Effect of neonatal complications in premature infants on early parent-infant interactions

Maternal stress experiences with neonatal intensive care unit admissions

Background

Mother experiences variety of stressors related to premature birth, baby’s medical condition, unpleasant neonatal intensive care unit (NICU) environment and intuit liability of the infant. Identifying factors that causes stress may be useful in assisting health personnel in understanding their importance and in improving the quality of care. Objective of the study is to assess the stress levels of mothers whose neonate is admitted to the NICU as measured by Parental Stress Scale: Neonatal Intensive Care Unit (PSS: NICU).

Methods

This prospective analytical study was conducted in NICU of a tertiary care hospital over a period of 12 months after obtaining permission from the institutional ethics committee. The self-administered questionnaire comprising questions on: sights and sounds experienced in NICU, baby’s looks and behaviour, parental role and relationship with her baby were collected. The mean score and standard deviation were calculated for each component of PSS: NICU Scale and mean scores are compared.

Results

Mothers having full term babies have experienced more stress than those having pre-term babies. As measured by PSS-NICU scale the highest mean scores of 2.3 ± 0.57, 4.36 ± 0.53, 4.43 ± 0.58 were obtained for questions “The other sick babies in the room” component of Sight and Sound, “Seeing my baby looking sick” Component of Looks and Behaviour, “Being separated from my baby” Component of Parental Role and Relationship respectively.

Conclusion

Present study summarises the overall impact of NICU environmental stressors affecting mothers in a developing country and also emphasises the need for further studies in this area for identification of factors that contribute to maternal stress. It may enable health professionals to facilitate mothers’ adaptation, thereby promoting optimal mother–infant relationships and subsequent infant development.

Parent-child bonding and attachment during pregnancy and early childhood following congenital heart disease diagnosis

Diagnosis and treatment of congenital heart disease (CHD) can present challenges to the developing parent-child relationship due to periods of infant hospitalization and intensive medical care, parent-infant separations, child neurodevelopmental delay and feeding problems, and significant parent and child distress and trauma. Yet, the ways in which CHD may affect the parent-child relationship are not well-understood. We systematically reviewed the evidence on parental bonding, parent-child interaction, and child attachment following CHD diagnosis, according to a pre-registered protocol (CRD42019135687). Six electronic databases were searched for English-language studies comparing a cardiac sample (i.e., expectant parents or parents and their child aged 0-5 years with CHD) with a healthy comparison group on relational outcomes. Of 22 unique studies, most used parent-report measures (73%) and yielded mixed results for parental bonding and parent-child interaction quality. Observational results also varied, although most studies (4 of 6) found difficulties in parent-child interaction on one or more affective or behavioural domains (e.g., lower maternal sensitivity, lower infant responsiveness). Research on parental-fetal bonding, father-child relationships, and child attachment behaviour was lacking. Stronger evidence is needed to determine the nature, prevalence, and predictors of relational disruptions following CHD diagnosis, and to inform targeted screening, prevention, and early intervention programs for at-risk dyads.

An Observational Study on Early Dyadic Interactive Behaviors of Mothers With Early-Preterm, Late-Preterm, and Full-Term Infants in Malawi

BACKGROUND

Mother-infant interactions are necessary for infant growth and development. However, preterm birth is associated with less positive mother-infant interactions than full-term birth. Malawi has the highest preterm birth rate in the world, but studies of the mother-infant relationship in Malawi are limited and studies that observed mother-infant interactions could not be located.

PURPOSE

This study explored mother-infant interactions among Malawian mothers of early-preterm, late-preterm, and full-term infants.

METHODS

This observational study explored maternal and infant interactive behaviors. We recruited 83 mother-infant dyads (27 early-preterm, 29 late-preterm, and 27 full-term dyads).

FINDINGS

Mothers of early-preterm infants looked at and rocked their infants less, and their infants looked at their mothers less, than mothers of either late-preterm infants or full-term infants. The infants in all groups were asleep most of the time, which contributed to low levels of interactive behaviors. Factors that were related to infant behaviors included marital status, maternal occupation, maternal education, infant medical complications, infant gender, history of neonatal deaths, and multiple births.

IMPLICATIONS FOR PRACTICE

Our findings provide evidence about the need to encourage mothers to engage interactive behaviors with their infants.

IMPLICATIONS FOR RESEARCH

Future studies of factors that contribute to positive interactions in Malawi are needed.

The Level and Sources of Stress in Mothers of Infants Admitted in Neonatal Intensive Care Unit

BACKGROUND

Hospitalization of a new-born child is stressful for parents. This study was done to determine the level and sources of stress in mothers of infants admitted in Neonatal Intensive Care Unit (NICU) and variance in stress by infant and maternal characteristics.

MATERIALS AND METHODS

Parental Stressor Scale for NICU was used as the primary outcome measure. Maternal socio-demography, maternal and infant characteristics such as gravidity, number of prenatal visits, perceived support from family members, perceived level of discomfort that the baby underwent, pregnancy and delivery complications, gestational age, sex, birth weight, length of NICU stay and ventilator support, and neonatal morbidity were also collected from maternal and infant hospital records.

RESULTS

Amongst these rural and poorly educated mothers, the appearance of the baby, sights and sounds of NICU environment were major sources of stress. Higher maternal stress was found to be associated with poor family support during pregnancy, mothers' perception of the baby's discomfort, lower birth weight of the baby, baby on ventilator, post-partum depression, and moderate to severe anxiety symptoms. Mothers who had higher levels of education and those with pregnancy complications were more stressed.

CONCLUSIONS

Before designing remediation programs for parents, local demography and the predominant NICU stressors need to be kept in mind. Possibility of screening at-risk mothers by questioning them about perception of baby's discomfort needs to be evaluated further.

Reducing toxic stress in the neonatal intensive care unit to improve infant outcomes

In 2011, the American Academy of Pediatrics (AAP) published a technical report on the lifelong effects of early toxic stress on human development, and included a new framework for promoting pediatric health: the Ecobiodevelopmental Framework for Early Childhood Policies and Programs. We believe that hospitalization is a specific form of toxic stress for the neonatal patient, and that toxic stress must be addressed by the nursing profession in order to substantially improve outcomes for the critically ill neonate. Approximately 4% of normal birthweight newborns and 85% of low birthweight newborns are hospitalized each year in the highly technological neonatal intensive care unit (NICU). Neonates are exposed to roughly 70 stressful procedures a day during hospitalization, which can permanently and negatively alter the infant's developing brain. Neurologic deficits can be partly attributed to the frequent, toxic, and cumulative exposure to stressors during NICU hospitalization. However, the AAP report does not provide specific action steps necessary to address toxic stress in the NICU and realize the new vision for pediatric health care outlined therein. Therefore, this paper applies the concepts and vision laid out in the AAP report to the care of the hospitalized neonate and provides action steps for true transformative change in neonatal intensive care. We review how the environment of the NICU is a significant source of toxic stress for hospitalized infants. We provide recommendations for caregiving practices that could significantly buffer the toxic stress experienced by hospitalized infants. We also identify areas of research inquiry that are needed to address gaps in nursing knowledge and to propel nursing science forward. Finally, we advocate for several public policies that are not fully addressed in the AAP technical report, but are vital to the health and development of all newborns.

Maternal Sensitivity in Parenting Preterm Children: A Meta-analysis

BACKGROUND AND OBJECTIVES

Preterm birth is a significant stressor for parents and may adversely impact maternal parenting behavior. However, findings have been inconsistent. The objective of this meta-analysis was to determine whether mothers of preterm children behave differently (eg, less responsive or sensitive) in their interactions with their children after they are discharged from the hospital than mothers of term children.

METHODS

Medline, PsychInfo, ERIC, PubMed, and Web of Science were searched from January 1980 through May 2014 with the following keywords: "premature", "preterm", "low birth weight" in conjunction with "maternal behavio*r", "mother-infant interaction", "maternal sensitivity", and "parenting". Both longitudinal and cross-sectional studies that used an observational measure of maternal parenting behavior were eligible. Study results relating to parenting behaviors defined as sensitivity, facilitation, and responsivity were extracted, and mean estimates were combined with random-effects meta-analysis.

RESULTS

Thirty-four studies were included in the meta-analysis. Mothers of preterm and full-term children did not differ significantly from each other in terms of their behavior toward their children (Hedges' g = -0.07; 95% confidence interval: -0.22 to 0.08; z = -0.94; P = .35). The heterogeneity between studies was significant and high (Q = 156.42; I(2) = 78.9, P = .001) and not explained by degree of prematurity, publication date, geographical area, infant age, or type of maternal behavior.

CONCLUSIONS

Mothers of preterm children were not found to be less sensitive or responsive toward their children than mothers of full-term children.

A Preliminary Study of Depressive Symptoms in Mothers of 3-Year-Old Prematurely Born Children

This exploratory study examined the effects of maternal depressive symptoms on mothers' perceptions of their 3-year-old prematurely born children, interactive behaviors, and child outcomes. Mother and child interactive behaviors were coded from naturalistic observations in their homes. Education and marital status were found to be significantly related to maternal depressive symptoms. Factor analyses were conducted to determine the most prominent behaviors related to maternal depressive symptoms. In a small sample of mothers, the quality of the maternal-child relationship was negatively affected by elevated depressive symptoms. Mothers of prematurely born children may report depressive symptoms that continue into early childhood.

The effectiveness of video interaction guidance in parents of premature infants: a multicenter randomised controlled trial

Background

Studies have consistently found a high incidence of neonatal medical problems, premature births and low birth weights in abused and neglected children. One of the explanations proposed for the relation between neonatal problems and adverse parenting is a possible delay or disturbance in the bonding process between the parent and infant. This hypothesis suggests that due to neonatal problems, the development of an affectionate bond between the parent and the infant is impeded. The disruption of an optimal parent-infant bond -on its turn- may predispose to distorted parent-infant interactions and thus facilitate abusive or neglectful behaviours. Video Interaction Guidance (VIG) is expected to promote the bond between parents and newborns and is expected to diminish non-optimal parenting behaviour.

Methods/design

This study is a multi-center randomised controlled trial to evaluate the effectiveness of Video Interaction Guidance in parents of premature infants. In this study 210 newborn infants with their parents will be included: n = 70 healthy term infants (>37 weeks GA), n = 70 moderate term infants (32–37 weeks GA) which are recruited from maternity wards of 6 general hospitals and n = 70 extremely preterm infants or very low birth weight infants (<32 weeks GA) recruited by the NICU of 2 specialized hospitals. The participating families will be divided into 3 groups: a reference group (i.e. full term infants and their parents, receiving care as usual), a control group (i.e. premature infants and their parents, receiving care as usual) and an intervention group (i.e. premature infants and their parents, receiving VIG). The data will be collected during the first six months after birth using observations of parent-infant interactions, questionnaires and semi-structured interviews. Primary outcomes are the quality of parental bonding and parent-infant interactive behaviour. Parental secondary outcomes are (posttraumatic) stress symptoms, depression, anxiety and feelings of anger and hostility. Infant secondary outcomes are behavioral aspects such as crying, eating, and sleeping.

Discussion

This is the first prospective study to empirically evaluate the effect of VIG in parents of premature infants. Family recruitment is expected to be completed in January 2012. First results should be available by 2012.

Trail registration number

NTR3423

Perinatal assessment of infant, parents, and parent-infant relationship: prematurity as an example

This article reviews the stresses for parents, infants, and other caregivers during the period surrounding the birth of the premature infant. Principles of assessment of infant discomfort, parental stress, the parent-infant relationship, and the match of the medical caregiving environment to the individual infant's needs are discussed. Relevant tools to aide in these aspects of assessment are reviewed. The role of early assessment as preventive intervention and the indication for subsequent intervention in complicated cases of premature infants and their parents are further discussed. The article offers detailed clinical examples to illustrate these and other points throughout.

Early interventions involving parents to improve neurodevelopmental outcomes of premature infants: a meta-analysis

OBJECTIVE

To determine in a systematic review, whether interventions for infant development that involve parents, improve neurodevelopment at 12 months corrected age or older.

STUDY DESIGN

Randomized trials were identified where an infant intervention was aimed to improve development and involved parents of preterms; and long-term neurodevelopment using standardized tests at 12 months (or longer) was reported.

RESULT

Identified studies (n=25) used a variety of interventions including parent education, infant stimulation, home visits or individualized developmental care. Meta-analysis at 12 months (N=2198 infants) found significantly higher mental (N=2198) and physical (N=1319) performance scores favoring the intervention group. At 24 months, the mental (N=1490) performance scores were improved, but physical (N=1025) performance scores were not statistically significant. The improvement in neurodevelopmental outcome was not sustained at 36 months (N=961) and 5 years (N=1017).

CONCLUSION

Positive clinically meaningful effects (>5 points) are seen to an age of 36 months, but are no longer present at 5 years.

Making babies real: dressing infants in the NICU

This article presents the physiologic rationale for dressing infants in the NICU. It reports interview responses from mothers and nurses on their feelings about one infant dressing program, proposes a care plan, discusses the advantages and disadvantages of infant dressing, and suggests ideas for related research. The goals of the program described here are to provide preterm and/or sick infants with increased insulation to improve thermoregulation, personalize and normalize care, promote developmentally appropriate care, promote discharge planning, and support all families equally, regardless of socioeconomic status.

Prediction of behavior problems in 4-year-olds born prematurely

Longitudinal follow-up data for 69 very low birthweight preterm infants were used to assess the influence of four factors (neonatal medical complications, infant temperament, mother-child relationships, and family environment) on mother and teacher reports of behavior problems at 4 years. The proposed model of such influences being tested assumed that (1) the effects of neonatal medical factors would be indirect, and (2) each of the other three factors would show high stability from 1 to 4 years and would have a direct influence on behavior problem outcomes. Neither neonatal medical data nor infant-mother attachment were good predictors of behavior problems at age 4. With these exceptions, teacher report of behavior problems was predicted in a fashion consistent with the preliminary model. However, mother reports of behavior problems was predicted only by prior mother reports of child temperament. Discussion focuses on reasons for discrepancies in these pathways of influence.

Newborn Individualized Developmental Care and Assessment Program (NIDCAP) - family-centered developmentally supportive care

The theoretical framework behind family-centered, developmentally supportive care (NIDCAP) is endorsed by research from several scientific fields, including neuroscience, developmental and family psychology, medicine and nursing. However, the introduction of NIDCAP involves a considerable investment at all levels of the organization. NIDCAP requires some physical changes in the NICU as well as substantial educational efforts and changes in the practice of care. The findings of the presented NIDCAP studies have been encouraging, and NIDCAP has been very well received by nursing staff, neonatologists and parents. It also is attractive from an ethical point of view. It appears reasonable to recommend that nurseries implement NIDCAP and investigate developmentally supportive care in different cultural contexts and with diversified, randomized multicenter trials.

Mothers' perception of Newborn Individualized Developmental Care and Assessment Program (NIDCAP) as compared to conventional care

BACKGROUND

Family-centred care according to the Newborn Individualized Developmental Care and Assessment Program (NIDCAP) has been reported to positively influence family function. The aim was to examine if NIDCAP affects the views of prematurely born infants' mothers regarding maternal role, perception of the infant and the neonatal care.

METHOD

Preterm infants with gestational age <32 weeks were randomly assigned to receive either care based on NIDCAP (n=12) or conventional neonatal care (n=13), forming two comparable groups with respect to gestational age, birth weight, female/male ratio, and initial illness severity. A questionnaire was designed to evaluate various aspects of the mothers' attitudes and apprehension of their maternal role, perception of their infant and the neonatal care. The questionnaire was validated and given to the mothers when the infants reached 36 weeks postmenstrual age (PMA).

RESULTS

Ten mothers in each group replied to the questionnaire. The mothers in the NIDCAP-group perceived more closeness to their infants than did the control mothers (p=0.022) and this feeling demonstrated no significant correlation to the infant's gestational age, weight at birth or severity of illness. Furthermore, the mothers in the NIDCAP-group tended to rate the staff's ability to support them in their role as a mother somewhat higher (p=0.066), but at the same time they expressed more anxiety than did the control mothers (p=0.033).

CONCLUSION

Early intervention according to NIDCAP seems to facilitate a feeling of closeness between the mother and her premature infant regardless of the infant's birth weight or health status. The higher level of anxiety in the mothers in the NIDCAP-group, may mirror that the mothers in the NIDCAP-group had already bonded to their infants during the hospital stay.

Unreife bei der Geburt

Zusammenfassung. Mit den Überlebenschancen ist in den vergangenen 20 Jahren auch das Forschungsinteresse an den Entwicklungsmöglichkeiten sehr und extrem unreif geborener Kinder deutlich gestiegen. Dabei stellt sich die Frage nach der Häufigkeit und Schwere von Entwicklungsstörungen, ihren Frühzeichen und dem Einfluss von biologischen und psychosozialen Faktoren auf ihr Entstehen. Überblicksarbeiten beziehen sich zumeist auf die Zusammenstellung der Befunde zur allgemeinen, zur kognitiven und zur motorischen Entwicklung. Dagegen fokussiert der vorliegende Überblick erstmals die zentralen Forschungsfragen auf die Sprachentwicklung unreif geborener Kinder. Angesichts der Heterogenität der Stichproben, des methodischen Vorgehens und der Befunde, wird ihre Beantwortung durch die Extraktion des gemeinsamen Nenners versucht.

Predictors of internalizing symptoms among very low birth weight young women

As part of a longitudinal study of the outcomes of very low birth weight children (<1.5 kg), we sought to examine the perinatal, childhood, and young adult predictors of internalizing symptoms among very low birth weight young women and their normal birth weight controls. The cohort included 125 very low birth weight and 124 normal birth weight 20-year-old subjects. Perinatal, childhood, and young adult predictors were examined via stepwise multivariate analyses. Results revealed very low birth weight to be a significant predictor of parent-reported internalizing symptoms of their daughters but only among white subjects who had mothers with high levels of psychological distress. Additional significant predictors of 20-year internalizing symptoms included child I.Q. and internalizing symptoms at age 8 years and family expressiveness. When the results were analyzed according to the young adult self-report, additional predictors of internalizing symptoms included a history of asthma and exposure to violence. Perinatal risk factors were not found to be predictive of internalizing symptoms at age 20 years. Future studies should prospectively examine social and environmental factors associated with the neonatal intensive care experience that might explain the effect of very low birth weight on later psychopathology.

Early developmental care for preterm neonates: a call for more research

Developmental care is the use of a range of medical and nursing interventions to decrease the stress of preterm neonates in neonatal intensive care units. This article reviews the theory underlying such interventions and research based data in different scientific fields, including neuroscience, developmental and family psychology, medicine, and nursing. The conclusion is that more research is needed.

Prematurity, maternal stress and mother-child interactions

OBJECTIVE

Previous studies have shown that premature birth and the immaturity of the child can affect the quality of the parent-child relationship. The present study examines the relationship between maternal and infant interactional behavior over time and infant perinatal risk factors as well as maternal perinatal recollected traumatic experience. Few studies have explored the relationship between maternal stress and the quality of parent-infant interaction.

DESIGN

Mother-child interaction was recorded at 6 and 18 months of infant's age, in a population of 47 preterm infants (GA<34 weeks) and 25 full-term infants, born in 1998, during a play interaction. According to the Care Index, sensitivity, control and unresponsiveness have been used to code maternal interactional characteristics, and cooperation, compliance-compulsiveness, difficulty and passivity have been used to code the infant's interactional characteristics. The level of maternal stress was evaluated with the Perinatal Posttraumatic Stress Disorder Questionnaire (PPQ), and the infant's perinatal risk factors were assessed with the Perinatal Risk Inventory (PERI).

RESULTS

Mothers of high-risk infants, as well as mothers that had experienced traumatic stress in the perinatal period, were less sensitive and more controlling at 6 months. The interactional behavior of the preterm infant was different from that of the full-term infant at 18 months of age, and was correlated with maternal traumatic stress but not with perinatal risk factors.

CONCLUSION

These results underline the importance of maternal traumatic experience related to premature birth and its potential long lasting influence on mother-child interactional behavior.

Behavioral and social development of children born extremely premature: 5-year follow-up

A cohort of extremely prematurely born children and matched term controls was assessed at 5 years of age. The parents completed a questionnaire on their behavioral and social development. The purpose was to illuminate whether the children's general intellectual ability and parental sensitivity were associated with behavioral and social development. The index children exhibited more hyperactive behavior and had poorer social skills than the controls. Lower Full Scale IQ (FSIQ) was associated with outward reacting and hyperactive behavior and poorer social skills. Sensitive parenting was associated with less outward reacting and less hyperactive behavior. When controlling for differences in FSIQ and parental sensitivity, the index children persisted to have an increased risk of exhibiting hyperactive behavior but not poorer social skills. The index children with normal intellectual development, however, did not exhibit more behavioral problems or poorer social skills than the control children did.

Assessment of parental sensitivity towards pre-school children born with very low birth weight

The article introduces the Parental Sensitivity Assessment Scale (PSAS) and examines the influence of the PSAS score and other factors on the general cognitive level in pre-school children born with very low birth weight (VLBW). McCarthy general cognitive index (GCI) was obtained for 102 VLBW and 92 normal birth weight (NBW) control children in Denmark in the mid-1980s. The mean ages of the two groups were 52.4 vs. 53.1 months. Parental sensitivity was assessed using PSAS. There was no significant difference in the mean PSAS score between the two birth weight groups (p > 0.3). Birth weight group (p < 0.001) and mother's schooling (p= 0.026) significantly correlated with GCI in the children. The PSAS score was highly significantly correlated to the variance of the GCI (p < 0.001), which was not explained by VLBW and mother's schooling. We found no interactional effect between parental sensitivity and birth weight group (p > 0.5) - the prematurely born children were not more affected by low parental sensitivity than were the control children.

Massage for promoting growth and development of preterm and/or low birth-weight infants

BACKGROUND

It has been argued that infants in Neonatal Intensive Care Units are subject both to a highly stressful environment - continuous, high-intensity noise and bright light - and to a lack of the tactile stimulation that they would otherwise experience in the womb or in general mothering care. As massage seems to both decrease stress and provide tactile stimulation, it has been recommended as an intervention to promote growth and development of preterm and low-birth weight infants.

OBJECTIVES

To determine whether preterm and/or low birth-weight infants exposed to massage experience improved weight gain and earlier discharge compared to infants receiving standard care; to determine whether massage has any other beneficial or harmful effects on this population.

SEARCH STRATEGY

The following databases were searched: the specialized register of the Cochrane Neonatal Review Group and that of the Cochrane Complementary Medicine Field. Searches were also undertaken of the Cochrane Central Register of Controlled Trials (CENTRAL, The Cochrane Library, Issue 3, 2003), MEDLINE, EMBASE, Psychlit, CINAHL and Dissertation Abstracts International (up to July 1, 2003). Further references were obtained by citation tracking, checking personal files and by correspondence with appropriate experts. Data provided in published reports was supplemented by information obtained by correspondence with authors. There were no language restrictions.

SELECTION CRITERIA

Randomised trials in which infants with gestational age at birth <37 weeks or weight at birth <2500g received systematic tactile stimulation by human hands. At least one outcome assessing weight gain, length of stay, behaviour or development must be reported.

DATA COLLECTION AND ANALYSIS

Data extracted from each trial were baseline characteristics of sample, weight gain, length of stay and behavioural and developmental outcomes. Physiological and biochemical outcomes were not recorded. Data were extracted by three reviewers independently. Statistical analysis was conducted using the standard Cochrane Collaboration methods.

MAIN RESULTS

Massage interventions improved daily weight gain by 5.1g (95% CI 3.5, 6.7g). There is no evidence that gentle, still touch is of benefit (increase in daily weight gain 0.2g; 95% CI -1.2, 1.6g). Massage interventions also appeared to reduce length of stay by 4.5 days (95% CI 2.4, 6.5) though there are methodological concerns about the blinding of this outcome. There was also some evidence that massage interventions have a slight, positive effect on postnatal complications and weight at 4 - 6 months. However, serious concerns about the methodological quality of the included studies, particularly with respect to selective reporting of outcomes, weaken credibility in these findings.

REVIEWERS' CONCLUSIONS

Evidence that massage for preterm infants is of benefit for developmental outcomes is weak and does not warrant wider use of preterm infant massage. Where massage is currently provided by nurses, consideration should be given as to whether this is a cost-effective use of time. Future research should assess the effects of massage interventions on clinical outcome measures, such as medical complications or length of stay, and on process-of-care outcomes, such as care-giver or parental satisfaction.

Mother-infant interaction in premature infants at three months after nursery discharge

Both the immature and disorganized behaviour of the premature infant and the psychosocial or socioeconomic factors which adversely affect a mother's responsiveness to her premature infant can jeopardize the mother-infant relationship. At three months after infant hospital discharge, the interactions of 50 premature infants (< or = 32 weeks) and their mothers were videotaped and coded using the Nursing Child Assessment Feeding Scale. The relationship between data derived from the feeding interaction and maternal psychosocial and infant perinatal variables collected at one month after birth and at three months after discharge from hospital were examined. Results showed that the mothers' use of coping strategies both in hospital and at home were important factors in explaining mother-infant interaction.

Nursing's Contribution to the Literature on Preterm Labor and Birth

Although preterm labor and birth continues to plague us as an unsolved mystery in maternal/child health, much has actually been learned over the past few decades. Most reviews of the preterm labor literature examine the research in an interdisciplinary manner; this article instead looks at the active role that nurses have taken in the research concerning preterm labor and birth. This article will categorize research conducted by nurses over the past 30 years on preterm labor and birth, emphasizing some of the changes in nursing practice engendered by nursing's important research effort.

Child mental health consultation with families of medically compromised infants

Prematurity and birth defects present parents with a crisis for which they have usually had little preparation and no prior education. Both types of early medical complications may represent a state of suspended animation for most parents. Even large premature infants with good prognoses induce anxiety and symbolize potential death and disability, and children with birth defects may portend years of medical procedures and long-term disability. The fear of serious neurologic impairment or mental retardation presents parents with a long period of ambiguity and chronic anxiety. During this period, they must be helpless observers rather than active participants. Recent research has indicated that the active involvement of parents in the care of their premature infants can be helpful in alleviating the guilt and anxiety related to loss and impairment. Similarly, early physical contact between parents and their severely malformed infant is equally critical. Even if the ultimate complexities of early attachment have yet to be delineated fully, this is a worthwhile practice and useful approach in the nursery. Child mental health professionals have important roles to fulfill in helping staff members deal with increased parental participation and directly managing family members with intense distress related to their infants' fragility. The role of the mental health professional in such consultation may cover five related tasks: 1. Understanding the nature of the biologic issues facing the child and integrating that understanding with an evaluation of the child's neurobehavioral profile. 2. Understanding the family's relationship with the child and their overall level of functioning during an acutely stressful time. 3. Developing an appreciation of the place of the child in his or her family and how the parents understand the nature of the medical problems. 4. Forming a collaborative relationship with the pediatricians and other subspecialists who care for the child so that behavioral and psychological interventions are integrated with the child's biomedical care. 5. Fostering a brief, or sometimes long-term, therapeutic relationship with the family or facilitating the family's finding such a relationship with another clinician. There will never be enough child and adolescent psychiatrists and psychologists to treat all families of medically compromised infants. Knowledge of normative responses has advanced to the point at which basic skills can be used by and transmitted to others who can provide basic services. There is much to be learned about the short- and long-term sequelae of such stressful situations on individuals and family systems with preexisting psychopathology. For such families, child mental health professionals are uniquely suited to play a further role in research and treatment.

Closed suctioning of intubated neonates maintains better physiologic stability: a randomized trial

OBJECTIVE

To evaluate the physiological variance in a closed (CS) vs an open suction (OS) protocol in intubated infants.

STUDY DESIGN

Infants were stratified into three weight groups in a randomized crossover trial. Heart rate, respiratory rate, blood pressure, oxygen saturation, transcutaneous oxygen and carbon dioxide, and end-tidal carbon dioxide were recorded prior to suctioning, during suctioning, and recovery to baseline. Following the procedures, recovery time to baseline parameters was measured. Data were analyzed using repeated measures ANOVA.

RESULTS

Overall, there was significantly less deviation from baseline physiological parameters with CS. Infants <1000 g had clinically significant decreases in heart rate with the OS method (-18% OS vs -6% CS; p=0.016). Recovery time in the OS group was twice that of the CS cohort (4 vs 2 minutes; p<0.001).

CONCLUSION

CS maintains better physiologic stability in intubated infants.

Testing a family intervention hypothesis: the contribution of mother-infant skin-to-skin contact (kangaroo care) to family interaction, proximity, and touch

The provision of maternal-infant body contact during a period of maternal separation was examined for its effects on parent-infant and triadic interactions. Participants were 146 three-month-old preterm infants and their parents, half of whom received skin-to-skin contact, or kangaroo care (KC), in the neonatal nursery. Global relational style and micro-patterns of proximity and touch were coded. Following KC, mothers and fathers were more sensitive and less intrusive, infants showed less negative affect, and family style was more cohesive. Among KC families, maternal and paternal affectionate touch of infant and spouse was more frequent, spouses remained in closer proximity, and infant proximity position was conducive to mutual gaze and touch during triadic play. The role of touch as a constituent of the co-regulatory parent-infant and triadic systems and the effects of maternal contact on mothering, co-parenting, and family processes are discussed.

Effect of newborn hospitalization on family and child behavior: a 12-year follow-up study

OBJECTIVE

To study the effects of a critical illness and hospitalization of a newborn on family functioning and child behavior during the subsequent 12 years.

METHODS

With the use of a randomized stratified cluster sampling, a follow-up of 1443 pregnant women was started at early pregnancy. These pregnancies resulted in 1294 deliveries. A total of 170 infants were admitted to neonatal units and were classified according to their medical risk, and 1112 healthy-born infants were eligible for the control group. After excluding the children with disabilities at 3 years of age, 134 remained in the risk groups and 952 children remained in the control group. The follow-up examinations were performed at the ages of 3 and 9 months and at 3 and 12 years. The main outcome measures were parents' subjective well-being and adjustment to the child, family functioning, and child's behavioral problems.

RESULTS

The families with a critically ill newborn experienced more need for support and maladaptation during the first year after delivery. They reported more child behavior problems at 3 years, but no differences were found at 12 years of age. The families with a hospitalized, low-risk infant coped as well as the controls.

CONCLUSIONS

A critical illness of a newborn had long-lasting effects on the family and child behavior. The hospitalization of a newborn with a low medical risk did not have any negative consequences on family or child behavior. This is encouraging for a large group of families that experience early separation from their newborn infant as a result of hospitalization.

Neonatal individualized care in practice: a Swedish experience

A family-centred, developmentally supportive approach to newborn intensive care referred to as NIDCAP (Newborn Individualized Developmental Care and Assessment Programme) has caught considerable interest during recent years. In this paper we review the scientific context behind its conceptual framework and summarize our experience from 10 years of training, implementation and research. We present the short- and long-term medical and developmental outcome of our Swedish NIDCAP studies as well as attitudes of nursing staff and neonatologists. Furthermore, ethical issues and scientific obstacles concerning this concept of care are discussed.

Positive Touch and massage in the neonatal unit: a British approach

There is now a general trend towards a more baby friendly, family centred approach in the Neonatal Unit. Aspects of that approach-including positive touch and massage- are gaining in popularity. This has caused much debate due to the ambiguity surrounding the implementation and validity of the interventions. Here the impact of these complementary practices (not to be confused with complementary therapies) is discussed. A review of the author's approach and potential guidelines for implementation is provided.

Comparison of skin-to-skin (kangaroo) and traditional care: parenting outcomes and preterm infant development

OBJECTIVE

To examine whether the kangaroo care (KC) intervention in premature infants affects parent-child interactions and infant development.

METHODS

Seventy-three preterm infants who received KC in the neonatal intensive care unit were matched with 73 control infants who received standard incubator care for birth weight, gestational age (GA), medical severity, and demographics. At 37 weeks' GA, mother-infant interaction, maternal depression, and mother perceptions were examined. At 3 months' corrected age, infant temperament, maternal and paternal sensitivity, and the home environment (with the Home Observation for Measurement of the Environment [HOME]) were observed. At 6 months' corrected age, cognitive development was measured with the Bayley-II and mother-infant interaction was filmed. Seven clusters of outcomes were examined at 3 time periods: at 37 weeks' GA, mother-infant interaction and maternal perceptions; at 3-month, HOME mothers, HOME fathers, and infant temperament; at 6 months, cognitive development and mother-infant interaction.

RESULTS

After KC, interactions were more positive at 37 weeks' GA: mothers showed more positive affect, touch, and adaptation to infant cues, and infants showed more alertness and less gaze aversion. Mothers reported less depression and perceived infants as less abnormal. At 3 months, mothers and fathers of KC infants were more sensitive and provided a better home environment. At 6 months, KC mothers were more sensitive and infants scored higher on the Bayley Mental Developmental Index (KC: mean: 96.39; controls: mean: 91.81) and the Psychomotor Developmental Index (KC: mean: 85.47; controls: mean: 80.53).

CONCLUSIONS

KC had a significant positive impact on the infant's perceptual-cognitive and motor development and on the parenting process. We speculate that KC has both a direct impact on infant development by contributing to neurophysiological organization and an indirect effect by improving parental mood, perceptions, and interactive behavior.

Maternal trade-off in treating high-risk children

Low birthweight and the infant's health status are expected to strongly influence the child's reproductive value and, thus, the maternal decisions on the amount and timing of investment. A total of 590 Hungarian primiparous mothers giving birth in the late 1980s were recruited for the longitudinal study. Mothers of high-risk infants shortened the duration of breast-feeding and interbirth intervals, compared to those with an infant of higher survival prospects. The most powerful predictor of the length of the lactation period was the infant's weight at birth, whereas birth spacing was significantly influenced by the health status of the older child. Socioeconomic status had a positive effect on maternal care as well, but it did not change the basic pattern of diminishing maternal care as a function of the infants' low reproductive value. The combination of the above factors resulted in a cumulative effect on maternal investment of mothers with handicapped children of various degrees of risk. An attempt has been made to exclude alternative explanations and to discuss the proximate mechanisms of discriminative parental solicitude.

Physiologic and behavioral effects of gentle human touch on preterm infants

The purpose of this study was to evaluate the effects of a gentle human touch (GHT) intervention provided to 42 preterm infants (27-33 weeks gestational age), for 10 min, three times daily for 10 days. There was no significant difference in mean HR levels or in percent of abnormal heart rate (HR) or O2 saturation comparing 10-min baseline (B), GHT, and 10-min post-touch (PT) phases. There were significantly lower levels of active sleep, motor activity, and behavioral distress during GHT compared to B and P phases. There were no differences among the 42 infants in the GHT group and 42 infants in a randomly assigned control group on any outcome variable including weight gain, morbidity status, or behavioral organization. The findings suggest that GHT generally is a safe and soothing type of touch to provide to young preterm infants, but that individual infant responses to touch need to be continuously monitored by NICU staff and parents.

Developmental outcome, child behaviour and mother-child interaction at 3 years of age following Newborn Individualized Developmental Care and Intervention Program (NIDCAP) intervention

The aim of the present pilot study was to investigate the impact of early intervention in the form of family-centred developmentally supportive care according to NIDCAP((R)) (Newborn Individualized Developmental Care and Assessment Program) on the development and behaviour of the child and on the mother-child interaction at 3 years of age. Two groups of very-low-birth-weight (VLBW) infants (< or = 1500 g) were studied. The control group (n=21) was born in 1990, i.e. prior to implementation of the NIDCAP. The intervention group, born in 1992-1993 (n=21), was subjected to formal NIDCAP observation once every 10 days. Development was assessed using the Griffiths' Developmental Scale II in conjunction with a neurological examination. Behaviour was assessed on the basis of a parental interview. Mother-child interaction was assessed according to the Parent-Child Early Relational Assessment Scale (ERA). There was no significant difference in motor development. The total developmental quotient (DQ) on the Griffiths' developmental scale was 109 (94-122) [median (range)] for the NIDCAP group and 108 (93-120) for the control group (n.s.). On the subscale hearing-speech, the intervention group scored 119 (72-157) and the control group 108 (84-130) (P=0.02). The total score with respect to the Behaviour Symptom Interview was 6 (0-20) for the NIDCAP group and 16 (0-54) for the control group (P=0.03). With respect to the mother-child interaction, there was a significant difference in the child cluster 'communication', the total score being 12 (11-13) for the NIDCAP group and 10 (9-13) for the control group (P=0.03). In conclusion, care of VLBW infants according to NIDCAP appears to have certain positive long-term effects on the child's behaviour and mother-child interaction.

Factors associated with vagal tone responses in preterm infants

The purpose of this study was to examine factors related to vagal tone (VNA) among preterm infants receiving a 10-minute gentle human touch (GHT) intervention three times daily for 10 days. VNA was measured continuously for 10 minutes before, during, and after each 10-minute GHT intervention. Findings indicated that there was a significant relationship between VNA and gestational age, although there were no relationships between VNA and measures of motor activity or behavioral distress. There was no difference in pattern of response to GHT or level of morbidity, average daily weight gain, or behavioral organization among infants with low, moderate, and high baseline VNA levels. There was no difference in VNA comparing infants in the GHT and control groups or during baseline, touch, and posttouch phases for infants in the GHT group. There is a need for further research to examine the usefulness of VNA as a measure of stress vulnerability among preterm infants.

Palivizumab for respiratory syncytial virus prophylaxis in high-risk infants: a cost-effectiveness analysis

BACKGROUND

Prophylactic therapy with palivizumab, a humanized monoclonal antibody, has been shown to reduce the number of respiratory syncytial virus (RSV)-related hospitalizations in preterm infants. The cost-effectiveness of this therapy has not been evaluated from the provider's perspective using cost data.

OBJECTIVES

The objectives of this study were to determine the cost per RSV infection episode avoided by using prophylactic palivizumab therapy in a high-risk infant population and to determine whether certain subgroups of infants derived greater benefit from prophylactic therapy.

METHODS

A decision-analytic model simulating an RSV infection episode was developed to evaluate the cost-effectiveness of palivizumab prophylaxis from the perspective of the health care system (provider). Data to populate the model were gathered from the medical literature (identified through a MEDLINE search of studies on the incidence of RSV infection) and the IMpact-RSV clinical trial. Data included incidence of RSV infection and the associated health care resource use and costs. Costs to the provider were determined using a university-affiliated hospital cost-accounting system. Cost-effectiveness ratios were calculated over a range of RSV infection incidence rates in a control population. Sensitivity analyses were performed for the cost of palivizumab therapy, the cost of RSV-related hospitalization, and the number of emergency department, physician office, and home health care visits. For the subgroup analysis, infants were classified by gestational age (<32 and > or = 32 weeks) and stratified by severity of chronic lung disease.

RESULTS

The cost per additional RSV infection episode avoided ranged from dollars 0 (cost savings) to dollars 39,591 for palivizumab prophylaxis costs of dollars 2500 and from dollars 2702 to dollars 79,706 for palivizumab prophylaxis costs of dollars 4500. The model was insensitive to changes in the number of emergency department, physician office, and home health care visits. The difference in RSV incidence between the treatment and control groups was greater among infants > or = 32 weeks' gestational age than among infants <32 weeks' gestational age. onclusions: The incremental cost-effectiveness of palivizumab compared with no prophylactic therapy was sensitive to changes in the incidence of RSV infection in control infants, the average cost of RSV hospitalization, and the cost of palivizumab. Clinicians may use this information along with additional factors to determine whether palivizumab is cost-effective in their clinical setting and geographic area.

Mothers' stories about their experiences in the neonatal intensive care unit

The purpose of this article is to let mothers tell the stories of their neonatal intensive care unit (NICU) experiences and to determine how well these experiences fit the Preterm Parental Distress Model. Interviews were conducted with 31 mothers when their infants were six months of age corrected for prematurity and were analyzed using the conceptual model as a framework. The analysis verified the presence in the data of the six major sources of stress indicated in the Preterm Parental Distress Model: (1) pre-existing and concurrent personal and family factors, (2) prenatal and perinatal experiences, (3) infant illness, treatments, and appearance in the NICU, (4) concerns about the infant's outcomes, (5) loss of the parental role, and (6) health care providers. The study indicates that health care providers, and especially nurses, can have a major role in reducing parental distress by maintaining ongoing communication with parents and providing competent care for their infants.

Massage for promoting growth and development of preterm and/or low birth-weight infants

BACKGROUND

It has been argued that infants in Neonatal Intensive Care Units are subject both to a highly stressful environment - continuous, high-intensity noise and bright light - and to a lack of the tactile stimulation that they would otherwise experience in the womb or in general mothering care. As massage seems to both decrease stress and provide tactile stimulation, it has been recommended as an intervention to promote growth and development of preterm and low-birth weight infants.

OBJECTIVES

To determine whether preterm and / or low birth-weight infants exposed to massage experience improved weight gain and earlier discharge compared to infants receiving standard care; to determine whether massage has any other beneficial or harmful effects on this population.

SEARCH STRATEGY

Databases were searched using the term 'massage', 'touch' or 'tactile stimulation' with 'infant - newborn', 'infant - premature' and 'infant - low birth weight'. The main databases searched were those of the Cochrane Collaboration Field in Complementary Medicine and the Neonatal Collaborative Review Group.

SELECTION CRITERIA

Randomised trials in which infants with gestational age at birth < 37 weeks or weight at birth < 2500g received systematic tactile stimulation by human hands. At least one outcome assessing weight gain, length of stay, behaviour or development must be reported.

DATA COLLECTION AND ANALYSIS

Data extracted from each trial were baseline characteristics of sample, weight gain, length of stay and behavioural and developmental outcomes. Physiological and biochemical outcomes were not recorded. Data were extracted by three reviewers independently. Statistical analysis was conducted using the standard Cochrane Collaboration methods.

MAIN RESULTS

Massage interventions improved daily weight gain by 5g (95% CI 3.5, 6.7g). There is no evidence that gentle, still touch is of benefit (increase in daily weight gain -0.2g; 95% CI -2.4, 1.9g). Massage interventions also appeared to reduce length of stay by 4.6 days (95% CI 2.6, 6.6) though there are methodological concerns about the blinding of this outcome. There was also some evidence that massage interventions have a slight, positive effect on postnatal complications and weight at 4 - 6 months. However, serious concerns about the methodological quality of the included studies, particularly with respect to selective reporting of outcomes, weaken credibility in these findings.

REVIEWER'S CONCLUSIONS

Evidence that massage for preterm infants is of benefit for developmental outcomes is weak and does not warrant wider use of preterm infant massage. Where massage is currently provided by nurses, consideration should be given as to whether this is a cost-effective use of time. Future research should assess the effects of massage interventions on clinical outcome measures, such as medical complications or length of stay, and on process-of-care outcomes, such as care-giver or parental satisfaction.

A randomized, controlled trial to evaluate the effects of the newborn individualized developmental care and assessment program in a Swedish setting

BACKGROUND AND OBJECTIVE

Family-centered developmentally supportive care of very low birth weight infants, provided by the Newborn Individualized Developmental Care and Assessment Program (NIDCAP) has been reported to have positive medical and economic impacts. Our aim was to investigate its effect on need of ventilatory assistance, growth, and hospitalization in a Swedish setting.

METHODS

Preterm infants born between September 1994 and April 1997 with a gestational age <32 weeks and with a need of ventilatory assistance at 24 hours were randomly assigned to either NIDCAP (n = 12) or conventional care (n = 13). The 2 groups were comparable (median [range]) with respect to birth weight (1083 [630-1411] vs 840[636-1939 g]), head circumference (24.0 [22.3-26.5] vs 24.0 [21. 1-30.0 cm]), gestational age (27.6 [24.0-28.7] vs 26.1 [23.9-30.3] weeks), female/male ratio (3/9 vs 9/8) and Clinical Risk Index for Babies (4.0 [0-11] vs 6.0 [2-15]). The infants in the intervention group were cared for in a separate room by a group of specially trained nurses. Formal weekly observations of these infants starting within 3 days after birth and continuing until 36 weeks postconception were used to develop individualized care plans. These plans provided recommendations as to how care might be attuned to the current developmental stage of the infant and how the family might be supported and stimulated to participate in this care. The treatment of the 2 groups was in all other respects identical.

RESULTS

The duration of mechanical ventilation (median [range] was 2.8 [0-36.7] days in the intervention group vs 4.8 [.1-29.8] days; not significant [NS]) among the controls and continuous positive airway pressure was applied for 26.1 (6.9-52.0) vs 43.9 (5.0-65.1) days. Supplementary oxygen was withdrawn at 33.0 (29.3-35.7) vs 38.1 (33.1-44.9) weeks of postconceptional age (PCA). The weight gain up to 35 weeks of PCA was 13.0 (6.7-21.0) vs 9.8 (6.8-16.6) g/day (NS). The head growth up to 35 weeks of PCA was.73 (.56-1.3) vs.63 (.56-. 77) cm/week (NS). The age of the infant at discharge was 38.3 (36. 1-57.7) vs 41.0 (36.9-48.4) weeks of PCA (NS).

CONCLUSIONS

NIDCAP does not seem to have detrimental effects on Swedish very low birth weight infants in comparison with conventional care. Indeed, NIDCAP might even be advantageous.

Morbidity assessment index for newborns: a composite tool for measuring newborn health

OBJECTIVE

The objective was to develop, validate, and recommend a scaling model for a discriminative obstetric outcome measure named the Morbidity Assessment Index for Newborns. The purpose of this tool is to allow comparison of obstetric therapeutic strategies on neonatal morbidity, particularly in the mild to moderate morbidity range.

STUDY DESIGN

A list of 66 check-mark (yes or no) items of readily available clinical and laboratory data from the early neonatal period was compiled by a panel of obstetric and neonatal experts. These data were collected on 411 neonates born at >/=28 weeks' gestation and representing all grades of morbidity. Detailed psychometric testing included dimensionality testing and item analysis with the item response theory. The scores obtained with this new assessment tool were correlated with newborn and maternal disease conditions or events and with other measures of newborn morbidity.

RESULTS

The Morbidity Assessment Index for Newborns is easy to apply in prospective or retrospective studies. Detailed psychometric evaluation resulted in modification of the list to 47 items, each item with a relative scale value according to severity of morbidity. The test was demonstrated to be a reliable and generalizable scaled index that performs optimally for the mild to moderate neonatal morbidity range.

CONCLUSION

The Morbidity Assessment Index for Newborns is a validated outcome measurement scale of neonatal morbidity. This new tool may facilitate the conduct of obstetric clinical trials or epidemiologic population-based studies in obstetrics.

Fatigue in mothers of infants discharged to the home on apnea monitors

A comparative study was done to determine differences in caregiver fatigue between two groups of mothers of preterm infants at baseline, in the hospital (Time 1), 1 week postdischarge (Time 2), and 1 month postdischarge (Time 3). Group 1 infants were discharged home on apnea monitors (AM) (n = 28), and Group 2 infants were not on apnea monitors (nonAM)(n = 46). Measured by the Multidimensional Assessment of Fatigue (MAF) scale, mean fatigue scores from Time 1 to Time 3 markedly increased for the monitor group and decreased for the nonmonitor group. The scores were significantly different between the two groups at Times 2 and 3 but not at baseline. Two-way analysis of variance (ANOVA) with repeated measures showed group by time interaction effects on fatigue. Monitoring and alleviation of fatigue in home caregivers of preterm infants on apnea monitors are necessary.