Connected: Preterm Infant Program Makes Progress

Kelly Ragan

October 17, 2022

Martha Welch, MD, spent the better part of three decades in private practice treating children with emotional, behavioral, and developmental disorders before accepting a job on the faculty of Columbia University in New York City in 1997.

Dr Martha Welch

She took the position, she said, with a mission: to find evidence to support what she'd observed in her practice — that parents could, by making stronger emotional connections, change the trajectory of development for preemie infants.

With that understanding, Welch created Family Nurture Intervention (FNI), which has been shown to improve the development of premature babies.

"We saw that no matter what happened to the baby, no matter how avoidant the baby might be, we're able to overcome this with emotional expression," said Welch, who is now a professor of psychiatry at Columbia University Medical Center.

Over the course of the intervention, families work with a specialist who helps bring mother and baby together — both physically and emotionally — until both are calm, which can initially take several hours and over time, minutes.

FNI appears to help families — especially mothers — re-establish an emotional connection often interrupted by their babies' stressful and uncertain stay in a neonatal intensive care unit (NICU). In turn, both the infant and maternal nervous systems become better regulated, according to researchers.

Early Challenges

Babies born preterm can face a range of short-term and long-term challenges such as breathing problems due to an underdeveloped respiratory system, an increased risk of infection from an underdeveloped immune system, and learning difficulties, according to the Mayo Clinic.

Many aspects of FNI are not new: The neonatal intensive care unit has long incorporated activities such as scent cloth exchanges, talking to the baby, and skin-to-skin contact. But the approach Welch and her colleagues advocate emphasizes building a bond between the mother and the infant.

Mounting evidence shows that FNI can improve a wide range of outcomes for premature babies. In a 2021 study, for example, Welch's group showed that FNI was associated with lower heart rates among preemies in the NICU. A 2016 study linked the intervention to reduced depression and anxiety symptoms in mothers of preterm infants. And a 2015 randomized controlled trial showed FNI improved development and behavioral outcomes in infants up to 18 months.

A new study published in Science Translational Medicine, showed that the intervention led to a greater likelihood that babies had improved cognitive development later on, narrowing the developmental gap between healthy, full-term babies.

Welch and her colleagues tested to see if FNI measurably changed brain development in preterm infants who were born at 26- to 34-weeks of a pregnancy.

"We were blown away by the strength of the effect," said Pauliina Yrjölä, MSc, a doctoral student and medical physicist at the University of Helsinki in Finland, who led the study on which Welch is a co-author.

Mothers in the intervention group made as much eye contact with the infants as possible with their babies and spoke with infants about their feelings.

Intimate sensory interactions between mothers and infants physically altered infants' cortical networks in the brain, and was later correlated to improved neurocognitive performance, according to the researchers.

"I was convinced there were physiological changes, I knew that from my clinical work," Welch said. "I wanted to show it in this concrete, scientific way."

Preterm Babies Face Many Hurdles

"If we can prevent problems in brain network organization to the extent that's shown in this study and improve their outcomes, this is worth millions of dollars in terms of cost to society, schooling, healthcare, especially education, and families," said Ruth Grunau, PhD, a professor in the Division of Neonatology in the Department of Pediatrics at the University of British Columbia, Canada, who was not involved with the most recent study but has worked with Welch previously.

Dr Ruth Grunau

Babies born too early, especially before 32 weeks, have higher rates of death and disability, according to the Centers for Disease Control and Prevention.

And preterm babies overall may experience breathing problems and feeding difficulties almost immediately following birth. They may also experience long-term problems such as developmental delays, vision problems, and hearing problems.

Grunau said that while many other programs and interventions have been used in the neonatal intensive care unit to help infants and mothers, the results from FNI stand out.

Yrjölä said she was surprised by the strength of the correlation as the infants continued to develop. The infants receiving the Family Nurture Intervention showed brain development close to the control group, which was infants born at full-term.

"Emotional connection is a state, not a trait — and a state can be changed," said Welch. "And in this case, it can be changed by the parent through emotional expression."

Steps Clinicians Can Take

Welch said the approach is highly scalable, and two NICUs that participated in the FNI studies have implemented the program as standard care.

The approach is also gaining interest outside of the clinical setting, as preschool partners have expressed interest in implementing some of the methods to promote development.

Parents, family members, and teachers can use many of the FNI techniques — such as eye contact and emotional expression — to continue to develop and strengthen connection.

For clinicians who want to implement parts of the intervention on their own, Welch said doctors can observe if the baby looks at or turns toward their mother.

Clinicians can encourage mothers to express deep, emotional feelings toward the infant. Welch stressed that feelings don't have to be positive, as many mothers with babies in the NICU have a hard time expressing positive emotions. Crying or talking about the difficulties of their childbirth experience count as expressing emotion. The important part is that the baby hears emotion, of any kind, in the mother's voice, Welch said.

As the connection develops, it will eventually take less time for the mother and the baby to form a bond, and eventually the pair will become autonomically regulated.

"This is what gives us hope," she said. "We affect each other in our autonomic nervous systems. It's why this treatment works."

The study was funded by the Finnish Pediatric Foundation, The Finnish Academy, the Juselius Foundation, Aivosäätiö, Neuroscience Center at University of Helsinki and Helsinki University Central Hospital, gifts from the Einhorn Family Charitable Trust, the Fleur Fairman Family, M. D. Stephenson, and The National Health and Medical Research Council of Australia. The authors have disclosed no relevant financial relationships.

Sci Transl Med. 2022;14(664):eabq4786. Abstract

Kelly Ragan is a journalist living in Colorado.

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