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Literature Review: Parent-Infant Attachment Post NICU Stay

Problem Statement

Children born prematurely are highly vulnerable to the environments their development is subject to. For this reason, the mutual attachment that they share with their parents, especially after their stay in the neonatal intensive care unit, is key to their development and ultimate survival. This paper is therefore subjective in addressing the connection that a parent would share with their young ones the moments that follow after their discharge from the NICU. It will provide an in-depth evaluation of the various literature relevant to the subject. Parent child relationship is one that nurtures the psychological relationship between children and parents. Bonding occurs when parents touch, speak and relate well with their children. The unique relationship between children and parents lays a foundation for a child’s personality and characters for the children. Rocking a baby at the back and helping then to get a sound sleep creates a good bond between the parents and the children. On the contrary, getting neonatal babies to have a good bond with their children may be challenging. It takes the effort of the parents to establish a better relationship with the parents. Neonatal children who interact with parents have always had a good relationship and created a good bond with their parents. A good relationship with their children helps the parents to establish better goals for the neonatal babies. Incase the babies are not handled with care, it brings more problems to the children as they are growing. The number of neonatal babies having a good relationship with their parents are limited. Despite being in hospitals at infancy levels, parents still find a way of creating a good relationship with their children as they grow.

Background Information

Several factors can potentially interrupt the mutual connection that a parent shares with their infant. These factors may be inclusive of the sickness of the newborn, psycho-emotional distress of the parent, and admission to the NICU that takes place almost immediately after the delivery. According to research, there are higher chances of disorganized attachment prevailing among children admitted in the NICU compared to their counterparts with no such records. This adverse development is often evident among the affected infants at the age of 3 (Ettenberger et al., 2021). Despite efforts by specialists to reverse this course, there are still high chances of manifestation of the various adversities related to the impaired relationship. In this case, the various parental roles are significantly altered, the victim’s family is also likely to suffer a post-traumatic shock, and higher possibilities of neurodevelopmental complications in the preterm baby.

The attachment process is better explained from the developmental view of human survival. For the efficient development of a child, the initial bond that they create with their primary caregiver is crucial. In this case, the caregiver is referred to as the ‘secure bag’ from where the young one can explore and adapt to the environments around them (He et al, 2021). Neurobiological findings on human attachment assert that the brain of the infant matures according to the kind of attachment they share with their mother. This development often takes place within the first two years of the child’s existence. The attachment referred to in this context refers to the connection that a mother shares with the infant. This type of bonding is more focused on the mother’s perception of their relationship with the child. The parent’s view can be defined by both psychological and behavioral domains in the same measure. However, the terms bonding and attachment may be viewed differently, they seem to be used interchangeably by the various authors of literature review on the subject.

There are two distinct perspectives of the parent-infant attachment during the post NICU stay. Older pieces of literature tend to view the process as one with unique features from a parent and infant bond to the next. This view is not shared by some of the recent researchers who argue that the process is autonomic. According to the literature, the parent-infant bond can potentially manifest through various protective features of the mother. They include: caregiving, maintaining proximity with the infant, nurturing touch, staying sensitive to the infant’s cues, and having sensitive responsiveness to the needs of the infant (Grunberg et al., 2019). However, the attachment process remains vulnerable to the early separation of the preterm baby from their respective parents. The traumatic technological environments that the infant is subjected to during their stay in the NICU is also a potential interruption of the connection after they are discharged from the facility’s critical care unit. Despite the different views on attachment by the different studies, they remain in unanimous agreement on the characteristic of the same. Both the older and recent pieces of literature meet at a consensus that the neonatal features of the parent-infant relationship are defined by factors of infant NICU environmental and family-related features (Harding et al., 2019). For this reason, the various efforts towards restricting or improving these features during the infant’s stay in the critical care unit should consequently be strategic in enhancing the parent-infant bond.

Multiple systematic reviews on applicable interventions on the aforementioned factors remain considerate of the health and family outcomes of the preterm baby. Health outcome areas addressed by the studies in this context include microbiome, neurodevelopment, the infant’s speech, and communication skills, and their health severity. On family outcomes on the same, the studies identify parental sensitivity, general family stress, and parental stress in particular (Lavallée et al., 2021). There is a detailed review of the various parental-based interventions on the parent-infant bond. However, no literature is exclusively subjective in evaluating the level of effectiveness that NICU-based interventions have on the promotion of the bond during the duo’s stay in the hospital, especially in their post NICU stay. There is an improvement potential in identifying the various interventions aimed at promoting the connection among NICU families following preterm birth. Such strategic interventions are aimed at fostering both short- and long-term developmental health results. They are also targeting to improve both maternal and parental wellbeing in the same measure. With the discussed background, literature in the subject area remains subject to a further comprehensive review. Information realized out of the review would act as a strategic guide towards the ultimate development and implementation of the various connection and relationship-oriented interventions within the context of neonatal clinical practice.

Purpose Statement

This literature review is subjective in conducting a comprehensive assessment on the impacts of the attachment and relationship-based interventions that are strategically designed to promote a parental closeness to their preterm infant. The review is also aimed at evaluating implications that the mother-infant relationship during their stay in the NICU has on the aftermath parenting and parenting roles. This review is therefore based on four broad areas related to the subject: the infant’s growth and development process; health outcomes of both the family and maternal aspects of the same; the outcome of clinical measures towards the affected infant, and the broader parental experience. There are also specific parameter questions that guide the review. One, if there are relation-based interventions effective in helping infants in the NICU; what is the level of effectiveness of the aforementioned intervention on the victim infants and their respective mother in terms of developmental health results of the infants, maternal and parental experiences.

Literature Review

Implications of Parent-Infant Relationship

According to studies in the US, more than 11% of children are delivered preterm. However, a substantial number of such infants survive their stays in the NICU. For this reason, families of the affected children have an investable responsibility to interact with the medical babies within the setting of the NICU. As they interact with the affected babies, they also become highly prone to various adversities of maternal distress and depression which are often elevated (Givrad et al., 2021). There has been, therefore, the need to counter the stressful environment created by NICU. Consequently, the various models of family-centered care have become prevalent to deal with the situation. The models are based on the principles of building on family potentials, integrating the affected families in decision-making, and offering support to the families through their transitioning to their homes. The models advocate for a skin-to-skin connection and parental awareness creation exclusively designed in aid of both development and good interaction features while at home (Mäkelä et al., 2018). However, according to other disputing studies, family-based models are often focused on the universal frameworks at the expense of the various preventions subjective to improving the quality of interaction for the affected families or those at the verge of suffering the same.

As already mentioned, the quality of interaction between a child and the mother plays a central role in the ultimate development of the former. This interaction forms the basis upon which the infants secure environmental attachment, the creation of joint attention and emotional control, and ultimately their socio-emotional and cognitive growth (Shoemark, 2018). For this reason, it becomes paramount to maintain the quality of the mutual interaction at its best. A secure attachment is highly beneficial to the infant. A child with secure attachment develops the ability to draw a level of conformity from the interaction in an event that a stressful or distressing condition checks in. In such a situation the child can use the attachment as a strategic basis to further explore the threatening environment with advanced confidence over time. As much as the quality of the parent-child interaction is supposed to remain paramount, it is often jeopardized when the infant is born prematurely. Preterm infants exhibit unique features while interacting with their normal counterparts, especially during play. In most cases, the affected children as seen to show less emotional positivity, cooperation, and responsiveness to the environment compared to term infants. Mothers to the affected infants also remain subject to certain behavioral defections. For instance, they are likely to engage in behaviors that are more intrusive and less sensitive (Shoemark, 2018). Other studies on the behavioral pattern of the mothers to preterm infants also indicate increased levels of intrusiveness, reduced levels of sensitivity, and less sensitive behaviors compared to their term counterpart mothers.

According to research, two main reasons make the interaction between a parent and infant born preterm vulnerable. To begin with, such infants are more likely to have lower vagal functions, increased difficulty with state control, and deterred visual attention compared to their term counterparts (Lean et al., 2018). For this reason, the parent-infant interaction in his context needs to remain responsive and sensitive to the needs of the affected infant. These features would ensure the emergence of both self-regulation and other skills crucial to the child’s ultimate development. The study by Lean et al. (2018) asserted that maternal responsiveness is an important component of the brain development of infants born preterm. Other supportive studies also indicate that sensitivity and responsiveness of the mother-infant interaction can potentially lead to improved self-regulation, better joint attention, and reduced behavioral problems among children born preterm.

Apart from the level of risks posed to the parent-child interaction by the neonatal status of the affected child, the interaction between the two is also vulnerable to interference by other various contextual factors that manifest as the infant remains under care in the NICU. Additionally, there are other studies that associate poor social support, maternal depression, and low socio-economic status of the affected families with a difficulty in coping with the child’s NICU stay and ultimate transition to home. It is also determined that the same factors are partially responsible for the quality of the parent-infant relationship throughout the early development stages of a preterm infant (Linnér et al., 2020). This reason makes it important to screen for the various challenging interactions between the mother and the preterm infant during their stay in the NICU. This function would aid identification of the most vulnerable infants for future undesirable interactions and potentially deterred development.

Most observational studies on the kind of interaction a parent has with their infants are often conducted out of both NICUs. They are done either in-home or laboratory settings with multiple exceptions. The results from such observations are then used as an assessment tool for evaluating the nature of the preterm infant’s stay in the NICU. They suggest the potential that the parent has in learning the various ways of identifying cues in the infant and subsequently providing stimulating interactions and ultimately a positive effect on the relationship (Ettenberger et al., 2021). Other studies have also used the parent-infant interactions to assess the child’s feeding outcomes, especially in the post NICU stages. However, the studies present potential limitations in the assessment of the areas aforementioned. For instance, they hardly provide for the long-term tracking or investigate the stability of the variables over the periods of assessment. Additionally, most of the studies on the parent-infant interaction hardly commence before the corrected age of 4 months. There is inadequate evidence on the relationship that studies of the parent-infant interaction have with later parenting functions that occur in environments where the child becomes more active. Later parenting at this stage is met with more experience in caring for their infants making it a crucial component of the parent-infant bond.

Impacts of Parent-Infant Interventions

The Parent-Child Early Relational Assessment (PCERA) is one measurement tool that is often used in the examination of the parent-infant interaction in the early stages of development for the latter. There are several developmental theories from which the tool draws its assumptions and conclusions. Among them are the attachment model, emotional presence, combined attention, self-psychology, and the various cognitive linguistic models (Grunberg et al., 2019). The PCERA provides a description of the pattern of the level of relationship that a parent has with the infant. For this reason, the tool can as well be used to record the value of affection and behavior in the parent-infant interaction, especially during the child’s play, feeding, or any other definite activities during infancy to early childhood stages.

PCERA was developed subjectively to provide profiles to specific areas of the parent-infant relationship. Targeted details were both strengths and concerns for which the therapeutic interventions are necessary. By so doing, the tool aims to record notable changes among particular parent-infant pacts that are more vulnerable to early relational impairments. According to various studies on the use of PCERA with preterm infants, there is more positivity than negativity in the parenting interactions that are associated with improved sleeping patterns, weight gain, advanced cognitive skills, and less attentional and behavioral complications (Grunberg et al., 2019). Just like any other applicable intervention in healthcare, the application of the PCERA indicates a practical gap. Only a few studies have used the model in a subsequent examination of the parent-infant interactions of the preterm children in the post NICU stay. Furthermore, studies that have used the model lack a long-term follow-up which is also crucial for the tool’s effectiveness. The studies are also said to delay until the infant turns 4 months old, an age that is deemed late for the observations. However, the effectiveness of the measure tool remains. Professionals can potentially utilize the PCERA strategically in the identification of parent-infant pacts at risk for various interaction constraints. In this case, the tool allows for the subsequent development of more sophisticated intervention tools for the affected families.

Search Strategy

This review deployed a step-by-step search model in aid of a comprehensive search on literature used. To begin with, the systematic review formulated the research questions to guide the process. Proposed questions for the review aligned to the subject area of parent-infant interaction during the post NICU stay. The next step was the identification of the key concepts to narrow the search to the subject area. Major concepts in parent-infant attachment were used in the evaluation of relevant literature for the review. To effectively execute the search on the already identified concepts, the review developed search terms on two different levels. The first level involved the development of free text terms while the other was on controlled vocabulary terms. The review then identified relevant search fields to execute literature findings. Lastly, there was practical phrase searching, use of wildcards, and proximity operators in the actual search.

Themes in Literature Review

Several themes are addressed in the systematic literature review. The most dominant theme in the literature review section of the paper was the theme of assessment. Assessment in this context implied follow-up on the nature of attachment that the parent has with their infant babies after transitioning from the NICU to their respective homes. Another theme that remains dominant in the review is the theme of parenting. The whole concept of parent-infant interaction is based on the various parenting obligations that the mother has to the child. It is therefore relevant to have the theme run through the entire review. The other themes that also remain relevant to the review are themes of prematurity and social support, both on the infant who is the main interest in all literature reviewed.

Supporting Content

The review utilized several studies relevant to the subject area. Most of the literature used was observational research on preterm infants during and after their stay in the NICU. There were specific inclusion criteria used in the identification of specific studies to be reviewed. The only studies reviewed lied within the past four years with the restriction of examining parent-infant attachment in preterm babies.


This systematic review had specific objectives towards the parent-infant bond past their NICU stay. The first aim was to examine feasibility levels for the observation of parent-child interaction in the post-NICU moments. This function was regardless of whether the interactions in the said periods relate to interactions during their stay in the NICU. Another strategic objective for the review was to determine the relationship that exists between the infant and the various maternal features. The paper also reviewed the impact that applicable interventions have on improving the attachment between a mother and their preterm baby.


Ettenberger, M., Bieleninik, Ł., Epstein, S., & Elefant, C. (2021). Defining attachment and bonding: overlaps, differences, and implications for music therapy clinical practice and research in the neonatal intensive care unit (NICU). International Journal of Environmental Research and Public Health18(4), 1733.

Givrad, S., Hartzell, G., & Scala, M. (2021). Promoting infant mental health in the neonatal intensive care unit (NICU): A review of nurturing factors and interventions for NICU infant-parent relationships. Early Human Development154, 105281.

Grunberg, V. A., Geller, P. A., Bonacquisti, A., & Patterson, C. A. (2019). NICU infant health severity and family outcomes: a systematic review of assessments and findings in psychosocial research. Journal of Perinatology39(2), 156-172.

Harding, C., Levin, A., Crossley, S. L., Murphy, R., & Van den Engel–Hoek, L. (2019). Effects of early communication intervention on speech and communication skills of preterm infants in the neonatal intensive care unit (NICU): a systematic review. Journal of Neonatal Nursing25(4), 177-188.

He, F. B., Axelin, A., Ahlqvist-Björkroth, S., Raiskila, S., Löyttyniemi, E., & Lehtonen, L. (2021). Effectiveness of the Close Collaboration with Parents intervention on parent-infant closeness in NICU. BMC pediatrics21(1), 1-8.

Lavallée, A., De Clifford-Faugère, G., Ballard, A., & Aita, M. (2021). Parent–infant interventions to promote parental sensitivity during NICU hospitalization: Systematic review and meta-analysis. Journal of Early Intervention, 1053815121991928.

Lean, R. E., Rogers, C. E., Paul, R. A., & Gerstein, E. D. (2018). NICU hospitalization: long-term implications on parenting and child behaviors. Current treatment options in pediatrics4(1), 49-69.

Linnér, A., Westrup, B., Lode-Kolz, K., Klemming, S., Lillieskold, S., Pike, H. M., … & Jonas, W. (2020). Immediate parent-infant skin-to-skin study (IPISTOSS): study protocol of a randomized controlled trial on very preterm infants cared for in skin-to-skin contact immediately after birth and potential physiological, epigenetic, psychological, and neurodevelopmental consequences. BMJ open10(7), e038938.

Mäkelä, H., Axelin, A., Feeley, N., & Niela-Vilén, H. (2018). Clinging to closeness: the parental view on developing a close bond with their infants in a NICU. Midwifery62, 183-188.

Shoemark, H. (2018). Time Together: A feasible program to promote parent-infant interaction in the NICU. Music Therapy Perspectives36(1), 6-16.


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