Maternal psychological distress and parenting stress after the birth of a very low-birth-weight infant

Maternal posttraumatic stress response after the birth of a very low-birth-weight infant

OBJECTIVE

For parents, the premature birth of a child represents a traumatic event for which they are poorly prepared. To date, the focus of scientific interest has been on maternal psychological stress responses, such as anxiety and depression, or on appropriate coping mechanisms, whereas only scant attention has been paid to the traumatic aspect of the maternal experience after very low-birth-weight (VLBW) birth. The present study is the first to investigate the posttraumatic stress response of mothers after the birth of a VLBW infant in a prospective longitudinal study.

METHODS

Fifty mothers of VLBW infants were examined at four measuring time points (1-3 days pp, 14 days pp and 6 and 14 months pp) with respect to posttraumatic symptoms [Impact of Event Scale (IES-R)], psychiatric diagnosis (SKID I for DSM-IV) and the extent of depression [Beck Depression Inventory (BDI) and Montgomery Asberg Depression Scale (MADRS)] and anxiety [State-Trait Anxiety Inventory (STAI) and Hamilton Anxiety Scale (HAMA)]. The control group comprised a group of 30 mothers after the uncomplicated spontaneous birth of a healthy child.

RESULTS

At all four measuring timepoints (except 6 months pp), the mothers of the premature infants recorded significantly higher values for traumatic experience and depressive symptoms and anxiety compared with the controls. In contrast to the mothers in the control group, the mothers of the premature infants displayed no significant reduction in posttraumatic symptoms (IES-total), even 14 months after birth.

CONCLUSION

The results indicate that the situation of a mother who has given birth to a VLBW infant is a complex, with long-term traumatic event necessitating ongoing emotional support extending beyond the period immediately after the birth.

Prematurity, maternal stress and mother-child interactions

OBJECTIVE

Previous studies have shown that premature birth and the immaturity of the child can affect the quality of the parent-child relationship. The present study examines the relationship between maternal and infant interactional behavior over time and infant perinatal risk factors as well as maternal perinatal recollected traumatic experience. Few studies have explored the relationship between maternal stress and the quality of parent-infant interaction.

DESIGN

Mother-child interaction was recorded at 6 and 18 months of infant's age, in a population of 47 preterm infants (GA<34 weeks) and 25 full-term infants, born in 1998, during a play interaction. According to the Care Index, sensitivity, control and unresponsiveness have been used to code maternal interactional characteristics, and cooperation, compliance-compulsiveness, difficulty and passivity have been used to code the infant's interactional characteristics. The level of maternal stress was evaluated with the Perinatal Posttraumatic Stress Disorder Questionnaire (PPQ), and the infant's perinatal risk factors were assessed with the Perinatal Risk Inventory (PERI).

RESULTS

Mothers of high-risk infants, as well as mothers that had experienced traumatic stress in the perinatal period, were less sensitive and more controlling at 6 months. The interactional behavior of the preterm infant was different from that of the full-term infant at 18 months of age, and was correlated with maternal traumatic stress but not with perinatal risk factors.

CONCLUSION

These results underline the importance of maternal traumatic experience related to premature birth and its potential long lasting influence on mother-child interactional behavior.

Behavioral and social development of children born extremely premature: 5-year follow-up

A cohort of extremely prematurely born children and matched term controls was assessed at 5 years of age. The parents completed a questionnaire on their behavioral and social development. The purpose was to illuminate whether the children's general intellectual ability and parental sensitivity were associated with behavioral and social development. The index children exhibited more hyperactive behavior and had poorer social skills than the controls. Lower Full Scale IQ (FSIQ) was associated with outward reacting and hyperactive behavior and poorer social skills. Sensitive parenting was associated with less outward reacting and less hyperactive behavior. When controlling for differences in FSIQ and parental sensitivity, the index children persisted to have an increased risk of exhibiting hyperactive behavior but not poorer social skills. The index children with normal intellectual development, however, did not exhibit more behavioral problems or poorer social skills than the control children did.

Preventing postnatal depression in mothers of very preterm infants: a randomised controlled trial

OBJECTIVE

To test whether a cognitive-behaviour therapy intervention program reduces the prevalence of depression during the first postnatal year in mothers of very preterm babies.

DESIGN

Prospective, single blind, randomised, controlled study.

SETTING

Perinatal centre in Western Australia.

PARTICIPANTS

One hundred and ninety-nine out of 673 English-speaking mothers of infants admitted to the neonatal unit.

INTERVENTION

A six-session cognitive-behaviour therapy intervention program provided by a research midwife between weeks two and six after birth. Women in the control group received standard care.

MAIN OUTCOME MEASURES

Depression and anxiety disorders occurring in the first year assessed by a clinical psychologist at structured interview using the Schedule for Affective Disorders and Schizophrenia (SADS) at 2 weeks, 2, 6 and 12 months.

RESULTS

One hundred and one women were randomised to the intervention group and 98 to the control group. Fifty-four mothers (27%) in the trial were diagnosed with minor or major depression in the 12 months following very preterm delivery, 29 (29%) in the intervention group and 25 (26%) in the control group (relative risk 1.1 [95% CI 0.80-1.5]). There were no differences in the time of onset or the duration of the episodes of depression between the groups. Overall, 74 mothers (37%) of the 199 met criteria for a diagnosis of psychological morbidity during the first year.

CONCLUSIONS

Our intervention program did not alter the prevalence of depression in these mothers. Rates of depression and stress reactions are high in these mothers.

Health status and health-related quality of life in a population-based sample of neonatal intensive care unit graduates

OBJECTIVE

To measure the health status (HS) and health-related quality of life (HRQL) of preschoolers who were admitted to a neonatal intensive care unit (NICU) at birth and their family caregivers and to investigate differences in HS and HRQL in relation to gestational age and major morbidity experienced during the NICU stay.

METHODS

Retrospective cross-sectional survey was conducted in the province of British Columbia, Canada. A total of 1140 of 2221 children who were admitted at birth to the 3 tertiary care NICUs in the province and 393 of 718 healthy full-term children recruited from 2 of these hospitals were studied. The main outcome measures were Infant and Toddler Quality of Life Questionnaire (ITQOL), Health Status Classification System Preschool Version (HSCS-PS), and Child Behavior Checklist/1.5-5 (CBCL) RESULTS: The overall response rate was 55%; the response rate for families that we located was 67.1%. NICU children differed from healthy children on the ITQOL in physical abilities, growth and development, temperament/moods, behavior, and general health perceptions, and caregivers differed on both parent-impact scales. On the HSCS-PS, proportionally more NICU children had a health problem in the following areas: sight, speech, getting around, using hands and fingers, taking care of self, learning and remembering, thinking and solving problems, pain and discomfort, general health, and behavior. The NICU sample reported more behavioral problems on the CBCL/1.5-5. Poorer HS and HRQL were reported for infants who were born at <27 weeks' gestation and for children who experienced > or =1 major morbidities during their NICU stay.

CONCLUSIONS

Preschool-aged children with conditions that require NICU care and their family caregivers had poorer HS and HRQL in a range of domains compared with healthy children. There were also differences within the sample by gestational age and major morbidity. The differences in health were small using the ITQOL and CBCL/1.5-5 but larger using the HSCS-PS.

Use of the parenting stress index in mothers of preterm infants

PURPOSE

This report describes parenting stress experienced by mothers of preterm infants following hospital discharge.

SUBJECTS

Twenty-nine mothers and their preterm infants were included in the analysis.

DESIGN AND METHODS

The study was conducted using a descriptive and exploratory single group design. The analysis included 29 mothers of preterm infants, mean gestational age 33.14 weeks, mean postnatal age 78.59 days, 6 to 10 weeks after discharge. Mothers were administered the Parenting Stress Index (PSI), a 101-item questionnaire that includes a total score and Parent and Child Domains. It also includes the following 13 scales: Adaptability, Acceptability, Demandingness, Mood, Distractibility/Hyperactivity, Reinforces Parent, Depression, Attachment, Restriction of Role, Sense of Competence, Social Isolation, Relationship with Spouse, and Parent Health.

PRINCIPAL RESULTS

A high rate of missing items was noted on the PSI. In particular, missing items occurred predominantly in the Child Domain. By following guidelines for scoring the PSI when items are missing, summary scores were calculated for 16 of the 29 participants. Total scores demonstrate the stress experienced by parents of preterm infants. Parent Domain scores were comparable with normative samples; however, Child Domain scores were above the 50th percentile for all child scales.

CONCLUSIONS

Mothers of preterm infants experience stress that is largely attributable to the particular characteristics of low gestation infants. The PSI may provide insight into parenting stress; however, future research should examine missing items more closely.

Failure to thrive in the term and preterm infants of mothers depressed in the postnatal period: a population-based birth cohort study

AIMS

To examine the relationship between failure to thrive in preterm and term infants and postnatal depression in their mothers.

METHOD

In a whole population birth cohort of 12,391 infants (excluding those born after term or with major congenital abnormalities) failure to thrive over the first nine months was identified using a conditional weight gain criterion which identified the slowest-gaining 5%. Depression symptoms were recorded using the Edinburgh Postnatal Depression Scale (EPDS) at 18 and 32 weeks of pregnancy and at 8 weeks and 8 months after delivery.

RESULTS

After the birth, high depression scores were significantly more common in the mothers of infants born preterm, and controlling for depression scores in pregnancy did not eliminate this association after the birth. Failure to thrive was identified in 4.5% of the children born at term (531/11718) and in 8.3% of those born preterm (56/673). The difference was highly significant (chi2 = 20.25 with 1 df, p < .0001). Using a conventional cut-off on the EPDS (score > 12) to identify mothers as 'depressed', the prevalence of failure to thrive in the term infants of mothers depressed at 8 weeks postpartum was 5.0%; in the remainder of the population (controls) it was 4.3%. In mothers depressed at 8 months the prevalence was 4.3% in both groups. The prevalence of failure to thrive in the preterm infants of mothers depressed at 8 weeks was 8.8% (7.0% in controls) and in those depressed at 8 months it was 12.3% (6.7% in controls). None of these differences in prevalence was statistically significant, and significant differences did not emerge from further analyses using more stringent criteria for depression.

CONCLUSIONS

Preterm births are specifically associated with high maternal depression scores in the postpartum period, and with a higher prevalence of failure to thrive. High depression scores in the postpartum period are not themselves associated with a higher prevalence of failure to thrive, however, either in infants born at term or in those born preterm.

Perception of child vulnerability among mothers of former premature infants

OBJECTIVES

Parents of premature infants often perceive their infants as medically vulnerable. High parental perception of child vulnerability (PPCV) is associated with disproportionately high health care utilization. The objectives of this study were to determine whether higher PPCV is correlated with worse developmental outcome in premature infants at 1-year adjusted age and to identify factors, present at neonatal discharge, that predict high PPCV.

METHODS

This prospective cohort study assessed mothers of 116 premature infants who were </=32 weeks' gestation and required supplemental oxygen at 36 weeks postmenstrual age. At neonatal discharge, mothers completed the Spielberger State Anxiety Inventory, Beck Depression Inventory, Impact on Family Scale, Life Orientation Test, General Health Survey, and Medical Outcomes Study social support survey. At 1-year adjusted age, child development was assessed using the Bayley Scales of Infant Development and Vineland Adaptive Behavior Scales, and mothers completed the Vulnerable Child Scale, a 16-item self-report measure of PPCV. Chart review was performed to determine the presence or absence of specific indicators of medical vulnerability at 1-year adjusted age.

RESULTS

Mean infant gestational age and birth weight were 26.5 +/- 2.5 weeks and 894 +/- 287 g. A total of 69% of mothers were white, and 78% were high school graduates. Higher PPCV (lower Vulnerable Child Scale score) was correlated with lower scores on the Vineland Adaptive Behavior Composite and Bayley Psychomotor Developmental Index but not on the Bayley Mental Developmental Index. After controlling for the presence of 1 or more indicators of medical vulnerability, higher PPCV was still correlated with lower adaptive development. This correlation was stronger in the group of children with no indicators of medical vulnerability. In univariate analyses, higher PPCV was predicted by nonfirstborn status; longer neonatal hospitalization; higher maternal anxiety and depression; greater impact of the illness on the family; and lower maternal optimism, life satisfaction, and social support. PPCV was not associated with maternal age, education, marital status, income, or ethnicity or with child gender, gestational age, birth weight, or length of mechanical ventilation. A linear regression model containing all variables significant at the univariate level explained 29% of the variance in PPCV. Maternal anxiety was the only variable that was statistically significant in the full model.

CONCLUSIONS

Higher PPCV is associated with worse developmental outcome in premature infants at 1-year adjusted age. Maternal anxiety at neonatal discharge predicts later high PPCV. Interventions to prevent or decrease PPCV in premature infants should be targeted at parents who are more anxious at hospital discharge.

Prepartum, postpartum, and chronic depression effects on newborns

In order to assess the effects of the onset and chronicity of maternal depression on neonatal physiology, eighty pregnant women were assessed for depression during mid-pregnancy (M gestational age = 25.9 weeks) and shortly after delivery. The women were classified as reporting depressive symptoms 1) only during the prepartum assessment; 2) only during the postpartum assessment; 3) during both the prepartum and postpartum assessments; or 4) reporting no depressive symptoms at either the prepartum or the postpartum assessment. Maternal mood and biochemistry were assessed during pregnancy, and the EEG and biochemical characteristics of their 1-week-old infants were assessed shortly after birth. As predicted, the newborns of the mothers with prepartum and postpartum depressive symptoms had elevated cortisol and norepinephrine levels, lower dopamine levels, and greater relative right frontal EEG asymmetry. The infants in the prepartum group also showed greater relative right frontal EEG asymmetry and higher norepinephrine levels. These data suggest that effects on newborn physiology depend more on prepartum than postpartum maternal depression but may also depend on the duration of the depressive symptoms.

State of the Science: Achievements and Challenges Across the Spectrum of Care for Preterm Infants

The spectrum of care for preterm infants includes the perinatal and immediate neonatal periods, the initial hospitalization period including neonatal intensive care, transition to discharge, and from discharge through the first year of life. Care issues are sometimes lifelong. Advances and achievements of the past 20 years, particularly during the perinatal period and in neonatal intensive care, have resulted in significant increases in survivability of even the smallest and least mature infants. Challenges remain, particularly in establishing evidence-based standards of nursing practice in areas such as transition to oral feedings, breastfeeding in the intensive-care nursery, and developmentally based care, and in reducing short- and long-term morbidities in children born prematurely. This article illustrates achievements and challenges across the spectrum of care for preterm infants in the 1st year of life.

PSYCHOMETRIC PROPERTIES OF THE PARENTAL STRESSOR SCALE

PURPOSE

This article reports the development and psychometric properties of the Parental Stressor Scale: Infant Hospitalization (PSS:IH), an instrument designed to measure parents' perceptions of stress associated with having their infant admitted to the hospital.

SUBJECTS

Eighty-one mothers and 43 fathers of medically fragile, hospitalized infants.Design and methods Psychometric study of the PSS:IH, an instrument that was adapted from the Parental Stressor Scale: Neonatal Intensive Care Unit (PSS:NICU) using literature review, parent interviews, and professional experts. Psychometric analysis was conducted from data collected in a longitudinal study of parents of medically fragile infants. Main outcome measure PSS:IH.

RESULTS

Correlation coefficients demonstrate its internal consistency reliability. Construct validity is supported by significant correlations between the PSS:IH scores during hospitalization with maternal distress after discharge.

CONCLUSIONS

The PSS:IH can be used as an outcome assessment instrument for quality assurance and in clinical research. Additional research could evaluate the scale for use in different populations and settings.

Preterm birth a long distance from home and its significant social and financial stress

The present paper reports a retrospective cohort of preterm infants admitted to our hospital who delivered outside the normal geographical catchment area of the mother's local level three neonatal nursery. Nineteen mothers had 21 preterm infants (23.1-34.9 weeks, 500-2330 g born) where 14 infants required ventilation (median 57 h, range 3-428). Eighteen survivors had a median length of stay of 41 days (range 3-91). Twelve of 19 mothers were interviewed: all described isolation, loneliness, poor social support and significant financial hardship related to getting their infants back to a local hospital or home. To avoid these problems, we recommend confining travel to within a short distance from home or local maternity unit after 22 weeks.

Parenting stress among caregivers of children with congenital cataracts

OBJECTIVE

To examine parenting stress among caregivers of young children with congenital cataracts and to assess whether diagnostic and/or treatment differences are associated with differences in perceived parenting stress.

METHODS

Parents of 41 preschool-age children with congenital cataracts (13 with bilateral cataracts [BCCs] and 28 with unilateral cataracts [UCCs], of whom 14 were aphakic and 14 were pseudophakic) completed the Parenting Stress Index (PSI) and/or a disease-specific parental stress measure, ie, the Ocular Treatment Index (OTI).

RESULTS

The 28-item OTI had excellent internal consistency (alpha = 0.94) and supported three of four a priori validity hypotheses. Parents of children with congenital cataracts reported normal parenting stress levels on the PSI. Parents of children with UCCs tended to report higher levels of stress, but not significantly so, than did parents of children with BCCs. Among parents of children with UCCs, those whose children were aphakic reported higher levels of stress on the OTI and all of the PSI subscales than did parents of pseudophakic children. These differences were statistically significant for two subscales (Adaptability [P =.03] and Mood [P =.01]).

CONCLUSIONS

Although parents of children with congenital cataracts generally did not report increased parenting stress levels, clinicians should be aware that parenting stress can adversely impact patients' families. We did observe higher stress levels in parents with children who had UCCs and did not receive an intraocular lens-particularly stress related to their child's reaction to sensory stimulation and mood-compared with parents of pseudophakic children. Thus, clinicians may want to consider parenting stress levels when choosing a treatment for children with UCCs, especially because such stress has been associated with poor treatment compliance for children with other chronic conditions.

Effects of infant risk status and maternal psychological distress on maternal-infant interactions during the first year of life

The associations of infant medical risk, prematurity, and maternal psychological distress with the quality of maternal-infant interactions during the first year of life were evaluated in a prospective, longitudinal follow-up from birth. A total of 103 high-risk very low birth weight (VLBW) infants with bronchopulmonary dysplasia, 68 low-risk VLBW infants without bronchopulmonary dysplasia, and 117 healthy term infants were seen at 1, 8, and 12 months of age. Videotaped feedings at each age were rated using the Nursing Child Assessment Feeding Scale, and mothers completed the Brief Symptom Inventory as a measure of psychological distress. VLBW infant status was related to both maternal and infant behaviors as well as to maternal distress, and these relationships varied with infant age. Overall, VLBW infants displayed fewer responsive, clear interactions, with differences from term infants increasing over time. Maternal distress was related to less cognitive growth fostering for all mothers. Because maternal distress is more prevalent in mothers of VLBW infants postpartum, intervention efforts should focus on assessment of maternal distress and the challenges posed by the interactive behaviors of VLBW infants.

From alienation to familiarity: experiences of mothers and fathers of preterm infants

BACKGROUND

The birth of a preterm infant has a long-term impact on both parents. Mothers report more stress and poor adjustment compared with fathers. Influencing factors, such as family situation and health status of the child, can support or weaken the coping ability of the parents. Studies on experiences of fathers are sparse.

AIM

The aim of this research was to study how mothers and fathers of preterm infants describe their experiences of parenthood during the infant's first 18 months of life.

METHODS

Seven consecutively selected sets of parents of preterm infants born at </=34 weeks of gestation with no serious congenital defects were interviewed 1-2 weeks after the infant's birth and at 2, 6 and 18 months of age, and the findings were analysed using a phenomenological method.

FINDINGS

Internalization of parenthood was described as a time-dependent process, with four syntheses of experiences - alienation, responsibility, confidence and familiarity. Within the syntheses, similarities in how mothers and fathers described their parental roles involved concern for the child, insecurity, adjustment and relationship with the child. Regarding differences, mothers experienced having more responsibility and control of the care and a need to be confirmed as a mother, while fathers described confidence in leaving the care to the staff and wanted to find a balance between work and family life. Important turning points in parenthood experiences often occurred when the infant could be removed from the incubator, discharged from the ward, and when the infant looked normal compared to full-term infants.

CONCLUSIONS

The structure of the phenomenon of parenthood was formed by the integration of the syntheses of alienation, responsibility, confidence and familiarity. The structure seems to be based on the parents' expectations of the parental role, the infant's health condition and the health care environment. These interacting factors are influenced by cultural beliefs.

Mothers' involvement in caring for their premature infants: an historical overview

BACKGROUND

Advances in technology have resulted in increasing survival rates even for extremely premature infants. While sophisticated medical management is vital to infant survival, research has found that social factors and care giving processes are important predictors of infants' later outcome. Consequently, evidence is accumulating to demonstrate the fundamental role of mothers and families to the optimal developmental outcome of premature infants.

AIM

The aim of the work reported here was to undertake an historical overview of premature infant care practices to increase neonatal nurse's knowledge of the crucial role of mothers and families in the care of their premature infants. Understanding past practice and current trends can provide neonatal nurses with critical insight which will assist in formulating current and future care.

METHOD

Research and historical articles focusing on maternal involvement in preterm infant care from the development of the incubator to the present time were examined. A search of the literature between 1960 and 2002 was conducted using the MEDLINE, CINAHL and PSYCLIT databases. The search terms were premature infant, neonatal intensive care, history, and maternal care.

FINDINGS

Three major themes were identified which reflect the development of neonatal care. Firstly, over the last century advances in medical and public health practice saw a decline in mortality rates for mothers and infants. Secondly, the application of this new knowledge resulted in the institutionalization and professionalization of obstetric and neonatal care which, in turn, resulted in the isolation of infants from their mothers. Finally, concurrent advances in infant research emphasized the importance of mother-infant relationships to infants' developmental outcome, resulting in greater flexibility in hospital practices regarding parental contact with their infants.

CONCLUSION

As biomedical advances in technology continue to help smaller, sicker premature infants to survive, neonatal nurses are strategically placed to promote positive outcomes for infants and their families through the integration of social science and behavioural research into nursing practice.

Initiation of breastfeeding among mothers of very low birth weight infants

OBJECTIVE

To examine factors that predict the initiation of expressed milk feedings and the transition to direct breastfeedings among mothers of very low birth weight (VLBW) infants.

METHODS

The sample consists of 361 mother-infant pairs enrolled in a follow-up study of children aged 6 to 8 years who were born weighing <1501 g in 1 of 5 hospitals between 1991-1993. Chart review at birth provided data on neonatal characteristics and demographic factors at delivery were obtained by postpartum maternal interview. Information regarding infant feeding practices was obtained at follow-up.

RESULTS

In this study, 60% of mothers initiated expressed milk feedings for their VLBW infants. However, the duration of these feedings was brief with 52% of infants receiving 1 to 3 months or less of human milk feedings. Greater educational attainment, private insurance, and breastfeeding experience were each independently associated with the decision to provide expressed milk feedings. Only 27% of mothers reported directly breastfeeding their VLBW infants. The transition from expressed milk feedings to direct breastfeedings was positively associated with sociodemographic factors including maternal age, insurance status, and breastfeeding experience as well as the length of hospitalization, an indicator of infant health.

CONCLUSIONS

Sociodemographic factors were associated with both the decision to initiate expressed milk feedings and the transition to direct breastfeedings. However, factors relating to infant health only influenced the transition to direct breastfeedings. Intervention programs need to consider the sociodemographic factors that influence infant feeding decisions as well as specific challenges encountered by mothers of VLBW infants.

Relationships between the family's way of functioning and children's temperament as rated by parents of pre-term children

This study examined the relationships between parents' perceptions of their family's way of functioning and their pre-term child's temperament. Forty-seven parents of infants born before the gestation age (GA) of 28 weeks during 1991, 1994 and 1997 answered the Family Relations Scale (FARS) and the Temperament Scale. One family function factor, enmeshment, was significantly higher in families with pre-term children than in other families, thus indicating certain difficulties in the inner life of the family (p < 0.001). Parents' perceptions of their pre-term child's temperament did not differ from those of other parents. There was a strong correlation both between temperament dimensions and the family's way of functioning (p < 0.0001) and between single-dimension impulsivity and the total scores for the family's way of functioning (p < 0.01).

Health-related quality of life of preterm children and their caregivers

As advances in medical science have extended the limit of viability downward to 23 or 24 weeks gestation, interest has turned from long-term health outcomes to quality of life for survivors. During the last decade, the first studies of the health-related quality of life (HRQOL) of children and young adults who were born extremely preterm were published. Taken from the fields of anthropology, economics, sociology, and psychology, the foundation of HRQOL is formed by theories of functionalism, positive well-being, and utility. HRQOL can be defined as the physical, psychological, and social domains of health, which can be influenced by an individual's experiences and perception. HRQOL instruments are generally composed of multiple domains and measure physical functioning, mental health, and social role functioning in some form. Utilities, or preferences for health outcomes under conditions of uncertainty, are also used. Studies of HRQOL to-date indicate that preterm children have, on average, poorer health than their normal birthweight peers, but the majority do not perceive their quality of life as significantly different than others of their own age. Measures of HRQOL should not replace the traditional measures of morbidity, but should become part of the standard battery of tools used to assess a preterm child's health and well-being. Ultimately, studies of the HRQOL of preterm children should identify aspects of life, physical, psychological, or social, that could be improved with intervention.

Testing a family intervention hypothesis: the contribution of mother-infant skin-to-skin contact (kangaroo care) to family interaction, proximity, and touch

The provision of maternal-infant body contact during a period of maternal separation was examined for its effects on parent-infant and triadic interactions. Participants were 146 three-month-old preterm infants and their parents, half of whom received skin-to-skin contact, or kangaroo care (KC), in the neonatal nursery. Global relational style and micro-patterns of proximity and touch were coded. Following KC, mothers and fathers were more sensitive and less intrusive, infants showed less negative affect, and family style was more cohesive. Among KC families, maternal and paternal affectionate touch of infant and spouse was more frequent, spouses remained in closer proximity, and infant proximity position was conducive to mutual gaze and touch during triadic play. The role of touch as a constituent of the co-regulatory parent-infant and triadic systems and the effects of maternal contact on mothering, co-parenting, and family processes are discussed.

Parent visiting and participation in infant caregiving activities in a neonatal unit

BACKGROUND

Active parent involvement in caring for their infants in the neonatal care unit is thought to improve parent-infant attachment and to moderate the psychological stress for parents, but few recent studies have examined parent visiting patterns and participation in infant caregiving. The study purposes were to describe the frequency and duration of parent visiting and participation in infant caregiving activities, and to identify parent and infant factors associated with parental participation.

METHODS

Parental visiting frequency, duration, and participation in social, cleaning, and feeding activities with their infant (n=110) were recorded on 12 days during a 3-month period in a tertiary neonatal unit.

RESULTS

Mothers visited more frequently (85% vs 45% of possible days) and for longer than fathers, and visited less frequently if the infant had other siblings, if the infant was over age 1 month, or if fathers made fewer visits. Fathers visited less frequently if the infant was over age 7 days and more frequently if the mothers visited more frequently. All mothers and most (96%) fathers carried out social activities, such as talking, stroking or holding, during their visits. Over 75 percent of mothers engaged in infant cleaning and feeding activities during visits in contrast with less than 20 percent of fathers. Mothers' participation in infant feeding was best predicted by the duration of their visit and their participation in infant cleaning. Fathers' participation in infant feeding was only related to their participation in infant cleaning.

CONCLUSIONS

Significant differences were found in this neonatal unit between mothers' and fathers' visiting patterns and infant caregiving activities. Neonatal unit staff should consider factors that may influence parental visiting and explore strategies to improve parental involvement in caregiving.

Effect of newborn hospitalization on family and child behavior: a 12-year follow-up study

OBJECTIVE

To study the effects of a critical illness and hospitalization of a newborn on family functioning and child behavior during the subsequent 12 years.

METHODS

With the use of a randomized stratified cluster sampling, a follow-up of 1443 pregnant women was started at early pregnancy. These pregnancies resulted in 1294 deliveries. A total of 170 infants were admitted to neonatal units and were classified according to their medical risk, and 1112 healthy-born infants were eligible for the control group. After excluding the children with disabilities at 3 years of age, 134 remained in the risk groups and 952 children remained in the control group. The follow-up examinations were performed at the ages of 3 and 9 months and at 3 and 12 years. The main outcome measures were parents' subjective well-being and adjustment to the child, family functioning, and child's behavioral problems.

RESULTS

The families with a critically ill newborn experienced more need for support and maladaptation during the first year after delivery. They reported more child behavior problems at 3 years, but no differences were found at 12 years of age. The families with a hospitalized, low-risk infant coped as well as the controls.

CONCLUSIONS

A critical illness of a newborn had long-lasting effects on the family and child behavior. The hospitalization of a newborn with a low medical risk did not have any negative consequences on family or child behavior. This is encouraging for a large group of families that experience early separation from their newborn infant as a result of hospitalization.

Impact of low birthweight on subsequent fertility: population-based register study

Adverse birth outcomes may influence a family's wish for additional children. We investigated the influence of low birthweight in live births on subsequent fertility, and estimated secular trends of such an effect in a population-based cohort study of births arranged in consecutive sibship records in the Medical Birth Registry of Norway. We included births of order one to seven to all 587 785 mothers in Norway who had a first singleton birth in 1967-91. Associations between birthweight in 1 158 072 surviving index births of order one to six, 1967-91, and subsequent fertility (probability of another birth), 1967-97, were estimated as fertility ratios in Cox regression analysis. Giving birth to a live infant weighing < 3000 g had a negative effect on subsequent fertility, increasingly strong for decreasing birthweight. Low birthweight (<2500 g) was associated with a fertility ratio of 0.88 [95% confidence interval 0.87, 0.89]. This negative impact was stronger if the mother had also given birth to surviving children of low birthweight previously, particularly if combined with caesarean section in the most recent birth. The negative fertility effect of low birthweight grew slightly stronger between 1967 and approximately 1980, according to year of first birth. This trend paralleled reduced population fertility in the same period. The moderate negative impact of giving birth to a live infant of low birthweight on subsequent fertility could result from the combination of reduced wish for additional children and biological subfertility.

Correlates of Depressive Symptoms in Mothers of Preterm Infants

Purpose: To identify factors related to depressive symptoms in mothers of preterm infants and to changes in depressive symptoms between hospitalization and when the infant was six months corrected age and to determine whether these factors differentiate mothers at high risk for depression from mothers at low risk for depression.

Design: Correlational.

Sample: During hospitalization, 39 mothers of preterm infants and, at six months corrected infant age, 34 mothers of preterm infants.

Main Outcome Variable: Depressive symptoms as measured on the Center for Epidemiological Studies Depression scale.

Results: At enrollment, 19 mothers (48.7 percent) had elevated depressive symptom scores. When the infants were six months corrected age, mean scores had decreased by 36 percent, and only 20 percent of the mothers had elevated scores. During hospitalization, the correlates of depressive symptoms were similar to the factors that differentiated between mothers at high risk and those at low risk for depression. However, the correlates of depressive symptoms during hospitalization were different from correlates of changes in depressive symptoms between hospitalization and six months corrected infant age. Identifying correlates of maternal depressive symptoms may lead to earlier identification and treatment of women at risk for depression, thereby decreasing the negative effects on infant development.

Coping and Psychological Distress in Mothers of Very Low Birth Weight Young Children

OBJECTIVE

This study sought to increase understanding of relations among coping strategies, sociodemographic variables, and psychological distress in mothers of high-risk (HR) and low-risk (LR) very low birth weight (VLBW; < 1,500g) infants.

DESIGN

The sample (N = 199) consisted of 77 mothers of HR VLBW infants, 43 mothers of LR VLBW infants, and a control group of 79 mothers of healthy, term infants. Data were collected with self-report questionnaires at birth and at 24 months postpartum. Relations among infant medical risk, multiple birth, maternal race, social class, and maternal coping were investigated. Hierarchical regression analyses were used to identify predictors of maternal psychological distress and to determine whether coping differentially moderated maternal psychological distress across groups.

RESULTS

Infant medical risk, social support, and maternal coping independently predicted maternal psychological distress. Mothers of HR VLBW infants reported significantly greater psychological distress than mothers of LR VLBW or term infants. Greater use of avoidant and express emotions coping predicted higher psychological distress for all mothers. Greater use of humor coping had a buffering effect, reducing distress only for mothers of HRVLBW infants. Maternal coping scores were related to maternal race and social class, rather than to severity of infant medical risk.

CONCLUSIONS

Sociocultural sources of resiliency, as well as biological risk factors, should be considered when developing strategies to enhance coping and parenting in HR populations.

Parental stress in families of 2 year old extremely low birthweight infants

OBJECTIVE

To compare the parental stress in the families of 2 year old extremely low birthweight (ELBW) infants with that in control families, and to compare the stress of mothers with that of fathers.

METHODS

The study population included all parents of ELBW infants (birth weight < 1000 g and gestational age at least 22 gestational weeks) born between 1 January 1996 and 31 December 1997 in Helsinki University Hospital and followed at the hospital's neuropaediatric department. The parents of full term, healthy infants born subsequent to each ELBW infant were eligible for the control group. The Swedish Parenthood Stress Questionnaire (SPSQ) translated into Finnish was completed by parents during the neurological assessment visit at 2 years of age.

RESULTS

No significant differences were found in total SPSQ or subscale scores when mothers of ELBW infants were compared with control mothers. Nor did the scores of fathers of ELBW infants differ from the scores of control fathers. However, in the comparison of all mothers with all fathers, several differences were found: mothers indicated significantly more distress than fathers with respect to role restriction, incompetence, and spouse relationship problems, and fathers indicated significantly more distress on the social isolation subscale.

CONCLUSION

The study shows that, although the birth of an ELBW infant is a stressful event for parents, most parents seem to have recovered well by the time the child has reached the age of 2. In both control families and those of ELBW infants, the overall stress of mothers seemed to be higher than that of fathers.

Evaluation of psycho-social support to parents with an infant born preterm

The birth of a preterm child is a trauma that causes crisis reactions in parents. The hypothesis was that parents need psycho-social support in order to manage this trauma. Psycho-social support was defined as both medical and social information, processing the emotional feelings, social support and starting the bonding process. The aim of the study was to explore the type and frequency of psycho-social support to parents of preterm children born during 1991, 1994 and 1997 in a Swedish university hospital. 47 parents answered a questionnaire based on previous focus group interviews. The children were born in gestation weeks 23-7. Medical and social information was more frequent during the first period of intensive care than later on during the care process. Contact frequency concerning feelings and emotional reactions was low and decreased over time. All parents were helped to start the bonding process. One-third of the parents reported long-term psychological problems due to the birth of the preterm child, while only a few reported financial (15%), practical (13%) or social (9%) long-term problems. Conclusions were that from a crisis theory perspective psycho-social support, defined as regular medical information also ought to be initiated later on in the care process and that increased emotional support concerning crisis reactions is desirable in order to process the feelings raised by the trauma.

Effects of cocaine/polydrug exposure and maternal psychological distress on infant birth outcomes

To assess teratogenic effects of cocaine exposure and maternal psychological distress on birth outcomes, we conducted a longitudinal prospective study of 415 infants (218 cocaine-exposed--CE, 197 nonexposed--NE). Drug exposure was determined through a combination of maternal self-report, urine, and meconium screens. Maternal psychological distress postpartum was evaluated through a standardized, normative, self-report assessment. An extensive set of confounding variables was controlled, including severity of exposure to alcohol, tobacco, marijuana and other drugs, maternal age, race, parity, number of prenatal care visits, educational, marital, and socioeconomic status, and verbal and nonverbal intelligence. CE infants were smaller on all birth parameters and more likely to be preterm, small for gestational age, and microcephalic than NE infants. Forty-one percent of cocaine users had clinically significant psychological symptoms, compared to 20% of a high-risk comparison group of noncocaine users. Consistent with a teratologic model, cocaine exposure independently predicted offspring birthweight, length, and head circumference. Maternal psychological distress self-reported postnatally also independently predicted head circumference. Tobacco, alcohol, and marijuana exposures were also significant independent predictors of some fetal growth parameters. In addition, maternal distress symptoms, which may be reflective of maternal mental health disorders or responses to stress, added significantly to the risk for poorer fetal growth.

Should postpartum depression be targeted to improve child mental health?

OBJECTIVE

To evaluate whether postpartum depression (PD) is an appropriate target to prevent poor child outcomes.

METHOD

Criteria are proposed for evaluating the appropriateness of targeting PD. The target factor should (1) be a causal factor for the negative outcome, (2) have high attributable risk for the negative outcome, (3) be alterable, and (4) be easily and accurately identified through screening. The associated intervention should (5) have characteristics to facilitate dissemination, (6) have low risk for adverse impact, and (7) be acceptable to key stakeholders.

RESULTS

PD is given a mixed endorsement as an appropriate target for a prevention intervention. Positive characteristics include that PD is moderately prevalent, it is linked with poor child outcomes, it requires inexpensive screening for detection, it is alterable through treatment interventions that may be realistically disseminated, and its treatment is likely to have popular and political support. However, efforts to detect syndromal depression may be costly, strength of the link between PD and poor child outcomes is undetermined, and risks associated with the intervention have not been investigated.

CONCLUSIONS

Further study is required to assess the appropriateness of PD as a prevention target for improving child outcomes. These provisional criteria may be useful for evaluating other proposed prevention targets.

Parenting Stress: A Comparison of Grandmother Caretakers and Mothers

Parenting stress in grandmother caretakers has not been directly compared with a matched sample of mothers in the caretaker role. This study examined the main and interaction effects of caretaker status, employment, and race on parenting stress and whether these factors affect parenting stress in a convenience sample of grandmothers raising grandchildren (n = 86) and a sample of mothers of preschoolers (n = 86), matched for women's partner status, race, and employment. Grandmothers raising grandchildren reported more overall parenting stress and parental distress than mothers. Non-employed women reported more negative perceptions of their children and more difficult interactions with them. When controlling for contextual variables, grandmother caretakers showed greater parenting distress, but employment was not related to parenting stress. Being Caucasian and caretaking of older children affected overall parenting stress, parent-child interactions, and perceptions of one's children. Future research needs to consider the effect of outside influences on grandmothers' stress.

Prevalence, persistence, and correlates of depressive symptoms in a national sample of mothers of toddlers

OBJECTIVES

To examine the prevalence, persistence, and correlates of depressive symptoms in mothers of toddlers in a nationally representative sample.

METHOD

The self-report components of two linked databases were used for this study, the 1988 National Maternal and Infant Health Survey and the 1991 Longitudinal Followup. Depressive symptoms of 7,537 mothers were measured by the Center for Epidemiologic Studies-Depression Scale (CES-D) at both time points. Weighted bivariate and multivariate analyses were used to assess the stability of maternal depressive symptoms across two time points and maternal and child predictors of elevated depressive symptoms.

RESULTS

Twenty-four percent of mothers at time 1 (mean child age 17 months) and 17% at time 2 (mean child age 35 months) had elevated depressive symptoms (CES-D score > or =16). Thirty-six percent of those with elevated scores at time 1 also had elevated scores at time 2. Not having breast-fed, a mistimed or unwanted pregnancy, and poor child health status were related to elevated depressive symptoms but not persistence.

CONCLUSIONS

Elevated depressive symptoms are common in mothers of toddlers. Given the potential magnitude of need, a systematic clinical and public health approach may be required.

Improving cognitive development of low-birth-weight premature infants with the COPE program: a pilot study of the benefit of early NICU intervention with mothers

The purpose of this pilot study was to evaluate the effectiveness of a parent-focused intervention program (COPE) on infant cognitive development and maternal coping. A randomized clinical trial was conducted with 42 mothers of low-birth-weight (LBW) premature infants hospitalized in a neonatal intensive care unit (NICU), with follow-up at 3 months' and 6 months' corrected ages. COPE mothers received the four-phase educational-behavioral program that began 2-4 days postbirth and continued through 1 week following discharge from the NICU. Comparison mothers received audiotaped information during the same four time frames. Results indicated that COPE infants had significantly higher mental development scores at a 3 months' corrected age (M = 100.3) than did the comparison infants (M = 93.9), and this difference widened at 6 months' corrected age, with COPE infants scoring 14 points higher. COPE mothers were significantly less stressed by the NICU sights and sounds and had significantly stronger beliefs about what behaviors and characteristics to expect from their premature infants. Findings from this study support the need for further testing of early NICU interventions with parents to determine their effectiveness on parental coping and infant developmental outcomes.

Spiritual and religious components of patient care in the neonatal intensive care unit: sacred themes in a secular setting

OBJECTIVE

We hypothesized that spiritual distress was a common, unrecognized theme for neonatal intensive care unit (NICU) care providers.

STUDY DESIGN

An anonymous questionnaire form assigned to a data table in a relational database was designed.

RESULTS

Surveys were completed by 66% of NICU staff. All respondents viewed a family's spiritual and religious concerns as having a place in patient care. Eighty-three percent reported praying for babies privately. Asked what theological sense they made of suffering of NICU babies, 2% replied that children do not suffer in the NICU. Regarding psychological suffering of families, the majority felt God could prevent this, with parents differing (p = 0.039) from nonparents.

CONCLUSION

There exists a strong undercurrent of spirituality and religiosity in the study NICU. These data document actual religious and spiritual attitudes and practices and support a need for pastoral resources for both families and care providers. NICU care providers approach difficulties of their work potentially within a religious and spiritual rather than a uniquely secular framework.

Attitudes of parents and health care professionals toward active treatment of extremely premature infants

OBJECTIVES

To compare the attitudes of neonatologists, neonatal nurses, the parents of extremely low birth weight (ELBW) children, and the parents of normal birth weight children toward saving infants of borderline viability and who should be involved in the decision-making process and to compare physicians' and nurses' estimates of the proportion of infants who are born at various gestational ages with regard to survival, morbidity, and treatment.

METHODS

A questionnaire was given to 169 parents of ELBW children and 123 parents of term children, who were part of a longitudinal study of the outcome of ELBW infants. A similar questionnaire was completed by 98 Canadian neonatologists and 99 neonatal nurses.

RESULTS

Physicians tended to be more optimistic than nurses regarding the probability of survival and freedom from serious disabilities and would recommend to parents life-saving interventions for their child at earlier gestational ages. A significant majority of parents believed that attempts should be made to save all infants, irrespective of condition or weight at birth, compared with only 6% of health professionals who endorsed this. In contrast to parents, health professionals believed that economic costs to society should be a factor in deciding whether to save an ELBW infant. However, health professionals did not believe that the economic status of the parents should be a factor, although the stress of raising an infant with disabilities should be. Most respondents believed that the parents and physicians should make the final decision but that other bodies, such as ethics committees or the courts, should not.

CONCLUSION

Health care professionals must recognize that their attitudes toward saving ELBW infants differ from those of parents. Parents, whether of term or extremely premature children, are more in favor of intervening to save the infant irrespective of its weight or condition at birth than are professionals. It therefore is imperative that there be joint decision making, combining the knowledge of the physician with the wishes of the parents.

Mothers' evaluation of their caregiving for premature and full-term infants through the first year: contributing factors

We explored change in mothers' evaluations of their caregiving through the first postterm year for full-term infants and for prematurely born, very low birth-weight infants with a history of lung disease, and we examined the contribution to this evaluation of infant, family, and mother conditions. Fifty-four mothers of premature infants and 49 mothers of full-term infants evaluated their caregiving relationship, performance, and satisfaction at 1, 4, 8, and 12 months infant postterm age. In addition, at the same intervals-1, 4, 8, and 12 months-mothers rated their symptoms of depression, infant responsiveness, and satisfaction with help from husband or partner. Positive and negative feeding behaviors of mother and of infant were rated from videotapes. Regression analysis, which included all rated variables, infant birth maturity/lung health status, and number of children in the mother's care, showed that the 1-month assessment differed significantly from the assessments at 4, 8, and 12 months. All conditions, except for infant birth maturity/lung health status and mother's positive feeding behavior, were significantly associated with caregiving evaluation. Findings support inclusion of infant, family, and mother conditions in a caregiving evaluation model. Infant responsiveness may be particularly salient to a mother's caregiving evaluation.

Behavioural problems in children who weigh 1000 g or less at birth in four countries

BACKGROUND

The increased survival chances of extremely low-birthweight (ELBW) infants (weighing <1000 g at birth) has led to concern about their behavioural outcome in childhood. In reports from several countries with different assessments at various ages, investigators have noted a higher frequency of behavioural problems in such infants, but cross-cultural comparisons are lacking. Our aim was to compare behavioural problems in ELBW children of similar ages from four countries.

METHODS

We prospectively studied 408 ELBW children aged 8-10 years, whose parents completed the child behaviour checklist. The children came from the Netherlands, Germany, Canada, and USA. The checklist provides a total problem score consisting of eight narrow-band scales. Of these, two (aggressive and delinquent behaviour) give a broad-band externalising score, three (anxious, somatic, and withdrawn behaviour) give a broad-band internalising score, and three (social, thought, and attention problems) indicate difficulties fitting neither broad-band dimension. For each cohort we analysed scores in ELBW children and those in normal- birthweight controls (two cohorts) or national normative controls (two cohorts). Across countries, we assessed deviations of the ELBW children from normative or control groups.

FINDINGS

ELBW children had higher total problem scores than normative or control children, but this increase was only significant in European countries. Narrow-band scores were raised only for the social, thought, and attention difficulty scales, which were 0.5-1.2 SD higher in ELBW children than in others. Except for the increase in internalising scores recorded for one cohort, ELBW children did not differ from normative or control children on internalising or externalising scales.

INTERPRETATION

Despite cultural differences, types of behavioural problems seen in ELBW children were very similar in the four countries. This finding suggests that biological mechanisms contribute to behavioural problems of ELBW children.

School-age consequences of birth weight less than 750 g: a review and update

Recent advances in perinatal care have led to the survival of increasing numbers of children born at the lower limits of viability. Children with very low birth weight (LBW; less than 1,500 g, 3 lb 5 oz) have been studied extensively. Findings document poorer outcomes relative to normal birth weight term-born controls in neurologic and health status, cognitive-neuropsychological skills, school performance, academic achievement, and behavior. This report reviews current knowledge regarding LBW children, with special emphasis on outcomes for children with birth weight less than 750 g (1 lb 10 oz). Results from an ongoing longitudinal study suggest a gradient of sequelae, with poorer outcomes in less than 750 g birth weight children compared to both 750 g to 1,499 g birth weight children and term-born controls. Children with less than 750 g birth weight fail to catch up with their peers over time and may even be at risk for age-related increases in sequelae. Outcomes are highly variable but related to neonatal medical complications of prematurity and social risk factors. Further research is needed to understand the etiology and neuropathological basis of sequelae, the long-term developmental implications of LBW, and treatment needs.

How parents of premature infants gather information and obtain support

PURPOSE

To identify the process by which parents of premature infants seek information, the kinds of information they seek, and the resources they use to meet their educational and support needs.

DESIGN/SAMPLE

Descriptive study using 19 parent interviews and 64 questionnaires. MAIN OUTCOME VARIABLE; The process parents use to obtain information and support.

RESULTS

Parents of premature infants make a transition from being passive recipients of information to actively seeking it. They spend 10-20 hours a week gathering information during the first month of the baby's hospitalization. They desire more information than is provided, particularly in the areas of infant health, infant care, and coping. Family is the primary source of support prior to birth and after discharge, but during the infant's convalescence, nurses are the main source of support and help for parents in understanding and adapting to their baby. Many parents would use a computer-based resource for information if it were available to them.

Maternal depressive symptoms and child behavior problems in a nationally representative normal birthweight sample

OBJECTIVE

To evaluate the association between maternal depressive symptoms and child behavior problems in a nationally representative sample of U.S. mothers of normal birthweight babies.

METHODS

We analyzed data from the 1988 National Maternal and Infant Health Survey (NMIHS) and a 1991 follow-up survey. Depressive symptoms were measured at both surveys using the CES-D, and child behavior problems were assessed by maternal self-report at follow-up.

RESULTS

Approximately 28% of the 5303 mothers reported depressive symptoms at a mean of 17 months after delivery, as did 20% at 36 months. In multivariate analyses, women with depressive symptoms at either or both surveys were significantly more likely than women without depressive symptoms to report that their children had frequent temper tantrums or difficulty getting along with other children, and were difficult to manage, unhappy, or fearful. Compared to women without depressive symptoms, the risks of reporting three out of the five child behavior problems for women with depressive symptoms were OR = 1.6 (CI = 1.1-2.1), 1988 only; OR = 2.3 (CI = 1.6-3.3), 1991 only; and OR = 3.6 (2.6-5.0), both 1988 and 1991.

CONCLUSIONS

Study findings indicate that a substantial proportion of mothers of young children in the United States experience depressive symptoms and that their children are at significantly increased risk of maternally reported behavior problems. Our results suggest that efforts to identify and treat depression in new mothers should be increased and that mothers whose children are found to have behavior problems should be assessed for depression.

Impact of extreme prematurity on families of adolescent children

OBJECTIVES

To compare the impact of burden of illness on families of teenaged children who were extremely low birth weight (ELBW) with that of members of a term control group (C) and to determine whether the attitudes toward active treatment of very immature infants differ between the 2 cohorts.

DESIGN

In a cross-sectional survey, parents of 145 (86%) of 169 members of an ELBW cohort and 123 (85%) of 145 members of a control cohort completed a 23-item self-completed questionnaire encompassing occupational, marital, and family-related issues and attitudes toward treatment of infants of borderline viability.

RESULTS

Both positive (P =.0003) and negative (P <.005) effects on marriage were higher in parents of the ELBW group; although more parents in the ELBW group felt that their child had brought their families closer together (P =.0001), their child's health had adversely affected their emotional health (P =.02) and that of other children in the family (P =.003). Despite this result, a significant proportion of parents from both cohorts supported saving all infants (ELBW 68%; C 58%) and favored the role of parents in decision making (ELBW 98%; C 97%).

CONCLUSIONS

In the long term, it appears that parents of ELBW children have adjusted fairly well to their work and family life. Although some negative effects were identified, there was still considerable support for active treatment of infants of borderline viability.

Effects of family coping and resources on family adjustment and parental stress in the acute phase of the NICU experience

PURPOSE

To determine the relationship between family coping and resources and family adjustment and parental stress in the acute phase of the NICU experience.

DESIGN

Correlational study based on the Resiliency Model of Family Stress, Adjustment, and Adaptation. Main study instruments included the State Anxiety scale of the State-Trait Anxiety Inventory, the Family Inventory of Resources for Management, the Family Crisis Oriented Personal Evaluation Scales, and the General Functioning subscale of the McMaster Family Assessment Device.

SAMPLE

Data collected from 124 mother and father pairs within two to four days of their infant's admission to the NICU.

MAIN OUTCOME VARIABLES

Family adjustment and parental stress.

RESULTS

Adequate resources were more strongly related to positive adjustment and decreased stress than were either coping or being a first-time parent. The relationships among the variables were generally the same for both parents. Mothers utilized more coping strategies than did fathers. PRACTICE RECOMMENDATIONS: Families with limited resources should be identified early to facilitate their adjustment to the NICU.

Mother-infant interaction: effects of a home intervention and ongoing maternal drug use

Examined the effects of a home-based intervention on mother-infant interaction among drug-using women and their infants. At 2 weeks postpartum, mothers and infants were randomly assigned to either an intervention (n = 84) or a control (n = 87) group. Control families received brief monthly tracking visits, and intervention families received weekly visits by trained lay visitors. Mother-infant interaction was evaluated at 6 months through observation of feeding. Although there were no direct effects of the intervention, in the control group, mothers who continued to use drugs were less responsive to their babies than mothers who were drug free. In the intervention group, drug use was not associated with maternal responsiveness. Weekly home-based intervention may be a protective strategy for children of drug-using women because it disrupts the relation between ongoing maternal drug use and low maternal responsiveness.

Kangaroo care compared to incubators in maintaining body warmth in preterm infants

Many preterm infants cared for in incubators do not experience Kangaroo Care (KC), skin-to-skin contact with their mothers, due to fear of body heat loss when being held outside the incubator. A randomized clinical trial of 16 KC and 13 control infants using a pretest-test-posttest design of three consecutive interfeeding intervals of 2.5 to 3.0 h duration each was conducted over 1 day. Infant abdominal and toe temperatures were measured in and out of the incubator; maternal breast temperature was measured during KC. Repeated measures ANOVA showed no change in abdominal temperature across all periods and between groups. Toe temperatures were significantly higher during KC than incubator periods, and maternal breast temperature met each infant's neutral thermal zone requirements within 5 min of onset of KC. Preterm infants similar to those studied here will maintain body warmth with up to 3 h of KC.