FACILITATING BEHAVIORS	INHIBITING BEHAVIORS
Visually alert; eye-to-eye contact; tracking or following of parent’s face	Sleepy; eyes closed most of the time; gaze aversion
Appealing facial appearance; randomness of body movements reflecting helplessness	Resemblance to person parent dislikes; hyperirritability or jerky body movements when touched
Smiles	Bland facial expression; infrequent smiles
Vocalization; crying only when hungry or wet	Crying for hours on end; colicky
Grasp reflex	Exaggerated motor reflex
Anticipatory approach behaviors for feedings; sucks well; feeds easily	Feeds poorly; regurgitates; vomits often
Enjoys being cuddled and held	Resists holding and cuddling by crying, stiffening body
Easily consolable	Inconsolable; unresponsive to parenting, caretaking tasks
Activity and regularity somewhat predictable	Unpredictable feeding and sleeping schedule
Attention span sufficient to focus on parents	Inability to attend to parent’s face or offered stimulation
Differential crying, smiling, and vocalizing; recognizes and prefers parents	Shows no preference for parents over others
Approaches through locomotion	Unresponsive to parent’s approaches
Clings to parent; puts arms around parent’s neck	Seeks attention from any adult in room
Lifts arms to parents in greeting	Ignores parents

Source: Gerson, E. (1973). Infant behavior in the first year of life. New York: Raven Press.

TABLE 15-2

Parental Behaviors Affecting Infant Attachment

FACILITATING BEHAVIORS	INHIBITING BEHAVIORS
Looks; gazes; takes in physical characteristics of infant; assumes en face position; eye contact	Turns away from infant; ignores infant’s presence
Hovers; maintains proximity; directs attention to, points to infant	Avoids infant; does not seek proximity; refuses to hold infant when given opportunity
Identifies infant as unique individual	Identifies infant with someone parent dislikes; fails to recognize any of infant’s unique features
Claims infant as family member; names infant	Fails to place infant in family context or identify infant with family member; has difficulty naming
Touches; progresses from fingertip to fingers to palms to encompassing contact	Fails to move from fingertip touch to palmar contact and holding
Smiles at infant	Maintains bland countenance or frowns at infant
Talks to, coos, or sings to infant	Wakes infant when infant is sleeping; handles roughly; hurries feeding by moving nipple continuously
Expresses pride in infant	Expresses disappointment, displeasure in infant
Relates infant’s behavior to familiar events	Does not incorporate infant into life
Assigns meaning to infant’s actions and sensitively interprets infant’s needs	Makes no effort to interpret infant’s actions or needs
Views infant’s behaviors and appearance in positive light	Views infant’s behavior as exploiting, deliberately uncooperative; views appearance as distasteful, ugly

Source: Mercer, R. (1983). Parent-infant attachment. In L. Sonstegard, K. Kowalski, & B. Jennings (Eds.), Women’s health (Vol. 2), Childbearing. New York: Grune & Stratton.

An important part of attachment is acquaintance. Parents use eye contact (Fig. 15-2), touching, talking, and exploring to become acquainted with their infant during the immediate postpartum period. Adoptive parents undergo the same process when they first meet their new child. During this period, families engage in the claiming process, which is the identification of the new baby (Fig. 15-3). The child is first identified in terms of “likeness” to other family members, then in terms of “differences,” and finally in terms of “uniqueness.” The unique newcomer is thus incorporated into the family. Mothers and fathers examine their infant carefully and point out characteristics that the child shares with other family members and that are indicative of a relationship between them. Maternal comments such as the following reveal the claiming process: “Everyone says, ‘He’s the image of his father,’ but I found one part like me—his toes are shaped like mine.”

Fig. 15-2 Early acquaintance between parents and newborn as mother holds infant in en face position. (Courtesy Kathryn Alden, Chapel Hill, NC.)

On the other hand, some mothers react negatively. They “claim” the infant in terms of the discomfort or pain the baby causes. The mother interprets the infant’s normal responses as being negative toward her and reacts to her child with dislike or indifference. She does not hold the child close or touch the child to be comforting. For example, “The nurse put the baby into Lydia’s arms. She promptly laid him across her knees and glanced up at the television. ‘Stay still until I finish watching; you’ve been enough trouble already.’”

Nursing interventions related to the promotion of parent-infant attachment are numerous and varied (Table 15-3). They can enhance positive parent-infant contacts by heightening parental awareness of an infant’s responses and ability to communicate. As the parent attempts to become competent and loving in that role, nurses can bolster the parent’s self-confidence and ego. Nurses are in prime positions to identify actual and potential problems and collaborate with other health care professionals who will provide care for the parents after discharge. Nursing considerations for fostering maternal-infant bonding among special populations may vary (Cultural Considerations box).

TABLE 15-3

Examples of Parent-Infant Attachment Interventions

INTERVENTION LABEL AND DEFINITION	ACTIVITIES
Attachment Promotion
Facilitation of development of parent-infant relationship	Provide opportunity for parent or parents to see, hold, and examine newborn immediately after birth. Encourage parent or parents to hold infant close to body. Assist parent or parents to participate in infant care. Provide rooming-in in hospital.
Environmental Management: Attachment Process
Manipulation of individuals’ surroundings to facilitate development of parent-infant relationship	Create environment that fosters privacy. Individualize daily routine to meet parents’ needs. Permit father or significant other to sleep in room with mother. Develop policies that permit presence of significant others as much as desired.
Family Integrity Promotion: Childbearing Family
Facilitation of growth of individuals or families who are adding infant to family unit	Prepare parent or parents for expected role changes involved in becoming a parent. Prepare parent or parents for responsibilities of parenthood. Monitor effects of newborn on family structure. Reinforce positive parenting behaviors.
Lactation Counseling
Use of interactive helping process to assist in maintenance of successful breastfeeding	Correct misconceptions, misinformation, and inaccuracies about breastfeeding. Assess feeding techniques and assist as needed. Evaluate parents’ understanding of infant’s feeding cues (e.g., rooting, sucking, alertness). Determine frequency of feedings in relation to infant’s needs. Demonstrate breast massage and discuss its advantages to increasing milk supply. Provide education, encouragement, and support.
Parent Education: Infant
Instruction on nurturing and physical care needed during first year of life	Determine parents’ knowledge, readiness, and ability to learn about infant care. Provide anticipatory guidance about developmental changes during first year of life. Teach parent or parents skills to care for newborn. Demonstrate ways in which parent or parents can stimulate infant’s development. Discuss infant’s capabilities for interaction. Demonstrate quieting techniques.
Risk Identification: Childbearing Family
Identification of individual or family likely to experience difficulties in parenting and assigning priorities to strategies to prevent parenting problems	Determine developmental stage of parent or parents. Review prenatal history for factors that predispose individuals or family to complications. Ascertain understanding of English or other language used in community. Monitor behavior that may indicate problem with attachment. Plan for risk-reduction activities in collaboration with individual or family.

Modified from Bulechek, G. M., Butcher, H. K., & Dochterman, J. M. (2008). Nursing interventions classification (NIC) (5th ed.). St. Louis: Mosby.

Cultural Considerations

Fostering Bonding in Women of Varying Ethnic and Cultural Groups

Childbearing practices and rituals of other cultures are not always congruent with standard practices associated with bonding in the Anglo-American culture. For example, Chinese families traditionally use extended family members to care for the newborn so that the mother can rest and recover, especially after a cesarean birth. Some Native-American, Asian, and Latina women do not initiate breastfeeding until their breast milk comes in. Haitian families do not name their babies until after the confinement month. Amount of eye contact varies among cultures as well. Yup’ik Eskimo mothers almost always position their babies so that they can make eye contact.

Nurses should become knowledgeable about the childbearing beliefs and practices of diverse cultural and ethnic groups. Because individual cultural variations exist within groups, nurses need to clarify with the patient and family members or friends what cultural norms they follow. Incorrect judgments may be made about parent-infant bonding if nurses do not practice culturally sensitive care.

Modified from Giger, J.N. (2012). Transcultural nursing: Assessment and intervention (6th ed.). St. Louis: Mosby.

Assessment of Attachment Behaviors

One of the most important areas of assessment is careful observation of specific behaviors thought to indicate the formation of emotional bonds between the newborn and the family, especially the mother. Unlike physical assessment of the neonate, which has concrete guidelines to follow, assessment of parent-infant attachment relies more on skillful observation and interviewing. Rooming-in of mother and infant and liberal visiting privileges for father or partner, siblings, and grandparents provide nurses with excellent opportunities to observe interactions and identify behaviors that demonstrate positive or negative attachment. Attachment behaviors can be easily observed during infant feeding sessions. Box 15-1 presents guidelines for assessment of attachment behaviors.

BOX 15-1 Assessing Attachment Behavior

• When the infant is brought to the parents, do they reach out for the infant and call the infant by name? (Recognize that, in some cultures, parents may not name the infant in the early newborn period.)

• Do the parents speak about the infant in terms of identification—whom the infant resembles, and what appears special about their infant over other infants?

• When parents are holding the infant, what kind of body contact is seen—do parents feel at ease in changing the infant’s position, are fingertips or whole hands used, and does the infant have parts of the body they avoid touching or parts of the body they investigate and scrutinize?

• When the infant is awake, what kinds of stimulation do the parents provide—do they talk to the infant, to each other, or to no one, and how do they look at the infant—direct visual contact, avoidance of eye contact, or looking at other people or objects?

• How comfortable do the parents appear in terms of caring for the infant? Do they express any concern regarding their ability or disgust for certain activities, such as changing diapers?

• What type of affection do they demonstrate to the newborn, such as smiling, stroking, kissing, or rocking?

• If the infant is fussy, what kinds of comforting techniques do the parents use, such as rocking, swaddling, talking, or stroking?

During pregnancy, and often even before conception occurs, parents develop an image of the “ideal” or “fantasy” infant. At birth the fantasy infant becomes the real infant. How closely the dream child resembles the real child influences the bonding process. Assessing such expectations during pregnancy and at the time of the infant’s birth allows identification of discrepancies in the parents’ view of the fantasy child versus the real child.

The labor process significantly affects the immediate attachment of mothers to their newborn infants. Factors such as a long labor, feeling tired or “drugged” after birth, and problems with breastfeeding can delay the development of initial positive feelings toward the newborn.

Parent-Infant Contact

As newborns become functionally able to sustain eye contact with their parents, they spend time in mutual gazing, often in the en face position, a position in which the parent’s face and the infant’s face are approximately 20 cm apart and on the same plane (see Fig. 15-2). Nurses and physicians or midwives can facilitate eye contact immediately after birth by positioning the infant on the mother’s abdomen or breasts with the mother’s and the infant’s faces on the same plane. Dimming the lights encourages the infant’s eyes to open. To promote eye contact, instillation of prophylactic antibiotic ointment in the infant’s eyes can be delayed until the infant and parents have had some time together in the first hour after birth.

Voice

The shared response of parents and infants to each other’s voices is remarkable. Parents wait tensely for the first cry. Once that cry has reassured them of the baby’s health, they begin comforting behaviors. As the parents talk in high-pitched voices, the infant is alerted and turns toward them.

Infants respond to higher-pitched voices and can distinguish their mother’s voice from others soon after birth. Infants use their cries to signal hunger, discomfort, boredom, and tiredness. With experience, parents learn to distinguish among such cries.

Odor

Another behavior shared by parents and infants is a response to each other’s odor. Mothers comment on the smell of their babies when first born and have noted that each infant has a unique odor. Infants learn rapidly to distinguish the odor of their mother’s breast milk.

Entrainment

Newborns move in time with the structure of adult speech, which is termed entrainment. They wave their arms, lift their heads, and kick their legs, seemingly “dancing in tune” to a parent’s voice. Culturally determined rhythms of speech are ingrained in the infant long before he or she uses spoken language to communicate. This shared rhythm also gives the parent positive feedback and establishes a positive setting for effective communication.

Biorhythmicity

The fetus is in tune with the mother’s natural rhythms—biorhythmicity—such as her heartbeat. After birth the mother’s heartbeat or a recording of a heartbeat can soothe a crying infant. One of the newborn’s tasks is to establish a personal biorhythm. Parents can help in this process by giving consistent loving care and using their infant’s alert state to develop responsive behavior and thereby increase social interactions and opportunities for learning (Fig. 15-5). The more quickly parents become competent in child care activities, the more quickly they can direct their psychologic energy toward observing and responding to the communication cues the infant gives them.

Fig. 15-5 Infant in alert state. (Courtesy Kathryn Alden, Chapel Hill, NC.)

Reciprocity and Synchrony

Reciprocity is a type of body movement or behavior that provides the observer with cues. The observer or receiver interprets those cues and responds to them. Reciprocity often takes several weeks to develop with a new baby. For example, when the newborn fusses and cries, the mother responds by picking up and cradling the infant; the baby becomes quiet and alert and establishes eye contact; the mother verbalizes, sings, and coos while the baby maintains eye contact. The baby then averts the eyes and yawns; the mother decreases her active response. If the parent continues to stimulate the infant, the baby may become fussy.

The term synchrony refers to the “fit” between the infant’s cues and the parent’s response. When parent and infant experience a synchronous interaction, it is mutually rewarding (Fig. 15-6). Parents need time to interpret the infant’s cues correctly. For example, after a certain time the infant develops a specific cry in response to different situations such as boredom, loneliness, hunger, and discomfort. The parent may need assistance in interpreting these cries, along with trial and error interventions, before synchrony develops.