‘Evidence based clinical practice is an approach to decision making in which the clinician uses the best evidence available, in consultation with the patient, to decide upon the option which suits that patient best’.
[Muir Gray].

INTRODUCTION

Staff working in Neonatal Intensive Care Units are increasingly looking for new ways to help newborn infants and their parents to manage the stressful experiences of the modern day Neonatal Intensive Care Unit (NICU). Neonates not only deserve to receive the best biomedical-technological care, but also the best possible humane, psychological, and emotional support [Leven]. One very popular way of helping to achieve this, is with the use of a Positive Touch approach.

Positive Touch (PT) is a touch-dialogue shared by the parent and baby. A carer, grandparent, or legal guardian may also use a PT approach but ‘parent’ is used for the purpose of this document.  PT brings the parent to forefront of caring, even when the infant is in intensive care. This connection is promoted by viewing the parent as the infant’s primary nurturing caregiver from day one. This dialogue is basically a five step approach, which is simple and easy to use; however the theory behind it is multifaceted.

BENEFITS

Enhanced parent-infant interaction promotes a positive relationship between parents’ perceived level of sense of confidence, and in all social interaction activities. 

The consequence of promoting parent-infant attachment is far reaching [Leavitt] and scientifically now measurable [Carter].  The infant’s experience is also enhanced by receiving loving touch from a consistent caregiver, and respectful, humane care-giving from the staff.
Therefore the main Benefits are:

• To gently guide parents to some sense of mastery and ownership of their infant, in a difficult atmosphere of uncertain circumstances.

• To facilitate parental attunement to the behaviour of their infant, with the intention that as the brain develops in sequence with more primitive structures, stabilizing their connections first, early infant interaction is potentially beneficial to future development.

• To enhance the immature infant’s experience. In the harsh NICU environment, avoiding prolonged stress, tactile aversion/avoidance and acute distress, which could have long-term health and behavioural benefits.

• To generally improve developmental outcomes on the premise of enhanced socio-environmental factors, which are known to be important predictors of optimal developmental and behavioural outcomes in preterm infants.

POSTNATAL DEPRESSION:

Early intervention is known to benefit maternal mental health. An early PT approach has the potential to reduce the increasing incidence of depression and post traumatic stress [Schore] after-effects of NICU admission. It can also help fathers adjust [Areias].
 In research from France, Henry Chabrol and colleagues reported that the use of antidepressants were the least preferred treatments for PND.
There is a close association between maternal mood state and unsettled infant behaviour [Murray].
Research has also shown that offspring of depressed caregivers are at increased risk for maladaptive development and emotional difficulties. Specifically, infants and toddlers of depressed mothers have been shown to exhibit higher percentages of insecure attachments and more behavioural difficulties than offspring of non-disordered mothers [Murray]. Recent research by Cherry Bond’s post-discharge infant massage group showed improvement in parental attachment, specifically for mothers with Post Natal Depression [Onozawa]. It is proposed [Herring] that for families in which either a parent or a child is depressed, strategies are based on a model that is founded on the developmental phase of the child, and that aims to strengthen attachment bonds among the family.

All of these proposals fit into the Positive Touch style of teaching. The PT programme, by facilitating an integrated approach, offers supportive guidance for both parents and infants.

CHILD PROTECTION FEARS

Concerns about the possible increased risk of abuse in infants who have been born preterm/sick are disquieting.  Children who have experienced positive touch from birth develop a strong ability to identify the difference between appropriate and inappropriate touch, which prepares them to discriminate in social interaction in later life [deYoung].  In a study by Dr Brandt Steele and Dr Pollock [Steele] parents of abused children in three generations of families, were invariably deprived of physical affection themselves during childhood. Studies have shown that abusive parenting can be changed by training [Stevenson].

Worldwide Alternatives to Violence (W.A.V.E.), was formed in the UK to develop an understanding of the causes of violence – especially child abuse – and to research effective measures to reduce it. They state that the prime time when humans develop the propensity to violence is as infants aged 0-3 years [The Hand that Rocks the Cradle - WAVE article]. An important concept is that of “attunement” between infant and carer.

Parents who empathise with their infants and sensitively read and respond to their signals, are less likely to abuse or neglect their children and are more likely to respond to their babies’ developmental capabilities accurately, leading to fewer non-accidental injuries [Peterson].

The long-term effect of introducing a Positive Touch approach into parenting practice aims to help reduce the incidence of child abuse in the future.

PROMOTION OF PARENT AWARENESS OF INFANT CUES & BEHAVIOUR.

The PT programme is based on NIDCAP, NBAS and Infant Massage (International Association of Infant Massage – the world-wide organisation) training methods. All these organisations give emphasis to the communication between the parent and baby and the appreciation of individualisied infant cues as an integral part of the philosophy of all their trainings.

The PT approach is grounded in interactions that facilitate parental awareness of infant behaviour, including infant cues. This helps the parents be more aware of their baby as a unique individual rather than merely focusing on their medical diagnosis. Helping parents to understand and respond to their child’s cues can have a positive effect on their response to infant distress [Lipsitt]. The quality of care given in early parent infant interactions can form a basis for intergenerational transmission of individual differences in stress reactivity [Meaney], and early buffering of stress may positively effect infant brain development and coping mechanisms in later life [Gunnar].

DEFINITION

The Positive Touch Programme is a parent-child interaction and education programme, (not a preterm infant massage course).
The essence of attachment theory is put across entirely through practical parental experience.

CRITERIA

All infants can benefit from having their parents care sensitively for them
All parents can participate in some form of interaction.
All staff who touch the baby in any way would benefit from this course.

The Positive Touch ‘moves’ are demonstrated on a specially designed doll while the parents copy them on their babies. The instructor does not demonstrate on the babies as this avoids any possibility that a baby may respond more positively to the instructor than to the parent. 

The use of a safe oil, which is used as a touch medium is an important resource.

THE VALUE OF THE SERVICE

By providing support in the form parent-infant interaction, the hospital is also seen as taking responsibility for the mental health of the mothers, fathers and infants following delivery, rather than promoting purely a medical model of care.
The Positive Touch programme is extremely popular with parents; potential for audit/studies on parental views would be particularly promising.

INFANT MASSAGE

Baby massage is an ancient art that, for centuries, has been part of childcare in many cultures of the world [Montagu]. However, working with fragile infants in the NICU one needs to adapt the touch to suit the individual baby and actual massage strokes can be much too stimulating and are not included in this programme.

BABY MASSAGE TRAINING

If NICU staff want to teach parents massage when they go home, or for particular problems (such as constipation) while still on the unit, this requires a specific, high quality training. The International Association of Infant Massage (a world-wide organisation named Infant Massage USA for America) is a gold standard, International training.

 The IAIM Mission Statement is to promote nurturing touch and communication through training, education and research so that parents, caregivers and children are loved, valued and respected throughout the world community.

POSITIVE TOUCH COURSE TUTOR: Cherry Bond

eMail Cherry Bond

Certified Infant Massage Instructor.
Registered Children’s Nurse, Registered General Nurse, Neonatal Intensive Care Nurse
Positive Touch Specialist,
Baby Yoga certificate,
Massage Therapist,
Lecturer/Trainer/Author, in Positive Touch on the Neonatal Unit.