The first three years of a child's life are a key period of physical, physiological, cognitive and social development, and the caregiver-infant relationship in early infancy plays an important role in influencing these aspects of development. Specifically, caregiver attunement facilitates the move from coregulation to self-regulation; a parent's ability to understand their infant's behaviour as communication is a key part of this process. Early, brief interventions such as the Neonatal Behavioral Assessment Scale (NBAS) or Neonatal Behavioral Observation (NBO) system are potential methods of improving outcomes for both infant and caregiver.
To assess the effects of the NBAS and NBO system for improving caregiver-infant interaction and related outcomes in caregivers and newborn babies. Secondary objectives were to determine whether the NBAS and NBO are more effective for particular groups of infants or parents, and to identify the factors associated with increased effectiveness (e.g. timing, duration, etc.).
In September 2017 we searched CENTRAL, MEDLINE, Embase, PsycINFO, 12 other databases and four trials registers. We also handsearched reference lists of included studies and relevant systematic reviews, and we contacted the Brazelton Institute and searched its websites to identify any ongoing and unpublished studies.
We included randomised controlled trials (RCTs) and quasi-RCTs that had used at least one standardised measure to assess the effects of the NBAS or NBO versus inactive control for improving outcomes for caregivers and their infants.
Data collection and analysis
Two reviewer authors independently assessed the records retrieved from the search. One reviewer extracted data, and a second checked them for accuracy. We presented the results for each outcome in each study as standardised mean differences (SMDs) or as risk ratios (RR) with 95% confidence intervals (CIs). When appropriate, we combined the results in a meta-analysis using standard methodological procedures expected by Cochrane. We used the GRADE approach to assess the overall quality of the body of evidence for each outcome.
We identified and included 16 RCTs in this review: 13 assessing the NBAS and 3 the NBO for improving outcomes in 851 randomised participants, including parents and their premature or newborn (aged 4 to 12 weeks) infants. All studies took place in the USA, and we judged all of them to be at high risk of bias. Seven studies involving 304 participants contributed data to one meta-analysis of the impact of the NBAS or NBO for caregiver-infant interaction, and the results suggest a significant, medium-sized difference between intervention and control groups (SMD −0.53, 95% CI −0.90 to −0.17; very low-quality evidence), with moderate heterogeneity (I2 = 51%). Subgroup analysis comparing the two types of programmes (i.e. NBAS and NBO) found a medium but non-significant effect for the NBAS (−0.49, 95% CI −0.99 to 0.00, 5 studies), with high levels of heterogeneity (I2 = 61%), compared with a significant, large effect size for the NBO (−0.69, 95% CI −1.18 to −0.20, 2 studies), with no heterogeneity (I2 = 0.0%). A test for subgroup differences between the two models, however, was not significant. One study found a significant impact on the secondary outcome of caregiver knowledge (SMD −1.30, 95% CI −2.16 to −0.44; very low-quality evidence). There was no evidence of an impact on maternal depression. We did not identify any adverse effects.
There is currently only very low-quality evidence for the effectiveness of the NBAS and NBO in terms of improving parent-infant interaction for mostly low-risk, first-time caregivers and their infants. Further research is underway regarding the effectiveness of the NBO and is necessary to corroborate these results.
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