27 Parent–infant attachment and support for parents of critically ill infants


Key topics


  • Parent–infant attachment (bonding)
  • Care of parents of critically ill infants
  • Caring for parents of an infant who dies





Introduction


Following important observations in the 1970s by Klaus and Kennell, it is now well accepted that a powerful parent–infant attachment (‘bonding’), has usually been established especially in mothers, by the time of birth. At the same time, it also became very clear that little attention had been given to the possible effects on parents of the death of an infant who had had little or no opportunity for life. Since then there has been considerable literature on perinatal death, revealing that the care of recently bereaved parents leaves much to be desired. Thus, an understanding of the parent–infant bonding process can help the doctor and other health care providers to minimize the devastating effect of perinatal loss, and also to understand the effects of prematurity and congenital abnormality on a family.


For mothers a bond is formed quite early in pregnancy, stimulated by hormonal changes, psychological preparation and fantasies about the unborn child. ‘Nesting’ behaviour is manifested by the preparation of a nursery and the purchase of baby clothes. For the father the attachment process is less recognizable during the pregnancy but heightens with the birth, enhanced by an involvement with the delivery and handling of the baby. A sense of pride and hope for the future ensues.


Parent–Infant Attachment (Bonding)


Steps in Attachment


The actual process by which attachment bonds are formed is unknown. There are thought to be critical stages essential to the establishment of attachment and these are listed in Box 27.1. The strength of the attachment during these stages may vary from one woman to another.



– – – – – – – – – –

Box 27.1 Phases of parent–infant attachment (bonding)


  • Planning the pregnancy
  • Confirming the pregnancy
  • Accepting the pregnancy
  • Onset of fetal movements (quickening)
  • Accepting the fetus as an individual
  • The birth process
  • Seeing the baby
  • Touching the baby
  • Taking care of the baby

– – – – – – – – – –

Most research, however, has concentrated on early contact in the immediate postnatal period. Extrapolation from animal research has proposed that there is a ‘maternal-sensitive’ or ‘maternal-critical period’, which is the optimal time for a bond of affection to develop between a mother and her infant. Although there is little doubt that the importance of this immediate postnatal period has been overemphasized in humans, this knowledge had major benefits such as early establishment of successful feeding and discharge from hospital. Some mothers are unable to achieve strong attachment without consistent contact. Failure to bond can result in rejection and resultant problems with child abuse, neglect and deprivation of nutrition, love and affection.


Parents learn to love their infant at varying times during the pregnancy and after birth. Parents are able to ‘bond’ to babies they have adopted, yet there has been no ‘maternal-critical period’. It is apparent that humans differ from other animals in their patterns of bonding.


Attachment after Birth


After birth a mother initially demonstrates attachment to her baby in several ways.



  • She is able to establish eye contact with the infant, who is in a state of arousal after birth.
  • If she is left alone with her naked infant, she may touch each part of the body with her fingertips.
  • A mother becomes overprotective of her infant in the first few days after delivery and becomes anxious about crying and minor difficulties. This anxiety may appear excessive to hospital staff and family around her.
  • Babies may mimic the facial expressions of their parents, e.g. protrude their tongues.
  • Breastfeeding may be used to comfort and pacify the infant.

Factors that Promote Attachment



  • The parents together plan the pregnancy and attend antenatal educational and physiotherapy classes. The antenatal preparation of breasts and nipples will assist with subsequent breastfeeding.
  • The father should support the mother during labour and witness the birth of the baby.
  • Unless the baby is ill, the mother and baby should be permitted to respond to each other in their own time and manner. Unnecessary separation of infant and mother must be avoided.
  • The infant should ‘room in’ with the mother for 24 h of the day and be taken out to the nursery at night only if the mother is ill, or if other mothers are being disturbed.
  • Breastfeeding on demand, even at night, should be actively encouraged. However, if a mother fails in her attempts to breastfeed despite skilled help and advice, or does not wish to do so, she must not be made to feel inadequate or guilty. Successful bottle feeding is much better than unsuccessful breastfeeding.

Risk Factors for Failure to Produce Attachment


Mothers who plan their pregnancies have good expectations of the outcome, breastfeed their babies and rarely subsequently maltreat them. Some of the risk factors that may have an adverse effect on bonding and render the family ‘at risk’ for child safety concerns are listed below.


During Pregnancy



  • Unsupported pregnancies.
  • Where the father was unfaithful or deserted the mother during pregnancy.
  • Frequent pregnancies with excessive workload.
  • Maternal depression during the pregnancy or a history of previous postnatal depression.
  • Loss of an emotionally significant person in relation to the pregnancy, e.g. the maternal grandmother, grandfather, a loved sibling, a child of the mother or even a close friend, especially when the mother was somewhat isolated.
  • Conception during a period of marital conflict.

During Labour and Delivery



  • Being left alone and afraid in the labour ward, or when the mother perceived the staff as unconcerned.
  • When the birth itself was more painful or prolonged than expected.
  • When breastfeeding was thrust upon the mother by the staff.
  • When the mother was unable to see the child after delivery, without explanation, or was told that the baby was damaged.
  • When the mother herself was damaged as a result of the birth.
  • When the father exhibited more interest in the infant than in his partner.

In the Neonatal and Postnatal Period



  • Prematurity.
  • Congenital malformations.
  • Critically ill infants requiring neonatal intensive care.
  • Postnatal depression.
  • There is a discrepancy between the idealized, perfect baby and the real baby: under these circumstances the parents require careful counselling and support.

Failure of Bonding or Attachment


When bonding fails there is non-acceptance or even rejection of the child. This may result in problems for both the child and the mother.


Long-Term Problems in the Child


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Jun 18, 2016 | Posted by in PEDIATRICS | Comments Off on 27 Parent–infant attachment and support for parents of critically ill infants

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