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Table of Contents
Year : 2022  |  Volume : 23  |  Issue : 1  |  Page : 6-11

Nurture intervention on neurodevelopmental outcome among pre-term neonates: Application of child health assessment interaction model in nursing research

Associate Professor and Nurse Quality Coordinator, St. John's College of Nursing, St. John's National Academy of Health Sciences, Bengaluru, Karnataka, India

Date of Submission25-May-2021
Date of Decision11-May-2022
Date of Acceptance12-May-2022
Date of Web Publication05-Jul-2022

Correspondence Address:
Ms. Monica Rita Hendricks
St. John's College of Nursing and St. John's Medical College Hospital, St. John's National Academy of Health Sciences, Bengaluru - 560 034, Karnataka
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Source of Support: None, Conflict of Interest: None

DOI: 10.4103/ijcn.ijcn_37_21

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With scientific advances, the survival rate of pre-term babies has increased from 50% to 85%, but the quality of life, morbidity status and neurodevelopment outcomes still remain questionable. A high-quality mother–infant interaction facilitates the child's socio-emotional, behavioural, cognitive and physical development. Fostering nurture-maternal touch, eye-to-eye contact, vocal soothing, odour exchange and Kangaroo Mother Care, to those born too soon and are within neonatal intensive care unit (NICU) constraints forms the background of the research. This article demonstrates how Kathryn E Barnard's Child health assessment interaction model is applied to a nursing research that aims at understanding the effect of nurture on neurodevelopmental outcomes of pre-term neonates admitted to the NICU of a tertiary care hospital. The four main concepts of the model are discussed in terms of interdependency on each other. The theory also brings to the forefront the influence of each component on the outcome.

Keywords: Barnard's model, child health assessment interaction model, neurodevelopmental outcome, nurture, pre-term neonates

How to cite this article:
Hendricks MR. Nurture intervention on neurodevelopmental outcome among pre-term neonates: Application of child health assessment interaction model in nursing research. Indian J Cont Nsg Edn 2022;23:6-11

How to cite this URL:
Hendricks MR. Nurture intervention on neurodevelopmental outcome among pre-term neonates: Application of child health assessment interaction model in nursing research. Indian J Cont Nsg Edn [serial online] 2022 [cited 2023 May 31];23:6-11. Available from: https://www.ijcne.org/text.asp?2022/23/1/6/349817

  Introduction Top

Increasing maternal morbidity has accelerated pre-term birth, defined as childbirth before 37 weeks.[1] India's pre-term birth rate – approximately 21% – accounts for 23.6% of global pre-term births.[2] Pre-term birth is a dominant cause of neonatal mortality and morbidity, accounting for 27% of 4 million annual neonatal deaths.[3] Pre-term birth also causes long-term physical and developmental problems.[3],[4] Premature infants have higher rates of cerebral palsy, sensory deficits, learning disabilities and respiratory illness compared with full-term infants. One study of neonates found that 32%–48% had impaired or delayed language development (born <30 weeks); about 30%–35% had language impairment (born 31–34 weeks).[5] Recent increases in autism incidence have been attributed to pre-term birth among other causes.[6],[7]

The principal investigator, therefore, arrived at the research question:

Among pre-term neonates between 26 and <34 weeks (population), does nurture interventions in addition to Kangaroo Mother Care (KMC) compared to KMC alone (Comparator) improve neurodevelopmental outcomes at 1 year corrected age (CA).

The study

The study was a non-blinded randomised control trial aimed at comparing the neurodevelopmental outcomes of pre-term babies between the nurture intervention and standard KMC care groups at 12 months of CA. The setting of the study was the neonatal intensive care unit (NICU) of a tertiary care hospital in Bangalore, India. This NICU is a level 3 unit with 36 beds.

The study population included pre-term infants between 26 and 34 weeks of gestation admitted to the NICU of St. John's Medical College Hospital in Bangalore for a minimum of 3 days after recruitment and declared stable enough to participate in the nurture intervention and KMC by the treating physician. Mothers of pre-term babies eligible for the study were deemed physically and psychologically stable using the Edinburgh Postnatal Depression Scale (EPDS) to participate. The estimated sample size was 106, 53/arm. Eligibility screening and assessment of the neonates were done, following which the mothers were screened using the EPDS. The mother-neonate dyads were then randomised into the standard care and nurture group. Participants in the standard care group received KMC, whereas the study group participants received structured nurture. Numerous long-term and short-term outcomes were assessed including maternal depression. Follow-up with both groups was done using the Ages and Stages Questionnaire (ASQ-3-12) and Language Evaluation Scale Trivandrum (LEST) at 12 months of CA. This study focussed on pre-term neonates' development and also tried to modify the animate environmental factors that might influence the development of the neonate. The study documented the neurodevelopment after facilitating maternal and neonatal interaction. Therefore, the investigator found Kathryn E Barnard's theory an appropriate fit for this research work.[8]

The aim of this article is to introduce the Child Health Assessment Interaction Model[8] postulated by Kathryn E. Barnard and explicate its use as a theoretical framework in this study.

  Child Health Assessment Interaction Model (CHAIN) and its Application Top

Kathryn E Barnard (1938–2015)[8],[9],[10] was an active researcher who did extensive work on neonates and children since the mid-1960s. She also developed the nursing child assessment training project. Her research work on nursing child assessment formed the basis for her child assessment interaction theory.[8],[9],[10] The child health assessment model is a model developed by Kathryn E Barnard in the year 1978, focusing on mother–infant interaction within the constraints of an environment. The theory has borrowed certain concepts from psychology and human development.[8],[10]

This model brings out the importance of interaction between the caregiver, the environment and the child. This interaction plays an important role in shaping specific outcomes in a child in terms of behaviour, development, temperament and regulation.[8],[9],[10] A relationship is further fostered based on day-to-day interaction and its qualities. The model stresses the importance of every little interaction between the caregiver, the child and the environment; presented with opportunities and challenges, which ultimately form the basis of the child's development.[8],[9],[10]

The model consists of four main components, each component is;[8],[9],[10]

  • Caregiver
  • Environment
  • Child
  • Interaction.

The interaction between a parent and a neonate admitted to the NICU is fragile as both are in distress and are coping with the challenges of being admitted to the (NICU). The mother is coping with the challenges of motherhood and finding a balance between taking care of herself and the neonate amidst the hormonal imbalances that she is posed with postnatally. The effective handling of the challenges and opportunities and sustenance of the natural mother–neonate bonding despite the physical and emotional separation plays a vital role in maternal and child relationship and child development[8],[9],[10] [Figure 1].
Figure 1: Application of child health assessment interaction model in enhancing Neurodevelopmental outcomes in preterm through nurture. NICU: Neonatal intensive care, GA: Gestational age, KMC: Kangaroo Mother Care, ASQ-3-12: Ages and Stages Questionnaire-3-12

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The theory emphasises the importance of physical health, mental health, education and coping of the caregiver.[8],[9],[10] Research has brought to the forefront that the successful neurodevelopment of a child depends on a safe and secure connection with the primary caregivers. Various studies have indicated the influence of maternal, social and demographic factors (mother's mental health, stressful events in mother's life, social and economic states, stressful jobs, cultural matters, drug abuse by parents, child abuse, low social support from mother and inappropriate parental behaviours) on the development of the child.

Studies have also emphasised the influence of maternal mental health on the quality of interaction with the neonate/child and the quality and quantity of care demonstrated. Research demonstrated the relationship between maternal depression and the gross motor and cognitive development of a child. Maternal depression limits the responsibilities and functioning as a mother and leads to unmet needs of a child, ultimately resulting in behavioural problems among these children.[11],[12]

The physical health of the mother, in this study, was elicited by collecting details such as age, gestational age (GA), parity, number of abortions, history of stillbirths, postnatal deaths and infertility, regularity of antenatal care, antenatal Doppler details and a detailed history of maternal medical and obstetric problems. The mental health of the mother was assessed using the EPDS on day 3 of delivery and at discharge from the hospital. Social factors of the mother such as education, occupation and economic status, habitat and consanguinity were also elicited.


According to the theory, the environment includes resources that are animate and inanimate. The inanimate environment includes non-social aspects such as space, light, noise and materials are a few to mention. The animate environment includes the social aspects of the caregiver.[8],[9],[10]

In the case of a pre-term birth, the growth of the pre-term brain is occurring completely out of the uterus instead of the protected environment in uteri. The outcome of the pre-term neonate depends on the experiences of the pre-term neonate in the new extra-uterine environment which is different from the environment in utero. These experiences are processed by the neonatal sensory system. The development of the neonatal sensory system occurs in a particular sequence-tactile and vestibular develops first, followed by olfactory and gustatory and the last are auditory and visual. The stimulation of the senses should occur in the above-mentioned sequence of development, and a disrupted sequence prevents normal maturation. Therefore, a structured care environment that supports, encourages and guides the developmental organisation of a pre-term baby is needed. This structured care environment means creating a womb-like environment for the pre-term neonate.[13] The challenge is in providing this optimal neurodevelopmental care to the neonates by striking the balance between the Hi-Tech environment required for the survival of the neonate and sensitive individualised neonatal care.

In the current study, babies born prematurely between the 26 and 34 weeks of GA, were admitted to the NICU. The NICU provides an environment that includes exposure to the noise, light, sensory overload and deprivation, in contrast to the protected environment in utero. However, the study did not modify any of the inanimate factors. The study concentrated on facilitating parent–neonate interaction which is defined as nurture in the current study. The mothers in the nurture group were encouraged to provide KMC to their babies, firm sustained touch, eye-to-eye contact, vocal soothing and odour exchange with the neonates; that was collectively called nurture. The mothers in the standard care group were encouraged to follow KMC as per the hospital protocol. Both groups were encouraged to follow the protocol that was specified to them. Both groups were supported by health education. Mothers were assisted by the investigator in KMC and nurture for the first few days, as needed, until they gained confidence in performing the intervention. Required privacy was provided while placing the neonate for KMC.


In the theory, the child denotes children under the age of 3 years. The demographic variables, physical health, mental health, behaviour and temperament are the components assessed in the child as per the model.[8],[9],[10]

In this study, pre-term neonates come under the component of 'child'. In this study, pre-term neonates included, pre-term infants who were between 26 weeks and 34 weeks of GA, admitted in the NICU for a minimum period of 3 days after recruitment to the study, at the tertiary care hospital, Bangalore. The baseline variables of the neonate included the date of birth, gender, multiple fetuses if any, temperature, thyroxine-stimulating hormone values and the GA assessed by the new Ballard score. Data on respiratory support, nutrition, morbidity, infection history, anthropometric measurements and short-term outcomes of the neonate (test findings of hearing screening, retinopathy of prematurity screening, magnetic resonance index at discharge and neurosonogram at 40 weeks of GA) were also included.

The pre-term neonate was also assessed and followed up till 12 months of CA for the neurodevelopment using ASQ-3–12 and language assessment was made using LEST.[14]


Interaction refers to the sensitive response of the caregiver to the cues from the neonate and engaging in meaningful interaction. This interaction fosters emotional and cognitive growth. Positive interaction among all three components results in healthy and normal development and negative interaction among the three components results in poor development.[8],[9],[10]

In this study, the interaction between the mother and the neonate was facilitated in both groups. The mothers in the standard care group performed KMC and the mothers in the nurture group provided odour exchange, vocal soothing firm sustained touch and eye-to-eye contact in addition to KMC. The mothers were encouraged to continue this interaction even post-discharge up to 4 months of CA. The odour exchange component was stopped after discharge from the NICU. Although KMC was encouraged up to 4 months. KMC could be stopped, after discharge when the baby himself/herself decides to stop.

  The Concept of Nurture Intervention as Interaction Top

In the author's study, nurture involved calming activities between the mother-neonate dyad within the confines of the NICU that aimed to facilitate mother and child interaction.

Nurture intervention referred to actions performed by a mother, which began with skin-to-skin contact between the mother and neonate for a minimum of 60 min at least three times per day, and also included firm sustained touch, vocal soothing, eye-to-eye contact when the mother visited the neonate in the NICU, and odour exchange each time the mother left the neonatal unit after each visit. These actions occurred only after mothers had been oriented to the nurture intervention by the investigator.[15] A minimum frequency of performing these interventions was at least three times a day, however, the mother was free to perform these activities for longer and more frequent intervals if she desired. The order of the interventions depended upon the convenience of the mother. Nurture interventions were provided for neonates born between 26 and 34 weeks of gestational admitted to the NICU of the tertiary care hospital along with their mothers, who met the eligibility criteria.

  Nurture Invention Components Driven by the Concept of Interaction in the Framework Top

Odour exchange

Studies have proven that pre-term neonates who have been exposed to breast milk odour from their biological mothers, demonstrated a significant decrease in salivary cortisol levels. This effect continued even after the intervention was terminated. Breast milk odour demonstrated a soothing effect on the neonate.[16] Another study depicted a decreased transition feeding time by 10 days among pre-term neonates after being exposed to a breast milk-impregnated pad which was used for olfactory stimulation. It was also observed that the duration of hospitalisation was reduced by 12 days in the study group.[17]

This nurture intervention consisted of the mother and the neonate exchanging two small cotton cloths (5–7 inches). Mothers were advised to avoid perfumes to avoid interference with olfactory stimulation of the neonate. In the intervention, a mother was given a cloth during her NICU visit to keep under her brassiere/breast. Another piece of cloth was placed under the neonate's cap throughout the nurture and KMC session. When the mother left the NICU, she took the neonate's clothand her cloth was placed in the neonate's cradle until the mother met the baby for the next visit. The clothes were sterilised every day. The mother was encouraged to repeat this cycle for a minimum of three times per day. Odour exchange was stopped after discharge from the NICU.

Firm sustained touch

In utero, the sensory nerve endings on the skin of the foetus are activated by the contact with amniotic fluid. It's a postulated hypothesis, that this mechanism underlies growth regulation in a foetus.[18] When a neonate is born pre-term, the neonate is deprived of this stimulation. Therefore, touch plays a vital role in a number of neonatal care activities-massage therapies, KMC, osteopathic manipulative treatment.[19] Touch and physical contact also is a social attribute that is shared and synchronous between individuals.[20],[21] Touch also has a requirement of physical closeness and thereby touch is accompanied by numerous other sensations like olfactory and visual and results in a multisensory feedback.[20],[21]

In this study, a mother established firm sustained touch by keeping her hand firmly on her infant's belly for a minimum of 5 min, for three times a day.[2] Mothers were encouraged to follow hand hygiene before touching the neonate. The mother was also advised to warm her hands before touching the baby.

Kangaroo Mother Care

Various research studies on touch have also influenced procedural changes in many hospitals by including KMC as a standard of care among neonates. A study done by Feldman et al. among neonates born between 31 and 34 weeks of gestation, found that premature neonates exposed to at least 1 h of KMC for 2 weeks, scored higher in the motor and mental components of Bayley's assessment scales. It was also proved that the intervention led to superior growth and developmental performance in infants.[22]

In this study mothers or relatives were instructed to hold the infant safely and securely skin-to-skin and chest-to-chest, between the breasts and under their clothes, in an upright position while seated in a designated reclining chair. The infant's head was tilted up to ensure the airway was not obstructed and a cloth was tied over the neonate's back to secure the position. Once initiated, the mother was encouraged to engage in the calming activity of KMC for a minimum of 60 min at least three times a day.[15] KMC was continued post discharge for up to 4 months of CA or when the baby decided to wriggle out of KMC.

Vocal soothing

Maternal voice has a positive effect on the cardiac response of the newborn. Seagall studied the effect of exposure of maternal voice for 30 min a day for 4–8 weeks, among pre-term neonates born between 28 and 32 weeks. The experimental group responded with a significantly greater decrease in heart rate in comparison to unfamiliar voice.[23] Malloy et al.[24] evaluated the effect of maternal voice on n = infant weight gain after a 34-day history of auditory stimulation. Infants exposed to lullaby and maternal voice gained weight 9.9 days (P < 0.05) and 6.2 days earlier than the control group, respectively.[23] This component of the intervention encouraged each mother to speak to her infant and respond to her infant's vocalisations in her native language using varying intonations while maintaining eye-to-eye contact. The mother was asked to express her feelings and emotions as part of vocal soothing.[15] Vocal soothing was recommended for at least 10 min during each of the three KMC sessions.

Eye contact

According to researchers at the University of Cambridge, eye-to-eye contact synchronises the brainwaves of the caregiver and the neonate and assists in learning and communication skills. Eye-to-eye contact also releases oxytocin and strengthens the bond between the caregiver and the neonate.[25] This component of nurture intervention encouraged the mother to maintain eye contact with her neonate for at least 10 min during any part of her interaction with the neonate. This was repeated three times a day as part of the nurture intervention.

The entire nurture intervention (Odor exchange. firm sustained touch, KMC, vocal soothing and eye contact) was administered by the mother three times a day. The benefits of nurture included cost-effectiveness and positive outcomes that were seen even within constraints. The intervention engaged mothers in the care of their neonates and cultivated a sense of responsibility, bonding and pride of parenthood. Although many nurture-related interventions occur in the NICU, more studies are required to facilitate evidence-based, structured nurture interventions. Such research-informed interventions could help mother–infant dyads to reduce short- and long-term negative effects of pre-term birth. This study introduced a more structured protocol for nurture intervention as part of routine neonatal care.[15]

During the neonate's hospital stay, the investigator personally observed the conduct of the intervention. In addition, this structured intervention was documented on KMC logs and nurture logs. The nurture intervention was the independent variable and the neurodevelopmental outcome was the dependent variable. The outcomes measured included short- and long-term outcomes. At each neonate's discharge hearing screening, retinopathy of prematurity screening, neurosonogram, magnetic resonance index, and feeding status was assessed.

At 12 months CA, ASQ-3-12 was used to assess neurodevelopmental outcomes and LEST was used to assess language development.

  Implications Top

Nursing service

The child health assessment model can be used as a vital component while caring for a neonate. The importance of influence of the caregiver, the environment and the neonate's health condition play an important role in the development of a child. Keeping this in mind, the model should be used to facilitate positive exchange between the mother, neonate and the environment. This model emphasizes the fact that the holistic development of the child depends on various factors such as the caregiver, the environment, and the health of the neonate. It does not look at the neonate in isolation, but gives the nurse a comprehensive view and thereby assists in providing comprehensive nursing care.

Nursing education

Educating the nurses about the extrinsic and intrinsic factors that affect the development of neonates is mandatory. The importance of caregiver and the environment in the development of the child should be highlighted and the impact of using this model has to be emphasised in the curriculum.

Nursing administration

The interaction between the mother, neonate and the environment, as per the model should be used as a basis for facilitating a caring environment by the child health nurse. The application of this holistic model may result in the good development of the newborn. Nursing administrators should facilitate a healing environment for the premature neonate and also encourage positive maternal neonate interaction.

Nursing research

Further research should be conducted in this area of neonatal nursing, as substantial research would contribute significantly in using this model as a standard for the assessment and care of a newborn.

  Conclusion Top

This article looked at only the application and fit of the CHAIN model as a research frame work for a study on the effect of nurture intervention on neurodevelopmental outcomes among pre-term infants. Barnard's theory comprehensively covers the caregiver–neonate interaction and its significance in the development of the neonate. It is vital to consider the neonate as part of the caregiver and environmental unit rather than looking at the neonate as a single entity. The model can form the basis of nursing assessment and care in the NICU. Facilitating caregiver neonate interaction within the limits of the NICU and modifying the external and internal environment would be much beneficial in neonates' health and development.

Financial support and sponsorship


Conflicts of interest

There are no conflicts of interest.

  References Top

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