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

Predictors of Health Status in Mothers of Premature Infants with Implications for Clinical Practice and Future Research

BACKGROUND

Postpartum health research has focused primarily on full-term mothers.

AIMS

To explore postpartum stress, depression, social support, health status, and predictors of health status in mothers of premature infants.

METHODS

This study employed a cross-sectional design. With convenience sampling, a total of 203 mothers of premature infants were recruited from two medical centers and four community teaching hospitals in southern Taiwan. The Hung Postpartum Stress Scale, Social Support Scale, Beck Depression Inventory, and Chinese Health Questionnaire were used to assess the mothers' psychosocial features during the first 6 weeks postpartum.

RESULTS

Mothers' health status differed significantly according to levels of postpartum stress and depression. The important health status predictors were age, education, postpartum stress, and depression level.

DISCUSSION

The concerns and needs of mothers of premature infants differed from those of full-term mothers during the first 6 weeks postpartum; premature infants' health status was found to be a major perceived stressor for their mothers.

LINKING EVIDENCE TO ACTION

In the process of caring for premature infants' mothers, healthcare providers should provide individualized care to meet their needs, thus facilitating the reduction of postpartum stress and depression levels. During premature infants' hospitalizations, healthcare providers should hold regular faculty meetings to provide postpartum women with relevant information about their infants' health and how to best care for them. Future studies should explore postpartum stress, social support, depression, and health status each postpartum week, which could serve as a guide for nursing interventions.

Very low birth-weight as a risk factor for postpartum depression four to six weeks postbirth in mothers and fathers: Cross-sectional results from a controlled multicentre cohort study

BACKGROUND

Preterm birth and survival rates of very low birth-weight (VLBW: <1.500g) infants have increased. Although new parents are frequently affected by depressive symptoms, little is known about prevalence, risk, and predictors of parental postpartum depression (PPD) following VLBW birth. Furthermore, most studies assessing PPD in parents of preterm children relied on self-report only.

METHODS

As part of the HaFEn cohort-study, data from the index groups of parents with VLBW infants and the control group of parents with term infants were cross-sectionally analysed. Families were recruited at the three largest centres of perinatal medical care in Hamburg, Germany. PPD was evaluated one month postpartum using standardized questionnaires and clinical interviews. Socioeconomic status, social support, risks during pregnancy, and psychiatric lifetime diagnoses were also assessed. A multiple random coefficient model was used to examine predictors of PPD in both parents simultaneously.

RESULTS

230 mothers and 173 fathers were included. Depending on the measure, the risk of being postnatally depressed was 4 to 18 times higher in mothers and 3 to 9 times higher in fathers from the index group. The most relevant risk factor for PPD was the birth of a VLBW infant, followed by female sex, lifetime psychiatric disorder, and low social support.

LIMITATIONS

Results presented here, are based on cross sectional data. Therefore no temporal relationships can be established.

CONCLUSIONS

Our findings highlight the importance of early screening for PPD in both parents of VLBW infants. Factors contributing to developing depression should also be considered in neonatal care.

Depression Management by NICU Nurses

The purpose of this article was to evaluate attitudes of mothers of newborns hospitalized on the neonatal intensive care unit (NICU) toward nurse-delivered depression screening and counseling. NICU mothers ( N = 200) completed questionnaires assessing their views toward being screened for depression by nurses, treatment provider preference, and interest in learning about Listening Visits (LV), a nurse-delivered intervention. The views of 23 LV recipients were also assessed. Most mothers were receptive to depression screening by nurses, two thirds would see a nurse for counseling, and half were interested in learning more about LV. Among LV recipients, half readily embraced the idea and the remaining recipients were skeptical but opted to try. After receiving LV, recipients unanimously rated LV and the skill of the LV provider highly. Screening and counseling by NICU nurses could increase detection of depression and treatment use among at-risk women. Assessing nurses’ perspectives about implementing this model of care is an important future research direction.

Maternal psychological distress and visitation to the neonatal intensive care unit

AIM

To examine associations between maternal neonatal intensive care unit (NICU) visitation rates, maternal psychological distress ('distress') and preterm infant outcome post-NICU discharge in a contemporary cohort of very low birthweight (VLBW) infants.

METHODS

This was a prospective study of 69 mothers and their VLBW infants. Distress was assessed 1-month postbirth, 2 weeks prior to NICU discharge and after NICU discharge at 4-month corrected age (CA). Maternal NICU visitation rates were calculated for the first 2 weeks and 1-month postbirth as well as for the entire NICU hospitalization. Regression analyses adjusted for the impact of (i) maternal and infant characteristics and distress on maternal visitation rates and (ii) the impact of visitation on long-term maternal distress and rates of infant clinic attendance and rehospitalization.

RESULTS

Greater number of children in the home, maternal exposure to a greater number of potentially traumatic events prior to childbirth and lower maternal anxiety consistently predicted lower visitation rate. Lower maternal visitation rate predicted higher maternal depression scores at infants' 4-month CA visit. Maternal NICU visitation rate did not predict post-NICU discharge infant clinic attendance or rehospitalization.

CONCLUSION

Distress is an important predictor of visitation. In turn, visitation is associated with long-term maternal distress.

Psychiatric support for mothers in the Neonatal Intensive Care Unit

OBJECTIVE

This study describes mental health treatment and follow-up for mothers of infants in a Neonatal Intensive Care Unit (NICU).

STUDY DESIGN

Data were collected retrospectively about 204 mothers referred to a Level 3 NICU Psychiatric Consult Liaison Team over 2 years. This included medical, demographic and treatment information about both mother and infant.

RESULT

Most mothers (69%) were referred within a week of birth, and 100 (49%) of the referred mothers received a psychiatric diagnosis. Psychiatric follow-up was recommended for 13% on leaving the NICU and additional follow-up referrals were made for another 16%. Mothers with more than one initial reason for referral, a past psychiatric history, receiving therapeutic services, receiving a psychiatric diagnosis and receiving pharmacotherapy were all significantly more likely to have follow-up recommended on discharge.

CONCLUSION

Approximately one-sixth of mothers in the NICU were referred, a large proportion received a psychiatric diagnosis, and over a quarter required follow-up after discharge, indicating the importance of the service.

Stress in parents of children born very preterm is predicted by child externalising behaviour and parent coping at age 7 years

OBJECTIVE

To examine factors which predict parenting stress in a longitudinal cohort of children born very preterm, and seen at age 7 years.

METHODS

We recruited 100 very preterm (≤32 weeks gestational age) child-parent dyads and a control group of 50 term-born dyads born between 2001 and 2004 with follow-up at 7 years. Parents completed the Parenting Stress Index, Ways of Coping Questionnaire, Child Behavior Check List, Beck Depression Inventory and the State Trait Anxiety Inventory questionnaires. Child IQ was assessed using the Wechsler Intelligence Scale-IV.

RESULTS

After controlling for maternal education, parents of preterm children (95% CI 111.1 to 121.4) scored higher (p=0.027) on the Parenting Stress Index than term-born controls (95% CI 97.8 to 113.2). Regression analyses showed that child externalising behaviour, sex and parent escape/avoidance coping style, predicted higher parenting stress in the preterm group. Parents of preterm girls expressed higher levels of stress than those of boys.

CONCLUSIONS

Maladaptive coping strategies contribute to greater stress in parents of very preterm children. Our findings suggest that these parents need support for many years after birth of a very preterm infant.

The outcomes of children with pediatric acute respiratory distress syndrome: proceedings from the Pediatric Acute Lung Injury Consensus Conference

OBJECTIVE

To provide additional details and evidence behind the recommendations for outcomes assessment of patients with pediatric acute respiratory distress syndrome from the Pediatric Acute Lung Injury Consensus Conference.

DESIGN

Consensus conference of experts in pediatric acute lung injury.

METHODS

A panel of 27 experts met over the course of 2 years to develop a taxonomy to define pediatric acute respiratory distress syndrome and to make recommendations regarding treatment and research priorities. The outcomes subgroup comprised four experts. When published data were lacking, a modified Delphi approach emphasizing strong professional agreement was used.

RESULTS

The Pediatric Acute Lung Injury Consensus Conference experts developed and voted on a total of 151 recommendations addressing the topics related to pediatric acute respiratory distress syndrome, seven of which related to outcomes after pediatric acute respiratory distress syndrome. All seven recommendations had strong agreement. Children with acute respiratory distress syndrome continue to have a high mortality, specifically, in relation to certain comorbidities and etiologies related to pediatric acute respiratory distress syndrome. Comorbid conditions, such as an immunocompromised state, increase the risk of mortality even further. Likewise, certain etiologies, such as non-pulmonary sepsis, also place children at a higher risk of mortality. Significant long-term effects were reported in adult survivors of acute respiratory distress syndrome: diminished lung function and exercise tolerance, reduced quality of life, and diminished neurocognitive function. Little knowledge of long-term outcomes exists in children who survive pediatric acute respiratory distress syndrome. Characterization of the longer term consequences of pediatric acute respiratory distress syndrome in children is vital to help identify opportunities for improved therapeutic and rehabilitative strategies that will lessen the long-term burden of pediatric acute respiratory distress syndrome and improve the quality of life in children.

CONCLUSIONS

The Consensus Conference developed pediatric-specific recommendations for pediatric acute respiratory distress syndrome regarding outcome measures and future research priorities. These recommendations are intended to promote optimization and consistency of care for children with pediatric acute respiratory distress syndrome and identify areas of uncertainty requiring further investigation.

Measurement Invariance Across Parent and Self-Ratings of Extremely Low Birth Weight Survivors and Normal Birth Weight Controls in Childhood and Adolescence on the Child Behavior Checklist and Youth Self-Report

OBJECTIVE

This study examined the measurement invariance of the Child Behavior Checklist (CBCL) and Youth Self-Report (YSR) DSM-oriented scales between extremely low birth weight (ELBW) and normal birth weight (NBW) youth.

METHODS

 The sample included 158 ELBW survivors and 145 matched, NBW controls at 8 and 12-16 years of age.

RESULTS

Strict invariance was established at 8 years for parent-reported CBCL attention-deficit hyperactivity, conduct, and oppositional defiant scales, though invariance could not be established for affective problems at 8 or 12-16 years. Strict invariance was observed between 12-16-year-old ELBW and NBW groups on attention-deficit hyperactivity, anxiety, and oppositional defiant CBCL and YSR scales. Invariance could not be established for youth-reported conduct problems.

CONCLUSIONS

While the majority of CBCL/YSR DSM-oriented subscales assess the same concepts in both ELBW and NBW children and adolescents across parent and youth reports, this may not be the case for affective and conduct problems.

Desperately seeking parenthood: neonatal nurses reflect on parental anguish

AIM AND OBJECTIVE

This paper aims to explore the ways in which neonatal nurses understand the experience of parents who have experienced infertility, conceived a baby via in vitro fertilisation and delivered an extremely premature infant. The chance of a poor long-term outcome for the baby is significant; therefore, parental anguish plays out in the neonatal intensive care.

BACKGROUND

Current literature suggests that infertility is a significant issue for ageing women and many couples experience multiple cycles of invitro-fertilisation (IVF) treatment to achieve a pregnancy. Babies conceived through IVF are more likely to have genetic disorders, and be born prematurely. When the baby is born through IVF and is also born extremely prematurely, it creates a crisis situation for the parents. This paper will focus on the parental anguish of achieving a pregnancy through IVF to see the baby born extremely prematurely (defined as ≤ 24-week gestation). It will examine parental anguish from caregiver perspective of the neonatal nurse who supports the parents through this very difficult time.

DESIGN

This study used interviews with neonatal nurses, and drew insights from interpretative phenomenology.

METHODS

This research used a combination of a questionnaire and a series of interviews in a qualitative study informed by phenomenology. The analysis of the interview data involved the creation of key themes following extensive coding of thematic statements and the analysis of the emerging themes.

RESULTS

This paper outlines the neonatal nurses' understanding of parental anguish and overwhelming sadness in parents whose baby was conceived by IVF, and was also born extremely prematurely. The theme of 'seeking parenthood' was synthesised from two sub-themes - 'longing for a baby' and 'the desperation to become parents'.

CONCLUSION

This study identified that neonatal nurses bear witness to parental anguish as their hopes of taking home a live baby might not be realised. The time, effort and money required to achieve a pregnancy does not mean that the baby will be spared the outcomes of extreme prematurity and the risk factors associated with IVF. The parents may be left empty handed. Therefore, the word precious becomes a metaphor for the IVF baby as the neonatal team try desperately to give the parents their much longed baby.

RELEVANCE TO CLINICAL PRACTICE

Delayed child bearing has an impact on fertility, with maternal age having the most impact on the ability to conceive. Babies conceived through IVF technologies have a higher risk of genetic abnormalities and being born prematurely, and this will impact on the neonatal intensive care availability. Extreme prematurity and IVF can significantly impact on the baby's outcome. Witnessing parental anguish can be a major source of stress for the neonatal nurses. Neonatal nurses need to develop strategies not only to help the parents but also to prevent the parents' overwhelming sadness from affecting their ability to function in the neonatal intensive care unit.

Raising multiples: mental health of mothers and fathers in early parenthood

The rate of twin and higher-order gestation births has risen dramatically in recent decades in the United States as well as other Western countries. Although the obstetrical and neonatal risks of multiple gestation pregnancies are well-documented, much less is known regarding the mental health impact on parents of multiples during the perinatal and early parenthood period. Given that parents of multiples face greater functional demands, as well as other pressures (financial, medical) this population may be at risk for heightened distress. We conducted a systematic review of quantitative, English language studies that assessed mental health outcomes of parents of multiples during pregnancy, in the first postpartum year, and in the period of early parenthood, including depression, anxiety, stress, and related constructs. Twenty-seven articles published between 1989 and 2014 met selection criteria and were included in the review. Studies utilized a wide range of methods and outcome constructs, often making comparisons difficult. Although some studies found no differences, most investigations that compared mental health outcomes in parents of multiples versus parents of singletons found that parents of multiples experience heightened symptoms of depression, anxiety, and parenting stress. We discuss gaps in the existing body of literature on parental mental health related to multiple gestation birth and conclude by discussing the need for novel intervention strategies to meet the needs of this growing population. Parents of multiples may experience worse mental health outcomes than parents of singletons. More research is needed, and future work should explore potential treatment and support options.

Transvaginal sonographic evaluation of cervical length in the second trimester of asymptomatic singleton pregnancies, and the risk of preterm delivery

OBJECTIVE

To evaluate cervical length in asymptomatic women with singleton pregnancies in the second trimester by means of transvaginal ultrasonography, and to examine the relation between cervical length and spontaneous preterm delivery.

DESIGN

Observational, prospective study.

SETTING

A university hospital and a county hospital in Western Sweden.

POPULATION

A total of 2122 asymptomatic women with live singleton pregnancies without fetal anomalies.

METHODS

Cervical length was measured at between 16 and 23 weeks of gestation by means of transvaginal ultrasonography. Data were analysed using logistic regression analysis.

MAIN OUTCOME MEASURES

Cervical length in relation to spontaneous preterm delivery <34 weeks (primary outcome) and <37 weeks of gestation (secondary outcome).

RESULTS

Eleven women had a cervical length of ≤25 mm (0.5%) and 73 women had a cervical length of ≤30 mm (3.4%). Spontaneous preterm delivery at <34 weeks occurred in 22/2061 women (1.1%) and at <37 weeks in 87/2061 women (4.2%). There was a significant association between cervical length and spontaneous preterm delivery at <34 weeks (odds ratio 1.78; 95% confidence interval 1.19-2.65 for a decrease of cervical length by 5 mm) but no significant association at <37 weeks.

CONCLUSIONS

The rate of short cervical length of ≤25 mm was lower than expected. The study confirmed the increased risk of spontaneous preterm delivery in women with a short cervix, although the analysis was based on only a few cases. In Sweden, a larger study is needed to evaluate the prevalence of short cervical length and the possible association with preterm delivery before universal screening can be recommended.

[Skin-to-skin care in the delivery room: impact of SpO2 monitoring]

BACKGROUND

Skin-to-skin care in the delivery room increases mother-newborn bonding, reduces the newborn's stress level, and facilitates breastfeeding. However, a few reports of life-threatening events in newborn infants during skin-to-skin care have prompted suggestions that SpO2 monitoring may be of value in the delivery room. The present study compared SpO2 monitoring with standard clinical practices during skin-to-skin care in the delivery room. The midwife's opinion and the mother's anxiety level were assessed for both procedures.

MATERIALS AND METHODS

The midwife's opinion was measured on a Likert scale and the mother's anxiety level was measured on the State-Trait Anxiety Inventory Y-A and Y-B scales. Two procedures (standard clinical practice vs. SpO2 monitoring) were compared prospectively in two consecutive 3-month periods.

RESULTS

Seventy case report forms were completed for the "standard clinical practice" group and 62 were completed for the "SpO2 monitoring" group. The care procedure was considered to be satisfactory or quite satisfactory in 60 cases (96.8%) in the "SpO2 monitoring" group and in 57 cases (81.4%; P<0.05) in the "standard clinical practice" group. There was no significant difference between the groups in terms of the mean maternal anxiety level.

CONCLUSION

SpO2 monitoring during skin-to-skin care in the delivery room was well accepted by the midwife. Relative to standard clinical practice alone, SpO2 monitoring was not associated with elevated maternal anxiety levels.

Longitudinal Analysis of Parenting Stress in Mothers and Fathers of Infants with and without Single-Suture Craniosynostosis

Objective

To examine longitudinal differences in reported stress between parents of children with and without single-suture craniosynostosis and to compare the stress reports of mothers and fathers.

Design

Multi-site, nonrandomized prospective study.

Setting/Participants

Children with single-suture craniosynostosis (cases) were identified via referral of the treating surgeon or physician at the time of diagnosis, and those without single-suture craniosynostosis (controls) were recruited from pediatric practices, birthing centers, and announcements in print media. When children were aged 6, 18, and 36 months (on average), mothers and fathers of children with and without single-suture craniosynostosis completed the Parenting Stress Index. For cases, 247 mothers and 211 fathers completed the Parenting Stress Index at the first visit; corresponding numbers for controls were 254 and 220, respectively.

Main Outcome Measures

The Parenting Stress Index Parent and Child Domains and subscales scores.

Results

We found few differences between parents of infants with and without single-suture craniosynostosis, regardless of parent gender. Irrespective of case status, mothers consistently reported higher stress than fathers on the Parent Domain. Within the Parent Domain, mothers reported more stress than fathers on the Role Restriction and Spousal Support subscales.

Conclusions

The parents of children with single-suture craniosynostosis reported levels of stress similar to those reported by parents of same-aged, unaffected children. Mothers reported greater stress than fathers, and these differences remained remarkably stable over time. This may reflect widely held perceptions of gender differences in parenting roles.

Primary Care Triple P for parents of NICU graduates with behavioral problems: a randomized, clinical trial using observations of parent-child interaction

Background

Preterm-born or asphyxiated term-born children show more emotional and behavioral problems at preschool age than term-born children without a medical condition. It is uncertain whether parenting intervention programs aimed at the general population, are effective in this specific group. In earlier findings from the present trial, Primary Care Triple P was not effective in reducing parent-reported child behavioral problems. However, parenting programs claim to positively change child behavior through enhancement of the parent–child interaction. Therefore, we investigated whether Primary Care Triple P is effective in improving the quality of parent–child interaction and increasing the application of trained parenting skills in parents of preterm-born or asphyxiated term-born preschoolers with behavioral problems.

Methods

For this pragmatic, open randomized clinical trial, participants were recruited from a cohort of infants admitted to the neonatal intensive care units of two Dutch hospitals. Children aged 2–5 years, with a gestational age <32 weeks and/or birth weight <1500 g and children with a gestational age 37–42 weeks and perinatal asphyxia were included. After screening for a t-score ≥60 on the Child Behavior Checklist, children were randomly assigned to Primary Care Triple P (n = 34) or a wait-list control group (n = 33). Trial outcomes were the quality of parent–child interaction and the application of trained parenting skills, both scored from structured observation tasks.

Results

There was no effect of the intervention on either of the observational outcome measures at the 6-month trial endpoint.

Conclusions

Primary Care Triple P, is not effective in improving the quality of parent–child interaction nor does it increase the application of trained parenting skills in parents of preterm-born or asphyxiated term-born children with behavioral problems. Further research should focus on personalized care for these parents, with an emphasis on psychological support to reduce stress and promote self-regulation.

Trial registration

Netherlands National Trial Register NTR2179. Registered 26 January 2010.

Electronic supplementary material

The online version of this article (doi:10.1186/s12887-014-0305-4) contains supplementary material, which is available to authorized users.

Prevalence and factors associated with depressive symptoms in mothers with infants or toddlers

BACKGROUND

The objective of this study is to explore the prevalence of and factors associated with depressive symptoms in mothers with young children.

METHODS

This is a cross-sectional face-to-face study performed between January 1, 2010 and June 30, 2011. Mothers of premature infants with a gestational age of less than 37 weeks were recruited. Premature infants with any congenital anomaly or severe congenital heart disease were excluded. Controls were mothers of full-term infants with birth weight over 2500 g and without admission to a neonatal intensive care unit. Outcome measures included the Center for Epidemiologic Studies Depression Scale for maternal depressive symptoms, the Family Apgar Index for family support, and the Chinese Maudsley Personality Inventory for personality traits.

RESULTS

A total of 102 mothers of preterm infants and 111 mothers of full-term infants were recruited. The prevalence of depressive symptoms was 27.7% (59/213) in all mothers of this study, 29.4% (30/102) in mothers of preterm infants, and 26.1% (29/111) in mothers of full-term infants. Predictors of maternal depressive symptoms included the following: extended family structure, lack of postpartum confinement, low family support, and a personality characterized by neuroticism.

CONCLUSION

Depressive symptoms were common among mothers of young children. Family function and neurotic personality were highly correlated with depressive symptoms in mothers caring for young children. Pediatric health care providers are suggested to screen for maternal depressive symptoms and provide family-oriented support in Taiwan.

Postpartum depression on the neonatal intensive care unit: current perspectives

As the most common complication of childbirth affecting 10%–15% of women, postpartum depression (PPD) goes vastly undetected and untreated, inflicting long-term consequences on both mother and child. Studies consistently show that mothers of infants in the neonatal intensive care unit (NICU) experience PPD at higher rates with more elevated symptomatology than mothers of healthy infants. Although there has been increased awareness regarding the overall prevalence of PPD and recognition of the need for health care providers to address this health issue, there has not been adequate attention to PPD in the context of the NICU. This review will focus on an overview of PPD and psychological morbidities, the prevalence of PPD in mothers of infants admitted to NICU, associated risk factors, potential PPD screening measures, promising intervention programs, the role of NICU health care providers in addressing PPD in the NICU, and suggested future research directions.

Risk of adverse outcomes among infants of immigrant women according to birth-weight curves tailored to maternal world region of origin

BACKGROUND

Infants of immigrant women in Western nations generally have lower birth weights than infants of native-born women. Whether this difference is physiologic or pathological is unclear. We determined whether the use of birth-weight curves tailored to maternal world region of origin would discriminate adverse neonatal and obstetric outcomes more accurately than a single birth-weight curve based on infants of Canadian-born women.

METHODS

We performed a retrospective cohort study of in-hospital singleton live births (328,387 to immigrant women, 761,260 to nonimmigrant women) in Ontario between 2002 and 2012 using population health services data linked to the national immigration database. We classified infants as small for gestational age (<10th percentile) or large for gestational age (≥90th percentile) using both Canadian and world region-specific birth-weight curves and compared associations with adverse neonatal and obstetric outcomes.

RESULTS

Compared with world region-specific birth-weight curves, the Canadian curve classified 20 431 (6.2%) additional newborns of immigrant women as small for gestational age, of whom 15,467 (75.7%) were of East or South Asian descent. The odds of neonatal death were lower among small-for-gestational-age infants of immigrant women than among those of nonimmigrant women based on the Canadian birth-weight curve (adjusted odds ratio [OR] 0.83, 95% confidence interval [CI] 0.72-0.95), but higher when small for gestational age was defined by the world region-specific curves (adjusted OR 1.24, 95% CI 1.08-1.42). Conversely, the odds of some adverse outcomes were lower among large-for-gestational-age infants of immigrant women than among those of nonimmigrant women based on world region-specific birth-weight curves, but were similar based on the Canadian curve.

INTERPRETATION

World region-specific birth-weight curves seemed to be more appropriate than a single Canadian population-based curve for assessing the risk of adverse neonatal and obstetric outcomes among small- and large-for-gestational-age infants born to immigrant women, especially those from the East and South Asian regions.

Paternal and maternal concerns for their very low-birth-weight infants transitioning from the NICU to home

This study examines qualitatively the concerns and coping mechanisms of fathers and mothers of very low-birth-weight (VLBW; <1500 g) neonatal intensive care unit (NICU) infants as they transition to home from the NICU. In-depth, semistructured phone interviews were conducted with a sample of fathers and mothers of VLBW NICU infants in the Chicago area who had transitioned home, and parental concerns were examined during the transition to home. Phone interviews lasting 30 to 60 minutes were transcribed verbatim, and all interviews were coded using content and narrative analysis. Twenty-five parents (10 fathers, 15 mothers) of 16 VLBW infants who had an average gestational age of 29.5 weeks and an average NICU stay of 58.38 days completed the interview. Overriding concerns included pervasive uncertainty, lingering medical concerns, and partner-related adjustment concerns that differed by gender. A variety of resilient coping methods during this stressful transition are also described. Fathers and mothers of VLBW NICU graduates have evolving but often differing concerns as they transition from the NICU to home. Many of these concerns can be addressed with improved discharge information exchanges and anticipatory guidance. Supporting parents during this stressful and often difficult transition may lead to decreased family stress, improved care, and better infant outcomes.

Existential meaning among first-time full-term and preterm mothers: a questionnaire study

Research indicates that childbirth is a time when a woman might experience existential disruptions and gain new perspectives on life. The 2-fold aim of this study was to investigate whether attitudes related to existential meaning among first-time mothers intensify and whether they differ between mothers who gave birth at full term and those who gave birth preterm. All first-time mothers who gave birth in Denmark in 2010 before the 32nd week of pregnancy and twice that number of full-term mothers (randomly sampled) were invited to participate in a national cross-sectional survey. Five core items concerning meaning in life, vulnerability of life, responsibility, thoughts about life and death, and "something bigger than oneself" were analyzed to compare mothers' attitudes on existential meaning. The overall response rate was 57% (517/913). Contrary to the hypothesis, attitudes related to existential meaning intensified to the same degree among mothers of full-term and preterm infants, with no statistically significant differences in terms of age, marital status, educational level, or birth method. Danish first-time mothers' attitudes related to existential meaning measured in 5 core items were intensified and almost similar, regardless of whether they gave birth full-term or preterm.

Infants of borderline viability: the ethics of delivery room care

For more than half a century neonatologists and ethicists alike have struggled with ethical dilemmas surrounding infants born at the limits of viability. Both doctors and parents face difficult decisions. Do we try to save these babies, knowing that such efforts are likely to be unsuccessful? Or do we provide only comfort care, knowing that, in doing so, you will inevitably allow some babies to die who might have been saved? In this paper, we review the outcome data on these babies and offer ten suggestions for doctors: (1) accept that there is a 'gray zone' during which decisions are not black and white; (2) do not place too much emphasis on gestational age; (3) dying is generally not in an infant's best interest; (4) impairment does not necessarily equal poor quality of life; (5) just because the train has left the station doesn't mean you can't get off; (6) respect powerful emotions; (7) be aware of the self-fulfilling prophecies; (8) time lag likely skews all outcome data; (9) statistics can be both confused and confusing; (10) never abandon parents.

Perinatal risk factors and mode of delivery associated with mortality in very low birth weight infants

OBJECTIVE

To investigate the association of perinatal risk factors including delivery mode with mortality in very low birthweight (VLBW) in a tertiary hospital setting.

METHODS

Medical records of 241 live-born VLBW infants (≤1500 g) were retrospectively reviewed. Details of maternal, obstetrical, perinatal risk factors and their associations with infant mortality were evaluated.

RESULTS

The overall infant mortality rate was 23.2%. Mortality was significantly higher for infants born at ≤27 gestational weeks and with a birthweight of ≤750 g (p = 0.000 and p = 0.000, respectively), showing a steep decrease thereafter. On ROC analysis, a cut off of 26.5 weeks was determined for mortality with a sensitivity of 57.1% and a specificity of 90.3% (area under the curve = 0.792, 95% CI: 0.719-0.866). On multivariate regression analysis, gestational week at birth, birthweight, antenatal steroid treatment and pathologic Doppler ultrasound findings were found as independent risk factors for mortality.

CONCLUSIONS

Gestational week at birth, birthweight and antenatal steroid treatment remain the most important perinatal risk factors for infant mortality in VLBW infants. Mode of delivery does not seem to be associated with mortality when adjusted for other perinatal risk factors.

Depression and anxiety symptoms in mothers of newborns hospitalized on the neonatal intensive care unit

BACKGROUND

Mothers of infants hospitalized in the neonatal intensive care unit (NICU) are at risk for clinically significant levels of depression and anxiety symptoms; however, the maternal/infant characteristics that predict risk have been difficult to determine. Previous studies have conceptualized depression and anxiety symptoms separately, ignoring their comorbidity. Moreover, risk factors for these symptoms have not been assessed together in one study sample.

OBJECTIVES

The primary aim of this study was to determine whether a diagnostic classification approach or a common factor model better explained the pattern of symptoms reported by NICU mothers, including depression, generalized anxiety, panic, and trauma. A secondary aim was to assess risk factors of aversive emotional states in NICU mothers based on the supported conceptual model.

METHOD

In this cross-sectional study, a nonprobability convenience sample of 200 NICU mothers completed questionnaires assessing maternal demographic and infant health characteristics, as well as maternal depression and anxiety symptoms. Structural equation modeling was used to test a diagnostic classification model and a common factor model of aversive emotional states and the risk factors of aversive emotional states in mothers in the NICU.

RESULTS

Maximum likelihood estimates indicated that examining symptoms of depression and anxiety disorders as separate diagnostic classifications did not fit the data well, whereas examining the common factor of negative emotionality rendered an adequate fit to the data and identified a history of depression, infant illness, and infant prematurity as significant risk factors.

DISCUSSION

This study supports a multidimensional view of depression and should guide both clinical practice and future research with NICU mothers.

Emotional reactions of mothers facing premature births: study of 100 mother-infant dyads 32 gestational weeks

OBJECTIVES

This current study has been conducted to clarify the relationship between the mother's post-traumatic reaction triggered by premature birth and the mother-infant interactions. In this article, the precocious maternal feelings are described.

METHODS

A multicenter prospective study was performed in three French hospitals. 100 dyads with 100 very premature infants and their mothers were recruited. Mothers completed, at two different times self-questionnaires of depression/anxiety, trauma and social support. The quality of interactions in the dyads was evaluated.

RESULTS

Thirty-nine percent of the mothers obtained a score at HADS suggesting a high risk of depression at the first visit and approximately one-third at visit two. Seventy-five percent of the mothers were at risk of suffering from an anxiety disorder at visit one and half remained so at visit two. A "depressed" score at visits one and two correlated with a hospitalization for a threatened premature labor. We noted a high risk of trauma for 35% of the mothers and high interactional synchrony was observed for approximately two-thirds of the dyads. The mothers' psychological reactions such as depression and anxiety or postnatal depression correlate strongly with the presence of an initial trauma. At visit one and visit two, a high score of satisfaction concerning social support correlates negatively with presence of a trauma. A maternal risk of trauma is more frequent with a C-section delivery.

CONCLUSIONS

Mothers' psychological reactions such as depression and anxiety correlate greatly with the presence of an initial trauma. The maternal traumatic reaction linked to premature birth does not correlate with the term at birth, but rather with the weight of the baby. Social support perceived by the mother is correlated with the absence of maternal trauma before returning home, and also seems to inhibit from depressive symptoms from the time of the infant's premature birth.

Learning disability in 10- to 16-year-old adolescents with very low birth weight in Japan

In recent years, there has been an increase in the number of infants with very low birth weight (VLBW, i.e., weight less than 1,500 g) in Japan. However, the effect of VLBW on subsequent behavioral development and mental health remains unknown. Subjects enrolled were 57 individuals (13.4 ± 1.9 years old) with VLBW (VLBW group), including 23 small-for-gestational-age (SGA) infants (i.e., the SGA/VLBW group) and 34 appropriate-for-gestational-age (AGA) infants (the AGA/VLBW group). The control group was 29 individuals born AGA at term. We used the questionnaires, the Pupil Rating Scale Revised (PRS) to screen for learning disabilities and the Children's Depression Inventory (CDI) to examine the presence of depression. The PRS score in the VLBW group was significantly lower than that of the control group (p < 0.001). Suspected learning disabilities (LD, defined by a score below 65 points on the PRS) were found in 6 out of the 56 subjects in the VLBW group (10.7%), whereas none were found in the 29 control subjects (p = 0.074). The frequency of suspected LD children was higher in the SGA/VLBW group (4 out of 22 evaluated infants, 18.2%) than that in the AGA/VLBW group (2/34, 5.9%). The frequency of suspected LD in the non-verbal field was significantly higher (p = 0.02) in the SGA/VLBW group (18.2%) than in the AGA/VLBW group (0%). However, CDI score did not significantly differ between groups. These findings suggest that VLBW and fetal growth restriction may pose a risk for LD among adolescents with VLBW.

Mother-child interactions in the NICU: relevance and implications for later parenting

OBJECTIVE

This study examined the feasibility of observing mother-child interactions in the neonatal intensive care unit (NICU), whether NICU interactions related to later interactions, and how interactions related to child and maternal characteristics.

METHODS

The sample included 130 preterm infants and their mothers, observed in a feeding interaction in the NICU. Dyads were observed through 36 months postterm.

RESULTS

Observed maternal positive affective involvement and verbalizations in the NICU were associated with the same parenting behaviors at 24 months, social support, socioeconomic status, and being born in the late preterm period. Maternal negative affect and behavior were unrelated to later maternal negativity or child and maternal characteristics.

CONCLUSIONS

Positive parenting assessed in the NICU appears related to later parenting interaction quality, suggesting early assessment is possible. Maternal negative affect and behavior toward children may not consistently emerge until later in development.

Mental health in women experiencing preterm birth

Background

The aim of the study was to explore the degree of psychological distress, anxiety, and trauma related stress reactions in mothers who experience preterm birth. Secondarily, we wanted to identify possible predictors of maternal mental health problems.

Methods

Twenty-nine mothers of 35 premature children born before 33rd week of pregnancy were assessed within two weeks after given birth. The standardized psychometric methods; Impact of Event Scale (IES), General Health Questionnaire (GHQ) and State Anxiety Inventory (STAI) assessed mental health problems. The predictors for maternal distress, anxiety, and trauma related stress reactions were pregnancy variables, preterm delivery, Gestation Age, maternal trait anxiety and parity. In addition, maternal prevalence of mental health problems was assessed by clinical diagnoses.

Results

Our study revealed a high prevalence (52%) of posttraumatic stress responses in the mothers.

Conclusions

Our results suggest an early examination of mothers’ psychological reactions to preterm birth at the maternity ward. An early intervention should be considered while the child still is in the neonatal intensive care unit.

Stress levels and depressive symptoms in NICU mothers in the early postpartum period

OBJECTIVE

This study examined whether particular maternal and infant factors can identify mothers at risk for increased stress upon admission to the neonatal intensive care unit (NICU).

METHODS

Eighty-five mothers of preterm infants (25-34 weeks gestation) were assessed using the Parental Stressor Scale (PSS:NICU) and the Edinburgh Postnatal Depression Scale (EPDS) within 3.24 ± 1.58 d postpartum. Hierarchical linear regression models were used to determine the extent to which maternal stress is influenced by individual factors.

RESULTS

Fifty-two percent of mothers experienced increased stress (PSS:NICU score ≥3) and 38% had significant depressive symptoms (EPDS score ≥10). Stress related to alterations in parental role was the most significant source of stress among NICU mothers. Distance from the hospital and married marital status were significant predictors for stress related to alterations in parental role (p = 0.003) and NICU sights and sounds (p = 0.01), respectively. Higher stress levels were associated with higher depressive scores (p = 0.001). Maternal mental health factors, demographic factors, pregnancy factors and infant characteristics were not associated with increased stress.

CONCLUSION

Elevated stress levels and depressive symptoms are already present in mothers of preterm infants upon NICU admission. Being married or living long distance from the hospital is associated with higher stress. Future work is needed to develop effective interventions for alleviating stress in NICU mothers and preventing its potential development into postnatal depression.

Parents' experiences of their premature infants' transportation from a university hospital NICU to the NICU at two local hospitals

The aim of this study was to describe how the parents of premature infants experience the transportation of their baby from the neonatal intensive care unit at a university hospital (NICU-U) to such a unit at a local hospital (NICU-L). This descriptive qualitative study comprises interviews with nine sets of parents and two mothers. The qualitative content analysis resulted in one theme: living in uncertainty about whether the baby will survive, and three categories: being distanced from the baby; fearing that something would happen to the baby during transportation; and experiencing closeness to the baby. The results also revealed that the parents experienced developmental, situational and health-illness transitions.

Very preterm birth: maternal experiences of the neonatal intensive care environment

OBJECTIVE

Examine sources, predictors and child outcomes associated with neonatal intensive care unit (NICU)-related stress for mothers of infants born very preterm (VPT).

STUDY DESIGN

Participants were 133 mothers of VPT infants admitted to a regional level-III NICU. At term equivalent, mothers completed the Parental Stressor Scale: NICU and were interviewed about their psychological well-being and family circumstances. Infant clinical data were also collected. At corrected age 4 years, 49 children were assessed for cognition, language and socio-emotional development.

RESULT

Mothers reported moderate to low stress, with parental role alteration considered most stressful and parent-staff communications least stressful. Predictors of overall stress included maternal educational underachievement, stressful life events, postnatal depression and infant unsettled-irregular behavior. NICU-related stress was associated with child anxiety and poorer language development.

CONCLUSION

Parental well-being is an important focus of care in the neonatal setting. Strategies are needed to optimize early engagement and reduce stress levels to assist improved child outcomes.

Parenting stress in families with very low birth weight preterm infants in early infancy

Taking care of a premature infant adds an extra burden to already stressed parents. Previous studies have shown that parental stress occurs during the initial hospitalization. However, there is little information on parental stress over time, and the few existing results are conflicting. In addition, many studies have focused on maternal stress but there is little information about a father's long-term adaptation to stress. The purpose of this study was to examine the degree and type of parenting stress in the families of very low birth weight (VLBW) preterm infants over the first two years of life. We compared parenting stress in families with preterm infants with control families, while also comparing the stress in mothers to that in fathers. Furthermore, we explored the relationship between parenting stress in the preterm group with identified factors that included the infant's age, medical complications, and parents' perceived feeding issues after they had been discharged from the hospital. This was an exploratory study with a cross sectional design. Participants included a total of 505 mothers from Tainan, Taiwan; 297 with preterm children (239 mothers, 58 fathers) and 208 with full-term children (181 mothers, 27 fathers). Assessments including the Parenting Stress Index, Neonatal Medical Index and Behavior-based Feeding Questionnaire were used to measure parental distress, infants' medical complications and parents' perceived feeding issues, respectively. Results of the study, though not statistically significant, indicated the presence of increased parenting stress in parents of preterm infants as compared to parents of full-term infants. 13.1% of mothers with preterm infants demonstrated total stress levels that warranted clinical intervention. We also found that mothers of preterm infants presented different parenting stress patterns than fathers of preterm infants. Fathers of preterm infants tended to have overall higher stress scores than mothers. On the other hand, mothers of preterm infants tended to report more health related difficulties, more depression, higher social isolation and role restriction, and less support from their spouses, than reported by fathers. Moreover, as time went on, parents with preterm infants continued to experience greater parenting stress than those with full-term infants. Understanding the experiences of parents with preterm children is important for health care providers while interviewing parents for information regarding their children and designing intervention programs to improve children's outcomes.

Very low birth weight and perinatal periods of risk: disparities in St. Louis

Objective. Very low birth weight (VLBW) is a significant issue in St. Louis, Missouri. Our study evaluated risk factors associated with VLBW in this predominantly urban community. Methods. From 2000 to 2009, birth and fetal death certificates were evaluated (n = 160, 189), and mortality rates were calculated for perinatal periods of risk. The Kitagawa method was used to explore fetoinfant mortality rates (FIMR) in terms of birth weight distribution and birthweight specific mortality. Multivariable logistic regression was used to assess the magnitude of association of selected risk factors with VLBW. Results. VLBW contributes to 50% of the excess FIMR in St. Louis City and County. The highest proportion of VLBW can be attributed to black maternal race (40.6%) in St. Louis City, inadequate prenatal care (19.8%), and gestational hypertension (12.0%) among black women. Medicaid was found to have a protective effect for VLBW among black women (population attributable risk (PAR) = −14.5). Discussion. Interventions targeting the health of women before and during conception may be most successful at reducing the disparities in VLBW in this population. Interventions geared towards smoking cessation and improvements in Medicaid and prenatal care access for black mothers and St. Louis City residents can greatly reduce VLBW rates.

Mental health related determinants of parenting stress among urban mothers of young children--results from a birth-cohort study in Ghana and Côte d'Ivoire

BACKGROUND

There are limited data on the parenting stress (PS) levels in sub-Saharan African mothers and on the association between ante- and postnatal depression and anxiety on PS.

METHODS

A longitudinal birth cohort of 577 women from Ghana and Côte d'Ivoire was followed from the 3rd trimester in pregnancy to 2 years postpartum between 2010 and 2013. Depression and anxiety were assessed by the Patient Health Questionnaire depression module (PHQ-9) and the Generalized Anxiety Disorder (GAD-7) at baseline, 3 month, 12 month and 24 month postpartum. PS was measured using the Parenting Stress Index-Short Form (PSI-SF) at 3, 12 and 24 month. The mean total PS score and the subscale scores were compared among depressed vs. non-depressed and among anxious vs. non-anxious mothers at 3, 12 and 24 month postpartum. The proportions of clinical PS (PSI-SF raw score > 90) in depressed vs. non-depressed and anxious vs. non-anxious mothers were also compared. A generalized estimating equation (GEE) approach was used to estimate population-averaged associations between women's depression/anxiety and PS adjusting for age, child sex, women's anemia, education, occupation, spouse's education, and number of sick child visits.

RESULTS

A total of 577, 531 and 264 women completed the PS assessment at 3 month, 12 month and 24 month postpartum across the two sites and the prevalences of clinical PS at each time point was 33.1%, 24.4% and 14.9% in Ghana and 30.2%, 33.5% and 22.6% in Côte d'Ivoire, respectively. At all three time points, the PS scores were significantly higher among depressed mothers vs. non-depressed mothers. In the multivariate regression analyses, antepartum and postpartum depression were consistently associated with PS after adjusting for other variables.

CONCLUSIONS

Parenting stress is frequent and levels are high compared with previous studies from high-income countries. Antepartum and postpartum depression were both associated with PS, while antepartum and postpartum anxiety were not after adjusting for confounders. More quantitative and qualitative data are needed in sub-Saharan African populations to assess the burden of PS and understand associated mechanisms. Should our findings be replicated, it appears prudent to design and subsequently evaluate intervention strategies.

Maternal Concepts and Expectations regarding a Preterm Infant

The objective of the present study was: (a) to identify the concerns, verbally expressed, of 50 mothers regarding their preterm infants (PT) and then compare their verbal expression with those of 25 mothers of full-term infants (FT); and (b) to correlate the mothers' verbal expressions with maternal and infant variables. The following instruments were used to compose and characterize the sample: Structure Clinical Interview for DSM III-R Non-Patient (SCID/NP), State-Trait Anxiety Inventory (STAI), Beck Depression Inventory (BDI), and medical charts. Results showed that there was no difference between groups in term of mothers' expectations and conceptualizations; both groups exhibited predominantly positive expectations and concepts. In comparison with FT mothers, PT mothers verbally expressed more feelings and reactions predominantly negative or conflicting in relation to infant birth. Higher levels of maternal anxiety and depression in the PT Group were correlated with more verbal expressions about negative or conflicting emotions. In addition, lower birth weight, higher neonatal risk and longer length of stay in intensive care nursery of the infants were related with more negative or conflicting concepts by the mothers.

Parent and family outcomes following very preterm or very low birth weight birth: a review

Parents and the family environment have a pronounced influence on child development. For children at increased risk such as those born very preterm (VPT) or with very low birth weight (VLBW), parent and family functioning can influence the child's level of risk or resilience. This review describes parent and family outcomes after VPT/VLBW birth, specifically parental mental health, parenting stress and the impact of the child on the family. Factors associated with these outcomes are examined, as well as the specific outcomes for fathers. Overall the influence of VPT/VLBW birth on parents and the family appears to be more pronounced in early childhood, with less influence seen by the time of adolescence. Emerging evidence suggests that fathers experience high rates of psychological distress in the first months after VPT birth. Whereas characteristics of the VPT/VLBW child are strongly associated with parent and family outcomes, parent and social factors are also important influences.

Associations between parental psychological well-being and socio-emotional development in 5-year-old preterm children

BACKGROUND

Preterm children are at risk for developing behavioral and emotional problems, as well as being less socially competent. Premature birth causes chronic distress in the parents.

AIMS

The aim of the paper is to discover whether parental psychological well-being is associated with the social, behavioral, and functional development of very low birth weight (VLBW, ≤1500g) children at 5years of age.

STUDY DESIGN

A longitudinal prospective cohort study.

SUBJECTS

A cohort of 201 VLBW infants (≤1500g, <37weeks of gestation) born during 2001-2006 in Turku University Hospital, Finland was studied.

OUTCOME MEASURES

At 4-year chronological age of their child, parents independently completed validated questionnaires (Beck Depression Inventory, Parenting Stress Index and Sense of Coherence Scale). At 5years, parents and day-care providers evaluated the development of the child by completing the Five to Fifteen questionnaire.

RESULTS

The parents of VLBW children reported significantly more problems in child development compared to the Finnish normative data. Depressive symptoms and weaker sense of coherence in mothers, but not in fathers, were associated with more problems in child development. Parenting stress, for both mothers and fathers, was associated with developmental problems in their child at 5years of age.

CONCLUSIONS

Maternal depressive symptoms and parenting stress of both parents may be risk factors for the social, behavioral, and functional development of 5-year-old preterm children. On the other hand, stronger maternal sense of coherence may be a protective factor.

Screening for symptoms of postpartum traumatic stress in a sample of mothers with preterm infants

There are no established screening criteria to help identify mothers of premature infants who are at risk for symptoms of emotional distress. The current study, using data obtained from recruitment and screening in preparation for a randomized controlled trial, aimed to identify potential risk factors associated with symptoms of depression, anxiety and posttraumatic stress in a sample of mothers with premature infants hospitalized in a neonatal intensive care unit. One hundred, thirty-five mothers of preterm infants born at 26-34 weeks of gestation completed three self-report measures: the Stanford Acute Stress Reaction Questionnaire, the Beck Depression Inventory (2nd ed.), and the Beck Anxiety Inventory to determine their eligibility for inclusion in a treatment intervention study based on clinical cut-off scores for each measure. Maternal sociodemographic measures, including race, ethnicity, age, maternal pregnancy history, and measures of infant medical severity were not helpful in differentiating mothers who screened positive on one or more of the measures from those who screened negative. Programs to screen parents of premature infants for the presence of symptoms of posttraumatic stress, anxiety, and depression will need to adopt universal screening rather than profiling of potential high risk parents based on their sociodemographic characteristics or measures of their infant's medical severity.

Very preterm birth influences parental mental health and family outcomes seven years after birth

OBJECTIVE

To evaluate the long-term influence of very preterm birth on parental mental health, family functioning, and parenting stress at age 2 and 7 years.

STUDY DESIGN

Participants were 183 children born very preterm (<30 weeks gestation; n = 148 families) and 69 term-born children (n = 66 families). When children were age 7 years, parents were assessed based on the Hospital Anxiety and Depression Scale, the Family Assessment Device, the Parenting Stress Index, and the Social Support Questionnaire. Similar measures were evaluated at age 2 years.

RESULTS

When the children were age 7 years, parents of the very preterm-born children were more likely to report moderate to severe anxiety symptoms (P = .03), higher levels of depression symptoms (P = .03), poorer family functioning (P < .05), and higher levels of parenting stress (P < .001) compared with parents of the children born at term. Group differences in parenting stress and family functioning persisted after adjustment for social risk and child neurodevelopmental disability. There was strong evidence of a relationship between family functioning and parent-related stress at age 2 and 7 years (P < .001), but little evidence that parental mental health problems at 2 years were predictive of anxiety (P = .15) or depression (P = .28) at 7 years for parents of very preterm children.

CONCLUSION

These findings demonstrate that very preterm birth has a negative influence on parent and family functioning at 7 years after birth, which for some families is consistent with their functioning at 2 years. These results have implications for the support required by parents of very preterm children.

Biocompatibility of a sonicated silk gel for cervical injection during pregnancy: in vivo and in vitro study

OBJECTIVE

To evaluate the biocompatibility of silk gel for cervical injection.

STUDY DESIGN

Silk gel was injected into the cervix of pregnant rats on day 13 (n = 11) and harvested at day 17. Histology of silk gel was compared with suture controls. Also, human cervical fibroblasts were cultured on silk gel and tissue culture plastic (TCP) in vitro. Cell viability, proliferation, metabolic activity, gene expression (COL1A1, COL3A1, and COX2), and release of proinflammatory mediators (interleukin [IL] 6 and IL-8) were evaluated.

RESULTS

In vivo, a mild foreign body response was seen surrounding the silk gel and suture controls. In vitro, cervical fibroblasts were viable, metabolically active, and proliferating at 72 hours. Release of IL-6 and IL-8 was similar on silk gel and TCP. Collagen and COX2 gene expression was similar or slightly decreased compared with TCP.

CONCLUSIONS

Silk gel was well tolerated in vivo and in vitro, which supports continuing efforts to develop silk gels as an alternative to cervical cerclage.

Preterm infant's early crying associated with child's behavioral problems and parents' stress

OBJECTIVE

To study how the early crying behavior of preterm infants at term, 6 weeks, and 5 months of corrected age is related to later behavioral problems at age 3 and 4 years and parenting stress at 2 and 4 years.

METHODS

The study group included 202 live-born, low birth weight infants (birth weight ≤1500 g) born from January 2001 through December 2006 at the Turku University Hospital, Finland. A Baby Day Diary was used to assess the preterm infants' crying behavior at term, 6 weeks, and 5 months of corrected age. The children's behavior was assessed using the Child Behavior Check List at 3 and 4 years old, and parenting stress was assessed by using the Parenting Stress Index when the child was 2 and 4 years old.

RESULTS

The duration and frequency of crying bouts in infancy was associated with Child Behavior Check List scores at 4 years old and to both mothers' and fathers' stress when the child was 2 and 4 years old.

CONCLUSIONS

Early excessive crying, especially if lasting up to 5 months of corrected age, is a clinically relevant signal in preterm infants because it may reflect infants' regulatory problems and/or parenting stress. The crying behavior of preterm infants should be systematically inquired about at well-baby clinics.

Outcomes following periviable birth

This review is presented in three segments: (1) important background concepts, (2) recent reports from regional geographically defined cohorts, and (3) prognosis research from the National Institutes of Health Neonatal Research Network. Extending the use of intensive care to newborns of lower gestational ages will unavoidably result in a higher proportion and a higher absolute number of survivors with morbidity, unless other changes in practice offset the increased risk associated with decreasing gestational age. In geographically defined cohort studies, the proportion of periviable newborns delivered in perinatal centers and the practices around foregoing and withdrawing intensive care are two important determinants of outcomes following periviable birth. It is much easier to quantify the effect of the former than the latter. Decisions regarding comfort care vs. intensive are frequently based on gestational age as the sole predictor variable, although multiple factors can be readily used to more accurately assess the benefits and burdens of intensive care and facilitate better informed parental counseling and decision making.