Michael L. Spear

Communicating with parents of premature infants: who is the informant?

Objectives:To determine what sources of information are most helpful for neonatal intensive care unit (NICU) parents, who provides NICU parents with the information, and also what expectations parents have regarding obtaining information.Study design:A 19-item questionnaire was given to the parents of infants 32 weeks or younger prior to discharge from the NICU.Results:Out of the 101 parents who consented, almost all of the parents (96%) felt that ‘the medical team gave them the information they needed about their baby’ and that the ‘neonatologist did a good job of communicating’ with them (91%). However, the nurse was chosen as ‘the person who spent the most time explaining the babys condition, ‘the best source of information,’ and the person who told them ‘about important changes in their babys condition’ (P<0.01).Conclusion:Although the neonatologists role in parent education is satisfactory, the parents identified the nurses as the primary source of information.

Forgotten parent: NICU paternal emotional response.

PURPOSE:To evaluate and compare the presence of perceived paternal stress and depressive symptomatology in fathers of preterm infants over time. SUBJECTS:Fathers of NICU infants born before 30 weeks of gestation. DESIGN:Prospective convenience sample. METHODS:Consenting fathers were given 2 self-report questionnaires: Center for Epidemiologic Studies-Depression Scale (CES-D) and Parent Stressor Scale: Infant Hospitalization (PSS:IH) on 7th (time 1), 21st (time 2), and 35th (time 3) days of life. Objective measurement of illness severity was quantified by Score for Neonatal Acute Physiology. Statistical methods included generalized linear estimating equation and mixed linear modeling. MAIN OUTCOME MEASURES:Stress and depressive symptomatology in fathers of preterm infants. RESULTS:Stress scores (PSS:IH) were unchanged over time (P = .62) indicating that fathers (n = 35) remain significantly stressed. Individual subcomponents of stress (parent role alteration, infant appearance/behavior, NICU sights/sounds) also remained constant over the study period (P = .05 for each). Stress scores over time were not modified by demographic characteristics (marriage, education, insurance). Mean depressive symptomatology scores (CES-D) decreased over time (P = .04). The percentage of fathers with elevated CES-D scores (>16) decreased from a baseline 60% but did not diminish between times 2 (39%) and 3 (36%). Parent Stressor Scale: Infant Hospitalization stress scores were correlated with CES-D depressive symptomatology scores (P < .01). Socioeconomic factors influenced initial CES-D scores, but only marriage ameliorated subsequent changes in measurements. Objective measurement of infant illness (Score for Neonatal Acute Physiology) did not influence paternal CES-D or PSS:IH scores. CONCLUSION:Fathers of premature infants in a medical NICU demonstrated elevated levels of stress that persisted across time for all domains of measured stress. Paternal self-reported stress and depressive symptomatology was independent of infant illness. One third of fathers had persistently elevated CES-D scores. If these findings are representative of general NICU population, then the emotional needs of our fathers are not being fully addressed.

Stress in fathers of surgical neonatal intensive care unit babies.

The purpose of this study was to identify and measure components of perceived stress in fathers of infants in a surgical neonatal intensive care unit (NICU). The Parent Stressor Scale: Infant Hospitalization (PSS:IH) was used to assess perceived stress in 22 fathers. Paternal stress was highest in the domains of “Parental Role Alteration” and “Infant Appearance and Behavior.” “Sights and Sounds” did not appear to be associated with self-reported stress. This study demonstrates elevated levels of perceived stress among fathers of surgical NICU babies. Attention to fathers may be assisted by findings.

Growth in human milk-Fed very low birth weight infants receiving a new human milk fortifier.

Background/Aims: Human milk fortification has been advocated to enhance premature infants’ growth. We, therefore, undertook this study of a new human milk fortifier containing more protein than a reference one. Methods: Open, randomized, controlled, multiclinic trial, with weekly growth parameters and safety evaluations in premature infants <1,500 g. Results: The 2 groups did not differ in demographic and baseline characteristics. The adjusted daily milk intake was significantly higher in the infants fed reference human milk fortifier (n = 29; 154.2 ± 2.1 vs. 144.4 ± 2.5 ml/kg/day, mean ± SE; p < 0.05). Both human milk fortifiers produced increases over baseline in weight, length, and head circumference, with greater gains observed in the new human milk fortifier-fed infants for the former two parameters (weight gain 26.8 ± 1.3 and 20.4 ± 1.2 g/day, p < 0.05; head circumference 1.0 ± 0.1 and 0.8 ± 0.1 cm/week; length 0.9 ± 0.1 and 0.8 ± 0.1 cm/week, respectively). Serum chemistries were normal and acceptable for age. Study events were typical for premature infants and similar in both groups. Conclusions: This new human milk fortifier had comparable safety to the reference human milk fortifier and promoted faster weight gain and head circumference growth.

Soluble interleukin-2 receptor as a predictor of neonatal sepsis

We prospectively measured soluble interleukin-2 receptor levels in 56 premature infants with suspected sepsis and demonstrated significant differences between those with positive results on blood, urine, or cerebrospinal fluid cultures, and those with negative results. Soluble interleukin-2 receptor levels can be used to facilitate the diagnosis of sepsis in premature infants with negative blood culture results.

Immaturity or Starvation? Longitudinal Study of Leptin Levels in Premature Infants

Objective: Leptin, the protein product of the ob gene, is a potential placental growth factor and is integral to the body’s system of energy regulation as shown in animal models. Premature infants are especially vulnerable to changes in energy regulation, and several studies have demonstrated a rapid fall in leptin values at birth. The purpose of the present investigation was to measure leptin levels in premature infants throughout hospitalization. Methods: Eligible infants were less than 32 weeks’ gestation, appropriate for gestational age, and hospitalized at Christiana Hospital Special Care Nursery. Serum samples for leptin analysis were drawn within 24 h of birth and twice a week thereafter until discharge. Concurrent growth measurements were obtained with each leptin sample. Body mass index, ponderal index, and midarm circumference/head circumference ratios were calculated to assess growth. Results: Leptin levels were low and remained low for the duration of the premature infants’ hospitalization (mean ± SD = 1.35 ± 0.63 ng/ml/ml, range 0–3.06). After controlling for weight, there was a small (r2 = 0.1, p < 0.00001) but significant correlation between leptin and postnatal age after 4 days of age. Despite an increase in caloric intake during the study period, there was no relationship between leptin and caloric intake. There were significant negative correlations between measurements of growth and both leptin and the leptin/weight ratio. Maternal diabetes and the use of steroids had small but significant effects on the leptin/weight ratio. Conclusion: In this population of predominantly female premature infants, leptin levels were very low as compared to term infants, children and adults, and did not change appreciably over the study period. The low leptin levels seen in these premature infants are similar to those levels seen in malnourished adults, anorexics, and in animal models of starvation. We speculate that a critical adipose store needs to be reached before increased amounts of leptin can be adequately produced. Persistently low leptin levels may also reflect an immaturity in the hypothalamic-pituitary-adrenal axis.

Effect of Sleep Position on Apnea and Bradycardia in High-Risk Infants

OBJECTIVE:The purpose of this investigation was to investigate, in high-risk infants, the occurrence of abnormalities in documented monitor downloads during the side versus prone position.STUDY DESIGN:Forty infants admitted to the A. I. duPont Hospital for Children with diagnoses associated with sudden infant death syndrome were included in this investigation. During an overnight hospitalization, infants were placed on home apnea monitors, with computer memory to capture alarms for apnea >20 seconds, age-defined bradycardia, and tachycardia. Infants were studied for 12 hours. Each infant was assigned to 6 hours of prone and side during the 12-hour period, with order of position randomly assigned by random number generation. Differences between the two positions in alarm frequency and significant events, as determined by a blinded interpreting physician were analyzed by Fisher exact test, with p<0.05. Power analysis necessitated 20 patients in each group, with beta error of 0.2.RESULTS:Eleven episodes of apnea occurred in the prone position, and 16 in the side position (p=NS). The mean numbers of apnea events per tracing in the prone position was 0.27±0.84 and 0.39±1.1 in the side position (p=0.58). The mean number of bradycardia events per tracing in the prone position was 0.44±1.45 and 0.49±1.94 in the side position(p=0.9).CONCLUSION:Clinicians need to be cautious when recommending the side or prone position in this group of high-risk infants. The results in this investigation provide support for the Back to Sleep Campaign recommendations to be applied, not only to healthy term infants, but higher risk infants as well. Studies of the high-risk infant in the supine position are warranted.

Placental Leptin: An Important New Growth Factor in Intrauterine and Neonatal Development? † 1379

BACKGROUND Leptin, the protein product of the ob gene, is produced by the adipocyte and seems to function as a link between adiposity, satiety, and activity. Leptin has also been found to be necessary for pubertal development, conception, and pregnancy in mice, and is increased in prepubertal children, independent of adiposity, suggesting a role in childhood growth and development. This study investigated 100 mother/newborn pairs to determine the role of leptin in neonatal development. Placental tissue was assayed for leptin mRNA to evaluate it as a source of leptin production in utero. METHODS One hundred mother/newborn pairs were enrolled in this study. Radioimmunoassay was performed for leptin on maternal venous and newborn cord blood. Leptin concentrations were measured in 43 children in Tanner stages 1 and 2 as a control group. Placental tissue was obtained from five mothers and assayed for leptin mRNA by reverse transcription/polymerase chain reaction (RT/PCR). Human placental cell lines JAR and JEG-3 were also assayed for leptin mRNA expression. RESULTS Leptin was present in all newborns studied at a mean concentration of 8.8 ng/mL (+/-9.6 standard deviations). Leptin concentrations in cord blood correlated with newborn weight (r = .51), body mass index (BMI) (r = .48), and arm fat (r = .42). There was no correlation between leptin and insulin. When statistically covarying for adiposity for newborns and Tanner stages 1 and 2 children, newborns had greater concentrations of leptin (mean, 10.57 ng/mL) than children (mean, 3.04 ng/mL). Leptin was present in all mothers at a mean value of 28.8 ng/mL (+/-22.2 standard deviations). Leptin concentration correlated with prepregnancy BMI (r = .56), BMI at time of delivery (r = .74), and arm fat (r = .73). Maternal leptin correlated with serum insulin (r = .49). There was no correlation between maternal and newborn leptin concentrations. Thirteen percent of newborns had higher leptin concentrations than their mothers. Placental tissue from five separate placentas expressed leptin mRNA at comparable or greater levels than adipose tissue. Two human trophoblastic placental cell lines, JAR and JEG-3, also expressed leptin mRNA. CONCLUSIONS The correlation between leptin and adiposity found in children and adults was also found in newborns. Serum leptin concentrations in newborns were increased more than three-fold compared with children in Tanner stages 1 and 2 when controlling for adiposity, suggesting that leptin concentrations in the newborn are not explained by adiposity alone. Maternal leptin concentrations correlated with measures of adiposity at delivery but did not correlate with newborn adiposity or leptin. Leptin mRNA was expressed both in placental tissue and in two human placental cell lines. These data suggest that leptin has a role in intrauterine and neonatal development and that the placenta provides a source of leptin for the growing fetus.

The Newborn at High Risk of Brain Damage

Despite marked improvements in perinatal practice, perinatal brain injury remains one of the most common complications causing chronic handicapping conditions. Experimental advances have elucidated many of the cellular and vascular mechanisms of perinatal brain damage showing a correlation between the nature of the injury and the maturation of the brain. New diagnostic tools, such as quantitative three-dimensional magnetic resonance (MR) imaging, diffusion-weighted MR imaging and proton MR spectroscopy, are presented in this review article that allow to assess brain development, detect early brain injury and monitor effects of perinatal brain injury on subsequent brain development and brain plasticity. These techniques will guide future therapeutic interventions aimed at minimizing irreversible perinatal brain injury.

Developmental Changes in Family Reactions during Their Infant's Prolonged Hospitalization in the Neonatal Intensive Care Unit

Developmental Changes in Family Reactions during Their Infants Prolonged Hospitalization in the Neonatal Intensive Care Unit