Structural Racism Operationalized via Adverse Social Events in a Single-Center Neonatal Intensive Care Unit

Reimagining Supportive Approaches at the Intersection of Mandatory Reporting Policies for the Mother-Infant Dyad Affected by Substance Use

BACKGROUND

As rates of substance use during pregnancy persist, the health and optimal development of infants with prenatal substance exposure remain a key priority. Nurses are tasked with identifying and reporting suspected cases of child maltreatment, including abuse and neglect, which is often assumed to be synonymous with substance use during pregnancy. While policies aimed at protecting infants from child abuse and neglect are well intentioned, literature regarding the short- and long-term social and legal implications of mandatory reporting policies is emerging.

PURPOSE

In this article, we explore the intersections between the condition of substance use in pregnancy and policies related to mandatory reporting.

METHODS

We provide an overview of historical and current trends in mandatory reporting policies for nurses related to substance use in pregnancy and related ethical and social implications for mother-infant dyads.

RESULTS

Nurses often function at the intersection of healthcare and social services, underscoring the important role they play in advocating for ethical and equitable care for both members of the mother-infant dyad affected by substance use.

IMPLICATIONS FOR PRACTICE AND RESEARCH

We offer recommendations for practice including the integration of respectful care and family-centered support for the mother-infant dyad affected by substance use. Cross-sectoral collaborations, inclusive of the family, are important to the advancement of evidence-based and equity-focused research, advocacy, and policy initiatives to support familial preservation and reduce mother-infant separation.

Social determinants of health and language outcomes in preterm infants with public and private insurance

OBJECTIVE

To evaluate associations of maternal social determinants of health (SDOH) with language outcomes of preterm infants with public and private insurance.

STUDY DESIGN

Single center study of 375 neonates born ≤ 28 weeks. Perinatal characteristics were collected, and the Bayley III was administered at 18-24 months. Primary outcome was language scores of <85. Bivariate and multivariable analyses were used to compare groups.

RESULTS

Mothers with public insurance had higher rates of psychosocial risk factors. In regression analysis, People of Color (aOR 2.4, 1.47-4.04), non-English speaking household (aOR 4.05, 1.47-11.15) and public insurance (aOR 2.03, 1.18-3.49) significantly increased the odds of having a language composite score of <85, whereas breast milk (aOR 0.47, 0.28-0.79) was protective.

CONCLUSIONS

Preterm infants with public insurance are at increased risk of exposure to multiple SDOH which are independently associated with language delay at 18-24 months.

The Ladder of Inference as a tool to reduce implicit bias in pediatric clinical practice

Implicit bias in healthcare professionals is a widespread phenomenon that leads to worse healthcare outcomes for marginalized patient populations. One tool that can help providers identify when biases are impacting the clinical care they are providing and enable them to take corrective action in real time is the "Ladder of Inference" (LOI). The LOI is an instrument that elucidates the process by which we take in information about another person, filter that data through our own interests, needs, perspectives and biases, and then use it to draw conclusions about the individual. These conclusions are often profoundly inaccurate, yet we then act upon them. Thus, we propose the LOI as an "implicit bias detection tool" for neonatal intensive care unit (NICU) clinical practice. We demonstrate on two common NICU cases how utilizing the LOI can uncover mechanisms by which positive and negative feedback loops secondary to unregulated implicit bias lead to a stepwise increase or decrease in the quality of care. As the cases demonstrate, the subtle differences in individual steps up the ladder can lead to care differences of a large magnitude in either direction, hugely positive or detrimentally negative. This shift in the quality of care, then, may contribute to the significant neonatal outcome disparities in infants from minoritized groups. Using the LOI as a practical tool, we demonstrate how it becomes possible to detect one's own implicit biases and thus to consciously monitor the inferences we are making about patients and their families in order to counteract them.

Equity, inclusion and cultural humility: contemporizing the neonatal intensive care unit family-centered care model

Existing NICU family centered care models lack the key elements of equity, inclusion and cultural humility. These models were conceived to support families during the stressful life event of an infant's NICU admission. Their development, however, occurred prior to recognition of the medical field's systematic shortcomings in providing equitable care and their impact on outcome disparities for marginalized communities; thus, they do not include cultural or equitable healthcare considerations. Given the significant neonatal care inequities for marginalized groups, incorporating the experience of these patients in a targeted manner into family centered care frameworks is of critical importance to ensure culturally humble and thus more just and equitable treatment. Here, we review past approaches to NICU family centered care and propose a novel, updated framework which integrates culturally humble care into the NICU family centered care framework.

Do dyadic interventions impact biomarkers of child health? A state-of-the-science narrative review

BACKGROUND

Early life adversity is related to numerous poor health outcomes in childhood; however, dyadic interventions that promote sensitive and responsive caregiving may protect children from the negative consequences of such exposures. To date, quasi-experimental and randomized controlled trials (RCTs) have examined the impact of dyadic interventions on a range of individual biomarkers in children, which may elucidate the relation between early stress exposure and transdiagnostic risk factors for prospective poor health. However, the content of interventions, analytic strategies, and findings vary widely across studies, obscuring key themes in the science and hindering policy and research efforts.

METHODS

We use a narrative approach to review findings from methodologically rigorous (predominantly RCT) studies of dyadic interventions' impacts on different biomarkers in children, including indicators of the hypothalamic-pituitary-adrenal (HPA) axis, parasympathetic (PNS) and sympathetic nervous systems (SNS), brain development, inflammation, and intracellular DNA processes. We contribute to this important area of inquiry through integrating findings across biological systems and identifying contextual and mechanistic factors to depict the current state of the field.

RESULTS

Evidence suggests dyadic interventions improved PNS functioning and advanced brain maturation. Some studies indicated interventions reduced hair cortisol concentrations, systemic inflammation, and resulted in differences in DNA methylation patterns. Findings did not support main effect-level change in salivary measures of HPA axis activity, SNS activity, or telomere length. Importantly, reviewed studies indicated significant heterogeneity in effects across biological systems, underscoring the importance of contextual factors (e.g., adversity subtype and severity) as potential moderators of effects. Further, findings suggested enhanced parenting behaviors may be a mechanism through which dyadic interventions operate on biomarkers.

CONCLUSIONS

We close with future policy and research directions, emphasizing the promise of biologically-informed dyadic interventions for understanding and ameliorating the effects of early adversity on transdiagnostic biomarkers of health.

Responding Effectively to Disruptive Patient Behaviors: Beyond Behavior Contracts

This Viewpoint discusses the use of behavior contracts with patients in response to increasing workplace violence in health care, and highlights the importance of building the evidence base for approaches to dealing with violent behaviors that are effective and just.