presents the
standardized mean
difference and 95%
confidence intervals.
When it was not
possible to synthesize
data, effect sizes and
95% confidence
intervals were
calculated for
individual outcomes in
each study.
Clinical importance:
Infant massage has
been reported to
provide benefits to
maternal-infant
relationships. By
appraising the
evidence, it may be
possible to support this
assertion.
A British study
showed improvements
in three aspects of
infant interaction:
attentiveness,
liveliness, and
happiness. The study
Statistical significance:
A .05 level of
significance was used
Clinical importance:
Infant massage has not
only been suggested as
beneficial in healthy
infants, but premature
infants as well. This
study aims to identify
these benefits.
Few abnormal heart
rate values were noted
during the study and
there were no
differences in mea heart
rate or percentage of
abnormal heart rates
Interventions for Maternal-Infant Bonding
Appraisal - Worth to
Practice:
Strengths/Limitations
Risk/harm
Feasibility for my
practice
Impact on My Practice
54
studies and no metaanalysis was possible
for these outcomes.
also showed
significant
improvement in
mother-infant
interaction using
coded video
recordings.
Strengths: One
strength noted by the
authors is that this
review noted little to
no risk. In the absence
of harm, the findings
provide tentative
evidence to support
infant massage in the
community setting
Limitations: The
authors decided after
further appraisal that
13 studies needed to
be analyzed separately
from the other studies
due to concerns about
the uniformly
significant results,
inadequate
information about the
design and conduct of
Strengths: Trials were
assigned a quality
category based on
allocation
concealment. A
modified version of
the Critical Appraisal
Skills Program was
used as a checklist to
assess the quality of
other aspects of the
study that may cause
bias. These aspects
include: sample size,
number of infants lost
to follow up, the
method of dealing
with attrition/drop out,
use of blinding to
assess outcomes, and
whether there was any
assessment of the
between baseline,
parent touch, and post
visit periods, four of the
independent variables
predicted infants’ hear
rate responses to parent
touch. The amount of
prior handling, birth
weight, and amount of
nurse touch accounted
for 23% of the variance
in mean heart rate.
Infants who had
received more handling
prior had lower mean
heart rates and lower
percentage of abnormal
hear rate values which
was unexpected
because previous
studies suggested that
increased handling is
associated with
increased distress.
Strengths: The
strengths of the study
were not reported.
Limitations: It was not
possible to control all
of the extraneous
variables that could
have possibly
influenced the infant’s
physiological response
to parent touch.
Feasibility: This study
would not be feasible
for me to implement in
my practice. The cost
and specialists needed
would be too great.
Impact: This study
serves as background
evidence for possible
future studies for my
practice.
Interventions for Maternal-Infant Bonding
Confidence to Act:
Level of evidence
Quality of evidence
Strength of evidence
55
these studies, and the
reported absence of
any dropout.
Considerable
statistical
heterogeneity was
noted even after taking
account of individual
results. Do to this, the
results of the studies
must be applied
cautiously.
Feasibility: Due to the
large size of this
review, it required a
lot of time for the
researchers to compile.
While it did consume a
large amount of time,
there were adequate
sources available to
the researchers. For an
organization able to
conduct large reviews,
this would be a
feasible review. For
my purposes as a
student, it would not
be feasible for me to
implement.
Impact: This study
served as an overview
of the relevant
evidence related to
healthy infants and the
effects of infant
massage.
Level of evidence:
Level I Qualitative
Evidence
distribution of
confounders.
Level of evidence:
Level I Qualitative
Evidence
Level of evidence:
Level VI Qualitative
Evidence
Quality of Evidence: I
found this source to be
both valid and
applicable to my
patient population.
Quality of Evidence: I
found this source to be
applicable to my target
patient population, but
ultimately, I
Quality of Evidence: I
determined that this
source was neither
reliable more valid.
There was too much
Limitations: The
review did not include
the limitations.
Feasibility: Again, due
to the large size of this
review, it required a
lot of time for the
researchers to compile.
While it did consume a
large amount of time,
there were adequate
sources available to
the researchers. For an
organization able to
conduct large reviews,
this would be a
feasible review. For
my purposes as a
student, it would not
be feasible for me to
implement.
Impact: This study
served to overview the
relevant evidence
related to the
beneficial effects of
infant massage.
Interventions for Maternal-Infant Bonding
I concluded that this
source
Strength of Evidence:
95% CI
Decision:
Keep for use
Background only
Discard
Decision: Keep for use
Because I found this
systematic review to
be valid and reliable, I
would keep it for use
in my current practice.
56
determined that the
results were invalid
and therefore should
not be applied to my
practice.
Strength of Evidence:
95% CI
Decision: Background
Only
Due to the fact that I
found this review to
have invalid
information, I would
keep it for background
reference only. It did
contain many reliable
aspects, but certain
features lacked
reliability and
therefore I cannot keep
it for use in practice.
missing data in order to
conclude otherwise.
Strength of Evidence:
95% CI
Decision: Background
Only
Because this was a
descriptive study, and
therefore is a low level
of evidence, I would
not use this information
to apply evidence into
practice. Although, I
would keep it as
background
information because it
still contains valid and
reliable information.
Interventions for Maternal-Infant Bonding
57
Appendix K
Individual Participation in Team Assignment
Name: Laura Wiegand
Name: Emily Frank
Contributions to this portion of the assignment
(Include your participation in gathering,
interpreting, synthesizing, and evaluating the
evidence as well as the written assignment or
oral presentation)
Contributions to this portion of the assignment
(Include your participation in gathering,
interpreting, synthesizing, and evaluating the
evidence as well as the written assignment or
oral presentation)
First, I participated in this project by selecting
a mutual topic of interest with Emily. After
choosing the topic of maternal-infant bonding,
we started contemplating nursing interventions.
Kangaroo care became the main idea of my
PICOT question.
I participated in this assignment by working
with Laura to choose a topic of interest. It took
us a long time to decide on a topic because we
wanted to choose a topic that was interesting to
us if we were going to have to work on it for a
whole semester. Once we decided on a topic,
we set out to try and find some articles that
would fit our PICO. After much research, we
decided that breast-feeding was not a nursing
intervention, and therefore altered our PICO to
include infant massage instead. After
solidifying the topic and PICO, I wrote my
individual paper identifying the background
information.
I searched the AHRQ, Cochrane, CINAHL,
and PubMed databases in order to find articles
that described studies relevant to my PICOT. I
chose multiple articles to review. Then, I
assured that the three articles that I chose were
considered higher levels of evidence.
I then completed Rapid Critical Appraisal
forms for each article. After completing the
Rapid Critical Appraisal forms for
Randomized Control Trials, I was able to
develop summarizations of the information
gathered from these studies.
Finally, I contributed to the creation of the
introduction, the body, and the conclusion of
the paper. I included my references on the
combined reference page and I contributed to
the self-evaluation at the end of the paper.
For part two of the paper, I researched multiple
databases including: CINAHL, PubMed, Med
Line, AHRQ, Cochrane Library, and Ebsco
Host. Once I began the paper, I ended up
choosing new articles because my original
choices did not fit the requirements of the
assignment. I wrote my three RCA appendixes
and evaluation table on my own. Once this was
completed, Laura and I met to work on the
introduction, conclusion, and rubric together.
Interventions for Maternal-Infant Bonding
58
Interventions for Maternal-Infant Bonding
59