Breastfeeding, Early Prenatal Stress Intervention, and Infant Neurodevelopment

The Impact of Prenatal Stress Management Program on Maternal Breastfeeding and Neonatal Neurodevelopmental Parameters

The goal of this clinical trial is to determine whether antenatal maternal stress management using relaxation techniques improves breastfeeding effectiveness and neonatal neurodevelopmental outcomes. It is hypothesized that reducing maternal stress during pregnancy will enhance the initiation and continuation of exclusive breastfeeding until six months postpartum.

The management of antenatal maternal stress is expected to be reflected in both the newborn's behavior and proteins associated with neurodevelopment, such as Brain-Derived Neurotrophic Factor (BDNF) and Reelin.

The main research questions of this study include the following:

1. Does stress management in pregnant women using relaxation techniques increase the likelihood of exclusive breastfeeding at one and six months postpartum?
2. Does it impact neonatal and infant growth and behavior?
3. Does it alter neurotrophin levels in the fetus? This trial will provide insight into the potential benefits of prenatal stress reduction for both maternal and infant health outcomes.
4. "If prenatal stress management leads to changes in neurotrophins in the fetus, could these changes be linked to the success and duration of breastfeeding, as well as the infant's growth and behavior?

METHODOLOGY Researchers will compare three groups of pregnant women who will receive three different types of information during pregnancy.

• The first group, or intervention group (IG), will be trained in 8-10 structured individual sessions of relaxation techniques that they will apply throughout the pregnancy, along with structured information about breastfeeding.
• The second group, or Active Control group (ACG), will receive 8 individual structured educational courses about breastfeeding, childbirth and the needs of the newborn, and
• The third group, or Control Group (CG), will receive a standard use information provided by the hospital midwife stuff about childbirth and breastfeeding in 3-4 group meetings .

Participants will be primipara pregnant women native speaking of the Greek language and they will be included in the study after randomization based on the electronic system random.org , between the 15th and 20th week of gestation They will be studied in 4 time periods (phases) .

• The first phase, will be prenatally at the beginning of the study between 15th -20th week of gestation,
• the second phase, will be prenatally at the end of the study between the 34th and 36th week of gestation,
• the third phase, will be in the first month after childbirth and
• the fourth phase, will be in the 6th month of their baby's life. The study as well, will include the newborns of the participants in the third and fourth phase of the study, corresponding them to the group of their mothers.

Comparisons will be in each group and between the groups investigating the alteration of stress, anxiety and depression during the four time periods pre and postnatally . Concurrently the change in the belief of successful breastfeeding during the two first periods of time (phase 1 and 2 ) , prenatally, will be compared with the real outcome at the phase 3 and 4.

For each participant, the following data will be recorded:

Phases 1 and 2:

1. Demographic data
2. Pregnancy stress, assessed using the Prenatal Experience Brief Scale
3. Pregnancy anxiety, assessed using the Pregnancy Anxiety Questionnaire
4. Prenatal breastfeeding self-efficacy, assessed using the Prenatal e. Breastfeeding Self-Efficacy Scale

Phases 1, 2, 3, and 4:

1. Perceived stress, assessed using the Perceived Stress Scale-14 (PSS-14)
2. Postpartum depression, assessed using the Edinburgh Postpartum Depression Scale (EPDS)
3. Anxiety, assessed using the Spielberger State-Trait Anxiety Inventory (STAI)

Phases 3 and 4:

1. Breastfeeding self-efficacy, assessed using the Breastfeeding Self-Efficacy Scale
2. Breastfeeding-related questions from the Pregnancy Risk Assessment Monitoring System (PRAMS) of the CDC

Phase 4 only :

1. Maternal attachment, assessed using the Maternal Attachment Scale
2. Infant behavior, assessed using the Infant Behavior Questionnaire

For each newborn, the following data will be recorded:

1. Anthropometric measurements at birth (3rd phase) and at six months of age (4th phase).
2. Neonatal behavior, assessed between the 4th and 7th day of life (3rd phase) using the Neonatal Behavioral Assessment Scale (NBAS). The evaluation will be conducted by a healthcare professional trained and familiar with the use of this specific behavioral assessment tool.
3. Developmental milestones at six months of age (4th phase).
4. Infant behavior assessment at six months of age (4th phase), conducted using the Infant Behavior Questionnaire, which will be completed by the parents based on their own observations and assessment

Biological Markers Collection and Analysis

The collection of biological markers is structured according to the study phase:

• In phases 1 and 2, salivary cortisol will be measured in pregnant participants. Participants will be asked to collect saliva using Salivettes (Sarstedt), following specific instructions provided by the manufacturer.
• In phases 1 and 3, maternal serum neurotrophins (BDNF and Reelin) will be analyzed. Additionally, in phase 3, umbilical cord serum neurotrophins will be measured.

Saliva Collection and Analysis

Saliva collection will be conducted at four time points throughout the day to assess the circadian rhythm of each pregnant participant:

• Morning, immediately upon awakening
• 30 minutes after awakening
• Afternoon, before lunch (around 3:00 PM)
• Night, before bedtime (around 12:00 AM) Pregnant participants will store the collected samples in the refrigerator until they bring them to the laboratory the following day. At the laboratory, the samples will undergo centrifugation followed by measurement using Chromatography/Mass Spectrometry.. The saliva samples will be centrifuged for 2 minutes at 1,000 × g, following the manufacturer's instructions.

Neurotrophin Measurement (BDNF & Reelin) - Phases 1 and 3

The measurement of BDNF and Reelin neurotrophins will be performed on serum blood samples collected at three time points:

1. Phase 1: At the start of the intervention (between 15-20 weeks of gestation) - maternal blood serum.
2. Phase 3: Before delivery (at hospital admission, marking the end of the prenatal intervention) - maternal blood serum.
3. Phase 3: During delivery - umbilical cord serum only. All blood samples will undergo centrifugation at 3500 rpm for 5-6 minutes. The separated serum will then be transferred into Eppendorf tubes and stored at -80°C until further analysis. Neurotrophin levels (BDNF & Reelin) will be measured using the ELISA method.

Inclusion Criteria:

• Primiparous pregnant women
• 14-20 weeks of Gestational Age
• Intention to give birth at the specific maternity hospital
• Greek women or foreigners who know the Greek language very well
• Place of residence: Greece

Exclusion Criteria:

• Use of benzodiazepines, major neuroleptics, or psychostimulant medications.
• Pregnant women diagnosed with incurable physical or mental diseases.
• Pregnant women carrying fetuses or newborns with major congenital anomalies or criteria for perinatal asphyxia.
• Pregnant women with stillbirths or newborns who do not survive.
• All mothers and their newborns born before 34 weeks of gestation or requiring hospitalization in the Neonatal Intensive Care Unit (NICU) for more than 7 days.