Dr. Maria José Alvarez Gómez. Pediatrician. Mendillorri Primary Care Health Centre. Pamplona, Spain

V. RESULTS
The Parent Questionnaire was completed by 72% of parents (88% mothers, 12% fathers). Parent characteristics included:

VI. DISCUSSION
Focusing on babies' first interactions with parents is a promising approach for primary pediatric care providers. Creating a therapeutic alliance with parents strengthens these interventions. More specifically, this study shows that the NBO can be used to engage families and support the parent-child relationship, and in turn, improve child developmental outcomes.

The NBO helps health professionals communicate with parents. It seems to facilitate an attitude of respectful listening to parents'; it fosters collaborative interactions with families and promotes the development of a common language with a family that focuses on the child's behavior. Together, these elements reinforce child strengths and support and empower families in their role as parents. As a result, parents are better able to share their ideas and participate in their child's medical visit.

In this study, parents reported learning a lot about their newborns' competencies after the NBO visit. Several parents commented "But… can they already see?" and "Oh, I thought they couldn't see properly; maybe they can see some shadows." when they witnessed their child tracking the red ball or the rattle. More than 81% of families felt that the NBO helped them know their baby more. Similarly, the attachment relationship between child and parent was reinforced when the newborn looked at the parents' face or turned its head toward the parent's voice. Eighty percent of the parents felt closer to their baby as a result of the session. The NBO enabled families to appreciate their child's individual characteristics (i.e. strengths and limitations) and perceive the newborn as a real person.

Figure 3: Aimar's mother observes how he tracks the ball

Furthermore, parents said they learned how to interact with and respond to their infant because they realized how the baby communicates through his/her behavior. As a result, parents felt confident and empowered. By observing infant behaviors collaboratively and encouraging parents to respond to those behaviors, the NBO offers parents an opportunity to discover the strengths in their child and in themselves, skills that they can hopefully, take with them and practice at home.

Figure 4: Pablo prefers mummy's voice

NBO observations revealed that 5% of newborns cried "a lot" and were difficult to soothe. More over, 10% of the infants did not demonstrate competent state regulation. These findings compare to previously reported statistics (Chess & Thomas, 1996) of "difficult" temperament in the broader population. Infant temperament can have a major influence on parenting. Hypersensitive children with difficult temperaments, who are difficult to soothe are stressful for caregivers. In these situations, parents may experience heightened anxiety, tension and/or negative perception of the child, all of which undermine parental confidence and nurturing caregiving. During times such as these, offering strategies to parents to help them manage their child's behavior can be helpful.

During my visit with parents, if a baby began to cry I would wait for a short while to observe if the infant was capable of self-soothing. If the newborn could not manage to self-regulate on his/her own, I would model different ways of soothing and then encourage the parent to try their own ways. Some manipulated their voice, face and/or posture to comfort the baby while others tried swaddling, rocking, and sucking techniques. For most parents, a crying baby is a sign of their failure as a parent; they feel guilty and responsible for their child's distress. Many parents will ask "What am I doing wrong?" With the NBO, parents are able to discover that newborns are born with self-regulating capacities and that their external support facilitates this skill. Reinforcing the importance of swift, frequent responsiveness to a child's behavior was particularly relevant for families in Spain because of the cultural belief that responding to a crying baby is indulgent and leads to the child being spoiled.

All of child development exists in context (Bronfrennbrenner, 2001; Bronfrenbreener, 2005; Fogel, A., Maria, & Lyra, 1997; Moen, Elder, & Luscher, 1995) and is especially affected by the parent-child relationship (Bigelow, 1999; Bornstein & Bornstein, 1995; Bowlby, 1988; Brazelton, & Cramer, 1990; Bronfrenbrenner, 1986). Helping parents recognize the behaviors of their newborn and the important role they play has implications for child outcomes. As described above, newborn emotional regulation is just one example of how infant behavior can be influenced by the quality of parent-child interactions.

With the NBO, providers are able to guide parents to discover the individual behaviors of the newborn and improve their responsiveness as parents. By establishing a therapeutic alliance with families, providers can transform parent's perceptions of their newborn. Using the strengths of the child, parents redefine the baby. Offering parents strategies for interacting with their child reeducates parents. Showing parents how the newborn can change his/her behavior as a result of their nurturance remediates the infant (Sameroff, 2000).

To conclude, documenting the effectiveness of relationship-based interventions like the NBO is important for both scientists and clinicians alike. This study shows that the NBO approach has a positive effect on the infant and parent and on the development of the infant-parent relationship. In the words of some parents in this study:

• "This first visit to the paediatrician has been a very positive experience. I've felt that my son is somebody really important for the paediatrician. I felt very safe and protected knowing that the paediatrician is interested in many other things besides weight and height."
• "In my case, it has helped me to "name" some of the reactions I had observed in my baby and whose causes I knew by intuition".
• "It has reinforced my confidence as a mother".
• "It also makes you trust more in your paediatrician and, personally I think that, without being less important her help as a doctor, is even more important her capacity to generate parents confidence"
• "We find the new focus of the paediatric visit is more attentive to the individual development of each baby and makes parent's not obsess with numbers regarding weight and height".
• "It's very unusual that our medical system dedicates time to observe and listen and we have to thank the fact that things are not made in a mechanical way but with interest".
• "I think having a clearer idea of the baby's temperament may be very useful".
• "Just some days of life and they are able to do so many things. Sounds, colors, how he focuses the gaze...I couldn't believe it!"
• "More than anything to see how my baby turned to me while I was speaking; even if she was crying..."
• "I think to assess the baby's development in so many aspects is right, so is the fact the visit is so relaxed and we parents feel like participants".
• "A wonderful session"
• "I think it's going to help us very much to communicate with the baby as he's growing up".

Acknowledgements:
Maria Ángeles Nuin Villanueva for her help with statistical analyses.
(Evaluation and Quality Medical Attendance Service of Primary Care in Servicio Navarro de Salud. Pamplona, Spain)

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