Lois Howland

Integrated Review of Cytokines in Maternal, Cord, and Newborn Blood: Part I—Associations With Preterm Birth

Preterm birth (PTB; spontaneous delivery prior to 37 weeks gestation) affects one out of eight infants born in the United States and is the most common cause of neonatal morbidity and mortality. Although the pathogenesis of PTB is multifactorial, a growing body of literature supports the hypothesis that one cause of PTB is inflammation in pregnancy. Investigators have implicated mediators of inflammation, most notably proinflammatory cytokines, as being associated with and perhaps a playing a causal role in the pathogenesis of preterm labor and adverse early fetal outcomes. Though researchers have pursued the association of cytokines with preterm labor and subsequent early adverse fetal outcomes as a line of research, there has been little integration of diverse findings across studies. This systematic review appraises the empirical evidence from human studies for the association of levels of cytokines in blood with preterm labor and adverse early fetal outcome to examine the current state of the science in this important area of biobehavioral research. The most consistent finding is that increased levels of proinflammatory cytokines, particularly interleukin (IL) 6, IL-β1, and tumor necrosis factor α (TNF-α), are associated with PTB as compared to levels found at term birth. However, there have been relatively few studies and results have not been consistent. Therefore, further research is needed to elucidate the association of these inflammatory mediators with adverse pregnancy outcomes.

Integrated Review of Cytokines in Maternal, Cord, and Newborn Blood: Part II— Associations With Early Infection and Increased Risk of Neurologic Damage in Preterm Infants

A growing body of literature supports the relationship of maternal inflammation with preterm birth and adverse neonatal outcomes, including infection and central nervous system (CNS) dysfunction. Mediators of inflammation, most notably proinflammatory cytokines, have been implicated as having an association with and perhaps playing a causal role in the pathogenesis, leading to adverse neonatal outcomes. Even though the association of cytokines with early adverse neonatal outcomes has been actively pursued as a line of research, there has been little integration of diverse findings across studies. Therefore, the purpose of this systematic review was to appraise and classify empirical evidence from human studies for the association of cytokine levels in blood (serum, plasma, or cells; maternal, cord, or neonatal) with two adverse early outcomes in preterm infants: early infection and increased risk of neurologic damage. The review revealed that the proinflammatory cytokines most frequently linked with sepsis are in the interleukin (IL) 1 family as well as tumor necrosis factor α (TNF-α) and IL-6. The proinflammatory cytokines most frequently linked to neurologic insult in the reviewed studies were IL-1β, IL-6, and IL-8. In all cases where IL-1β was studied, the levels were increased when there was neurologic insult. A better understanding of the relationship of these inflammatory substances with these adverse conditions is needed for the future development of maternal and neonatal biobehavioral nursing research.

Exploring Biobehavioral Outcomes in Mothers of Preterm Infants

PurposeTo evaluate physiologic measures of stress with self-reported perceived stress and depressive symptoms among mothers of preterm babies currently hospitalized in an NICU. Study Design and MethodsThis was a cross-sectional, descriptive, single-visit study of 20 mothers of hospitalized preterm infants. Data collected included self-report behavioral measures and a brief structured interview. Biological data were available on 17 mothers. Data were analyzed using descriptive and inferential statistics. ResultsMothers reported high levels of stress and depressive symptoms. Higher levels of stress and more depressive symptoms were associated with higher levels of certain serum cytokines, higher levels of waking and afternoon salivary cortisol, and abnormal diurnal patterns of salivary α-amylase. Clinical ImplicationsA NICU admission is a stressful time for which families typically have not had the opportunity to prepare. Mothers with higher levels of stress and depressive symptoms may be at higher risk for poorer physical and mental health. This study highlights the high levels of stress and depressive symptoms that may be experienced by mothers of preterm infants, and suggests the potential value of developing effective strategies to target maternal psychological distress.

The Patient Protection and Affordable Care Act of 2010 (PL 111-148): an analysis of maternal-child health home visitation.

On March 23, 2010, President Obama signed the Patient Protection and Affordable Care Act, setting in motion a historic and, for many, a long-awaited radical change to the current American health care system. Section 2951 of the PPACA addresses provision and funding of maternal, infant, and early childhood home visiting programs. The purpose of this article is to acquaint the reader with the legislative odyssey of home visitation services to at-risk prenatal and postpartum women and children as delineated in the PPACA and to discuss the nursing practice and research implications of this landmark legislation. Few question the need for more rigorous methodology in all phases of home visitation research. Public health nursing may provide the comprehensive approach to evaluating effective home visitation programs.

Posttraumatic Stress Syndrome Associated With Stays in the Intensive Care Unit: Importance of Nurses’ Involvement

More patients in the intensive care unit are surviving their critical illnesses because of advances in medical care. This change in survival has led to an increased awareness of the emotional consequences of being critically ill. Posttraumatic stress disorder has been identified in approximately 9% to 27% of critically ill patients compared with 7% of the general US population. Risk factors such as treatment with mechanical ventilation, sedation, delusional memories, and agitation are associated with development of posttraumatic stress disorder in patients in the intensive care unit. Individuals with posttraumatic stress disorder are more likely to experience negative physical and psychiatric health outcomes and a lower quality of life than are patients without the disorder. Early identification and treatment of patients experiencing these signs and symptoms may reduce these physical and psychological comorbid conditions. Through careful monitoring of medications, early mobilization, sleep promotion, and pain management, nurses may be able to reduce signs and symptoms of posttraumatic stress disorder.

Guided imagery: an innovative approach to improving maternal sleep quality.

Mothers of preterm infants are at risk for poor sleep quality, which may adversely affect their health, maternal-infant attachment, and infant caretaking activities. This study examined the relationship of an 8-week relaxation guided imagery intervention on sleep quality and the association between sleep quality and maternal distress (perceived stress, depressive symptoms, and state anxiety) in 20 mothers of hospitalized preterm infants. Mothers received a CD (compact disc) with three 20-minutes recordings and were asked to listen to at least 1 recording daily for 8 weeks. This analysis used self-report data gathered at baseline and 8 weeks. Pearson correlations were used to examine the relationships between mean cumulative relaxation guided imagery use and measures of maternal distress and sleep quality scores at 8 weeks. Complete data on 19 mothers were available for analysis. At 8 weeks, higher mean relaxation guided imagery use was inversely correlated with sleep quality scores (r = −0.30); sleep quality scores were positively correlated with stress (r = 0.42), depressive symptoms (r = 0.34), and anxiety (r = 0.39) scores. In mothers of preterm infants, sleep quality was negatively affected by mental distress and may be improved by a guided imagery intervention.

Oxytocin Levels in Community-Collected Saliva Samples Transported by Dry Versus Wet Ice

Oxytocin (OT), a neuropeptide produced primarily in the hypothalamus, is associated with both critical physiological and psychological processes, particularly stress and feelings of affiliation. Increasingly, researchers are seeking ways to reliably incorporate OT as an outcome biomarker in clinical research. Previously, OT levels were measured in plasma or urine. Recently, researchers have measured this biomarker in saliva, particularly when conducting research in clinical and community settings. In spite of increased interest in the use of salivary OT in clinical research, procedures for handling, transport, and analysis of specimens vary. It is not known if significant OT protein degradation occurs if samples are initially transported on wet ice before being frozen. The aim of this study is to evaluate the effect of transport media (wet vs. dry ice) on OT levels derived from saliva collected from 12 postpartum women residing in the community. Saliva collected from each participant was divided between two microcentrifuge tubes (MIDSCI, Valley Park, MO), one placed on wet ice and one on dry ice for transport from the participant’s home to the laboratory freezer. Time from collection to storage freezer was recorded. Laboratory personnel, blinded to method of transport, batch processed the samples. No significant differences in OT levels were found by transport method. Despite large interperson variations in OT levels, there were negligible intraperson variations. Although further research is required to identify factors (including transport time) related to interperson variation, this study supports the use of wet ice as a means of transporting salivary OT specimens in community-based research.

Feasibility of a Relaxation Guided Imagery Intervention to Reduce Maternal Stress in the NICU

Objective To test the feasibility of a relaxation guided imagery (RGI) intervention for mothers of hospitalized preterm infants and to explore the biobehavioral effects of RGI on their distress, responsiveness, and physiological stress. Design Single sample, pretest–posttest design. Setting A large Level III NICU in Southern California. Participants Twenty mothers of hospitalized preterm infants (24–32 weeks gestational age). Methods Correlational analyses of RGI use with self‐reported measures of distress (perceived stress, state anxiety, and depression symptoms), awakening salivary cortisol level, and salivary cortisol awakening response collected from mothers at baseline and after 8 weeks of an RGI intervention. Results Nineteen mothers completed the study. Average use of RGI varied from 1.7 to 7.4 times per week (mean = 4.46, standard deviation = 2.7). Greater average use of RGI was correlated with lower awakening cortisol levels (r = −.38), greater cortisol awakening response (r = .36), and lower levels of distress (perceived stress [r = −.38], anxiety [r = −.43], and depression [r = −.41]). Conclusion Relaxation guided imagery may be a feasible and acceptable intervention to reduce mental and physiologic stress and improve responsiveness in mothers of hospitalized preterm infants.