Comparison of the Effects of Attachment Training for Mothers on the Behavioral Responses of Premature Infants: A Randomized Clinical Trial

Document Type: Original Article


1 Community-Based Psychiatric Care Research Center, Department of Pediatric Nursing, School of Nursing and Midwifery, Shiraz University of Medical Sciences, Shiraz, Iran

2 Student Research Committee, Shiraz University of Medical Sciences, Shiraz, Iran

3 Department of Pediatric Nursing, School of Nursing and Midwifery, Shiraz University of Medical Sciences, Shiraz, Iran

4 Department of Pediatrics, Neonatology Research Center, Shiraz University of Medical Sciences, Shiraz, Iran

5 Hematology Research Center, Shiraz University of Medical Sciences, Shiraz, Iran


Background: Premature infants are among high-risk groups in community who need to be hospitalized at intensive care units for survival and receiving basic or special care. Hospitalization at neonatal intensive care units (NICUs) unsettles the family and leads to the separation of parents from their infants. This study aimed to determine the effects of maternal attachment behaviors on the behavioral responses of premature infants, hospitalized at NICUs.
Methods: In this randomized clinical trial, 64 premature infants, who were hospitalized at NICUs and were eligible for the study, were randomly allocated to study and control groups. Attachment behaviors including touching, massage and kangaroo care were applied for the study group, while the conventional attachment method was adopted for the control group. Behavioral responses were evaluated two hours before and two hours after training attachment behaviors. Data were analyzed, using Chi-square and student’s t-test.
Results: The mean difference in the duration of deep sleep and consciousness was more significant in the study group, compared to the control group. Furthermore, the duration of drowsiness was significantly less in the study group, compared to the control group.
Conclusion: The implementation of attachment training at NICUs decreased the time of drowsiness and improved behavioral responses, deep sleep time and consciousness.


  1. Edwards LD. Adaptation to parenthood. In: Lowdermilk BP, editor. Maternity Nursing. 5th ed. St. Louis: Mosby; 1999.P.450.
  2. Bowlby J. Attachment and loss: vol.I. Attachment. London: The Hogarth press and institute of psycho and lysis,1969: 70-433
  3. Bretherton I. The Origins of Attachment Theory: John Bowlby & Maty Ainsworth. Developmental Psychology. 1992; 28: 759-75.
  4. Dadestan P. Evolutionary psychology of childhood illness to adult. Tehran: Semat; 2009:12-50.
  5. Van Wanger, K. Attachment theory [On-line]; 2008. Available from: http://psychology.about.Com.
  6. Fallahi M, Jodaki N, Mohseni H. The causes of mortality of hospitalized neonatal in Tajrish Hospital in 2004-2007. J Pajohande. 2009; 14(1):43-6. (Perisian).
  7. Ohgi S, Fukuda M, Moriuchi H, Kusumoto T, Akiyama T, Nugent JK, et al. Comparison of kangaroo care and standard care: Behavioral organization and temperament in healthy, low birth weight infants through 1 year. J PePerinatol. 2002; 22:374-9.
  8. Hockenberry MJ, Wilson D. Wong's Nursing Care of Neonatal and Children.8nd ed. St. Louis: Mosbey Elsevier Co; 2007:55-91.
  9. Mok E, Loung SF. Nurses as providers of support for mothers of premature infant. J Clin Nurs. 2006; 15:726-34.
10. Melnyk BM, Fischbeck-Feinstein N, Alpert-Gillis L, Fairbanks E, Crean HF, Sinkin RA, et al. Reducing premature infants' length of stay and improving parents' mental health outcomes with the Creating Opportunities for Parent Empowerment (COPE) neonatal intensive care unit program: a randomized controlled trial. Pediatrics. 2006; 118: 1414-37.

11. Colville G, Darkinsb J, HeskethbJ, Bennett V, Alcock J, Noyes J. The impact on parents of a child's admission to intensive care: integration of qualitative findings from a cross-sectional study. Intensive Crit Care Nurs. 2009;25(2):72-9

12. Johnson AN. Promoting maternal confidence in the NICU. Pediatr Health care J. 2008;22(4):254-7

13. Valizadeh L, Hasani P. [Mothers and nurses viewpoint about experience mother of premature newborn]. JTUMS.2009; 6(1):38-48. (Persian).

14. Marandy S, Soltanizadeh M. Neonatals. Tehran: Nashre Moalefan; 1998.

15. Hutti MH. Social and Professional Support Needs of Families after Perinatal Loss. J Obstet Gynecol Neonatal Nurs. 2005; 34:630-8.

16. Jarvi A, Haapamaki ML, Paavilainen E. Emotional and Informational during Their Child’sIllness. Int Nurs Rev. 2006; 53:205-10.

17. Johnson AN. Kangaroo holding beyond the NICU. Pediatr Nurs. 2005; 31:53-6.

18. Nagafii GT. The effect of foot massage on the physiological responses of women with cancer. Iranian Journal of Nursing 2004; 36(16): 16-21. (Persian).

19. Ludington-Hoe SM, Anderson GC, Simpson S, Hollingsead A, Argote LA, Rey H. Brith- related fatigue in 34-36-week preterm neonates: rapid recovery with very early kangaroo (skin-to-skin) care. Journal of gynocology and neonates nursing. 1999; 28(1):94-103.

20. Prodromidis MField TArendt RSinger LYando RBendell D. Mothers touching newborns: A camparison of rooming –in versuse minimal contact. Birth. 1995; 22:196-200.

21. Blackburn S, Lowen L. Impact of an Infant’s Premature Birth on the grandparents & Parents. J Obstet Gynecol Neonatal Nurs. 1986; 15:173-8.

22. Lightbody T. The importance of family-centered care in the NICU. Can Nurse. 2009; 105:11-20.

23. Salimi T, Shahbazy L, Eslami Z, Dehghanpoor M. Review’s effect contact skin on vital sign and behavioral status of hospitalization in premature infant. University of Medical Sciences Tehran - Iran Dec 2009; (16):85-93.

24. Johnston CCStevens BPinelli JGibbins SFilion FJack A. Kangaroo care is effective in diminishing pain response in preterm Neonates. Arch Pediatr Adolesc Med. 2003; 157: 1084 – 8.

25. Ludington, SM. Energy conservation During Skin to skin contact between premature infants and their mothers. Heart lung. 1990; 19:445-51.