An educational intervention program for parents of infants born prematurely that is implemented early in the Neonatal Intensive Care Unit (NICU) can reduce parental stress, depression and anxiety, enhance parent-infant interactions, and reduce hospital length of stay, according to a study led by Dr. Bernadette Melnyk, Dean and Distinguished Foundation Professor in Nursing at Arizona State University College of Nursing & Healthcare Innovation, Phoenix.

The study, which was funded by the National Institute of Nursing Research (NINR), a component of the National Institutes of Health, set out to evaluate the efficacy of an intervention program [Creating Opportunities for Parent Empowerment (COPE)] that was designed to make parent-infant interactions a more positive experience and enhance parent mental health outcomes for the ultimate purpose of improving child development and behavior outcomes.

Two hundred and sixty families with preterm infants participated in a randomized, controlled trial conducted from 2001 to 2004 in two NICUs, in Rochester and Syracuse, New York. Subjects at each of the two study sites were randomly assigned to receive the COPE program or a comparison intervention program.

The researchers describe COPE as a four-phase educational-behavioral intervention program, with each phase providing parents with information on:

• The appearance and behavioral characteristics of premature infants and how parents can participate in their infant's care, meet their infant's needs, make interactions with their infant a more positive experience, and aid in their infant's development;
• Activities that assist parents in implementing the experimental information, such as recognizing their infants' alert states and stress cues, and identifying special characteristics of their infants.

Phase I of the COPE program occurred 2 to 4 days after the infants' admission to the NICU; Phase II occurred 2 to 4 days after completion of Phase I; Phase III occurred 1 to 4 days before discharge; Phase IV was delivered in the parents' home 1 week after infant discharge.

The investigators packaged the intervention as audiotaped and written information along with prescribed activities so that it could be easily reproduced and administered to all parents of preterm infants in NICUs at low cost. Their goal was for the COPE program to achieve widespread use without requiring intensive staff training and time.

The study, which appears in the November issue of Pediatrics, found that mothers in the COPE program reported significantly less stress in the NICU and less depression and anxiety than mothers in the comparison group when evaluated 2 months following the intervention. Trained observers in the study rated mothers and fathers in the COPE program as more positive in interactions with their infants. Mothers and fathers also reported stronger beliefs about their parental role and what behaviors and characteristics to expect of their infants during hospitalization. Also, infants in the COPE program had a 3.8-day shorter NICU length of stay and a 3.9-day shorter total hospital length of stay than did comparison infants. In addition, for very low birth weight infants in the study (those less than 1500 grams), the COPE infants had an eight-day shorter length of stay than comparison infants.

The researchers also report that the COPE group's shortened hospital stay resulted in decreased hospital costs of $5000 per infant (4 days x $1,250/day). They further note that with 480,000 low birth weight premature infants born every year in the U.S., approximately $2.4 billion could be saved annually within our national health care system if the COPE program were to be adopted by NICUs across the country.

According to the investigators, this is believed to be the first randomized controlled trial to demonstrate that a reproducible theory-based intervention with parents of premature infants that commences early in the NICU produces less parental stress in the NICU, more positive parent-interactions in the NICU, less parental anxiety and depressive symptoms following hospitalization, and reduced length of stay for preterms.

"This study demonstrates the important role that nurse scientists can play not only in helping families cope during a highly stressful period in their lives, but also in contributing to a family's long-term quality of life and well being," said Dr. Patricia A. Grady, Director, National Institute of Nursing Research.

The research team is continuing to follow these children and their parents to determine if these lower patterns of depressive and anxiety symptoms will continue over time through 3 years of age or escalate as developmental changes occur and lags in infant development are discovered.

Dr. Melnyk and her team point out that "interventions such as the COPE program, targeted to lessen depressive symptoms, are especially important in that depressed mothers have been found to be less responsive, affectionate, and positive during interactions with their infants, which leads to later adverse child outcomes. Specifically, maternal depression has been empirically linked with family violence, marital discord, impaired cognitive development, child abuse and neglect, and childhood mental health and behavior disorders." "Despite the high incidence of maternal depression in women with premature infants, these women rarely seek professional assistance for their condition, often unaware of their symptoms or minimizing them," they conclude.

Dr. Melnyk's key research collaborators include Dr. Nancy Feinstein, Dr. Linda Alpert-Gillis, Eileen Fairbanks, Dr. Hugh Crean, and Dr. Xin Tu, University of Rochester, New York; Dr. Leigh Small, Arizona State University College of Nursing and Healthcare Innovation; Dr. Robert Sinkin, The University of Virginia Medical Center; Dr. Steve Gross, Crouse Hospital in Syracuse, New York; and Dr. Pat Stone, Columbia University, New York.

The primary mission of the NINR, one of 27 Institutes and Centers at the National Institutes of Health, is to support clinical and basic research and establish a scientific basis for the care of individuals across the life span. For additional information, visit the NINR Web site at http://ninr.nih.gov.

The National Institutes of Health (NIH) — The Nation's Medical Research Agency — includes 27 Institutes and Centers and is a component of the U.S. Department of Health and Human Services. It is the primary federal agency for conducting and supporting basic, clinical and translational medical research, and it investigates the causes, treatments, and cures for both common and rare diseases. For more information about NIH and its programs, visit www.nih.gov.