Deborah K. Steward

Schore’s Regulation Theory Maternal–Infant Interaction in the NICU as a Mechanism for Reducing the Effects of Allostatic Load on Neurodevelopment in Premature Infants

Premature infants confront numerous physiologic and environmental stressors in the neonatal intensive care unit (NICU) that have the potential to permanently alter their neurodevelopment. Schore’s regulation theory postulates that positive maternal–infant interactions can shape the infant’s developmental outcomes through inducing mechanistic changes in brain structure and function. The purposes of this article are to explain the regulation of infant neurobiological processes during interactions between mothers and healthy infants in the context of Schore’s theory, to identify threats to these processes for premature infants, and to propose principles of clinical practice and areas of research necessary to establish a supportive environment and prevent or reduce maladaptive consequences for these vulnerable infants. A premature birth results in the disruption of neurodevelopment at a critical time. Chronic exposure to stressors related to the NICU environment overwhelms immature physiologic and stress systems, resulting in significant allostatic load, as measured by long-term neurodevelopmental impairments in the premature infant. Positive maternal–infant interactions during NICU hospitalization and beyond have the potential to reduce neurologic deficits and maximize positive neurodevelopmental outcomes in premature infants. The quality of the maternal–infant interaction is affected not only by the infant’s developing neurobiology but also by the mother’s responses to the stressors surrounding a premature birth and mothering an infant in the NICU environment. Nurses can empower mothers to overcome these stressors, promote sensitive interactions with their infants, and facilitate neurodevelopment. Research is critically needed to develop and test nursing interventions directed at assisting mothers in supporting optimal neurodevelopment for their infants.

Caring for medically fragile children in the home: an alternative theoretical approach.

Medically fragile children require extensive, ongoing care that is typically provided in the home environment. The phenomenon of “caregiver burden” has been the topic of many studies in which the hardships and everyday life stressors of families with medically fragile children are examined. These studies are limited in that they focus merely on the difficulties of care, which represent only one dimension of the larger phenomenon of caregiving. It is the purpose of this article to review the literature from an alternative perspective in an attempt to provide a more thorough understanding of the dynamic of caregiving for a medically fragile child.

Exploration of the contribution of biobehavioral variables to the energy expenditure of preterm infants.

Variation in energy expended by preterm infants may be due to infant maturity and history of resolved acute lung disease (respiratory distress syndrome [RDS]) as well as growth, caloric intake, and activity. Indirect calorimetry was used in this exploratory, short-term longitudinal study to estimate energy expenditure (EE) from measures of inspired and expired O2 and CO2.The sample included 35 assessments for 10 preterm infants (5 with and 5 without RDS history). Lung disease history (resolved RDS, no RDS diagnosis), weight gain (g/d) from the day on which birth weight had been regained to the study day, mean activity level, the number of the assessment (1 6), and the interaction of lung disease history and time were included in a linear mixed model for repeated measures. Time was an index of postconceptional and postnatal age; all 3 were highly correlated. Because of high correlation with weight gain, caloric intake was not included in the analytic model. Lung disease history, mean activity level, and time were significant contributors to EE. A more precise measure of medical status than absence or presence of lung disease history, evenly spaced repetitions of EE assessment, and exploration of contexts in which the infants exhibit a higher activity level are needed in a replication study with a larger sample.

Medical record documentation and symptom management at the end of life in the NICU.

Purpose:In neonates, the course of illness is often unpredictable and symptom assessment is difficult. This is even truer at the end of life (EOL). Time to death can take minutes to days, and ongoing management of the infant is needed during the time between discontinuation of life-sustaining treatment and death to ensure that the infant remains free of pain and suffering. The symptoms experienced by neonates as they die, as well as best ways to treat those symptoms, are understudied. The purpose of this study was to examine symptoms exhibited by neonates at the EOL and the treatments used to manage those symptoms as documented in the medical record during the last 24 hours of life. Subjects:The sample included 20 neonates who died at a large childrens hospital. Design:This was an exploratory, descriptive study. Methods:Descriptive data, such as diagnosis, ongoing therapy at time of treatment withdrawal or withholding, pharmacologic and nonpharmacologic interventions associated with treatment withdrawal, time of treatment withdrawal and death, age at time of death, signs and symptoms exhibited during EOL care, and pain scores, were abstracted from the infants medical record. Main Outcome Measures:Inadequate documentation in the medical record resulted in missing data that made it not possible to fully explore aspects of symptom management during the last 24 hours of life; however, some important results were found. Results:This study showed a difference in the way neonates approach the EOL period. Other findings were that most infants in the study received pain medication, even though pain scores were infrequently documented and drug dosages varied across infants. Finally, documentation of nonpharmacologic interventions utilized at the EOL was also lacking.

Stability of Respiratory Quotient and Growth Outcomes of Very Low Birth Weight Infants

Nutritional management of very low birth weight (VLBW) infants involves promoting growth at rates that mimic intrauterine rates. Nutritional intake at the recommended energy level to promote growth results in fat accretion at levels that exceed intrauterine rates for fat accretion. The respiratory quotient (RQ), the ratio of carbon dioxide produced to oxygen consumed during oxidation, provides a measure of the percentage of substrates used for energy. An RQ of greater than 0.9 indicates carbohydrate is used to meet energy needs, allowing the majority of fat intake to be stored as newtissue. The purpose of this study was to examine the stability of the RQ across time in relation to nutritional intake and growth in VLBW infants. Subjects were 9 enterally fed VLBW infants. Measurements to determine the RQ were obtained weekly for 3 weeks by indirect calorimetry. Nutritional intake and growth velocity were examined. There was no significant difference in the RQ across 3 weeks. The mean (± SD) RQs for each of the 3 weeks were 1.08 (±0.04), 1.06 (±0.05), and 1.06 (±0.07), respectively. No significant differences were found across the 3 weeks for any of the macronutrient variables. Growth velocity for the period was 15.7 g/kg/day. By discharge from the NICU, 66% of the infants had weights less than the 10th percentile on an intrauterine growth reference. An RQ greater than 1.0 indicates VLBW infants are depositing excess fat. However, increased accretion rates of fat did not improve the growth outcomes of these VLBW infants.

A New Framework to Evaluate the Quality of a Neonatal Death

Management of the infant in the neonatal intensive care unit (NICU) focuses on stabilization and survival but sometimes death is an inevitable outcome. Dying neonates deserve a good death. It is unknown whether we are providing neonates with a good death. This article introduces a framework describing components needed for a good death in the NICU. Initially based on an adult model, this new framework incorporates appropriate components of Emanuel and Emanuels framework (1998) and puts them into a context applicable to neonates. The proposed concepts and relationships will require future testing and revision as indicated by the evidence.

Nonorganic failure to thrive: a theoretical approach.

Nonorganic failure to thrive (NOFTT) is a significant health problem of infancy. Although NOFTT is thought to be a result of multiple factors, exactly what these factors are is unclear. Explaining the development of NOFTT has been hindered by a lack of a theoretical approach. The purpose of this article is to provide a review of the literature and the discussion of a theoretical framework to guide future research in the area of NOFTT.

Oxytocin trajectories and social engagement in extremely premature infants during NICU hospitalization

Extremely premature infants, born 28 weeks gestation or less, are at high risk for impaired socioemotional development, due in part to exposure to early stressful social experiences that alter brain development. Understanding mediators that link experience with outcomes is necessary to assess premature infant responses to social experiences that are critical to brain development. The hormone oxytocin (OT), released during supportive interactions, has potential as a biomarker of the premature infants responses to social experiences. The purpose of this study was to examine associations among infant plasma OT trajectories and maternal-infant social engagement behaviors during initial hospitalization. This study also examined demographic correlates of engagement behaviors in mothers and infants. Plasma from 28 extremely premature infants, born gestational ages 25-28 6/7 weeks, was collected at 14 days of life, then weekly until 34 weeks. Social engagement behaviors were measured by the Parent-Child Early Relational Assessment during a videotaped feeding when the infant was receiving one-quarter full oral feeds. Maternal-infant demographics were extracted from the medical record. Higher infant plasma OT was associated with lower infant social engagement, but no associations were found with maternal social engagement. Infant social engagement was positively related to maternal social engagement. Maternal parity was related to maternal social engagement, and infant demographics did not predict infant social engagement. The significant, yet negative, association between infant OT and engagement provides support for the measurement of OT as a neurobiological antecedent to infant social behaviors. Finally, this research suggests that during the earliest period of infant socio-behavioral development, premature infants are behaviorally reactive to the social engagement behaviors of their mothers.

Paid Family Leave to Enhance the Health Outcomes of Preterm Infants

Prematurity is the largest contributor to perinatal morbidity and mortality. Preterm infants and their families are a significant vulnerable population burdened with limited resources, numerous health risks, and poor health outcomes. The social determinants of health greatly shape the economic and psychosocial resources that families possess to promote optimal outcomes for their preterm infants. The purposes of this article are to analyze the resource availability, relative risks, and health outcomes of preterm infants and their families and to discuss why universal paid family leave could be one potential public policy that would promote optimal outcomes for this infant population. First, we discuss the history of family leave in the United States and draw comparisons with other countries around the world. We use the vulnerable populations conceptual model as a framework to discuss why universal paid family leave is needed and to review how disparities in resource availability are driving the health status of preterm infants. We conclude with implications for research, nursing practice, and public policy. Although health care providers, policy makers, and other key stakeholders have paid considerable attention to and allocated resources for preventing and treating prematurity, this attention is geared toward individual-based health strategies for promoting preconception health, preventing a preterm birth, and improving individual infant outcomes. Our view is that public policies addressing the social determinants of health (e.g., universal paid family leave) would have a much greater impact on the health outcomes of preterm infants and their families than current strategies.

A qualitative study of nurse observations of symptoms in infants at end-of-life in the neonatal intensive care unit

OBJECTIVES Assessment and management of symptoms exhibited by infants can be challenging, especially at the end-of-life, because of immature physiology, non-verbal status, and limited symptoms assessment tools for staff nurses to utilize. This study explored how nurses observed and managed infant symptoms at the end-of-life in a neonatal intensive care unit. METHODOLOGY/DESIGNMETHODS This was a qualitative, exploratory study utilizing semi-structured face-to-face interviews, which were tape-recorded, transcribed verbatim, and then analyzed using the Framework Approach. SETTING The sample included 14 staff nurses who cared for 20 infants who died at a large childrens hospital in the Midwestern United States. MAIN OUTCOME MEASURES Nurses had difficulty recalling and identifying infant symptoms. Barriers to symptom identification were discovered based on the nursing tasks associated with the level of care provided. RESULTS Three core concepts emerged from analyses of the transcripts: Uncertainty, Discomfort, and Chaos. Nurses struggled with difficulties related to infant prognosis, time of transition to end-of-life care, symptom recognition and treatment, lack of knowledge related to various cultural and religious customs, and limited formal end-of-life education. CONCLUSION Continued research is needed to improve symptom assessment of infants and increase nurse comfort with the provision of end-of-life care in the neonatal intensive care unit.