Early educational and behavioral RCT interventions to reduce maternal symptoms of psychological trauma following preterm birth: a systematic review

Providing "Compassionate Care" in the Neonatal Intensive Care Unit Through Infant and Family Needs-Based Care

OBJECTIVE

Provision of compassionate care to infants and their families in the neonatal intensive care unit (NICU) is a key component of competent critical care. Although recognized as an essential aspect of NICU care, compassionate care for infants and families in a NICU setting has been underexplored. This study defined and described compassionate care according to NICU staff.

STUDY DESIGN

Voice-recorded, face-to-face individual interviews occurred with NICU nurses (n = 45), NICU nurse practitioners (n = 15), and neonatologists (n = 9) from two NICUs in the midwestern United States. Semantic content analysis was used. Consolidated criteria for Reporting Qualitative research guidelines were followed.

RESULTS

Three dynamic and interactive qualitative themes emerged: excellent standard of intensive care, commitment, and engaged family communication. A conceptual framework entitled patient and family needs-based care was developed from the qualitative interviews.

CONCLUSION

The framework developed from this study supports the therapeutic journey of NICU infants and families by integrating a focus on compassionate personalized care within the context of keen clinical and communication skillsets that staff have gained throughout their NICU careers.

KEY POINTS

· While clinical competence is emphasized as a practice standard, compassion remains a core care value.. · A working definition of compassionate care and the description of its defining pillars has been underexplored.. · This study describes the perspectives of NICU staff on the actionable components of compassionate care for ill infant and their families..

Methodological Insights on Recruitment and Retention From a Remote Randomized Controlled Trial Examining the Effectiveness of an Alcohol Reduction App: Descriptive Analysis Study

BACKGROUND

Randomized controlled trials (RCTs) with no in-person contact (ie, remote) between researchers and participants offer savings in terms of cost and time but present unique challenges.

OBJECTIVE

The goal of this study is to examine the differences between different forms of remote recruitment (eg, National Health Service [NHS] website, social media, and radio advertising) in the proportion of participants recruited, demographic diversity, follow-up rates, and cost. We also examine the cost per participant of sequential methods of follow-up (emails, phone calls, postal surveys, and postcards). Finally, our experience with broader issues around study advertising and participant deception is discussed.

METHODS

We conducted a descriptive analysis of 5602 increasing-and-higher-risk drinkers (Alcohol Use Disorders Identification Test score ≥8), taking part in a 2-arm, parallel group, remote RCT with a 1:1 allocation, comparing the intervention (Drink Less app) with usual digital care (NHS alcohol advice web page). Participants were recruited between July 2020 and March 2022 and compensated with gift vouchers of up to £36 (a currency exchange rate of £1=US $1.26988 is applicable) for completing follow-up surveys, with 4 stages of follow-up: email reminders, phone calls, postal survey, and postcard.

RESULTS

The three main recruitment methods were advertisements on (1) social media (2483/5602, 44.32%), (2) the NHS website (1961/5602, 35.01%), and (3) radio and newspapers (745/5602, 13.3%), with the remaining methods of recruitment accounting 7.37% (413/5602) of the sample. The overall recruitment cost per participant varied from £0 to £11.01. Costs were greater when recruiting participants who were men (£0-£28.85), from an ethnic minority group (£0-£303.81), and more disadvantaged (£0-£49.12). Targeted approaches were useful for recruiting more men but less useful in achieving diversity in ethnicity and socioeconomic status. Follow-up at 6 months was 79.58% (4458/5602). Of those who responded, 92.4% (4119/4458) responded by email. Each additional stage of follow-up resulted in an additional 2-3 percentage points of the overall sample being followed up, although phone calls, postal surveys, and postcards were more resource intensive than email reminders.

CONCLUSIONS

For remote RCTs, researchers could benefit from using a range of recruitment methods and cost-targeted approaches to achieve demographic diversity. Automated emails with substantial financial incentives for prompt completion can achieve good follow-up rates, and sequential, offline follow-up options, such as phone calls and postal surveys, can further increase follow-up rates but are comparatively expensive. We also make broader recommendations focused on striking the right balance when designing remote RCTs. Careful planning, ongoing maintenance, and dynamic decision-making are required throughout a trial to balance the competing demands of participation among those eligible, deceptive participation among those who are not eligible, and ensuring no postrandomization bias is introduced by data-checking protocols.

Early Intervention for Children Aged 0 to 2 Years With or at High Risk of Cerebral Palsy: International Clinical Practice Guideline Based on Systematic Reviews

IMPORTANCE

Cerebral palsy (CP) is the most common childhood physical disability. Early intervention for children younger than 2 years with or at risk of CP is critical. Now that an evidence-based guideline for early accurate diagnosis of CP exists, there is a need to summarize effective, CP-specific early intervention and conduct new trials that harness plasticity to improve function and increase participation. Our recommendations apply primarily to children at high risk of CP or with a diagnosis of CP, aged 0 to 2 years.

OBJECTIVE

To systematically review the best available evidence about CP-specific early interventions across 9 domains promoting motor function, cognitive skills, communication, eating and drinking, vision, sleep, managing muscle tone, musculoskeletal health, and parental support.

EVIDENCE REVIEW

The literature was systematically searched for the best available evidence for intervention for children aged 0 to 2 years at high risk of or with CP. Databases included CINAHL, Cochrane, Embase, MEDLINE, PsycInfo, and Scopus. Systematic reviews and randomized clinical trials (RCTs) were appraised by A Measurement Tool to Assess Systematic Reviews (AMSTAR) or Cochrane Risk of Bias tools. Recommendations were formed using the Grading of Recommendations Assessment, Development, and Evaluation (GRADE) framework and reported according to the Appraisal of Guidelines, Research, and Evaluation (AGREE) II instrument.

FINDINGS

Sixteen systematic reviews and 27 RCTs met inclusion criteria. Quality varied. Three best-practice principles were supported for the 9 domains: (1) immediate referral for intervention after a diagnosis of high risk of CP, (2) building parental capacity for attachment, and (3) parental goal-setting at the commencement of intervention. Twenty-eight recommendations (24 for and 4 against) specific to the 9 domains are supported with key evidence: motor function (4 recommendations), cognitive skills (2), communication (7), eating and drinking (2), vision (4), sleep (7), tone (1), musculoskeletal health (2), and parent support (5).

CONCLUSIONS AND RELEVANCE

When a child meets the criteria of high risk of CP, intervention should start as soon as possible. Parents want an early diagnosis and treatment and support implementation as soon as possible. Early intervention builds on a critical developmental time for plasticity of developing systems. Referrals for intervention across the 9 domains should be specific as per recommendations in this guideline.

The Effect of Problem-Solving-Approach-Based Counselling on Maternal Role Adaptation in Women with Late Preterm Infant: A Randomized Controlled Trial

Introduction: Mothers with preterm infants experience numerous stressful problems which can have negative effects on maternal role adaptation. This study aimed to investigate the effectiveness of consultation using a problem-solving approach on adaptation to the maternal role in women with late preterm infants.

Methods: This randomized controlled trial (RCT) was carried out on 80 women with spontaneous late preterm infants recruited at Ayatollah Mousavi Hospital of Zanjan. Using convenience sampling method, the participants were assigned into two groups of intervention and control according to block design. Taking a problem-solving approach, counselling was carried out individually in four sessions. The control group received only routine care. The data were collected using adaptation to maternal role questionnaire including 33 items based on a five-point Likert scale ranging in seven areas, in two steps (before counselling and one month after the last counselling session). Data analysis was performed using the SPSS ver. 16.0 software (SPSS, Inc., Chicago, IL).

Results: The total score of adaptations to maternal role and its areas was significantly higher in the intervention group after the follow-up period.

Conclusion: A comprehensive counselling including various dimensions of maternity adaptation had a positive effect on improving the adaptation to maternal role in mothers with late preterm infants.

Association between extremely preterm caesarean delivery and maternal depressive and anxious symptoms: a national population-based cohort study

OBJECTIVE

To evaluate whether caesarean delivery before 26 weeks of gestation was associated with symptoms of depression and anxiety in mothers in comparison with deliveries between 26 and 34 weeks.

DESIGN

Prospective national population-based EPIPAGE-2 cohort study.

SETTING

268 neonatology departments in France, March to December 2011.

POPULATION

Mothers who delivered between 22 and 34 weeks and whose self-reported symptoms of depression (Center for Epidemiologic Studies Depression Scale: CES-D) and anxiety (State-Trait Anxiety Inventory: STAI) were assessed at the moment of neonatal discharge.

METHODS

The association of caesarean delivery before 26 weeks with severe symptoms of depression (CES-D ≥16) and anxiety (STAI ≥45) was assessed by weighted and design-based log-linear regression model.

MAIN OUTCOME MEASURES

Severe symptoms of depression and anxiety in mothers of preterm infants.

RESULTS

Among the 2270 women completing CES-D and STAI questionnaires at the time of neonatal discharge, severe symptoms of depression occurred in 25 (65.8%) women having a caesarean before 26 weeks versus in 748 (50.6%) women having a caesarean after 26 weeks. Caesarean delivery before 26 weeks was associated with severe symptoms of depression compared with caesarean delivery after 26 weeks (adjusted relative risk [aRR] 1.42, 95% CI 1.12-1.81) adjusted to neonatal birthweight and severe neonatal morbidity among other factors. There was no evidence of an association between mode of delivery and symptoms of anxiety.

CONCLUSIONS

Mothers having a caesarean delivery before 26 weeks' gestation are at high risk of symptoms of depression and may benefit from specific preventive care.

TWEETABLE ABSTRACT

Mothers having caesarean delivery before 26 weeks' gestation are at high risk of symptoms of depression.

Individualised developmental care for babies and parents in the NICU: Evidence-based best practice guideline recommendations

Advances in neonatal care have improved survival of premature and critically ill infants; and while rates of some long-term neurodevelopmental problems in survivors have improved, such as cerebral palsy, there are others such as learning and behavioural difficulties that have not. The goal of improving long term neurodevelopmental morbidity has led to an increased focus on improving developmental care not only in neonatal long term follow- up clinics but within the NICU itself to capture the period of earliest brain neuroplasticity. The application of a systematic approach to improve practice is considered the most effective strategy for implementing neuroprotective developmentally supportive care. The content of this paper incorporates evidence-based systematic reviews to guide clinicians in the application of developmentally supportive interventions.

"Weathering the storm:" Mothers' and fathers' experiences of parenting a preterm infant

Parenting preterm infants is a unique experience distinct from parenting full-term infants, characterized by a delayed transition to parenthood and limited caregiving opportunities. This study explored mothers' and fathers' lived experiences of parenting during infancy in the context of preterm birth. Semistructured qualitative interviews were conducted with 13 parents (6 fathers, 7 mothers) of preterm infants. Data were analyzed using interpretative phenomenological analysis. Four superordinate themes emerged: (a) An unnatural disaster: The traumatic nature of preterm birth, (b) The immediate aftermath: Disconnected and displaced, (c) Breaking the ice: Moving from frozen to melted, and (d) Aftershocks: Transitioning home. Both parents experienced preterm birth as traumatic. Similarities and differences in mothers' and fathers' experiences were identified. Preterm birth posed challenges for nurturant and social caregiving and resulted in anxiety, hypervigilance, and overprotective parenting behavior. The results highlight the need for trauma-informed care and further research developing and testing empirically based interventions.

Reducing parental trauma and stress in neonatal intensive care: systematic review and meta-analysis of hospital interventions

OBJECTIVE

To classify NICU interventions for parental distress and quantify their effectiveness.

STUDY DESIGN

We systematically reviewed controlled studies published before 2017 measuring NICU parental distress, defined broad intervention categories, and used random-effects meta-analysis to quantify treatment effectiveness.

RESULTS

Among 1643 unique records, 58 eligible trials predominantly studied mothers of preterm infants. Interventions tested in 22 randomized trials decreased parental distress (p < 0.001) and demonstrated improvement beyond 6 months (p < 0.005). In subgroup analyses, complementary/alternative medicine and family-centered instruction interventions each decreased distress symptoms (p < 0.01), with fathers and mothers improving to similar extents. Most psychotherapy studies decreased distress individually but did not qualify for meta-analysis as a group.

CONCLUSION

NICU interventions modestly reduced parental distress. We identified family-centered instruction as a target for implementation and complementary/alternative medicine as a target for further study. Investigators must develop psychosocial interventions that serve NICU parents at large, including fathers and parents of full-term infants.

Early Diagnosis and Treatment of Cerebral Palsy in Children with a History of Preterm Birth

Infants born preterm are at increased risk of cerebral palsy (CP), with the risk increasing with decreasing gestational age. Although preterm children are at increased risk of CP compared with their term-born peers, most preterm children do not have CP and thus, it is important to have a standardized process for detecting those children at high risk of CP early. A combination of clinical history, neuroimaging, and physical examination is recommended to ensure early, accurate diagnosis. Early detection of CP is essential for timely early intervention to optimize outcomes for children and their families.

Commonly occurring adverse birth outcomes and maternal depression: a longitudinal study

OBJECTIVES

Little is known about whether commonly occurring adverse birth outcomes have a long-term impact on the mental health of mothers. The aim of this study was to investigate whether commonly occurring adverse birth outcomes predicted mothers' depressive-symptom trajectories over a 27-year period following the birth of a baby.

STUDY DESIGN

Longitudinal study.

METHODS

Participants comprised a sub-group of women from the longitudinal cohort of the Mater and University of Queensland Study of Pregnancy. Maternal depression was measured at six time points from the first clinic visit of an index pregnancy to 27 years after birth. A semi-parametric mixture model was used to identify three symptom trajectories of low-stable, moderate-stable and moderate-rising depression. Multinomial logistic regression was then used to determine whether a number of commonly occurring birth outcomes predicted moderate-stable and/or moderate-rising depression trajectories over the subsequent 27 years. Sociodemographic and behavioural factors were used to adjust for possible confounding.

RESULTS

After adjustment for potential confounders, none of the adverse birth outcomes predicted subsequent maternal depression trajectories. Teenage pregnancy, not completing high school, low family income, obesity, poorer quality partnership and not exercising, measured at women's first clinic visit, and small social networks at three to five days after birth, were significantly associated with women's moderate-rising depressive-symptoms trajectory over 27 years.

CONCLUSIONS

Commonly occurring adverse birth outcomes do not predict long-term depressive trajectories. A number of sociodemographic and behavioural factors present at the index pregnancy predict women's long-term pattern of depression throughout their reproductive life course.

Eight principles for patient-centred and family-centred care for newborns in the neonatal intensive care unit

Despite the recent improvements in perinatal medical care leading to an increase in survival rates, adverse neurodevelopmental outcomes occur more frequently in preterm and/or high-risk infants. Medical risk factors for neurodevelopmental delays like male gender or intrauterine growth restriction and family sociocultural characteristics have been identified. Significant data have provided evidence of the detrimental impact of overhelming environmental sensory inputs, such as pain and stress, on the developing human brain and strategies aimed at preventing this impact. These strategies, such as free parental access or sleep protection, could be considered 'principles of care'. Implementation of these principles do not require additional research due to the body of evidence. We review the scientific evidence for these principles here.

British Association for Psychopharmacology consensus guidance on the use of psychotropic medication preconception, in pregnancy and postpartum 2017

Decisions about the use of psychotropic medication in pregnancy are an ongoing challenge for clinicians and women with mental health problems, owing to the uncertainties around risks of the illness itself to mother and fetus/infant, effectiveness of medications in pregnancy and risks to the fetus/infant from in utero exposure or via breast milk. These consensus guidelines aim to provide pragmatic advice regarding these issues. They are divided into sections on risks of untreated illness in pregnancy; general principles of using drugs in the perinatal period; benefits and harms associated with individual drugs; and recommendations for the management of specific disorders.

NICU-based Interventions To Reduce Maternal Depressive and Anxiety Symptoms: A Meta-analysis

CONTEXT

Parents whose infants are being treated in the NICU are at high risk for depression and anxiety, with negative implications for parenting and infant development.

OBJECTIVE

We conducted a systematic review and meta-analysis of NICU-based interventions to reduce maternal depressive or anxiety symptoms.

DATA SOURCES

PubMed, Embase, PsychInfo, Cochrane, and CINAHL were searched for relevant studies. Reference lists from selected studies were reviewed.

STUDY SELECTION

Inclusion criteria included randomized controlled design, a parent-focused intervention delivered in the NICU, valid maternal depressive or anxiety symptom measures at pre- and postintervention, and publication in a peer-reviewed journal in English.

DATA EXTRACTION

Data extraction was conducted independently by 2 coders.

RESULTS

Twelve studies met inclusion criteria for qualitative review; 2 were excluded from quantitative analyses for high risk of bias. Fixed- and random-effects models, with 7 eligible studies assessing depressive symptoms, indicated an effect of -0.16 (95% confidence interval [CI], -0.32 to -0.002; P < .05) and, with 8 studies assessing anxiety symptoms, indicated an effect of -0.12 (95% CI, -0.29 to 0.05; P = .17). The subset of interventions using cognitive behavioral therapy significantly reduced depressive symptoms (effect, -0.44; 95% CI, -0.77 to -0.11; P = .01).

LIMITATIONS

The small number and methodological shortcomings of studies limit conclusions regarding intervention effects.

CONCLUSIONS

Combined intervention effects significantly reduced maternal depressive but not anxiety symptoms. The evidence is strongest for the impact of cognitive behavioral therapy interventions on maternal depressive symptoms.

PREMM: preterm early massage by the mother: protocol of a randomised controlled trial of massage therapy in very preterm infants

Background

Preterm infants follow an altered neurodevelopmental trajectory compared to their term born peers as a result of the influence of early birth, and the altered environment. Infant massage in the preterm infant has shown positive effects on weight gain and reduced length of hospital stay. There is however, limited current evidence of improved neurodevelopment or improved attachment, maternal mood or anxiety. The aim of this study is to investigate the effects of infant massage performed by the mother in very preterm (VPT) infants. Effects on the infant will be assessed at the electrophysiological, neuroradiological and clinical levels.  Effects on maternal mood, anxiety and mother-infant attachment will also be measured.

Methods/Design

A randomised controlled trial to investigate the effect of massage therapy in VPT infants. Sixty VPT infants, born at 28 to 32 weeks and 6 days gestational age, who are stable, off supplemental oxygen therapy and have normal cranial ultrasounds will be recruited and randomised to an intervention (infant massage) group or a control (standard care) group. Ten healthy term born infants will be recruited as a reference comparison group. The intervention group will receive standardised massage therapy administered by the mother from recruitment, until term equivalent age (TEA). The control group will receive care as usual (CAU). Infants and their mothers will be assessed at baseline, TEA, 12 months and 24 months corrected age (CA), with a battery of clinical, neuroimaging and electrophysiological measures, as well as structured questionnaires, psychoanalytic observations and neurodevelopmental assessments.

Discussion

Optimising preterm infant neurodevelopment is a key aim of neonatal research, which could substantially improve long-term outcomes and reduce the socio-economic impact of VPT birth. This study has the potential to give insights into the mother-baby relationship and any positive effects of infant massage on neurodevelopment. An early intervention such as massage that is relatively easy to administer and could alter the trajectory of preterm infant brain development, holds potential to improve neurodevelopmental outcomes in this vulnerable population.

Trial registration

Australian New Zealand Clinical Trials Registry: ACTRN12612000335897. Date registered: 22/3/2012.

Depression and anxiety symptoms of mothers of preterm infants are decreased at 4 months corrected age with Family Nurture Intervention in the NICU

Preterm delivery can precipitate maternal psychological morbidities. Family Nurture Intervention (FNI) was designed to minimize these by facilitating the emotional connection between mother and infant, beginning early in the infant's neonatal intensive care unit (NICU) stay. We examined depression and anxiety symptoms of mothers of preterm infants at 4 months infant corrected age (CA). One hundred fifteen mothers who delivered between 26 and 34 weeks gestational age were randomized to receive standard care (SC) or standard care plus FNI. Mothers' self-reported depressive symptoms (Center for Epidemiologic Studies Depression Scale: CES-D) and state anxiety (Spielberger State-Trait Anxiety Inventory: STAI) symptoms were assessed at enrollment, near to term age, and 4 months (CA). At 4 months CA, mean CES-D and STAI scores were significantly lower in FNI mothers compared to SC mothers. Effectiveness of FNI can only be evaluated as an integrated intervention strategy as it was not possible to control all aspects of FNI activities. Although there was considerable loss to follow-up, analyses suggest that resulting biases could have masked rather than inflated the measured effect size for depressive symptoms. FNI may be a feasible and practicable way to diminish the impact of premature delivery on maternal depressive and anxiety symptoms.

Depression Management by NICU Nurses

The purpose of this article was to evaluate attitudes of mothers of newborns hospitalized on the neonatal intensive care unit (NICU) toward nurse-delivered depression screening and counseling. NICU mothers ( N = 200) completed questionnaires assessing their views toward being screened for depression by nurses, treatment provider preference, and interest in learning about Listening Visits (LV), a nurse-delivered intervention. The views of 23 LV recipients were also assessed. Most mothers were receptive to depression screening by nurses, two thirds would see a nurse for counseling, and half were interested in learning more about LV. Among LV recipients, half readily embraced the idea and the remaining recipients were skeptical but opted to try. After receiving LV, recipients unanimously rated LV and the skill of the LV provider highly. Screening and counseling by NICU nurses could increase detection of depression and treatment use among at-risk women. Assessing nurses’ perspectives about implementing this model of care is an important future research direction.