Salivary cortisol response in mother-infant dyads at high psychosocial risk

Glucose variability increases during minimally invasive procedures in very preterm infants

The objective of this study is to assess the effect of neonatal procedures on glucose variability in very preterm infants. Preterm infants (≤ 32 weeks gestation and/or birthweight ≤ 1500 g) were started on continuous glucose monitoring (CGM) on day 2 of birth and monitored for 5 days. Minimally invasive (heel stick, venipunctures) and non-invasive (nappy change, parental presence) procedures were recorded. CGM data were analyzed 30 min before and after each procedure. The primary outcome was the coefficient of glucose variation (CV = SD/mean) before and after the procedure; SD and median glucose were also evaluated. We analyzed 496 procedures in 22 neonates (GA 30.5 weeks [29-31]; birthweight 1300 g [950-1476]). Median glucose did not change before and after each procedure, while CV and SD increased after heel prick (p = 0.017 and 0.030), venipuncture (p = 0.010 and 0.030), and nappy change (p < 0.001 and < 0.001), in the absence of a difference during parental presence.

CONCLUSIONS

Non-invasive and minimally invasive procedures increase glucose variability in the absence of changes of mean glucose.

WHAT IS KNOWN

• Minimally invasive procedures - including nappy change - may increase neonatal stress in preterm infants.

WHAT IS NEW

• Continuous glucose monitoring provides a quantitative measure of neonatal stress during neonatal care procedures demonstrating an increase of glucose variability.

Basal and reactive cortisol: A systematic literature review of offspring of parents with depressive and bipolar disorders

One of the most consistent biological findings in the study of affective disorders is that those with depression commonly show abnormal cortisol response, which suggests dysregulation of the hypothalamic-pituitary-adrenal (HPA) axis. Children of parents with mood disorders offer the opportunity to explore the biological pathways that may confer risk for psychopathology. This review explores basal and reactive cortisol in the offspring of parents who are currently depressed or have had a history of a depressive or bipolar disorder. Using PRISMA guidelines, search terms yielded 2002 manuscripts. After screening, 87 of these manuscripts were included. Results from the literature suggest that while the degree and direction of dysregulation varies, offspring of a parent with depression tend to show elevations in both basal (particularly morning and evening) and reactive (tentatively for social stressors) cortisol levels. There were few studies focused on offspring of parents with bipolar disorder. This review also discusses implications and recommendations for future research regarding the HPA axis in the intergenerational transmission of depressive disorders.

A Randomized Trial of Continuous Versus Intermittent Skin-to-Skin Contact After Premature Birth and the Effects on Mother-Infant Interaction

BACKGROUND

Premature birth affects opportunities for interaction between infants and mothers. Skin-to-skin contact (SSC) is standard care in neonatal care but has not been sufficiently studied regarding the effects on interaction between preterm infant and mothers.

PURPOSE

The purpose of this study was to compare interaction between preterm infants and their mothers after continuous versus intermittent SSC from birth to discharge. A secondary aim was to study a potential dose-response effect between time in SSC and quality of interaction.

METHODS

Families were randomly assigned to either continuous (n = 17) or intermittent (n = 14) SSC before delivery. Interaction was measured from videotapes of a Still-Face Paradigm collected at 4 months' corrected age. Face-to-face interaction was coded according to Ainsworth's Maternal Sensitivity Scales and the Maternal Sensitivity and Responsivity Scales-R. Dose-response correlations were calculated between mean time spent in SSC and each of the interaction scales.

RESULTS

There were no statistically significant differences between groups in maternal interactive behavior toward their infants regarding sensitivity, interference, availability, acceptance, withdrawal, or intrusivity. There was no correlation between mean time in SSC and quality of interaction.

IMPLICATIONS FOR PRACTICE

Continuous SSC from birth to discharge was not superior to intermittent SSC concerning mother-infant interaction between preterm infants and their mothers at 4 months' corrected age. However, compared with other studies, mean time in SSC was also high in the intermittent group.

IMPLICATIONS FOR RESEARCH

Further studies are needed to find out how interaction between parents and preterm infants can be improved, supported, and facilitated in the neonatal intensive care unit (NICU) and whether there is an optimal dose for SSC.

The psychobiological consequences of child separation at the border: lessons from research on attachment and emotion regulation

In the spring of 2018, the Attorney General of the United States issued a memorandum declaring a "zero tolerance policy" under which all adults entering the United States illegally would be criminally prosecuted, and, if traveling with minor children, forcibly separated from their children. Although the government was ordered to reunite the children with their parents it is still unclear how many children have been or remain separated. Given the high risk of permanent harm to a vulnerable population, and the fact that this risk may continue into the near future, we present a review of what nearly eight decades of scholarly research has taught us about the damaging impact of deprivation and separation from parents. The article briefly reviews the origins of attachment theory as well as empirical studies that examine the psychobiological impact on children who experienced parental deprivation or separation. The paper concludes with recommendations, for future research.

Pain, Parental Involvement, and Oxytocin in the Neonatal Intensive Care Unit

Preterm infants (PTI) typically experience many painful and stressful procedures or events during their first weeks of life in a neonatal intensive care unit, and these can profoundly impact subsequent brain development and function. Several protective interventions during this sensitive period stimulate the oxytocin system, reduce pain and stress, and improve brain development. This review provides an overview of the environmental risk factors experienced by PTI during hospitalization, with a focus on the effects of pain, and early maternal separation. We also describe the long-term adverse effects of the simultaneous experiences of pain and maternal separation, and the potential beneficial effects of maternal vocalizations, parental contact, and several related processes, which appear to be mediated by the oxytocin system.

Effect of skin-to-skin contact on parents' sleep quality, mood, parent-infant interaction and cortisol concentrations in neonatal care units: study protocol of a randomised controlled trial

INTRODUCTION

Separation after preterm birth is a major stressor for infants and parents. Skin-to-skin contact (SSC) is a method of care suitable to use in the neonatal intensive care unit (NICU) to minimise separation between parents and infants. Less separation leads to increased possibilities for parent-infant interaction, provided that the parents' sleep quality is satisfactory. We aimed to evaluate the effect of continuous SSC on sleep quality and mood in parents of preterm infants born <33 weeks of gestation as well as the quality of parent-infant interaction and salivary cortisol concentrations at the time of discharge.

METHODS AND ANALYSIS

A randomised intervention study with two arms-intervention versus standard care. Data will be collected from 50 families. Eligible families will be randomly allocated to intervention or standard care when transferred from the intensive care room to the family-room in the NICU. The intervention consists of continuous SSC for four consecutive days and nights in the family-room. Data will be collected every day during the intervention and again at the time of discharge from the hospital. Outcome measures comprise activity tracker (Actigraph); validated self-rated questionnaires concerning sleep, mood and bonding; observed scorings of parental sensitivity and emotional availability and salivary cortisol. Data will be analysed with pairwise, repeated measures, Mann Whitney U-test will be used to compare groups and analysis of variance will be used to adjust for different hospitals and parents' gender.

ETHICS AND DISSEMINATION

The study is approved by the Regional Research Ethics Board at an appropriate university (2016/89-31). The results will be published in scientific journals. We will also use conferences and social media to disseminate our findings.

TRIAL REGISTRATION NUMBER

NCT03004677.

Preterm behavioral epigenetics: A systematic review

Behavioral epigenetics is revealing new pathways that lead individuals from early adversity exposures to later-in-life detrimental outcomes. Preterm birth constitutes one of the major adverse events in human development. Preterm infants are hospitalized in the Neonatal Intensive Care Unit (NICU) where they are exposed to life-saving yet pain-inducing procedures and to protective care. The application of behavioral epigenetics to the field of preterm studies (i.e., Preterm Behavioral Epigenetics, PBE) is rapidly growing and holds promises to provide valid insights for research and clinical activity. Here, the evidence of the epigenetic correlates of prenatal adversities, NICU-related environment and development of preterm infants is systematically reviewed. The findings suggest that a number of prenatal adverse (e.g., maternal depression and stress) and post-natal (e.g., NICU-related pain-related stress) events affect the developmental trajectories of preterm infants and children via epigenetic alterations of imprinted and stress-related genes. Nonetheless, the potential epigenetic vestiges of early care and protective interventions in NICU have not been investigated yet and this represents a fascinating challenge for future PBE research.

Telomere Length in Preterm Infants: A Promising Biomarker of Early Adversity and Care in the Neonatal Intensive Care Unit?

Preterm infants present an immature neurobehavioral profile at birth, even in absence of severe brain injuries and perinatal complications. As such, they require a long-lasting hospitalization in the Neonatal Intensive Care Unit (NICU), which is thought to grant at-risk newborns' survival, but still entails a number of physical, painful, and socio-emotional stressors. Hence, preterm birth and NICU stay represent an early adverse experience, which has been linked to detrimental consequences for neurological, neuro-endocrinal, behavioral, and socio-emotional development, as well as to disease later in life. Recent advances in the behavioral epigenetic field are helping us to unveil the potential mechanisms through which early NICU-related stress may lead to negative developmental outcomes. From this perspective, telomere regulation might be a key programming mechanism. Telomeres are the terminal portion of chromosomes and are known to get shorter with age. Moreover, telomere length (TL) is affected by the exposure to stress during early development. As such, TL might be an innovative biomarker of early adverse exposures in young infants and children. Unfortunately, there is paucity of studies investigating TL in populations of preterm infants and its association with known NICU-related stressors remains unexplored. In the present paper, the potential relevance of TL for research and clinical work with preterm infants will be underlined in the light of recent contributions linking progressive telomere shortening and early exposure to adverse experiences and stressful environments in humans. Finally, insights will be provided to guide clinically relevant translational research on TL in the field of VPT birth and NICU stay.

Biologic effects of stress and bonding in mother-infant pairs

OBJECTIVE

Maternal stress in humans influences behavior of children and can be assessed using biological markers. Mothers and their one-month-old infants were recruited from an existing study to examine baseline maternal serum oxytocin and hypothalamic-pituitary-adrenal axis response to infant blood heel stick stress as measured by salivary cortisol in the dyads. Objectives were to explore (1) relationships between mother and infant cortisol levels, (2) gender differences in infant biologic cortisol response, and (3) the association of cortisol levels in the dyads and maternal oxytocin levels

METHODS

Forty-two mother-infant dyads provided biologic samples and self-report data. Maternal oxytocin samples were obtained. Initial salivary cortisol was assessed in both the mother and infant, followed by a heel stick blood draw. Twenty minutes later, salivary cortisol was collected again from dyads.

RESULTS

Self-report measures were negative for depression and risk for childhood neglect. Although oxytocin and baseline cortisol in the infants was higher in mothers that did some breast-feeding, there was no statistically significant difference (p = 0.2 and p = 0.1, respectively). Analyses showed (a) higher baseline cortisol in mothers was related to higher baseline cortisol in infants (p ≤ 0.0001), (b) following the stressor, female infants had a larger positive change in cortisol, after adjusting for baseline cortisol (p = 0.045), and (c) there was no relationship between dyad cortisol levels and maternal oxytocin.

CONCLUSIONS

Maternal and infant biologic stress measures are related. Female infants have a larger hypothalamic-pituitary-adrenal response to a blood draw stressor as measured by salivary cortisol than male infants.

Salivary Cortisol Reactivity in Preterm Infants in Neonatal Intensive Care: An Integrative Review

Recently, more and more researchers have been using salivary cortisol reactivity to evaluate stress in preterm infants in the neonatal intensive care unit (NICU). The aim of this integrative literature review was to summarize the evidence of interventions leading to a change in salivary cortisol from the baseline in preterm infants in the NICU. The electronic databases of PubMed, CINAHL, Web of Science, and Scopus were searched for relevant studies. The inclusion criteria were studies with preterm infants exposed to an intervention evaluated by salivary cortisol reactivity before discharge from the NICU, which were published in English. In total, 16 studies were included. Eye-screening examination and heel lance provoked an increase in the salivary cortisol level. Music, prone position, and co-bedding among twins decreased the salivary cortisol level. Several studies reported a low rate of successful saliva sampling or did not use control groups. Future studies need to focus on non-painful interventions in order to learn more about salivary cortisol regulation in preterm infants. Moreover, these studies should use study designs comprising homogenous gestational and postnatal age groups, control groups, and reliable analysis methods that are able to detect cortisol in small amounts of saliva.

A randomised trial of continuous skin-to-skin contact after preterm birth and the effects on salivary cortisol, parental stress, depression, and breastfeeding

AIM

To evaluate the effects of almost continuous skin-to-skin contact (SSC) on salivary cortisol, parental stress, parental depression, and breastfeeding.

STUDY DESIGN

This is a randomised study engaging families of late preterm infants (32-35 weeks gestation). Salivary cortisol reactivity was measured in infants during a nappy change at one month corrected age, and in infants and mothers during still-face at four month corrected age. Both parents completed the Swedish Parenthood Stress Questionnaire (SPSQ) at one month and the Edinburgh Postnatal Depression Scale (EPDS) at one and four months. Ainsworth's sensitivity scale was used to control for parental sensitivity.

SUBJECTS

Thirty-seven families from two different neonatal care units in Sweden, randomised to either almost continuous SSC or standard care (SC).

RESULTS

Infants randomised to SSC had a lower salivary cortisol reactivity at one month (p=0.01). There was a correlation between the mothers' and the preterm infants' salivary cortisol levels at four months in the SSC group (ρ=0.65, p=0.005), but not in the SC group (ρ=0.14, p=0.63). Fathers in SSC scored lower on the SPSQ sub-scale spouse relationship problems compared to fathers in SC (p<0.05).

CONCLUSIONS

Almost continuous SSC decreases infants' cortisol reactivity in response to handling, improves the concordance between mothers' and infants' salivary cortisol levels, and decreases fathers' experiences of spouse relationship problems.

Does skin-to-skin contact reduce stress during diaper change in preterm infants?

BACKGROUND

Skin-to-skin contact reduces pain response in preterm infants subjected to minor painful procedures, such as heel lance. Diaper change is a procedure performed several times daily in hospitalized preterm infants. Routine care giving tasks such as diaper change may be stressful for the infant.

AIMS

The purpose of this study was to investigate whether diaper change induces stress and if skin-to-skin contact could reduce such stress, measured by changes in skin conductance.

STUDY DESIGN

This was a randomized crossover pilot study in 19 preterm infants with gestational age between 28 and 34 weeks. The diaper change procedure was done twice in each infant, once during skin-to-skin contact, and once in incubator or bed with the mother present.

OUTCOME MEASURES

During diaper change heart rate (HR), peripheral oxygen saturation (SpO2), and changes in skin conductance (SC) peaks per sec, using the Skin Conductance Algesimeter (SCA), were registered.

RESULTS

The mean SC peaks/sec increased/decreased significantly under/after change of diapers which thereby underpins that this is a stressful procedure for the preterm infant. Skin-to-skin contact (SSC) entails significantly lower stress levels (p<0.05) compared to diaper changed in an incubator/bed measured by the SCA.

CONCLUSIONS

Diaper change is a stressful procedure for preterm infants and may be ameliorated by skin-to-skin contact.

Closeness and separation in neonatal intensive care

In this paper, we highlight the need for acknowledging the importance and impact of both physical and emotional closeness between the preterm infant and parent in the neonatal intensive care unit. Physical closeness refers to being spatially close and emotional closeness to parental feelings of being emotionally connected to the infant (experiencing feelings of love, warmth and affection). Through consideration of the literature in this area, we outline some of the reasons why physical closeness and emotional closeness are crucial to the physical, emotional and social well-being of both the infant and the parent. These include positive effects on infant brain development, parent psychological well-being and on the parent–infant relationship. The influence of the neonatal unit environment and culture on physical and emotional closeness is also discussed.

The Stockholm Neonatal Family-Centered Care Study: effects on salivary cortisol in infants and their mothers

BACKGROUND

Parental involvement in the care of preterm infants in neonatal intensive care units (NICUs) is common, but little is known about the effect on stress responses in mothers and infants.

AIMS

The aim of this study is to evaluate the effect of family-centered care on salivary cortisol reactivity in mothers and preterm infants and the correlation between the mothers' and the preterm infants' salivary cortisol levels.

METHODS

This study is part of a randomized controlled trial conducted at two level-II NICUs, including Family Care (FC), where parents were able to stay 24h/day from admission to discharge, and Standard Care (SC). To investigate the cortisol response, saliva was collected from 289 preterm infants and their mothers before and after a diaper change at the time of discharge.

RESULTS

No significant differences were found between the two groups in salivary cortisol reactivity, either in mothers or in infants. The results revealed a correlation between preterm infants' and their mothers' baseline and response cortisol in the FC group: r=0.31 (p=0.001) and r=0.24 (p=0.01), respectively. Such correlation was not observed in the SC group: r=0.14 (p=0.14) and r=0.18 (p=0.07), respectively.

CONCLUSIONS

Family-centered care had no effect on salivary cortisol reactivity during diaper change. However, sharing the same environment may increase the concordance between preterm infants' and their mothers' salivary cortisol levels.

Family nurture intervention (FNI): methods and treatment protocol of a randomized controlled trial in the NICU

BACKGROUND

The stress that results from preterm birth, requisite acute care and prolonged physical separation in the Neonatal Intensive Care Unit (NICU) can have adverse physiological/psychological effects on both the infant and the mother. In particular, the experience compromises the establishment and maintenance of optimal mother-infant relationship, the subsequent development of the infant, and the mother's emotional well-being. These findings highlight the importance of investigating early interventions that are designed to overcome or reduce the effects of these environmental insults and challenges.

METHODS

This study is a randomized controlled trial (RCT) with blinded assessment comparing Standard Care (SC) with a novel Family Nurture Intervention (FNI). FNI targets preterm infants born 26-34 weeks postmenstrual age (PMA) and their mothers in the NICU. The intervention incorporates elements of mother-infant interventions with known efficacy and organizes them under a new theoretical context referred to collectively as calming activities. This intervention is facilitated by specially trained Nurture Specialists in three ways: 1) In the isolette through calming interactions between mother and infant via odor exchange, firm sustained touch and vocal soothing, and eye contact; 2) Outside the isolette during holding and feeding via the Calming Cycle; and 3) through family sessions designed to engage help and support the mother. In concert with infant neurobehavioral and physiological assessments from birth through 24 months corrected age (CA), maternal assessments are made using standard tools including anxiety, depression, attachment, support systems, temperament as well as physiological stress parameters. Quality of mother-infant interaction is also assessed. Our projected enrolment is 260 families (130 per group).

DISCUSSION

The FNI is designed to increase biologically important activities and behaviors that enhance maternally-mediated sensory experiences of preterm infants, as well as infant-mediated sensory experiences of the mother. Consequently, we are enlarging the testing of preterm infant neurodevelopment beyond that of previous research to include outcomes related to mother-infant interactions and mother-infant co-regulation. Our primary objective is to determine whether repeated engagement of the mother and her infant in the intervention's calming activities will improve the infant's developmental trajectory with respect to multiple outcomes. Our secondary objective is to assess the effectiveness of FNI in the physiological and psychological co-regulation of the mother and infant. We include aspects of neurodevelopment that have not been comprehensively measured in previous NICU interventions.

TRIAL REGISTRATION

ClinicalTrials.gov: NCT01439269.

Altered stress responses in children exposed to early adversity: a systematic review of salivary cortisol studies

Pathological stress responses are implicated in numerous disorders. Hypothalamic-pituitary-adrenal axis function is influenced by gene-environment interaction, with early-life environmental adversity having long-lasting effects. We examine the evidence that, in humans, these effects are apparent from infancy. We systematically reviewed published findings on cortisol response to a stressor, in 0-5-year-olds already exposed to adversity. Adversity was defined as a negative environmental influence present post-conception. We searched Ovid MEDLINE (1950-May 2010), EMBASE (1980-May 2010) and PsychINFO (1806-May 2010). We included peer-reviewed, English language studies that analysed salivary cortisol before and after a standardised stressor. We identified 30 studies, of which 27 reported a significant effect of adversity on the cortisol response to stress. Six of these demonstrated an effect of prenatal substance exposure. Thirteen studies found that psychosocial adversity increased cortisol reactivity. Three studies reported that cortisol reactivity could be normalised by intervention programmes. The studies were heterogeneous, both in nature of adversity studied and in stressor used, precluding meta-analysis and assessment of publication bias. Our review presents evidence that adversity disrupts the stress response from an early age. Longitudinal studies are required to determine whether effects persist, alter with time, or are reversible with intervention.

Maternal sensitivity buffers the adrenocortical implications of intimate partner violence exposure during early childhood

This study prospectively examined the effect of intimate partner violence (IPV) on adrenocortical reactivity and recovery during early childhood. The sample (n = 1102 mother–infant dyads; 49.2% male) was racially diverse and from predominantly low-income, rural communities. To measure IPV exposure mothers completed the Conflicts Tactics Scale, and her caretaking behaviors were observed when her child was approximately 7, 15, and 24 months of age. Children's saliva samples, later assayed for cortisol, were collected around challenge tasks designed to elicit emotional reactivity. IPV was related to a trajectory of increased cortisol reactivity from infancy to toddlerhood. By contrast, the trajectory for non-IPV-exposed children decreased in cortisol reactivity across 7 to 24 months of age. At the 24-month assessment, on average, toddlers did not exhibit a cortisol reaction; however, those exposed to high levels of violence continued to have reactivity. Accumulative levels of IPV across the first 2 years of life predicted cortisol reactivity at 24 months of age. Early (7-month) sensitive maternal behavior moderated this relationship, so that only children exposed to both early insensitivity and high accumulated IPV exhibited increased reactivity at the 24-month assessment. Findings are discussed in relation to the risky family framework.

Pharmacotherapeutic intervention in impulsive preschool children: The need for a comprehensive therapeutic approach

Impulsive and aggressive behaviour symptoms often are serious problems in children, even already at preschool age. Thus, effective treatment approaches are requested. In this comment pharmacotherapeutic treatment approaches, first of all risperidone, their limitations and alternative psychotherapeutic approaches are outlined.

Stress responses of neonates related to maternal characteristics

PURPOSE

To investigate the pre- and post-heelstick stress response patterns of infants and to identify related maternal factors.

MATERIALS AND METHODS

Fifty-two mothers and their 57 infants were studied. Stress response patterns in neonates were collected by measurements of pulse rate, oxygen saturation, and salivary cortisol. Maternal demographic factors and awakening saliva were collected.

RESULTS

Median level of pulse rate of infant increased from 132.1 to 140.4 beats per minute and salivary cortisol was elevated from 0.41 μg/dL to 0.70 μg/dL during the periods of discomfort, while oxygen saturation decreased from 97% to 95%. Infant's pulse rate change was negatively correlated with gestational age (GA) (r = - 0.37, p < 0.05), whereas the change of infants' salivary cortisol was correlated positively with maternal age (r = 0.29, p < 0.05). GA was the only independently significant predictor of pulse rate responses (R(2) = 0.15, p < 0.05). Influence of maternal age on infants' salivary cortisol changes (R(2) = 0.09, p < 0.05) was observed in a stepwise multiple regression.

CONCLUSION

These findings suggest that maternal age and gestational period can be influential factors for stress responses in infants. Therefore, it would be important to consider the demographic characteristics of mother-infant pairs to evaluate these influential factors.

Stressor paradigms in developmental studies: what does and does not work to produce mean increases in salivary cortisol

The stress response system is comprised of an intricate interconnected network that includes the hypothalamic-pituitary-adrenocortical (HPA) axis. The HPA axis maintains the organism's capacity to respond to acute and prolonged stressors and is a focus of research on the sequelae of stress. Human studies of the HPA system have been facilitated enormously by the development of salivary assays which measure cortisol, the steroid end-product of the HPA axis. The use of salivary cortisol is prevalent in child development stress research. However, in order to measure children's acute cortisol reactivity to circumscribed stressors, researchers must put children in stressful situations which produce elevated levels of cortisol. Unfortunately, many studies on the cortisol stress response in children use paradigms that fail to produce mean elevations in cortisol. This paper reviews stressor paradigms used with infants, children, and adolescents to guide researchers in selecting effective stressor tasks. A number of different types of stressor paradigms were examined, including: public speaking, negative emotion, relationship disruption/threatening, novelty, handling, and mild pain paradigms. With development, marked changes are evident in the effectiveness of the same stressor paradigm to provoke elevations in cortisol. Several factors appear to be critical in determining whether a stressor paradigm is successful, including the availability of coping resources and the extent to which, in older children, the task threatens the social self. A consideration of these issues is needed to promote the implementation of more effective stressor paradigms in human developmental psychoendocrine research.

Stress at three-month immunization: parents' and infants' salivary cortisol response in relation to the use of pacifier and oral glucose

The aims of the present study were to investigate (1) whether the salivary cortisol response could be dampened during a routine three-month immunization if the infant received sweet-tasting solution in combination with a pacifier and (2) stress experienced by parents during immunization of the infant. Ninety-eight infants were included into one of four intervention groups: 'glucose and pacifier', 'water and pacifier', 'glucose', or 'water'. Saliva was collected before and 30 min after the immunization. Infants' crying-time and parents' self-reported stress (VAS) were measured before and after immunization. Infants in the 'pacifier and glucose' group had a significantly smaller change in salivary cortisol than infants in the other groups (F(3,72)=3.1, p<0.05). In the 'glucose and pacifier' group the median salivary cortisol levels decreased 33% after the immunization. In the 'water and pacifier', 'glucose', and 'water' group median cortisol increased with 50%, 42%, and 8%, respectively. No significant differences in crying-time were observed between the intervention groups. If the infant cried before the immunization, the crying-time during the immunization was longer (p<0.01) and cortisol increased more (p<0.05). Median cortisol levels for parents decreased after the immunization (p<0.01). Median VAS increased 50% (p<0.0001) after immunization. First time parents rated higher stress on VAS before immunization (p<0.01). Parents' change in cortisol and VAS were significantly related to infants' crying time. In conclusion, the combination of oral glucose and pacifier dampen infants' salivary cortisol in response to the three-month immunization.