Stress levels and depressive symptoms in NICU mothers in the early postpartum period

Maternal Stress Experience in the Neonatal Intensive Care Unit after Preterm Delivery

OBJECTIVE

 Preterm delivery with the admission of a child in the neonatal intensive care unit (NICU) is extremely challenging for parents. Being separated from the baby and seeing her infant feeling pain and being sick together with the complexity of the NICU environment, the mother experiences great anxiety, fear, and stress. The purpose of the study was to assess NICU-related stress and to identify maternal and infant factors associated with increased stress in mothers of preterm infants.

STUDY DESIGN

 The maternal stress level was assessed in 122 mothers of preterm infants using the Parental Stressor Scale: NICU (PSS: NICU) in which items were distributed in three subscales as follows: Sights and Sounds of NICU-subscale 1 (S1), Infant Appearance and Behavior-S2, and Parental Role Alteration-S3.

RESULTS

 Maternal total PSS: NICU score was 3.46 ± 0.71. Parenteral Role Alteration was the most stressful (4.20 ± 0.79) followed by Infant Appearance and Behavior (3.51 ± 0.91) and Sights and Sounds subscale (2.28 ± 0.95); p (S1-S2) < 0.001, p (S1-S3) < 0.001, and p (S2-S3) < 0.001. Total PSS: NICU and Infant Appearance and Behavior scores correlated positively with maternal age (r = 0.189; p = 0.040 and r = 0.204; p = 0.027, respectively) and duration of NICU treatment (r = 0.188; p = 0.044 and r = 0.190; p = 0.042). More visits in NICU by a mother were associated with a lower PSS: NICU score (p = 0.049) and neonatal seizures and invasive ventilation in infants were associated with higher stress scores (p = 0.007 and p = 0.042).

CONCLUSION

 Mothers of preterm infants admitted in the NICU experience significant stress which is correlated with maternal age and NICU treatment duration and is associated with frequency of NICU visits, presence of neonatal seizures, and need for ventilator support. Parental role alteration is the greatest stressor followed by Infant Appearance and Behavior and NICU-surrounding stressor factors which show the need for interventions and counseling focused on mothers' role, their involvement in infant's care, and thus, family-centered care implementation.

KEY POINTS

· Mothers of preterm infants experience significant stress.. · Parental role alteration is the greatest maternal stressor.. · Maternal stress is correlated with age and NICU duration, and is associated with the frequency of NICU visits and infant's health status.

Preparedness and training of genetic counselors practicing in inpatient settings

As rapid genomic testing technology increasingly allows for real-time answers that could alter management for acutely ill patients, opportunities for genetic counselors to work in inpatient settings will increase. However, genetic counselors' preparedness and the training provided by graduate programs to work in inpatient settings are unknown. We conducted semi-structured interviews with 13 genetic counselors who provided services in varied inpatient settings to assess genetic counselors' readiness for inpatient positions. We also surveyed members of the Association of Genetic Counseling Program Directors (AGCPD) about inpatient training practices of genetic counseling graduate programs. Genetic counselors were recruited through the National Society of Genetic Counselors (NSGC) Inpatient Special Interest Group listserv and graduate program faculty were recruited through the AGCPD listserv. Some challenges reported by genetic counselors in inpatient settings included working in a fast-paced hospital environment which necessitated focused interactions with patients; collaborating with diverse providers who may not understand the role of genetic counselors; and navigating grief experiences of families and of themselves as a provider. Although genetic counselors felt that many of their skills developed in graduate school were transferrable to the inpatient setting, those who had minimal or no inpatient exposure in graduate school often described feeling unprepared for working in the inpatient setting. The majority of AGCPD respondents (23/28) indicated their program provided some type of exposure to the inpatient setting for students, the most common (22/23) being an inpatient clinical rotation, which suggests many graduate programs are already recognizing the importance of providing inpatient training. Our findings indicate that while many skills are transferrable to inpatient positions, genetic counselors face unique challenges in inpatient settings. Our results suggest that graduate exposure to the inpatient setting and professional support of inpatient genetic counselors are beneficial to support genetic counselors' preparedness to take on inpatient positions.

"My Brigham Baby" Application: A Pilot Study Using Technology to Enhance Parent's Experience in the Neonatal Intensive Care Unit

OBJECTIVE

 This study aimed to describe the family psychosocial experience in a level-III neonatal intensive care unit (NICU), and to assess how it evolved after rollout of an educational smartphone application (App) called "My Brigham Baby."

STUDY DESIGN

 We surveyed 25 NICU parents pre-App rollout (before coronavirus disease 2019 [COVID-19] pandemic) and 25 parents post-App rollout (during pandemic). Collected data included parental self-reported discharge readiness, symptoms of stress and anxiety, and parenting skill confidence. Survey scores were assessed as total or mean scores, and by category of severity.

RESULTS

 Pre-and post-App parents had comparable demographics, and their infants had similar clinical characteristics during their NICU stay. Discharge readiness differed by group status (p = 0.02) and was characterized by a greater frequency in being "very ready" for discharge among the post-App rollout parent group compared with the pre-App group (56 vs. 20%, p = 0.027), and parenting confidence shifted toward more optimal scores post-App rollout. Parental stress and anxiety symptoms did not significantly differ between groups despite possible stress contagion from the COVID-19 pandemic.

CONCLUSION

 This pilot study suggests that technology Apps are feasible interventions within NICU settings and may enhance parental experiences related to NICU hospitalization.

KEY POINTS

· Parents' experience increased psychological distress during the time their infant is cared for in the NICU, which has downstream consequences for the family unit.. · In our study, surveyed parents reported higher discharge readiness and parenting confidence shifted toward improvement after rollout of a family education and support smartphone application in a level-III NICU.. · This pilot study suggests that technology applications are feasible interventions that might enhance parental experiences during NICU hospitalization..

Mother's mental health and the interaction with her moderate preterm baby in the NICU

INTRODUCTION

Moderate preterm infants, born between 320/7 and 336/7 weeks, represent a significant number of preterm-born infants; however, they remain a poorly studied group despite their vulnerability. The objective of this correlational study is to describe the impact of having a moderate preterm infant hospitalised in the NICU on the mothers' mental health and how this relates to the interaction between the dyad.

METHOD

During the hospitalisation period, 85 moderate preterm mother-infant dyads participated in this study. The participants provided self-reports of depression, parental stress, and skin to skin and breastfeeding practices. Also, mother-infant interaction was assessed in the NICU with an observational scale.

RESULTS

Mothers evidenced high levels of stress and depressive symptoms during the hospitalization. The stress experienced by these women was significant, although weakly, associated with the interaction with their babies; and mothers of small for gestational age babies showed difficulties in this area.

CONCLUSIONS

The results of this study could represent a contribution to a better understanding of the relation between the characteristics of moderate preterm babies, maternal emotional wellbeing, and the quality of mother-infant interactions in NICU settings.

Mental health in the two years following hypertensive and normotensive pregnancy: The Postpartum, Physiology, Psychology and Paediatric follow-up (P4) cohort study

BACKGROUND

Postpartum mental illnesses and hypertensive disorders of pregnancy (HDP) are both common, and both associated with adverse maternal and child health outcomes. However, the relationship between them is unclear. This study aimed to investigate prevalence and symptom severity of depression, anxiety, and post-traumatic stress disorder (PTSD) 2-years postpartum in women with normal blood pressure (NBP) during pregnancy versus preeclampsia or gestational hypertension (GH).

METHODS

Two-years follow-up of the prospective Postpartum, Physiology, Psychology and Paediatric (P4) Cohort Study was conducted in metropolitan Australia. Prevalence and symptom severity of depression (Edinburgh Postnatal Depression Scale, EPDS > 12), anxiety (7-item Generalized Anxiety Disorder scale, GAD-7 ≥ 10) and PTSD (Posttraumatic stress Diagnostic Scale, PDS/PDS-5) were measured and calculated for women with NBP, preeclampsia and GH.

RESULTS

Among 365 participants (NBP: n = 271, preeclampsia: n = 75, GH: n = 19), 2-years postpartum depression prevalence was 3.9% (95% CI 2.3-6.4%): 4.4% after NBP, and 2.7% after preeclampsia (p = 0.53). Anxiety prevalence was higher after GH than NBP (15.8% versus 3.3%, p = 0.02). Prevalence of any mental illness (depression/anxiety/PTSD) was 5.9% (95% CI 3.8-8.8%); 5.6% after NBP, 4.1% after PE, and 15.8% after GH (p = 0.15). Although PTSD prevalence was low (1.4%), and similar between groups (p = 0.97), around 3 times more women after PE (8.1%), compared to NBP (2.5%), recalled childbirth as traumatic (p = 0.003).

CONCLUSIONS

Preeclampsia, although associated with persistent perceptions of traumatic childbirth, did not alter the risk of mental illnesses at 2-years postpartum. GH (albeit in a small subgroup) was associated with increased anxiety scores. Larger, multicentre studies are required to clarify relationships between HDP and postpartum mental illness.

TRIAL REGISTRATION

Retrospectively registered on 18/11/2013 with the Australian and New Zealand Clinical Trials Registry.

REGISTRATION NUMBER

ACTRN 12613 00,126 0718.

Providing Continuity in Infant Mental Health Services for Medically Fragile Infants and Their Families

Having a baby who is prenatally or postnatally diagnosed with a medical condition places considerable stress on the parents, infants, and their developing relationship. Infant mental health (IMH) services offer an opportunity to address the challenges and support the parent-infant relationship. The present study outlined a continuum of care IMH program embedded within various medical settings of a large metropolitan children's hospital. Applications of IMH principles within the fetal care center, neonatal intensive care unit, high risk infant follow-up clinic, and the patient's home are described. Descriptive data about families served across settings and a case study are provided in order to illustrate the implementation of this unique IMH intervention model.

Preterm Birth and Maternal Mood States: What Is the Impact on Bonding?

Preterm birth is a significant global health issue affecting millions of infants each year, with potential implications for their developmental outcomes. This study investigated the impact of preterm birth on maternal mood states during the early postpartum period and its subsequent effects on mother-infant bonding. Mothers of 90 preterm infants were involved in the assessment of maternal mood states, examined with the Profile of Mood States (POMS) questionnaire and the evaluation of mother-infant bonding, carried out through the Postpartum Bonding Questionnaire (PBQ). Contrary to expectations, there was no significant correlation between preterm birth characteristics and maternal mood states. On the other hand, significant correlations emerged between specific maternal mood states and the quality of mother-child bonding. More specifically, regression analyses showed that feelings of tension, anger, and confusion experienced by the mother tend to negatively affect the quality of her bond with her child. These findings emphasize the crucial role of maternal mental well-being in shaping the mother-infant relationship in the early postpartum period. The study highlights the importance of identifying and addressing maternal mood disorders to promote positive mother-infant bonding and child development, further underlining the need for comprehensive support and interventions for mothers of preterm infants.

The Protective Role of Maternal-Fetal Bonding for Postpartum Bonding Following a NICU Admission

INTRODUCTION

Admission of a newborn to a neonatal intensive care unit (NICU) can be a highly stressful event that affects maternal psychological well-being and disrupts the early maternal-infant bonding relationship. Determining factors that promote maternal-infant bonding among those with a NICU admission is essential for the development of effective interventions.

METHODS

Using a longitudinal clinic-based sample of diverse and low-income pregnant women, we examined whether maternal-fetal bonding measured during the second trimester moderated the association between NICU admission and postpartum bonding measured at six months post birth, controlling for demographic characteristics.

RESULTS

Approximately 18% of the sample experienced a NICU admission at birth. NICU admission was associated with lower postpartum bonding (b = -8.74; p < .001, Model 1), whereas maternal-fetal bonding was associated with higher bonding reported at six months postpartum (b = 3.74, p < .001, Model 2). Results of the interaction revealed that women who reported higher maternal-fetal bonding reported higher postnatal bonding regardless of NICU admission status.

DISCUSSION

Because maternal-fetal bonding can be enhanced through intervention, it is a promising target for reducing the risks of NICU admission for the early maternal-infant relationship.

Stress Levels in Mothers of Admitted Newborns in NICU and Effect of Counseling

OBJECTIVES

To examine the effect of counseling on stress levels in mothers of neonates admitted to the Neonatal Intensive Care Unit (NICU).

METHODS

This prospective research was carried out from January 2020 to December 2020 in a central India teaching hospital providing tertiary care. Parental Stressor Scale (PSS):NICU questionnaire was used to measure maternal stress among mothers of 540 admitted infants between 3 and 7 d of admission. Counseling was done at the time of recruitment and its effect was measured after 72 h and re-counseling was done. This cycle of stress assessment and counseling was repeated every 72 h till the baby was admitted in the NICU. Overall stress levels for each subscale were determined, and pre- and post-counseling stress was compared.

RESULTS

For the subscales of sight and sound, appearance and behavior, change in the parental role, and staff behavior and communication, the median scores were 1.5 (IQR-1.2-1.88), 2.5 (2.3-2.9), 3.3 (3.0-3.6) and 1.3 (1.1-1.62), respectively indicating high stress in the parental role alteration. Counseling was effective in reducing stress levels among all mothers irrespective of various maternal factors (p <0.01). Stress reduces more with increasing number of counseling, as suggested by higher change in the stress score with increased number of counseling.

CONCLUSIONS

This study shows that NICU mothers are under remarkable stress and repeated counseling sessions targeted at particular concerns might assist.

The role of stress in perinatal depression and anxiety - A systematic review

Perinatal depression (PND) and anxiety affect around 20% of women, but available pharmacotherapy is not sufficiently effective in 20-60% of them, indicating a need for better understanding of these diseases. Since stress is a significant risk factor for PND, the aim was to examine the role of biological, environmental and psychological stress in PND and anxiety through a systematic literature search. Overall 210 studies were included, among which numerous rodent studies showed that perinatal stress induced depressive-like and anxious behavior, which was associated with HPA-axis alterations and morphological brain changes. Human studies indicated that the relationship between cortisol and perinatal depression/anxiety was not as clear and with many contradictions, although social and psychological stress were clearly positively associated with PND. Finally, oxytocin, synthetic neuroactive steroid and n-3 PUFA diet have been identified as potentially beneficial in the therapy of PND and anxiety, worth to be investigated in the future.

Transdiagnostic therapy compared to progressive muscle relaxation on the emotional health of mothers with premature infants: A randomized controlled trial

OBJECTIVE

The aim of this study was to compare the effects of transdiagnostic therapy compared to progressive muscle relaxation (PMR) on emotion regulation strategies, self-compassion, maternal role adaptation, and social and work adjustment in mothers of premature infants.

MATERIALS AND METHODS

This was a randomized controlled trial with two groups and pre-test, post-test, and a two-month follow-up assessment. Included were 27 mothers randomly assigned to either the transdiagnostic therapy group or the PMR group (13 in the transdiagnostic group and 14 in the PMR group). The experimental group received eight sessions of transdiagnostic therapy while the control group received eight sessions of PMR. The participants completed the following scales: Emotion Regulation Questionnaire, Self-Compassion Scale, Maternal Role Adaptation Scale, and Work and Social Adjustment Scale.

RESULTS

Transdiagnostic therapy was significantly more effective than PMR in improving emotion regulation strategies, self-compassion, maternal role adaptation, and social and work adjustment based on the between-group comparison conducted at post-test and follow-up (p < 0.01).

CONCLUSION

Transdiagnostic therapy was shown to be effective in improving the emotional health of mothers with premature infants and was more effective than PMR techniques.

Development and content validation of yoga module for the mental health of NICU mothers

BACKGROUND

Postnatal yoga has been found to be effective for maternal mental health management. But a validated yoga module for the mental health of early postpartum mothers with infants admitted to the Neonatal Intensive Care Unit (NICU) is lacking.

AIM

To design and validate a yoga module for the mental health of early postpartum mothers having infants admitted to the NICU.

MATERIALS AND METHODS

First phase: A yoga module was designed through a review of published research articles and yogic texts for NICU mothers. Second phase: thirty-eight yoga experts validated the yoga module. Lawshe's formula was used to calculate each item's content validity ratio (CVR). The intra-class correlation coefficient was determined for the validated yoga module. Third phase: The validated yoga module was pilot-tested with a sample size of 20 NICU mothers.

RESULTS

Thirty-eight yoga experts validated the yoga module for NICU mothers. Thirteen practices included in the module indicated good content validity (cutoff value: 0.316). The module's content validity index (CVI) and intra-class correlation coefficient were 0.672 and 0.924, respectively. Ten days of practicing the yoga module resulted in a significant reduction in maternal stress levels in the yoga group (p < 0.001) compared to the control group (p = 0.427).

CONCLUSION

The present study suggests good content validity of the yoga module for the mental health of NICU mothers. However, future randomized controlled trials must be carried out to determine both the feasibility and clinical efficacy of the Yoga Module for NICU mothers.

Does Educational Status Influence Parents' Response to Bad News in the NICU?

Communication in neonatal intensive care units and the relationship between families and staff have been reported to influence parental mental well-being. Research has also shown an impact of parental educational level on their well-being. However, whether different educational levels result in different reactions to breaking bad news (BBN) by physicians remains unanswered so far. We therefore examined the impact of parental level of education on their mental state after a BBN conversation and their relation to physicians. A prospective quantitative survey was conducted amongst 54 parents whose preterm or term infants were hospitalized in three German neonatal units. Parental education was classified as low (lower secondary/less (1), n: 23) or high (higher secondary/more (2), n: 31). Parents answered questions about certain aspects of and their mental state after BBN and their trust in physicians. The two groups did not differ significantly in their mental condition after BBN, with both reporting high levels of exhaustion and worries, each (median (min;max): (1): 16 (6;20) vs. (2): 14 (5;20), (scaling: 5-20)). However, lower-educated parents reported a lower trust in physicians (median (min;max): (1): 2 (0;9) vs. (2): 1 (0;6), p < 0.05 (scaling: 0-10)) and felt less safe during BBN (median (min;max): (1): 15 (9;35) vs. (2): 13 (9;33), p < 0.05). Only among higher-educated parents was trust in physicians significantly correlated with the safety and orientation provided during BBN (r: 0.583, p < 0.05, r: 0.584, p < 0.01). Concurrently, only among less-educated parents was safety correlated with the hope conveyed during BBN (r: 0.763, p < 0.01). Therefore, in BBN discussions with less-educated parents, physicians should focus more on giving them hope to promote safety.

Development and Effects of Mobile-Application-Based Parenting Support Program for Premature Infants' Mothers

BACKGROUND

Premature infants are separated from their parents after birth and are admitted to the neonatal intensive care unit. Separation of babies from mothers causes various problems. Therefore, as the number of premature infants increases every year, educational programs to continuously support baby care are needed.

METHODS

In this study, a nonequivalent control group non-synchronized design was employed. The subjects of the study were 52 mothers of premature infants (16 in the app-based program group, 18 in the electronic document group, and 18 in the control group) using a portal site for parents from February to April 2023. The app-based program and electronic document group followed a parenting support program for two weeks.

RESULTS

There were significant differences in maternal confidence between the app-based, electronic document, and control groups (F = 7.354, p = 0.002).

CONCLUSIONS

Providing necessary information and emotional support through professional counseling centers' app-based programs for premature infants' mothers, and providing interaction through member community bulletin boards, are proposed to form an effective educational program.

Neurodevelopmental, Mental Health, and Parenting Issues in Preterm Infants

The World Health Organization in its recommendations for the care of preterm infants has drawn attention to the need to address issues related to family involvement and support, including education, counseling, discharge preparation, and peer support. A failure to address these issues may translate into poor outcomes that extend across the lifespan. In this paper, we review the often far-reaching impact of preterm birth on the health and wellbeing of the parents and highlight the ways in which psychological stress may have a negative long-term impact on the parent-child interaction, attachment, and the styles of parenting. This paper addresses the following topics: (1) neurodevelopmental outcomes in preterm infants, including cognitive, sensory, and motor difficulties, (2) long-term mental health issues in premature infants that include elevated rates of anxiety and depressive disorders, autism, and somatization, which may affect social relationships and quality of life, (3) adverse mental health outcomes for parents that include elevated rates of depression, anxiety, and symptoms of post-traumatic stress, as well as increased rates of substance abuse, and relationship strain, (4) negative impacts on the parent-infant relationship, potentially mediated by maternal sensitivity, parent child-interactions, and attachment, and (5) impact on the parenting behaviors, including patterns of overprotective parenting, and development of Vulnerable Child Syndrome. Greater awareness of these issues has led to the development of programs in neonatal mental health and developmental care with some data suggesting benefits in terms of shorter lengths of stay and decreased health care costs.

Unmet Parental Mental Health Service Needs in Neonatal Follow-Up Programs: Parent and Service Provider Perspectives

Parental mental health services in neonatal follow-up programs (NFUPs) are lacking though needed. This study aimed to determine (1) the unmet mental health needs of parents and (2) the parent and provider perspectives on barriers and opportunities to increase mental health service access. Study 1: Parents in a central Canadian NFUP (N = 49) completed a mixed-method online survey (analyzed descriptively and by content analysis) to elucidate their mental health, related service use, barriers to service use, and service preferences. Study 2: Virtual focus groups with NFUP service providers (N = 5) were run to inform service improvements (analyzed by reflexive thematic analysis). The results show that parents endorsed a 2-4 times higher prevalence of clinically significant depression (59.2%), anxiety (51.0%), and PTSD (26.5%) than the general postpartum population. Most parents were not using mental health services (55.1%) due to resource insecurity among parents (e.g., time, cost) and the organization (e.g., staffing, training, referrals). Consolidating parents' and service providers' perspectives revealed four opportunities for service improvements: bridging services, mental health screening, online psychoeducation, and peer support. Findings clarify how a central Canadian NFUP can address parental mental health in ways that are desired by parents and feasible for service providers.

Addressing caregiver mental health in the neonatal ICU

PURPOSE OF REVIEW

The neonatal ICU (NICU) setting is a unique opportunity to not only detect major changes in caregiver mental health through universal perinatal mood and anxiety disorder (PMAD) screening but also intervene with specialized support. We review evidence for addressing caregiver mental health in the NICU, explore current guidelines and models for integrated behavioural health programmes, and describe challenges specific to NICUs, particularly in standalone paediatric hospitals.

RECENT FINDINGS

Parents of infants admitted to the NICU are at an increased risk for developing PMADs at rates well above the general postpartum community. Select NICUs within the United States and internationally have recognized the importance of having an embedded psychologist to address caregiver PMADs. However, organizational structures within paediatric healthcare systems are not equipped to manage the logistical, ethical, legal and practical needs of comprehensive caregiver mental health programmes.

SUMMARY

To properly address caregiver mental health in NICU settings, clinical and administrative teams must work together to ensure seamless service provision. Systems that facilitate the development of unique parent medical records at the onset of paediatric care are likely to significantly reduce potential liability risks and solve several challenges related to caregiver-focused mental health support in the NICU.

VIDEO ABSTRACT

http://links.lww.com/MOP/A70.

Social Determinants of Health and Parenting Self-Efficacy Among Mothers of Preterm Infants

Objective

To explore the relationships between social and environmental factors and parenting self-efficacy (PSE) among mothers of preterm infants hospitalized in neonatal intensive care units (NICUs) using a social determinants of health (SDoH) framework.

Method

We analyzed data from a prospective cohort study that included 187 mother-infant dyads admitted to four NICUs in the Mountain West region between June 2017 and December 2019. We used multivariable linear regression models to assess the independent associations between maternal and infant characteristics and PSE.

Results

Our final multiple linear regression model predicting the efficacy score including maternal race/ethnicity, age, insurance, employment status before giving birth, gestational age, depression, and having other children was significant (F(12,160) = 3.17, p = .0004, adjusted R¬2 = .131). Significant predictors of PSE were race/ethnicity (β= 3.3, p = .022), having another child/children (β= 4.2, p = .005), and depression (β= -4.2, p = .004).

Conclusions

Findings suggest that social workers and medical practitioners should consider SDoH, such as insurance type, household income, and employment, along with traditional clinical indicators when assessing families' infant care needs. Social workers, medical practitioners, and researchers should be mindful of how implicit bias may influence the allocation of care and parental supports.

Virtual family-centered hospital rounds in the neonatal intensive care unit: protocol for a cluster randomized controlled trial

BACKGROUND

Family-centered rounds is recognized as a best practice for hospitalized children, but it has only been possible for children whose families can physically be at the bedside during hospital rounds. The use of telehealth to bring a family member virtually to the child's bedside during hospital rounds is a promising solution. We aim to evaluate the impact of virtual family-centered hospital rounds in the neonatal intensive care unit on parental and neonatal outcomes.

METHODS

This two-arm cluster randomized controlled trial will randomize families of hospitalized infants to have the option to use telehealth for virtual hospital rounds (intervention) or usual care (control). The intervention-arm families will also have the option to participate in hospital rounds in-person or to not participate in hospital rounds. All eligible infants who are admitted to this single-site neonatal intensive care unit during the study period will be included. Eligibility requires that there be an English-proficient adult parent or guardian. We will measure participant-level outcome data to test the impact on family-centered rounds attendance, parent experience, family-centered care, parent activation, parent health-related quality of life, length of stay, breastmilk feeding, and neonatal growth. Additionally, we will conduct a mixed methods implementation evaluation using the RE-AIM (Reach, Effectiveness, Adoption, Implementation, Maintenance) framework.

DISCUSSION

The findings from this trial will increase our understanding about virtual family-centered hospital rounds in the neonatal intensive care unit. The mixed methods implementation evaluation will enhance our understanding about the contextual factors that influence the implementation and rigorous evaluation of our intervention.

TRIAL REGISTRATION

ClinicalTrials.gov Identifier: NCT05762835. Status: Not yet recruiting. First posted: March 10, 2023; last update posted: March 10, 2023.

Virtual Family-Centered Rounds in the Neonatal Intensive Care Unit: Protocol for a Cluster Randomized Controlled Trial

Background: Family-centered rounds is recognized as a best practice for hospitalized children, but it has only been possible for children whose families can physically be at the bedside during hospital rounds. The use of telehealth to bring a family member virtually to the child’s bedside during rounds is a promising solution. We aim to evaluate the impact of virtual family-centered rounds in the neonatal intensive care unit on parental and neonatal outcomes. Methods: This two-arm cluster randomized controlled trial will randomize families of hospitalized infants to have the option to use telehealth for virtual rounds (intervention) or usual care (control). The intervention-arm families will also have the option to participate in rounds in-person or to not participate in rounds. All eligible infants who are admitted to this single-site neonatal intensive care unit during the study period will be included. Eligibility requires that there be an English-proficient adult parent or guardian. We will measure participant-level outcome data to test the impact on family-centered rounds attendance, parent experience, family-centered care, parent activation, parent health-related quality of life, length of stay, breastmilk feeding, and neonatal growth. Additionally, we will conduct a mixed methods implementation evaluation using the RE-AIM (Reach, Effectiveness, Adoption, Implementation, Maintenance) framework. Discussion: The findings from this trial will increase our understanding about virtual family-centered rounds in the neonatal intensive care unit. The mixed methods implementation evaluation will enhance our understanding about the contextual factors that influence the implementation and rigorous evaluation of our intervention. Trial registration: ClinicalTrials.gov Identifier: NCT05762835. Status: Not yet recruiting. First Posted: 3/10/2023; Last Update Posted: 3/10/2023.

Sociodemographic risk factors, parental stress and social support in the neonatal intensive care unit

OBJECTIVE

Investigate relationships among neonatal intensive care unit (NICU) parent demographics, reported stress and social support.

DESIGN

Cross-sectional observation.

SETTING

Tertiary referral NICU in Mid-Atlantic USA.

PATIENTS

Parents (n=300) in the Giving Parents Support trial at enrolment.

MEASURES

Psychometric scales measured general stress, parental stress, NICU stress and social support. Demographic variables included education level, health insurance type, race, relationship status, age and gender. Length of stay was used to control for illness severity. Associations and potential modifying effects were evaluated using linear regression.

RESULTS

Having less than a college degree (b=-2.52, SE=0.91) and female parent gender (b=-3.42, SE=1.47) were associated with lower parental stress scores. Older age in years was associated with higher parental stress scores (b=0.21, SE=0.07) but lower NICU stress scores (b=-0.01, SE=0.01). Greater social support scores were associated with lower scores of general (b=-2.76, SE=0.39) and parental stress (b=-1.71, SE=0.47). Less than a college degree (b=-0.26, SE=0.11), Medicaid insurance (b=-0.43, SE=0.11) and black race (b=-0.56, SE=0.12) were associated with decreased social support scores. Level of social support modified the relationship between education and parental stress, with higher social support decreasing education-based differences in parental stress scores (p=0.049).

CONCLUSION

Sociodemographic risk factors may not infer stress or risk in the anticipated direction. Practice and future research should focus on identifying and supporting NICU families at high risk for stress and low support.

TRIAL REGISTRATION NUMBER

NCT02643472.

Oxytocin Levels Increase and Anxiety Decreases in Mothers Who Sing and Talk to Their Premature Infants during a Painful Procedure

(1) Background: Preterm infants spend their first weeks of life in the hospital partially separated from their parents and subjected to frequent potentially painful clinical procedures. Previous research has found that early vocal contact reduces infant pain perception while simultaneously increasing oxytocin (OXT) levels. The current study aims to assess the effect of maternal singing and speaking on mothers. (2) Methods: During a painful procedure over two days, twenty preterm infants were randomly exposed to their mother's live voice (speaking or singing). Maternal OXT levels were measured twice: before and after singing, as well as before and after speaking. The anxiety and resilience responses of mothers were studied before and after the two-day interventions, regardless of the speaking/singing condition. OXT levels in mothers increased in response to both singing and speech. Concurrently, anxiety levels decreased, but no significant effects on maternal resilience were found. (3) Conclusions: OXT could be identified as a key mechanism for anxiety regulation in parents, even in sensitive care situations, such as when their infant is in pain. Active involvement of parents in the care of their preterm infants can have a positive effect on their anxiety as well as potential benefits to their sensitivity and care abilities through OXT.

Associations between provider-assigned Apgar score and neonatal race

BACKGROUND

For decades, the Apgar scoring system has been used to evaluate neonatal status and determine need for resuscitation or escalation in care, such as admission to a neonatal intensive care unit. However, the variation and accuracy of provider-assigned Apgar scores across neonatal racial groups have yet to be evaluated.

OBJECTIVE

This study aimed to investigate how provider-assigned Apgar scores vary by neonatal race independently of clinical factors and umbilical cord gas values.

STUDY DESIGN

We conducted a retrospective cohort study at an urban academic medical center. All live births at ≥23 weeks and 0 days of gestation from January 1, 2019 through December 31, 2019 with complete data available were included. Data were queried from the electronic medical record and included race, ethnicity, gestational age of neonate, umbilical cord gas values (umbilical artery pH and base deficit), admission to the neonatal intensive care unit, and presence of maternal-fetal complications. Primary outcome measures were neonates' Apgar scores at 1 and 5 minutes. Color Apgar score and admission to the neonatal intensive care unit served as secondary outcome measures. We performed 3 partially proportional ordinal regression models controlling for an increasing number of covariates, with Model 1, the baseline model, adjusted for gestational age, Model 2 additionally adjusted for umbilical cord gases, and Model 3 additionally adjusted for maternal medical conditions and pregnancy complications.

RESULTS

A total of 977 neonates met selection criteria; 553 (56.6%) were Black. Providers assigned Black neonates significantly lower Apgar scores at 1 minute (odds ratio, 0.63; 95% confidence interval, 0.49-0.80) and 5 minutes (odds ratio, 0.64; 95% confidence interval, 0.47-0.87), when controlling for umbilical artery gases, gestational age, and maternal-fetal complications. This difference seemed related to significantly lower assigned color Apgar scores at 1 minute when controlling for all the above factors (odds ratio, 0.52; 95% confidence interval, 0.39-0.68). Providers admitted full-term Black neonates to the neonatal intensive care unit at higher rates than non-Black neonates when controlling for all factors (odds ratio, 1.29; 95% confidence interval, 0.94-1.77). Black neonates did not have more abnormal cord gas values (mean umbilical artery pH of 7.259 for Black vs 7.256 for non-Black neonates), which would have supported their admission to the neonatal intensive care unit.

CONCLUSION

Providers applied inaccurate Apgar scores to Black neonates given that the umbilical cord gases were not in agreement with lower Apgar scores. These inaccuracies may be a factor in unnecessary admissions to neonatal intensive care units, and suggest that colorism and racial biases exist among healthcare providers.

Prevalence of and factors associated with postnatal depression and anxiety among parents of preterm infants: A systematic review and meta-analysis

BACKGROUND

This study aimed to determine the prevalence of and factors associated with postpartum depression and anxiety among mothers and fathers of preterm infants and to examine the relationships between maternal and paternal symptoms.

METHODS

Six electronic databases were searched to identify eligible studies reporting parental depression and anxiety within 1 year postpartum. Data were extracted for a random-effects meta-analysis to estimate the prevalence with 95 % confidence intervals (CIs). Subgroup and meta-regression analyses were conducted to analyze associations between study characteristics and prevalence estimates.

RESULTS

In total, 79 studies were included. The meta-analysis of studies on mothers generated estimates of prevalence for depression (29.2 %, 95 % CI, 21.8 %-37.9 %) and anxiety (37.7 %, 95 % CI, 24.1 %-53.6 %). The meta-analysis of fathers indicated a pooled depression prevalence of 17.4 % (95 % CI, 12.5 %-23.8 %) and an anxiety estimate of 18.3 % (95 % CI, 8.1 %-36.3 %). Assessment time points and methods as well as the geographic continent in which the study was conducted were significant moderators of depression and anxiety. Significant inter-correlations were found between mothers' and fathers' depression and anxiety symptoms (p < 0.05).

LIMITATIONS

Limited data from specific geographic continents, including Africa and Asia.

CONCLUSIONS

Prevalence of depression and anxiety among preterm infants' parents was high, highlighting the need for early psychological screening and assessment. Further research is required to improve services that focus on parents' postpartum psychological needs in the family context.

NeoConnect: The Design, Implementation, and Impact of a Virtual Family-Centered NICU Program

BACKGROUND

Familial involvement in the neonatal intensive care unit (NICU) reduces parental stress and strengthens parental-infant bonding. However, parents often face barriers to in-person visitation. The coronavirus disease-2019 COVID-19 pandemic has exacerbated limitations to parental bedside presence.

OBJECTIVE

To design, implement, and evaluate a technology-based program to connect NICU babies with their families during the COVID-19 pandemic.

METHODS

We created NeoConnect at our level IV NICU, which included parental audio recordings and video chats between parents and their babies. Parental and NICU staff input on NeoConnect was gathered via preimplementation surveys. Inaugural families and staff members completed a postparticipation survey.

RESULTS

Prior to implementation, all parents who were surveyed (n = 24) wished they could be more involved in their baby's care. In the first 3 months of NeoConnect, 48 families participated in the audio recording project and 14 families participated in the video chat initiative. Following implementation, 85% of surveyed staff (28/33) reported that the patients became calmer when listening to their parents' recorded voice and 100% of surveyed parents (6/6) reported that video chats reduced their stress level.

CONCLUSION

Harnessing technology as a tool to increase parental involvement in the NICU is feasible and beneficial for NICU patients and their families.

Acceptability and feasibility of a digital educational intervention designed to improve the psychological well-being of parents with a preterm infant at the neonatal intensive care unit: A pilot project

BACKGROUND

Families experience psychological distress when their preterm infant is in the Neonatal Intensive Care Unit. A tailored educational intervention may be beneficial for their psychological well-being. Unfortunately, existing websites have moderate to low information quality and there is no educational website for French-speaking parents.

AIM

To measure the acceptability and feasibility of a digital educational intervention designed to improve the psychological well-being of parents with a preterm infant, as well as the acceptability and feasibility of the study methods used.

METHODS

A pilot randomized controlled trial was conducted. Participants were randomized to have access to either an educational website or information pamphlet. They were invited to complete an online questionnaire about stress and depressive symptoms 2 and 4 weeks after recruitment. An online questionnaire regarding the acceptability of the intervention and the data collection process was completed 5 weeks after recruitment.

RESULTS

Twenty parents participated. All participants with access to the website considered it was acceptable in terms of the appropriateness, convenience, and efficiency to meet their informational needs. 85 % of participants assigned to the website viewed it 1 to 3 times per day during the data collection period and 69.4 % consulted the website for 5 to 20 min each time. The data collection process was acceptable for 85 % to 95 % of participants.

DISCUSSION

The educational website was an acceptable and feasible intervention and the data collection process used was acceptable according to participants.

Implementing genomics in the neonatal period: An assessment of parental decision making and anxiety

As uptake of rapid genome sequencing (GS) in the neonatal period steadily increases, a clinical genetics service that is optimized to the needs of parents becomes increasingly important. We aimed to investigate factors that influence decision making about rapid GS by parents of infants admitted to neonatal intensive care units (NICU) and explore their experiences of decisional conflict and anxiety during this time. Parents of neonates suspected of having a genetic disorder and offered rapid GS in the NICU completed a questionnaire measuring experience with GS counseling, decisional conflict, and anxiety level. Our results demonstrate that despite a largely positive GS experience (70%; 21/30) among the survey respondents, 50.0% (14/28) experienced moderate to severe anxiety measured using the GAD-7 scale, and 34.6% (9/26) experienced decisional conflict measured using the SURE scale. We also showed that prematurity may be a modifier of anxiety in this group of parents and although not statistically significant, distance lived away from the hospital site could have practical significance. Open-ended responses to survey questions highlighted that feeling overwhelmed, the types of engagements parents had with healthcare providers, and the timing of information provision also influenced parental decision making in this setting. We suggest that the GAD-7 scale for generalized anxiety and SURE scale for decisional conflict could be incorporated by genetic counselors into routine care of parents of neonates who have been offered rapid GS to identify those who may need additional support (resources, information, or psychological). These tools may inform ways that communication between patients and providers can be improved and enhanced and clinical genetics services in the NICU can be optimized. We suggest that integrating genetic counselors into the NICU care team could increase access for this population and ensure delivery of optimized patient education and counseling.

Maternal psychological distress in the early postpartum period during COVID-19 pandemic: a pilot study

Background

The coronavirus disease 2019 infection (COVID-19) pandemic is a new global outbreak disease. According to the Taiwan Centers for Diseases Control statement, hospitals had to change their corresponding measures to prevent the spread of COVID-19. The frequency of parental visits to the special care nursery was reduced from three times to once daily. Visiting was not permitted from April 4 to May 10, 2020, and rooming-in with healthy neonates was discontinued, which could increase maternal postpartum distress. Therefore, this study was conducted to determine whether COVID-19 prevention increased maternal psychological distress.

Methods

This prospective study used convenience sampling to enroll healthy mothers who had just delivered via normal spontaneous delivery. Based on the neonates’ status and visiting times, mothers were grouped into no-rooming-in, rooming-in, no-visiting, and one-visit/day groups. Mothers’ baseline characteristics were compared using the Chi-square or Fisher's exact test and t-test. Salivary cortisol levels and scores of Chinese versions of the Perceived Stress Scale (PSS) and State-Trait Anxiety Inventory were evaluated on postpartum days 1 and 3 and analyzed by one-way analysis of variance and a paired t-test.

Results

There were 16, 58, 28, and 47 women categorized as no-rooming-in, rooming-in, no-visit, and one-visit/day groups, respectively. No significant differences were found between groups in mothers’ baseline characteristics and postpartum salivary cortisol levels. The PSS on day 3 was significantly higher than on day 1 in every group (p < 0.001). The PSS increasing trend in the no-rooming-in group was significantly greater than that in the no-visit group (p = 0.02) and significantly greater in the rooming-in group than that in the one-visit/day group (p = 0.001).

Conclusion

Postpartum stress increased for all mothers and was an even more significant response to the COVID-19 pandemic than the stress associated with neonates’ hospitalization.

Factors Influencing Mothers' Quality of Sleep during Their Infants' NICU Hospitalization

STUDY OBJECTIVES

The purpose of this study is to identify factors associated with Neonatal Intensive Care Unit (NICU) mothers' quality of sleep as measured with the General Sleep Disturbance Scale (GSDS).

METHODS

Recruitment took place in a level 3 NICU. At enrollment, mothers completed a socio-demographic questionnaire, described their presence in the unit and their breast milk expression behavior. They also completed online or paper questionnaires about NICU-related stress, symptoms of postpartum depression, family-centered care, perception of noise and light in the unit, and sleep disturbances. Data regarding the infant's clinical condition were collected from their medical file. Pearson correlations were performed to identify associations between mothers' quality of sleep and other study variables. Subsequently, to compare mothers with a clinically significant GSDS score to mothers with a non-significant score, a binary logistic regression model was conducted.

RESULTS

132 mothers participated. Sleep disturbances of mothers with an infant hospitalized in the NICU was positively correlated with stress (r = 0.40; p = .00), depressive symptoms (r = 0.51; p = .00), and breast milk expression (r = 0.23; p = .01). In addition, for mothers with significant levels of depressive symptoms (OR = 1.19; p = .00), with greater presence in the unit (OR = 1.36; p = .04), or with other children at home (OR = 3.12; p = .04), the likelihood of clinically significant sleep disturbances was increased.

CONCLUSIONS

These results improve our understanding of the factors influencing the quality of sleep of mothers whose premature infant is hospitalized for 2 weeks or more in the NICU. In addition, these results allow the identification of mothers having a higher possibility for sleep disturbance, which enables the implementation of targeted interventions to promote adequate sleep.

Effective stress intervention programs for parents of premature children: A systematic review

The birth of a child alters family dynamics and can be stressful for parents, especially in the case of prematurity. This article carried out a systematic review on interventions in parents to reduce the stress experienced by the birth of a premature infant. The aims were to describe and classify the different interventions and to have an overview of their effectiveness. We used the Preferred Reporting Items for Systematic Reviews and Meta-Analyses guide and the PICO model. For searching the bibliography, we used Web of Science, Science Direct, PubMed and PsycINFO databases. From a total of 450 articles identified, this review finally included 46 studies with empirical evidence. The articles clustered into different types of interventions, such as psychoeducational and parental or maternal support programs, relaxation techniques, expressive writing, art therapy, music therapy and interventions related to interaction and tactile stimulation. There is a wide range of effectiveness in reducing parental stress to a greater or lesser degree. There is a great heterogeneity of interventions. Despite that, they all have a parental educational component that needs to be studied in greater depth.

Driving new technologies in hospitals: association of organizational and personal factors with the readiness of neonatal intensive care unit staff toward webcam implementation

Background

The use of webcam technology in neonatal intensive care units (NICUs) enables parents to see their child when the parents cannot be present at the NICU. The webcam’s use has been gaining increasing attention. Lead physicians and lead nursing staff play a key role in the decision of whether to implement webcams. This study investigates factors that are associated with the readiness for the implementation of a webcam system among lead NICU staff.

Methods

A postal survey was conducted among all lead physicians and lead nursing staff in all German NICUs between December 2020 and April 2021 (total N = 416, one lead physician and one lead nursing staff per NICU, N = 208). On the basis of normalization process theory, personal (technology acceptance) and organizational (innovation climate) attributes were chosen to determine their association with the readiness for the implementation of a webcam system. The association of these factors was determined using multiple linear regression models for both lead physicians and lead nurses.

Results

Overall, a response rate of 66.59% (n = 277) was achieved. Technology acceptance proved to be a significant factor associated with the readiness for the implementation of a webcam system among lead physicians. Furthermore, staff already working with webcams in their NICUs indicated a significantly higher level of technology acceptance than staff without webcam experience and without any desire to use a webcam in the future. No significant association was found between innovation climate and the readiness for the implementation of a webcam system.

Conclusions

Technology acceptance was identified as a factor associated with the readiness for the implementation of a webcam system. The insights from this study can be used to manage potential barriers regarding the readiness for implementation of webcams in NICUs.

Trial registration

The Neo-CamCare study is registered at the German Clinical Trials Register. DRKS-ID: DRKS00017755. Date of Registration in DRKS: 25-09-2019.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12913-022-08072-5.

Words matter: exploring communication between parents and neonatologists

OBJECTIVE

To evaluate how neonatologists and NICU parents perceive communication in the NICU.

STUDY DESIGN

A mixed-methods approach using an online survey and three focus groups with NICU parents and neonatologists, utilizing videos of simulated conversations between a neonatologist and mother.

RESULTS

A total of 72 participants responded to the online survey. Parents ranked the invasiveness of common NICU clinical procedures differently than the neonatologist standard but assessed the quality of the simulated conversation similarly. A total of 13 parents and 6 physicians participated in the focus groups. Major themes from both neonatologist and parent focus groups were the impact of making a connection with the parents, the importance of making decisions yet not making assumptions based on the divergent use of language by neonatologists and parents, and providing hope.

CONCLUSIONS

Parents and neonatologists differ in their perception of key aspects of NICU language use and communication but also agree on many aspects.

Pilot Study of Sham Feeding in Postoperative Neonates

OBJECTIVE

Sham feeding may enhance development of oral skills in neonates after bowel surgery and decrease stress levels in mothers. In this pilot study, we test the feasibility of sham feeding, identify safety hazards, and assess maternal satisfaction.

STUDY DESIGN

A convenience sample of 15 postoperative neonates was enrolled. Sham feeding with unfortified human milk was offered following a strict advancement protocol beginning with 5 mL once daily and increasing up to 30 mL, three times daily. Continuous gastric suction was used during sham feeding. Each mother completed a satisfaction survey. Sham-fed gastroschisis patients were compared with a historic cohort.

RESULTS

All 15 patients were able to sham feed. A total of 312 sham feeds were offered with a median of 23 sham events per patient. Four minor complications occurred during sham feeding. No differences were noted between 11 sham-fed gastroschisis patients and 81 historic controls. The mothers reported a decrease in stress after sham feeding using a 5-point score (3.8 ± 1.4 vs. 1.5 ± 0.7, p < 0.005) and 100% satisfaction with sham feeding.

CONCLUSION

Sham feeding is feasible for neonates after bowel surgery and is highly rated by mothers.

KEY POINTS

· Sham-feeding human milk to neonates after bowel surgery is feasible and safe.. · A novel postoperative sham feeding protocol is described.. · Mothers of sham-fed infants report it reduces stress compared with not feeding..

Association of a Zero-Separation Neonatal Care Model With Stress in Mothers of Preterm Infants

IMPORTANCE

Active participation in care by parents and zero separation between parents and their newborns is highly recommended during infant hospitalization in the neonatal intensive care unit (NICU).

OBJECTIVE

To study the association of a family integrated care (FICare) model with maternal mental health at hospital discharge of their preterm newborn compared with standard neonatal care (SNC).

DESIGN, SETTING, AND PARTICIPANTS

This prospective, multicenter cohort study included mothers with infants born preterm treated in level-2 neonatal units in the Netherlands (1 unit with single family rooms [the FICare model] and 2 control sites with standard care in open bay units) between May 2017 and January 2020 as part of the AMICA study (fAMily Integrated CAre in the neonatal ward). Participants included mothers of preterm newborns admitted to participating units. Data analysis was performed from January to April 2021.

EXPOSURES

FICare model in single family rooms with complete couplet-care for the mother-newborn dyad during maternity and/or neonatal care.

MAIN OUTCOMES AND MEASURES

Maternal mental health, measured using the Parental Stress Scale: NICU (PSS-NICU). Secondary outcomes included survey scores on the Hospital Anxiety and Depression Scale, Postpartum Bonding Questionnaire, Perceived Maternal Parenting Self-efficacy Scale, and satisfaction with care (using EMPATHIC-N). Parent participation (using the CO-PARTNER tool) was assessed as a potential mediator of the association of the FICare model on outcomes with mediation analyses.

RESULTS

A total of 296 mothers were included; 124 of 141 mothers (87.9%) in the FICare model and 115 of 155 (74.2%) mothers in SNC responded to questionnaires (mean [SD] age: FICare, 33.3 [4.0] years; SNC, 33.3 [4.1] years). Mothers in the FICare model had lower total PSS-NICU stress scores at discharge (adjusted mean difference, -12.24; 95% CI, -18.44 to -6.04) than mothers in SNC, and specifically had lower scores for mother-newborn separation (adjusted mean difference, -1.273; 95% CI, -1.835 to -0.712). Mothers in the FICare model were present more (>8 hours per day: 105 of 125 [84.0%] mothers vs 42 of 115 [36.5%]; adjusted odds ratio, 19.35; 95% CI, 8.13 to 46.08) and participated more in neonatal care (mean [SD] score: 46.7 [6.9] vs 40.8 [6.7]; adjusted mean difference, 5.618; 95% CI, 3.705 to 7.532). Active parent participation was a significant mediator of the association between the FICare model and less maternal depression and anxiety (adjusted indirect effect, -0.133; 95% CI, -0.226 to -0.055), higher maternal self-efficacy (adjusted indirect effect, 1.855; 95% CI, 0.693 to 3.348), and better mother-newborn bonding (adjusted indirect effect, -0.169; 95% CI, -0.292 to -0.068).

CONCLUSIONS AND RELEVANCE

The FICare model in our study was associated with less maternal stress at discharge; mothers were more present and participated more in the care for their newborn than in SNC, which was associated with improved maternal mental health outcomes. Future intervention strategies should aim at reducing mother-newborn separation and intensifying active parent participation in neonatal care.

TRIAL REGISTRATION

Netherlands Trial Register identifier NL6175.

COVID-19 Pandemic Experiences and Maternal Stress in Neonatal Intensive Care Units

COVID-19 compounds the already high levels of psychological distress experienced by NICU mothers. We aimed to describe the rates of NICU-related maternal stress during the COVID-19 pandemic and to determine how COVID-19 experiences correlate with high levels of stress experienced by NICU mothers. We conducted a cross-sectional analysis based on responses to a nationwide online survey to understand the relationship between COVID-19-related experiences and the stress experienced by mothers of infants admitted to U.S. NICUs (n = 108) during the pandemic. Results indicate that 61.9% of surveyed mothers reported experiencing high levels of stress on the Parental Stressor Scale: NICU. COVID-19-related grief was significantly associated with higher levels of maternal stress, as it related to seeing the baby’s appearance and behavior in the NICU and exposure to sights and sounds within the NICU environment. No significant associations were noted between parental stress and COVID-19-related health worries or worries about resources. Of note, our recruitment relied on convenience sampling, limiting the generalizability of study results. In conclusion, mothers who experience COVID-19-related grief appear to be more vulnerable to NICU-related stress. Prioritizing parent involvement and enhancing psychosocial support are essential strategies to mitigate the long-term consequences of heightened stress for NICU families.

Psychological impact of neonatal intensive care unit admissions on parents: A regional perspective

OBJECTIVE

This study aimed to report the prevalence of adverse psychological symptoms and health behaviours of parents who had a baby admitted to a regional neonatal intensive care unit to spotlight mental health care in these unique settings.

DESIGN

This was a prospective, prevalence-based study using quantitative data.

SETTING

The study was conducted at the Townsville University Hospital, Queensland.

PARTICIPANTS

Participants comprised 114 parents of 79 infants enrolled in the study (mothers = 69 and fathers = 45).

MAIN OUTCOME MEASURES

Trauma, depression, anxiety, stress, alcohol and drug use, prior mental health history and bonding experience were assessed by standardised self-report questionnaires and a structured diagnostic interview within 2 weeks and at 3 months post-admission to neonatal intensive care unit.

RESULTS

Clinically significant acute trauma symptoms (16% of mothers only), depression (22% mothers; 4% of fathers), anxiety (27% mothers; 11% fathers) and stress (24% mothers; 13% fathers) were reported within the first 2 weeks after their baby was admitted to the neonatal intensive care unit. Notably, 18% of parents reported engaging in harmful alcohol use behaviour within 2 weeks post-birth; 29% of fathers continued to report risky drinking at 3 months. At 3 months, 21%, 8% and 6% of mothers met diagnostic criteria for generalised anxiety disorder, major depressive disorder and post-traumatic stress disorder, respectively.

CONCLUSION

Screening for psychological distress and alcohol use of parents of neonatal intensive care unit babies can ensure that support services are made available post-discharge to optimise family function and development of the preterm infant.

Short-term Music Therapy for Families With Preterm Infants: A Randomized Trial

OBJECTIVES

To evaluate short-term effects of music therapy (MT) for premature infants and their caregivers on mother-infant bonding, parental anxiety, and maternal depression.

METHODS

Parallel, pragmatic, randomized controlled-trial conducted in 7 level III NICUs and 1 level IV NICU in 5 countries enrolling premature infants (<35 weeks gestational age at birth) and their parents. MT included 3 sessions per week with parent-led, infant-directed singing supported by a music therapist. Primary outcome was mother-infant bonding as measured by the Postpartum Bonding Questionnaire (PBQ) at discharge from NICU. Secondary outcomes were parents' symptoms of anxiety measured by General Anxiety Disorder-7 (GAD-7) and maternal depression measured by Edinburgh Postpartum Depression Scale (EPDS). Group differences at the assessment timepoint of discharge from hospital were tested by linear mixed effect models (ANCOVA).

RESULTS

From August 2018 to April 2020, 213 families were enrolled in the study, of whom 108 were randomly assigned to standard care and 105 to MT. Of the participants, 208 of 213 (98%) completed treatment and assessments. Participants in the MT group received a mean (SD) of 10 sessions (5.95), and 87 of 105 participants (83%) received the minimum of 6 sessions. The estimated group effect (95% confidence interval) for PBQ was -0.61 (-1.82 to 0.59). No significant differences between groups were found (P = .32). No significant effects for secondary outcomes or subgroups were found.

CONCLUSIONS

Parent-led, infant-directed singing supported by a music therapist resulted in no significant differences between groups in mother-infant bonding, parental anxiety, or maternal depression at discharge.

The Relationship Between Neonatal Surgery, Postpartum Depression, and Infant Clinical Course

OBJECTIVE

Postpartum depression (PPD) affects 10-15% of mothers in the general population, and studies show increased incidence for mothers of infants with serious health conditions. This study investigates incidence of PPD in mothers of surgical patients in the neonatal intensive care unit (NICU) and characterizes these patients' clinical and neurodevelopmental outcomes.

METHODS

This retrospective cohort study analyzed Nebraska's Tracking Infant Progress Statewide (TIPS) database and referring hospital medical records from February 2013 to June 2018. Upon NICU discharge, children were referred to the TIPS program, with scheduled follow-up appointments at approximately 6 months corrected age. All patients seen in NICU follow-up clinic with recorded scores for maternal Edinburgh postnatal depression screen (EPDS) were eligible except infants with congenital heart disease as this cohort was previously studied. Patients were stratified into groups based on presence or absence of a general surgical procedure within the first 6 months of life and positive (≥ 10) or negative (< 10) EPDS score. Statistical analyses assessed for significant differences between groups regarding gestational age, birth weight, maternal age, length of NICU stay (LOS), number of days on a ventilator, payment method, ethnicity, developmental testing, and rate of referral for early intervention services.

RESULTS

Of 436 patients, 83 were surgical patients (16 with positive EPDS; 19.3% incidence), and 353 were non-surgical patients (44 with positive EPDS; 12.5% incidence). Statistical analysis showed no significant relationship between neonatal surgery and positive EPDS (χ² = 2.6, p = 0.1). While the surgical cohort had longer LOS and days on ventilator, maternal EPDS did not predict these factors. In the surgical cohort, mothers of children not independent on oral feeding at discharge were more likely to screen positive for depression (7/14, 50% vs. 7/61, 11%; p < 0.05).

CONCLUSION

Mothers of surgical patients are not significantly more likely to screen positive for post-partum depression compared to other NICU mothers. This underscores the importance of routine screening for PPD in mothers of both surgical and non-surgical NICU patients in order to identify parents and children at risk.

Postpartum Health Experiences of Women with Newborns in Intensive Care: The Desire to Be by the Infant Bedside as a Driver of Postpartum Health

INTRODUCTION

Women with infants in a neonatal intensive care unit (NICU) encounter multiple challenges following childbirth, including greater burden of chronic disease and increased risk for depression, compared with women with well infants. At the same time, they are confronted with the trauma of a hospitalized infant while also managing their postpartum recovery. Limited research exists describing the health needs of these women, despite the many numbers living this experience daily. This study aimed to better understand postpartum health needs of women with infants in the NICU in the 90 days following birth and to propose actionable system improvements to address identified needs.

METHODS

The authors conducted in-depth individual interviews with 50 postpartum women of infants admitted to the NICU at a quaternary care hospital. Eligible women were aged at least 18 years, spoke English or Spanish, and had infants in the NICU longer than 3 days. Interview topics included NICU experience, recommended and desired health care, and suggestions for improvement. Interviews were audiotaped and transcribed verbatim. The authors used qualitative description techniques including memo-writing, coding, matrices, diagramming, and team discussion to analyze the data.

RESULTS

Women reported significant intrapartum health conditions and concerns (eg, preeclampsia, emergency cesarean birth, anxiety) and described unmet social, emotional, mental, and physical health needs. Unmet practical needs while in the NICU (eg, a place to rest, affordable parking, access to food, childcare) caused considerable burden. Despite disease burden and emergent health needs, few women reported regular monitoring of their postpartum health by maternal health care providers. Women frequently minimized and delayed care for their health needs so as to remain by the infant bedside.

DISCUSSION

Women with infants in the NICU would benefit from patient-centered care that provides greater attention to their postpartum health and recovery while also supporting their drive to remain close to their hospitalized infant.

Measurement of Cumulative Preterm Neonatal and Maternal Stressors During Neonatal Intensive Care Unit Admission

OBJECTIVES

By nature, the neonatal intensive care unit (NICU) environment is stressful for both infants and mothers. This study aimed to explore and quantify the severity of early life stressors in premature infants admitted to the NICU and evaluate the effect of cumulative neonatal stressors on maternal mental health.

METHODS

This cross-sectional study included 100 preterm infants admitted to the NICU for at least 10 days. Daily experiences with painful/stressful procedures for 10 days were determined using the Neonatal Infant Stressor Scale. The included mothers were assessed for their psychological well-being 1 week after NICU admission using the Parental Stressor Scale: NICU and Edinburgh Postnatal Depression Scale.

RESULTS

During the first 10 days of NICU admission, preterm infants experienced an average of 350.76 ± 84.43 acute procedures and an average of 44.84 ± 11.12 cumulative hours of chronic events, with the highest scores recorded on first 3 days of admission. Although intravenous flushing for patency was the most frequent acute procedure, blood gas sampling was the most painful. Forty-five percent of the mothers showed significant depressive symptoms, with the maternal role alteration reported as the most stressful experience, especially for young and new mothers (p < .001). The cumulative stressors experienced by infants were significantly associated with elevated maternal perception of psychological maladjustment (p < .001).

CONCLUSION

This study confirmed that the NICU environment is stressful for both infants and mothers, with the total cumulative stressors experienced by preemies in the NICU having an negative impact on maternal mental health.

Optimism as a mediator of the association between social support and peripartum depression among mothers of neonatal intensive care unit hospitalized preterm infants

The birth of a preterm infant and the hospitalization in a neonatal intensive care unit (NICU) add extra functional and emotional demands to the typical transition to motherhood. Therefore, the prevalence of peripartum depression (PPD) among preterm mothers is especially high. As optimism was found to be a mediator of the association between social support and depression, the current study aimed to test this mediation in the population of NICU mothers. A sample of 128 Israeli mothers of 214 NICU hospitalized infants filled out self-report questionnaires regarding background variables, social support, optimism, and PPD symptoms. As hypothesized, optimism was found to partially mediate the association between social support and PPD symptoms among mother of preterm infants. The higher the perceived social support reported, the higher maternal optimism reported, and in turn, the lower PPD symptoms reported. In accordance with the Transactional Stress Theory, social support and optimism reflect maternal secondary appraisals that impact the way mothers of preterm infants cope with the challenging situation of a preterm birth and NICU hospitalization. Healthcare professionals should encourage preterm mothers' use of social support to increase optimism and reduce the risk of developing PPD.

Maternal Stress, Depression, and Attachment in the Neonatal Intensive Care Unit Before and During the COVID Pandemic: An Exploratory Study

The main aim of the present study was to investigate the effects of the COVID-19 pandemic on the mothers' postnatal depression, stress, and attachment during their stay in the Neonatal Intensive Care Unit (NICU). Twenty mothers of very premature infants born before 32weeks of gestational age were recruited at the Geneva University Hospital between January 2018 and February 2020 before the COVID-19 pandemic started. Mothers were screened for postnatal depression after their preterm infant's birth (Edinburgh Postnatal Depression Scale, EPDS), then for stress (Parental Stressor Scale: Neonatal Intensive Care Unit, PSS:NICU), and attachment (Maternal Postnatal Attachment Scale, MPAS) at infant's term-equivalent age. Data were compared with 14 mothers recruited between November 2020 and June 2021 during the COVID-19 pandemic. No significant differences were found in the scores for depression, stress, and attachment between the two groups. However, a non-statistically significant trend showed a general increase of depression symptoms in mothers during the COVID-19 pandemic, which significantly correlated to the attachment and stress scores. Moreover, the PSS:NICU Sights and Sounds score was significantly positively correlated with EPDS scores and negatively with the MPAS score only in the During-COVID group. To conclude, we discussed a possible dampened effect of the several protective family-based actions that have been adopted in the Geneva University Hospital during the health crisis, and we discussed the most appropriate interventions to support parents in this traumatic period during the COVID-19 pandemic.

The Effect of Supportive Nursing Interventions on Reducing Stress Levels of Mothers of Infants in the Neonatal Intensive Care Unit: A Randomized Controlled Trial

The purpose of this study was to determine the effects of supportive interventions on the stress levels of mothers with infants hospitalized in the Neonatal Intensive Care Unit (NICU). This study was a prospective, pre-and post-test randomized controlled trial. The research was completed with 85 mothers in two groups of 45 subjects and 40 controls selected at random. Data collection used the Parental Stressor Scale: Neonatal Intensive Care Unit (PSS:NICU), NICU Parent Belief Scale (NICU:PBS), State-Trait Anxiety Inventory (STAI TX-2) and saliva cortisol analysis. There were statistically significant differences in favor of the experiment group for the PSS:NICU images and sounds subscale and PBS total points after supportive interventions (p < .05). Supportive nursing interventions were effective in reducing stress related to the intensive care environment, anxiety levels and saliva cortisol levels and increasing parental belief among mothers.

The Experiences of Parent Dyads in the Neonatal Intensive Care Unit: A Qualitative Description

Background The hospitalization of an infant in the neonatal intensive care unit (NICU) is a distressing and often unexpected event for parents. Parents have risk for depression, anxiety, and posttraumatic stress, which can adversely impact them and their relationship. The hospitalization and subsequent stress may affect parents' capability to connect with and parent their child. Purpose Describe parents' experiences and ability to cope with the NICU; identify experiential and coping differences between mothers and fathers; examine the effect of the NICU hospitalization on the parent dyad relationship. Methods A qualitative descriptive design with dyadic interviews examined parents' experiences and coping skills, and subsequent effects on the parental relationship. Data collection continued until saturation was achieved and no new themes emerged. Through content analysis, an accurate description of parents' experiences in the NICU was rendered. Findings Nine themes from eight dyad interviews emerged and were categorized within the six domains of the transactional theory of stress and coping. The major themes were: Deeply Distressing, Unexpected and Unprepared, Expecting to Hear and Be Heard, Becoming Parents, Stronger Together, Support is Key, Parents Want Better Communication, and Adjusting to the NICU. Implications for practice Support from professionals and family, and clear and consistent communication from the treatment team helped alleviate parents' anxiety about their infant. Implications for research Research regarding the impact of a NICU hospitalization on the relationship between parent dyad members, specifically longitudinal studies, may lead to a better understanding of the long-term effects of this specific stressor on parents.

Psychological Wellbeing of Parents with Infants Admitted to the Neonatal Intensive Care Unit during SARS-CoV-2 Pandemic

The current SARS-CoV-2 disease (COVID-19) pandemic is a sudden major stressor superimposed on pre-existing high distress in parents of infants admitted to the neonatal intensive care unit (NICU). This study aimed to investigate the psychological wellbeing of NICU parents during the COVID-19 pandemic. Forty-four parents of 25 inpatients of the Padua University Hospital NICU were included from June 2020 to February 2021. At 7–14 days postpartum parents completed the Edinburgh Postnatal Depression Scale (EPDS), State-Trait Anxiety Inventory (STAI), Parental Stressor Scale: NICU (PSS:NICU) and an ad-hoc questionnaire measuring parental COVID-19 related stress. About one third of parents reported extreme/high stress and a relevant negative impact on parenthood experience. Less time (82%) and less physical contact (73%) with infants due to COVID-19 preventive measures were the most frequent negative factors. Higher COVID-19 related parental stress was positively associated with anxiety, depression, NICU parental stress, stress related to NICU environment, and parental role alterations. Depression symptoms, stress related to infant condition and parental role alterations were higher in mothers. The pandemic affected parental emotional and relational wellbeing directly through additional stress due to COVID-19 concerns and indirectly through the impact of restrictions on the experience of becoming parents.

Associations of Maternal-Infant Bonding with Maternal Mental Health, Infant's Characteristics and Socio-Demographical Variables in the Early Postpartum Period: A Cross-Sectional Study

(1) Background: There is a continuing discussion concerning the impact of preterm birth on Maternal-Infant bonding with inconsistent results. The large burden of preterm births calls for research to evaluate the impact of it on material psychological outcome in the early postpartum period. Thus, the aim of this study was to evaluate the relationship between maternal postpartum bonding with maternal mental health, socio-demographical factors, and child's characteristics. (2) Methods: A cross-sectional study design was used. In total, 72 women (a mean age of 31.44 years old) of preterm infants (mean gestational age = 33.54; range 24-36) filled out socio-demographic questionnaires, Postpartum Bonding Questionnaire (PBQ), Edinburgh Postpartum Depression Scale (EPDS), Postpartum Depression Screening Scale (PDSS), Generalized Anxiety Disorder Assessment (GAD-7), and Parental Stress Scale (PSS) 1-3 days post-delivery; (3) Results: The results analyses have shown positive correlations between the overall result of maternal postpartum bonding with stress (p < 0.01), maternal educational level (p < 0.01), maternal age (p < 0.05) and the number of children (p < 0.01). However, there were no significant relationships between other investigated variables. The results of linear regression have revelated the important role of the overall scores in experience of stress among mothers (explaining 49% of the variability). The mediating role of maternal stress on maternal postpartum bonding was not found. That relationship of maternal postpartum bonding and maternal stress was not moderated through socio-demographic variables. (4) Conclusions: In this study mothers of prematurely born children had a good level of Maternal-Infant bonding. Maternal stress was found to be a predictor of maternal postpartum bonding among the tested variables. Surprisingly, the study results did not show significant relationships between maternal postpartum bonding and maternal mental health (depression and anxiety).

The Soundscape of Neonatal Intensive Care: A Mixed-Methods Study of the Parents' Experience

Parents who have infants hospitalised in neonatal intensive care units (NICUs) experience high levels of stress, including post-traumatic stress disorder (PTSD) symptoms. However, whether sounds contribute to parents’ stress remains largely unknown. Critically, researchers lack a comprehensive instrument to investigate the relationship between sounds in NICUs and parental stress. To address this gap, this report presents the “Soundscape of NICU Questionnaire” (SON-Q), which was developed specifically to capture parents’ perceptions and beliefs about the impact that sound had on them and their infants, from pre-birth throughout the NICU stay and in the first postdischarge period. Parents of children born preterm (n = 386) completed the SON-Q and the Perinatal PTSD Questionnaire (PPQ). Principal Component Analysis identifying underlying dimensions comprising the parental experience of the NICU soundscape was followed by an exploration of the relationships between subscales of the SON-Q and the PPQ. Moderation analysis was carried out to further elucidate relationships between variables. Finally, thematic analysis was employed to analyse one memory of sounds in NICU open question. The results highlight systematic associations between aspects of the NICU soundscape and parental stress/trauma. The findings underscore the importance of developing specific studies in this area and devising interventions to best support parents’ mental health, which could in turn support infants’ developmental outcomes.

Coached, Coordinated, Enhanced Neonatal Transition (CCENT): protocol for a multicentre pragmatic randomised controlled trial of transition-to-home support for parents of high-risk infants

INTRODUCTION

Having an infant admitted to the neonatal intensive care unit (NICU) is associated with increased parental stress, anxiety and depression. Enhanced support for parents may decrease parental stress and improve subsequent parent and child outcomes. The Coached, Coordinated, Enhanced Neonatal Transition (CCENT) programme is a novel bundled intervention of psychosocial support delivered by a nurse navigator that includes Acceptance and Commitment Therapy-based coaching, care coordination and anticipatory education for parents of high-risk infants in the NICU through the first year at home. The primary objective is to evaluate the impact of the intervention on parent stress at 12 months.

METHODS AND ANALYSIS

This is a multicentre pragmatic randomised controlled superiority trial with 1:1 allocation to the CCENT model versus control (standard neonatal follow-up). Parents of high-risk infants (n=236) will be recruited from seven NICUs across three Canadian provinces. Intervention participants are assigned a nurse navigator who will provide the intervention for 12 months. Outcomes are measured at baseline, 6 weeks, 4, 12 and 18 months. The primary outcome measure is the total score of the Parenting Stress Index Fourth Edition Short Form at 12 months. Secondary outcomes include parental mental health, empowerment and health-related quality of life for calculation of quality-adjusted life years (QALYs). A cost-effectiveness analysis will examine the incremental cost of CCENT versus usual care per QALY gained. Qualitative interviews will explore parent and healthcare provider experiences with the intervention.

ETHICS AND DISSEMINATION

Research ethics approval was obtained from Clinical Trials Ontario, Children's Hospital of Eastern Ontario Research Ethics Board (REB), The Hospital for Sick Children REB, UBC Children's and Women's REB and McGill University Health Centre REB. Results will be shared with Canadian level III NICUs, neonatal follow-up programmes and academic forums.

TRIAL REGISTRATION NUMBER

ClinicalTrials.gov Registry (NCT03350243).

Maternal Anxiety, Infant Stress, and the Role of Live-Performed Music Therapy during NICU Stay in The Netherlands

Having an infant in the neonatal intensive care unit (NICU) elicits maternal anxiety, which may hamper parent-child bonding. We performed a prospective cohort study to describe anxiety in mothers of infants born before 30 weeks of gestation during NICU stay in The Netherlands, and investigated the influence of infant stress and gestational age. Second, we performed a randomized-controlled live-performed music therapy trial (LPMT trial) to investigate whether music therapy applied to the infant alleviated maternal anxiety. The relation between infant stress, gestational age, and maternal anxiety was measured in 45 mother-infant dyads, using the Neonatal Infant Stressor Scale and the State-Trait Anxiety Inventory (STAI). The effect of LPMT on anxiety was assessed in 21 mothers whose infants were assigned to either LPMT (n = 12) or waitlist (n = 9). Mothers completed the STAI before and after this period. Maternal anxiety decreased over time in all mothers, and was strongly related with infant stress (r = 0.706, p < 0.001), but not with gestational age. Anxiety scores decreased by 12% after LMPT, and increased by 1% after a waitlist period (p = 0.30). Our results indicate that LPMT in the weeks after birth may accelerate the reduction of maternal anxiety. Further research should focus on the effects on mother-child bonding.

Differences in perceived parental stress between parents with very low birth weight infants and nurses in neonatal intensive care units, South Korea

PURPOSE

This descriptive study compared the perceived parental stress levels between parents with very low birth weight infants (VLBWIs) and nurses in the neonatal intensive care unit (NICU).

METHODS

In total, 83 parents of VLBWIs and 78 NICU nurses were enrolled. Data were collected with the Parental Stress Scale (PSS) and analyzed using the t-test and analysis of variance in SAS version 9.4.

RESULTS

The average PSS score was 3.31 among parents and 3.45 among nurses. The stress score was significantly higher among nurses with children (t=2.46, p=.016) and senior nurses (t=2.12, p=.037). There was a significant difference in the stress score according to parents' education (t=3.29, p=.002) and occupation (F=3.14, p=.049) in the sights and sounds subscale. Mothers had significantly higher stress scores than fathers in the parental role alterations subscale (t=2.32, p=.023). Parental stress scores were higher than those perceived by nurses in the infant's appearance and behaviors subscale for breathing patterns (t=2.95, p=.004), followed by jerky/restless behavior (t=2.70, p=.008).

CONCLUSION

Nurses should provide explanations to parents of VLBWIs in order to reduce parental stress about the appearances and behavior of VLBWIs. This is more important than aspect of the NICU environment and education about parental roles.