The Light Side of Preterm Behavioral Epigenetics: An Epigenetic Perspective on Caregiver Engagement

Introduction

Preterm birth is a major concern for healthcare services, ranging from about 5% to 18% worldwide (Field et al., 2009). Preterm birth is associated with a heightened risk for long-term detrimental consequences for development, including sensorial, behavioral, neurological, and emotional disorders (Stoll et al., 2010). Notably, even in absence of severe illness condition, preterm infants are especially fragile and they require long-term hospitalization and specialized multi-disciplinary interventions in a medical environment (i.e., Neonatal Intensive Care Unit, NICU), which clearly is not a surrogate of the maternal womb.

Specific features of NICU environment are sources of multiple stress for preterm infants, including painful stimuli, disruption of sleep, excessive noise and light levels, frequent handling associated with medical or nursing procedures, maternal separation and disrupted parenting (Peng et al., 2009). Effects of early exposure to NICU-related stress may be at least partially alleviated by caregiver engagement interventions. Despite there is considerable variations in caregiver engagement among different NICUs, Samra and colleagues (Samra et al., 2015) recently proposed a comprehensive definition. Caregiver engagement should be considered as a complex, dynamic, goal-oriented, and guided multifaceted process through which parents participate in the care of their infant to influence the outcome within a specific period and context (Samra et al., 2015). As such, caregiver engagement is a process aimed at enhancing parent parents’ situational awareness (understanding of health care communication, awareness of cues in the environment, realistic perception of their infant’s condition and cues), ability to problem solve, set goals, make appropriate care decisions, and acquire skills and knowledge to support their infant health needs. The caregiver engagement process in the NICU appears to be aimed at least at two main directions: engaging parents as partners of NICU staff and engaging parents in interacting with their own newborn and infant (Provenzi, Barello, & Graffigna, 2016a).

Caregiver engagement interventions encompass different Developmental Care (DC) practices (Westrup, 2007). DC includes a broad category of interventions designed to minimize the effects of NICU stress exposure encompassing control of external stimuli (vestibular, auditory, visual, tactile), kangaroo care and parental involvement (e.g., breastfeeding, policies of NICUs toward parental visiting, promoting infant-parent bonding), developmental activities of daily living (i.e., nesting, swaddling, prone position) and infant pain management (Symington & Pinelli, 2006). During last decades, parents have been increasingly engaged by NICU staff through a set of family-centered actions (Provenzi et al., 2016a). Caregiver presence in NICU has been shown to be beneficial for both the infants and their parents (Montirosso et al., 2012a). Specific ways of engaging parents in the NICU, such as skin-to-skin contact and kangaroo care, are able to exert positive long-lasting neuro-protective effects for the neuro-behavioral and psycho-biological development of preterm infants (Altimier, Kenner, & Damus, 2015). Hence, caregiver engagement in the NICU holds the potential to be a low-cost and high-quality intervention to provide positive influence on health outcomes of preterm infants (Samra et al., 2015).