Parental Experiences Caring for Their Hospitalized Medically Fragile Infants: A Description of Grief, Stress, and Coping

BACKGROUND

Advances in care have increased survival and improved outcomes of infants with complex and chronic diseases. These medically fragile infants require long-term hospitalization and depend on technology for survival. Parents of these infants experience stress and difficulties adapting to their parental role.

PURPOSE

To present an account of parental experiences as they provided care for their hospitalized medically fragile infant.

METHODS

This study was part of a larger constructivist grounded theory study to provide a holistic understanding of the processes of care for medically fragile infants. For this sub-study, 21 parents of hospitalized medically fragile infants were recruited from a pediatric hospital in Western Canada. Parents participated in face-to-face, semi-structured interviews, which were transcribed and analyzed using initial and focused coding.

RESULTS

Parents of hospitalized medically fragile infants grieved the loss of parenting a healthy infant, and they experienced multiple stressors. Parents utilized various coping strategies to manage their grief and stressors. Some parents were unable to cope, which exacted a heavy toll on their physical and mental health. Parents recommended psychological support, access to physical activity, primary nursing, and health system navigators.

CONCLUSIONS

Parental recommendations can inform the design of interventions for parents of hospitalized medically fragile infants.

A scoping review of parental experiences caring for their hospitalised medically fragile infants

AIM

To synthesise and summarise evidence from published research articles regarding parental experiences caring for their hospitalised medically fragile infant.

METHODS

We searched four electronic databases in April 2018 using three main concepts individually and in combination: infant, medically fragile, parents. We examined articles about experiences of parents caring for the medically fragile infant in a hospital setting. We conducted thematic analysis on the 34 included articles.

RESULTS

Parents experienced high rates of depressive symptoms, depression, stress, anxiety, distress and post traumatic stress. Parent-infant interactions were disrupted. Parents experienced loss and worry in response to the diagnosis of their infant, which altered or delayed parental role attainment. Supports and coping were key for parents to manage their stress.

CONCLUSION

Parents of medically fragile infants experience multiple stressors, elevated levels of mental health difficulties, trouble attaining their parental role and often struggle to cope. Development of interventional research is needed to test targeted strategies aimed at reducing parental stress and mental health difficulties. Interventions should include: screening for parental mental health, psychological support, healthcare professional education, strategies to enhance parent-infant interactions and improved relationship competencies among healthcare professionals.

Interactive behaviors of American Indian mothers and their premature infants

The interactive behaviors of 17 American Indian mothers and their premature infants and selected maternal and infant factors affecting those behaviors were measured using naturalistic observation and the Home Observation for Measurement of the Environment (HOME) Inventory at 3, 6, and 12 months corrected infant age. The frequency of some maternal behaviors changed over the first 12 months. Mothers spent less time holding, looking at, touching, and interacting with their premature infants and more time uninvolved as the infant aged. Maternal education and infant illness severity were associated with mother-infant interactive behaviors and HOME Inventory scores. These findings emphasize the importance of maternal and infant factors affecting the interactions between American Indian premature infants and their mothers.

Maternal role attainment with medically fragile infants: Part 2. relationship to the quality of parenting

We examined which components of maternal role attainment (identity, presence, competence) influenced quality of parenting for 72 medically fragile infants, controlling for maternal education and infant illness severity. Maternal competence was related to responsiveness. Maternal presence and technology dependence were inversely related to participation. Greater competence and maternal education were associated with better normal caregiving. Presence was negatively related although competence was positively related to illness-related caregiving. Mothers with lower competence and more technology dependent children perceived their children as more vulnerable and child cues as more difficult to read. Maternal role attainment influenced parenting quality for these infants more than did child illness severity; thus interventions are needed to help mothers develop their maternal role during hospitalization and after discharge. © 2010 Wiley Periodicals, Inc. Res Nurs Health 34:35-48, 2011.

Effects of maternal depressive symptoms and infant gender on the interactions between mothers and their medically at-risk infants

OBJECTIVE

To examine the effects of maternal depressive symptoms and infant gender on interactions between mothers and medically at-risk infants.

DESIGN

Longitudinal, descriptive secondary analysis.

SETTING

Neonatal intensive care unit, intermediate care unit, and infectious disease clinic of the tertiary medical centers in the Southeast and East.

PARTICIPANTS

One hundred and eight preterm infants and their mothers, 67 medically fragile infants and their mothers, and 83 infants seropositive for HIV and their primary caregivers were studied in their homes between 6 and 24 months.

MAIN OUTCOME MEASURES

Observation and the Home Observation for Measurement of the Environment Inventory were used to assess the interactions of mothers and their medically at-risk infants. Maternal depressive symptoms were assessed using the Center for Epidemiologic Studies Depression Scale.

RESULTS

The level of depressive symptoms did not differ between the mothers of boys and mothers of girls in the three groups. Mothers of medically fragile infants had higher levels of depressive symptoms than mothers of preterm infants at 6 months corrected age and similar levels of depressive symptoms as HIV-positive mothers at 12 months. Mothers of medically fragile infants with elevated depressive symptoms were less attentive and more restrictive to their infants. HIV-positive mothers with elevated depressive symptoms were less attentive to their infants. The effects of gender on mother-infant interactions were not moderated by maternal depressive symptoms.

CONCLUSION

Maternal depressive symptoms had a somewhat negative effect on the interactions of mothers and medically at-risk infants.

The influence of maternal and child characteristics and paternal support on interactions of mothers and their medically fragile infants

The influences of maternal characteristics, infant characteristics, and paternal support on maternal positive involvement and developmental stimulation were examined over time in 59 mothers and their medically fragile infants using an ecological framework. Higher maternal education was associated with greater maternal positive involvement. More maternal depressive symptoms, more infant technological dependence, and lower birthweights were associated with less maternal positive involvement at 6 months but greater involvement at 12 months. Higher paternal helpfulness facilitated positive involvement in mothers with low depressive symptoms but not in those with elevated symptoms. Higher maternal education and more depressive symptoms were associated with more developmental stimulation. Thus, maternal interactive behaviors are affected by maternal, infant, and environment factors, and these effects change over time.

Fathers' support to mothers of medically fragile infants

OBJECTIVE

To examine mothers' perceptions of support from fathers over the 1st year after birth of a medically fragile infant.

DESIGN

A descriptive, correlation design based on an ecologic systems view of the family. It was hypothesized that the levels of paternal support would be influenced by factors within the two subsystems: the mother-father system (marital status) and the child subsystem (health and gender).

SETTING

A tertiary care children's hospital.

PARTICIPANTS

Sixty-four mothers of medically fragile term and preterm infants, who were married or living with the father.

MAIN OUTCOME MEASURES

The Stress Support Scale assessed maternal perceptions of helpfulness and satisfaction with paternal support at enrollment, after discharge, and around 1 year of age.

RESULTS

Mothers reported high levels of help from fathers at enrollment. Married mothers did not differ from unmarried mothers in their perceptions of helpfulness of support but were more satisfied with support. Mothers of female infants received more help from fathers than mothers of male infants, and this difference increased over time. However, mothers of female infants were not more satisfied with paternal support. Neither number of technologies nor birthweight related the maternal perceptions of paternal support.

CONCLUSIONS

Family systems factors were more significant in maternal perceptions of paternal support than the health status of the infant.

Mother-infant interactions of medically fragile infants and non-chronically ill premature infants

At 6 months corrected for prematurity, 41 medically fragile prematures, 20 medically fragile full-terms, and 28 prematures without chronic illnesses were observed interacting with their mothers for 1 hr. Mothers of non-chronically ill prematures gestured to and touched their infants less, were uninvolved with them for a longer time, and spent less time interacting and looking at their infants than did mothers of medically fragile infants. Medically fragile full-terms slept more than the non-chronically ill prematures. The non-chronically ill premature group played with objects more and exhibited more locomotion. Thus, the non-chronically ill prematures had more mature behaviors but less frequent interactions than did the medically fragile infants. These disparities reflect differences both in the infants' functional maturity and in maternal compensation for infant vulnerability.

Developmental outcomes of infants with bronchopulmonary dysplasia: comparison with other medically fragile infants

The purpose of this study was to compare the developmental outcomes and mother-infant interactions of infants with bronchopulmonary dysplasia (BPD) and those of other medically fragile infants. One-hour behavioral observations were made of the interactions of mothers with two groups of infants (23 with BPD, 39 medically fragile without BPD or neurological problems) at enrollment, every 2 months during hospitalization, 1 month after discharge, and at 6 months' and 12 months' corrected age. Assessment of the home environment also was done at 6 and 12 months. Multiple regressions were calculated separately for child mental, adaptive, language, and motor outcomes. Predictors were: home environment assessment, measures of maternal interactive behaviors (positive attention, expression of negative affect, medicalized caregiving), infant group membership, and presence of intraventricular hemorrhage (IVH) in the infant. There were no significant differences between the two groups in any of the developmental outcomes or interactive variables, and the presence of IVH had no effect on these variables. Maternal positive attention and the home environment were correlated with mental development, and mother negative affect was related to adaptive behavior for both groups. Differences in developmental and interactive behaviors between infants with BPD and other prematurely born infants found in other studies appear to be a result of chronic health problems and, thus, are not unique to infants with BPD.

Feeding and non-feeding interactions of mothers and prematures

The interactions between mothers and premature infants during feeding and nonfeeding periods were explored. Twenty-nine premature infants and their mothers were observed interacting for 1 hour in their homes at 6 months corrected for prematurity. Mothers were more likely to engage in the following behaviors involving close contact during feeding: looking at the infant, holding the infant, having body contact, and rocking their infants. They interacted with their infants 96% of feeding time. During nonfeeding periods, they were more likely to engage in more distal behaviors (e.g., gesturing, touching, and playing with the infant) and spent only 67% of the time interacting with the infant. Infants were more likely to be alert, vocalize, play with objects, express negative affect, and locomote during nonfeeding, and they were more likely to be drowsy or asleep during feeding. Therefore, a complete understanding of interactions between mothers and prematures can only come from examining both feeding and nonfeeding periods.

The usefulness of an assessment of emotional involvement of HIV-positive mothers and their infants

INTRODUCTION

A positive mother-infant relationship is crucial for optimal child development; however, many factors may interfere with the development of a such a relationship. One group at risk for compromised mother-infant interactions is women with HIV infection. The purposes of this study were (a) to examine the usefulness of the Attachment During Stress scale (ADS) for measuring the emotional involvement of HIV-positive mothers with their infants during a clinic visit and (b) to explore the effects of maternal health status, age, parity, and educational level on mother-infant involvement.

METHOD

A descriptive, longitudinal study was conducted with 57 primarily African American HIV-positive mothers and their infants who were patients at 1 of 2 regional referral centers. The ADS was completed during the child's physical examination at 3, 6, and 12 months of age, and mothers completed questionnaires during these visits.

RESULTS

Maternal age, education level, health status, and parity were not related to maternal emotional involvement. However, the emotional involvement of the mother and infant were correlated (r = 0.73, P < .001).

DISCUSSION

These findings suggest that the ADS may be a useful screening tool to supplement the nurse's clinical judgment in a pediatric outpatient setting. The ADS provides some useful information about the emotional involvement of the mother and infant, although it does not provide a comprehensive assessment of their relationship.

Distress and growth outcomes in mothers of medically fragile infants

BACKGROUND

With recent advances in medical and nursing care, many high-risk infants are surviving the neonatal period with severe, life-threatening chronic illnesses, resulting in extended hospitalizations and/or frequent rehospitalizations and long periods of dependence on technology for survival.

OBJECTIVE

To describe the factors predicting maternal adjustment in mothers caring for medically fragile infants.

METHOD

Subjects were mothers (n = 67) whose infants had a serious life-threatening illness requiring hospitalization and technology for survival. Data for this longitudinal study were collected at enrollment and hospital discharge, and at 6, 12, and 16 months after birth. Distress was measured as depressive symptoms using the Center for Epidemiologic Studies Depression Scale, and growth was assessed using a personal developmental impact rating scale. Data about personal characteristics, parental role attainment, infant-illness characteristics, and maternal illness distress were collected.

RESULTS

Mothers of medically fragile infants experience distress and growth as a result of their child's illness. Mean scores on the depression scale at both time points were moderately high and a high percentage of mothers scored at risk for depressive symptoms. Maternal developmental impact ratings at 6 months were neutral to slightly negative and at 16 months were between neutral and positive. While the mean depressive symptom scores and maternal developmental ratings were lower at the later time points, these differences were not significant. Maternal depressive symptoms and developmental impact ratings were moderately but negatively correlated at 6 and 16 months, indicating that higher depressive symptoms were related to more negative developmental impact ratings. Distress was influenced by maternal characteristics, hospital environmental stress, and worry about the child's health. Growth was influenced by characteristics of the child's illness, hospital environmental stress, concern about the child's health, and level of maternal role attainment.

CONCLUSIONS

Nurses should consider personal characteristics and level of parental role attainment as well as characteristics of the child and illness-related distress in their approaches to intervention with mothers of critically ill infants.