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van der Kemp J, Ketelaar M, Rentinck ICM, Sommers-Spijkerman MPJ, Benders MJNL, Gorter JW. Exploring Parents' Experiences and Needs During Disclosure of a Cerebral Palsy Diagnosis of Their Young Child: A Scoping Review. Child Care Health Dev 2024; 50:e13327. [PMID: 39343726 DOI: 10.1111/cch.13327] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/14/2024] [Revised: 07/07/2024] [Accepted: 08/14/2024] [Indexed: 10/01/2024]
Abstract
BACKGROUND Parents often perceive the news that their child has cerebral palsy (CP) as overwhelming and shocking. They are at increased risk of parental stress and mental health problems, which in turn can affect the interaction between the parent and the child. Parental mental health outcomes are known to be affected by the process of disclosure of a diagnosis. In this study, we aimed to synthesize the current knowledge about parents' experiences and needs regarding communication during the disclosure of the diagnosis of their child with (or at risk of) CP. METHODS A scoping review following the methodological steps outlined by the Joanna Briggs Institute was performed using PubMed, Embase, CINAHL and PsycINFO. We qualitatively explored parent-reported experiences and needs across included studies, using thematic analysis. RESULTS A total of 19 studies were included. Six themes were identified, three in relation to experiences (i.e., preceding experiences and feelings, perceptions of the disclosure and emotional impact) and three in relation to needs (i.e., transparency in information, supportive attitude and having a say). Despite high variability across studies regarding parental needs, most studies reported the need for (i) honest and clear information, (ii) good communication skills amongst professionals and (iii) emotional and practical support after diagnosis. CONCLUSIONS Our findings suggest that parents' experiences and needs in the period when their child's diagnosis of (high risk of) CP is communicated are highly variable, due to an interplay of personal and contextual factors. To facilitate good communication during disclosure, it is crucial that health care professionals assess and understand this complex process and consider parents' needs for open communication and autonomy in the process. Therefore, professionals need to attune to parents' needs and their individual preferences regarding conversations about their child with (or at risk of) CP.
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Affiliation(s)
- J van der Kemp
- Center of Excellence for Rehabilitation Medicine, UMC Utrecht Brain Center, University Medical Center Utrecht, De Hoogstraat Rehabilitation, Utrecht, The Netherlands
| | - M Ketelaar
- Center of Excellence for Rehabilitation Medicine, UMC Utrecht Brain Center, University Medical Center Utrecht, De Hoogstraat Rehabilitation, Utrecht, The Netherlands
- CanChild, Center for Childhood Disability Research, McMaster University, Hamilton, Canada
| | - I C M Rentinck
- Department of Pediatric Psychology, Wilhelmina Children's Hospital, University Medical Center Utrecht, Utrecht, The Netherlands
| | - M P J Sommers-Spijkerman
- Center of Excellence for Rehabilitation Medicine, UMC Utrecht Brain Center, University Medical Center Utrecht, De Hoogstraat Rehabilitation, Utrecht, The Netherlands
| | - M J N L Benders
- Department of Neonatology, Wilhelmina Children's Hospital, University Medical Center Utrecht, Utrecht, The Netherlands
| | - J W Gorter
- Center of Excellence for Rehabilitation Medicine, UMC Utrecht Brain Center, University Medical Center Utrecht, De Hoogstraat Rehabilitation, Utrecht, The Netherlands
- CanChild, Center for Childhood Disability Research, McMaster University, Hamilton, Canada
- Department of Rehabilitation, Physical Therapy Science and Sports, University Medical Center Utrecht, Utrecht, The Netherlands
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2
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Baker AC, Mercurio MR, Donn SM, Fanaroff JM. Ethical and Legal Perspectives on the Treatment of Hypoxic Ischemic Encephalopathy in the Newborn. Clin Perinatol 2024; 51:725-734. [PMID: 39095106 DOI: 10.1016/j.clp.2024.04.010] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 08/04/2024]
Abstract
Hypoxic ischemic encephalopathy (HIE) in neonates can cause severe, life-long functional impairments or death. Treatment of these neonates can involve ethically challenging questions about if, when, and how it may be appropriate to limit life-sustaining medical therapy. Further, parents whose infants suffer severe neurologic damage may seek recourse in the form of a medical malpractice lawsuit. This study uses several hypothetical cases to highlight important ethical and legal considerations in the care of infants with HIE.
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Affiliation(s)
- Alice C Baker
- Department of Pediatrics, Yale University School of Medicine, PO Box 208064, 333 Cedar Street, New Haven, CT 06519, USA
| | - Mark R Mercurio
- Program for Biomedical Ethics, Department of Pediatrics, Yale University School of Medicine, PO Box 208064, 333 Cedar Street, New Haven, CT 06519, USA
| | - Steven M Donn
- Division of Neonatal-Perinatal Medicine, Department of Pediatrics, C.S. Mott Children's Hospital, Michigan Medicine, 1540 East Hospital Drive, Ann Arbor, MI 48109, USA
| | - Jonathan M Fanaroff
- Department of Pediatrics, Case Western Reserve University School of Medicine, 11100 Euclid Avenue, Cleveland, OH 44106, USA; Rainbow Center for Pediatric Ethics, Rainbow Babies & Children's Hospital, Cleveland, OH, USA.
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3
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Camerota M, Lester BM. Neurobehavioral outcomes of preterm infants: toward a holistic approach. Pediatr Res 2024:10.1038/s41390-024-03505-9. [PMID: 39179875 DOI: 10.1038/s41390-024-03505-9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/01/2024] [Revised: 07/30/2024] [Accepted: 08/07/2024] [Indexed: 08/26/2024]
Abstract
Children born very preterm (VPT; <32 weeks gestation) are at high risk for adverse developmental outcomes, yet not all children fare poorly. Some children born VPT have few or no neurodevelopmental concerns, while others have significant impairment in one or more domains. Historically, research has taken a variable-centered approach, reporting rates of impairment in single domains or single assessments as if they are independent of one another. More recently, child-centered approaches have been applied to studying outcomes for preterm children. Child-centered analyses allow us to integrate across multiple measures and domains to more holistically describe groups of children who vary in terms of the severity and co-occurrence of neurodevelopmental and behavioral strengths and difficulties. In this review, we will summarize current research that has taken a "whole child" approach to describing neurodevelopmental outcomes following preterm birth while highlighting the implications of this approach for research and clinical practice. We end by describing unanswered questions and areas that are in need of future research. IMPACT: Most research on outcomes for children born very preterm has reported rates of impairment in single domains or on single instruments. Recent findings suggest that a child-centered approach can identify unique phenotypes composed of multiple measures and domains that may be of clinical interest. A better understanding of unique combinations of neurodevelopmental and behavioral strengths and weaknesses could improve post-NICU care by emphasizing a personalized approach to intervention and treatment.
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Affiliation(s)
- Marie Camerota
- Center for the Study of Children at Risk, Warren Alpert Medical School of Brown University & Women and Infants Hospital, Providence, RI, US.
| | - Barry M Lester
- Center for the Study of Children at Risk, Warren Alpert Medical School of Brown University & Women and Infants Hospital, Providence, RI, US
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4
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Vermilion P, Boss R. Pediatric Perspectives on Palliative Care in the Neurocritical Care Unit. Neurocrit Care 2024:10.1007/s12028-024-02076-1. [PMID: 39138717 DOI: 10.1007/s12028-024-02076-1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/13/2024] [Accepted: 07/09/2024] [Indexed: 08/15/2024]
Abstract
Pediatric neurocritical care teams care for patients and families facing the potential for significant neurologic impairment and high mortality. Such admissions are often marked by significant prognostic uncertainty, high levels of parental emotional overload, and multiple potentially life-altering decision points. In addition to clinical acumen, families desire clear and consistent communication, supported decision-making, a multidisciplinary approach to psychosocial supports throughout an admission, and comprehensive bereavement support after a death. Distinct from their adult counterparts, pediatric providers care for a broader set of rare diagnoses with limited prognostic information. Decision-making requires its own ethical framework, with substitutive judgment giving way to the best interest standard as well as "good parent" narratives. When a child dies, bereavement support is often needed for the broader community. There will always be a role for specialist palliative care consultation in the pediatric neurocritical care unit, but the care of every patient and family will be well served by improving these primary palliative care skills.
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Affiliation(s)
- Paul Vermilion
- Department of Medicine, Pediatrics, and Neurology, University of Rochester Medical Center, 601 Elmwood Avenue, Box 687 , Rochester, NY, USA.
| | - Renee Boss
- Department of Pediatric Palliative Care, Johns Hopkins University School of Medicine, Baltimore, MD, USA
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5
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Guez-Barber D, Pilon B. Parental impact during and after neonatal intensive care admission. Semin Perinatol 2024; 48:151926. [PMID: 38964994 DOI: 10.1016/j.semperi.2024.151926] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 07/06/2024]
Abstract
Parents play a pivotal role in neurodevelopmental outcomes of their children in the neonatal intensive care unit (NICU) and beyond. Integration of parents in clinical care and research is synergistic. Engaged parents yield more comprehensive clinical care and more robust and meaningful research products. Subsequently, successful clinical and research efforts improve outcomes for children. We review strategies for parental integration into NICU clinical care and research, including parental involvement in therapeutic interventions and neurodevelopmental care, and effective communication strategies for clinicians and researchers. We discuss challenges in neonatal trials and emphasize the need for building a culture of research, collaborative partnerships with patient advocacy organizations, and ongoing support beyond the NICU. Overall, we call for recognizing and fostering the impactful role of parents as teammates with clinicians and researchers in optimizing neurodevelopmental outcomes in the NICU and beyond.
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Affiliation(s)
- Danielle Guez-Barber
- Instructor, Division of Neurology, Department of Pediatrics, The Children's Hospital of Philadelphia (CHOP), Philadelphia, PA 19104, USA; University of Pennsylvania Perelman School of Medicine, Philadelphia, PA 19104, USA.
| | - Betsy Pilon
- Executive Director, Hope for HIE, West Bloomfield, MI 48325, USA
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6
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Baba A, Aregbesola A, Caldwell PHY, Elliott SA, Elsman EBM, Fernandes RM, Hartling L, Heath A, Kelly LE, Preston J, Sammy A, Webbe J, Williams K, Woolfall K, Klassen TP, Offringa M. Developments in the Design, Conduct, and Reporting of Child Health Trials. Pediatrics 2024; 154:e2024065799. [PMID: 38832441 DOI: 10.1542/peds.2024-065799] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/17/2024] [Revised: 03/25/2024] [Accepted: 03/28/2024] [Indexed: 06/05/2024] Open
Abstract
To identify priority areas to improve the design, conduct, and reporting of pediatric clinical trials, the international expert network, Standards for Research (StaR) in Child Health, was assembled and published the first 6 Standards in Pediatrics in 2012. After a recent review summarizing the 247 publications by StaR Child Health authors that highlight research practices that add value and reduce research "waste," the current review assesses the progress in key child health trial methods areas: consent and recruitment, containing risk of bias, roles of data monitoring committees, appropriate sample size calculations, outcome selection and measurement, and age groups for pediatric trials. Although meaningful change has occurred within the child health research ecosystem, measurable progress is still disappointingly slow. In this context, we identify and review emerging trends that will advance the agenda of increased clinical usefulness of pediatric trials, including patient and public engagement, Bayesian statistical approaches, adaptive designs, and platform trials. We explore how implementation science approaches could be applied to effect measurable improvements in the design, conducted, and reporting of child health research.
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Affiliation(s)
- Ami Baba
- Child Health Evaluative Sciences, The Hospital for Sick Children Research Institute, Toronto, Ontario, Canada
| | - Alex Aregbesola
- Children's Hospital Research Institute of Manitoba, Winnipeg, Manitoba, Canada
- Department of Pediatrics and Child Health, Max Rady College of Medicine, Rady Faculty of Health Sciences, University of Manitoba, Winnipeg, Canada
| | - Patrina H Y Caldwell
- Discipline of Child and Adolescent Health, University of Sydney, Sydney, Australia
| | - Sarah A Elliott
- Cochrane Child Health
- Alberta Research Centre for Health Evidence, Department of Pediatrics, Faculty of Medicine and Dentistry, University of Alberta, Edmonton, Alberta, Canada
| | - Ellen B M Elsman
- Child Health Evaluative Sciences, The Hospital for Sick Children Research Institute, Toronto, Ontario, Canada
| | - Ricardo M Fernandes
- Clinical Pharmacology and Therapeutics, Faculty of Medicine, University of Lisbon, Lisbon, Portugal
| | - Lisa Hartling
- Cochrane Child Health
- Alberta Research Centre for Health Evidence, Department of Pediatrics, Faculty of Medicine and Dentistry, University of Alberta, Edmonton, Alberta, Canada
| | - Anna Heath
- Child Health Evaluative Sciences, The Hospital for Sick Children Research Institute, Toronto, Ontario, Canada
- Division of Biostatistics, Dalla Lana School of Public Health, University of Toronto, Toronto, Ontario, Canada
- Department of Statistical Science, University College London, London, United Kingdom
| | - Lauren E Kelly
- Children's Hospital Research Institute of Manitoba, Winnipeg, Manitoba, Canada
- Department of Pharmacology and Therapeutics, Rady Faculty of Medicine, University of Manitoba, Winnipeg, Canada
| | - Jennifer Preston
- National Institute for Health and Care Research (NIHR) Alder Hey Clinical Research Facility, Liverpool, United Kingdom
| | - Adrian Sammy
- Child Health Evaluative Sciences, The Hospital for Sick Children Research Institute, Toronto, Ontario, Canada
| | - James Webbe
- Section of Neonatal Medicine, Imperial College London, London, United Kingdom
| | - Katrina Williams
- Department of Paediatrics, Monash University and Developmental Paediatrics, Monash Children's Hospital, Melbourne, Australia
| | - Kerry Woolfall
- Department of Public Health, Policy and Systems, University of Liverpool, Liverpool, United Kingdom
| | - Terry P Klassen
- Children's Hospital Research Institute of Manitoba, Winnipeg, Manitoba, Canada
| | - Martin Offringa
- Child Health Evaluative Sciences, The Hospital for Sick Children Research Institute, Toronto, Ontario, Canada
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7
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Callahan KP, Farrell K, Gibbs K, Kielt MJ, Morris H, Nilan K, Thomas S, DeMauro SB. Childhood outcomes following discharge from a referral bronchopulmonary dysplasia program. J Perinatol 2024:10.1038/s41372-024-02035-w. [PMID: 38937610 DOI: 10.1038/s41372-024-02035-w] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/29/2024] [Revised: 06/13/2024] [Accepted: 06/18/2024] [Indexed: 06/29/2024]
Abstract
OBJECTIVES The primary objective of this study was to profile the childhood health, development, and health-related quality of life (HR QoL) for children with the most severe bronchopulmonary dysplasia (BPD), those discharged from a quaternary referral program. STUDY DESIGN We collected cross-sectional data through telephone interviews with 282 families of children ages 18 months to 11 years who had been discharged from a BPD referral program. RESULTS Respiratory morbidities were near universal, with 42% of children ever having required a tracheostomy and severity of these morbidities correlated with parent-reported health and QoL. Developmental morbidities were also marked: 97% required an individualized educational plan. While respiratory morbidities and overall health improved over time, developmental morbidities were increasingly prominent, resulting in lower quality of life. CONCLUSIONS Among children referred to a quaternary BPD program, respiratory and developmental morbidities are on numerous counts more severe than any reported in the literature.
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Affiliation(s)
- Katharine P Callahan
- Division of Neonatology, Children's Hospital of Philadelphia, Philadelphia, PA, USA.
- Department of Medical Ethics and Health Policy, The Perelman School of Medicine at the University of Pennsylvania, Philadelphia, PA, USA.
- The Perelman School of Medicine at the University of Pennsylvania, Philadelphia, PA, USA.
| | - Kathryn Farrell
- The Perelman School of Medicine at the University of Pennsylvania, Philadelphia, PA, USA
| | - Kathleen Gibbs
- Department of Medical Ethics and Health Policy, The Perelman School of Medicine at the University of Pennsylvania, Philadelphia, PA, USA
- The Perelman School of Medicine at the University of Pennsylvania, Philadelphia, PA, USA
| | | | - Heidi Morris
- Division of Neonatology, Children's Hospital of Philadelphia, Philadelphia, PA, USA
| | - Kathleen Nilan
- Division of Neonatology, Children's Hospital of Philadelphia, Philadelphia, PA, USA
| | | | - Sara B DeMauro
- Division of Neonatology, Children's Hospital of Philadelphia, Philadelphia, PA, USA
- The Perelman School of Medicine at the University of Pennsylvania, Philadelphia, PA, USA
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8
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Jansen L, Steggerda S, Rijken M, van Steenis A, de Vries L, Peeters-Scholte C, Vermeiren R, van Klink J. Social-emotional and behavioural issues after very preterm birth: Parental and teachers experiences. J Child Health Care 2024; 28:277-290. [PMID: 35993442 DOI: 10.1177/13674935221121881] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
Preterm infants are at risk of developing social-emotional and behavioural difficulties. To understand the experiences of their caregivers in day-to-day life, parents (at 2 and 10 years) and teachers (at 10 years) completed a behavioural questionnaire and answered two open-ended questions addressing their concerns and the most positive aspects regarding their child and/or pupil (born <32 weeks gestation). Their answers were analyzed using thematic content analysis. Parental concerns at two years related equally to themes in the clusters Developmental Milestones, Physical Development and Development in Relation to the Self and Others. At 10 years, both parents and teachers reported mainly within the cluster Development in Relation to the Self and Others, but the underlying themes differed. While parents more often mentioned their child's emotional development, teachers were more concerned about their pupils' difficulties interacting with their peers, due to a lack of social skills. In-depth qualitative analysis of what parents and teachers experience from day-to-day improves our understanding of the social-emotional and behavioural development of children born very preterm, revealing important topics that should be addressed during follow-up.
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Affiliation(s)
- Lisette Jansen
- Department of Medical Psychology, Leiden University Medical Center, Leiden, Netherlands
- Curium-LUMC Department of Child and Adolescent Psychiatry, Leiden University Medical Center, Leiden, Netherlands
| | - Sylke Steggerda
- Department of Neonatology, Leiden University Medical Center, Leiden, Netherlands
| | - Monique Rijken
- Department of Neonatology, Leiden University Medical Center, Leiden, Netherlands
| | - Andrea van Steenis
- Department of Neonatology, Leiden University Medical Center, Leiden, Netherlands
| | - Linda de Vries
- Department of Neonatology, Leiden University Medical Center, Leiden, Netherlands
| | | | - Robert Vermeiren
- Curium-LUMC Department of Child and Adolescent Psychiatry, Leiden University Medical Center, Leiden, Netherlands
- Youz, Parnassia Psychiatric Institute, The Hague, The Netherlands
| | - Jeanine van Klink
- Department of Medical Psychology, Leiden University Medical Center, Leiden, Netherlands
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9
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Meadow J, Arzu J, Rychlik K, Henner N. Trial of Therapy on Trial: Inconsistent Thresholds for Discussing Withdrawal of Life-Sustaining Therapies in the Neonatal Intensive Care Unit. Am J Perinatol 2024; 41:e794-e802. [PMID: 36096150 DOI: 10.1055/a-1941-4285] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/01/2022]
Abstract
OBJECTIVE This study aimed to establish the degree of variability in thresholds for discussing withdrawal of life-sustaining therapies (WLST) in periviable infants among neonatal intensive care unit (NICU) personnel. STUDY DESIGN A vignette-style survey was administered to NICU personnel at two urban NICUs assessing likelihood of discussing WLST or support for discussing WLST (on a scale from 1, not at all likely/supportive to 10, extremely likely/supportive) in 10 clinical scenarios. RESULTS Response rates ranged by clinical role from 26 to 89%. Participant responses ranged from 1 to 10 in 5 out of 10 vignettes for NICU attendings, and 9 out of 10 vignettes for bedside nurses. Lower gestational age (22-23 vs. 24-25 weeks) was associated with increased likelihood to discuss WLST in some but not all scenarios. CONCLUSION NICU personnel have widely variable criteria for discussing WLST which threatens the informed consent process surrounding resuscitation decisions in a "trial of therapy" framework. KEY POINTS · NICU personnel have variable criteria for WLST.. · Parents have little say in whether WLST is offered.. · Disclosure of variable criteria is not routine..
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Affiliation(s)
- Jacqueline Meadow
- Division of Neonatal-Perinatal Medicine, Department of Pediatrics, University of Michigan, C.S. Mott Children's Hospital, Ann Arbor, Michigan
| | - Jennifer Arzu
- Department of Preventive Medicine, Northwestern University Feinberg School of Medicine, Chicago, Illinois
| | - Karen Rychlik
- Department of Pediatrics, Northwestern University Feinberg School of Medicine, Chicago, Illinois
| | - Natalia Henner
- Division of Neonatology, Department of Pediatrics, Ann and Robert H. Lurie Children's Hospital of Chicago, Chicago, Illinois
- Division of Neonatology, Department of Pediatrics, Northwestern University Feinberg School of Medicine, Chicago, Illinois
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10
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Kilpatrick R, Greenberg RG. Making the Most of Missing Data. Pediatrics 2024; 153:e2023064938. [PMID: 38389480 DOI: 10.1542/peds.2023-064938] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 12/11/2023] [Indexed: 02/24/2024] Open
Affiliation(s)
- Ryan Kilpatrick
- Department of Pediatrics, Tufts University School of Medicine, Boston, Massachusetts
| | - Rachel G Greenberg
- Department of Pediatrics, Duke University Medical Center, Durham, North Carolina
- Duke Clinical Research Institute, Durham, North Carolina
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11
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Forth FA, Hammerle F, König J, Urschitz MS, Neuweiler P, Mildenberger E, Kidszun A. Optimistic vs Pessimistic Message Framing in Communicating Prognosis to Parents of Very Preterm Infants: The COPE Randomized Clinical Trial. JAMA Netw Open 2024; 7:e240105. [PMID: 38393728 PMCID: PMC10891472 DOI: 10.1001/jamanetworkopen.2024.0105] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/03/2023] [Accepted: 01/03/2024] [Indexed: 02/25/2024] Open
Abstract
Importance In the neonatal intensive care unit, there is a lack of understanding about how best to communicate the prognosis of a serious complication to parents. Objective To examine parental preferences and the effects of optimistic vs pessimistic message framing when providing prognostic information about a serious complication. Design, Setting, and Participants This crossover randomized clinical trial was conducted at a single German university medical center between June and October 2021. Eligible participants were parents of surviving preterm infants with a birth weight under 1500 g. Data were analyzed between October 2021 and August 2022. Interventions Alternating exposure to 2 scripted video vignettes showing a standardized conversation between a neonatologist and parents, portrayed by professional actors, about the prognosis of a hypothetical very preterm infant with severe intraventricular hemorrhage. The video vignettes differed in the framing of identical numerical outcome estimates as either probability of survival and probability of nonimpairment (optimistic framing) or a risk of death and impaired survival (pessimistic framing). Main Outcomes and Measures The primary outcome was preference odds (ratio of preference for optimistic vs pessimistic framing). Secondary outcomes included state anxiety, perceptions of communication, and recall of numerical estimates. Results Of 220 enrolled parents (142 [64.5%] mothers; mean [SD] age: mothers, 39.1 [5.6] years; fathers, 42.7 [6.9] years), 196 (89.1%) preferred optimistic and 24 (10.1%) preferred pessimistic framing (preference odds, 11.0; 95% CI, 6.28-19.10; P < .001). Preference for optimistic framing was more pronounced when presented second than when presented first (preference odds, 5.41; 95% CI, 1.77-16.48; P = .003). State anxiety scores were similar in both groups at baseline (mean difference, -0.34; -1.18 to 0.49; P = .42) and increased equally after the first video (mean difference, -0.55; 95% CI, -1.79 to 0.69; P = .39). After the second video, state anxiety scores decreased when optimistic framing followed pessimistic framing but remained unchanged when pessimistic framing followed optimistic framing (mean difference, 2.15; 95% CI, 0.91 to 3.39; P < .001). With optimistic framing, participants recalled numerical estimates more accurately for survival (odds ratio, 4.00; 95% CI, 1.64-9.79; P = .002) but not for impairment (odds ratio, 1.50; 95% CI, 0.85-2.63; P = .16). Conclusions and Relevance When given prognostic information about a serious complication, parents of very preterm infants may prefer optimistic framing. Optimistic framing may lead to more realistic expectations for survival, but not for impairment. Trial Registration German Clinical Trials Register (DRKS): DRKS00024466.
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Affiliation(s)
- Fiona A. Forth
- Division of Neonatology, Center for Pediatric and Adolescent Medicine, University Medical Center of the Johannes Gutenberg-University Mainz, Mainz, Germany
| | - Florian Hammerle
- Department of Pediatric and Adolescent Psychiatry and Psychotherapy, University Medical Center of the Johannes Gutenberg-University Mainz, Mainz, Germany
| | - Jochem König
- Division of Pediatric Epidemiology, Institute for Medical Biostatistics, Epidemiology and Informatics, University Medical Center of the Johannes Gutenberg-University Mainz, Mainz, Germany
| | - Michael S. Urschitz
- Division of Pediatric Epidemiology, Institute for Medical Biostatistics, Epidemiology and Informatics, University Medical Center of the Johannes Gutenberg-University Mainz, Mainz, Germany
| | - Philipp Neuweiler
- Journalistisches Seminar, Johannes Gutenberg-University Mainz, Mainz, Germany
| | - Eva Mildenberger
- Division of Neonatology, Center for Pediatric and Adolescent Medicine, University Medical Center of the Johannes Gutenberg-University Mainz, Mainz, Germany
| | - André Kidszun
- Division of Neonatology, Center for Pediatric and Adolescent Medicine, University Medical Center of the Johannes Gutenberg-University Mainz, Mainz, Germany
- Division of Neonatology, Department of Pediatrics, Inselspital, Bern University Hospital, University of Bern, Bern, Switzerland
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12
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Litt JS, Halfon N, Msall ME, Russ SA, Hintz SR. Ensuring Optimal Outcomes for Preterm Infants after NICU Discharge: A Life Course Health Development Approach to High-Risk Infant Follow-Up. CHILDREN (BASEL, SWITZERLAND) 2024; 11:146. [PMID: 38397258 PMCID: PMC10886801 DOI: 10.3390/children11020146] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 12/18/2023] [Revised: 01/18/2024] [Accepted: 01/20/2024] [Indexed: 02/25/2024]
Abstract
Children born prematurely (<37 weeks' gestation) have an increased risk for chronic health problems and developmental challenges compared to their term-born peers. The threats to health and development posed by prematurity, the unintended effects of life-sustaining neonatal intensive care, the associated neonatal morbidities, and the profound stressors to families affect well-being during infancy, childhood, adolescence, and beyond. Specialized clinical programs provide medical and developmental follow-up care for preterm infants after hospital discharge. High-risk infant follow-up, like most post-discharge health services, has many shortcomings, including unclear goals, inadequate support for infants, parents, and families, fragmented service provisions, poor coordination among providers, and an artificially foreshortened time horizon. There are well-documented inequities in care access and delivery. We propose applying a life course health development framework to clinical follow-up for children born prematurely that is contextually appropriate, developmentally responsive, and equitably deployed. The concepts of health development, unfolding, complexity, timing, plasticity, thriving, and harmony can be mapped to key components of follow-up care delivery to address pressing health challenges. This new approach envisions a more effective version of clinical follow-up to support the best possible functional outcomes and the opportunity for every premature infant to thrive within their family and community environments over their life course.
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Affiliation(s)
- Jonathan S. Litt
- Division of Newborn Medicine, Department of Pediatrics, Harvard Medical School, Boston, MA 02115, USA
- Department of Social and Behavioral Pediatrics, Harvard TH Chan School of Public Health, Boston, MA 02115, USA
| | - Neal Halfon
- Center for Healthier Children, Families, and Communities, University of California, Los Angeles, CA 90024, USA; (N.H.); (S.A.R.)
- Department of Pediatrics, University of California, Los Angeles David Geffen School of Medicine, Los Angeles, CA 90024, USA
- Department of Health Policy and Management, UCLA Fielding School of Public Health, Los Angeles, CA 90095, USA
- Department of Public Policy, UCLA Luskin School of Public Affairs, Los Angeles, CA 90095, USA
| | - Michael E. Msall
- Department of Pediatrics, Sections of Developmental and Behavioral Pediatrics and Kennedy Research Center on Intellectual and Neurodevelopmental Disabilities, University of Chicago Medicine, Chicago, IL 60637, USA;
| | - Shirley Ann Russ
- Center for Healthier Children, Families, and Communities, University of California, Los Angeles, CA 90024, USA; (N.H.); (S.A.R.)
- Department of Pediatrics, University of California, Los Angeles David Geffen School of Medicine, Los Angeles, CA 90024, USA
| | - Susan R. Hintz
- Division of Neonatal and Developmental Medicine, Department of Pediatrics, Stanford University School of Medicine, Palo Alto, CA 94305, USA;
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13
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Morillo Palomo A, Esquerda Aresté M, Riverola de Veciana A, Cambra Lasaosa FJ. End-of-life decision-making in the neonatal intensive care unit. Front Pediatr 2024; 11:1352485. [PMID: 38259598 PMCID: PMC10800896 DOI: 10.3389/fped.2023.1352485] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/08/2023] [Accepted: 12/27/2023] [Indexed: 01/24/2024] Open
Abstract
Most paediatric deaths occur in the neonatal period, many of them in neonatal intensive care units after withdrawal of life support or the decision not to initiate new treatments. In these circumstances, discussions with families and decision-making are fundamental elements of the care and attention given to newborn babies. In this context, bioethical deliberation can help us to identify the values at stake, the different courses of action to be taken, and the means to ensure that family-shared decision-making is appropriate to the patient's situation and in accordance with the family's values.
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Affiliation(s)
- Ana Morillo Palomo
- Neonatal Intensive Care Unit, Sant Joan de Déu Hospital, Barcelona, Spain
| | - Montse Esquerda Aresté
- Institut Borja de Bioètica, Universitat Ramon Llull, Barcelona, Spain
- School of Medicine, University of Lleida, Lleida, Spain
| | | | - Francisco José Cambra Lasaosa
- Institut Borja de Bioètica, Universitat Ramon Llull, Barcelona, Spain
- Pediatric Intensive Care Unit, Sant Joan de Déu Hospital, Barcelona, Spain
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14
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Kim S, Pistawka C, Langlois S, Osiovich H, Virani A, Kitchin V, Elliott AM. Genetic counselling considerations with genetic/genomic testing in Neonatal and Pediatric Intensive Care Units: A scoping review. Clin Genet 2024; 105:13-33. [PMID: 37927209 DOI: 10.1111/cge.14446] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/28/2023] [Revised: 09/23/2023] [Accepted: 10/15/2023] [Indexed: 11/07/2023]
Abstract
Genetic and genomic technologies can effectively diagnose numerous genetic disorders. Patients benefit when genetic counselling accompanies genetic testing and international guidelines recommend pre- and post-test genetic counselling with genome-wide sequencing. However, there is a gap in knowledge regarding the unique genetic counselling considerations with different types of genetic testing in the Neonatal Intensive Care Unit (NICU) and the Pediatric Intensive Care Unit (PICU). This scoping review was conducted to identify the gaps in care with respect to genetic counselling for infants/pediatric patients undergoing genetic and genomic testing in NICUs and PICUs and understand areas in need of improvement in order to optimize clinical care for patients, caregivers, and healthcare providers. Five databases (MEDLINE [Ovid], Embase [Ovid], PsycINFO [Ebsco], CENTRAL [Ovid], and CINHAL [Ebsco]) and grey literature were searched. A total of 170 studies were included and used for data extraction and analysis. This scoping review includes descriptive analysis, followed by a narrative account of the extracted data. Results were divided into three groups: pre-test, post-test, and comprehensive (both pre- and post-test) genetic counselling considerations based on indication for testing. More studies were conducted in the NICU than the PICU. Comprehensive genetic counselling was discussed in only 31% of all the included studies demonstrating the need for both pre-test and post-test genetic counselling for different clinical indications in addition to the need to account for different cultural aspects based on ethnicity and geographic factors.
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Affiliation(s)
- Sunu Kim
- Department of Medical Genetics, University of British Columbia, Vancouver, British Columbia, Canada
| | - Carly Pistawka
- Department of Microbiology and Immunology, University of British Columbia, Vancouver, British Columbia, Canada
| | - Sylvie Langlois
- Department of Medical Genetics, University of British Columbia, Vancouver, British Columbia, Canada
- BC Children's Hospital Research Institute, Vancouver, British Columbia, Canada
- Women's Health Research Institute, Vancouver, British Columbia, Canada
| | - Horacio Osiovich
- BC Children's Hospital Research Institute, Vancouver, British Columbia, Canada
- Women's Health Research Institute, Vancouver, British Columbia, Canada
- Department of Pediatrics, University of British Columbia, Vancouver, British Columbia, Canada
| | - Alice Virani
- Department of Medical Genetics, University of British Columbia, Vancouver, British Columbia, Canada
- Ethics Service, Provincial Health Services Authority, Vancouver, British Columbia, Canada
| | - Vanessa Kitchin
- Woodward Library, University of British Columbia, Vancouver, British Columbia, Canada
| | - Alison M Elliott
- Department of Medical Genetics, University of British Columbia, Vancouver, British Columbia, Canada
- BC Children's Hospital Research Institute, Vancouver, British Columbia, Canada
- Women's Health Research Institute, Vancouver, British Columbia, Canada
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15
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Bernstein SM, Barks MC, Ubel PA, Weinfurt K, Barlet MH, Farley S, Jiao MG, Bansal S, Fisher K, Lemmon ME. Prognostic Discordance Among Parents and Physicians Caring for Infants with Neurologic Conditions. J Pediatr 2023; 263:113677. [PMID: 37611734 PMCID: PMC10841319 DOI: 10.1016/j.jpeds.2023.113677] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/24/2023] [Revised: 07/09/2023] [Accepted: 08/14/2023] [Indexed: 08/25/2023]
Abstract
OBJECTIVE To determine the frequency, degree, and nature of prognostic discordance between parents and physicians caring for infants with neurologic conditions. STUDY DESIGN In this observational cohort study, we enrolled parents and physicians caring for infants with neurologic conditions in advance of a family conference. Parent-physician dyads completed a postconference survey targeting expected neurologic outcomes across 3 domains (motor, speech, and cognition) using a 6-point scale. Prognostic discordance was defined as a difference of ≥2 response options and was considered moderate (difference of 2-3 response options) or high (difference of 4-5 response options). Responses were categorized as differences in belief and/or differences in understanding using an existing paradigm. RESULTS Forty parent-physician dyads of 28 infants completed surveys. Parent-physician discordance about prognosis occurred in ≥1 domain in the majority of dyads (n = 28/40, 70%). Discordance was generally moderate in degree (n = 23/28, 82%) and occurred with similar frequency across all domains. Of parent-physician dyads with discordance, the majority contained a difference in understanding in at least 1 domain (n = 25/28, 89%), while a minority contained a difference of belief (n = 6/28, 21%). When discordance was present, parents were typically more optimistic in their predictions compared with physicians (n = 25/28, 89%). CONCLUSIONS Differing perceptions about the prognosis of critically ill infants are common and due to differences in both understanding and belief. These findings can be used to develop targeted interventions to improve prognostic communication.
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Affiliation(s)
- Sarah M Bernstein
- University of Utah School of Medicine, Salt Lake City, UT; Duke University Medical Center, Durham, NC.
| | - Mary C Barks
- Duke Margolis Center for Health Policy, Durham, NC
| | | | | | | | | | - Megan G Jiao
- Duke Margolis Center for Health Policy, Durham, NC
| | | | | | - Monica E Lemmon
- Duke University Medical Center, Durham, NC; Duke Margolis Center for Health Policy, Durham, NC
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Kielt MJ, Levin JC. To Trach or Not To Trach: Long-term Tracheostomy Outcomes in Infants with BPD. Neoreviews 2023; 24:e704-e719. [PMID: 37907398 DOI: 10.1542/neo.24-11-e704] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/02/2023]
Abstract
See Bonus NeoBriefs videos and downloadable teaching slides Infants born preterm who are diagnosed with bronchopulmonary dysplasia (BPD) demonstrate a wide spectrum of illness severity. For infants with the most severe forms of BPD, safe discharge from the hospital may only be possible by providing long-term ventilation via a surgically placed tracheostomy. Though tracheostomy placement in infants with BPD is infrequent, recent reports suggest that rates of tracheostomy placement are increasing in this population. Even though there are known respiratory and neurodevelopmental risks associated with tracheostomy placement, no evidence-based criteria or consensus clinical practice guidelines exist to inform tracheostomy placement in this growing and vulnerable population. An incomplete knowledge of long-term post-tracheostomy outcomes in infants with BPD may unduly bias medical decision-making and family counseling regarding tracheostomy placement. This review aims to summarize our current knowledge of the epidemiology and long-term outcomes of tracheostomy placement in infants with BPD to provide a family-centered framework for tracheostomy counseling.
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Affiliation(s)
- Matthew J Kielt
- Comprehensive Center for Bronchopulmonary Dysplasia, Nationwide Children's Hospital, Columbus, OH
- Department of Pediatrics, The Ohio State University College of Medicine, Columbus, OH
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17
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de Boer A, van Beek PE, Andriessen P, Groenendaal F, Hogeveen M, Meijer JS, Obermann-Borst SA, Onland W, Scheepers L(HCJ, Vermeulen MJ, Verweij EJT(J, De Proost L, Geurtzen R. Opportunities and Challenges of Prognostic Models for Extremely Preterm Infants. CHILDREN (BASEL, SWITZERLAND) 2023; 10:1712. [PMID: 37892375 PMCID: PMC10605480 DOI: 10.3390/children10101712] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 09/11/2023] [Revised: 10/06/2023] [Accepted: 10/19/2023] [Indexed: 10/29/2023]
Abstract
Predicting the short- and long-term outcomes of extremely preterm infants remains a challenge. Multivariable prognostic models might be valuable tools for clinicians, parents, and policymakers for providing accurate outcome estimates. In this perspective, we discuss the opportunities and challenges of using prognostic models in extremely preterm infants at population and individual levels. At a population level, these models could support the development of guidelines for decisions about treatment limits and may support policy processes such as benchmarking and resource allocation. At an individual level, these models may enhance prenatal counselling conversations by considering multiple variables and improving transparency about expected outcomes. Furthermore, they may improve consistency in projections shared with parents. For the development of prognostic models, we discuss important considerations such as predictor and outcome measure selection, clinical impact assessment, and generalizability. Lastly, future recommendations for developing and using prognostic models are suggested. Importantly, the purpose of a prognostic model should be clearly defined, and integrating these models into prenatal counselling requires thoughtful consideration.
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Affiliation(s)
- Angret de Boer
- Department of Neonatology, Amalia Children’s Hospital, Radboud University Medical Center, Geert Grooteplein Zuid 32, 6525 GA Nijmegen, The Netherlands; (P.E.v.B.); (M.H.); (R.G.)
- Department of Obstetrics and Gynecology, Leiden University Medical Centre, 2333 ZA Leiden, The Netherlands;
| | - Pauline E. van Beek
- Department of Neonatology, Amalia Children’s Hospital, Radboud University Medical Center, Geert Grooteplein Zuid 32, 6525 GA Nijmegen, The Netherlands; (P.E.v.B.); (M.H.); (R.G.)
- Department of Neonatology, Máxima Medical Center, 5504 DB Veldhoven, The Netherlands; (P.A.); (J.S.M.)
| | - Peter Andriessen
- Department of Neonatology, Máxima Medical Center, 5504 DB Veldhoven, The Netherlands; (P.A.); (J.S.M.)
| | - Floris Groenendaal
- Department of Neonatology, Wilhelmina Children’s Hospital, University Medical Center Utrecht, 3584 EA Utrecht, The Netherlands;
| | - Marije Hogeveen
- Department of Neonatology, Amalia Children’s Hospital, Radboud University Medical Center, Geert Grooteplein Zuid 32, 6525 GA Nijmegen, The Netherlands; (P.E.v.B.); (M.H.); (R.G.)
| | - Julia S. Meijer
- Department of Neonatology, Máxima Medical Center, 5504 DB Veldhoven, The Netherlands; (P.A.); (J.S.M.)
| | - Sylvia A. Obermann-Borst
- Care4Neo, Dutch Neonatal Patient and Parent Advocacy Organization, 3068 JN Rotterdam, The Netherlands; (S.A.O.-B.); (M.J.V.)
| | - Wes Onland
- Department of Neonatology, Emma Children’s Hospital, Amsterdam University Medical Center, 1105 AZ Amsterdam, The Netherlands;
- Amsterdam Reproduction & Development, 1105 AZ Amsterdam, The Netherlands
| | | | - Marijn J. Vermeulen
- Care4Neo, Dutch Neonatal Patient and Parent Advocacy Organization, 3068 JN Rotterdam, The Netherlands; (S.A.O.-B.); (M.J.V.)
- Department of Neonatal and Pediatric Intensive Care, Division of Neonatology, Sophia Children’s Hospital, Erasmus Medical Center, 3015 CN Rotterdam, The Netherlands
| | - E. J. T. (Joanne) Verweij
- Department of Obstetrics and Gynecology, Leiden University Medical Centre, 2333 ZA Leiden, The Netherlands;
| | - Lien De Proost
- Department of Ethics and Law, Leiden University Medical Centre, 2333 ZA Leiden, The Netherlands;
| | - Rosa Geurtzen
- Department of Neonatology, Amalia Children’s Hospital, Radboud University Medical Center, Geert Grooteplein Zuid 32, 6525 GA Nijmegen, The Netherlands; (P.E.v.B.); (M.H.); (R.G.)
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18
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Katz TA, Bancalari E, Gordijn SJ, Higgins RD, Isayama T, Jensen EA, Offringa M, Pillow JJ, Shah PS, Soll RF, Stoecklin B, Mugie SM, van Kaam AH, Onland W. Towards a harmonized bronchopulmonary dysplasia definition: a study protocol for an international Delphi procedure. BMJ Paediatr Open 2023; 7:e002112. [PMID: 37899128 PMCID: PMC10619096 DOI: 10.1136/bmjpo-2023-002112] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/02/2023] [Accepted: 08/09/2023] [Indexed: 10/31/2023] Open
Abstract
INTRODUCTION Bronchopulmonary dysplasia (BPD) remains the most common complication of preterm birth with lifelong consequences. Multiple BPD definitions are currently used in daily practice. Uniformity in defining BPD is important for clinical care, research and benchmarking. The aim of this Delphi procedure is to determine what clinicians and researchers consider the key features for defining BPD. With the results of this study, we hope to advance the process of reaching consensus on the diagnosis of BPD. METHODS AND ANALYSIS A Delphi procedure will be used to establish why, when and how clinicians propose BPD should be diagnosed. This semi-anonymous iterative technique ensures an objective approach towards gaining these insights. An international multidisciplinary panel of clinicians and researchers working with preterm infants and/or patients diagnosed with BPD will participate. Steering committee members will recruit potential participants in their own region or network following eligibility guidelines to complete a first round survey online. This round will collect demographic information and opinions on key features of BPD definitions. Subsequent rounds will provide participants with the results from the previous round, for final acceptance or rejection of key features. Statements will be rated using a 5-point Likert scale. After completing the Delphi procedure, an (online) consensus meeting will be organised to discuss the results. ETHICS AND DISSEMINATION For this study, ethical approval a waiver has been provided. However, all participants will be asked to provide consent for the use of personal data. After the Delphi procedure is completed, it will be published in a peer-reviewed journal and disseminated at international conferences.
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Affiliation(s)
- Trixie A Katz
- Amsterdam Reproduction & Development, Amsterdam, The Netherlands
- Department of Neonatology, Emma Childrens' Hospital UMC, Amsterdam, The Netherlands
| | - Eduardo Bancalari
- Division of Neonatology, Jackson Memorial Hospital, Miami, Florida, USA
| | - Sanne J Gordijn
- Department of Obstetrics and Gynecology, UMCG, Groningen, The Netherlands
| | - Rosemary D Higgins
- Research and Sponsored Programs, Florida Gulf Coast University, Fort Myers, Florida, USA
| | - Tetsuya Isayama
- Division of Neonatology, National Center for Child Health and Development, Tokyo, Japan
| | - Erik A Jensen
- Division of Neonatology, The Children's Hospital, Philadelphia, Pennsylvania, USA
| | - Martin Offringa
- Division of Neonatology, Hospital for Sick Children, Toronto, Ontario, Canada
| | - J Jane Pillow
- Division of Pediatrics, Medical School, The University of Western Australia and Telethon Kids Institute, Perth, Washington, Australia
| | - Prakesh S Shah
- Division of Neonatology, Mount Sinai Hospital, Toronto, Ontario, Canada
| | - Roger F Soll
- Division of Neonatology, University of Vermont Medical Center, Burlington, Vermont, USA
| | - Benjamin Stoecklin
- Department of Neonatology, University Children's Hospital Basel, Basel, Switzerland
| | - Suzanne M Mugie
- Amsterdam Reproduction & Development, Amsterdam, The Netherlands
- Department of Neonatology, Emma Childrens' Hospital UMC, Amsterdam, The Netherlands
| | - Anton H van Kaam
- Amsterdam Reproduction & Development, Amsterdam, The Netherlands
- Department of Neonatology, Emma Childrens' Hospital UMC, Amsterdam, The Netherlands
| | - Wes Onland
- Amsterdam Reproduction & Development, Amsterdam, The Netherlands
- Department of Neonatology, Emma Childrens' Hospital UMC, Amsterdam, The Netherlands
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19
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Hurt L, Odd D, Mann M, Beetham H, Dorgeat E, Isaac TC, Ashman A, Wood F. What matters to families about the healthcare of preterm or low birth weight infants: A qualitative evidence synthesis. PATIENT EDUCATION AND COUNSELING 2023; 115:107893. [PMID: 37473603 DOI: 10.1016/j.pec.2023.107893] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 01/31/2023] [Revised: 07/06/2023] [Accepted: 07/07/2023] [Indexed: 07/22/2023]
Abstract
OBJECTIVE We examined what matters to families about the healthcare provided to preterm or LBW infants in hospital and the community, to ensure that care meets the needs of infants and parents. METHODS We searched databases to identify eligible studies examining the views and expectations of families. Study quality was assessed using the CASP checklist for qualitative studies. The GRADE-CERQual approach was used to assess confidence in review findings. Studies were sampled and data analysed using thematic synthesis. RESULTS 222 studies (227 papers) were eligible for inclusion. 54 studies (57 papers) were sampled based on data richness, methodological quality, and representation across settings. Eight analytical themes were identified. Confidence in results was moderate to high. What mattered was a positive outcome for the child; active involvement in care; being supported to cope at home after discharge; emotional support; the healthcare environment; information needs met; logistical support available; and positive relationships with staff. CONCLUSION Although parents and family members reported a variety of experiences in the care of their infant, we found high consistency in what matters to families. PRACTICE IMPLICATIONS This review identifies approaches to improve experiences of parents which are consistent with the Family Centred Care model of healthcare.
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Affiliation(s)
- Lisa Hurt
- Division of Population Medicine, Cardiff University School of Medicine, Cardiff, UK.
| | - David Odd
- Division of Population Medicine, Cardiff University School of Medicine, Cardiff, UK
| | - Mala Mann
- Specialist Unit for Review Evidence, Cardiff University, Cardiff, UK
| | | | - Emma Dorgeat
- Cardiff University School of Medicine, Cardiff, UK
| | | | | | - Fiona Wood
- Division of Population Medicine, Cardiff University School of Medicine, Cardiff, UK
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20
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Webbe J, Baba A, Butcher NJ, Rodrigues C, Stallwood E, Goren K, Monsour A, Chang ASM, Trivedi A, Manley BJ, McCall E, Bogossian F, Namba F, Schmölzer GM, Popat H, Nguyen KA, Doyle LW, Jardine L, Rysavy MA, Konstantinidis M, Muhd Helmi MA, Lai NM, Hay S, Onland W, Choo YM, Gale C, Soll RF, Offringa M. Strengthening Reporting of Neonatal Trials. Pediatrics 2023; 152:e2022060765. [PMID: 37641894 DOI: 10.1542/peds.2022-060765] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 06/26/2023] [Indexed: 08/31/2023] Open
Abstract
BACKGROUND AND OBJECTIVES There is variability in the selection and reporting of outcomes in neonatal trials with key information frequently omitted. This can impact applicability of trial findings to clinicians, families, and caregivers, and impair evidence synthesis. The Neonatal Core Outcomes Set describes outcomes agreed as clinically important that should be assessed in all neonatal trials, and Consolidated Standards of Reporting Trials (CONSORT)-Outcomes 2022 is a new, harmonized, evidence-based reporting guideline for trial outcomes. We reviewed published trials using CONSORT-Outcomes 2022 guidance to identify exemplars of neonatal core outcome reporting to strengthen description of outcomes in future trial publications. METHODS Neonatal trials including >100 participants per arm published between 2015 to 2020 with a primary outcome included in the Neonatal Core Outcome Set were identified. Primary outcome reporting was reviewed using CONSORT 2010 and CONSORT-Outcomes 2022 guidelines by assessors recruited from Cochrane Neonatal. Examples of clear and complete outcome reporting were identified with verbatim text extracted from trial reports. RESULTS Thirty-six trials were reviewed by 39 assessors. Examples of good reporting for CONSORT 2010 and CONSORT-Outcomes 2022 criteria were identified and subdivided into 3 outcome categories: "survival," "short-term neonatal complications," and "long-term developmental outcomes" depending on the core outcomes to which they relate. These examples are presented to strengthen future research reporting. CONCLUSIONS We have identified examples of good trial outcome reporting. These illustrate how important neonatal outcomes should be reported to meet the CONSORT 2010 and CONSORT-Outcomes 2022 guidelines. Emulating these examples will improve the transmission of information relating to outcomes and reduce associated research waste.
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Affiliation(s)
- James Webbe
- Neonatal Medicine, School of Public Health, Imperial College London, United Kingdom
| | - Ami Baba
- Child Health Evaluative Sciences, The Hospital for Sick Children Research Institute, Toronto, Ontario, Canada
| | - Nancy J Butcher
- Child Health Evaluative Sciences, The Hospital for Sick Children Research Institute, Toronto, Ontario, Canada
- Department of Psychiatry, University of Toronto, Toronto, Ontario, Canada
| | - Craig Rodrigues
- Child Health Evaluative Sciences, The Hospital for Sick Children Research Institute, Toronto, Ontario, Canada
| | - Emma Stallwood
- Child Health Evaluative Sciences, The Hospital for Sick Children Research Institute, Toronto, Ontario, Canada
| | - Katherine Goren
- Child Health Evaluative Sciences, The Hospital for Sick Children Research Institute, Toronto, Ontario, Canada
| | - Andrea Monsour
- Child Health Evaluative Sciences, The Hospital for Sick Children Research Institute, Toronto, Ontario, Canada
| | - Alvin S M Chang
- Quality, Safety and Risk Management (QSRM) and Department of Neonatology, KK Women's and Children's Hospital, Singapore
- DUKE-NUS Medical School, Singapore
| | - Amit Trivedi
- The Children's Hospital at Westmead, New South Wales, Australia
| | | | - Emma McCall
- School of Nursing and Midwifery, Queen's University Belfast, Northern Ireland
| | | | - Fumihiko Namba
- Department of Pediatrics, Saitama Medical Center, Saitama Medical University, Saitama, Japan
| | | | - Himanshu Popat
- The Children's Hospital at Westmead, New South Wales, Australia
| | | | - Lex W Doyle
- Department of Obstetrics and Gynaecology, The Royal Women's Hospital, University of Melbourne, Parkville, Victoria, Australia
| | - Luke Jardine
- Department of Neonatology, Mater Mothers' Hospital, South Brisbane, Queensland, Australia
- University of Queensland, Brisbane, Australia
| | - Matthew A Rysavy
- University of Texas Health Science Centre at Houston, Houston, Texas
| | - Menelaos Konstantinidis
- Li Ka Shing Knowledge Institute, St Michael's Hospital, Unity Health Toronto, Toronto, Ontario, Canada
- Institute of Health Policy, Management and Evaluation, University of Toronto, Toronto, Ontario, Canada
| | - Muhd Alwi Muhd Helmi
- Department of Paediatrics, International Islamic University, Kuala Lumpur, Malaysia
| | - Nai Ming Lai
- School of Medicine, Faculty of Health and Medical Sciences, Taylor's University, Selangor, Malaysia
| | - Susanne Hay
- Department of Neonatology, Beth Israel Deaconess Medical Center, Boston, Massachusetts
- Harvard Medical School, Boston, Massachusetts
| | - Wes Onland
- Department of Neonatology, Emma Children's Hospital, Amsterdam UMC, University of Amsterdam, Amsterdam, Netherlands
- Amsterdam Reproduction and Development Research Institute, Amsterdam, Netherlands
| | - Yao Mun Choo
- Neonatal Medicine, School of Public Health, Imperial College London, United Kingdom
| | - Chris Gale
- Neonatal Medicine, School of Public Health, Imperial College London, United Kingdom
| | - Roger F Soll
- Child Health Evaluative Sciences, The Hospital for Sick Children Research Institute, Toronto, Ontario, Canada
- Department of Psychiatry, University of Toronto, Toronto, Ontario, Canada
| | - Martin Offringa
- Child Health Evaluative Sciences, The Hospital for Sick Children Research Institute, Toronto, Ontario, Canada
- Institute of Health Policy, Management and Evaluation, University of Toronto, Toronto, Ontario, Canada
- Division of Neonatology, The Hospital for Sick Children, University of Toronto, Toronto, Ontario, Canada
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21
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Callahan KP, Kielt MJ, Feudtner C, Barkman D, Bamat N, Fierro J, Fiest E, DeMauro SB. Ranking Future Outcomes Most Important to Parents of Children with Bronchopulmonary Dysplasia. J Pediatr 2023; 259:113455. [PMID: 37172804 PMCID: PMC10524943 DOI: 10.1016/j.jpeds.2023.113455] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/13/2023] [Revised: 04/06/2023] [Accepted: 04/30/2023] [Indexed: 05/15/2023]
Abstract
OBJECTIVE To assess which potential future outcomes are most important to parents of children with bronchopulmonary dysplasia, a disease that affects future respiratory, medical, and developmental outcomes for children born preterm. STUDY DESIGN We recruited parents from 2 children's hospitals' neonatal follow-up clinics and elicited their importance rating for 20 different potential future outcomes associated with bronchopulmonary dysplasia. These outcomes were identified and selected through a literature review and discussions with panels of parents and clinician stakeholders, via a discrete choice experiment. RESULTS One hundred and 5 parents participated. Overall, parents ranked "Will my child be more vulnerable to other problems because of having lung disease?" as the most important outcome, with other respiratory health related outcomes also highly ranked. Outcomes related to child development and effects on the family were among the lowest ranked. Individually, parents rated outcomes differently, resulting in a broad distribution of importance scores for many of the outcomes. CONCLUSIONS The overall rankings suggest that parents prioritize future outcomes related to physical health and safety. Notably, for guiding research, some top-rated outcomes are not traditionally measured in outcome studies. For guiding individual counseling, the broad distribution of importance scores for many outcomes highlights the extent to which parents differ in their prioritization of outcomes.
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Affiliation(s)
- Katharine Press Callahan
- Children's Hospital of Philadelphia; Philadelphia, PA; Department of Medical Ethics and Health Policy, Perelman School of Medicine at the University of Pennsylvania; Philadelphia, PA.
| | | | - Chris Feudtner
- Children's Hospital of Philadelphia; Philadelphia, PA; Department of Medical Ethics and Health Policy, Perelman School of Medicine at the University of Pennsylvania; Philadelphia, PA
| | | | - Nicolas Bamat
- Children's Hospital of Philadelphia; Philadelphia, PA
| | - Julie Fierro
- Children's Hospital of Philadelphia; Philadelphia, PA
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22
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Alexander D, Quirke M, Doyle C, Hill K, Masterson K, Brenner M. Technology solutionism in paediatric intensive care: clinicians' perspectives of bioethical considerations. BMC Med Ethics 2023; 24:55. [PMID: 37507700 PMCID: PMC10386660 DOI: 10.1186/s12910-023-00937-6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/09/2022] [Accepted: 07/24/2023] [Indexed: 07/30/2023] Open
Abstract
BACKGROUND The use of long-term life-sustaining technology for children improves survival rates in paediatric intensive care units (PICUs), but it may also increase long-term morbidity. One example of this is children who are dependent on invasive long-term ventilation. Clinicians caring for these children navigate an increasing array of ethical complexities. This study looks at the meaning clinicians give to the bioethical considerations associated with the availability of increasingly sophisticated technology. METHODS A hermeneutic phenomenological exploration of the experiences of clinicians in deciding whether to initiate invasive long-term ventilation in children took place, via unstructured interviews. Data were analysed to gain insight into the lived experiences of clinicians. Participants were from PICUs, or closely allied to the care of children in PICUs, in four countries. RESULTS Three themes developed from the data that portray the experiences of the clinicians: forming and managing relationships with parents and other clinicians considering, or using, life sustaining technology; the responsibility for moral and professional integrity in the use of technology; and keeping up with technological developments, and the resulting ethical and moral considerations. DISCUSSION There are many benefits of the availability of long-term life-sustaining technology for a child, however, clinicians must also consider increasingly complex ethical dilemmas. Bioethical norms are adapting to aid clinicians, but challenges remain. CONCLUSION During a time of technological solutionism, more needs to be understood about the influences on the initiation of invasive long-term ventilation for a child. Further research to better understand how clinicians, and bioethics services, support care delivery may positively impact this arena of health care.
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Affiliation(s)
- Denise Alexander
- School of Nursing, Midwifery & Health Systems, University College Dublin, Dublin, Ireland
| | - Mary Quirke
- School of Nursing, Midwifery & Health Systems, University College Dublin, Dublin, Ireland
| | - Carmel Doyle
- School of Nursing & Midwifery, Trinity College Dublin, Dublin, Ireland
| | - Katie Hill
- School of Nursing, Midwifery & Health Systems, University College Dublin, Dublin, Ireland
| | - Kate Masterson
- School of Nursing, Midwifery & Health Systems, University College Dublin, Dublin, Ireland
| | - Maria Brenner
- School of Nursing, Midwifery & Health Systems, University College Dublin, Dublin, Ireland.
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Anderson NM, Hicks M, Cheung PY. Prognosticating the Outcomes of HIE with Certainty: Mission Impossible? - Commentary on "Clinical Prediction Models and Predictors for Death or Adverse Neurodevelopmental Outcome in Term Newborns with Hypoxic Ischemic Encephalopathy: A Systematic Review of the Literature". Neonatology 2023; 120:670-672. [PMID: 37379813 DOI: 10.1159/000531189] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/04/2023] [Accepted: 05/10/2023] [Indexed: 06/30/2023]
Affiliation(s)
- Nicole M Anderson
- Department of Pediatrics, University of Alberta, Edmonton, Alberta, Canada
| | - Matthew Hicks
- Department of Pediatrics, University of Alberta, Edmonton, Alberta, Canada
| | - Po-Yin Cheung
- Department of Pediatrics, University of Alberta, Edmonton, Alberta, Canada
- Centre for the Studies of Asphyxia and Resuscitation at the Royal Alexandra Hospital, Edmonton, Alberta, Canada
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24
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Peralta D, Bogetz J, Lemmon ME. Seminars in Fetal & neonatal medicine: Palliative and end of life care in the NICU. Semin Fetal Neonatal Med 2023; 28:101457. [PMID: 37230860 PMCID: PMC10827319 DOI: 10.1016/j.siny.2023.101457] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 05/27/2023]
Affiliation(s)
- Dana Peralta
- Duke North Pavilion, 2400 Pratt Street, 8th Floor, DUMC 102509, Durham, NC 27710, USA.
| | - Jori Bogetz
- 1900 Ninth Ave, JMB-6, Seattle, WA 98101, USA.
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Chevallier M, Barrington KJ, Terrien Church P, Luu TM, Janvier A. Decision-making for extremely preterm infants with severe hemorrhages on head ultrasound: Science, values, and communication skills. Semin Fetal Neonatal Med 2023; 28:101444. [PMID: 37150640 DOI: 10.1016/j.siny.2023.101444] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 05/09/2023]
Abstract
Severe intracranial hemorrhages are not rare in extremely preterm infants. They occur early, generally when babies require life-sustaining interventions. This may lead to ethical discussions and decision-making about levels of care. Prognosis is variable and depends on the extent, location, and laterality of the lesions, and, importantly also on the subsequent occurrence of other clinical complications or progressive ventricular dilatation. Decision-making should depend on prognosis and parental values. This article will review prognosis and the uncertainty of outcomes for different lesions and provide an outline of ways to conduct an ethically appropriate discussion on the decision of whether to continue life sustaining therapy. It is possible to communicate in a compassionate and honest way with parents and engage in decision-making, focussing on personalized information and decisions, and on function, as opposed to diagnosis.
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Affiliation(s)
- M Chevallier
- Department of Neonatal Intensive Care Unit, CHU Grenoble, Grenoble, France; TIMC-IMAG Research Department; Grenoble Alps University; Grenoble, France
| | - K J Barrington
- Department of Pediatrics, Université de Montréal, Montréal, Canada; Division of Neonatology, CHU Sainte-Justine Research Center, CHU Sainte-Justine, Montréal, Canada; Centre de Recherche Du CHU Sainte-Justine, Montréal, Québec, Canada
| | - P Terrien Church
- Department of Pediatrics, University of Toronto, Toronto, Ontario, Canada
| | - T M Luu
- Department of Pediatrics, Université de Montréal, Montréal, Canada; Centre de Recherche Du CHU Sainte-Justine, Montréal, Québec, Canada
| | - A Janvier
- Department of Pediatrics, Université de Montréal, Montréal, Canada; Division of Neonatology, CHU Sainte-Justine Research Center, CHU Sainte-Justine, Montréal, Canada; Centre de Recherche Du CHU Sainte-Justine, Montréal, Québec, Canada; Bureau de L'éthique Clinique, Université de Montréal, Canada; Unité D'éthique Clinique, Unité de Soins Palliatifs, Bureau Du Partenariat Patients-Familles-Soignants; CHU Sainte-Justine, Montréal, Canada.
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26
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Hintz SR, deRegnier RA, Vohr BR. Outcomes of Preterm Infants: Shifting Focus, Extending the View. Clin Perinatol 2023; 50:1-16. [PMID: 36868700 DOI: 10.1016/j.clp.2022.10.001] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 03/05/2023]
Abstract
Advances in perinatal care have led to remarkable long-term survival for infants who are born preterm. This article reviews the broader context of follow-up care, highlighting the need to reenvision some areas, such as improving parental support by embedding parental involvement in the neonatal intensive care unit, incorporating parental perspectives about outcomes into follow-up care models and research, supporting their mental health, addressing social determinants of health and disparities, and advocating for change. Multicenter quality improvement networks allow identification and implementation of best practices for follow-up care.
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Affiliation(s)
- Susan R Hintz
- Division of Neonatal and Developmental Medicine, Department of Pediatrics, Stanford University School of Medicine, 453 Quarry Road, 4th Floor, Palo Alto, CA 94304, USA.
| | - Raye-Ann deRegnier
- Ann & Robert H. Lurie Children's Hospital of Chicago, Northwestern University Feinberg School of Medicine, 225 East Chicago Avenue, Box 45, Chicago, IL 60611, USA
| | - Betty R Vohr
- Division of Neonatology, Department of Pediatrics, Women & Infants Hospital, Alpert Medical School of Brown University, 101 Dudley Street, Providence, RI 02905, USA
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27
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Milette AA, Richter LL, Bourque CJ, Janvier A, Pearce R, Church PT, Synnes A, Luu TM. Parental perspectives of outcomes following very preterm birth: Seeing the good, not just the bad. Acta Paediatr 2023; 112:398-408. [PMID: 36479723 DOI: 10.1111/apa.16616] [Citation(s) in RCA: 8] [Impact Index Per Article: 8.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/02/2022] [Revised: 11/16/2022] [Accepted: 12/05/2022] [Indexed: 12/12/2022]
Abstract
AIM To describe parental perspective on health and developmental outcomes of their preterm child in relation to level of neurodevelopmental impairment (NDI). METHODS A parental survey about their children aged 15-36 months corrected age born ˂29 weeks' gestation investigated parental concerns and positive attributes. Parental responses in relation to their child's level of NDI were examined using Kruskal-Wallis and chi-square for trend tests. RESULTS One hundred ninety-nine parental responses were obtained for 163 children, including 44% with NDI. Vast majority of parents reported their children were developing well with good physical health. All parents, irrespective of NDI, reported their children were happy and had a positive personality. Appreciation of social interactions was higher for parents of children without versus with NDI (96% vs. 87%, p = 0.039). Parents of children with NDI were more likely to express concerns than those without NDI. Overall, development was the most common area of concern (45%), followed by the child's future (40%) and physical health (35%). CONCLUSION Parents of preterm children report many positive points and concerns, some of which are not examined in neonatal follow-up data. These parental perspectives could be used to inform parents of preterm infants, both antenatally and in the neonatal unit.
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Affiliation(s)
- Audrey-Anne Milette
- Department of Pediatrics, Research Center, CHU Sainte-Justine, University of Montreal, Quebec, Montreal, Canada
| | - Lindsay L Richter
- Department of Pediatrics, British Columbia Women's Hospital, University of British Columbia, British Columbia, Vancouver, Canada
| | - Claude Julie Bourque
- Department of Pediatrics, Research Center, CHU Sainte-Justine, University of Montreal, Quebec, Montreal, Canada.,Clinical Ethics Unit, CHU Sainte-Justine, Quebec, Montreal, Canada
| | - Annie Janvier
- Department of Pediatrics, Research Center, CHU Sainte-Justine, University of Montreal, Quebec, Montreal, Canada.,Clinical Ethics Unit, CHU Sainte-Justine, Quebec, Montreal, Canada.,Palliative Care Unit, CHU Sainte-Justine, Quebec, Montréal, Canada.,Bureau du Partenariat Patients-Familles-Soignants, CHU Sainte-Justine, Quebec, Montreal, Canada.,Bureau de l'éthique clinique, Université de Montréal, Quebec, Montreal, Canada
| | - Rebecca Pearce
- Bureau du Partenariat Patients-Familles-Soignants, CHU Sainte-Justine, Quebec, Montreal, Canada
| | - Paige Terrien Church
- Department of Pediatrics, Sunnybrook Health Sciences Centre, University of Toronto, Ontario, Toronto, Canada
| | - Anne Synnes
- Department of Pediatrics, British Columbia Women's Hospital, University of British Columbia, British Columbia, Vancouver, Canada
| | - Thuy Mai Luu
- Department of Pediatrics, Research Center, CHU Sainte-Justine, University of Montreal, Quebec, Montreal, Canada
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28
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Litt JS, Campbell DE. High-Risk Infant Follow-Up After NICU Discharge: Current Care Models and Future Considerations. Clin Perinatol 2023; 50:225-238. [PMID: 36868707 DOI: 10.1016/j.clp.2022.11.004] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 03/05/2023]
Abstract
Preterm infants are at heightened risk for chronic health problems and developmental delays compared with term-born peers. High-risk infant follow-up programs provide surveillance and support for problems that may emerge during infancy and early childhood. Although considered standard of care, program structure, content, and timing are highly variable. Families face challenges accessing recommended follow-up services. Here, the authors review common models of high-risk infant follow-up, describe novel approaches, and outline considerations for improving the quality, value, and equity of follow-up care.
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Affiliation(s)
- Jonathan S Litt
- Department of Neonatology, Beth Israel Deaconess Medical Center, 330 Brookline Avenue, Boston, MA 02215, USA; Department of Pediatrics, Harvard Medical School; Department of Social and Behavioral Sciences, Harvard TH Chan School of Public Health.
| | - Deborah E Campbell
- Division of Neonatology, Children's Hospital at Montefiore, Weiler Einstein Campus, 1601 Tenbroeck Avenue, Bronx, NY 10461, USA; Department of Pediatrics, Albert Einstein College of Medicine
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29
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Lemmon ME, Barks MC, Bansal S, Bernstein S, Kaye EC, Glass HC, Ubel PA, Brandon D, Pollak KI. The ALIGN Framework: A Parent-Informed Approach to Prognostic Communication for Infants With Neurologic Conditions. Neurology 2023; 100:e800-e807. [PMID: 36456199 PMCID: PMC9984217 DOI: 10.1212/wnl.0000000000201600] [Citation(s) in RCA: 16] [Impact Index Per Article: 16.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/16/2022] [Accepted: 10/07/2022] [Indexed: 12/03/2022] Open
Abstract
BACKGROUND AND OBJECTIVES Clinicians often communicate complex, uncertain, and distressing information about neurologic prognosis to parents of critically ill infants. Although communication tools have been developed in other disciplines and settings, none address the unique needs of the neonatal and pediatric neurology context. We aimed to develop a parent-informed framework to guide clinicians in communicating information about neurologic prognosis. METHODS Parents of infants with neurologic conditions in the intensive care unit were enrolled in a longitudinal study of shared decision-making from 2018 to 2020. Parents completed semistructured interviews following recorded family meetings with the health care team, at hospital discharge, and 6 months after discharge. All interviews targeted information about parent preferences for prognostic disclosure. We analyzed the data using a conventional content analysis approach. Two study team members independently coded all interview transcripts, and discrepancies were resolved in consensus. We used NVIVO 12 qualitative software to index and organize codes. RESULTS Fifty-two parents of 37 infants completed 123 interviews. Parents were predominantly mothers (n = 37/52, 71%) with a median age of 31 (range 19-46) years. Half were Black (n = 26/52, 50%), and a minority reported Hispanic ethnicity (n = 2/52, 4%). Inductive analysis resulted in the emergence of 5 phases of prognostic communication (Approach, Learn, Inform, Give support, and Next steps: ALIGN): (1) Approach: parents appreciated receiving consistent information about their child's neurologic outcome from clinicians who knew their child well. (2) Learn: parents valued when clinicians asked them how they preferred receiving information and what they already knew about their child's outcome prior to information delivery. (3) Inform: parents valued honest, thorough, and balanced information that disclosed prognostic uncertainty and acknowledged room for hope. (4) Give support: parents valued empathic communication and appreciated clinicians who offered real-time emotional support. (5) Next steps: parents appreciated clinicians who connected them to resources, including peer support. DISCUSSION The ALIGN framework offers a novel, parent-informed strategy to effectively communicate neurologic prognosis. Although ALIGN represents key elements of a conversation about prognosis, each clinician can adapt this framework to their own approach. Future work will assess the effectiveness of this framework on communication quality and prognostic understanding.
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Affiliation(s)
- Monica E Lemmon
- From the Departments of Pediatrics (M.E.L., M.C.B., S. Bansal, S. Bernstein), Population Health Sciences (M.E.L., K.I.P.), Duke University School of Medicine, Durham, NC; University of Utah School of Medicine (S. Bernstein), Salt Lack City; Department of Oncology (E.C.K.), St. Jude Children's Research Hospital, Memphis, TN; Departments of Neurology and Pediatrics (E.C.K.), UCSF Benioff Children's Hospital and Department of Epidemiology & Biostatistics (H.C.G.), University of California, San Francisco; Fuqua School of Business and Sanford School of Public Policy (P.A.U.), Duke University, Durham; and Duke University School of Nursing (D.B.), Durham; Cancer Prevention and Control (KIP), Duke Cancer Institute, Durham, NC.
| | - Mary C Barks
- From the Departments of Pediatrics (M.E.L., M.C.B., S. Bansal, S. Bernstein), Population Health Sciences (M.E.L., K.I.P.), Duke University School of Medicine, Durham, NC; University of Utah School of Medicine (S. Bernstein), Salt Lack City; Department of Oncology (E.C.K.), St. Jude Children's Research Hospital, Memphis, TN; Departments of Neurology and Pediatrics (E.C.K.), UCSF Benioff Children's Hospital and Department of Epidemiology & Biostatistics (H.C.G.), University of California, San Francisco; Fuqua School of Business and Sanford School of Public Policy (P.A.U.), Duke University, Durham; and Duke University School of Nursing (D.B.), Durham; Cancer Prevention and Control (KIP), Duke Cancer Institute, Durham, NC
| | - Simran Bansal
- From the Departments of Pediatrics (M.E.L., M.C.B., S. Bansal, S. Bernstein), Population Health Sciences (M.E.L., K.I.P.), Duke University School of Medicine, Durham, NC; University of Utah School of Medicine (S. Bernstein), Salt Lack City; Department of Oncology (E.C.K.), St. Jude Children's Research Hospital, Memphis, TN; Departments of Neurology and Pediatrics (E.C.K.), UCSF Benioff Children's Hospital and Department of Epidemiology & Biostatistics (H.C.G.), University of California, San Francisco; Fuqua School of Business and Sanford School of Public Policy (P.A.U.), Duke University, Durham; and Duke University School of Nursing (D.B.), Durham; Cancer Prevention and Control (KIP), Duke Cancer Institute, Durham, NC
| | - Sarah Bernstein
- From the Departments of Pediatrics (M.E.L., M.C.B., S. Bansal, S. Bernstein), Population Health Sciences (M.E.L., K.I.P.), Duke University School of Medicine, Durham, NC; University of Utah School of Medicine (S. Bernstein), Salt Lack City; Department of Oncology (E.C.K.), St. Jude Children's Research Hospital, Memphis, TN; Departments of Neurology and Pediatrics (E.C.K.), UCSF Benioff Children's Hospital and Department of Epidemiology & Biostatistics (H.C.G.), University of California, San Francisco; Fuqua School of Business and Sanford School of Public Policy (P.A.U.), Duke University, Durham; and Duke University School of Nursing (D.B.), Durham; Cancer Prevention and Control (KIP), Duke Cancer Institute, Durham, NC
| | - Erica C Kaye
- From the Departments of Pediatrics (M.E.L., M.C.B., S. Bansal, S. Bernstein), Population Health Sciences (M.E.L., K.I.P.), Duke University School of Medicine, Durham, NC; University of Utah School of Medicine (S. Bernstein), Salt Lack City; Department of Oncology (E.C.K.), St. Jude Children's Research Hospital, Memphis, TN; Departments of Neurology and Pediatrics (E.C.K.), UCSF Benioff Children's Hospital and Department of Epidemiology & Biostatistics (H.C.G.), University of California, San Francisco; Fuqua School of Business and Sanford School of Public Policy (P.A.U.), Duke University, Durham; and Duke University School of Nursing (D.B.), Durham; Cancer Prevention and Control (KIP), Duke Cancer Institute, Durham, NC
| | - Hannah C Glass
- From the Departments of Pediatrics (M.E.L., M.C.B., S. Bansal, S. Bernstein), Population Health Sciences (M.E.L., K.I.P.), Duke University School of Medicine, Durham, NC; University of Utah School of Medicine (S. Bernstein), Salt Lack City; Department of Oncology (E.C.K.), St. Jude Children's Research Hospital, Memphis, TN; Departments of Neurology and Pediatrics (E.C.K.), UCSF Benioff Children's Hospital and Department of Epidemiology & Biostatistics (H.C.G.), University of California, San Francisco; Fuqua School of Business and Sanford School of Public Policy (P.A.U.), Duke University, Durham; and Duke University School of Nursing (D.B.), Durham; Cancer Prevention and Control (KIP), Duke Cancer Institute, Durham, NC
| | - Peter A Ubel
- From the Departments of Pediatrics (M.E.L., M.C.B., S. Bansal, S. Bernstein), Population Health Sciences (M.E.L., K.I.P.), Duke University School of Medicine, Durham, NC; University of Utah School of Medicine (S. Bernstein), Salt Lack City; Department of Oncology (E.C.K.), St. Jude Children's Research Hospital, Memphis, TN; Departments of Neurology and Pediatrics (E.C.K.), UCSF Benioff Children's Hospital and Department of Epidemiology & Biostatistics (H.C.G.), University of California, San Francisco; Fuqua School of Business and Sanford School of Public Policy (P.A.U.), Duke University, Durham; and Duke University School of Nursing (D.B.), Durham; Cancer Prevention and Control (KIP), Duke Cancer Institute, Durham, NC
| | - Debra Brandon
- From the Departments of Pediatrics (M.E.L., M.C.B., S. Bansal, S. Bernstein), Population Health Sciences (M.E.L., K.I.P.), Duke University School of Medicine, Durham, NC; University of Utah School of Medicine (S. Bernstein), Salt Lack City; Department of Oncology (E.C.K.), St. Jude Children's Research Hospital, Memphis, TN; Departments of Neurology and Pediatrics (E.C.K.), UCSF Benioff Children's Hospital and Department of Epidemiology & Biostatistics (H.C.G.), University of California, San Francisco; Fuqua School of Business and Sanford School of Public Policy (P.A.U.), Duke University, Durham; and Duke University School of Nursing (D.B.), Durham; Cancer Prevention and Control (KIP), Duke Cancer Institute, Durham, NC
| | - Kathryn I Pollak
- From the Departments of Pediatrics (M.E.L., M.C.B., S. Bansal, S. Bernstein), Population Health Sciences (M.E.L., K.I.P.), Duke University School of Medicine, Durham, NC; University of Utah School of Medicine (S. Bernstein), Salt Lack City; Department of Oncology (E.C.K.), St. Jude Children's Research Hospital, Memphis, TN; Departments of Neurology and Pediatrics (E.C.K.), UCSF Benioff Children's Hospital and Department of Epidemiology & Biostatistics (H.C.G.), University of California, San Francisco; Fuqua School of Business and Sanford School of Public Policy (P.A.U.), Duke University, Durham; and Duke University School of Nursing (D.B.), Durham; Cancer Prevention and Control (KIP), Duke Cancer Institute, Durham, NC
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Katz TA, van Kaam AH, Schuit E, Mugie SM, Aarnoudse-Moens CSH, Weber EH, de Groof F, van Laerhoven H, Counsilman CE, van der Schoor SRD, Rijpert M, Schiering IA, Wilms J, Leemhuis AG, Onland W. Comparison of New Bronchopulmonary Dysplasia Definitions on Long-Term Outcomes in Preterm Infants. J Pediatr 2023; 253:86-93.e4. [PMID: 36150504 DOI: 10.1016/j.jpeds.2022.09.022] [Citation(s) in RCA: 10] [Impact Index Per Article: 10.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/25/2022] [Revised: 09/12/2022] [Accepted: 09/16/2022] [Indexed: 11/23/2022]
Abstract
OBJECTIVE To compare the discriminative performances of the 2018 National Institutes of Health (NIH) and the 2019 Jensen definitions of bronchopulmonary dysplasia (BPD) with the 2001 NIH definition on adverse neurodevelopmental and respiratory outcomes at 2 years and 5 years corrected age. STUDY DESIGN In this single-center retrospective cohort study, outcomes of infants born at <30 weeks of gestational age were collected. The 3 definitions of BPD were compared by adding the different definitions to the National Institute of Child Health and Human Development's outcome prediction model for neurodevelopmental impairment (NDI) or death. Discriminative performance was compared for both outcomes at 2 years and 5 years corrected age by calculating the areas under the receiver operating characteristic curve and z-statistics. RESULTS The presence of BPD and its severity were determined in 584 infants. There were considerable shifts in BPD grading among the different definitions. At both time points, all BPD definition models had comparable discriminating power for NDI and respiratory morbidity, with one exception. Compared with the 2001 NIH definition, the 2018 NIH definition had less predictive power for the neurologic outcome at 2 years corrected age. CONCLUSIONS Our comparison of the 3 BPD definitions shows similar discriminative performance on long term neurodevelopmental and respiratory outcomes at 2 years and 5 years corrected age.
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Affiliation(s)
- Trixie A Katz
- Department of Neonatology, Emma Children's Hospital, Amsterdam University Medical Centers, Amsterdam, The Netherlands; Amsterdam Reproduction & Development, Amsterdam, The Netherlands
| | - Anton H van Kaam
- Department of Neonatology, Emma Children's Hospital, Amsterdam University Medical Centers, Amsterdam, The Netherlands; Amsterdam Reproduction & Development, Amsterdam, The Netherlands
| | - Ewoud Schuit
- Julius Center for Health Sciences and Primary Care, University Medical Center Utrecht, Utrecht University, Utrecht, The Netherlands
| | - Suzanne M Mugie
- Department of Neonatology, Emma Children's Hospital, Amsterdam University Medical Centers, Amsterdam, The Netherlands; Amsterdam Reproduction & Development, Amsterdam, The Netherlands
| | - Cornelieke S H Aarnoudse-Moens
- Department of Neonatology, Emma Children's Hospital, Amsterdam University Medical Centers, Amsterdam, The Netherlands; Amsterdam Reproduction & Development, Amsterdam, The Netherlands
| | - Elske H Weber
- Department of Pediatrics, Northwest Clinics, Alkmaar, The Netherlands
| | - Femke de Groof
- Department of Pediatrics, Northwest Clinics, Alkmaar, The Netherlands
| | | | | | | | - Maarten Rijpert
- Department of Pediatrics, Zaans Medisch Centrum, Zaandam, The Netherlands
| | - Irene A Schiering
- Department of Pediatrics, Spaarne Gasthuis, Haarlem, The Netherlands
| | - Janneke Wilms
- Department of Pediatrics, Bovenij ziekenhuis, Amsterdam, The Netherlands
| | - Aleid G Leemhuis
- Department of Neonatology, Emma Children's Hospital, Amsterdam University Medical Centers, Amsterdam, The Netherlands; Amsterdam Reproduction & Development, Amsterdam, The Netherlands
| | - Wes Onland
- Department of Neonatology, Emma Children's Hospital, Amsterdam University Medical Centers, Amsterdam, The Netherlands; Amsterdam Reproduction & Development, Amsterdam, The Netherlands.
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Garvelink MM, Daniels K, de Weerdt O, van der Nat PB. Why real world outcome information is indispensable in making treatment decisions for multiple myeloma. ZEITSCHRIFT FUR EVIDENZ, FORTBILDUNG UND QUALITAT IM GESUNDHEITSWESEN 2023; 176:42-50. [PMID: 36464588 DOI: 10.1016/j.zefq.2022.09.011] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 02/23/2021] [Revised: 08/31/2022] [Accepted: 09/27/2022] [Indexed: 12/03/2022]
Abstract
OBJECTIVE A next step in value-based healthcare (VBHC) is to use outcome information (OI) to inform patients about (personalized) outcomes of care in order to support decision-making processes. We aimed to explore multiple myeloma (MM) patients' and caregivers' views on communication of OI and (shared) decision-making (SDM). METHODS Focus groups with MM patients and caregivers. Main topics were experiences and needs with information provision, communication, decision-making, and use of OI. Focus groups were audiotaped, transcribed verbatim and analyzed in an iterative process by two researchers using open coding. Member checks were performed. RESULTS Two focus groups were held with 11 patients (91% male, M=71 years old) and 10 caregivers (89% partners). Information needs were different per moment in the disease trajectory and purpose. Patients were implicitly involved in decisions, but they were not always aware of options and no active weighing of values took place. Outcome information was mostly provided on an individual level, to monitor disease progression and initiate decisions about the need for changes in ongoing treatment regimens (follow-up treatment lines). Patients appreciated the current process of information provision and decision-making, but prefer more option awareness, a bigger role in decision-making and more OI to 1) weigh outcomes for decision-making; 2) get insight in their care trajectory; and 3) compare with other patients. CONCLUSIONS Participants were satisfied with information provision and decision-making, but they were only implicitly involved in decisions. Real world OI derived from VBHC improvement cycles for MM may fulfil MM patients' and caregivers' information needs and support treatment decision-making.
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Affiliation(s)
| | - Kirsten Daniels
- Department of Value Based Healthcare, St Antonius Hospital, Nieuwegein, The Netherlands; Radboud university medical center, Radboud Institute for Health Sciences, Scientific Center for Quality of Healthcare (IQ healthcare), The Netherlands
| | - Okke de Weerdt
- Department of Hematology, St Antonius Hospital, Nieuwegein, The Netherlands
| | - Paul Bastiaan van der Nat
- Department of Value Based Healthcare, St Antonius Hospital, Nieuwegein, The Netherlands; Radboud university medical center, Radboud Institute for Health Sciences, Scientific Center for Quality of Healthcare (IQ healthcare), The Netherlands
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Rees P, Callan C, Chadda KR, Vaal M, Diviney J, Sabti S, Harnden F, Gardiner J, Battersby C, Gale C, Sutcliffe A. Preterm Brain Injury and Neurodevelopmental Outcomes: A Meta-analysis. Pediatrics 2022; 150:e2022057442. [PMID: 36330752 PMCID: PMC9724175 DOI: 10.1542/peds.2022-057442] [Citation(s) in RCA: 28] [Impact Index Per Article: 14.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 07/08/2022] [Indexed: 11/06/2022] Open
Abstract
CONTEXT Preterm brain injuries are common; neurodevelopmental outcomes following contemporary neonatal care are continually evolving. OBJECTIVE To systematically review and meta-analyze neurodevelopmental outcomes among preterm infants after intraventricular hemorrhage (IVH) and white matter injury (WMI). DATA SOURCES Published and grey literature were searched across 10 databases between 2000 and 2021. STUDY SELECTION Observational studies reporting 3-year neurodevelopmental outcomes for preterm infants with IVH or WMI compared with preterm infants without injury. DATA EXTRACTION Study characteristics, population characteristics, and outcome data were extracted. RESULTS Thirty eight studies were included. There was an increased adjusted risk of moderate-severe neurodevelopmental impairment after IVH grade 1 to 2 (adjusted odds ratio 1.35 [95% confidence interval 1.05-1.75]) and IVH grade 3 to 4 (adjusted odds ratio 4.26 [3.25-5.59]). Children with IVH grade 1 to 2 had higher risks of cerebral palsy (odds ratio [OR] 1.76 [1.39-2.24]), cognitive (OR 1.79 [1.09-2.95]), hearing (OR 1.83 [1.03-3.24]), and visual impairment (OR 1.77 [1.08-2.9]). Children with IVH grade 3 to 4 had markedly higher risks of cerebral palsy (OR 4.98 [4.13-6.00]), motor (OR 2.7 [1.52-4.8]), cognitive (OR 2.3 [1.67-3.15]), hearing (OR 2.44 [1.42-4.2]), and visual impairment (OR 5.42 [2.77-10.58]). Children with WMI had much higher risks of cerebral palsy (OR 14.91 [7.3-30.46]), motor (OR 5.3 [3-9.36]), and cognitive impairment (OR 3.48 [2.18-5.53]). LIMITATIONS Heterogeneity of outcome data. CONCLUSIONS Mild IVH, severe IVH, and WMI are associated with adverse neurodevelopmental outcomes. Utilization of core outcome sets and availability of open-access study data would improve our understanding of the nuances of these outcomes.
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Affiliation(s)
- Philippa Rees
- Population Policy and Practice, Great Ormond Street UCL Institute of Child Health, London, United Kingdon
| | - Caitriona Callan
- Nuffield Department of Primary Care Health Sciences, University of Oxford, Oxford, United Kingdom
| | - Karan R. Chadda
- Department of Paediatrics, Cambridge University Hospitals NHS Foundation Trust, Cambridge, United Kingdom
| | - Meriel Vaal
- Population Policy and Practice, Great Ormond Street UCL Institute of Child Health, London, United Kingdon
| | - James Diviney
- Paediatric ICU, Great Ormond Street Hospital, London, United Kingdom
| | | | - Fergus Harnden
- Chelsea and Westminster Hospital NHS Foundation Trust, London, United Kingdom
| | - Julian Gardiner
- Population Policy and Practice, Great Ormond Street UCL Institute of Child Health, London, United Kingdon
| | | | | | - Alastair Sutcliffe
- Population Policy and Practice, Great Ormond Street UCL Institute of Child Health, London, United Kingdon
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Krick JA, Feltman DM, Arnolds M. Decision-Making for Extremely Preterm Infants: A Qualitative Systematic Review. J Pediatr 2022; 251:6-16. [PMID: 35940293 DOI: 10.1016/j.jpeds.2022.07.017] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/09/2022] [Revised: 07/11/2022] [Accepted: 07/20/2022] [Indexed: 11/28/2022]
Abstract
OBJECTIVE To synthesize and describe important elements of decision-making during antenatal consultation for threatened preterm delivery at the margin of gestational viability. STUDY DESIGN Data sources including PubMed, EMBASE, Web of Science, and CINAHL Plus were searched. We included all qualitative literature published on decision-making from 1990 to July 2021. Two authors independently screened and evaluated each study using the Critical Appraisal Skills Programme checklist; studies reaching moderate and high quality were included. We developed an extraction tool to collect and categorize data from each qualitative article, then used thematic analysis to analyze and describe the findings. RESULTS Twenty-five articles incorporating the views of 504 providers and 352 parents were included for final review. Thematic analysis revealed 4 main themes describing the experience of health care providers and parents participating in decision-making: factors that influence decision-making, information sharing, building a partnership, and making the decision. Parents and providers were not always in agreement upon which elements were most essential to the process of decision-making. Articles published in languages other than English were excluded. CONCLUSIONS Qualitative literature highlighting key factors which are important during antenatal counseling can inform and guide providers through the process of shared decision-making. Communicating clear, honest, and balanced information; avoiding artificially dichotomized options; and focusing on partnership building with families will help providers use the antenatal consultation to reach personalized decisions for each infant.
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Affiliation(s)
- Jeanne A Krick
- Department of Pediatrics, Brooke Army Medical Center, San Antonio, TX.
| | - Dalia M Feltman
- Division of Neonatology, Department of Pediatrics, Evanston Hospital, NorthShore University Health System, Evanston, IL; Pritzker School of Medicine, University of Chicago, Chicago, IL
| | - Marin Arnolds
- Division of Neonatal-Perinatal Medicine, Department of Pediatrics, University of Michigan, Ann Arbor, MI
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Kilbride HW, Vohr BR, McGowan EM, Peralta-Carcelen M, Stringer K, Das A, Archer SW, Hintz SR. Early neurodevelopmental follow-up in the NICHD neonatal research network: Advancing neonatal care and outcomes, opportunities for the future. Semin Perinatol 2022; 46:151642. [PMID: 35842320 PMCID: PMC11068160 DOI: 10.1016/j.semperi.2022.151642] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/31/2022]
Abstract
At the inception of the Eunice Kennedy Shriver National Institute of Child Health and Development Neonatal Research Network (NRN), provision of care for extremely preterm (EPT) infants was considered experimental. The NRN Follow-up Study Group, initiated in 1993, developed infrastructure with certification processes and standards, allowing the NRN to assess 2-year outcomes for EPT and to provide important metrics for randomized clinical trials. This chapter will review the NRN Follow-up Study Group's contributions to understanding factors related to improved neurodevelopmental, behavioral, and social-emotional outcomes of EPT infants. We will also discuss follow up challenges, including reassessing which outcomes are most meaningful for parents and investigators. Finally, we will explore how outcome studies have informed clinical decisions and ethical considerations, given limitations of prediction of complex later childhood outcomes from early neurodevelopmental findings.
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Affiliation(s)
- Howard W Kilbride
- Department of Pediatrics, Children's Mercy-Kansas City and the University of Missouri-Kansas City, 2401 Gillham Road, 3rd Floor Annex, Kansas City, MO.
| | - Betty R Vohr
- Department of Pediatrics, Women and Infants Hospital of Rhode Island and Brown University, Providence, RI
| | - Elisabeth M McGowan
- Department of Pediatrics, Women and Infants Hospital of Rhode Island and Brown University, Providence, RI
| | | | - Kimberlly Stringer
- Division of Neonatology, University of Alabama at Birmingham, Birmingham, AL
| | - Abhik Das
- Social, Statistical, and Environmental Sciences Unit, RTI International, Rockville, MD
| | - Stephanie Wilson Archer
- Eunice Kennedy Shriver National Institute of Child Health and Human Development, Bethesda, MD
| | - Susan R Hintz
- Department of Pediatrics, Stanford University School of Medicine, Palo Alto, CA
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Gallagher K, Shaw C, Parisaei M, Marlow N, Aladangady N. Attitudes About Extremely Preterm Birth Among Obstetric and Neonatal Health Care Professionals in England: A Qualitative Study. JAMA Netw Open 2022; 5:e2241802. [PMID: 36374500 PMCID: PMC9664260 DOI: 10.1001/jamanetworkopen.2022.41802] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/05/2022] [Accepted: 09/29/2022] [Indexed: 11/16/2022] Open
Abstract
Importance Variation in attitudes between health care professionals involved in the counseling of parents facing extremely preterm birth (<24 wk gestational age) may lead to parental confusion and professional misalignment. Objective To explore the attitudes of health care professionals involved in the counseling of parents facing preterm birth on the treatment of extremely preterm infants. Design, Setting, and Participants This qualitative study used Q methods to explore the attitudes of neonatal nurses, neonatologists, midwives, and obstetricians involved in the care of extremely preterm infants in 4 UK National Health Service perinatal centers between February 10, 2020, and April 30, 2021. Each participating center had a tertiary level neonatal unit and maternity center. Individuals volunteered participation through choosing to complete the study following a presentation by researchers at each center. A link to the online Q study was emailed to all potential participants by local principal investigators. Participants ranked 53 statements about the treatment of extremely preterm infants in an online quasi-normal distribution grid from strongly agree (6) to strongly disagree (-6). Main Outcomes and Measures Distinguishing factors per professional group (representing different attitudes) identified through by-person factor analysis of Q sort-data were the primary outcome. Areas of shared agreement (consensus) between professional groups were also explored. Q sorts achieving a factor loading of greater than 0.46 (P < .01) on a given factor were included. Results In total, 155 health care professionals volunteered participation (128 [82.6%] women; mean [SD] age, 41.6 [10.2] years, mean [SD] experience, 14.1 [9.6] years). Four distinguishing factors were identified between neonatal nurses, 3 for midwives, 5 for neonatologists, and 4 for obstetricians. Analysis of factors within and between professional groups highlighted significant variation in attitudes of professionals toward parental engagement in decision-making, the perceived importance of potential disability in decision-making, and the use of medical technology. Areas of consensus highlighted that most professionals disagreed with statements suggesting disability equates to reduced quality of life. The statement suggesting the parents' decision was considered the most important when considering neonatal resuscitation was placed in the neutral (middistribution) position by all professionals. Conclusions and Relevance The findings of this qualitative study suggest that parental counseling at extremely low gestations is a complex scenario further complicated by the differences in attitudes within and between professional disciplines toward treatment approaches. The development of multidisciplinary training encompassing all professional groups may facilitate a more consistent and individualized approach toward parental engagement in decision-making.
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Affiliation(s)
- Katie Gallagher
- EGA Institute for Women’s Health, University College London, London, United Kingdom
| | - Chloe Shaw
- EGA Institute for Women’s Health, University College London, London, United Kingdom
| | - Maryam Parisaei
- Department of Obstetrics and Gynaecology, Homerton Healthcare NHS Foundation Trust, London, United Kingdom
| | - Neil Marlow
- EGA Institute for Women’s Health, University College London, London, United Kingdom
| | - Narendra Aladangady
- Department of Neonatology, Homerton Healthcare NHS Foundation Trust, London, United Kingdom
- Centre for Paediatrics, Barts and the London School of Medicine and Dentistry, QMUL, London, United Kingdom
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Jaworski M, Janvier A, Bourque CJ, Mai-Vo TA, Pearce R, Synnes AR, Luu TM. Parental perspective on important health outcomes of extremely preterm infants. Arch Dis Child Fetal Neonatal Ed 2022; 107:495-500. [PMID: 34815239 PMCID: PMC9411910 DOI: 10.1136/archdischild-2021-322711] [Citation(s) in RCA: 19] [Impact Index Per Article: 9.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/22/2021] [Accepted: 11/03/2021] [Indexed: 11/06/2022]
Abstract
BACKGROUND AND OBJECTIVE Neonatal outcome research and clinical follow-up principally focus on neurodevelopmental impairment (NDI) after extremely preterm birth, as defined by the scientific community, without parental input. This survey aimed to investigate parental perspectives about the health and development of their preterm children. METHODS Parents of children aged 18 months to 7 years born <29 weeks' gestational age presenting at a neonatal follow-up clinic over a 1-year period were asked to evaluate their children's health and development. They were also asked the following question: 'if you could improve two things about your child, what would they be?' Responses were analysed using mixed methods. Logistic regressions were done to compare parental responses. RESULTS 248 parents of 213 children (mean gestational age 26.6±1.6 weeks, 20% with severe NDI) were recruited. Parents evaluated their children's health at a median of 9/10. Parental priorities for health improvements were (1) development, mainly behaviour, emotional health and language/communication (55%); (2) respiratory heath and overall medical fragility (25%); and (3) feeding/growth issues (14%). Nineteen per cent explicitly mentioned 'no improvements'. Parents were more likely to state 'no improvements' if child had no versus severe NDI OR 4.33 (95% CI 1.47 to 12.75)) or if parents had no versus at least a high school diploma (OR 4.01 (95% 1.99 to 8.10)). CONCLUSIONS Parents evaluate the health of their preterm children as being very good, with positive perspectives. Parental concerns outside the developmental sphere should also be addressed both in clinical follow-up and research.
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Affiliation(s)
- Magdalena Jaworski
- Department of pediatrics, Centre Hospitalier Universitaire Sainte-Justine, Montreal, Québec, Canada,Clinical Ethics Unit, Centre Hospitalier Universitaire Sainte-Justine, Montreal, Québec, Canada
| | - Annie Janvier
- Department of pediatrics, Centre Hospitalier Universitaire Sainte-Justine, Montreal, Québec, Canada,Clinical Ethics Unit, Centre Hospitalier Universitaire Sainte-Justine, Montreal, Québec, Canada,Clinical Ethics and Family Partnership Research Unit, CHU Sainte-Justine Centre de Recherche, Montreal, Québec, Canada,Palliative care unit, Centre Hospitalier Universitaire Sainte-Justine, Montreal, Québec, Canada,Centre Hospitalier Universitaire Sainte-Justine Research Center, Montreal, Québec, Canada,Bureau du partenariat patients-familles-soignants, Centre Hospitalier Universitaire Sainte-Justine, Montreal, Québec, Canada,Bureau de l'éthique clinique, Université de Montréal, Montreal, Québec, Canada
| | - Claude Julie Bourque
- Clinical Ethics Unit, Centre Hospitalier Universitaire Sainte-Justine, Montreal, Québec, Canada,Clinical Ethics and Family Partnership Research Unit, CHU Sainte-Justine Centre de Recherche, Montreal, Québec, Canada,Centre Hospitalier Universitaire Sainte-Justine Research Center, Montreal, Québec, Canada
| | - Thuy-An Mai-Vo
- Centre Hospitalier Universitaire Sainte-Justine Research Center, Montreal, Québec, Canada
| | - Rebecca Pearce
- Bureau du partenariat patients-familles-soignants, Centre Hospitalier Universitaire Sainte-Justine, Montreal, Québec, Canada
| | - Anne R Synnes
- British Columbia Children's Hospital Research Institute, Vancouver, British Columbia, Canada
| | - Thuy Mai Luu
- Department of pediatrics, Centre Hospitalier Universitaire Sainte-Justine, Montreal, Québec, Canada .,Centre Hospitalier Universitaire Sainte-Justine Research Center, Montreal, Québec, Canada
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Ethical considerations in the management of infants with severe intraventricular hemorrhage. Semin Perinatol 2022; 46:151599. [PMID: 35450739 DOI: 10.1016/j.semperi.2022.151599] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/22/2022]
Abstract
Intrinsic and extrinsic factors unique to neonatal care can complicate predictions of neurological outcomes for infants who suffer from severe intraventricular hemorrhage. While care decisions are driven by the same bioethical principles used in other domains, neurological prognostication can challenge concepts of futility, require careful examination of parental values, uncover biases and/or potentially compromise the best interests of the future child. In the following chapter we will review bioethical principles and relevant concepts, explore challenges to decision-making surrounding diagnoses of severe intraventricular hemorrhage and conclude with a brief review of practical approaches for counseling parents about neurodevelopmental impairment given the constraints of prognostic uncertainty and assumptions related to quality of life. We will argue that neurological findings alone, even in the setting of severe intraventricular hemorrhage, often do not constitute enough evidence for redirection of care but can be permissible when the entire neonatal condition is considered.
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38
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Personalized support of parents of extremely preterm infants before, during and after birth. Semin Fetal Neonatal Med 2022; 27:101335. [PMID: 35780043 DOI: 10.1016/j.siny.2022.101335] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/23/2022]
Abstract
The emotional turmoil associated with extremely preterm birth is inescapable parents. How each parent handles the unexpected, makes sense of the unknown and learns to parent their child is uniquely personal. A rigid standardized approach to support families through their journey before and during neonatal intensive care disregards this individuality. This article reviews general concepts and practices that can be learned and applied by clinicians to promote resiliency and help parents cope adaptively. This review will describe how to personalize parenting support during the antenatal consultation and hospitalization for parents of extremely premature infants. To facilitate this, mindsets and care delivery models need to shift from inflexible standardized protocols to flexible guidelines that enable personalized communications, support structures and care delivery models tailored to each person's characteristics, preferences, and values.
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Gralton KS, Doering J, Ngui E, Pan A, Schiffman R. Family resiliency and family functioning in Non-Hispanic Black and Non-Hispanic White families of preterm infants. J Pediatr Nurs 2022; 64:102-110. [PMID: 35248955 DOI: 10.1016/j.pedn.2022.02.010] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/13/2021] [Revised: 02/06/2022] [Accepted: 02/17/2022] [Indexed: 11/15/2022]
Abstract
PURPOSE The purpose of this study was to examine the relationship between resiliency factors and family functioning in families of preterm infants (< 37 weeks gestation) from two different racial groups hospitalized in a neonatal intensive care unit (NICU). DESIGN AND METHODS A cross-sectional design was used at five Level III/IV NICUs in a Midwestern city/suburbs. Seventy-nine family units (24 Non-Hispanic Black and 55 Non-Hispanic White) completed four instruments that assessed families' use of specific resiliency factors and a measure of family functioning. Demographic data were also collected. RESULTS Using linear mixed modeling, the significant predictors of family functioning for both Non-Hispanic Black and Non-Hispanic White, even after adjusting for education, income and race, were the protective factors "hardiness" (coefficient = -0.021) and "resources" (coefficient = -0.0052). The fixed effects in the model accounted for 48% (Marginal R2 = 0.48) of the variance on family functioning and the fixed and random effects accounted for 59% (Conditional R2, 0.59) of the variance on family functioning. Sixteen percent of the total sample rated their family as dysfunctional. CONCLUSIONS Findings from this study suggest that assessment of protective factors related to hardiness and resources individualize nursing interventions to support the resiliency of both Non-Hispanic Black and Non-Hispanic White families, regardless of differences in income and education. Further research studying resiliency in families of preterm infants is needed to understand the impact on long-term family functioning. PRACTICE IMPLICATIONS Understandingindividual family strengths,through the identification of resiliency (protective and recovery) factors could predict at-risk families before discharge. In collaboration with other health care professionals, nurses can assess individual family needs and strengths, within the context of their socioeconomic environment, and the racial and cultural influences that are important to the family.
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Affiliation(s)
| | - Jennifer Doering
- College of Nursing, University of Wisconsin-Milwaukee, Milwaukee, WI, USA
| | - Emmanuel Ngui
- School of Public Health, University of Wisconsin-Milwaukee, Milwaukee, WI, USA
| | - Amy Pan
- Medical College of Wisconsin, WI, USA
| | - Rachel Schiffman
- College of Nursing, University of Wisconsin-Milwaukee, Milwaukee, WI, USA
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Sun L, Bao Y, Zhang H, Zhu J. Identification of Premature Infants at High Risk of Late Respiratory Diseases: A Retrospective Cohort Study. Front Pediatr 2022; 10:869963. [PMID: 35515352 PMCID: PMC9067161 DOI: 10.3389/fped.2022.869963] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/05/2022] [Accepted: 03/14/2022] [Indexed: 11/13/2022] Open
Abstract
Aim To identify infants with very low birth weight at risk of late respiratory diseases after discharge. Methods This retrospective longitudinal study included 388 preterm infants with gestational age of < 32 weeks and birth weight of < 1,500 g and evaluated perinatal information, assessments performed while in the neonatal intensive care unit, and longitudinal follow-up via questionnaire until the corrected gestational age of 18-24 months. Results The mean birth weight and gestational age were 1,191.2 ± 191.8 g and 29.1 ± 1.4 weeks, respectively. Sixty-four (16.5%) infants developed late respiratory diseases after discharge to the corrected gestational age of 18-24 months. Univariate analyses showed that gestational age, birth weight, respiratory support, oxygen use, bronchopulmonary dysplasia diagnosed at 36 weeks' postmenstrual age and length of hospital stay were associated with late respiratory diseases. After adjusting for covariates, respiratory support was significantly associated with serious respiratory morbidities to 18-24 months corrected gestational age. With each day of respiratory support, the odds of late respiratory diseases increased by 1.033-fold. Conclusion Respiratory support was associated with increased odds of developing late respiratory diseases during early childhood, which may be an early predictor to late respiratory morbidities. Thus, it is imperative to identify a safe and effective strategy to prevent chronic dependency on respiratory support.
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Affiliation(s)
| | | | | | - Jiajun Zhu
- Department of Neonatology, Women’s Hospital, Zhejiang University School of Medicine, Hangzhou, China
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Abstract
Neonatal follow-up studies traditionally report on long-term neurodevelopmental outcomes as a metric of success of neonatal intensive care. Research endpoints are also typically deficit-based, assessing whether disabilities, such as cerebral palsy, cognitive impairment, deafness or blindness, are present or not. These historical approaches have resulted in neonatal follow-up programs that narrowly focus on the early identification of neurodevelopmental problems, possibly to the detriment of other outcomes that matter to parents. This focus on neurodevelopmental disability may also contribute to the negative stereotypes associated with extreme preterm birth. In this article, we discuss parental perspectives regarding important long-term outcomes. We examine limitations with current definitions of outcomes and propose a strength-based approach to generate meaningful findings both for clinicians and families.
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Personalized communication with parents of children born at less than 25 weeks: Moving from doctor-driven to parent-personalized discussions. Semin Perinatol 2022; 46:151551. [PMID: 34893335 DOI: 10.1016/j.semperi.2021.151551] [Citation(s) in RCA: 12] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/09/2023]
Abstract
Communication with parents is an essential component of neonatal care. For extremely preterm infants born at less than 25 weeks, this process is complicated by the substantial risk of mortality or major morbidity. For some babies with specific prognostic factors, the majority die. Although many of these deaths occur after admission to the intensive care unit, position statements have focused on communication during the prenatal consultation. This review takes a more comprehensive approach and covers personalized and parent-centered communication in the clinical setting during three distinct yet inter-related phases: the antenatal consultation, the neonatal intensive care hospitalization, and the dying process (when this happens). We advocate that a 'one-size-fits-all' communication model focused on standardizing information does not lead to partnerships. It is possible to standardize personalized approaches that recognize and adapt to parental heterogeneity. This can help clinicians and parents build effective partnerships of trust and affective support to engage in personalized decision-making. These practices begin with self-reflection on the part of the clinician and continue with practical frameworks and stepwise approaches supporting personalization and parent-centered communication.
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Bell EF, Hintz SR, Hansen NI, Bann CM, Wyckoff MH, DeMauro SB, Walsh MC, Vohr BR, Stoll BJ, Carlo WA, Van Meurs KP, Rysavy MA, Patel RM, Merhar SL, Sánchez PJ, Laptook AR, Hibbs AM, Cotten CM, D’Angio CT, Winter S, Fuller J, Das A. Mortality, In-Hospital Morbidity, Care Practices, and 2-Year Outcomes for Extremely Preterm Infants in the US, 2013-2018. JAMA 2022; 327:248-263. [PMID: 35040888 PMCID: PMC8767441 DOI: 10.1001/jama.2021.23580] [Citation(s) in RCA: 276] [Impact Index Per Article: 138.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/12/2021] [Accepted: 12/10/2021] [Indexed: 12/19/2022]
Abstract
IMPORTANCE Despite improvement during recent decades, extremely preterm infants continue to contribute disproportionately to neonatal mortality and childhood morbidity. OBJECTIVE To review survival, in-hospital morbidities, care practices, and neurodevelopmental and functional outcomes at 22-26 months' corrected age for extremely preterm infants. DESIGN, SETTING, AND PARTICIPANTS Prospective registry for extremely preterm infants born at 19 US academic centers that are part of the Eunice Kennedy Shriver National Institute of Child Health and Human Development Neonatal Research Network. The study included 10 877 infants born at 22-28 weeks' gestational age between January 1, 2013, and December 31, 2018, including 2566 infants born before 27 weeks between January 1, 2013, and December 31, 2016, who completed follow-up assessments at 22-26 months' corrected age. The last assessment was completed on August 13, 2019. Outcomes were compared with a similar cohort of infants born in 2008-2012 adjusting for gestational age. EXPOSURES Extremely preterm birth. MAIN OUTCOMES AND MEASURES Survival and 12 in-hospital morbidities were assessed, including necrotizing enterocolitis, infection, intracranial hemorrhage, retinopathy of prematurity, and bronchopulmonary dysplasia. Infants were assessed at 22-26 months' corrected age for 12 health and functional outcomes, including neurodevelopment, cerebral palsy, vision, hearing, rehospitalizations, and need for assistive devices. RESULTS The 10 877 infants were 49.0% female and 51.0% male; 78.3% (8495/10848) survived to discharge, an increase from 76.0% in 2008-2012 (adjusted difference, 2.0%; 95% CI, 1.0%-2.9%). Survival to discharge was 10.9% (60/549) for live-born infants at 22 weeks and 94.0% (2267/2412) at 28 weeks. Survival among actively treated infants was 30.0% (60/200) at 22 weeks and 55.8% (535/958) at 23 weeks. All in-hospital morbidities were more likely among infants born at earlier gestational ages. Overall, 8.9% (890/9956) of infants had necrotizing enterocolitis, 2.4% (238/9957) had early-onset infection, 19.9% (1911/9610) had late-onset infection, 14.3% (1386/9705) had severe intracranial hemorrhage, 12.8% (1099/8585) had severe retinopathy of prematurity, and 8.0% (666/8305) had severe bronchopulmonary dysplasia. Among 2930 surviving infants with gestational ages of 22-26 weeks eligible for follow-up, 2566 (87.6%) were examined. By 2-year follow-up, 8.4% (214/2555) of children had moderate to severe cerebral palsy, 1.5% (38/2555) had bilateral blindness, 2.5% (64/2527) required hearing aids or cochlear implants, 49.9% (1277/2561) had been rehospitalized, and 15.4% (393/2560) required mobility aids or other supportive devices. Among 2458 fully evaluated infants, 48.7% (1198/2458) had no or mild neurodevelopmental impairment at follow-up, 29.3% (709/2419) had moderate neurodevelopmental impairment, and 21.2% (512/2419) had severe neurodevelopmental impairment. CONCLUSIONS AND RELEVANCE Among extremely preterm infants born in 2013-2018 and treated at 19 US academic medical centers, 78.3% survived to discharge, a significantly higher rate than for infants born in 2008-2012. Among infants born at less than 27 weeks' gestational age, rehospitalization and neurodevelopmental impairment were common at 2 years of age.
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Affiliation(s)
| | - Susan R. Hintz
- Department of Pediatrics, Stanford University, Palo Alto, California
| | - Nellie I. Hansen
- Social, Statistical, and Environmental Sciences Unit, RTI International, Research Triangle Park, North Carolina
| | - Carla M. Bann
- Social, Statistical, and Environmental Sciences Unit, RTI International, Research Triangle Park, North Carolina
| | - Myra H. Wyckoff
- Department of Pediatrics, University of Texas Southwestern, Dallas
| | - Sara B. DeMauro
- Department of Pediatrics, University of Pennsylvania, Philadelphia
| | - Michele C. Walsh
- Eunice Kennedy Shriver National Institute of Child Health and Human Development, Bethesda, Maryland
| | - Betty R. Vohr
- Department of Pediatrics, Brown University, Providence, Rhode Island
| | - Barbara J. Stoll
- Department of Pediatrics, Emory University School of Medicine and Children’s Healthcare of Atlanta, Atlanta, Georgia
| | | | | | | | - Ravi M. Patel
- Department of Pediatrics, Emory University School of Medicine and Children’s Healthcare of Atlanta, Atlanta, Georgia
| | | | - Pablo J. Sánchez
- Department of Pediatrics, The Ohio State University and Nationwide Children’s Hospital, Columbus
| | - Abbot R. Laptook
- Department of Pediatrics, Brown University, Providence, Rhode Island
| | - Anna Maria Hibbs
- Department of Pediatrics, Case Western Reserve University, Cleveland, Ohio
| | | | - Carl T. D’Angio
- Department of Pediatrics, University of Rochester, Rochester, New York
| | - Sarah Winter
- Department of Pediatrics, University of Utah, Salt Lake City
| | - Janell Fuller
- Department of Pediatrics, University of New Mexico, Albuquerque
| | - Abhik Das
- Social, Statistical, and Environmental Sciences Unit, RTI International, Rockville, Maryland
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Schouten E, Haupt J, Ramirez J, Sillett N, Nielsen C, Clarke A, Matkin L, Joseph A, Been J, Bolaños González I, Cheong J, Daly M, Kirpalani H, Mader S, Maria A, Matijasevich A, Mittal R, Mutesu-Kapembwa K, Vavouraki E, Webbe J, Wolke D, Zeitlin J, Flemmer A. Standardized Outcome Measures for Preterm and Hospitalized Neonates: An ICHOM Standard Set. Neonatology 2022; 119:443-454. [PMID: 35545018 PMCID: PMC9533443 DOI: 10.1159/000522318] [Citation(s) in RCA: 5] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/06/2021] [Accepted: 01/10/2022] [Indexed: 11/20/2022]
Abstract
INTRODUCTION Approximately, one in ten infants is born preterm or requires hospitalization at birth. These complications at birth have long-term consequences that can extend into childhood and adulthood. Timely detection of developmental delay through surveillance could enable tailored support for these babies and their families. However, the possibilities for follow-up are limited, especially in middle- and low-income countries, and the tools to do so are either not available or too expensive. A standardized and core set of outcomes for neonates, with feasible tools for evaluation and follow-up, could result in improving quality, enhance shared decision-making, and enable global benchmarking. METHODS The International Consortium for Health Outcomes Measurement (ICHOM) convened an international working group, which was comprised of 14 health-care professionals (HCP) and 6 patient representatives in the field of neonatal care. An outcome set was developed using a three-round modified Delphi process, and it was endorsed through a patient representative-validation survey and an HCP survey. RESULTS A literature review revealed 1,076 articles and 26 registries which were screened for meaningful outcomes, patient-reported outcome measures, clinical measures, and case mix variables. This resulted in a neonatal set with 21 core outcomes covering three domains (physical, social, and mental functioning) and 14 tools to assess these outcomes at three timepoints. DISCUSSION This set can be implemented globally and it will allow comparison of outcomes across different settings and countries. The transparent consensus-driven development process which involved stakeholders and professionals from all over the world ensures global relevance.
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Affiliation(s)
- Esther Schouten
- Divison of Neonatology, LMU University Children's Hospital, Dr. V. Hauner, Munich, Germany
| | - Johanna Haupt
- Divison of Neonatology, LMU University Children's Hospital, Dr. V. Hauner, Munich, Germany,
| | - Jessily Ramirez
- International Consortium for Health Outcomes Measurement (ICHOM), Boston, Massachusetts, USA
| | - Nick Sillett
- International Consortium for Health Outcomes Measurement (ICHOM), London, United Kingdom
| | - Christina Nielsen
- International Consortium for Health Outcomes Measurement (ICHOM), Boston, Massachusetts, USA
| | - Anna Clarke
- International Consortium for Health Outcomes Measurement (ICHOM), London, United Kingdom
| | - Lucy Matkin
- International Consortium for Health Outcomes Measurement (ICHOM), London, United Kingdom
| | - Andria Joseph
- International Consortium for Health Outcomes Measurement (ICHOM), London, United Kingdom
| | - Jasper Been
- Division of Neonatology, Department of Paediatrics, Erasmus MC Sophia Children's Hospital, University Medical Centre Rotterdam, Rotterdam, The Netherlands.,Department of Obstetrics and Gynaecology, Erasmus MC Sophia Children's Hospital, University Medical Centre Rotterdam, Rotterdam, The Netherlands.,Department of Public Health, Erasmus MC Sophia Children's Hospital, University Medical Centre Rotterdam, Rotterdam, The Netherlands
| | - Ilein Bolaños González
- Con Amor Vencerás A.C., Mexico City, Mexico.,GLANCE (GLobal Alliance for Newborn CarE), Mexico City, Mexico
| | - Jeanie Cheong
- Clinical Sciences, Murdoch Children's Research Institute, Melbourne, Victoria, Australia.,Neonatal Services, Royal Women's Hospital, Parkville, Victoria, Australia.,Department of Obstetrics and Gynaecology, University of Melbourne, Parkville, Victoria, Australia
| | - Mandy Daly
- Advocacy and Policymaking Institutional, Irish Neonatal Health Alliance, Co Wicklow, Ireland
| | - Haresh Kirpalani
- Emeritus, Neonatology, University Pennsylvania, Philadelphia, Pennsylvania, USA.,Paediatrics, McMaster University, Hamilton, Ontario, Canada
| | - Silke Mader
- European Foundation for the Care of Newborn Infants, Munich, Germany
| | - Arti Maria
- Department of Neonatology Institutional, ABVIMS &Dr RML Hospital, New Delhi, India
| | - Alicia Matijasevich
- Departamento de Medicina Preventiva, Faculdade de Medicina FMUSP, Universidade de São Paulo, São Paulo, Brazil
| | - Rashmi Mittal
- Department of Neonatology, K.K. Women's and Children's Hospital, Singapore, Singapore
| | - Kunda Mutesu-Kapembwa
- Department of Neonatology, Women and Newborn Hospital, University Teaching Hospital, Lusaka, Zambia
| | - Eleni Vavouraki
- GLANCE (GLobal Alliance for Newborn CarE), Ilitominon, Greece
| | - James Webbe
- Section of Neonatal Medicine, Imperial College London, London, United Kingdom
| | - Dieter Wolke
- Department of Psychology and Division of Health Sciences (Warwick Medical School), University of Warwick, Coventry, United Kingdom
| | - Jennifer Zeitlin
- EPOPé, INSERM, INRA, CRESS, Obstetrical Perinatal and Pediatric Epidemiology Research Team, Université de Paris, Paris, France
| | - Andreas Flemmer
- Divison of Neonatology, LMU University Children's Hospital, Dr. V. Hauner, Munich, Germany
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45
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Neonatal sepsis: a systematic review of core outcomes from randomised clinical trials. Pediatr Res 2022; 91:735-742. [PMID: 34997225 PMCID: PMC9064797 DOI: 10.1038/s41390-021-01883-y] [Citation(s) in RCA: 5] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/23/2021] [Revised: 10/23/2021] [Accepted: 10/28/2021] [Indexed: 12/21/2022]
Abstract
BACKGROUND The lack of a consensus definition of neonatal sepsis and a core outcome set (COS) proves a substantial impediment to research that influences policy and practice relevant to key stakeholders, patients and parents. METHODS A systematic review of the literature was performed according to the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines. In the included studies, the described outcomes were extracted in accordance with the provisions of the Core Outcome Measures in Effectiveness Trials (COMET) handbook and registered. RESULTS Among 884 abstracts identified, 90 randomised controlled trials (RCTs) were included in this review. Only 30 manuscripts explicitly stated the primary and/or secondary outcomes. A total of 88 distinct outcomes were recorded across all 90 studies included. These were then assigned to seven different domains in line with the taxonomy for classification proposed by the COMET initiative. The most frequently reported outcome was survival with 74% (n = 67) of the studies reporting an outcome within this domain. CONCLUSIONS This systematic review constitutes one of the initial phases in the protocol for developing a COS in neonatal sepsis. The paucity of standardised outcome reporting in neonatal sepsis hinders comparison and synthesis of data. The final phase will involve a Delphi Survey to generate a COS in neonatal sepsis by consensus recommendation. IMPACT This systematic review identified a wide variation of outcomes reported among published RCTs on the management of neonatal sepsis. The paucity of standardised outcome reporting hinders comparison and synthesis of data and future meta-analyses with conclusive recommendations on the management of neonatal sepsis are unlikely. The final phase will involve a Delphi Survey to determine a COS by consensus recommendation with input from all relevant stakeholders.
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46
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Abstract
While medical advancements have led to improved survival of extremely premature infants, children remain at risk for brain injury and neurodevelopmental impairment. Brain imaging can offer insight into an infant's acute and long-term outcome; however, counseling parents about the results and implications of brain imaging remains challenging. The purpose of this article is to review the current literature and describe the challenges associated with counseling families of premature infants on neuroimaging findings. We propose a framework to guide clinicians in counseling parents about brain imaging results, informed by best practices in other disciplines: (FIGURE): 1) Formulate a plan 2) Identify parental needs and values 3) Give information 4) Acknowledge Uncertainty 5) Recognize and Respond to emotions 6) Discuss Expectations and Establish follow-up.
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Affiliation(s)
- Sarah M Bernstein
- Department of Pediatrics, Duke University Medical Center, Durham, NC, United States
| | | | - Monica E Lemmon
- Departments of Pediatrics and Population Health Sciences, Duke University Medical Center, Duke-Margolis Center for Health Policy, DUMC 3936, Durham, NC 27710, United States.
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47
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Lemmon ME, Wusthoff CJ, Boss RD, Rasmussen LA. Ethical considerations in the care of encephalopathic neonates treated with therapeutic hypothermia. Semin Fetal Neonatal Med 2021; 26:101258. [PMID: 34176763 PMCID: PMC8627487 DOI: 10.1016/j.siny.2021.101258] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/21/2022]
Abstract
Engaging with ethical issues is central to the management of neonatal encephalopathy (NE). As treatment for these neonates evolves, new ethical issues will arise and many existing challenges will remain. We highlight three key ethical issues that arise in the care of neonates with NE treated with therapeutic hypothermia: facilitating shared decision making, understanding futility, and defining the boundaries between standard of care and research. Awareness of these issues will help clinicians counsel families in light of evolving treatments and outcomes.
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Affiliation(s)
- Monica E. Lemmon
- Division of Pediatric Neurology and Developmental Medicine, Departments of Pediatrics and Population Health Sciences, Duke University School of Medicine, DUMC 3936, Durham, NC, 27710, USA,Corresponding author. (M.E. Lemmon)
| | - Courtney J. Wusthoff
- Departments of Neurology and Pediatrics, Stanford University, Stanford, 750 Welch Road, Suite 317, Palo Alto, CA, 94304, USA
| | - Renee D. Boss
- Division of Neonatology, Department of Pediatrics, Johns Hopkins University School of Medicine, Johns Hopkins Berman Institute of Bioethics, 200 N. Wolfe St, Suite 2019, Baltimore, MD, 21287, United States
| | - Lisa Anne Rasmussen
- Division of Palliative Care, Department of Family Medicine, Department of Neurology, Department of Pediatrics, Larner College of Medicine, University of Vermont, UVM Medical Center Palliative Care, 111 Colchester Avenue, Main Campus, Smith 262, Burlington, VT, 05401-1473, USA.
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48
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McDonnell S, Yan K, Kim UO, Flynn KE, Liegl MN, Leuthner SR, McIntosh JJ, Basir MA. Information Order for Periviable Counseling: Does It Make a Difference? J Pediatr 2021; 235:100-106.e1. [PMID: 33811868 PMCID: PMC8316277 DOI: 10.1016/j.jpeds.2021.03.058] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/05/2021] [Revised: 03/15/2021] [Accepted: 03/26/2021] [Indexed: 12/28/2022]
Abstract
OBJECTIVES To examine whether the order of presenting survival vs disability information, with or without the description of infant neonatal intensive care unit (NICU) experiences would influence treatment choice during hypothetical periviable birth counseling. STUDY DESIGN An internet sample of childbearing-aged women (n = 839) viewed a pictograph displaying the chances of survival and a pictograph on the chances of disability for a baby resuscitated during the periviable period. The sample was randomized to the order of pictographs and level of description of infant NICU experiences. Participants selected between intensive care or comfort care and reported their personal values. RESULTS The order of the information influenced treatment choices (P = .02); participants were more likely to choose intensive care if they saw the survival pictograph first (70%) than the disability pictograph first (62%). Level of description of premature infant NICU experiences did not influence treatment choice (P = .92). Participants who valued sanctity of life, autonomy in making decisions, who were more religious, and had adequate health literacy were more likely to choose intensive care. Such participant characteristics had greater explanatory power than the experimental manipulations. CONCLUSIONS Subtle differences in how information is presented may influence critical decisions. However, even among women with the same values, diversity in treatment choice remains.
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Affiliation(s)
- Siobhan McDonnell
- Department of Pediatrics, Division of Neonatology, Medical College of Wisconsin, Milwaukee, WI
| | - Ke Yan
- Department of Pediatrics, Division of Quantitative Health Sciences, Medical College of Wisconsin, Milwaukee, WI
| | - U Olivia Kim
- Department of Pediatrics, Division of Neonatology, Medical College of Wisconsin, Milwaukee, WI
| | - Kathryn E Flynn
- Department of Medicine, Division of Hematology and Oncology, Medical College of Wisconsin, Milwaukee, WI
| | - Melodee Nugent Liegl
- Department of Pediatrics, Division of Quantitative Health Sciences, Medical College of Wisconsin, Milwaukee, WI
| | - Steven R Leuthner
- Department of Pediatrics, Division of Neonatology, Medical College of Wisconsin, Milwaukee, WI; Department of Population Health, Center for the Study of Bioethics, Medical College of Wisconsin, Milwaukee, WI
| | - Jennifer J McIntosh
- Department of Obstetrics and Gynecology, Division of Maternal Fetal Medicine, Medical College of Wisconsin, Milwaukee, WI
| | - Mir A Basir
- Department of Pediatrics, Division of Neonatology, Medical College of Wisconsin, Milwaukee, WI.
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49
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Haward MF, Lorenz JM, Janvier A, Fischhoff B. Bereaved Parents: Insights for the Antenatal Consultation. Am J Perinatol 2021; 40:874-882. [PMID: 34255335 DOI: 10.1055/s-0041-1731651] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/20/2022]
Abstract
OBJECTIVE The study aimed to explore experiences of extremely preterm infant loss in the delivery room and perspectives about antenatal consultation. STUDY DESIGN Bereaved participants were interviewed, following a semi-structured protocol. Personal narratives were analyzed with a mixed-methods approach. RESULTS In total, 13 participants, reflecting on 17 pregnancies, shared positive, healing and negative, harmful interactions with clinicians and institutions: feeling cared for or abandoned, doubted or believed, being treated rigidly or flexibly, and feeling that infant's life was valued or not. Participants stressed their need for personalized information, individualized approaches, and affective support. Their decision processes varied; some wanted different things for themselves than what they recommended for others. These interactions shaped their immediate experiences, long-term well-being, healing, and regrets. All had successful subsequent pregnancies; few returned to institutions where they felt poorly treated. CONCLUSION Antenatal consultations can be strengthened by personalizing them, within a strong caregiver relationship and supportive institutional practices. KEY POINTS · Personalized antenatal consultations should strive to balance cognitive and affective needs.. · Including perspectives from bereaved parents can strengthen antenatal consultations.. · Trusting provider-parent partnerships are pivotal for risk communication..
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Affiliation(s)
- Marlyse F Haward
- Department of Pediatrics, Children's Hospital at Montefiore, Albert Einstein College of Medicine, Bronx, New York
| | - John M Lorenz
- Department of Pediatrics, Morgan Stanley Children Hospital of New York, Columbia University Vagelos College of Physicians and Surgeons, New York City, New York
| | - Annie Janvier
- Department of Pediatrics, Bureau de l'Éthique Clinique, Université de Montréal, Montréal, Canada.,Division of Neonatology, Research Center, Clinical Ethics Unit, Palliative Care Unit, Unité de recherche en éthique clinique et partenariat famille, CHU Sainte-Justine, Montréal, Canada
| | - Baruch Fischhoff
- Department of Engineering and Public Policy and Institute for Politics and Strategy, Carnegie Mellon University, Pittsburgh, Pennsylvania
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50
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Kim BH, Feltman DM, Schneider S, Herron C, Montes A, Anani UE, Murray PD, Arnolds M, Krick J. What Information Do Clinicians Deem Important for Counseling Parents Facing Extremely Early Deliveries?: Results from an Online Survey. Am J Perinatol 2021; 40:657-665. [PMID: 34100274 DOI: 10.1055/s-0041-1730430] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/21/2022]
Abstract
OBJECTIVE The study aimed to better understand how neonatology and maternal fetal medicine (MFM) physicians convey information during antenatal counseling that requires facilitating shared decision-making with parents facing options of resuscitation versus comfort care after extremely early delivery STUDY DESIGN: Attending physicians at US centers with both Neo and MFM fellowships were invited to answer an original online survey about antenatal counseling for extremely early newborns. The survey assessed information conveyed, processes for facilitating shared decision-making (reported separately), and clinical experiences. Neonatology and MFM responses were compared. Multivariable logistic regression analyzed topics often and seldom discussed by specialty groups with respect to respondents' clinical experience and resuscitation option preferences at different gestational weeks. RESULTS In total, 74 MFM and 167 neonatologists representing 94% of the 81 centers surveyed responded. Grouped by specialty, respondents were similar in counseling experience and distribution of allowing choices between resuscitation and no resuscitation for delivery at specific weeks of gestational ages. MFM versus neonatology reported similar rates of discussing long-term health and developmental concerns and differed in all other categories of topics. Neonatologists were less likely than MFM to discuss caregiver impacts (odds ratio [OR]: 0.14, 95% confidence interval [CI]: 0.11-0.18, p < 0.001) and comfort care details (OR: 0.19, 95% CI: 0.15-0.25, p < 0.001). Conversely, neonatology versus MFM respondents more frequently reported "usually" discussing topics pertaining to parenting in the NICU (OR: 1.5, 95% CI: 1.2-1.8, p < 0.001) and those regarding stabilizing interventions in the delivery room (OR: 1.8, 95% CI: 1.4-2.2, p < 0.001). Compared with less-experienced respondents, those with 17 years' or more of clinical experience had greater likelihood in both specialties to say they "usually" discussed otherwise infrequently reported topics pertaining to caregiver impacts. CONCLUSION Parents require information to make difficult decisions for their extremely early newborns. Our findings endorse the value of co-consultation by MFM and neonatology clinicians and of trainee education on antenatal consultation education to support these families. KEY POINTS · Neonatology versus MFM counselors provide complementary information.. · More experience was linked to discussing some topics.. · Co-consultation and trainee education is supported.. · What information parents value requires study..
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Affiliation(s)
- Brennan Hodgson Kim
- Department of Pediatrics, University of Chicago Comer Children's Hospital, Chicago, Illinois
| | - Dalia M Feltman
- Department of Pediatrics, NorthShore University HealthSystem Evanston Hospital, Evanston, Illinois
| | - Simone Schneider
- Department of Pediatrics, University of Chicago Pritzker School of Medicine, Chicago, Illinois.,Department of Pediatrics, The University of North Carolina at Chapel Hill, Chapel Hill, North Carolina
| | - Constance Herron
- Graduate Student Intern, School of Health Studies, Northern Illinois University, DeKalb, Illinois
| | - Andres Montes
- Department of Obstetrics and Gynecology, University of Virginia School of Medicine, Charlottesville, Virginia
| | - Uchenna E Anani
- Department of Pediatrics, Vanderbilt University Medical Center, Nashville, Tennessee
| | - Peter D Murray
- Department of Pediatrics, University of Virginia School of Medicine, Charlottesville, Virginia
| | - Marin Arnolds
- Department of Pediatrics, NorthShore University HealthSystem Evanston Hospital, Evanston, Illinois.,Department of Pediatrics, University of Chicago Pritzker School of Medicine, Chicago, Illinois
| | - Jeanne Krick
- Department of Pediatrics, Madigan Army Medical Center, Tacoma, Washington
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