New perspectives on responsive infant care: A qualitative study of the ways in which Neuroprotective Developmental Care (NDC) shapes mother-infant co-occupations

ABSTRACT

Background

Becoming a parent is a significant occupational transition. Many contemporary approaches to infant care focus on algorithmic schedules and rigid routines for sleep and feeding; delayed responses to cues related to feeding, sleep, and cry-fuss communication; minimising sensory stimulation for feeding, sleep, and to address cry-fuss communication; and sometimes highly medicalized approaches to unsettled infant behaviour via lenses of reflux, allergy, and tongue-tie, often without a supportive evidence-base or adequate assessment. Such interventions are at odds with a co-occupation perspective. Neuroprotective Developmental Care (NDC) provides information and guidance to support evidence-based infant care that supports caregivers to respond to their infant’s communication cues. This research aimed to explore how day-to-day co-occupations of parents and infants are shaped by accessing NDC.

Methods

This qualitative thematic analysis was guided by interpretive description. Twelve mothers who had accessed NDC with their infant in Australia participated in semi-structured telephone/Zoom video interviews.

Findings

Flexibility across the days was identified as the overarching theme regarding mother-infant co-occupations within the data. Three sub-themes describe how mothers changed the ways they put together their daily occupations with their babies in relation to 1) sleep, 2) feeding, and 3) calming through sensory nourishment.

Conclusion

This research offers novel insights into responsive care from the perspective of the ways in which mothers flexibly orchestrate their days so that they can respond to their infants’ communication throughout the days. Mothers’ responses offered insights regarding an occupational approach to responsive infant care which warrants further research.

RESUME

Contexte : devenir parent est une transition occupationnelle importante. De nombreuses approches contemporaines des soins aux nourrissons se concentrent sur des horaires algorithmiques et des routines rigides pour le sommeil et l'alimentation ; des réponses retardées aux signaux liés à l'alimentation, au sommeil et à la communication par les pleurs ; la minimisation de la stimulation sensorielle pour l'alimentation, le sommeil et la communication par les pleurs ; et parfois des approches très médicalisées du comportement instable du nourrisson sous l'angle du reflux, de l'allergie et de la longueur du frein de la langue, souvent sans base de données probantes ou sans évaluation adéquate. Ces interventions vont à l'encontre d'une perspective qui tiennent compte des co-occupations en cause. Les soins de développement neuroprotecteurs (SDN) fournissent des informations et des conseils pour soutenir les soins aux nourrissons fondés sur des données probantes, qui aident les les parents à répondre aux signaux de communication de leur enfant. Cette recherche visait à explorer comment les co-occupations quotidiennes des parents et des nourrissons sont façonnées par l'accès aux SDN. Méthodes : un devis descriptif interprétatif a été utilisé, en s'appuyant sur une analyse thématique qualitative. Douze mères ayant accédé à des SDN avec leur enfant en Australie ont participé à des entretiens semi-structurés par téléphone et par vidéoconférence Zoom. Résultats : la flexibilité au fil des jours a été identifiée comme le thème principal pour décrire les co-occupations mère-nourrisson. Trois sous-thèmes décrivent comment les mères ont modifié leur façon d'organiser leurs activités quotidiennes avec leur bébé en ce qui concerne 1) le sommeil, 2) l'alimentation et 3) l'apaisement par l'alimentation sensorielle. Conclusion : cette recherche offre de nouvelles perspectives sur les soins sensibles à la manière dont les mères orchestrent leurs journées de manière flexible afin de pouvoir répondre à la communication de leurs nourrissons tout au long de la journée. Les réponses des mères offrent des indications sur une approche occupationnelle des soins, sensible aux besoins des nourrissons, ce qui justifie des recherches plus approfondies.

KEYWORDS:

• Occupational science
• Mothers
• Infant care
• Orchestration of occupations
• Responsive parenting
• Neuroprotective developmental care
• Co-occupations

MOTS-CLÉS:

• Sciences de l'occupation
• mères
• soins du nourrisson
• orchestration des occupations
• parentalité adaptée
• soins de développement neuroprotecteurs
• co-occupations

Infant caregiving involves patterns of occupational and co-occupational engagement including bathing, feeding, changing nappies, entertaining the baby, tasks related to the baby’s sleep, homemaking tasks, and child-centred leisure occupations such as attending mother and baby groups or local day trips (Horne et al., 2005). For many families, infant caregiving also involves balancing work and family arrangements (Arpino & Luppi, 2020).

Whilst parents do much to prepare for their role as caregivers, many report that this time can also bring about great stress as they take on new roles and engage in new occupations and co-occupations (Andersson & Hildingsson, 2015; Barimani et al., 2017). Examples include facing challenges in infant feeding (Froehlich et al., 2015), responding to infant crying and fussing (Leerkes & Qu, 2020) and managing sleep difficulties (Parade et al., 2019). High quality, evidence based, client-centred services for caregivers of infants during this period of life are essential.

Contemporary infant care often comprises a focus on schedules, algorithms, and set routines along with promotion of limited/delayed responses to infants’ communication for feeding, sleep, and cry-fuss communication; blanket advice to minimise sensory stimulation for feeding, sleep, and to address cry-fuss problems, without consideration of developmental needs and each individual infant’s sensory preferences; and viewing unsettled infant behaviour primarily through medicalized lenses of reflux, allergy, and tongue-tie, without consideration of other infant emotional regulation factors (Ball et al., 2018; Douglas & Hill, 2013a, 2013b; Douglas & Hiscock, 2010; McInnes & Chambers, 2008). These common contemporary perspectives exclude consideration of evidence-based, non-medical interpretations of infant communication based on biomechanical, neuro-hormonal, sensory, and developmental frames of reference. From an occupational perspective, these types of approaches are not congruent with meaningful caregiver-infant co-occupational engagement. They do not provide physical closeness, provide opportunities for emotional co-regulation, and do not support the intentionality of doing together, which is the core of co-occupation (Pickens & Pizur-Barnekow, 2009).

Co-occupation refers to the engagement of two people in an occupation, where each person influences the other person and their life experiences (Pierce, 2009; Zemke & Clark, 1996). It entails responding to each other in physical, emotional, and intentional ways that involve sharing physical and emotional responses and engaging with each other’s intentions (Pickens & Pizur-Barnekow, 2009). When holding, carrying, and in physical contact during feeding (Little et al., 2018), two-way physical responses are at play. The co-regulation of emotions (Evans & Porter, 2009; Vasak et al., 2015) and sensory and calming strategies to support infants to sleep (Barry, 2019; Blunden & Baills, 2013) demonstrate two-way physical and emotional responses, which can also be seen in the mutual neuro-hormonal changes that mother-infant social and reciprocal play interactions bring about (Scatliffe et al., 2019). Reciprocal caregiver-infant communication occurs to fulfil an infant’s needs, including in play (Goodman, 2019), and this also illustrates two-way intentional responses involved in infant-caregiver co-occupation.

During co-occupations, infants are intentional in their communication and caregivers are intentional in the way in which they respond (Leclère et al., 2014; Piallini et al., 2015). For example, infants might communicate non-verbally or pre-verbally for feeding, sleep, social interaction, or an emotional response to environmental stimuli. A caregiver notices, interprets, and responds to the infant’s cues, attempting to fulfil the infant’s needs. Mother-infant co-occupations such as infant sleep, feeding, and mother-baby interactions for play and emotional regulation are central to infant and maternal well-being (Slootjes et al., 2016).

Neuroprotective Developmental Care (NDC) is an integrated approach that combines interdisciplinary knowledge from developmental psychology, neuroscience, lactation science, medical science, behavioural theory, and evolutionary science, and draws upon techniques from Acceptance and Commitment Therapy (ACT) to provide a method of care for both well infants and those with cry-fuss, feeding, or sleeping difficulties. Table 1 provides a picture of how NDC services are delivered by outlining key elements of NDC support. Caregivers can receive education and support through resources including 1:1 consultation with NDC practitioners, shared medical appointments with other parents/caregivers, NDC focused books for parents, website content with video and written resources and parent/caregiver online support groups (Crawford et al., 2022). It is grounded in strong evidence from systematic reviews and meta-analyses of high-quality evidence (Douglas & Geddes, 2018; Douglas & Hill, 2013a, 2013b).

Table 1. Overview of key elements of NDC support

Area of Support	Key elements of support	Described in references
Sleep	Education on normal infant sleep and development and variability amongst infants Provide education and support on two biological sleep regulators – sleep pressure (sleep-wake homeostat) and circadian clock Holistic approach considering interactions between five NDC domains including environmental enrichment Support for maternal sleep efficacy Empowerment through parental education and trial-and-error learning	Ball et al., 2018, 2020 Crawford et al., 2021 Douglas & Gedded, 2018 Öztürk et al. 2020 Whittingham et al. 2020 Whittingham & Douglas, 2014, 2016
Feeding	Gestalt Breastfeeding/ Bottle-feeding Support for baby ‘Fit-and-hold’ for breastfeeding based on gestalt biomechanical model with an overarching goal of maximising intra-oral breast tissue intake to achieve efficient milk transfer with minimal pain including: o mother’s positioning and use of body and limbs o awareness of baby’s positioning and use of micro-movements to adjust o minimising breast tissue drag o achieving positional stability during feeds o use of a clear ‘landing pad’ to avoid interference with fit-and-hold o mindfulness during feeding Use of paced-bottle-feeding when expressed breast milk or formula are being used by the family Offering flexible feeds throughout the day for a range of reasons, including nutrition, responsiveness to infant/maternal connection and allowing the infant to dial down at the breast/ bottle	Crawford et al., 2021 Douglas & Geddes, 2018 Douglas & Keogh, 2017 Douglas et al., 2022
Crying and Fussing	Education on normal infant crying behaviour over time and natural variability between infants Support to understand sympathetic nervous system and hypothalamic arousal and hyperarousal – ‘dialling up’, ‘dialling down’, and ‘conditioned dialling up at the breast’ Education about two tools for dialling down – feeds and sensory nourishment Use of the five-domain approach where sleep, maternal health, infant health, and feeding and sensory domains are considered when cry-fuss communication is considered	Crawford et al., 2021 Douglas et al., 2011 Douglas & Hill, 2011, 2013a, b
Parent Mental Health	Integrating Acceptance and Commitment Therapy approach when facing challenges with maternal mental health and/or infant care (acceptance, cognitive defusion, being present, self as context, values, and committed action) Mothers consider care for self (e.g., uncoupling sleep and maternal self-care) Use of mindfulness approach	Crawford et al., 2021 Harris, 2019 Whittingham & Douglas, 2016 Whittingham et al., 2020

NDC supports provision of cue-based care across infant-caregiver co-occupations such as sleep, feeding, and emotional regulation when infants are crying and fussing. This approach focuses on empowerment of families through education so that they can find and experiment with strategies that are workable within their own context. It aims to equip families with evidence-based ways (see Table 1 for references which detail this underpinning evidence) to care for their infant that are least invasive and benefit both infant and maternal well-being, including:

• ensuring infant cues are not ignored and responses are not delayed

• flexibility and two-way interaction are emphasised over rigid and inflexible, externally determined or parentally determined routines, algorithms, and schedules

• accounting for normal infant variability when considering the broad range of normal infant behaviour

• considering each family’s unique values, life circumstances, and ideas regarding what is workable in their own contexts

• framing assessment and intervention across five interdependent domains of infant sleep, infant feeding, infant sensory experiences for emotional regulation, maternal health (including mental health), and infant health, and

• avoiding over-medicalisation of normal infant behaviour. For example, ensuring thorough evidence-based assessment is carried out for reflux and ankyloglossia (tongue-tie) and, where relevant, providing families with alternative explanatory theories and strategies for sleep, cry-fuss, and feeding challenges.

Previous preliminary research supports the effectiveness of NDC in reducing infant crying time, improving mothers’ perceptions of infant sleep and their own sleep, and improvement of maternal mental health (Crawford et al., 2022), and indicates that parents’ experiences with this type of care involve increased feelings of enjoyment in the parenting role, reduced anxiety, and improved self-efficacy (Ball et al., 2018). Preliminary research with infants under 16 weeks of age also suggests that NDC reduced crying durations and elevated maternal mood (Douglas et al., 2013). Despite NDC being an approach to infant care that centres on infant-caregiver co-occupations of sleep, feeding, and emotional co-regulation, the ways in which NDC influences caregivers’ engagement in co-occupations with their infants is yet to be explored in research. Therefore, this study aimed to explore how day-to-day occupations of parents and infants are shaped by accessing NDC.

Methods

This project was part of a larger study that aimed to understand health professionals’ and caregivers’ perspectives on families’ experiences of receiving NDC services. The research question that underpinned this paper was, “How are daily occupations of parents/caregivers and infants shaped by accessing NDC services?” Ethical approval for this study was obtained from the Human Research Ethics Committee at the University of Queensland (project number 2021/HE000148).

Study design

This qualitative study was underpinned by an interpretive description approach (Thorne, 2016) and used inductive and deductive processes of thematic analysis (Fereday & Muir-Cochrane, 2006). Interpretive description was used to gain an understanding of the experiences of caregivers who used NDC, which provided knowledge with the potential to change practice in infant and maternal care (Thorne, 2016). Interpretive description acknowledges that researchers’ experience in clinical and research roles provide a source of insight throughout the research planning, data collection, and analysis phases (Thorne, 2016). This supports project design and interpretations of the data collected that are sensitive to the nuances of the real-world context and interwoven with practice-relevant perspectives on the phenomenon described by participants (Thorne, 2016). Interpretive description is considered to have increased legitimacy in clinical contexts (Thorne, 2016).

Researchers in this study included an occupational therapy researcher who had experience as a parent recipient of NDC services and had become an accredited NDC practitioner with some practice experience delivering NDC services (EJC), a qualified occupational therapist completing a Masters course (LW), an occupational therapy Honours Student (ECC), and the Possums & Co. founder, who is a general practitioner that developed NDC and has extensive experience delivering NDC services (PD). The two researchers with prior experience with NDC provided contextualisation and clinical perspectives to inform the research questions, methodology, and interpretations of the data in alignment with an interpretive description approach (Thorne, 2016). The two researchers with no previous experience with NDC provided balanced perspectives to ensure that interpretations were not only contextually and clinically informed but also closely reflective of the data (Thorne, 2016).

Research context

This research was carried out in 2021 through Possums & Co., which is a registered Australian Charity that delivers NDC services. It is based in Brisbane and delivers services online and face-to-face. The NDC program offers a five-domain approach that considers infant health, mother health, sleep, sensory experiences, and feeding (Crawford et al., 2022; Douglas & Hill, 2013b; Whittingham & Douglas, 2016). It acknowledges that difficulties with infant sleep, breastfeeding, cry-fuss behaviours, and maternal mood are commonly influential upon each other (Blunden & Dawson, 2020; Butler et al., 2021; Douglas, 2013; Douglas & Hill, 2011; Petzoldt, 2018). An overview of this program can be seen in Table 1, and a detailed explanation can be found in Crawford et al. (2022).

Participants and recruitment

Participants were recruited through purposive sampling via Possums & Co. social media pages (Possums & Co. website, Facebook, and Linked In) from March until May 2021. Participants provided informed consent through the secure online platform, Checkbox®. Inclusion criteria were:

1.	A caregiver of an infant(s) who is accessing or has previously accessed NDC services within Australia during the first 12-months of their infant’s life. The larger study also recruited health professionals, but this had not been done prior to data analysis for this component of the study
2.	English speaking or have access to an interpreter
3.	Provided informed consent. Participants were excluded if (1) not residents of Australia at the time of accessing NDC, or (2) if the caregiver or infant was acutely unwell at the time of recruitment or data collection.

Of the 20 people who registered their interest, two were excluded due to accessing services while living outside of Australia, and six did not reply to follow up emails after initial registration. There were 12 participants in total. Participants accessed services which use a mix of billing, which indicates that participants were self-funded service users. Some participants may have been able to claim some of their fees through Medicare.

Data collection

Data were gathered through semi-structured in-depth interviews with infant caregivers (all mothers). Participants were given the option of face-to-face, telephone, or online interviews, with participants choosing online video conferencing (n = 9) or telephone call (n = 3). An iterative consent process occurred, where verbal consent was also gained prior to the interview and throughout the interview process (Crawford & Turpin, 2018), with all participants consenting to the recording of interviews.

EJC conducted one interview for training purposes and 11 were conducted by LW. Five interviews were reviewed by EJC, with feedback on the interviewing process provided to LW. The semi-structured interviews were audio-recorded and ranged from 47-98 minutes in duration. All but one were transcribed verbatim, as one recording failed and detailed notes were written after the interview in place of a transcript.

Closed questions were used to gather demographic information on family income, age of participant and infant, educational attainment level, gender, and family structure. Family income was classified by quantiles as per Australian Bureau of Statistics household income, ranging from (1) AU$24,336, to (2) AU$53,248, to (3) AU$88,764, to (4) AU$135,928 to (5) AU$280,956 and above (Australian Bureau of Statistics, 2019).

The interviewers used open questions to gather rich information and to encourage reflection. The Intentional Strengths Interviewing model informed the interview guide by asking about what works, how things could be better when challenges existed, and using strengths-based follow up questions to respond to experiences shared by participants (Crawford & Turpin, 2018). An occupational perspective was used to inform the interview guide (Njelesani et al., 2014). For example, the interview asked about occupations in a typical day and how NDC shaped those occupations (see Table 2). Interviewers reflexively followed the natural conversational flow and consequently, questions were not always asked in the same order (Patton, 2002). Field notes were documented after each interview. Data were stored on a password protected server and participants were given pseudonyms upon registration.

Table 2. Interview Guide

Main Question	Prompting Questions
Demographic Information	Age of participant Age of infant (when interviewed and when first accessed NDC) Gender Educational attainment level Family income bracket Family structure Primary reason for accessing NDC and the number of sessions / types of service accessed
(1) Tell me about a typical day for you, your baby, and your family, from wake-up time right through to bedtime?	Have you incorporated any NDC strategies into that? If so, how? If not, why not? Have you found that these NDC strategies have worked? Have you had any challenges with implementing these strategies?
(2) Since accessing NDC, what has been the biggest change for your family?	Considering this change, what is the story of this change? Tell me about it. How did this change come about? What contributed to this change? What has helped with this change? Has it been a positive or negative change? Did you face any challenges in this process of change? What were they? Did you overcome them? What supported you to do that? What could be better so that you could overcome those challenges?
(3) Thinking about the NDC practitioner that you have been seeing, what could other infant care professionals learn from their work with your family?
(4) What would you like to see to improve in the service you have accessed? What are those improvements? Why do you suggest these changes to practice?
(5) NDC practitioners provide lots of information and do not prescribe what to do, but rather encourage you to experiment with strategies that you feel are a good fit for your family.	How did this feel for you? Tell me more about that Could you provide an example? Where do you think this feeling comes from/what does that mean to you? What could have made things easier/better/ less < insert feeling if negative>
(6) You came to Possums to receive support for sleep/feeding/cry-fuss and NDC advice is different to most of the mainstream advice that’s freely available.	How did receiving this different type of information feel for you? How did the people around you respond to it?
(7) Is there anything we haven’t talked about that you would like to tell me?

Data analysis

The thematic analysis combined inductive and deductive approaches (Fereday & Muir-Cochrane, 2006). Data were analysed using NVivo12 software. Themes that inductively arose from within the data were viewed in light of pre-formed ideas stemming from occupational science, relating to co-occupations, occupational orchestration, and occupational balance. The process is described below.

Prior to indexing the data, a process of inductive theme identification from within the data occurred. Initially three authors (EJC, ECC & LW) independently read the interview transcripts to familiarise themselves with the data. Each author then independently identified potential themes within the data using an inductive process, then met to discuss their ideas and arrived at an initial list of themes. After this initial theme identification, relevant occupational science concepts were identified as a way of understanding the experiences of the mothers who accessed NDC. For example, when a theme was identified regarding mothers balancing their occupations, concepts of occupational balance were then deductively identified.

The researchers then asked, “What are mothers saying about how their experiences with NDC have influenced occupational balance for them and their babies?”. The researchers returned to the data, with further reading of transcripts resulting in additional sub-themes being identified, for example, “flexibility in how mothers engaged in activities focused on caring for babies”. Oscillating between inductive and deductive approaches to analysis allowed for an occupationally focused thematic analysis which was strongly linked to the data, resulting in specific, rich descriptions of participants’ experiences (Braun & Clarke, 2016; Fereday & Muir-Cochrane, 2006; Lapan et al., 2012).

An iterative process of thematic inquiry was followed, where initial themes were continuously updated as the data were reviewed throughout the analysis. The process was informed by the methods developed by Morgan and Nica (2020). This involved writing rich descriptions of initial themes, prior to indexing the data, to ensure researchers’ preconceived notions of the themes were recorded. This ensured trustworthiness of the analysis. This process included identification of sub-themes within the initial theme descriptions, devising a preliminary codebook of themes and sub-themes; meeting with PD, who confirmed that the themes aligned with her independent readings of the data, along with her insights drawn from practice experience and feedback from Possums Program service users (Thorne, 2016); and indexing data in NVivo 12 using the codebook (Nowell et al., 2017). No themes were prioritized as having greater importance or significance than others.

Themes were then evaluated through indexing of the data by one author (ECC). Several new codes arose and were added to the codebook with no other changes to the original theme structure. Examination of the coding by another researcher (EJC) achieved 100% agreement. Examples of newly identified themes include “Mothers discuss the importance of NDC evidence base”, and “Positive societal reactions to NDC”. The initial write-up of the themes was revised to include newly identified themes and additional descriptions of the themes after all the data had been indexed, to arrive at the final descriptions of the themes.

Trustworthiness was enhanced via researcher triangulation, which involved multiple researchers with varying experience contributing to the analysis (Carter et al., 2014). Member checking was completed, where transcripts were provided to all participants prior to analysis (Doyle, 2007). No response was considered an indication of agreement with the data. Two out of ten participants responded to confirm the data collected was accurate and one participant provided additional comments on their experiences and personal reflections since the interview. An audit-trail was maintained, recording steps taken and keeping documentation for recruitment, data collection, analysis, and write-up.

Findings

All 12 participants were females and are hereafter referred to as “mothers”. All mothers had accessed NDC services in Australia as first-time mothers, except for one who accessed the service with her second child. When describing the infants of the participating mothers, the term “babies” is used because this was the language mothers used to refer to their own infant.

All participants (12) had a higher education degree (Bachelor or above) and were cohabiting with a male partner, who was the child’s father. Table 3 shows the study participants by age, educational attainment, family income, reason for and timing of accessing NDC services, and the services accessed. Pseudonyms have been used to ensure participants’ anonymity.

Table 3. Characteristics of interview participants

Pseudonym Name	Age	Educational Attainment Level	Family Income Quantile	Age of infant when access to NDC was initiated	Primary Reason for accessing NDC	Services Accessed
						Book	1:1 consult	Online Resources	SMA	PIPPS
Amy	30	Doctorate	3	Pregnancy, 16 weeks	Sleep	✓	✓
Belinda	37	Master’s Degree	3	Pregnancy, 12 weeks	Sleep	✓		✓
Caitlin	39	Master’s Degree	5	12 weeks	Cry-fuss		✓	✓
Daisy	35	Graduate Diploma	5	8 weeks	Feeding		✓		✓
Eva	32	Master’s Degree	4	8 weeks	Feeding		✓		✓	✓
Freya	31	Master’s Degree	2	Pregnancy	Feeding, sleep	✓		✓
Grace	29	Bachelor’s Degree	4	20 weeks	Feeding, sleep			✓
Hannah	31	Bachelor’s Degree	3	12 weeks (2^nd child)	Sleep			✓		✓
Ingrid	34	Master’s Degree	4	20 weeks	Sleep		✓	✓
Josie	36	Bachelor’s Degree	4	Pregnancy, 6 days	Feeding	✓	✓
Kathleen	40	Master’s Degree	4	9 weeks	Feeding		✓
Laura	34	Bachelor’s Degree	4	7 weeks	Feeding, cry-fuss	✓	✓

Note: 1:1 consult denotes a direct consultation with an NDC practitioner either face-to-face or online via a private Zoom session; online resources refer to Possums & Co. website and online videos/documents; book refers to ‘The discontented little baby book’ about NDC by Dr. Pamela Douglas, and PIPPS is the Possums & Co. parent portal (online resource videos, online mother’s group, support from parent mentors).

One overarching theme was identified regarding occupational engagement that focused on infant care: flexibility in activities and routines across the day. Mothers communicated that through engaging with NDC they were able to find better balance in their lives with flexibility when “thinking about the day as a whole” (Freya). Balance was found through engaging in occupations with their babies in a way that allowed them to be responsive and feel at-ease with the way they flexibly supported their babies to sleep, feed, and explore the world.

Flexibility in activities and routines across the day was described by mothers in relation to three sub-themes: sleep, feeding, and calming through sensory nourishment.

Flexibility in activities and routines across the day

Through engagement with NDC, mothers described that they started to put their own and their babies’ daily occupations together in new ways. Mothers described how new ways of arranging their days led to feeling more positively and that they had flexibility in their daily routines. Flexibility across the day was brought about by new understandings of what their babies’ needs were, and mothers trying new ways of engaging in mother-baby co-occupations through learning NDC strategies. Most mothers reported that when using an NDC approach, they felt free to observe their baby and respond based on what felt right to them according to their baby’s communication.

Mothers described how making decisions about their actions and plans based on their baby’s cues rather than predetermined schedules or set routines, helped them to respond to their baby:

If you know that you want to be a responsive parent and if you know that you don’t want to put your child down at (strictly) 2 o’clock each day, then you are going to follow what they say on Possums (NDC). (Grace)

Flexibility extended beyond just themselves and their baby. Mothers catered to the needs of other family members such as siblings, coordinating with other caregivers such as fathers, partners, grandparents, childcare, and babysitters. Most participants talked about developing new understandings about infant development and what is “normal”, babies’ needs, and new ways of interpreting babies’ communication. These new understandings underpinned mothers’ new insights into how they might flexibly orchestrate their occupations with their babies throughout the day, rather than following rigid routines and schedules. The ways in which mothers began to put their days together in new and more flexible ways with a focus on sleep, feeding, and settling are described.

Sleep

One of the main messages regarding daily routines was that NDC helped parents to let go of strict sleep schedules or routines and allowed parents to follow their babies’ cues for when they needed to sleep. Many mothers also discussed how NDC helped them understand normal variation in infant sleep times, and how this helped them to better understand their babies’ needs as individuals as well as reduce worry that “something was wrong” with their baby, when they did not conform to mainstream advice about amounts and times that babies should be sleeping, as discussed by Grace.

I thought there was something wrong with him, you know, and, like, I should be, you know, trying to get him to link the cycles and everything like that but then, um, you know, when [NDC practitioner] was talking about the 10 minutes, you know, like 10 minutes in the car is enough for some kids. Like that was him down to a T. Um, you know, and there are kids with, like, higher sleep needs but he’s not one of those kids.

Letting go of strict day time sleep routines such as strict sleep times, and sleeping in a cot in a dark room, helped parents have more freedom to go about their day. This allowed parents to not be restricted to only leaving their homes at certain times, allowing for parents to balance many daily occupations as discussed by Eva.

It was very different when we’d organised to catch up. I was always the one who was flexible with when we could go and where we would go, whereas she [mother who did not use NDC] was very timewise, had to be at certain places at certain times.

New understandings of babies’ communication or cues, as well as new knowledge of the concept of ‘building sleep pressure’ throughout the day, helped parents know when their baby was ready to sleep, rather than following predetermined sleep schedules, as discussed by Caitlin.

Just stop trying to force her to go to sleep when she didn’t want to go to sleep. Like one little eye rub shouldn’t be when – I mean, instant snooze now, otherwise the day is sunk, kind of thing.

Many parents also implemented new strategies, including having a regular wake up time to regulate baby’s circadian clock, co-sleeping with baby to reduce disruption to the parents’ sleep, and feeding to sleep. Eva explained how her family incorporated different sleep strategies.

We definitely use a set wake up time and then we use the no pressure on sleep as a way of building sleep pressure because we’re just doing other things. … she naps on the go, out in the bright light, in the noise, um, whether that’s on the floor, on a mattress, in the pram or it used to be the carrier or pram … And there’s trust that she’ll get the sleep she needs.

Feeding

Difficulties with feeding brought many families to access NDC services. Mothers discussed how NDC empowered them to feel like they could offer to feed their infant based on infant communication, rather than feeding based on a schedule, and this created more flexibility in daily routines. Hannah commented that she felt she could feed on cue with her second child, and this helped with her milk supply as well as enhanced her connection with her baby. This differed from her experience before accessing NDC with her first child.

So, for [younger child] to be able to feed him whenever he wanted to and not feel guilty about that has been really good. Because with [older child] I would feed him on cue, but, um had a lot of pressure from other people about that. Where with [youngest child], I know he doesn’t need a three-hour cycle. He can just feed whenever he wants to. And that’s really good for my supply and that idea of comfort sucking or needing a dummy. And I just say, well that’s his way of connecting with me and to me and he may be getting milk, he may not be getting milk, but it doesn’t really matter. It’s not why he is asking for a feed.

Almost all participants discussed their new understandings of how feeding frequently and flexibly in response to baby’s communication supported babies settling and sleep. This saw mothers using feeding as a tool to help their baby fall asleep or re-settle back to sleep in the night rather than only feeding for nourishment or feeding in a scheduled manner.

Mothers also discussed that they were able to reduce pain and discomfort by learning new ways of breastfeeding, reduce worry and anxiety about feeding, and reframe feeding as a time for bonding and enjoying time with baby rather than an activity to only provide nutrition that should take a certain amount of time at relatively regular intervals. Mothers described how the freedom to flexibly feed in response to their baby’s needs helped them to bond and connect with their infants. Kathleen described how she used feeding as a tool for responding to her baby’s cues, supporting her to settle her baby.

I guess the biggest thing as far as saying from go-to-woe, there was just lots of feeding after I had been to [NDC practitioner]. Like using the feeding for comfort or whatever I needed to.

Calming through sensory nourishment

Mothers discussed calming their babies using the term “dial down” to explain helping their babies to regulate their emotions and the behaviours they used to communicate their emotions, such as crying, fussing, back arching, screaming, or kicking. They explained that after accessing NDC, they were increasingly focused on providing meaningful activities to allow their babies to receive sensory nourishment from their environment that supported regulation of emotions and associated behavioural/communication responses. All mothers described seeking opportunities to provide more sensory nourishment for their babies throughout their days. All mothers discussed that after accessing NDC they began to consider how they could modify, and often increase, their infants’ sensory experiences to help calm their babies and began to try to incorporate “sensory nourishment” into their daily routines. Hannah described this as having her baby “experience the world”.

For mothers who accessed NDC, sensory nourishment meant providing their babies with everyday sensory experiences by engaging in meaningful occupations that allowed babies to receive stimulation from their environment. Mothers understood provision of sensory stimulation, through occupation, as one way of supporting their babies to dial down their emotional responses. For some mothers providing sensory nourishment involved planning occupations such as going to the “park” (Ingrid) or “art gallery” (Daisy), whereas for other mothers it was enriching everyday experiences such as bath time.

Through NDC, many mothers described learning about sensory needs and how they could respond to changes in their babies as they went through different developmental stages. This helped mothers to engage in mother-baby co-occupations in new ways and provided a range of strategies mothers could use flexibly as their infants changed across the first year of life when their infants became unsettled. Amy explained realising her baby needed increasing sensory stimulation as she developed in the early weeks.

I think she was about 6 weeks and that was when [NDC practitioner] said, ‘Now the sensory needs have changed.’ And then all of a sudden, like, 6 weeks in, it was already like, ‘The breast is not everything!’

Caitlin described changing her thinking about bath time so that she could respond to her baby’s need for sensory experiences. She began to see bath time as “sensory time” rather than “functional time”, which supported her to calm her baby for sleep, making night times more manageable. “Like our half hour sensory, all singing, all dancing baths, they’re a new thing since Possums (NDC), whereas previously it was like right, wash the baby”.

Mothers discussed how new understandings of their babies’ sensory needs helped them to better understand their babies’ communications, especially around nighttime sleeping. For many mothers, this was noticing when their babies were “dialled up” and using sensory strategies such as a change in environment to help their babies dial down, as well and noticing how tired their babies were and changing their routine to help build sleep pressure.

We can keep the evening going, and so we make sure that we’re still – yeah, we’ll still go for a walk in the evening. If she’s really dialled up, which often she is at some point, we’ll either go outside in the backyard or for a walk and that’s about settling her. (Amy)

Discussion

The aim of this research was to understand parents’ perspectives on how NDC services shaped their co-occupations with their infants. The analysis focused on exploring how NDC influenced mothers and infants’ occupations and co-occupations. From NDC, the participating mothers learnt new information about their infants’ development, needs, and communication and used this information to orchestrate their days together in flexible ways. This discussion provides an overview of the findings in the context of existing literature with specific focus on how these findings offer new perspectives on responsive infant care.

The process of orchestrating daily life might be considered central to the role of mothers of infants. Occupational orchestration is the mental and physical process that mothers/caregivers do in order to plan, co-ordinate, and enact their and their child’s current and emerging desires and needs (Larson, 2000; Larson & Miller-Bishoff, 2014). Other research that describes occupational orchestration has highlighted that this process is part of the maternal role for mothers of children with disabilities (Larson, 2000; McAuliffe et al., 2019). This research extends upon existing research about occupational orchestration by demonstrating mothers of typically developing infants orchestrating occupations and co-occupations to manage infant sleep, feeding, and emotional co-regulation. This research suggests that consideration of occupational orchestration may allow for reconceptualization of responsive infant care that supports flexibility in infant care and positive experiences for mothers.

After accessing NDC services, the participating mothers changed the way that they orchestrated their occupations and co-occupations with their infants to respond to their needs and communication. This was reflected in their descriptions of increased flexibility to respond to their infants throughout occupations and routines across the day for sleep, feeding, and calming baby with sensory experiences.

Previous research regarding NDC services has found that NDC is effective for improving sleep (Ball et al., 2018; Crawford et al., 2022; Whittingham et al., 2020), cry-fuss problems (Crawford et al., 2022; Douglas et al., 2013), and breastfeeding difficulties (Douglas et al., 2022; Öztürk et al., 2021) and mothers have reported improved mental health, reduced stress, reduced perceived sleep problems, and better quality of life, when using the NDC approach (Ball et al., 2018; Crawford et al., 2022). The qualitative findings from this study provide deeper insights into how NDC influenced meaningful everyday life occupations and routines for mothers and babies, with mothers becoming more flexible in co-occupations of sleep, feeding, and settling babies, which can be seen in light of responsive infant care.

Traditionally, responsive care has been understood as immediate reliable, contingent, and appropriate responses to infants’ pre-verbal signals (Ainsworth, 1979; Bornstein, 1989), by interpreting these cues with predetermined meanings. For example, that lip-smacking, head bobbing, or oral seeking indicates that an infant is hungry, and parents should respond rapidly with feeding their infant (Arnott & Brown, 2013). It has been linked to improved infant breastfeeding, sleep, and settling, as well as social, emotional, and cognitive development across childhood (Pearson et al., 2012). Responsive care is important to provide sensitive care that meets the needs of babies and supports their development (Feldman, 2015; Stein et al., 2013, 2014).

Overall, these findings bring to light a new view of responsive care, that zooms out from the call-and-response communication between infants and mothers/other caregivers. This novel and occupational view of responsive care elicited in these findings moves away from a reductionistic perspective of responding to each single infant cue, towards consideration of how a caregiver might respond more holistically by orchestrating their occupations throughout the day to respond to what they know of their infant and allow for flexibility to respond throughout the day. With consideration of existing literature describing NDC, this change is based on an understanding of the infant’s and mother’s individual physical and psychological needs, along with considerations of the mother-infant relationship (Crawford et al., 2022; Whittingham & Douglas, 2016). Thus, contrary to schedule based, prescriptive methods of infant care, which commonly encourage parents to delay or withhold responding to infant cues (Harries & Brown, 2019), these findings offer insights into a holistic, occupation-centric approach to infant care, NDC, that suits the individual baby and its needs and that allows the mother or primary caregiver to respond across the day and night.

The mothers in this study experienced changes in their perspectives. They began considering their babies’ communications within the context of occupations across the day, along with understandings of normal infant development, to work towards understanding the baby’s needs more holistically. This perspective suggests considering responsive care that includes parental registration of the infant’s pre-verbal cue and appropriate selection of a course of action (Young et al., 2017) but also goes further to consider the broader temporal context of daily life and understandings of infant development.

An approach to infant care that involves flexibility in fitting daily occupations with infants’ needs and communication was central to the findings and offers a new way of thinking about responsive care. For example, mothers experienced a shift in thinking to consider other factors that shape the sleep patterns of the baby, sensory needs, and other possible meanings behind infant communication such as “one little eye rub” within the wider context of infant’s communication and their development along with the context of the daily routine.

Mothers discussed learning to put together their day in new ways to make life more manageable for families in terms of sleep, feeding, and cry-fuss problems and they felt a sense of empowerment and freedom when making these changes. This shift in thinking towards a bigger-picture view of responsive infant care that centres on occupational orchestration has the potential to transform views of responsive care in relation to engagement in mother-infant co-occupations.

While various studies appear to support less responsive approaches to infant care, the findings are mixed and the quality of the research is questionable (Bryanton et al., 2013; Crichton & Symon, 2016; Douglas & Hill, 2013b; Kempler et al., 2015; Reuter et al., 2020). For example, research regarding sleep is often observational rather than involving randomised control trials (Adair et al., 1992; Smart & Hiscock, 2007). Many randomised control trials where the intervention requires restricting responsiveness have been unblinded and open to bias (Crichton & Symon, 2016). Overall, higher quality systematic reviews, meta-analysis, and randomised controlled trials suggest that more responsive care is most beneficial for infant and maternal health in the short and long term (Bryanton et al., 2013; Cooper et al., 2009; Douglas & Hill, 2013b; Öztürk et al., 2021). Delaying or withholding responses to infants’ cues can be distressing for parents and contribute to maternal depression and anxiety (Blunden et al., 2016; Etherton et al., 2016). In this research, mothers moved away from rigid schedules and routines that did not take infant communication into account and began to interact responsively with their infants.

Central to the role of mother or primary caregiver, dynamic thinking is required to make choices that support their child’s wants and needs in response to the child’s communication, while also considering how the care and opportunities they provide now may shape their future (Ring, 2006). The role of being a mother or primary caregiver is diverse and consistently evolving as they adapt to the everchanging needs of their developing child (Hansen, 2020). Some of a mother’s or primary caregiver’s role includes being their child’s educator, supporting play, and providing food and care to their child that supports their health and well-being (Hansen, 2020; Ring, 2006). Considering the findings in this analysis, that mothers of infants changed the way they orchestrated their occupations throughout the day to flexibly and responsively cater to the needs of their babies, perhaps suggests that adaptive thinking is central to how mothers provide responsive care. An increased focus on adaptive thinking and flexibility in infant and maternal care services may better support caregivers to provide responsive care.

The World Health Organisation (2020) advocated for services to support caregivers to provide responsive care for children under the age of 3 years. Given the new perspective on responsive care that has arisen through this research, antenatal education could include discussions with families about planning their days in ways that support balance in their lives and responsiveness to their infant. Currently most antenatal education has a medical focus on the birth and learning to care for their infant in the initial period (Australian Institute for Health and Welfare, 2021; Brock et al., 2014). Educating child and maternal health professionals about the concept of how mothers and other caregivers of infants plan and carry out their occupations through the day is crucial in providing support that addresses the normal yet modifiable stress faced by many families after babies are born related to feeding (Froehlich et al., 2015), crying and fussing (Leerkes & Qu, 2020), and sleep difficulties (Parade et al., 2019). With support, caregivers can respond to their infants when engaging in co-occupations, resulting in caregiver-infant bonding as well as promoting healthy infant development and maternal well-being (Slootjes et al., 2016). These research findings illustrate how NDC services have supported mothers to engage in responsive infant care.

Strengths, limitations, and future research

Participants self-selected to participate in this research. They are likely to have been self-funded service users (some of whom could claim Medicare rebates for part of their fees), and the sample size of 12 participants from Australia was relatively small, which may limit representativeness and transferability of the findings to other groups or settings. The findings should therefore be considered with caution. Future research might consider the perspectives and occupational experiences of families who experience socio-economic disadvantage and cannot access privately funded services. Research could also consider accessibility, relevance, and acceptability of NDC services in publicly funded services. Research considering international perspectives would extend on existing projects in the United Kingdom (Ball et al., 2020) and Turkey (Öztürk et al., 2021).

Participants learnt about this study through advertisements on Possums & Co. social media pages, webpage, and e-newsletters. Caregivers who experienced more challenging or negative experiences with Possums/NDC may not have been aware of this research project as they may have discontinued engagement with Possums & Co. or intentionally chosen to not participate. Caregivers who do not use online media would not have received information about this study.

This study includes participants who accessed NDC services across a broad range of locations and used a range of different resources, similar to some previous studies (Ball et al., 2018; Crawford et al., 2022), meaning these findings are not limited to one clinic. Participants in this study had varied household incomes (with parents in low-middle income earning brackets involved), which differs from previous NDC studies where predominately high earning families participated.

Participants in this project identified as mothers. This research did not include perspectives of fathers or other primary caregivers. Future research could include perspectives from a broader range of caregivers. Future research into the processes of how parents/caregivers of infants orchestrate their days and how this relates to responsive caregiving will expand understandings of responsive care beyond the traditional perspective.

Conclusion

This study aimed to understand caregivers’ perspectives on how NDC services shaped their co-occupations with their infants. Mothers in this study communicated that through engaging with NDC services they changed the ways in which they engaged in co-occupations with their infants and orchestrated their daily occupations. Mothers in this study found that NDC supported them to balance a range of different occupations flexibly, including leisure and social occupations and occupations to care for themselves. The findings elicited a new perspective on responsive infant care that moves beyond an approach that focuses on reading and responding to single instances of infant cuing, towards understanding how mothers/caregivers can orchestrate their days to be flexible and responsive to all their infant’s needs. Further research into how caregivers of infants flexibly orchestrate their occupations throughout the day to respond to their infants needs and communication could enhance support for families throughout the perinatal period.

Acknowledgments

We acknowledge and pay respect to the Traditional Owners and their custodianship of the many lands on which this work was carried out across Australia. We pay our respects to the Turrbal and Yugara peoples and their custodianship of the land on which the researchers live and work. We pay our respects to their Ancestors and their descendants, who continue cultural and spiritual connections to Country. We recognise their valuable contributions to Australian and global society.

We also acknowledge the generosity of the mothers who participated in this study. This project received no funding.

Disclosure Statement

No potential conflict of interest was reported by the author(s).