Part 1: Objective, Outline, Bibliography

Course Objectives

  1. Describe what child development literature says about the impact of nature and nurture and what communication literature says about effective language for teaching.
  2. Describe three Zones (or states) and a newborn’s SOSs (or stress responses).
  3. Describe how information on newborn Zones and SOS can help a parent calm their baby, help their baby sleep and eat well, and help their baby play so he or she can learn and grow.
  4. Describe three ways to integrate HUG principles into your work with young families.

Course Outline

  • 1) Introduction
    • a) History of child development’s view of what influences the developing child
      • i) Freud & Erickson – Nurture over Nature
      • ii) Embryologist – Nature over Nurture
      • iii) Thomas & Chess – Nature over Nurture
      • iv) Care of premature babies – Nurture over Nature
      • v) Current – Combination of Nature and Nurture – Mothers and fathers interact differently

    • b) Does intervention matter?
    • c) Does language for teaching matter?
      • i) Words must be clear (Use power of three)
      • ii) Words must be concrete, not abstract
      • iii) Words should associate new ideas with familiar ideas
  • 2) Describe three HUG Zones (or states)
    • a) What primary skills do parents need?
      • i) To understand a baby’s sleep/wake cycles (states)
      • ii) To recognize when a baby’s body is sending out a stress response
    • b) Understanding “Zones” instead of “States”
      • i) State is a combination of infant behaviors and responses that describe where a baby is on a continuum from asleep to crying
      • ii) Sleep/wake cycles develop in utero
    • c) HUG language
      • i) Resting Zone, Ready Zone, Rebooting Zone
      • ii) “Almost” refers to in-between Zones
    • d) Elements of Zones
      • i) baby’s general body activity
      • ii) eye movement
      • iii) facial movement
      • iv) vocalizing
      • v) breathing pattern
      • vi) level of responsiveness
    • e) Reasons it is important that babies develop stable and distinct Zones
      • i) Managing Zones determines how a baby presents himself.
      • ii) Managing Zones influences the parent’s behavior
      • iii) Zone regulation gives us a window neurological system
    • f) Zone regulation contribute to later cognitive, language and social development
  • 3) Describe newborn’s SOSs (Signs of Over-Stimulation) or stress response and explain how this information will help parents;
    • a) Recognize a baby’s SOS
      • i) Body SOS
        • (1) Change in color – red or pale
        • (2) Change in breathing – irregular or choppy
        • (3) Changes in movement – jerky or tremors
      • ii) Behavioral SOS
        • (1) Switching off (gaze aversion)
        • (2) Spacing Out (going from the Ready Zone toward the Resting Zone)
        • (3) Shutting Down (going from drowsy to the Resting Zone)
    • b) Is stress response important in babies? (Neurons to Neighborhoods study)
      • (1) Stress elevates cortisol
      • (2) Elevated cortisol changes brain
      • (3) Infant stress lowers threshold to stress later in life
      • (4) Negative consequences mediated by nurturing, dependable relationships
    • c) Organization of Zones and SOSs is a two-way street: parent to child, child to parent
  • 4) Describe self-comforting actions a baby might take, and list steps a parent can take to comfort a crying baby
    • a) What is normal crying – Increasing at 2 weeks, peaks at 6 weeks, and decreases at 12 weeks
    • b) Misunderstanding crying confuses parents
    • c) Triggers of excessive crying
      • i) Maternal – age, smoking, prenatal stress, psychological issues and substance abuse
      • ii) Baby – physical challenges, prematurity, temperament (increased intensity, persistence, activity level
    • d) Excessive crying: triggers child abuse, increases maternal depression
    • What T. O. DO
      • i) T = Talk – talk quietly to baby
      • ii) O = Observe – see if baby uses any self-comforting behaviors: bringing hand to mouth, self sucking, fencing reflex, “Switching Off”, “Spacing Out”, “Shutting Down”
      • iii) DO = Do comforting actions: bring hands to chest, swaddle, sway, encourage sucking, shooshing, and side lying
  • 5) Recognize two types of newborn sleep, and explain how this information will improve baby’s and mother’s sleep.
    • a) Influences on sleep
      • i) Development of types of sleep
        • (1) REM = active/light sleep (begins at 7 months gestation)
        • (2) Non-REM = still/deep sleep (begins at 8 months gestation)
      • ii) Development of circadian rhythm – melatonin hormone helps people tell day from night
        • (1) Begins in utero
        • (2) Established by 6 weeks
        • (3) Newborn sleeps 16-20 hours a day, awaking every 2-3 hours
      • iii) Parent’s care
        • (1) Prepare baby to sleep: quiet, dark room at night; active, light environment during day
        • (2) Get baby to sleep: put baby down awake
        • (3) Help baby stay asleep: don’t pick up during active/light sleep
    • b) Consequences of poor sleep - Postpartum depression (3 x hospitalization, 2 x use of corporal punishment, decreased use of smoke detectors and following back-to-sleep guidelines, changes in parent-infant interaction)
  • 6) Explain how information on newborn Zones and SOSs can enhance breastfeeding
    • a) Watch Zone and SOS changes:
      • i) If it’s not time to eat, don’t awaken baby
      • ii) If it is time to eat, awaken baby from active/light sleep.
      • iii) Comfort a baby who “Spaces Out” or “Shuts Down” at feeding time.
    • b) Lactation Cues: good latch, sucking well, emptying breast, gaining weight, lots of pees and poops
    • c) Non-feeding cues: ability to calm, to organize state, to cuddle, to become alert, to make and maintain eye contact
  • 7) Describe the range of a normal newborn’s ability to respond to visual and auditory stimulation
    • a) Baby’s capabilities
      • i) Baby’s vision
        • (1) Initially near-sighted, but like adults by 6 months
        • (2) Newborns distinguish red from gray, and 4 primary colors, by 3 months
        • (3) “Programmed” to look at faces
        • (4) Development of looking abilities
      • ii) Baby’s hearing
        • (1) Prefers music over noise
        • (2) Prefers high to low pitch
        • (3) Prefers “child directed” speech: exaggerated intonations, singsong rhythm, abbreviated utterances, repetition
    • b) Steps to paying attention – Quieting, turning, looking
    • c) Help parent see capabilities and how to engage with baby will enhance parent-child relationship
    • d) Babies can’t multitask – Use comforting techniques to help baby get to Ready Zone
      • i) Watch for SOSs:
      • ii) Get baby to the Ready Zone: swaddle, hold hands against chest, provide sucking
  • (8) Describe three ways to integrate HUG principles into your work with young families
    • a) Encourage colleagues take this online course.
    • b) Order this DVD to use with your families.
    • c) Encourage new parents and staff to read the free “Give The HUG” blog.
    • d) Encourage your local health department, hospitals, daycare council, and parent support centers to offer this program to their staff.
    • e) Make use of The HUG gifts (t-shirts, onesies, mugs, “Ask me about the HUG” buttons) to enhance staff’s ability to interest parents in The HUG techniques.

Course Bibliography

  1. Atkinson, M. (2004). Lend me your ears. New York: Oxford University Press.
  2. Barnard, E, & Summer, G. (2002) Promoting awareness of the infant’s behavioral patterns: Elements of anticipatory guidance for parents. In Gomes-Pedro, J, Nugent, J, Young, J, & Brazelton, T (Eds), The infant and family in the twenty-first century. New York: Brunner-Routledge.
  3. Barr, G., Frederick, P., Barr, M. et al. (2009). Effectiveness of educational materials designed to change knowledge and behaviors regarding crying and shaken-baby syndrome in mothers of newborns: A randomized, controlled trial. Pediatrics 123(3) 972-980.
  4. Beck, C. (2008). State of the science on postpartum depression: What nurse researchers have contributed Part 2. MCN. 33(3)151-156..
  5. Brazelton, T.B. (1995). Neonatal Behavioral Assessment Scale. London: Mac Knight Press.
  6. Bryanton, L., Beck, CT. (2010). Postnatal parental education for optimizing infant general health and parent-infant relationships. Cochrane Database Syst Rev. Jan 20;(1).
  7. Drake, E. Humenick, S., Amankwaa, L. et al. (2007). Predictors of maternal responsiveness. Journal of Nursing Scholarship. 39(2) 119-125.
  8. Fagan, J., Lee, Y. (2010). Perceptions and satisfaction with father involvement and adolescent mothers' postpartum depressive symptoms. J Youth Adolesc 39(9):1109-21.
  9. Gardner, M., & Deatrick, J. (2006). Understanding interventions and outcomes in mothers of infants. Issues in Comprehensive Pediatric Nursing, 29, 25–44.
  10. Goldbery, AE., Smiht, JZ. (2009). Perceived parenting skill across the transition to adoptive parenthood among lesbian, gay, and heterosexual couples. J Fam Psychol 23(6):861-70.
  11. Goodman, J. (2005). Becoming an involved father of an infant. Journal of Obstetric, Gynecologic, and Neonatal Nursing, 34, 190–200.
  12. Hake-Brooks, S. & Anderson, G. (2008). Kangaroo care and breastfeeding of mother-preterm infant dyads 0-19 months: A randomized, controlled trial. Neonatal Network 27(3):151-159.
  13. Haughton, J., Gregorio, D., Perez-Escamilla, R. (2010). Factors Associated With Breastfeeding Duration Among Connecticut Special Supplemental Nutrition Program for Women, Infants, and Children (WIC) Participants . J Hum Lact 26(3): 266-273.
  14. Hotelling, B. (2004). Newborn capabilities: Parent teaching is a necessity. Journal of Perinatal Education, 13(4), 43–49.
  15. Karl, D. (2004). Behavioral state organization: Breastfeeding. MCN: The American Journal of Maternal/Child Nursing, 29, 293–298.
  16. Karp, H. (2004). The happiest baby on the block: The new way to calm crying and help your newborn baby sleep longer. NY, NY: Bantam Press.
  17. Kendall-Tackett, K., Halel, TW. (2010). The use of antidepressants in pregnant and breastfeeding women: a review of recent studies. J Hum Lact 26(2):187-95.
  18. Lamb, M., Bornstein, M., Teti, D. (2002). Development in Infancy. Mahwah, NJ: Lawrence Erlbaum Associates.
  19. Leerkes, EM. (2010). Predictors of Maternal Sensitivity to Infant Distress. Parent Sci Pract. 10(3):219-239.
  20. Markova, G. & Legerstee, M. (2008). How infants come to learn about the minds of others. Zero to Three 28(5): 26-31.
  21. McRury, JM., Zolotor, AJ. (2010). A Randomized, Controlled Trial of a Behavioral Intervention to Reduce Crying among Infants. J of Am Board of Fam Med 23(3): 315-322.
  22. Mercer, R., & Walker, J. (2006). A review of nursing interventions to foster becoming a mother. Journal of Obstetric, Gynecologic, and Neonatal Nursing, 35, 568–582.
  23. Nugent, K. (1985). Using the NBAS with infants and their families. White Plains, NY: March of Dimes Birth Defects Foundation.
  24. Papousek, M., Schieche, M., & Wurmser, H. (2008). Disorders of Behavioral and Emotional Regulation in the First Years of Life. Washington, DC.: Zero to Three Press.
  25. Romano, A. & Lothian, J. (2008). Promoting, protecting, and supporting normal birth: A look at the evidence. JOGNN 37(1):94-105.
  26. Sadeh, A., Tikotzky, L., Scher, A. (2010). Parenting and infant sleep. Sleep Med Rev. 14(2):89-96.
  27. Sanders, L., & Buckner, E. (2006). The Newborn Behavioral Observations System as a nursing intervention to enhance engagement in first-time mothers: Feasibility and desirability. Pediatric Nursing, 32, 456–459.
  28. Sandler, IN., Schoenfelder, EN., Wolchik, SA., Mackinnon, DP. (2009). Long-Term Impact of Prevention Programs to Promote Effective Parenting: Lasting Effects but Uncertain Processes. Annu Rev Psychol. Dec 11.
  29. Shonkoff, J. & Phillips, D. (Eds.) (2000). From neurons to neighborhoods: The science of early childhood development. Washington, DC: National Academy Press.
  30. Tedder, J. (2007). The HUG: An innovative approach to pediatric nursing care. MCN, 32(4), 210-214.
  31. Tedder, J. (2007). HUG educational website:
  32. Tedder. J. (2008). Educational Blog:
  33. Tedder, J. (Spring, 2008). Give the HUG: An innovative approach to helping parents understand the language of their newborn. Jo of Perinatal Education. 17(2): 14-20.
  34. Thompson, R.A. (2008). The psychologist in the baby. Zero to Three 28(5): 5-12.
  35. Thulier, D., Mercer, J. (2009). Variable associated with Breastfeeding durantion. JOGNN May/June 38(3): 259-268.
  36. Van Sleuwen, B., Boere-Boonekamp, M., Kuis, W., et al. (2007). Swaddling: A systematic review. Pediatrics. 120 (4) e1097-1106.
  37. Zolotor, A., Burchinal, M., Skinner, D., et al. (2008). Maternal Psychological Adjustment and Knowledge of infant development as predictors of home safety practices in rural low-income communities. Pediatrics. 121 (6): e1668-1675.

One Response to Part 1: Objective, Outline, Bibliography

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