1. Holding Infants on Pediatric Units Increases Bonding and Therefore Increases Patient Outcomes
Catherine Fritz
Adelphi University
Contents

2. Holding Infants on Pediatric Units Increases Bonding and Therefore Increases Patient Outcomes 1
I.The Issue
II. Review of the Literature
III. Compare and Contrast
IV. Action Plan
i. Skin to Skin Care Committee
ii. Education and Training
iii. Skin to Skin Team
iv. Policy and Procedures
v. Evaluation
The importance of mother and infant bonding has been studied for years. According to
Johnson (2013), “maternal bonding has been described as the mother's concerns and actions
about the safety and well-being of the infant, as well as the mother's affection for the infant and
the place he or she holds in her world” (p. 17). In Vitello’s (2013) article, The two men who
realized the importance of skin to skin contact between mother and infant after birth were Dr.

3. Holding Infants on Pediatric Units Increases Bonding and Therefore Increases Patient Outcomes 2
John Kennel and Dr. Marshall H. Klaus. They changed hospital care for mothers and their
newborns in 1976 when their book, Maternal-Infant Bonding was published. According to The
World Health Organization, “A newborn infant, or neonate, is a child under 28 days of age.
During these first 28 days of life, the child is at highest risk of dying. It is thus crucial that
appropriate feeding and care are provided during this period, both to improve the child’s chances
of survival and to lay the foundations for a healthy life.”(2015).
As stated by Lerwick (2013), Psychologist Erik Erikson developed the eight
developmental stages, with trust vs. mistrust being the first stage. During this stage, the infant
gains trust and attachment to the caregiver because the caregiver is responsive to the infant’s
needs. However, the infant can become mistrustful if their needs are ignored by the caregiver or
if the caregiver is inconsistent with caring for the infant. If mistrust develops, the hospitalized
infant will eventually develop stranger anxiety and separation anxiety. “When infants cry they
need to experience the primary caregiver as a present, attentive, problem-solver. This helps the
infant master the virtue of hope. Alternatively, if an infant is ignored or if the caregiver is
incompetent, inconsistent, or distracted, hope does not become established” (p. 129). When a
nurse works on a pediatric floor, he or she may become distracted and may be inconsistent in
holding infants due to the high intensity and stress that comes with working in a hospital which
can affect an infant who is without a caregiver.
I. The Issue
The author has always been interested in pediatric nursing. During a clinical rotation at
night on a pediatric unit in a hospital in Manhattan where most of the patients came from low
economic standings had psychosocial issues affecting family dynamics. The author experienced
an infant who was in need of bonding.

4. Holding Infants on Pediatric Units Increases Bonding and Therefore Increases Patient Outcomes 3
The pediatric unit in this urban hospital was fairly large; however there were about 6
patients at maximum on the unit with three registered nurses and two licensed practical nurses.
The ratio of nurses to patients was proportional.The author noticed the nurses spending a lot of
time at the nurses station, not holding the infant's. Of the six patients the ages ranged from two
weeks old to 17 years old.
All of the patients, except for the two week old female infant, had a parent or caregiver
present during the day and night. The author took notice to the infant because no one except for
the nurses had been in her room. The infant was admitted to the pediatric unit due to an E. coli
infection. The little two week old infant was the tenth child of an unmediated bipolar mother
who did not have custody of any of her children except for her one year old and the patient. The
mother finally arrived at the hospital around 9pm and only stayed for a half hour. The author
noticed the mother did not hold the patient during her visit. She asked the nurses how infant was
doing, but that was the extent of her visit.
After the mother left, the author noticed the infant was awake in her crib while the nurses
were at the nurse’s station having their own conversations. Since this was a night shift, there was
not much for the nurses to do since all the patients were stable and with their parents, except for
the infant. The author decided to go into the infant’s room and hold her. At first the author
stroked the infant’s belly. The infant began to cry, panicking the author picked up the baby and
held her and the crying stopped. The author realized the infant must have been crying because
she wanted to be held. As the author learned in the obstetrics-pediatric class, infants love faces so
the author kept herself and the baby face to face. The author continued to hold the baby for
another hour which was the end of the shift. The following week, the patient had been
discharged, but was placed in foster care.

5. Holding Infants on Pediatric Units Increases Bonding and Therefore Increases Patient Outcomes 4
The author realized that all babies need to be held especially when there is not a caregiver
present in the hospital. The nurses involved in this patient's care did not make time to hold the
infant; they only went into her room to feed her, administer medication, and clean her. Nurses
are without a doubt busy, but time spent holding the infant should be included in the patient’s
plan of care to increase better outcomes for the infant.
II. Review of the Literature
According to Luddington-Hoe (2013), skin to skin contact has time and time again prove
to lower infant stress which is encouraged in the Neonatal Intensive Care Units and is now a vital
form of therapy to promote brain development. Neonatal Intensive Care Units encourage a type
of bonding called kangaroo care (KC), in which parents or the nurses hold the preterm infant's
chest to chest and in turn, bond with them and provide comfort. This provides a calm and
soothing environment for the preterm infant who is undergoing stressful procedures in a noisy
environment.“Within 20 min of KC's onset, serum cortisol values have dropped by 67%–72%.
Four days of intermittent KC sessions has cumulative effects on reduction of stress in most
infants, but even one session of KC significantly reduces stress level” (p. 73). While providing
kangaroo care, it is best to keep the infant in the prone position. By keeping the infant prone it
has been proven to lower the incidence of poor oxygenation, lung volume is greater, and motor
development can occur earlier. Also, keeping the infant’s head upright decreases bradycardia and
apneic episodes. It is not recommended to keep the infant supine when providing kangaroo care
as it has poor physiologic outcomes for the infant. “Physiologic stability, particularly
cardiorespiratory, begins within minutes of the onset of KC”(p. 73). Also, kangaroo care
provides deep and quiet sleep for the infant. This fosters brain development and maturity for the
infant.

6. Holding Infants on Pediatric Units Increases Bonding and Therefore Increases Patient Outcomes 5
According to Johnson (2013), “infants are born with a desire to participate in human
interactions” (p. 17). Especially early on in their lives, infants completely have to depend on a
caregiver to feed them, care for them, stimulate their minds, and protect them from harm.
Johnston states that according to Klaus and Kennell, bonding is a special, distinct, and
everlasting connection that starts with the mother and her infant's first interaction. “Because
mothers respond more affectionately to their infants with continuous contact and interaction,
bonding appears to develop progressively, rather than being completely present at birth” (p.17).
Bonding between mother and infant requires both parties to participate. Certain behaviors that
infants exhibit such as making eye contact, crying, and facial expressions can enhance maternal
bonding and increase the emotions of both mother and infant that are involved during bonding.
The role of the hormone oxytocin cannot be forgotten as it is an important hormone in the
mother-infant relationship. Oxytocin is made during labor, birth, and when the mother and infant
touch and are close together. This hormone creates attachment between mother and infant.
Oxytocin also “creates feelings of love, drowsiness, euphoria, and pain relief” between the
mother and infant. Skin to skin contact increases the release of oxytocin and is continuously
released after birth by breastfeeding, speaking to the infant, and facial cues. “Oxytocin is
significant in the initiation of bonding because of its role in decreasing stress, increasing trust,
and integrating psychological and physiological states to aid in calmness and approach”(p. 20).
Nurses and other licensed professionals working in the area of obstetrics and pediatrics should
identify mothers who may be at risk for ineffective bonding.
Crenshaw (2014) states that “the benefits of skin-to-skin care extend beyond the moment
of birth. Whether in a maternity care setting or at home, the maternal and newborn physical and
emotional need for each other continues. While together, the mother quickly learns her baby’s

7. Holding Infants on Pediatric Units Increases Bonding and Therefore Increases Patient Outcomes 6
needs and how best to care for, comfort, and soothe her newborn” (p. 4). Immediately after birth
and the days after birth, both mother and infant have a physical and biologic need to be close to
each other. The mother and her baby should be kept together because it is a prudent and harmless
health practice. There are plenty of chances for mother and infant to engage in skin to skin care
and it encourages positive outcomes. “When the newborn is placed skin to skin with the mother,
this heightened response stimulates behaviors that help to meet the newborn’s basic biological
needs, activates neuroprotective mechanisms, enables early neurobehavioral self-regulation and
reduces stress” (p. 2). Mothers and infants who are constantly separated can lead to negative
health outcomes and can be dangerous for the mother-infant relationship. “When health
professionals respect, honor, and support the physiologic need that mothers and babies have for
each other after birth, they also improve the short- and long-term health outcomes for mothers
and babies” (p. 6).
Allen (2014) states that holding infants in the Neonatal Intensive Care Units can be
difficult to provide when there is constantly doctors, medical equipment, and interventions
occurring. The same can be said for a full term hospitalized infant without a caregiver present;
they are not receiving appropriate tactile stimulation. Nurturing touch is crucial for the infant's
psychosocial development. Nurturing touch is simply stroking the infant's leg or arm and it has
be proven to improve sleep and awake patterns, lessen time spent in hospitals, lowers stress, and
can increase the development of cognitive and motor skills. “Nurturing touch and massage
contain all of the elements necessary to begin the process of bonding, introduce appropriate
tactile stimulation and encourage healthy development” (para. 14). Nurturing touch can be the
most comforting intervention for the infant when he or she is enduring several medical

8. Holding Infants on Pediatric Units Increases Bonding and Therefore Increases Patient Outcomes 7
procedures daily. Nurturing touch can also “encourage optimal development” (para. 14) for the
infant.
In an empirical study by Kymre and Bondas (2013), the participants included 18
Neonatal Intensive Care Units nurses from Norway, Denmark, and Sweden; six from each
country. The nurses recollected instances when parents could not be present with their infants in
the Neonatal Intensive Care Units and it was the nurses who filled the role of the caregiver.
These nurses comforted and held the infants. One of the participants stated, “It might be
excessive to have another woman’s child on your skin, but I unbuttoned, and held him skin-to-
skin, because it was his only possibility to have physical contact” (p. 6). In another scenario one
of the nurses recalled that several nurses in the Neonatal Intensive Care Units were specifically
hired to provide skin to skin care for the infants. The participants realized the importance of
hiring nurses to give skin to skin care to infants and they believe that is “the child’s rights and
needs, and staff’s responsibilities in comforting infants close to human bodies” (p. 6). The nurses
who participated in this study felt great responsibility for the infant to always have skin to skin
contact, whether it be with the nurse or caregiver. “The findings in this study indicate an
importance in reflecting on how nurses encourage parents to participate and feel needed as a
condition for the developmental care of their newborn” (p. 6). These nurses encouraged parent
involvement and participation in the care of their baby. The nurses also encouraged the parents to
give skin to skin care with their newborns. Some nurses even felt that it should be demanded that
the parents give skin to skin comfort to their baby.
III. Compare and Contrast
What the author witnessed in the clinical experience was similar in some ways to what
research has found and different in other ways. One example includes mental illness as a factor

9. Holding Infants on Pediatric Units Increases Bonding and Therefore Increases Patient Outcomes 8
in maternal infant bonding. The author discovered that the mother of the infant was bipolar and
not medicated. The author also noticed that the mother never interacted with her baby during the
visit. According to Johnson (2013), infant health and comfort have been attributed to bonding
and it is essential for the infant to receive this attachment from their caregiver. Bonding begins
and continues when mother and infant have skin to skin contact with one another. However,
bonding can be disrupted by several issues, in particular psychological problems, which relate to
the author's experience.
According to Kymre and Bondas (2013), the nurses provided bonding for the infants on
the neonatal intensive care unit when the caregiver was not present. They realized the importance
of making skin to skin contact a nursing intervention for the infants who were not receiving
nurturing touch. Even several nurses were hired to provide skin to skin contact with the
newborns. This example differs from what the author experienced. The author did not witness
the nurses on the pediatric floor providing skin to skin contact with the infant. Also, the hospital
did not hire nurses to specifically provide skin to skin care for the infants.
Another example that differs from the author’s experience is that according to the study
done by Kymre and Bondas (2013), the nurses in the neonatal intensive care unit encouraged the
mothers to comfort and provide skin to skin contact with their newborn. From what the author
experienced on the pediatric unit, the nurses never tried to encourage the infant's’ mother to
interact with her newborn. In fact, the nurse assigned to the two week old infant barely spoke to
the mother.
IV. Action Plan
Due to the day to day demands of society, caregivers may not always be present with
their babies for the entire hospital stay. Therefore, a plan of action must be formed to increase

10. Holding Infants on Pediatric Units Increases Bonding and Therefore Increases Patient Outcomes 9
patient outcomes and improve the quality of care. A possible action plan for providing skin to
skin care for hospitalized infants will contain the following:
i. Skin to Skin Care Committee
The first step in changing policy in the hospital regarding skin to skin care for infants and
to eventually change practice is to form a committee. The committee will be composed of
pediatric nurses, pediatric physicians, midwives, and doulas. These members of the healthcare
team will be the ones to change policy regarding skin to skin care when infants do not have a
caregiver on the pediatric unit. The committee will develop policy, procedures, and a program
for bonding by using evidence based practice and by observing infant responses. The committee
will also provide training for staff, volunteers, and parents about how to hold and console the
infants. A “happy baby survey” will be conducted to determine the infants satisfaction three
months after initiating the program. Twenty infants within the program will be evaluated and
compared to another twenty infants before the program begins, serving as the control group.
(Kymre and Bondas, 2013)
ii. Education and Training
For the skin to skin program to be effective, staff and volunteers need to be educated and
trained on how to provide skin to skin care to infants. There will be a mandatory informational
meeting held by the Skin to Skin Committee for pediatric staff and volunteers. During this
meeting, staff and volunteers will be educated on what skin to skin care actually is, the benefits
of skin to skin care, and finally the policies and procedures about the program. The staff and
volunteers attending this program will be comprised become the Skin to Skin Team. (Kymre and
Bondas, 2013)
iii. Skin to Skin Team

11. Holding Infants on Pediatric Units Increases Bonding and Therefore Increases Patient Outcomes 10
Almost anyone can become apart of the The Skin to Skin Team. This can include college
students, the elderly, and anyone else who wants to volunteer their time to hold infants who are
without a caregiver on the pediatric unit. Nurses who work on the pediatric unit will
automatically become apart of the Skin to Skin Team because skin to skin care will become a
required intervention of care for the infants who are without a caregiver. The team will be trained
by the Skin to Skin Committee. ( Kymre and Bondas, 2013)
iv. Policy and Procedures
The Skin to Skin program for Volunteers include the following:
1. Attend training program on how to hold infants and properly provide skin to skin care
and show competency
2. Attend training program on how to provide hygienic care for the infant and show
competency
3. Taught universal precautions and show competency
4. Shifts for volunteers will be 8am-5pm and they must commit to three hours for each day
they volunteer
5. Must be 21 years of age and older
6. Background check and drug testing required
7. Must complete an interview
Pediatric nurses are required to do the following:
1. Nurses on the day shift from 7am-7pm will provide skin to skin care for 20 minutes every
four hours and will document the time providing skin to skin care on the “skin to skin”
form

12. Holding Infants on Pediatric Units Increases Bonding and Therefore Increases Patient Outcomes 11
2. Nurses on the night shift from 7pm-7am will provide skin to skin care every two hours
for one hour and will document the time providing skin to skin care on the “skin to skin”
form
3. Nurses need to teach the caregiver how to provide skin to skin care and how to comfort
their baby
4. If a caregiver is not present, it is the nurse's responsibility to reach out to the family non-
judgmentally and encourage them to participate in their infants’ care.
5. Nurses need to provide education on the importance of the caregiver's presence and how
it affects their infant's’ development.
6. Nurses must monitor the volunteers
v. Evaluation of the Skin to Skin Program
Three months after the program begins, the program will be evaluated for better patient
outcomes. The evaluation will be done by nurses who will use the “happy baby survey” to
determine if the program has been successful. The nurses will evaluate twenty infants in a three
month's time span. The nurses will gather information from their own observations and
comments from the volunteers. The “happy baby survey” will contain a list of behaviors and
physiologic responses that the infant should be expressing if he or she is being held and
comforted. The behaviors and physiologic responses include less crying, easily comforted,
improved sleeping patterns, normal heart rate, normal respiratory rate, and better feeding
patterns. These findings will be compared to the survey done with the twenty infants who did not
participate in the program. (Ludington-Hoe, 2013).
In conclusion, full term infants who are hospitalized need bonding just as much as
preterm infants, especially if their parents or caregivers are absent. This is a sensitive part of their

13. Holding Infants on Pediatric Units Increases Bonding and Therefore Increases Patient Outcomes 12
development where the infant either has trust or mistrust of others and being hospitalized can
disturb this period where bonding is critical. All infants are immature, whether they are preterm
or full term, both require comforting and hospitalized full term infants should receive skin to skin
care from nurses when the caregiver is not present.
References
Allen, T. (2012). Nurturing touch in the NICU. Massage Today, 12(01). Retrieved April 22,
2015, from http://www.massagetoday.com/mpacms/mt/article.php?id=14518
Crenshaw, J. (2014). Healthy Birth Practice #6: Keep Mother and Baby Together— It’s Best for
Mother, Baby, and Breastfeeding. The Journal of Perinatal Education, 23(4).
Johnson, K. (2013). Maternal-infant bonding: a review of literature. International Journal of
Childbirth Education, 28(3), 17+. Retrieved from
http://go.galegroup.com/ps/i.do?id=GALE%7CA344155224&v=2.1&u=olr_health_watc
h&it=r&p=HRCA&sw=w&asid=54b4485a6907244a8a4622d85e641b63
Kymre, I. G., & Bondas, T. (2013). Balancing preterm infants’ developmental needs with
parents’ readiness for skin-to-skin care: A phenomenological study.International Journal
of Qualitative Studies on Health and Well-Being, 8, 10.3402/qhw.v8i0.21370.
doi:10.3402/qhw.v8i0.21370
Lerwick, J.(2013). Psychosocial implications of pediatric surgical hospitalization. Seminars in
Pediatric Surgery. doi:10.1053/j.sempedsurg.2013.04.003
Ludington-Hoe, S. (2013). Kangaroo Care as a Neonatal Therapy. Newborn and Infant Nursing
Reviews, 13(2), 73-75. Retrieved April 22, 2015, from
http://www.sciencedirect.com/science/article/pii/S1527336913000275
Vitello, P. (2013, September 13). John Kennell, Advocate of Infant Bonding, Dies at 91. The
New York Times. Retrieved April 12, 2015, from
http://www.nytimes.com/2013/09/22/health/john-kennell-advocate-of-infant-bonding-
dies-at-91.html?_r=1
World Health Organization. (2015). Infant, Newborn. Retrieved April 30, 2015, from
http://www.who.int/topics/infant_newborn/en/

14. Holding Infants on Pediatric Units Increases Bonding and Therefore Increases Patient Outcomes 13
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