Anxiety affects the relationship between parents and their very low birth weight infants

Supporting Fathers in a NICU: Effects of the HUG Your Baby Program on Fathers' Understanding of Preterm Infant Behavior

Fathers of preterm babies in a neonatal intensive care unit (NICU) are under stress. Lack of knowledge about a preterm infant's behavior challenges new fathers who may be required to make decisions about the hospitalized infant, to update concerned family and friends, and to provide support to the mother while she recovers from giving birth. The NICU nurses have the opportunity to support and guide these new fathers, although no previous research has confirmed how to do so effectively. This study confirmed that using The HUG Your Baby DVD and family-friendly educational program with fathers of preterm babies in a NICU increased fathers' knowledge of infant behavior and, as previous research suggests, is likely to boost fathers' confidence and to promote the parent-child relationship and strengthen the family unit.

A review of postpartum depression, preterm birth, and culture

Postpartum depression (PPD) varies worldwide and is considered a serious issue because of its devastating effects on mothers, families, and infants or children. Preterm birth may be a risk factor for PPD. In 2005, the global incidence of preterm birth was estimated to be 9.6%, and of these births, 85% occurred in Africa and Asia. Among Asian countries, Pakistan has a preterm birth rate of 15.7% and the highest prevalence rate of PPD (63.3%). A literature review was therefore undertaken to better understand the potential contribution of preterm birth to PPD and to identify gaps in the scientific literature. Limited studies compare prevalence rates of PPD in mothers of full-term infants and mothers of preterm infants. Furthermore, meta-analyses examining predictors of PPD have not included preterm birth as a variable. The interrelationship between preterm birth and PPD may be explained by early parental stress and mother-infant interaction among mothers of preterm infants. Culture plays an important role in shaping communication between mothers and their infants and defines social support rituals that may or may not mediate PPD. More research is needed to provide evidence for practice.

Easing maternal anxiety: an update

Maternal mental health is an important public health issue because of its effects not only on the mother's well-being and functional status, but also her relationship with her partner and the development of her children. There is accumulating evidence of the adverse sequelae of maternal anxiety on fetal development, obstetrical complications, pregnancy outcomes such as low birth weight, and subsequent child development. Evaluation of maternal anxiety and intervention to reduce these symptoms, may ensure optimal developmental outcomes, particularly in high-risk infants such as those born at very low birth weights. This article will outline recent advances in our understanding of the etiology, assessment and impact of maternal anxiety, and describe intervention strategies to promote maternal well-being.

Transitions in the early-life of late preterm infants: vulnerabilities and implications for postpartum care

The focus of this article is on the transition of late preterm infants from hospital to home. The current state of literature related to mortality, morbidities, emergency department visits, and rehospitalization underscores the vulnerability of late preterm infants following discharge from hospital. Universal provision of postpartum care to late preterm infants is viewed as an environmental support intended to facilitate transition of these vulnerable infants from hospital to home. Gaps in provision of postpartum care of late preterm infants are situated within the discussion of guidelines and models of postpartum care (home vs clinic) of late preterm infants.

Transition from hospital to home for parents of preterm infants

Research on the phenomenon of transition spans several decades. This article discusses the transition from hospital to home and the challenges parents of preterm infants experience during a neonatal intensive care unit stay and after discharge. The article explores the link between parental problems and rehospitalizations and the need for accurate measures of transitional concerns. An example of a theoretical model and instrument is described.

What helps the mother of a preterm infant become securely attached, responsive and well-adjusted?

OBJECTIVE

To investigate the relationship between the predictor variables of experiential avoidance, relationship satisfaction, prenatal expectations (compared to postnatal experience) and postpartum support, and the criterion variables of maternal attachment, maternal psychological symptoms and maternal responsiveness, after controlling for birth weight.

DESIGN

A quantitative survey study.

METHOD

The participants were 127 mothers of preterm infants (delivery prior to 37 weeks gestation, <24 months corrected age) recruited through parent support organisations. The web-based survey included measures of: demographics, postpartum support and prenatal expectations (compared to postnatal experience)-all designed for this study, as well as maternal attachment, (MPAS) maternal responsiveness (MIRI), experiential avoidance (AAQ), maternal psychological symptoms (DASS-21) and relationship satisfaction (RQI). Three standard multiple regression analyses were conducted.

RESULTS

The combined effects of experiential avoidance, relationship satisfaction, prenatal expectations (compared to postnatal experience) and postpartum support accounted for a significant 21% of variance in maternal attachment, Fch (4,121)=8.01, p<.001, a significant 38% of variance in maternal psychological symptoms Fch (4,121)=18.38, p<.001, and a significant 11% of variance in maternal responsiveness, Fch (4,121)=3.78, p=.013 after controlling for birth weight.

CONCLUSION

The four predictor variables predicted maternal attachment, psychological symptoms and responsiveness after controlling for birth weight, with experiential avoidance being the most important predictor, followed by prenatal expectations (compared to postnatal experience), relationship satisfaction, then postpartum support. This has implications for designing interventions to optimise attachment and responsiveness, and minimise psychological symptoms, in mothers of infants born preterm.

The cues and care randomized controlled trial of a neonatal intensive care unit intervention: effects on maternal psychological distress and mother-infant interaction

OBJECTIVE

This study tested the efficacy of a brief intervention (Cues program) with mothers of very low birth weight (VLBW <1500 g) infants. The primary hypothesis was that mothers in the Cues program would report lower levels of anxiety compared with mothers in the control group. Secondary hypotheses examined whether Cues mothers would report less stress, depression, and role restriction, and exhibit more sensitive interactive behavior, than control group mothers.

METHODS

A total of 121 mothers of VLBW infants were randomly assigned to either the experimental (Cues) intervention or an attention control (Care) condition. The Cues program combined training to reduce anxiety and enhance sensitivity. The control group received general information about infant care. Both programs were initiated during the neonatal intensive care unit stay. Maternal anxiety, stress, depression, and demographic variables were evaluated at baseline, prior to randomization. Postintervention outcomes were assessed during a home visit when the infant was ∼6 to 8 weeks of corrected age.

RESULTS

Although mothers in the Cues group demonstrated greater knowledge of the content of the experimental intervention than mothers in the Care group, the groups did not differ in levels of anxiety, depression, and symptoms of posttraumatic stress. They were similar in their reports of parental role restrictions and stress related to the infant's appearance and behavior. Cues and Care group mothers were equally sensitive in interaction with their infants.

CONCLUSION

Nonspecific attention was as effective as an early skill-based intervention in reducing maternal anxiety and enhancing sensitive behavior in mothers of VLBW infants.

Support like a walking stick: parent-buddy matching for language and culture in the NICU

PURPOSE

(1) To explore the experience of non-English-speaking mothers with preterm, very low birth weight (VLBW) infants (,1,500 g); and (2) to examine mothers' assessment of a peer support program matching them with linguistically and culturally similar parent-buddies.

DESIGN

An exploratory, qualitative analysis based on grounded theory.

SAMPLE

A convenience sample of eight mothers from four of the most prevalent non-English-speaking cultures (Spanish, Portuguese, Chinese, and Tamil) in an urban Canadian-teaching hospital.

MAIN OUTCOME VARIABLE

Non-Anglophone mothers' experience and support in the NICU.

RESULTS

Study mothers experienced intense role disequilibrium during the unanticipated crisis of preterm birth of a VLBW infant; situational crises owing to the high-tech NI CU environment and their infant's condition; and developmental crises with feelings of loss, guilt, helplessness, and anxiety. Language barriers compounded the difficulties. Parent-buddies helped non-English-speaking mothers mobilize their strengths. Culture and language are important determinants of service satisfaction for non-English-speaking mothers. Linguistically congruent parent-to-parent matching increases access to service.

Early maternal anxiety predicts cognitive and behavioural outcomes of VLBW children at 24 months corrected age

AIM

The present study examined the effects of maternal anxiety during infant hospitalization in the Neonatal Intensive Care Unit (NICU) on the child's cognitive and behavioural development at 24 months corrected age. Parental anxiety following the birth of a very low birthweight (VLBW, <1500 g) infant may impede their capacity to be sensitive to the infant's cues and adversely affect infant developmental outcomes.

METHODS

A sample of 88 mothers and their VLBW infants were recruited in the NICU; 57 were followed at 24 months corrected age. During the infant's hospitalization, mothers completed a self-report measure of trait anxiety. When the infants were 24 months corrected age, mother-child interaction was videotaped during free play at home. These videotaped observations were coded using Emotional Availability Scales. Child cognitive and behavioural outcomes were evaluated using the Bayley Scales of Infant Development (II) and the Child Behavior Checklist for Ages 1.5-5.

RESULTS

Maternal anxiety in the NICU was found to be a significant and independent predictor of child cognitive development and internalizing behaviour problems, controlling for maternal education and neonatal morbidity.

CONCLUSION

These results suggest that early intervention programmes targeting anxious mothers of VLBW infants are indicated, to promote optimal developmental outcomes.

Psychosocial parental support programs and short-term clinical outcomes in extremely low-birth-weight infants

OBJECTIVE

To describe the association between an individualized psychosocial parental support (PPS) program and short-term clinical outcomes of extremely low-birth-weight (ELBW) infants admitted to the neonatal intensive care unit (NICU).

METHODS

Medical records of ELBW infants (<1000 g) hospitalized in the NICU at Miami Children's Hospital between July 2006 and June 2008 were reviewed. Outborn infants admitted during their first 72 h of life and discharged home were included. Parents were divided in two groups according to their participation status in the PPS program. Neonatal outcomes in both groups were compared.

RESULTS

Forty-one infants were included (n = 41). Mean gestational age was 26.7±2 weeks, and birth weight was 860±125 g. Median length of stay (LOS) was 96 days (quartile range: 76-112 days). PPS was provided to 33.3% of these infants' parents. The median LOS in the PPS group was significantly lower than in control group (86 vs. 99 days; p < 0.05). No other differences in short-term neonatal outcomes were found.

CONCLUSIONS

The addition of individualized psychosocial parent support programs to standard care in the NICU may reduce LOS in surviving infants discharged home. Further larger and randomized prospective studies are needed.

Mothers' different styles of involvement in preterm infant pain care

OBJECTIVE

To describe and understand how mothers utilize the opportunity to actively participate in their preterm infants' pain care using facilitated tucking by parents (FTP).

DESIGN

Descriptive and exploratory study with postintervention interview.

SETTING

Finnish level III Neonatal Intensive Care Unit (NICU).

PARTICIPANTS

Twenty-three mothers who had preterm infants born at gestational ages of 32 to 34 weeks.

METHODS

The parents (N=45) of 29 preterm infants were taught to use FTP. In addition, all nurses in the NICU (N=76) received the same education to support the parents' use of FTP. After 2 to 4 weeks of FTP use, the mothers (n=23) were interviewed using the Clinical Interview for Parents of High-Risk Infants with additional questions related to the infants' pain care. The interviews were analyzed inductively with cross-case analysis and deductively with a previously developed coding scheme.

RESULTS

Facilitated tucking by parents was perceived positively and was used by all participating mothers. Three different styles of involvement in preterm infants' pain care with FTP were identified. They formed a continuum from external to random and finally to internalized involvement. In external involvement, the pain care with FTP was triggered by outside factors such as nurses, whereas in random and internalized involvement the motivation emerged from a parent. Mothers with external involvement thought that any person could apply the FTP. In random involvement, mothers were mainly absent during painful procedures, although they saw themselves as the best caregivers. In internalized involvement, the responsibility for infant pain care was shared within the family. Mothers' NICU-related stress and maternal attachment were associated with this variation.

CONCLUSION

This study showed that mothers' are willing to actively participate in their preterm infants' pain care. However, the participation is unique according to mother and her experiences before and during NICU admission. Nurses need to consider these differences in mothers when involving them in preterm infants' pain care.

Improving the outcome of infants born at <30 weeks' gestation--a randomized controlled trial of preventative care at home

BACKGROUND

Early developmental interventions to prevent the high rate of neurodevelopmental problems in very preterm children, including cognitive, motor and behavioral impairments, are urgently needed. These interventions should be multi-faceted and include modules for caregivers given their high rates of mental health problems.

METHODS/DESIGN

We have designed a randomized controlled trial to assess the effectiveness of a preventative care program delivered at home over the first 12 months of life for infants born very preterm (<30 weeks of gestational age) and their families, compared with standard medical follow-up. The aim of the program, delivered over nine sessions by a team comprising a physiotherapist and psychologist, is to improve infant development (cognitive, motor and language), behavioral regulation, caregiver-child interactions and caregiver mental health at 24 months' corrected age. The infants will be stratified by severity of brain white matter injury (assessed by magnetic resonance imaging) at term equivalent age, and then randomized. At 12 months' corrected age interim outcome measures will include motor development assessed using the Alberta Infant Motor Scale and the Neurological Sensory Motor Developmental Assessment. Caregivers will also complete a questionnaire at this time to obtain information on behavior, parenting, caregiver mental health, and social support. The primary outcomes are at 24 months' corrected age and include cognitive, motor and language development assessed with the Bayley Scales of Infant and Toddler Development (Bayley-III). Secondary outcomes at 24 months include caregiver-child interaction measured using an observational task, and infant behavior, parenting, caregiver mental health and social support measured via standardized parental questionnaires.

DISCUSSION

This paper presents the background, study design and protocol for a randomized controlled trial in very preterm infants utilizing a preventative care program in the first year after discharge home designed to improve cognitive, motor and behavioral outcomes of very preterm children and caregiver mental health at two-years' corrected age.

CLINICAL TRIAL REGISTRATION NUMBER

ACTRN12605000492651.

Patterns of distress in African-American mothers of preterm infants

OBJECTIVE

To examine inter-relationships among stress due to infant appearance and behavior in the neonatal intensive care unit (NICU), parental role alteration stress in the NICU, depressive symptoms, state anxiety, posttraumatic stress symptoms, and daily hassles exhibited by African-American mothers of preterm infants and to determine whether there were subgroups of mothers based on patterns of psychological distress.

METHOD

One hundred seventy-seven African-American mothers completed questionnaires on their psychological distress at enrollment during infant hospitalization and 2, 6, 12, 18, and 24 months after term.

RESULTS

Psychological distress measures were intercorrelated. There were four latent classes of mothers: the low distress class with low scores on all measures; the high NICU-related stress class with high infant appearance and parental role stress and moderate scores on other measures; the high depressive symptoms class with high depressive symptoms and state anxiety and moderately elevated scores on NICU-related stress and posttraumatic stress symptoms; the extreme distress class with the highest means on all measures. Infants in the high stress class were sicker than infants in the other classes. The extreme distress class mothers averaged the lowest educational level. The classes differed on distress measures, worry about the child, and parenting stress through 24 months with the extreme distress class having the highest values.

CONCLUSION

Although different types of maternal psychological distress were substantially related, there were distinct subgroups of mothers that were identifiable in the NICU. Moreover, these subgroups continued to differ on trajectories of distress and on their perceptions of the infants and parenting through 24 months after term.

Persistent maternal anxiety affects the interaction between mothers and their very low birthweight children at 24 months

BACKGROUND

Parental distress following the birth of a premature infant diminishes the parent's ability to be sensitive to the infant's cues, and this may affect infant developmental outcomes.

AIMS

The present study examined the effects of maternal anxiety during infant hospitalization in the Neonatal Intensive Care Unit (NICU) on the interactive behavior of mothers with their very low birthweight (VLBW) children in toddlerhood.

SUBJECTS

A sample of 56 mothers and their VLBW infants were recruited in the NICU.

STUDY DESIGN

During the infant's NICU stay, mothers completed a self-report measure of trait anxiety. These mothers and their infants were followed when the infants were 24 months corrected age, when mothers and their children were videotaped during free play at home. These videotapes were then coded using the Emotional Availability Scales.

RESULTS

Maternal anxiety was not found to be related to severity of neonatal illness. Maternal anxiety in the NICU was associated with less sensitivity and less structure in interaction with their toddlers at 24 months corrected age, even controlling for maternal education and child birthweight. Children of mothers with higher anxiety scores in the NICU were less likely to involve their mothers in their play at 24 months corrected age.

CONCLUSIONS

Maternal anxiety in the NICU predicted adverse interactive behaviors when the children were 24 months corrected age. Early identification of anxious mothers in the NICU is needed in order to initiate preventive intervention to support the mother-infant relationship.