Post-discharge responsive parenting programmes

Authors

Flierman M, Jeukens-Visser M, Huening B, Wolke D, Okay I, Pierrat V

Target group

Infants born very preterm or those infants with risk factors (see preamble Follow-up & continuing care), parents and their families

User group

Healthcare professionals, neonatal units, hospitals, follow-up teams, and health services

Statement of standard

All very preterm born infants or infants with risk factors and their families are offered preventive responsive parenting support after discharge home.

Rationale

The strong influence of early experience and environmental influences on brain architecture makes the first years of life a period of both opportunity and vulnerability for development.(1)

Particularly, the consistency of responsive interactions between children and their parents is of pivotal influence: consisting of understanding the behavioural cues and developmental needs of the infant and offering the adequate responsive support.

Very preterm birth effects brain development and has adverse developmental consequences. (2) In very preterm parent-infant dyads, difficulties in responsive interactions may easily occur. At home, the infants may have more feeding and sleeping difficulties and/or experience more stress and disorganisation, causing the infants to be less responsive and explorative. (3) The interaction problems may be bidirectional, as risk factors like depression or chronic stress are more common in parents of preterm infants and may impede the parental neurobiological and psychological changes that support responsive parenting under normal conditions. (4,5) Consequently, very preterm infants may need more sensitive/responsive parenting, at a time when the parents themselves are often under additional stress.

The first postnatal year offers a window of opportunity, because at this early stage, the brains of both the preterm infant and parent are particularly receptive to interventions that address responsive parenting. (2,5,6)Therefore, supporting both parents and infants as well as the parent-infant relationship is recommended (‘two generation approach’) to enhance very preterm infant developmental opportunities. (7–9) Examples of responsive parenting programs that improve development during infancy and preschool age are the IBAIP, MITP or VIBES. (10–12)

Benefits

Short-term benefits

N/A

Long-term benefits

Improved motor and cognitive development, behaviour, self-regulation, and wellbeing (8,9,13–19)
Less referral for paramedical support (20)
Improved health, sleeping, eating and early communication between infant and parent (consensus)
Improved parental wellbeing and parent-child interactions (8,14,21–23)
Less parenting stress (15,19)
Improved satisfaction with care (20,24)

Components of the standard

Component

Grading of evidence

Indicator of meeting the standard

For parents and family

Parents are informed by healthcare professionals about responsive parenting support in the first year after discharge. (25–29)

A (High quality)
B (High quality)

Patient information sheet¹

Important components of intervention programs are support for infant development, the parent-infant relationship, and parent support. (9,17,23,30,31)

A (High quality)

Guideline, parent feedback

Intervention to support the parent-infant relationship may start in hospital or in the home environment (see Infant- & family-centred developmental care). (1,17,25–29)

A (High quality)

Guideline

Parents contribute to reports of developmental progress as equal partners with healthcare professionals.

B (Moderate quality)

Clinical records, parent feedback

Both mothers and fathers of very preterm infants are targeted and engaged in intervention. (2,31)

B (Moderate quality)

Clinical records, parent feedback

For healthcare professionals

A guideline on early post-discharge responsive parenting programmes is adhered to by all healthcare professionals.

B (High quality)

Guideline

Continuous professional development in a responsive parenting programme, based on evidence or best practice is attended by all responsible healthcare professionals.(11,25–29,32)

A (High quality)
B (High quality)

Training documentation, training records

For neonatal unit, hospital, and follow-up team

A guideline on early post-discharge responsive parenting programmes is available and regularly updated.

B (High quality)

Guideline

Continuous professional development in a responsive parenting programme, based on evidence or best practice is ensured. (11,25–29,32)

A (High quality)
B (High quality)

Training documentation

For health service

A national guideline on early post-discharge responsive parenting programmes is available and regularly updated.

B (High quality)

Guideline

Appropriate funding for early post-discharge responsive parenting programmes is provided.(20,25–29)

A (Moderate quality)
B (High quality)

Audit report²

Uptake and parental satisfaction of early post-discharge responsive parenting programmes is monitored. (20)

A (Moderate quality)
B (High quality)

Audit report²

¹The indicator ‘patient information sheet’ is an example for written, detailed information, in which digital solutions are included, such as web-based systems, apps, brochures, information leaflets, and booklets.

²The indicator ‘audit report” can also be defined as a benchmarking report.

Where to go

Further development

Grading of evidence

For parents and family

Consider post discharge parenting programmes for other vulnerable groups of children, starting with moderately preterm infants.(25–29)

B (High quality)

For healthcare professionals

Consider extensions of evidence-based post-discharge intervention programmes at other critical periods in the development of a preterm child.(25–29,33,34)

A (Moderate quality)
B (High quality)

For neonatal unit, hospital, and follow-up team

Include a minimum dataset in the follow-up programmes to better assess the impact of post-discharge intervention programmes. (20)

B (Moderate quality)

For health service

Encourage studies that develop more individualised responsive parenting programmes. (30)

B (Moderate quality)

Consider developing web-based interventions or e-health applications, to overcome the barrier of access. (31,36,37)

Getting started

Initial steps

For parents and family

Parents receive information about the impact of prematurity and practical guidance for supporting their infant’s needs.
Parents are informed by healthcare professionals about anticipatory guidance on the transition to parenthood and are asked about their own wellbeing.

For healthcare professionals

Attend training on preterm child development and long-term impact of preterm birth, parenting influences, and responsive parenting.
Develop networks for services and interventions.

For neonatal unit, hospital, and follow-up team

Develop and implement a guideline on follow-up and continuing care including responsive parenting programmes for parents of very preterm infants.
Develop tailored information material for parents to support positive responsive parenting and the first period at home.
Assess the availability of post-discharge intervention programmes and create a network to support parents.
Support healthcare professionals to participate in training on preterm child development, and long-term impact of preterm birth, parenting influences, and responsive parenting.
Ensure appropriate healthcare professionals have extra time and knowledge needed to support parents and infants in responsive parenting programmes.

For health service

Develop and implement a national guideline on follow-up and continuing care including responsive parenting programmes for parents of very preterm infants.
Raise awareness about the critical early years for infant development, and the need to give positive support to parents of preterm born children.
Encourage health systems to invest in development of and training in responsive parenting interventions.

Key features of programmes to support parenting are:

Increasing parental responsiveness:

Parents are engaged to interact with their infant. During joint observations, the interventionist supports the parents to understand the behavioural cues of their very preterm infant and seek an adequate response.

Providing information:

Knowledge about infant development is known as a strong protective factor. Strengthening parental understanding of environmental influences on early brain development, providing inspiring information on the infant’s small next steps may help parents in their mediating task
In addition, knowledge of the sensitive periods in brain development and the infant’s developmental trajectory enables parents to support their child’s age-specific development and needs at any time in order to thrive in an optimal way.

Parents are supported through ‘strength-based’ intervention suggestions.

Responsive parenting programmes that have a strength-based approach focus on reinforcing the strengths and resources that already exist in the infant and parent. A positive approach helps parents to respect and enjoy their child’s behavioural efforts and skills, and gives the satisfaction to be able to help their child; it may support parental self-efficacy and confidence in themselves and their child.

Parent support:

Information about the transition to parenthood and psycho-education during the sensitive period of the neurobiological transition to parenthood may enhance a positive feed-forward loop: parental wellbeing supports parents’ sensitivity and responsive interactions, which is reflected in more structural growth and activity in the reward and motivational circuits in their brain. This appears significant, as these changes are also associated with more sensitive and caring maternal and paternal behaviours.

1. Timing_Quality_Early_Experiences-1.pdf [Internet]. [cited 22 June 2018]. Available: http://developingchild.harvard.edu/wp-content/uploads/2007/05/Timing_Quality_Early_Experiences-1.pdf
2. Inder TE, Volpe JJ, Anderson PJ. Defining the Neurologic Consequences of Preterm Birth. N Engl J Med. 3. August 2023;389(5):441–53.
3. Bilgin A, Wolke D. Regulatory Problems in Very Preterm and Full-Term Infants Over the First 18 Months. J Dev Behav Pediatr JDBP. Mai 2016;37(4):298–305.
4. Pace CC, Spittle AJ, Molesworth CML, Lee KJ, Northam EA, Cheong JLY, u. a. Evolution of Depression and Anxiety Symptoms in Parents of Very Preterm Infants During the Newborn Period. JAMA Pediatr. 1. September 2016;170(9):863–70.
5. Spittle A, Treyvaud K. The role of early developmental intervention to influence neurobehavioral outcomes of children born preterm. Semin Perinatol. 2016;40(8):542–8.
6. Treyvaud K, Thompson DK, Kelly CE, Loh WY, Inder TE, Cheong JLY, u. a. Early parenting is associated with the developing brains of children born very preterm. Clin Neuropsychol. Juli 2021;35(5):885–903.
7. Shonkoff JP, Fisher PA. Rethinking evidence-based practice and two-generation programs to create the future of early childhood policy. Dev Psychopathol. November 2013;25(4 Pt 2):1635–53.
8. Puthussery S, Chutiyami M, Tseng PC, Kilby L, Kapadia J. Effectiveness of early intervention programs for parents of preterm infants: a meta-review of systematic reviews. BMC Pediatr. 9. Juli 2018;18(1):223.
9. Herd M, Whittingham K, Sanders M, Colditz P, Boyd RN. Efficacy of preventative parenting interventions for parents of preterm infants on later child behavior: a systematic review and meta-analysis. Infant Ment Health J. 2014;35(6):630–41.
10. Koldewijn K, Wolf MJ, van Wassenaer A, Meijssen D, van Sonderen L, van Baar A, u. a. The Infant Behavioral Assessment and Intervention Program for very low birth weight infants at 6 months corrected age. J Pediatr. Januar 2009;154(1):33-38.e2.
11. Nordhov SM, Rønning JA, Dahl LB, Ulvund SE, Tunby J, Kaaresen PI. Early intervention improves cognitive outcomes for preterm infants: randomized controlled trial. Pediatrics. November 2010;126(5):e1088-1094.
12. Spittle AJ, Anderson PJ, Lee KJ, Ferretti C, Eeles A, Orton J, u. a. Preventive care at home for very preterm infants improves infant and caregiver outcomes at 2 years. Pediatrics. Juli 2010;126(1):e171-178.
13. Van Hus J, Jeukens-Visser M, Koldewijn K, Holman R, Kok JH, Nollet F, u. a. Early intervention leads to long-term developmental improvements in very preterm infants, especially infants with bronchopulmonary dysplasia. Acta Paediatr Oslo Nor 1992. Juli 2016;105(7):773–81.
14. Landsem IP, Handegård BH, Ulvund SE, Kaaresen PI, Rønning JA. Early intervention influences positively quality of life as reported by prematurely born children at age nine and their parents; a randomized clinical trial. Health Qual Life Outcomes [Internet]. 22. Feb 2015;13. Available: https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4343051/
15. Wu YC, Hsieh WS, Hsu CH, Chang JH, Chou HC, Hsu HC, u. a. Intervention effects on emotion regulation in preterm infants with very low birth weight: A randomize controlled trial. Res Dev Disabil. Januar 2016;48:1–12.
16. Olafsen KS, Rønning JA, Handegård BH, Ulvund SE, Dahl LB, Kaaresen PI. Regulatory competence and social communication in term and preterm infants at 12 months corrected age. Results from a randomized controlled trial. Infant Behav Dev. Februar 2012;35(1):140–9.
17. Orton J, Doyle LW, Tripathi T, Boyd R, Anderson PJ, Spittle A. Early developmental intervention programmes provided post hospital discharge to prevent motor and cognitive impairment in preterm infants. Cochrane Database Syst Rev. 13. Februar 2024;2(2):CD005495.
18. Stedall PM, Spencer-Smith MM, Mainzer RM, Treyvaud K, Burnett AC, Doyle LW, u. a. Thirteen-Year Outcomes of a Randomized Clinical Trial of Early Preventive Care for Very Preterm Infants and Their Parents. J Pediatr. Juli 2022;246:80-88.e4.
19. Patronick J, Glazer S, Sidol C, Parikh NA, Wade SL. Parenting Interventions Targeting Behavior for Children Born Preterm or Low Birth Weight: A Systematic Review. J Pediatr Psychol. 29. August 2023;48(8):676–87.
20. Jeukens-Visser M, Koldewijn K, van Wassenaer-Leemhuis AG, Flierman M, Nollet F, Wolf MJ. Development and nationwide implementation of a postdischarge responsive parenting intervention program for very preterm born children: The TOP program. Infant Ment Health J. Mai 2021;42(3):423–37.
21. Landsem IP, Handegård BH, Tunby J, Ulvund SE, Rønning JA. Early intervention program reduces stress in parents of preterms during childhood, a randomized controlled trial. Trials. 4. Oktober 2014;15:387.
22. Girabent-Farrés M, Jimenez-Gónzalez A, Romero-Galisteo RP, Amor-Barbosa M, Bagur-Calafat C. Effects of early intervention on parenting stress after preterm birth: A meta-analysis. Child Care Health Dev. Mai 2021;47(3):400–10.
23. Benzies KM, Magill-Evans JE, Hayden K, Ballantyne M. Key components of early intervention programs for preterm infants and their parents: a systematic review and meta-analysis. BMC Pregnancy Childbirth. 2013;13(Suppl 1):S10.
24. Øberg GK, Sørvoll M, Labori C, Girolami GL, Håkstad RB. A systematic synthesis of qualitative studies on parents’ experiences of participating in early intervention programs with their infant born preterm. Front Psychol. 13. Juli 2023;14:1172578.
25. Scribd [Internet]. [cited 22. Juni 2018]. The Importance of caregiver-child interactions for the survival and healthy development of young children | Attachment Theory | Caregiver. Available: https://www.scribd.com/document/117815507/The-Importance-of-caregiver-child-interactions-for-the-survival-and-healthy-development-of-young-children
26. March of Dimes, PMNCH, Save the Children, WHO. Born Too Soon: The Global Action Report on Preterm Birth. [Internet]. World Health Organization; 2012. Available: http://www.who.int/pmnch/media/news/2012/201204_borntoosoon-report.pdf
27. For_every_child_a_fair_chance.pdf [Internet]. [cited 22. Juni 2018]. Available: https://www.unicef.org/publications/files/For_every_child_a_fair_chance.pdf
28. Building-Core-Capabilities-for-Life.pdf [Internet]. [cited 22. Juni 2018]. Available: https://46y5eh11fhgw3ve3ytpwxt9r-wpengine.netdna-ssl.com/wp-content/uploads/2016/03/Building-Core-Capabilities-for-Life.pdf
29. Britto PR, Lye SJ, Proulx K, Yousafzai AK, Matthews SG, Vaivada T, u. a. Nurturing care: promoting early childhood development. The Lancet. 7. Januar 2017;389(10064):91–102.
30. Ferreira DLS, Williams DM, Kangas AJ, Soininen P, Ala-Korpela M, Smith GD, u. a. Association of pre-pregnancy body mass index with offspring metabolic profile: Analyses of 3 European prospective birth cohorts. PLOS Med. 22. August 2017;14(8):e1002376.
31. Anderson PJ, Treyvaud K, Spittle AJ. Early developmental interventions for infants born very preterm – what works? Semin Fetal Neonatal Med. Juni 2020;25(3):101119.
32. Koldewijn K, van Wassenaer A, Wolf MJ, Meijssen D, Houtzager B, Beelen A, u. a. A neurobehavioral intervention and assessment program in very low birth weight infants: outcome at 24 months. J Pediatr. März 2010;156(3):359–65.
33. Landry SH, Smith KE, Swank PR, Guttentag C. A Responsive Parenting Intervention: The Optimal Timing Across Early Childhood For Impacting Maternal Behaviors And Child Outcomes. Dev Psychol. September 2008;44(5):1335–53.
34. Flierman M, Koldewijn K, Meijssen D, van Wassenaer-Leemhuis A, Aarnoudse-Moens C, van Schie P, u. a. Feasibility of a Preventive Parenting Intervention for Very Preterm Children at 18 Months Corrected Age: A Randomized Pilot Trial. J Pediatr. September 2016;176:79-85.e1.
35. From_Best_Practices_to_Breakthrough_Impacts-4.pdf [Internet]. [cited 22. Juni 2018]. Available: https://46y5eh11fhgw3ve3ytpwxt9r-wpengine.netdna-ssl.com/wp-content/uploads/2016/05/From_Best_Practices_to_Breakthrough_Impacts-4.pdf
36. Treyvaud K, Eeles AL, Spittle AJ, Lee KJ, Cheong JLY, Shah P, u. a. Preterm Infant Outcomes at 24 Months After Clinician-Supported Web-Based Intervention. Pediatrics. 1. Oktober 2022;150(4):e2021055398.
37. Garfield CF, Kerrigan E, Christie R, Jackson KL, Lee YS. A Mobile Health Intervention to Support Parenting Self-Efficacy in the Neonatal Intensive Care Unit from Admission to Home. J Pediatr. Mai 2022;244:92–100.