Long-term impact of sudden infant death: a 12- to 15-year follow-up

The psychological consequences of Sudden Infant Death Syndrome (SIDS) for the family system: A systematic review

The Sudden Infant Death Syndrome (SIDS) is a tragic and difficult experience for families. It involves not only the death of the baby but also the loss of a future as a parent, sibling or grandparent. The subsequent grief is multifaceted and each family member has different needs and resources. Through a systematic review of literature, we identified 24 studies between 1982 and 2021: they dealt with individual, family and couple experience when a SIDS occurs; in addition, some studies compared perinatal loss and neonatal loss with SIDS loss. Our results point out the need for an intervention that focuses on the needs of each family member and tailored around the specifics of SIDS loss rather than general grief.

One Size Doesn't Fit All in Early Pediatric Oncology Bereavement Support

CONTENT

Parents who experience the death of a child have significantly higher rates of psychological distress compared to non-bereaved parents. The effectiveness of current bereavement supports, and ideal types and timing of future supportive interventions aimed at improving negative sequalae are relatively unknown.

OBJECTIVES

This interview-based study explored the early bereavement needs of 15 parents of children who died from cancer, including the bereavement support received, perceived barriers to support, and desired additional supportive interventions.

METHODS

Parents who previously participated in a survey-based study examining the early grief experience were invited to partake in a semi-structured interview. Interviews focused on examining bereavement support for parents within the first three years following the child's death and barriers to adequate support; transcribed interviews underwent thematic analysis.

RESULTS

Fifteen parents completed the interview; 14 parents (93%) were White and non-Hispanic, five were male. Parents participated on average 19 months (range 12-34) following their child's death. Parents identified numerous supports that were and were not helpful. Augmented informative materials, professional, organized, and religious/spiritual support, and connections with others were identified as key elements in a supportive intervention.

CONCLUSION

Bereaved parents identified many supportive needs, most of which already exist at the community and institution level. Suggestions outlined by parents may provide a useful framework for developing novel supportive interventions and ways to tailor strategies to support bereaved parents. Researchers must continue to seek feedback from bereaved parents and families about their met and unmet needs and use this information to design early supportive bereavement interventions.

Bereaved parents’ experiences of being informed about autopsy findings after the sudden and unexpected loss of an infant or small child

Background: Following the sudden and unexpected loss of an infant or small child, the police usually request a forensic autopsy. National guidelines exist for how the autopsy report should be made available for the bereaved parents, but there is limited knowledge whether the guidelines are followed. This study aims to explore bereaved parents’ experiences of being informed about autopsy findings.

Methodology: As part of in-depth follow-up interviews at 13 months post-loss, 24 couples were asked how they experienced being informed about autopsy findings. Participants’ responses underwent thematic analysis.

Results: The results show that the waiting period before the autopsy report was made available was a burden for many parents, particularly those who experienced a delay in the process. Two main themes related to parents’ experiences of being informed when the report was available: ‘informed in a supportive and caring way’ and ‘difficult or negative experiences’.

Conclusion: Several factors are described that help parents cope with being informed about autopsy findings, such as: being informed according to the given timeframe by competent health personnel, face-to-face meetings at the hospital, being able to ask questions and routine follow-up contact. These factors are mostly described in the national guidelines. This study shows that when guidelines were followed, the majority of parents were satisfied with how they were informed. Unfortunately, some parents had negative experiences. Regular training and continuing education for health personnel are recommended.

The Grief of Parents After the Death of a Young Child

Research demonstrates that severe forms of grief and grief-related pathology exist in the general population. Less attention, however, has been paid to the grief of parents following the death of a young, dependent child. In this review, we summarize a search of Pubmed, PsycINFO and Web of Science from 1995 to 2017, using the terms 'parental complicated grief', 'parental traumatic grief', and 'parent Prolonged Grief Disorder', specifically addressing parental grief and identified risk factors for complicated or prolonged grief. Forty-two studies met criteria and indicate a significant burden of complicated or prolonged grief in parents of children dying from virtually any cause. It appears that the empiric literature is undermined by great variability, including the composition of samples, the causes of death studied, the psychometric measures used, and post-loss intervals. We conclude that the uniform severity of grief experiences following the death of a young child is potentially a distinct subtype of grief, deserving of attention in its own right in future research and diagnostic formulations.

Pre-loss personal factors and prolonged grief disorder in bereaved mothers

BACKGROUND

Identifying characteristics of individuals at greatest risk for prolonged grief disorder (PGD) can improve its detection and elucidate the etiology of the disorder. The Safe Passage Study, a study of women at high risk for sudden infant death syndrome (SIDS), prospectively examined the psychosocial functioning of women while monitoring their healthy pregnancies. Mothers whose infants died of SIDS were followed in bereavement.

METHODS

Pre-loss data were collected from 12 000 pregnant mothers and analyzed for their associations with grief symptoms and PGD in 50 mothers whose infants died from SIDS, from 2 to 48 months after their infant's death, focusing on pre-loss risk factors of anxiety, depression, alcohol use, maternal age, the presence of other living children in the home, and previous child loss.

RESULTS

The presence of any four risk factors significantly predicted PGD for 24 months post-loss (p < 0.003); 2-3 risk factors predicted PGD for 12 months (p = 0.02). PGD rates increased in the second post-loss year, converging in all groups to approximately 40% by 3 years. Pre-loss depressive symptoms were significantly associated with PGD. Higher alcohol intake and older maternal age were consistently positively associated with PGD. Predicted risk scores showed good discrimination between PGD and no PGD 6-24 months after loss (C-statistic = 0.83).

CONCLUSIONS

A combination of personal risk factors predicted PGD in 2 years of bereavement. There is a convergence of risk groups to high rates at 2-3 years, marked by increased PGD rates in mothers at low risk. The risk factors showed different effects on PGD.

Place, Age, and Mode of Death of Infants and Children with Hypoplastic Left Heart Syndrome: Implications for Medical Counselling, Psychological Counselling, and Palliative Care

A review of outcomes of hypoplastic left heart syndrome at a pediatric hospital 1983–2004 identified 154 deaths among 206 children (75%). Of 134 surgically treated, 82 (62%) died: 68 (83%) in intensive care, six (7%) in the operating theatre, three (4%) during transport from home, two (2%) on the cardiac ward, one (1 %) at home, one (1 %) in the emergency department, and one (1 %) elsewhere. Seventy died after stage one Norwood surgery (median age: 13 days), three died after second stage surgery (ages: 3, 4, and 20 months), two died after third stage surgery (ages: 1.2 and 3.5 years), two died after heart transplantation (ages: 4.6 and 15 years), and five died after non-Norwood surgery. All 72 infants treated without surgery died: 68 died at a median age 3 days; 57 (79%) in intensive care, three (4%) on the ward, and 12 (17%) elsewhere. Discussion involves strategies to support parents and staff at diagnosis, and before and after a child's death.

Life after loss: Parent bereavement and coping experiences after infant death in the neonatal intensive care unit

The death of an infant in the neonatal intensive care unit (NICU) is a profound and unexpected loss for parents that results in a complex process of coping with bereavement. A descriptive qualitative approach was used to explore parent bereavement and coping experiences after infant death in the NICU. The dual process model of coping with bereavement was used as a conceptual framework to help understand how parents cope with grief after infant death. Living with infant death was a process that resulted in major life changes and a process of oscillating among various coping strategies.

Are Past Adverse Pregnancy Outcomes Associated with Maternal Anxiety and Depressive Symptoms in a Sample of Currently Pregnant Women?

Background

There has been a great deal of concern about the mental health of women whose pregnancies involve miscarriage, termination of a pregnancy (ToP), child death or where a child has been given up for adoption. Despite this concern there has been remarkably little population-based research which has addressed the long-term consequences of pregnancy loss and child death. This study investigated the maternal mental health consequences of women whose pregnancies involve miscarriage, ToP, child death or where a child has been given up for adoption at two different time points, adjusting for socio-demographic characteristics and baseline mental health.

Methods

The Mater-University of Queensland Study of Pregnancy is a prospective pre-birth cohort study. Women were recruited early in pregnancy over the period 1981 to 1983 at their first antenatal clinic visit (FCV). Women were interviewed again at the 14-year follow-up. Data from 4403 mothers were analysed using maternal reports of a prior history of giving a child up for adoption, miscarriage, ToP, and neonatal, infant and/or child deaths. Symptoms of maternal anxiety and depression were measured at FCV and the 14-year follow-up using the Delusions-Symptoms-States Inventory. We carried out logistic regression analysis using Stata 13. Odds ratios (ORs) with 95% confidence intervals (CIs) were used to display the findings.

Results

A prior miscarriage was associated with anxiety (adjusted OR (AOR) = 1.30; 95% CI: 1.10-1.66) and depressive (AOR = 1.70; 95% CI: 1.21-2.39) symptoms at the 14-year follow-up. Having had a neonatal, infant and/or child deaths was associated with symptoms of depression at 14-year follow-up (AOR = 2.12; 95% CI: 1.06-4.25).

Conclusion

The period after a child loss which involves a new pregnancy may be associated with relatively good mental health despite the fact that some mothers have experienced previous adverse pregnancy outcomes.

The Grief of Mothers After the Sudden Unexpected Death of Their Infants

: media-1vid110.1542/5741323271001PEDS-VA_2017-3651Video Abstract BACKGROUND: The loss of a child is associated with elevated grief severity, and sudden infant death syndrome (SIDS) is the leading cause of postneonatal mortality in the United States. The diagnosis of prolonged grief disorder (PGD) has gained broader acceptance and use. Little is known about PGD in mothers after SIDS.

METHODS

Between May 2013 and July 2016, we assessed 49 SIDS-bereaved mothers living in informal settlements near Cape Town, South Africa, and on the Pine Ridge Indian Reservation and 359 SIDS-bereaved mothers affiliated with SIDS parent-support organizations in the United States, United Kingdom, Australia, New Zealand, and the Netherlands. We examined PGD symptom severity and diagnostic prevalence rates between the samples and other significant grief indicators during the period 2 to 48 months after the deaths of their infants.

RESULTS

Extremely high, persistent, and similar rates of PGD were found in both samples at every time interval. The prevalence of PGD was 50.0% in either sample (mean months from loss: 20.5 vs 24.9). Daily, intrusive emotional pain or yearning was found in 68.1% of subjects; yearning was significantly associated with emotional pain (P < .0001). Role confusion and anger were the most prevalent symptoms, reported by the majority at every time interval. Rates of role confusion, anger, and diminished trust in others remained constant. Acceptance was less prevalent than other grief indicators at every interval.

CONCLUSIONS

Severe symptoms and heightened risk for PGD was seen in mothers after their infants died of SIDS, with discernible symptom profiles. Given their involvement with families after SIDS, pediatricians may have a unique role in identifying this problem and helping address its consequences.

What aspects of post-traumatic growth are experienced by bereaved parents? A systematic review

Background: The death of a child of any age can be traumatic and can leave bereaved parents experiencing negative psychological outcomes. Recent research has shown the potential utility for understanding more about the development of post-traumatic growth following bereavement. Objective: This paper sought to identify the aspects of post-traumatic growth experienced by bereaved parents and the factors that may be involved in facilitating or preventing post-traumatic growth. Methods: A systematic search of peer-reviewed articles with a primary focus on positive personal growth in bereaved parents was conducted. Thirteen articles met the inclusion criteria, and were analysed and synthesized according to common and divergent themes. Results: Bereaved parents were able to experience elements of growth proposed by the post-traumatic growth model (changes in self-perception, relationships, new possibilities, appreciation of life and existential views). The papers also indicated that (1) mothers appeared to experience more growth than fathers, (2) cultural variation may impact on some participants' experience of growth, and (3) participants were able to identify growth only once some time had passed. Potential facilitators of post-traumatic growth involved making meaning, keeping ongoing bonds with the child, being with bereaved families, and family and personal characteristics. Social networks were identified as having the potential to be either a facilitator or a barrier to growth. Conclusions: In addition to experiencing grief, bereaved parents may experience aspects of post-traumatic growth, and a variety of factors have been identified as potential facilitators and barriers of these changes. The findings may have implications for support services (e.g. expert-by-experience services).

Life Experience of Bereaved Parents After the 2014 Sewol Ferry Disaster in South Korea

The aim of this study was to identify the outcomes of parental bereavement and the changes in life experience that follow the traumatic death of a teenage child. The results of the study are aimed to assist counselors and educators who work with themes of grief and loss. From 17 in-depth interviews from parents bereaved by the Sewol ferry disaster of 2014 in South Korea, three main categories were found to capture the reality for parents after the sudden and traumatic death of a teenage child: (a) personal changes, (b) changes in close relationships, and (c) changes in social life. Recommendations for future research and potential implications were discussed.

Parents' Perception of Their Relationship Following the Loss of a Child

It is known that if one partner wants to talk after the loss of a child, while the other does not, the less satisfied they are with the relationship. The aim of this study was to increase our understanding of parental relationships following the loss of a child. A questionnaire on various aspects of the relationship was sent to 1,027 members of bereavement support organizations for parents who have lost children in Norway. The studied sample ( N = 285) consisted of 169 women (59.3%) and 116 men (40.7%), representing 175 couples. Although the participants were generally satisfied with their relationship and felt that it was strengthened, there were challenges of communication and interaction. The loss made the relationship special, and they felt they had learned to know each other on a deeper level. The importance of talking together and communicating thoughts and feelings was emphasized by the parents. Women initiated talk more often and evidenced a greater need to talk. A deterioration of the relationship tended to be related to a lack of understanding, communication, and care. Communication, respect, and understanding were underlined as core factors for perceiving a relationship as positive.

End-of-Life and Bereavement Care in Pediatric Intensive Care Units

Most childhood deaths in the United States occur in hospitals. Pediatric intensive care clinicians must anticipate and effectively treat dying children's pain and suffering and support the psychosocial and spiritual needs of families. These actions may help family members adjust to their loss, particularly bereaved parents who often experience reduced mental and physical health. Candid and compassionate communication is paramount to successful end-of-life (EOL) care as is creating an environment that fosters meaningful family interaction. EOL care in the pediatric intensive care unit is associated with challenging ethical issues, of which clinicians must maintain a sound and working understanding.

Factors Related to Parent Attendance at a Follow-Up Meeting With an Intensivist After a Child's Death in the Pediatric Intensive Care Unit

Parents who experience the death of a child are at high risk for psychopathology. Because a large percentage of pediatric deaths occur in the pediatric intensive care unit each year, a follow-up meeting between bereaved parents and intensivists could provide essential emotional support, although some parents may not attend. The aim of this study was to explore demographic and medical factors that may distinguish between bereaved parents who attend a follow-up meeting with their child's pediatric intensivist and those who do not. Our analysis revealed that parents of children who died of trauma were less likely to attend a follow-up meeting with an intensivist. It is possible that symptoms of posttraumatic stress play a role in these findings. Enhanced efforts to identify other interventions for this specific subset of bereaved parents may be necessary.

Parental coping in the context of having a child who is facing death: A theoretical framework

Objective:

While improvements in healthcare have resulted in children with complex and life-threatening conditions living longer, a proportion of them still die. The death of a child puts parents at increased risk for anxiety, depression, and complicated grief. Increasing our understanding of the coping strategies that parents use under such extreme circumstances will enable us to best provide support to families, before and after a child's death. Our aim herein was to develop a theoretical framework of parental coping.

Method:

Evidence from the literature was employed to develop a theoretical framework to describe parental coping in the context of having a child with a life-limiting illness who is declining and facing eventual death.

Results:

The reasoning and argument consists of three guiding elements: (1) the importance of approach as well as avoidance (as coping strategies) in the context of managing the extreme emotions; (2) the importance of the social aspect of coping within a family, whereby parents cope for others as well as for themselves; and (3) the importance of a flexible and balanced coping profile, with parents using different coping strategies simultaneously. Central to the proposed framework is that effective coping, in terms of adjustment, is achieved by balancing coping strategies: accessing different coping strategies simultaneously or in parallel with a specific focus on (1) approach and avoidance and (2) coping aimed at self and others.

Significance of results:

Understanding of parental coping strategies is essential for health professionals in order to support parents effectively.

Sexual Health Research With Young Black Men Who Have Sex With Men: Experiences of Benefits and Harms

Young Black men who have sex with men (YBMSM) are often underrepresented in sexual health research because of concerns about safety, privacy, and the potential for research harms. Empirical data are needed to understand YBMSM experience of participating in research, benefits and harms (discomfort), to inform policy and regulatory decisions. Using qualitative methods, this article examines 50 YBMSM, aged 15-19 years, experiences of benefits/harms, challenges of participating in sexual health research, and contextual factors impacting research experiences. Participants were asked about benefits and harms experienced in answering questions about sexual orientation, first same-sex attraction, and same-sex sexual experiences after completing an in-depth interview. Interviews were transcribed and coded. Inductive open coding was used to identify themes within and between interviews. Participants were able to describe perceived direct benefits resulting from research interview participation, including awareness of risky sexual behaviors, a safe space to share early coming out stories and same-sex sexual experiences, and a sense of empowerment and comfort with one's sexual orientation. Indirect benefits described by participants included perceptions of helping others and the larger gay community. Few participants described harms (discomfort recalling experiences). Our data suggest that participating in qualitative sexual health research focused on sexual orientation, sexual attraction, and early same-sex sexual experiences may result in minimal harms for YBMSM and multiple benefits, including feeling more comfortable than in a general medical visit.

Empowering Bereaved Parents Through the Development of a Comprehensive Bereavement Program

Parents who experience the loss of a child have unique and valuable insights into the grief journey and can help health care providers identify key components intrinsic to the development, implementation, and maintenance of a comprehensive bereavement program. The bereavement program at St. Jude Children's Research Hospital was developed by pediatric palliative care experts in collaboration with bereaved parents to standardize and improve the institutional support provided to families around and after the death of a child. This article describes the components of a parent-derived bereavement program and presents early results on the effects of specific program components. The program, under the leadership of the bereavement coordinator, includes clinical and supportive interventions offered throughout the grief journey, parent-created bereavement support materials, and opportunities for parents and families to participate in research, quality improvement initiatives and educational interventions. Parents report that services and interventions provided through the bereavement program are beneficial to families after the death of their child. In addition, both health care providers and bereaved parents report that participation in educational interventions positively impacts their experiences as clinicians and parents, respectively. The innovative nature of this parent-driven, comprehensive bereavement program may serve as a paradigm for the development of bereavement programs in the fields of pediatrics, palliative oncology and hospice and palliative medicine.

Young Road Fatalities

This study presents the findings from in-depth interviews with 24 people from 15 families in Norway who lost their young son or daughter in a traffic accident. Their grief has several dimensions: the loss of a young life, the loss of life quality, the effect on family events and their meaning, and the new responsibilities brought onto family members. For each young fatality, many relatives and friends are affected with a wide range of emotional and socioeconomic consequences. Parents report that grief is more overwhelming during the first few years and never disappears, while over the years they slowly learn to cope with it. Here we especially highlight the role of traffic authorities and what professional actors can do to meet the bereaved with empathy and minimize negative effects.

Examining longer-term effects of parental death in adolescents and young adults: Evidence from the national longitudinal survey of adolescent to adult health

Using longitudinal data spanning a 7-year period, we investigated the behavioral and psycho-social effects resulting from a parent's death during early childhood or teenage years on adolescent and early adulthood functioning. Findings confirmed previous work demonstrating various behavioral problems and social-psychological adjustment deficits during adolescence. Results suggested that most detrimental adjustment behaviors among parentally bereaved youth fade as they entered into young adulthood. Yet, premature school withdrawals and diminished interests in college attendance at Wave 1 left many of these young adults with diminished academic accomplishments, lingering economic disadvantages and for females a hesitancy to marry as their lives progressed into adulthood.

A Synthesis of Coping Experiences After Infant Death

The purpose of this article was to synthesize qualitative research data that examine parental coping strategies following infant death. This qualitative synthesis found that parents who effectively cope with the death of their infant would continue the bond with the deceased child, have differences in the way they manage their emotions about the loss, and have intergenerational support in the form of family being present, acknowledging the death, performing immediate tasks, and providing helpful information. Nurses should be vigilant to ensure parents receive "memories" of their infant after an in-hospital death. Knowledge of the coping process can assist nurses and clinicians to better care and support parents following an infant death and, in turn, facilitate the healing process.

Posttraumatic stress disorder in parents following infant death: A systematic review

Parents who have lost an infant prior to, during, or following birth often interpret the event as highly traumatic. The present systematic review included 46 articles based on 31 different studies of posttraumatic stress disorder (PTSD) in parents bereaved by infant death. The PTSD prevalence in mothers differed widely across studies with estimated rates at 0.6-39%. PTSD in fathers following infant loss has been less extensively studied but PTSD levels were generally much lower than in mothers with reported prevalence rates at 0-15.6% across studies. PTSD symptoms were not found to differ much depending on whether the death occurred prior to, during, or following birth and nor was gestational age consistently associated with PTSD severity. A number of risk and protective factors have been found to be associated with PTSD severity. Relevant focus areas for future research are presented along with considerations for future pregnancies and children. The suffering associated with PTSD following infant loss is overwhelming because of the rates at which such losses occur around the world. For this reason, it is problematic that not all types of infant loss resulting in sufficient symptoms of re-experiencing, avoidance, and arousal can elicit a DSM-5 PTSD diagnosis.

Parental Grief Following the Death of a Child from Cancer: The Ongoing Odyssey

BACKGROUND

The death of a child is a devastating event that results in profound grief and significant psychosocial and physical morbidities in parents. The parental grief journey is a complex phenomenon necessitating the utilization of newer models of bereavement with a focus on relationships and exploration of parents' perceived meanings of the experience.

OBJECTIVES

To further characterize the grief journey of parents whose child died from cancer in order to better identify parents who can benefit from additional bereavement support and design strategies to improve bereavement services for these parents.

DESIGN

We conducted focus group sessions with 11 bereaved parents. The parents were given two prompts to describe their grief journey before and after their child's death, and their responses in a narrative form were audio-recorded. The responses were coded and studied independently by semantic content analysis.

RESULTS

Collation and analysis of the coded responses to both prompts results in the emergence of four concepts from the parental narratives: (1) description of the grief trajectory and evolution of grief over time, (2) mechanisms of parental coping throughout the grief journey, (3) factors that exacerbate parental grief, and (4) sources of parental support throughout the grief journey.

CONCLUSIONS

The narratives highlighted that parents whose child died of cancer experience a unique and evolving form of grief and they wish to continue their bond with the deceased child. We recommend that healthcare providers and institutions incorporate support systems into a comprehensive bereavement program for families of children who die from cancer.

Features of Prolonged Grief Symptoms in Chinese and Swiss Bereaved Parents

This study investigates clinical expressions of prolonged grief in samples of 32 Chinese and 33 Swiss bereaved parents, according to the proposed International Classification of Diseases, 11th Revision model of prolonged grief disorder (PGD). Sex differences and predictors (cultural attitudes, sense of coherence, and posttraumatic growth) of PGD were analyzed. In result, after controlling for sociodemographic and loss-related sample differences, both samples showed similar PGD symptom profiles, with Swiss parents exhibiting more severe grief-related preoccupation and Chinese parents exhibiting some accessory symptoms and functional impairment to a greater extent. Multivariate analyses revealed for the Chinese sample primary predictions of PGD by life satisfaction, general health and one's world view (social cynicism) and for the Swiss sample by female sex, sense of coherence, and life satisfaction. The findings substantiate the basic appropriateness of the International Classification of Diseases, 11th Revision PGD in distinct cultural groups and may contribute to a better understanding of grief expression and its potential predictors across different cultures.

Micro-Sociological Analysis of Social Support Following Traumatic Bereavement: Unhelpful and Avoidant Responses from the Community

This article explores the reasons why parts of the social support to survivors of traumatic deaths fail. The data is based on in-depth interviews with 69 parents who lost their offspring due to suicide, SIDS, or accident between August 1, 1997 and December 31, 1998. Despite considerable positive support from their social nework, the majority of the survivors also experienced some unhelpful encounters or lack of anticipated support. Network members often find it difficult to communicate support in a way that is helpful, and this is termed “social ineptitude.” This ineptitude on the part of networks is explained by the lack of norms to guide this uncommon type of social encounter. The bereaved parents claim that “openness” and frankness about their situation is their best empowering strategy to meet this “social ineptitude.” These concepts, as they are elaborated in survivors' accounts are discussed within a communicational and interactional perspective. A micro-sociological model of communication provides the frame of reference for the discussion.

Parental understanding and self-blame following sudden infant death: a mixed-methods study of bereaved parents' and professionals' experiences

OBJECTIVES

Improvements in our understanding of the role of modifiable risk factors for sudden infant death syndrome (SIDS) mean that previous reassurance to parents that these deaths were unpreventable may no longer be appropriate. This study aimed to learn of bereaved parents' and healthcare professionals' experiences of understanding causes of death following detailed sudden unexpected death in infancy (SUDI) investigations. The research questions were: How do bereaved parents understand the cause of death and risk factors identified during detailed investigation following a sudden unexpected infant death? What is the association between bereaved parents' mental health and this understanding? What are healthcare professionals' experiences of sharing such information with families?

DESIGN

This was a mixed-methods study using a Framework Approach.

SETTING

Specialist paediatric services.

PARTICIPANTS

Bereaved parents were recruited following detailed multiagency SUDI investigations; 21/113 eligible families and 27 professionals participated giving theoretical saturation of data.

DATA COLLECTION

We analysed case records from all agencies, interviewed professionals and invited parents to complete the Hospital Anxiety and Depression Scale (HADS) and questionnaires or in-depth interviews.

RESULTS

Nearly all bereaved parents were able to understand the cause of death and several SIDS parents had a good understanding of the relevant modifiable risk factors even when these related directly to their actions. Paediatricians worried that discussing risk factors with parents would result in parental self-blame and some deliberately avoided these discussions. Over half the families did not mention blame or blamed no one. The cause of death of the infants of these families varied. 3/21 mothers expressed overwhelming feelings of self-blame and had clinically significant scores on HADS.

CONCLUSIONS

Bereaved parents want detailed information about their child's death. Our study suggests parents want health professionals to explain the role of risk factors in SIDS. We found no evidence that sharing this information is a direct cause of parental self-blame.

An evaluation of a teaching strategy: The use of literature when teaching pre-registration midwifery students on pregnancy and loss

Facilitating emotional intelligence and insight in midwifery can be challenging, and the purpose of this paper is to illustrate how this can be nurtured through the use of poetry, in particular Seamus Heaney's poem Elegy for a Still Born Child. Students' ability to gain insight into the experience of bereaved parents and achieve an emotional grasp of the situation through vicarious experience were evaluated. Qualitative data from evaluations was content analysed and significant themes emerged. Students' comments clearly support the suggestion that use of this poem has enhanced emotional intelligence. The data also indicates that vicarious experience gained through reading this poem has helped to nurture sensitivity and professional insight into the impact of still birth on a father.

Supporting SIDS Families: The Public Health Nurse SIDS Home Visit

Sudden infant death syndrome (SIDS) death has a devastating effect on parents. There is no known cause, so parents experience guilt about what they might have done or not done to contribute to the death. Although some SIDS parents may receive support from family and friends, the public health nurse (PHN) has an important professional role in providing grief support, SIDS education, and offering SIDS resources and referrals. Based on years of clinical practice, we recommend the following: Perform the home visit as soon as possible. Show care and compassion. Personalize the baby by using his or her name and asking to see photographs. Reassure the parents that grief is a process which takes time. Educate about what SIDS is and what it is not. Increasingly, SIDS deaths occur in the presence of risk factors. Explain that risk factors are not causes of death. As an authority in health care, reassuring families that they did not cause their baby's death has a tremendous impact on relieving guilt. Putting newly bereaved SIDS parents in contact with other SIDS parents is one of the most helpful actions a PHN can take to help families.

Evaluating a bereavement follow-up intervention for grieving mothers after the death of a child

AIM

The aim of this study was to produce information about parental grief intervention and its impacts on maternal grief.

BACKGROUND

The grief after death of a child is a lifelong process. Social support is often stated as the most important factor in coping after the death of a child.

DESIGN

A single measure post-test control group design was used to evaluate whether there are differences in the grief reactions between the mothers in the intervention program (n = 83) and the mothers in the control group (n = 53).

METHOD

The data were collected by using a questionnaire which included background variables and Hogan Grief Reactions Checklist 6 months after the child's death. The data were analysed by statistical methods.

RESULTS

There were no significant differences in the grief reactions between the intervention group and the control group. However, greater support from the healthcare professionals was associated with stronger personal growth. The mothers' age, self-perceived health status and the age of deceased child were associated with the grief reactions. This study emphasises the importance of social support to grieving mothers.

CONCLUSION

Health care professionals are in an important role when considering support for grieving mothers; the given support may relieve the mothers' grief reactions.

Situating and Constructing Diversity in Semi-Structured Interviews

Although semi-structured interviews (SSIs) are used extensively in research, scant attention is given to their diversity, underlying assumptions, construction, and broad applications to qualitative and mixed-method research. In this three-part article, we discuss the following: (a) how the SSI is situated historically including its evolution and diversification, (b) the principles of constructing SSIs, and

Negative Changes in a Couple’s Relationship After a Child’s Death

The purpose of this study was to describe negative changes in parents’ relationships following the death of their child. A request to join the study was presented to members of grief associations through email and websites. Additionally, data were gathered through closed internet-groups where parents who had experienced the death of their child were logged in (e.g. in Facebook). The study participants were mothers (n = 321) and fathers (n = 36) whose child had died. The data were analysed using inductive qualitative content analysis. As negative changes in their relationship following the death of their child, parents reported the following: problems caused by failing mental health, problems due to changes in identity, increased difficulty of emotional communication, and decreased sexual intimacy. In addition, decreased sense of togetherness, behaviour that damages the relationship, everyday life straining the relationship, and emotions straining the relationship. It is concluded that a child’s death brings many kinds of negative changes to the parents’ relationship. The changes manifest as problems in the parents’ interaction, their behaviour, and their emotional life. The results can be utilized in supporting the relationships of grieving parents, developing different kinds of support interventions, and in nursing education.

What do bereaved parents want from professionals after the sudden death of their child: a systematic review of the literature

Background

The death of a child is a devastating event for parents. In many high income countries, following an unexpected death, there are formal investigations to find the cause of death as part of wider integrated child death review processes. These processes have a clear aim of establishing the cause of death but it is less clear how bereaved families are supported. In order to inform better practice, a literature review was undertaken to identify what is known about what bereaved parents want from professionals following an unexpected child death.

Methods

This was a mixed studies systematic review with a thematic analysis to synthesize findings. The review included papers from Europe, North America or Australasia; papers had to detail parents’ experiences rather than professional practices.

Results

The review includes data from 52 papers, concerning 4000 bereaved parents. After a child has died, parents wish to be able to say goodbye to them at the hospital or Emergency Department, they would like time and privacy to see and hold their child; parents may bitterly regret not being able to do so. Parents need to know the full details about their child’s death and may feel that they are being deliberately evaded when not given this information. Parents often struggle to obtain and understand the autopsy results even in the cases where they consented for the procedure. Parents would like follow-up appointments from health care professionals after the death; this is to enable them to obtain further information as they may have been too distraught at the time of the death to ask appropriate questions or comprehend the answers. Parents also value the emotional support provided by continuing contact with health-care professionals.

Conclusion

All professionals involved with child deaths should ensure that procedures are in place to support parents; to allow them to say goodbye to their child, to be able to understand why their child died and to offer the parents follow-up appointments with appropriate health-care professionals.

Electronic supplementary material

The online version of this article (doi:10.1186/1471-2431-14-269) contains supplementary material, which is available to authorized users.

Experiences of african american parents following perinatal or pediatric death: a literature review

A child's death is one of life's most difficult experiences. Little is known about the unique factors that influence the grief experience for bereaved African American parents. Through an integrative review of 10 publications, the authors describe the grief responses, outcomes, and implications for African American parents who experience the death of a child. Four themes emerged: (a) emotional response to loss; (b) factors that added to the burden of loss; (c) coping strategies; and (d) health consequences of grief. Healthcare providers, administrators, and policymakers should be sensitive to the unique needs of African American parents following a child's death.

Parents' experiences of pediatric palliative care and the impact on long-term parental grief

CONTEXT

Approximately 25% of children diagnosed with cancer eventually die. Losing a child puts parents at increased risk for developing psychological problems.

OBJECTIVES

To explore parents' perceptions of the interaction with health care professionals (communication, continuity of care, and parental involvement) and symptom management during the pediatric palliative phase, and to investigate the influence on long-term grief in parents who lost a child to cancer.

METHODS

A total of 89 parents of 57 children who died of cancer between 2000 and 2004 participated in this retrospective cross-sectional study by completing a set of questionnaires measuring grief (Inventory of Traumatic Grief), parents' perceptions of the interaction with health care professionals (communication, continuity of care, and parental involvement), and symptom management during the palliative phase. Care was assessed on a five point Likert scale (1=disagree and 5=agree).

RESULTS

Parents highly rated communication (4.6±0.6), continuity of care (4.3±0.6), and parental involvement (4.6±0.7) during the palliative phase. Parents' most often reported physical and psychological symptoms of their child during the palliative phase were fatigue (75%), pain (74%), anxiety to be alone (52%), and anger (48%). Higher ratings of parents on communication (β=-9.08, P=0.03) and continuity of care (β=-11.74, P=0.01) were associated with lower levels of long-term parental grief. The severity of the child's dyspnea (β=2.96, P=0.05), anxiety to be alone (β=4.52, P<0.01), anxiety about the future (β=5.02, P<0.01), anger (β=4.90, P<0.01), and uncontrolled pain (β=6.60, P<0.01) were associated with higher levels of long-term parental grief. Multivariate models combining the interaction with health care professionals and symptom management showed a significant influence of both aspects on long-term parental grief.

CONCLUSION

Both interaction with health care professionals, especially communication and continuity of care, and symptom management in children dying of cancer are associated with long-term parental grief levels.

The duty of the physician to care for the family in pediatric palliative care: context, communication, and caring

Pediatric palliative care physicians have an ethical duty to care for the families of children with life-threatening conditions through their illness and bereavement. This duty is predicated on 2 important factors: (1) best interest of the child and (2) nonabandonment. Children exist in the context of a family and therefore excellent care for the child must include attention to the needs of the family, including siblings. The principle of nonabandonment is an important one in pediatric palliative care, as many families report being well cared for during their child's treatment, but feel as if the physicians and team members suddenly disappear after the death of the child. Family-centered care requires frequent, kind, and accurate communication with parents that leads to shared decision-making during treatment, care of parents and siblings during end-of-life, and assistance to the family in bereavement after death. Despite the challenges to this comprehensive care, physicians can support and be supported by their transdisciplinary palliative care team members in providing compassionate, ethical, and holistic care to the entire family when a child is ill.

Losing a child: finding meaning in bereavement

BACKGROUND

Confronting the loss of a loved one leads us to the core questions of human existence. Bereaved parents have to deal with the rupture of a widely shared concept of what is perceived to be the natural course of life and are forced into meaning reconstruction.

OBJECTIVE

This study aims to expand upon existing work concerning specific themes of meaning reconstruction in a sample of bereaved parents. More specifically, the relationship between meaning reconstruction, complicated grief, and posttraumatic growth was analyzed, with special attention focused on traumatic and unexpected losses.

METHOD

In a mixed methods approach, themes of meaning reconstruction (sense-making and benefit-finding) were assessed in in-depth interviews with a total of 30 bereaved parents. Posttraumatic growth and complicated grief were assessed using standardized questionnaires, and qualitative and quantitative results were then merged using data transformation methods.

RESULTS

In total 42 themes of meaning reconstruction were abstracted from oral material. It was shown that sense-making themes ranged from causal explanations to complex philosophical beliefs about life and death. Benefit-finding themes contained thoughts about personal improvement as well as descriptions about social actions. Significant correlations were found between the extent of sense-making and posttraumatic growth scores (r s=0.54, r s=0.49; p<0.01), especially when the death was traumatic or unexpected (r s=0.67, r s=0.63; p<0.01). However, analysis revealed no significant correlation with complicated grief. Overall results corroborate meaning reconstruction themes and the importance of meaning reconstruction for posttraumatic growth.

Untold stories of infant loss: the importance of contact with the baby for bereaved parents

This article presents secondary analysis of data from parents who, 50 to 70 years ago, birthed stillborn babies or babies with lethal anomalies and from adult children born after these losses. The stories reflect a time in history when parents were "protected" from seeing or holding their babies and mothers were unable to attend the funeral. There was no understanding by society or caregivers for parents' need to process the loss or resources to build memories. They provide a strong argument for health care providers to offer such resources to parents today and offer grief support.

A sibling death in the family: common and consequential

Although a large literature analyzes the determinants of child mortality and suggests policy and medical interventions aimed at its reduction, there is little existing analysis illuminating the consequences of child mortality for other family members. In particular, there is little evidence exploring the consequences of experiencing the death of a sibling on one's own development and transition to adulthood. This article examines the prevalence and consequences of experiencing a sibling death during one's childhood using two U.S. data sets. We show that even in a rich developed country, these experiences are quite common, affecting between 5 % and 8 % of the children with one or more siblings in our two data sets. We then show that these experiences are associated with important reductions in years of schooling as well as a broad range of adult socioeconomic outcomes. Our findings also suggest that sisters are far more affected than brothers and that the cause of death is an important factor in sibling effects. Overall, our findings point to important previously unexamined consequences of child mortality, adding to the societal costs associated with childhood mortality as well as suggesting additional benefits from policy and medical innovations aimed at curbing both such deaths and subsequent effects on family members.

Systematic review of psychosocial morbidities among bereaved parents of children with cancer

The objective of this review was to comprehensively summarize existing studies utilizing validated instruments to measure psychosocial outcomes among bereaved parents of children with cancer. This population has increased risks of anxiety, depression, prolonged grief, and poor quality of life. Parental morbidity is associated with psychiatric co-morbidities, prior loss, economic hardship, duration, and intensity of child's cancer-therapy, perceptions of medical care, child's quality of life, preparedness for and location of the child's death. Rigorous, prospective research is needed to identify risk-groups, define outcomes, and design interventions which will improve parental outcomes after the death of a child due to cancer.

Swedish parents' experiences of parenthood and the need for support to siblings when a baby is stillborn

BACKGROUND

It has been argued that having a stillborn baby in the family affects older siblings more than parents realize. The aim of this study was to describe parenthood and the needs of siblings after stillbirth from the parents' perspective.

METHODS

Six focus groups were held with 27 parents who had experienced a stillbirth and who had had children before the loss. The discussion concerned parents' support to the siblings, and the sibling's meeting, farewell, and memories of their little sister or brother. Data were analyzed using qualitative content analysis.

RESULTS

The overall theme of the findings was parenthood in a balance between grief and everyday life. In the analysis, three categories emerged that described the construction of the theme: support in an acute situation, sharing the experiences within the family, and adjusting to the situation.

CONCLUSIONS

The siblings' situation is characterized by having a parent who tries to maintain a balance between grief and everyday life. Parents are present and engaged in joint activities around the stillbirth together with the siblings of the stillborn baby. Although parents are aware of the sibling's situation, they feel that they are left somewhat alone in their parenthood after stillbirth and therefore need support and guidance from others.

Sexuality following the loss of a child

The aim of study was to increase our understanding of sexuality and intimacy following the loss of a child. A questionnaire on intimacy and sexuality was sent to 1,027 members of the 2 major bereavement support organizations for parents who have lost children in Norway. A total of 321 (33%) were returned. In addition, 10 couples were interviewed in depth about their experiences. The final sample (n = 285) consisted of 169 women (59.3%) and 116 men (40.7%) who represented 175 couples. Parents who were neither married nor cohabitants were excluded, as were nonbiological parents. Around 2/3 of the parents had resumed sexual contact within the first 3 months after their child's death. The activity of about 1/3 had been reduced. Significantly fewer mothers than fathers experienced sexual pleasure and close to 30% of the mothers reported that this had been reduced since the death. Only 11% noted that sexuality as an issue was raised in follow-up conversations. Many parents have only a few sexuality-related problems following a child's death, but a fairly large minority, especially women, experience major problems, There are clear gender differences in reactions and perceptions, often agreed upon by the 2 genders. Men are ready to resume activity in the sexual area much earlier than women. Women suffer much more from grief that in different ways intrudes on the sexual act and they more often perceive sex as somehow being wrong. Men also easily misunderstand women's need for closeness as a wish for sex.

Siblings' farewell to a stillborn sister or brother and parents' support to their older children: a questionnaire study from the parents' perspective

This study aims to capture parental descriptions of how siblings take leave of and mourn a stillborn brother or sister and how their parents support them. Data were collected by questionnaires from 16 parents of siblings to a stillborn child one year after the stillbirth. Data were analysed numerically for the multiple-choice questions and content analysis was used for parental comments and descriptions. The results describe siblings' farewell to a stillborn brother or sister and how their parents in the midst of their own grief were involved in supporting siblings' wellbeing, and observed their mourning reactions. Although the findings need to be interpreted with caution, they may provide insight that enables staff to become more sensitive to the whole family experience in the practice of their profession. Further research into siblings' grief and parental support after stillbirth is crucial so that further light may be shed on their situation.

Acts of resistance: breaking the silence of grief following traffic crash fatalities

Theoretical arguments and empirical evidence demonstrate the limited utility of a narrow construction of "normal" grief. Sudden and violent death, the young age of the deceased, and perceptions of death preventability are associated with grief reactions that extend beyond an expected grief response. Interviews were conducted with 21 adults bereaved through the death of a family member in a traffic crash. We present their attempts to resist notions of "working through" grief and "recovery" from it and consider how the participants' constructions of an alternative discourse, or normative narrative, possess the potential to challenge a prevailing grief discourse.

Therapeutic Effects of Psychological Autopsies

Background. Several authors have observed a therapeutic impact of the psychological autopsy on the interviewee, although they do not explicitly define what aspects of the process were helpful. Aims. This article aims to identify these therapeutic effects and to discuss their potential impact on participants’ narratives. Methods. This article derives from 35 psychological autopsy interviews that were conducted to better understand adolescent and young adult suicide. Interviews lasted approximately 6 to 8 h each and consisted of both a battery of questionnaires and open-ended questions. They were mostly conducted with the families of the deceased, including parents and siblings, and on occasion were done with a single family member or friend. The time elapsed since the suicide ranged from 6 to 18 months. Results. Psychological autopsies were helpful to interviewees in allowing them to find meaning in the suicide, to find purpose through their altruistic participation, to obtain psychological support, to experience connectedness with others, to accept the loss as real, and to gain insight into their functioning. Negative reactions to the interviews, albeit uncommon, are also briefly described. Conclusions. We recommend that interviewers receive preparatory training and ongoing supervision while conducting interviews, to assure a reflective and professional stance.

Meaning-making in the aftermath of sudden infant death syndrome

The reconstruction of meaning in the aftermath of sudden infant death syndrome (SIDS) is part of the grieving process but has to date been poorly understood. Earlier theorists including Freud, Bowlby and Kübler-Ross provided a foundation for what occurs during this time using stage theories. More recent researchers, often using qualitative techniques, have provided a more complex and expanded view that enhances our knowledge of meaning reconstruction following infant loss. This overview of representative contemporary authors compares and contrasts them with the longstanding models that are being supplanted within the emerging field of thanatology. Understanding parental reactions within this new framework can help healthcare professionals in dealing with those affected by SIDS and provide a more empathic and sensitive approach to individual differences. Parents' own accounts of their post-SIDS experience are consistent with these newer theories. Comprehending how parents cope and reconstruct their lives is an important element in providing appropriate psychological support services.