Power and Efficacy of Maternal Voice in Neonatal Intensive Care Units: Implicit Bias and Family-Centered Care

Implicit Bias and Health Disparities Education in the Neonatal Intensive Care Unit

OBJECTIVE

 This study aimed to characterize implicit bias (IB) and health disparities (HD) education in neonatal-perinatal medicine (NPM), including current educational opportunities, resources, and barriers.

STUDY DESIGN

 A national web-based survey was sent to NPM fellows, neonatologists, and frontline providers after iterative review by education experts from the National Neonatology Curriculum Committee. Quantitative data were analyzed with chi-square and Fisher's exact tests. Qualitative data were evaluated using thematic analysis.

RESULTS

 Of the 452 NPM survey respondents, most desired additional IB (76%) and HD (83%) education. A greater proportion of neonatologists than fellows received IB (83 vs. 57%) and HD (87 vs. 74%) education. Only 41% of neonatologists reported that their institution requires IB training. A greater proportion of fellows than neonatologists expressed dissatisfaction with the current approaches for IB (51 vs. 25%, p < 0.001) and HD (43 vs. 25%, p = 0.015) education. The leading drivers of dissatisfaction included insufficient time spent on the topics, lack of specificity to NPM, inadequate curricular scope or depth, and lack of local educator expertise. A minority of faculty who were tasked to educate others have received specific educator training on IB (21%) and HD (16%). Thematic analysis of survey free-text responses identified three main themes on the facilitators and barriers to successful IB and HD education: individual, environmental, and curricular design variables.

CONCLUSION

 NPM trainees and neonatologists desire tailored, active, and expert-guided IB and HD education. Identified barriers are important to address in developing an effective IB/HD curriculum for the NPM community.

KEY POINTS

· There is a gap between the current delivery of IB/HD education and the needs of the NPM community.. · NPM trainees and neonatologists desire tailored, active, and expert-guided IB and HD education.. · A successful curriculum should be widely accessible, NPM-specific, and include facilitator training..

Parent and grandparent neonatal intensive care unit visitation for preterm infants

OBJECTIVE

Characterize family NICU visitation and examine associations with maternal health and social factors and infant health outcomes.

STUDY DESIGN

Retrospective cohort study of 167 infants born ≤32 weeks at two urban NICUs 01/2019-03/2020. Average nurse-documented family member visitation and associations of visitation with maternal and infant factors and outcomes were compared.

RESULTS

Mothers visited 4.4 days/week, fathers 2.6 days/week, and grandparents 0.4 days/week. Older maternal age, nulliparity, and non-English primary language were associated with more frequent family visitation. Mothers with depression or anxiety history visited less. Maternal depression and public insurance were associated with fewer father visits. Low parental visitation was associated with lower odds of feeding any maternal milk at discharge and low maternal visitation with 11.5% fewer completed infant subspecialty appointments in the year following discharge (95% CI -20.0%, -3.0%).

CONCLUSION

Families with social disadvantage visited less often. Parental visitation was associated with infant feeding and follow-up.

Disparities in the Diagnosis and Management of Infants Hospitalized With Inadequate Weight Gain

OBJECTIVES

To evaluate the association between race and the named etiology for inadequate weight gain among hospitalized infants and assess the differences in management.

METHODS

This single-center retrospective cohort study of infants hospitalized for the workup and management of inadequate weight gain used infant race and neighborhood-level socioeconomic deprivation as exposures. The etiology of inadequate weight gain was categorized as nonorganic, subjective organic (ie, gastroesophageal reflux and cow's milk protein intolerance), or objective organic (eg, hypothyroidism). The management of inadequate weight gain was examined in secondary outcomes.

RESULTS

Among 380 infants, most were white and had a nonorganic etiology of inadequate weight gain. Black infants had 2.3 times higher unadjusted odds (95% credible interval [CI] 1.17-4.76) of a nonorganic etiology of inadequate weight gain compared with white infants. After adjustment, there was no association between race and etiology (adjusted odds ratio 0.8, 95% CI [0.44-2.08]); however, each 0.1 increase in neighborhood-level deprivation was associated with 80% increased adjusted odds of a nonorganic etiology of inadequate weight gain (95% CI [1.37-2.4]). Infants with a nonorganic etiology of inadequate weight gain were more likely to have social work and child protective service involvement and less likely to have nasogastric tube placement, gastroenterology consults, and speech therapy consults.

CONCLUSIONS

Infants from neighborhoods with greater socioeconomic deprivation were more likely to have nonorganic causes of inadequate weight gain, disproportionately affecting infants of Black race. A nonorganic etiology was associated with a higher likelihood of social interventions and a lower likelihood of medical interventions.

Effects of recorded maternal voice on anthropometric parameters and heart rate in premature infants: A pilot randomised controlled trial

PURPOSE

To explore the benefits of a recorded maternal voice intervention on weight, recumbent length, head circumference, and heart rate of preterm infants in the neonatal intensive care unit.

METHODS

A pilot randomised controlled trial was conducted in this study. Preterm infants in the neonatal intensive care unit (N = 109) were recruited and randomly assigned to an intervention or control group. Both groups received routine nursing care, while preterm infants in the intervention group received a recorded maternal voice program of 20 min, twice daily for 21 days. Preterm infants' daily weight, recumbent length, head circumference, and heart rate were collected during the 21-day intervention. Participants' heart rate in the intervention group was also recorded once a day pre-during-after the recorded maternal voice program.

RESULTS

Preterm infants in the intervention group showed a significant increase in weight (-75.94, 95% CI -108.04, -43.85, P < 0.001), recumbent length (-0.54, 95% CI -0.76, -0.32, P < 0.001), and head circumference (-0.37, 95%CI -0.56, -0.18, P < 0.001) compared with the control group. Preterm infants in the intervention group also showed significant changes in heart rate pre-during-after the recorded maternal voice program. However, no significant differences were found in the heart rate scores between the two groups.

DISCUSSION

The changes in heart rate pre-during-after the intervention may help explain participants' more significant increase in weight, recumbent length, and head circumference.

PRACTICE IMPLICATIONS

The recorded maternal voice intervention could be incorporated into clinical practice to promote growth and development in preterm infants in the neonatal intensive care unit.

STUDY REGISTRATION

Australian New Zealand Clinical Trials Register, https://www.anzctr.org.au/; (registration number: ACTRN12622000019707).

Maternal voice reduces procedural pain in neonates: A meta-analysis of randomized controlled trials

BACKGROUND

Procedural pain management is a very important part in the clinical care of neonates. We aimed to conduct a meta-analysis to evaluate the effects of maternal voice on neonatal procedural pain, to provide insights to the clinical pain care of neonates.

METHODS

Two researchers independently searched PubMed, EMBASE, The Cochrane Library, CINAHL, Web of Science, China Biomedical Literature Database, China National Knowledge Infrastructure, Wanfang and Weipu Database for randomized controlled trials (RCTs) involving the effects of maternal voice on the procedural pain of neonates up to October 25, 2022. Two investigators screened the literature based on the inclusion and exclusion criteria and evaluated the methodological quality of the inclusion study. RevMan 5.3 software was used for the meta-analysis.

RESULTS

A total of 8 RCTs with a total of 584 neonates were included. Our meta-analysis indicated that maternal voice reduces the pain score (SMD = -0.60, 95% CI: -0.81 to -0.39) and heart rate (SMD = -0.81, 95% CI: -1.44 to -0.18) and increases the comfort level (SMD = -0.47, 95% CI: -0.83 to -0.11) and blood oxygen saturation (SMD = 0.70, 95% CI: 0.03-1.38) during procedure (all P < .05). Moreover, maternal voice reduces the pain score (SMD = -0.58, 95% CI: -0.88 to -0.28) and heart rate (SMD = -0.44, 95% CI: -0.75 to -0.12) and increases the blood oxygen saturation (SMD = 0.41, 95% CI: 0.00 to -0.82) after procedure (all P < .05). No publication biases were detected by the funnel plots and Egger tests (all P > .05).

CONCLUSION

Maternal voice is beneficial to reduce procedural pain and improve the physiological indicators in neonates. It is still necessary to conduct high-quality, large sample studies in the future to further elucidate the effect of maternal voice on neonatal pain care.

Association of Racial Disparities With In-Hospital Outcomes in Severe Bronchopulmonary Dysplasia

IMPORTANCE

Bronchopulmonary dysplasia (BPD) is the most common serious morbidity of preterm birth. Short-term respiratory outcomes for infants with the most severe forms of BPD are highly variable. The mechanisms that explain this variability remain unknown and may be mediated by racial disparities.

OBJECTIVE

To determine the association of maternal race with death and length of hospital stay in a multicenter cohort of infants with severe BPD.

DESIGN, SETTING, AND PARTICIPANTS

This multicenter cohort study included preterm infants enrolled in the BPD Collaborative registry from January 1, 2015, to July 19, 2021, involving 8 BPD Collaborative centers located in the US. Included patients were born at less than 32 weeks' gestation, had a diagnosis of severe BPD as defined by the 2001 National Institutes of Health Consensus Criteria, and were born to Black or White mothers.

EXPOSURES

Maternal race: Black vs White.

MAIN OUTCOMES AND MEASURES

Death and length of hospital stay.

RESULTS

Among 834 registry infants (median [IQR] gestational age, 25 [24-27] weeks; 492 male infants [59%]) meeting inclusion criteria, the majority were born to White mothers (558 [67%]). Death was observed infrequently in the study cohort (32 [4%]), but Black maternal race was associated with an increased odds of death (adjusted odds ratio, 2.1; 95% CI, 1.2-3.5) after adjusting for center. Black maternal race was also significantly associated with length of hospital stay (adjusted between-group difference, 10 days; 95% CI, 3-17 days).

CONCLUSIONS AND RELEVANCE

In a multicenter severe BPD cohort, study results suggest that infants born to Black mothers had increased likelihood of death and increased length of hospital stay compared with infants born to White mothers. Prospective studies are needed to define the sociodemographic mechanisms underlying disparate health outcomes for Black infants with severe BPD.

Disparities and Early Engagement Associated with the 18- to 36-Month High-Risk Infant Follow-Up Visit among Very Low Birthweight Infants in California

OBJECTIVE

To determine follow-up rates for the high-risk infant follow-up (HRIF) visit at 18-36 months among infants with very low birthweights and identify factors associated with completion.

STUDY DESIGN

We completed a retrospective cohort study using linked California Perinatal Quality of Care Collaborative neonatal intensive care unit, California Perinatal Quality of Care Collaborative California Children's Services HRIF, and Vital Statistics Birth Cohort databases. We identified maternal, sociodemographic, neonatal, clinical, and HRIF program level factors associated with the 18- to 36-month follow-up using multivariable Poisson regression.

RESULTS

From 2010 to 2015, among 19 284 infants with very low birthweight expected to attend at least 1 visit at 18-36 months, 10 249 (53%) attended. On multivariable analysis, factors independently associated with attendance at an 18- to 36-month visit included estimated gestational age (relative risk [RR], 1.21; 95% CI, 1.15-1.26; <26 weeks vs ≥31 weeks), maternal education (RR, 1.09; 95% CI, 1.06-1.12; college degree or more vs high school), distance from clinic (RR, 0.92; 95% CI, 0.89-0.97; fourth quartile vs first quartile), and Black non-Hispanic race vs White race (RR, 0.88; 95% CI, 0.84-0.92). However, completion of an initial HRIF visit within the first 12 months was the factor most strongly associated with completion of an 18- to 36-month visit (RR, 6.47; 95% CI, 5.91-7.08).

CONCLUSIONS

In a California very low birthweight cohort, maternal education, race, and distance from the clinic were associated with sustained HRIF participation, but attendance at a visit by 12 months was the most significantly associated factor. These findings highlight the importance of early engagement with all families to ensure equitable follow-through for children born preterm.