Premature Babies + Hugs, Cuddles = Improved Outcomes For Infants! NICU Cuddler Program At NYU Langone Long Island Helps With Many Health Conditions

Babies in the NICU at the Long Island branch of NYU Langone are treated to extra-special care – volunteer cuddlers, trained and vetted by the hospital, visit the babies each day, and talk to the babies, cuddle the babies, and read stories to the babies. 

This has been proven to improve outcomes, including total time in the hospital, episodes of spit-up, and the ability of babies to sleep.  

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After many decades of research  in the fields of touch therapy, particularly as it relates to infants and children, there are at this point mountains of evidence pointing to the benefits of touch.  While touch is most important during infancy, and is in fact critical to proper attachment, it is important throughout one’s life.   

While on the one hand, our culture appears to be devolving into a no-touch or very low touch culture, other individuals in our society are becoming aware of the importance of caring touch.  The nursing field in general has come to a greater understanding of the value of touch when it comes to helping people recover more quickly and completely from a variety of health conditions. 

The Touch Research Institute, headed by Tiffany Field, has been researching touch as a therapy for many years.  What they have found is that touch therapy is effective in countless ways, many of which are poorly or completely not understood. There are vague references to vagus nerve stimulation, but the real answer is, we know that touch is important more than why it is important.   

To start with, loving affectionate touch helps babies to grow into happy, healthy people, as LaShon made clear when speaking about the benefits of loving touch on newborns, particularly premature infants. 

In this interview, we are introduced to Jean Zebroski-Clifford, Director, Volunteer Services, LaShon Pitter, Nurse Manager, Neonatal ICU, and Leticia Rios, Nursing Professional Developmental Specialist.  These three dedicated, caring people work at the NYU Langone branch located on Long Island.  Together, they helped create, coordinate, and put together a NICU Cuddler program at their hospital, which is staffed by volunteers coordinated by Jean, educated by Leticia, and overseen also by LaShon.  

Conceiving and Implementing the NICU Cuddler Program 

I was surprised to learn how easy it was for them to conceive and implement the program, and that it was a few dedicated nurses and teachers who were about to retire that formed the nexus of the idea at this hospital.  This was followed by Jean learning more about such a program at a volunteer conference, following which she began to look at the research. 

And the amount of research available proved astonishing results.  So they decided to institute the program in their hospital.  Finding and vetting the volunteers, who would then be trained in how to care for and cuddle the babies, the special needs that they commonly suffer from, and other techniques they can use for babies that cannot be held (since this is primarily but not exclusively about holding them – singing to them and reading to them are practiced as well).  

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This program is reminiscent of the idea kernel that formed in the mind of a physician working in a hospital without an incubator at all in their NICU.  Unlike here in the US, and most other Western countries, there are some hospitals across the world with no neonatal incubators, and not much of NICU at all.  In such hospitals, prematurity meant there was a very good chance that the babies would not survive.  

So, colleagues Rey and Martinez had an idea.  Why not strap the babies to their parents’ chests, to allow them to be ‘incubated’ by their mother or father’s body heat?  Using something akin to a baby wearing wrap, they proceeded to strap the babies to their parents’ chests for as many hours a day as possible.  What were the results?  It provided a 33-40% or greater decrease in premature baby mortality.  The babies were able to survive just with their parents’ loving, caring cuddling of them.  This one thing helped these babies, who had been born prematurely, to survive.  

According to the Wikipedia entry about Kangaroo Mother Care as it was termed, “The early KMC technique was first presented by Rey and Martinez in 1983,[1] in Bogotá, Colombia, where it was developed as an alternative to inadequate and insufficient incubator care for those preterm newborn infants who had overcome initial problems and required only to feed and grow. Decades of research and development, much from researchers from emerging economies, has improved upon the initial work and has documented that modern evidence-based KMC lowers infant mortality and the risk of hospital-acquired infection, increases weight gain of infants, increases rates of breastfeeding, protects neuromotor and brain development of infants, and improves mother-infants bonding, among other benefits.[3] Today, the WHO recommends “Kangaroo mother care (KMC) for preterm or low-birth-weight infants should be started as soon as possible after birth”[2] based on “high-certainty evidence”

Kangaroo care is where many of the ideas about the benefits of skin-to-skin contact originated, and the body of evidence has only grown since the 1990s, and since 2003 when the World Health Organization started recommending kangaroo care or skin-to-skin contact.  As a Baby-Friendly hospital, NYU Langone certainly uses skin-to-skin contact for all term infants, and parents in any hospital can request to hold their baby in this way.  It helps them to feed better, improves their health outcomes, and can help to achieve the ideal goal of exclusive breastfeeding wherever possible. 

NICU Cuddler Program – A Natural Outgrowth Of Touch Research and Knowledge 

Fast-forwarding to today, NICU Cuddler programs are available at five hospitals in the New York City and surrounding areas, including at New York Presbyterian Hospital, Brookdale University Hospital and Medical Center, and NYU Langone – Long Island.  There are also other hospitals, in the midwest, who have instituted similar programs.  

During our discussion, the NYU staff members talked about some of the conditions that were specifically helped by cuddling and affection.  One was Neonatal Abstinence Syndrome, whose name has since been changed to Neonatal Opioid Withdrawal Syndrome, and another is GERD, also known as acid reflux, where babies need to be held in an upright position for about thirty minutes after eating, or they will spit up.  The holding upright works much better than placing them, alone, in an inclined bassinet.  After introducing the program, the NICU unit saw a marked decrease in the number of spt-up episodes among the babies in their care.  

Neonatal Abstinence Syndrome is when a baby is born to a mother who uses or was using drugs during the pregnancy.  Such babies are more irritable, they can have insomnia, and they can find it difficult to sleep on their own.  In most cases in the NICU, parents are, for one reason or another, unable to spend all of their time with their babies.  Thus, the cuddlers come in and provide some one-on-one loving, tender care, which can help these babies recover from the syndrome more quickly, allowing them to be comforted or sleep more deeply.  

While it is true that a NICU Cuddler program helps babies with certain syndromes, it should be remembered that healthy, loving touch is essential for all newborns.  In a situation where there isn’t prematurity, the parents at home would be cuddling their newborns all of the time.  And even premature babies without other conditions can be helped by cuddling.  

Another common candidate for the program is the case of twins.  Much of the time, twins can be born prematurely.  Whether through a scheduled C-section prior to the due-date or an emergency delivery due to distress or preterm labor, it often happens that one twin needs extra care in the NICU while the other is able to go home with the parents.  This causes new parents to become quite torn, wanting to be with both of their infants, but finding it impossible to do so.  From what Jean said, there are many times where parents are greatly helped by the cuddlers when they have one twin at the hospital.  

Much of our knowledge about babies and the need for touch in infancy came from the controversial rhesus monkey studies in the 1930s conducted by Harry Harlow.  Harlow would breed baby rhesus monkeys and take them away from their mothers immediately.  He then proceeded to perform experiments related to this maternal deprivation.  Providing them the choice of a steel wire ‘mother’ who provided them food, or a cloth mother who they would cling to or affection, his experiments made it clear what deprivation of affection does to baby monkeys.  Many of the effects suffered by the baby monkeys have been seen in humans who were similarly deprived, though usually for other reasons.  The monkeys in the experiments did not do well being deprived of affection and care, and many of them developed severe psychological issues that persisted in their lives.  

Secure and Insecure Attachment, How These Affect Behavior, And The Importance Of Physical Affection On Development, Social Skills 

Further experiments, in the 1980s to now, have shown that so-called ‘attachment disorders’ primarily stem from affectionate care or the lack thereof.  It has been found that a child who is properly attached will be more likely to become truly independent.  Since their parent has demonstrated that they are there for them, and they care about their child no matter what, that child is much more able to experience and value freedom.  The opposite is true for a child where the parental affection has been withheld, or where it has been beset by rules that the child must follow in order to ‘earn’ the parents’ love and affection, rather than it being freely given.  

To help visualize this in real terms, take two children, one is what is called ‘securely attached’ and the other is ‘insecurely attached.’  The securely attached child has had a home life characterized by affection freely given, loving parents, gentle but effective discipline where consequences may be imposed for bad behavior, but the love of the parents for the child is never withheld or in question.  

The second child is ‘insecurely attached.’  This child’s parents likely have very little time for them, causing them to question their parents’ caring or love for them.  They are inconsistent in their care for the child, verging on neglect.  Perhaps they leave the diaper unchanged for long periods of time, or they forget to make dinner on time and regularly.  Possibly the missing of dinner is used as a punishment, and punishments of all types are frequent.  Such a child may, in fact, begin to misbehave in response to the unwarranted discipline, leading to a situation where the discipline becomes necessary, often being seen as justified, leading to harsher and more severe punishment over time.  

The first child, who is securely attached, might have the following type of experience in a therapy assessment session with a new therapist.  The parents would be in the room, where the child is allowed to play with some toys.  The child plays with the toys, occasionally glancing over at the parent, but mostly playing on their own.  At a certain point, the parent was instructed to tell the child they will be going into another room.  They would then hug them and leave the room.  A securely attached child would be less fazed by this turn of events, trusting that the parent would return at some point to bring them home.  They would continue to play with toys, and they may even be responsive to the therapist.  

For the child who is insecurely attached, in the same scenario as above, they would be likely to hold onto their parents instead of playing with the toys.  They may eventually venture over to the toys if continually coaxed to do so, but there would be many glances toward the parent to be sure they are still there.  When the parent wants to leave, as in the scenario above, the child who is insecurely attached may hold onto their parents’ leg, preventing them from leaving.  They might throw a temper tantrum or cry for a while.  If the parent leaves, they are likely to run after them.  

Why is there so much of a difference?  And, more importantly, it is very common for parents to believe that the child in the first scenario is insecurely attached, and in the second scenario they are securely attached.  Many misunderstand the behaviors of the second child as being affection-seeking, when they are in fact distrusting that the parent will return to take care of them.  This is likely due to inconsistent affection, and affection that the child has to work for.  Since children need unconditional love, having conditions placed on the affection they need for their very existence can be mentally damaging.  Insecure attachment is a disordered condition, and can often take many years of treatment in therapy to overcome.  Such a disorder can also lead to other social and mental issues, including narcissism and sociopathy, both of which can be the result of long-term persistent emotional abuse or neglect.  

While there is a range of attachment, and there are many gradations between securely attached and insecurely attached, these two extremes can help you to see the difference more starkly, and the importance that tender, loving touch can have, particularly in the youngest of children. 

Benjamin Spock and Cry It Out, Possibly Damaging To Infants and Small Children, With Conflicting Studies on Both Sides 

Some parents in the 1970s utilized the Cry It Out method of sleep training.  This type of training involved allowing a child to cry without offering comfort until they went to sleep on their own.  Years later, there were studies that showed that doing this can cause the child to feel that there was no point to crying, that no one was coming.  The stress hormones released by stress were just as high even after the child stopped crying.  For that reason, today’s proponents of the technique have adapted it to require that parents come to comfort the child after a set point of time, and eventually, the child will fall asleep on their own.  They do not let them cry themselves to sleep, but do offer comfort after a period of time.  Importantly, this type of sleep training cannot be commenced before a certain age, when they are ready.

Some parents find that this type of sleep training can cause attachment disorders, and there is evidence on both sides of the argument.  But many parents are not able to or comfortable with sleep training, and it turns out that it may not be necessary.  In most cases, at a certain point in their development, a child will naturally begin to sleep through the night on their own.

Sleep training stems from the belief that the parents should control when their child sleeps through the night.  After a certain period of time, say 9 months, they will begin to naturally sleep on their own, and using sleep training is usually not really necessary.  The desire for it stems from the same type of rigidity that insists that everyone develops at the same rate and reaches the milestones at the same time.  This is not true, and when given care and comfort, children will sleep through the night without any training at all.  It is a natural part of maturing.

However, there is research that shows that children who are at the developmental stage of 4-6 months who do not learn good sleep habits continue to have problems sleeping at four years of age.  In certain instances, sleep training can be helpful, but it is not the only solution. There are so many ways that don’t involve a parent emotionally torturing themselves to follow the cry-it-out method that it is surprising that it is even still used by anyone.  Even nurses in the NICU want to run to comfort a crying baby, because that it what we are naturally wired to do.  Short-circuiting this can cause trauma for the parent, too, which is likely best avoided.

Liddlekidz Foundation and the Importance of Touch for Babies and Children in Orphanages

Tina Allen, who is the founder and president of the LiddleKidz Foundation, takes trips with therapists trained in Pediatric Touch Therapy to orphanages around the world.  The group teaches people who work in orphanages the importance of touch for babies and children, particularly those that have suffered the loss of their parent, as they have no one to turn to who is automatically there for them.  Compounding that with lack of affection and caring touch, where most orphanages lack sufficient staff to ideally care for children, these children often suffer from other issues.  In an interview, Tina said the following:

“Liddle Kidz Foundation Global uses the power of touch to reach the world’s most vulnerable children with experiences of appropriate nurturing touch that they often lack. We recognize orphans have many physical needs, and because these are the most immediate, they are the most urgent. However, dealing with the effects of finding themselves alone and without parents is clearly a major emotional trauma.

“Our experience has shown that orphanages find it a challenge to meet the emotional and developmental requirements of children, including personalized care and attention. The goal of LKF is to provide infants and children with nurturing touch while working directly with their caregivers to provide education and support. This is what makes LKF programs both sustainable and replicable.

“Our foundation has the ability to provide caregivers with the tools that will ensure infants are cradled with nurturing arms, toddlers will be provided with stimulation and interaction that establishes a foundation for healthy brain development, and adolescents will gain self-confidence and self-esteem that is essential for becoming a productive, compassionate citizen of our global community.

“It is through these outreach journeys that we strive to make a difference in the lives and futures of these children and their caregivers.”

Meeting these non-physical needs of infants and children can have lasting effects in their lives.  It can help with attachment disorders, behavioral issues such as ADD, and other health conditions as well.  Something as simple as caring touch can have incredible effects on children in orphanages, in addition to being helpful for premature infants and babies with health conditions.

It has been definitively shown that deprivation of affection and touch in infants and children in institutional settings has long-lasting effects, even carrying into adulthood, and these effects are apparent even when a nurturing caregiver adopts or otherwise cares for them after years of neglect or abuse.

This study summarized the evidence, particularly that gleaned from residents of orphanages who were neglected and deprived of affection and care for most of their lives.

From thestudy:  “Children within institutional care settings experience significant global growth suppression, which is more profound in children with a higher baseline risk of growth impairment (e.g., low birth weight [LBW] infants and children exposed to alcohol in utero). Nutritional insufficiencies as well as suppression of the growth hormone–insulin-like growth factor axis (GH-IGF-1) caused by social deprivation likely both contribute to the etiology of psychosocial growth failure within these settings…

“Growth recovery has wider implications for child well-being than size alone, because catch-up in height is a positive predictor of cognitive recovery as well. Even with growth recovery, persistent abnormalities of the hypothalamic-pituitary-adrenal system or the exacerbation of micronutrient deficiencies associated with robust catch-up growth during critical periods of development could potentially influence or be responsible for the cognitive, behavioral, and emotional sequelae of early childhood deprivation. Findings in growth-restricted infants and those children with psychosocial growth are similar, suggesting that children experiencing growth restriction within institutional settings may also share the risk of developing the metabolic syndrome in adulthood (obesity, Type 2 diabetes mellitus, hypertension, heart disease). Psychosocial deprivation within any care-giving environment during early life must be viewed with as much concern as any severely debilitating childhood disease.”

Positive Outcomes Shown With Infant Cuddling Programs 

According to NYU Langone, “ Science has shown physical touch, like hugging, has a powerful effect on infants’ mental, emotional, and physical development, both in the short and long term.  

Some of the benefits to NICU babies of the Cuddler program are:

• Better tolerance of pain
• Enhanced cognitive development
• Faster weight gain
• Improved sleep
• Enhanced social milestone achievement and/or reduction of developmental delay
• Shorter hospital stay
• Reduction of anxiety and stress
• Improved language skills
• Stable heart rate
• Stronger immune system
• Builds trust and social bonding

A study published in Paediatrics & Child Health, (Hignell A, Carlyle K, Bishop C, Murphy M, Valenzano T, Turner S, Sgro M. The Infant Cuddler Study: Evaluating the effectiveness of volunteer cuddling in infants with neonatal abstinence syndrome. Paediatr Child Health. 2019 Oct 9;25(7):414-418. doi: 10.1093/pch/pxz127. PMID: 33173551; PMCID: PMC7606161.) demonstrated that an infant cuddler program for infants with neonatal abstinence syndrome reduced the length of stay by more  than 6 days.  This study mentions the cost savings to the hospital of this type of program, which is volunteer based.  While there is a cost to implement it, including training, vetting, and coordinating between multiple different departments, the cost savings are likely to be higher, thus justifying the program for any hospital looking to implement it.   

According to Fritsch-deBruyn R, Capalbo M, Rea A, Siano B. Cuddler Program provides soothing answers. Neonatal Netw. 1990 Jun;8(6):45-9. PMID: 2348814, “Although the fragile premature infant may not always appear to respond overtly, the weight gain, and social and mental development of the cuddled babies give testimony to the effectiveness of human attention. The infants’ improved well-being and subsequent earlier hospital discharge as a result of cuddling are convincing rationale to implement a cuddler program.” 

From another study (Bushroe K, Lloyd B, McDaneld C, Mathur A, Rao R. Feasibility and Impact of a Pilot Neonatal Cuddler Program on Preterm Infants in the Neonatal Intensive Care Unit. Am J Perinatol. 2022 Nov 30. doi: 10.1055/s-0042-1758726. Epub ahead of print. PMID: 36451624.) The effects of a NICU Cuddler program on weight gain in preterm infants was studied.  The infants had gastric and intestinal issues, and both groups had the same length of stay,   

“Forty-five infants interacted with a volunteer (intervention group, n = 45) compared with the control group (n = 56) following coronavirus disease 2019 restrictions. The median (range) time of interaction with a volunteer in the intervention group was 90.0 (5.0-705.0) minutes per infant. Infants in the two groups had similar gestational ages, birth weights, lengths, and occipitofrontal circumferences (OFC). Infants in the intervention group had higher rates of spontaneous intestinal perforation, bronchopulmonary dysplasia, and reached full enteral feeds later….

“At discharge, infants in the intervention group weighed more (p = 0.04) and had higher OFC’s (p = 0.01) and OFC z-scores (p = 0.03). The change in z-scores from birth to discharge was significant for the weight (p = 0.02) but not length or OFC”

One can legitimately conclude, from the scientific and anecdotal evidence, that a NICU Cuddler program provides a net benefit to infants and their parents alike, from reducing parental stress about not being able to be in the NICU all the time, to allowing infants to go home and begin their normal lives sooner.  The benefits of a program such as this cannot be overstated, and in all seriousness, every hospital with a NICU should have one.  The patient benefits of such a program are incredible, and so are the benefits to the cuddlers themselves.

Most importantly, the premature babies are the ones who get the most out of such a program.  Considering the waiting lists at most hospitals with such a program, finding the volunteers is the easiest part.  Giving the nurses an extra set of hands to help out when multiple babies are crying, and getting to see those patients go home sooner, is priceless,  and well worth the effort necessary to institute this type of program.  Hopefully, more hospitals will have such a program, thus adding to the net benefit for babies everywhere.

Banner Image: NICU Cuddler video title. Image Credit – Staten Islander News