Developmental care, neonatal behavior and postnatal maternal depressive symptomatology predict internalizing problems at 18 months for very preterm children

Parental stress and mental health outcomes following very preterm birth: A systematic review of recent findings

BACKGROUND

In recent years, there has been a wide array of research studies published on parental mental health and stress following very preterm birth. This review aims at reviewing the prevalence and risk factors of long-term parental depression, anxiety, post-traumatic stress symptoms and parenting stress following very preterm birth.

METHODS

We searched PubMed, PsychINFO and Web of Science for descriptive, cross-sectional and longitudinal studies published between January 2013 and August 2022.

RESULTS

45 studies met our inclusion criteria. In the first two years, depression, anxiety, post-traumatic stress symptoms and parenting stress were present in ∼20 % of mothers of extreme and very low birth weight (E/VLBW) infants. Long-term psychological distress symptoms could be observed, although few studies have focused on symptoms into school age and longer. Fathers of VLBW infants might experience more psychological distress as well, however, they were only included in ten studies. We found that parental distress is more common when the co-parent is struggling with mental health symptoms. Many risk factors were identified such as social risk, history of mental illness, interpersonal factors (i.e. social support) and child-related factors (i.e. intraventricular hemorrhage, disability, use of medical equipment at home).

LIMITATIONS

Several studies have methodological issues, such as a lack of control of known confounders and there is a large variety of measures employed.

CONCLUSION

Important risk factors for stress and mental health symptoms were identified. More evidence is needed to determine if long-term symptoms persist into school age. Research should focus on taking a family-based approach in order to identify preventive strategies and resilience factors in parents of VLBW infants.

Developing and Implementing a Father-Friendly Neonatal Intensive Care Unit Improved Nurses' Self-Efficacy

BACKGROUND

The need for paternal support is rarely addressed in neonatal intensive care units (NICUs). Neonatal nurses often primarily focus on the needs of the mother and infant and may not be trained in support of fathers.

PURPOSE

To investigate nurses' self-efficacy (SE) in guiding and supporting fathers after implementing a father-friendly NICU.

METHODS

Nurses from the intervention NICU and 13 control NICUs were included in a before-and-after intervention study. Questionnaires measuring nurses' SE regarding support of fathers and mothers were obtained when starting the development process, before and 18 months after the implementation. The primary outcome was the difference between nurses' SE scores for father and mother questions in the intervention group compared with the control group.

RESULTS

In total, 294, 330, and 288 nurses responded to the first, second, and third questionnaires, respectively. From the first to third questionnaires, the intervention group showed a significantly higher increase in SE scores for father questions compared with the control group (0.53 vs 0.20, P = .005) and a nonsignificantly higher increase for mother questions (0.30 vs 0.09, P = .13). In the third questionnaire, the intervention group showed a higher SE score for father questions compared with the control group (9.02 vs 8.45, P = .002) and the first questionnaire (9.02 vs 8.49, P = .02).

IMPLICATIONS FOR PRACTICE AND RESEARCH

By implementing a father-friendly NICU, nurses' SE for providing support to fathers increased significantly. Training in a father-friendly approach increases nurses' ability to support both parents.

A Comparison of the Clinical Presentation of Preterm Birth and Autism Spectrum Disorder: Commonalities and Distinctions in Children Under 3

Premature infants and infants later diagnosed with autism spectrum disorder (ASD) share many commonalities in clinical presentations. However, prematurity and ASD also have differences in clinical presentation. These overlapping phenotypes can lead to misdiagnoses of ASD or missing a diagnosis of ASD in preterm infants. We document these commonalities and differences in various developmental domains with the hope of aiding in the accurate early detection of ASD and timely intervention implementation in children born premature. Given the degree of similarities in presentation, evidence-based interventions designed specifically for preterm toddlers or toddlers with ASD may ultimately aid both populations.

Analysis of Neonatal Neurobehavior and Developmental Outcomes Among Preterm Infants

IMPORTANCE

The ability to identify poor outcomes and treatable risk factors among very preterm infants remains challenging; improving early risk detection and intervention targets to potentially address developmental and behavioral delays is needed.

OBJECTIVE

To determine associations between neonatal neurobehavior using the Neonatal Intensive Care Unit (NICU) Network Neurobehavioral Scale (NNNS), neonatal medical risk, and 2-year outcomes.

DESIGN, SETTING, AND PARTICIPANTS

This multicenter cohort enrolled infants born at less than 30 weeks' gestation at 9 US university-affiliated NICUs. Enrollment was conducted from April 2014 to June 2016 with 2-year adjusted age follow-up assessment. Data were analyzed from December 2019 to January 2022.

EXPOSURES

Adverse medical and psychosocial conditions; neurobehavior.

MAIN OUTCOMES AND MEASURES

Bayley Scales of Infant and Toddler Development, third edition (Bayley-III), cognitive, language, and motor scores of less than 85 and Child Behavior Checklist (CBCL) T scores greater than 63. NNNS examinations were completed the week of NICU discharge, and 6 profiles of neurobehavior were identified by latent profile analysis. Generalized estimating equations tested associations among NNNS profiles, neonatal medical risk, and 2-year outcomes while adjusting for site, maternal socioeconomic and demographic factors, maternal psychopathology, and infant sex.

RESULTS

A total of 679 enrolled infants had medical and NNNS data; 2-year follow-up data were available for 479 mothers and 556 infants (mean [SD] postmenstrual age at birth, 27.0 [1.9] weeks; 255 [45.9%] female). Overall, 268 mothers (55.9%) were of minority race and ethnicity, and 127 (26.6%) lived in single-parent households. The most common neonatal medical morbidity was BPD (287 [51.7%]). Two NNNS behavior profiles, including 157 infants, were considered high behavioral risk. Infants with at least 2 medical morbidities (n = 123) were considered high medical risk. Infants with high behavioral and high medical risk were 4 times more likely to have Bayley-III motor scores less than 85 compared with those with low behavioral and low medical risk (adjusted relative risk [aRR], 4.1; 95% CI, 2.9-5.1). Infants with high behavioral and high medical risk also had increased risk for cognitive scores less than 85 (aRR, 2.7; 95% CI, 1.8-3.4). Only infants with high behavioral and low medical risk were in the clinical range for CBCL internalizing and total problem scores (internalizing: aRR, 2.3; 95% CI, 1.1-4.5; total: aRR, 2.5; 95% CI, 1.2-4.4).

CONCLUSIONS AND RELEVANCE

In this study, high-risk neonatal neurobehavioral patterns at NICU discharge were associated with adverse cognitive, motor, and behavioral outcomes at 2 years. Used in conjunction with medical risk, neonatal neurobehavioral assessments could enhance identification of infants at highest risk for delay and offer opportunities to provide early, targeted therapies.

Neonatal neurobehavior in infants with autism spectrum disorder

AIM

To investigate neurobehavioral maturation for neonates who are later diagnosed with autism spectrum disorder (ASD).

METHOD

In a prospective longitudinal design, neonatal neurobehavior was examined monthly in 1- to 3-month-old infants at elevated and low familial likelihood of ASD (n=60). At 2 years, infants were seen for a clinical best-estimate evaluation, resulting in 18 infants with ASD and 36 typically developing infants. Repeated-measures analysis of variance models were conducted to examine the effects of age, diagnostic group, and their interactions.

RESULTS

Neurobehavioral maturation of infants diagnosed with ASD was largely comparable to typically developing infants from 1 to 3 months, with the exception of the development of attention. Object-focused attention was significantly attenuated for infants with ASD beginning at 2 to 3 months and was predictive of social-communication skills 2 years later.

INTERPRETATION

This is the first study to prospectively examine neonatal neurobehavior of infants at an elevated familial likelihood of ASD who later received a diagnosis. Despite relatively intact neurological and behavioral maturation in the neonatal period, attention to objects emerged as a key early indicator of ASD. This suggests a complex attentional vulnerability within the first 3 months of life that may be associated with cascading sequelae of social-communication challenges and the emergence of ASD.

DNA Methylation and Allelic Polymorphism at the Dopamine Transporter Promoter Affect Internalizing and Externalizing Symptoms in Preschoolers

The role of the dopamine transporter (DAT) in the onset and maintenance of emotional-behavioral difficulties is recognized in adults, adolescents and school-age children, whereas few studies in this field have focused on preschoolers. The study recruited 2-year old children (N = 152) in the general population assessing the possible effect of DAT methylation and allelic polymorphism on internalizing and externalizing symptoms, also exploring whether epigenetic and genetic variability interact. Our results showed that DAT methylation is significantly associated with all the dimensions of children's emotional/behavioral functioning in children carrying 10/10-3/3-8/10 polymorphisms but not in children carrying 9/10-9/9 allele repeats. Understanding the influence of genetic/epigenetic factors on maladaptive emotional/behavioral outcomes in young children, can be of great help in programming effective prevention and intervention plans and can be a valid aid to alleviate psychopathological symptoms before they crystalize into more severe clinical conditions in later life.

A global perspective on parental stress in the neonatal intensive care unit: a meta-analytic study

OBJECTIVES

The Parental Stressor Scale: Neonatal Intensive Care Unit (PSS:NICU) is a well-validated tool to assess different sources of stress in parents during the NICU hospitalization of their infant. The present meta-analytic study assessed the relative impact of different NICU-related sources of parental stress in a pool of studies conducted in a wide set of different countries. Also, differences in stress levels by parent gender and country, as well as the impact of infants' neonatal characteristics and clinical conditions were explored.

METHODS

Records were searched on PubMed, Scopus, and Web of Science (January 1993-December 2019). A purposive open search string was adopted: ["PSS:NICU"] OR ["PSS-NICU"] OR ["Parental Stressor Scale"]. A multiple random-effect meta-analysis was conducted on data from 53 studies extracted by independent coders.

RESULTS

Parental role alteration emerged as the greatest source of stress for both mothers and fathers. Mothers reported higher stress levels compared to fathers. A significant difference emerged only for the subscale related to sights and sounds physical stimuli. No significant effects of infants' neonatal characteristics (gestational age, birth weight) and clinical conditions (comorbidities) emerged. A marginal positive effect of NICU length of stay emerged on the global level of parents' stress.

CONCLUSIONS

The current meta-analysis underlines that parental stress related to NICU admission is a worldwide healthcare issue. Immediate and tailored support to parents after the birth of their at-risk infant should be prioritized to reduce parental stress and to promote mothers and fathers' emotional well-being and new-born neurodevelopmental outcomes.

Psychometric Properties of the Turkish Version of the Developmental Support Competency Scale for Nurses (DSCS-N)

PURPOSE

Developmental care is considered an important component of development and health promotion of premature infants, however, studies regarding assessment of nurses' competency of developmental care are inadequate. This study is designed to determine the psychometric properties of the Turkish version of the Developmental Support Competency Scale for Nurses (DSCS-N).

DESIGN AND METHODS

This methodological study includes 140 nurses working at a tertiary level neonatal intensive care unit (NICU). Data were collected using the Nurse Introductory Form and Developmental Support Competency Scale for Nurses. The scale was assessed in terms of language and content validity, construct validity, internal consistency and time invariance.

RESULTS

The scale consisted of 19 items and six subscales. In the confirmatory analysis, which is a validity analysis, it was found that the scale's factor loadings ranged between 0.27 and 0.92, and the ratio of chi-square to degrees of freedom was 1.64. Other fit indices (CFI = 0.96, NFI = 0.92, NNFI = 0.95) were at desirable levels. Cronbach's alpha coefficient was found to be 0.90. According to item analysis results, item-total correlations ranged between 0.26 and 0.66. It was found that nurses' responses to the scale items at two different times were consistent and did not change over time (p > 0.05).

CONCLUSIONS

DSCS-N is a valid and reliable scale for measuring Turkish nurses' competency of developmental support.

PRACTICE IMPLICATIONS

DSCS-N can be used as a tool contributing to the implementation of developmental care. The scale can help nurses working in neonatal intensive care units to determine their competency of developmental care.

French neonatal society position paper stresses the importance of an early family-centred approach to discharging preterm infants from hospital

AIM

The families of hospitalised preterm infants risk depression and post-traumatic stress and the preterm infants risk re-hospitalisation. The French neonatal society's aim was to review the literature on how the transition from hospital to home could limit these risks and to produce a position paper.

METHODS

A systematic literature review was performed covering 1 January 2000 to 1 January 2018, and multidisciplinary experts examined the scientific evidence.

RESULTS

We identified 939 English and French papers and 169 are quoted in the position paper. Most studies stressed the importance of early, personalised and progressive involvement of the family. Healthcare staff and families should assess discharge preparations jointly. This evaluation should assess the capacities of the newborn infant, with regard to its physiological maturity. It should also assess the family's ability to supply the medical, psychological and social assistance required before and after discharge. There should be a structured follow-up process that includes effective communication, various tools, interventions, networks, health and social professionals.

CONCLUSION

Discharge preparations may improve the transition from hospital to home and the outcomes for the parents and newborn preterm infant. This early family-centred approach should be structured, coordinated and based on individual needs and circumstances.

Risk-adjusted/neuroprotective care services in the NICU: the elemental role of the neonatal therapist (OT, PT, SLP)

Infants admitted to neonatal intensive care units (NICU) require carefully designed risk-adjusted management encompassing a broad spectrum of neonatal subgroups. Key components of an optimal neuroprotective healing NICU environment are presented to support consistent quality of care delivery across NICU settings and levels of care. This article presents a perspective on the role of neonatal therapists-occupational therapists, physical therapists, and speech-language pathologists-in the provision of elemental risk-adjusted neuroprotective care services. In alignment with professional organization competency recommendations from these disciplines, a broad overview of neonatal therapy services is described. Recognizing the staffing budget as one of the more difficult challenges hospital department leaders face, the authors present a formula-based approach to address staff allocations for neonatal therapists working in NICU settings. The article has been reviewed and endorsed by the National Association of Neonatal Therapists, National Association of Neonatal Nurses, and the National Perinatal Association.

Psychosocial and medical adversity associated with neonatal neurobehavior in infants born before 30 weeks gestation

BACKGROUND

Psychosocial adversity escalates medical risk for poor outcomes in infants born <30 weeks gestation. Neonatal neurobehavior and maternal psychological and socioenvironmental assessments may identify the earliest specific intervention needs. We hypothesized that maternal prenatal anxiety, depression, and adverse medical and socioenvironmental conditions would be associated with less optimal neonatal neurobehavior at neonatal intensive care unit (NICU) discharge.

METHODS

We studied 665 infants at 9 university NICUs. Risk indices of socioenvironmental, maternal, and neonatal medical factors were obtained from standardized, structured maternal interviews and medical record reviews. Brain injuries were classified by consensus ultrasonogram readings. NICU Network Neurobehavioral Scale (NNNS) exams were conducted at NICU discharge.

RESULTS

On the NNNS, generalized estimating equations indicated infants of mothers with prenatal anxiety had less optimal attention, and those born to mothers with prenatal depression had increased lethargy. Maternal medical complications predicted suboptimal reflexes. Socioenvironmental risk predicted lower self-regulation and movement quality. Infants with more severe neonatal medical complications had lower attention, increased lethargy, and suboptimal reflexes.

CONCLUSIONS

Combined information from the observed associations among adverse prenatal maternal medical and psychosocial conditions, and neonatal complications may assist in the early identification of infants at elevated neurobehavioral risk.

[Research advances in the effect of environmental stress in the neonatal intensive care unit on the neurodevelopment of preterm infants and its epigenetics]

Adverse environmental stimulation in the neonatal intensive care unit (NICU) can affect neurodevelopment through epigenetic modification and thus has adverse effects on the long-term developmental outcome of preterm infants. Developmental care can reverse epigenetic changes in genes and promote neurodevelopment in preterm infants. This article reviews the influence of environmental stress in the NICU and developmental care on neurodevelopment in preterm infants, as well as related epigenetic effects, in order to provide a reference for epigenetic studies of preterm infants.

Factors Influencing Developmental Care Practice Among Neonatal Intensive Care Unit Nurses

PURPOSE

This study aimed to examine factors that influence developmental care practice among neonatal intensive care unit nurses.

DESIGN AND METHODS

This descriptive, cross-sectional study was conducted using a questionnaire. Data were collected from 141 neonatal intensive care unit nurses from 6 hospitals in South Korea. Multiple linear regression analysis was used to examine factors influencing developmental care practice.

RESULTS

This study found that professional efficacy had the largest influence on developmental care practice, followed by perception of developmental care and a task-oriented organizational culture. Clinical and educational experience regarding developmental care and working environment was not associated with developmental care practice among NICU nurses.

CONCLUSIONS

To enhance nurses' practice of developmental care, enhancement of nurses' individual competency, positive perception of developmental care, and organizational efforts are required. A practical training program should be provided to nurses to promote confidence in implementing developmental care for preterm infants.

IMPLICATIONS

A trained nurse should provide staff nurses with useful information on developmental care to encourage them to have a positive attitude towards developmental care. The nurse manager should create an organizational culture in which nurses perceive developmental care to be an essential nursing task in their unit.

NICU infant health severity and family outcomes: a systematic review of assessments and findings in psychosocial research

Many infants (7-15%) spend time in the neonatal intensive care unit (NICU) and continue to experience medical issues after discharge. Family psychological responses range widely depending on burden of care, access to resources, and parental characteristics. The current systematic review examined how infant health severity is assessed and related to family psychological (e.g., mental health) and social (e.g., parent-infant attachment) outcomes. Seventy articles were deemed relevant. Infant health was operationalized in several ways including validated assessments, indices of infant health (e.g., diagnosis, length of stay), or novel measures. Parents of infants with increased medical complications reported greater family impact, increased stress, and more intrusive parenting style. A validated assessment of infant health that utilizes parent report is warranted to allow for more accessible and easily disseminated research across medical centers. Understanding NICU infant health severity and family outcomes can be used to identify families at risk for negative psychosocial sequelae.

Socio-Emotional and Cognitive Development in Intrauterine Growth Restricted (IUGR) and Typical Development Infants: Early Interactive Patterns and Underlying Neural Correlates. Rationale and Methods of the Study

Intrauterine growth restriction (IUGR) is defined as a fetal growth retardation, resulting in an estimated fetal weight less than the 10th centile for gestational age. IUGR developing brain is affected by the atypical fetal growth, presenting altered structure and connectivity and increased risk for neurodevelopmental impairments. Behaviorally, IUGR infants show reduced responsiveness and engagement with human faces during mother-child exchanges. The neural mechanisms of these patterns of interactions remain unexplored, as well as their potential role in shaping socio-cognitive trajectories of development. Aim of this research project will be to longitudinally investigate mother-infant interactions and infant's event-related potential (ERP) components of face processing (infant N170, P400, Negative central) in 4 and 9 months IUGR as potential early markers of expected atypical cognitive and behavioral outcomes observed at 12 months. Thirty IUGR participants will be recruited after receiving the in utero diagnosis (>28th gestational week). Thirty healthy infants will be enrolled as the control group. Maternal environment will be assessed via Emotional Availability Scales (EASs), with child responsiveness and maternal sensitivity as variables of interest. Infants' scalp-recorded cortical activity in response to social and non-social stimuli will be investigated using a high-density EEG system (EGI Geodesic system). Neurodevelopment will be measured at 12 months of child's life, using Bayley Scales for Infant Development (BSID), while the possible presence of emotional-behavioral problems will be rated via Child Behavior Checklist (CBCL). We expect that being IUGR significantly affects cognitive and behavioral outcomes, through mediation effects of both infants' neural and behavioral capacity to respond to social stimuli. Indeed, we expect an altered response to social stimuli in IUGR infants, resulting in smaller ERP components amplitude in response to human faces compared to healthy matched peers. A significant association between neural response to social stimuli and infants' responsiveness to maternal stimulation during interactions is expected, with impoverished performances on the interactive domain in IUGR, compared to healthy peers. This study will enhance understanding on neural mechanisms underpinning the interactive patterns sustaining socio-cognitive development in IUGR and healthy infants. The study will help in clarifying the role of postnatal environment in buffering the vulnerability experienced by children delayed in their fetal growth.