Isolated and On Guard: Preparing Neonatal Intensive Care Unit Families for Life with Hydrocephalus

The Needs and Experiences of Black Families in the Neonatal Intensive Care Unit

OBJECTIVES

To identify opportunities for improvement in quality of care, we explore Black families' experiences of family support in the neonatal intensive care unit (NICU) during their infant's hospital stay.

METHODS

Semistructured qualitative interviews or focus groups (FGs) were conducted to explore Black families' experiences of NICU hospitalization. Inclusion criteria were self-identification as a Black family member and infant admission to our NICU between January 2020 and February 2022. We conducted reflexive thematic analysis of recorded transcripts using Dedoose software.

RESULTS

Three interviews and 2 FGs were conducted with 9 unique families (n = 13 individuals). We organized 10 key themes into "Experiences" and "Recommendations." Experience themes included distrust and fear of the medical setting, hypervigilance and trauma trajectory formation, the myth of "Black hardiness," policing and surveillance, and undermining of Black parenting. Recommendation themes implored NICU staff to earn rather than assume trust, respect family concerns, improve mental health support, provide compassionate care, and support the parenting role.

CONCLUSIONS

In this single-center qualitative study of Black families' NICU encounters, families continue to experience differential treatment, which reinforces an untrustworthy medical system perpetuating structural racism. Family recommendations for improving care through transparent communication, advocacy and mental health support, increased engagement in their parental role, and decreasing biased treatment and provision of resources may improve their experience and mitigate hypervigilance and trajectory formation in our NICU.

Pediatric Perspectives on Palliative Care in the Neurocritical Care Unit

Pediatric neurocritical care teams care for patients and families facing the potential for significant neurologic impairment and high mortality. Such admissions are often marked by significant prognostic uncertainty, high levels of parental emotional overload, and multiple potentially life-altering decision points. In addition to clinical acumen, families desire clear and consistent communication, supported decision-making, a multidisciplinary approach to psychosocial supports throughout an admission, and comprehensive bereavement support after a death. Distinct from their adult counterparts, pediatric providers care for a broader set of rare diagnoses with limited prognostic information. Decision-making requires its own ethical framework, with substitutive judgment giving way to the best interest standard as well as "good parent" narratives. When a child dies, bereavement support is often needed for the broader community. There will always be a role for specialist palliative care consultation in the pediatric neurocritical care unit, but the care of every patient and family will be well served by improving these primary palliative care skills.

Life on the Frontlines: Caregiver Experience of Pediatric Cerebrospinal Shunt Malfunction

BACKGROUND

We aimed to characterize the caregiver experience in the detection and evaluation of pediatric cerebrospinal shunt malfunction.

METHODS

In this descriptive qualitative study, we recruited English-speaking caregivers of children aged five years or less in collaboration with a stakeholder organization. Semistructured interviews were completed; content targeted the caregiver experience of shunt malfunction. Interviews were audio-recorded, transcribed, and deidentified. Qualitative data were analyzed using a conventional content analysis approach.

RESULTS

We enrolled 20 caregivers (n = 20 mothers). The median child age at the time of the interview was 2.8 years; about half (n = 11) were born prematurely and the majority (n = 15) had shunts placed at age less than six months. Caregiver experiences of shunt malfunction were grouped into three major themes: (1) my error could be life or death: the high stakes of shunt malfunction and the ambiguity of malfunction symptoms exacerbated baseline caregiver vigilance; (2) finding and engaging people who can help: hurdles during malfunction evaluation included locating trusted clinicians and advocating for parental intuition; and (3) how the shunt defines our family: caregivers described evolving expertise and modifications made to everyday life due to the threat of malfunction.

CONCLUSIONS

In this study, caregivers highlighted the challenges associated with recognizing shunt malfunction, accessing necessary treatment, and the impact of their child's shunt on family life. Future work should leverage these findings to inform counseling about shunt malfunction, develop interventions to better support families in shunt malfunction identification, and educate medical providers.

Cumulative Damage: Cell Death in Posthemorrhagic Hydrocephalus of Prematurity

Globally, approximately 11% of all infants are born preterm, prior to 37 weeks’ gestation. In these high-risk neonates, encephalopathy of prematurity (EoP) is a major cause of both morbidity and mortality, especially for neonates who are born very preterm (<32 weeks gestation). EoP encompasses numerous types of preterm birth-related brain abnormalities and injuries, and can culminate in a diverse array of neurodevelopmental impairments. Of note, posthemorrhagic hydrocephalus of prematurity (PHHP) can be conceptualized as a severe manifestation of EoP. PHHP impacts the immature neonatal brain at a crucial timepoint during neurodevelopment, and can result in permanent, detrimental consequences to not only cerebrospinal fluid (CSF) dynamics, but also to white and gray matter development. In this review, the relevant literature related to the diverse mechanisms of cell death in the setting of PHHP will be thoroughly discussed. Loss of the epithelial cells of the choroid plexus, ependymal cells and their motile cilia, and cellular structures within the glymphatic system are of particular interest. Greater insights into the injuries, initiating targets, and downstream signaling pathways involved in excess cell death shed light on promising areas for therapeutic intervention. This will bolster current efforts to prevent, mitigate, and reverse the consequential brain remodeling that occurs as a result of hydrocephalus and other components of EoP.