Michelle M. Greene

I have faith in my milk: the meaning of milk for mothers of very low birth weight infants hospitalized in the neonatal intensive care unit.

Background: Mothers who deliver a premature infant often choose to provide milk because it is the “one thing that only the mother can do” to optimize her infant’s outcome, helps mothers feel a connection with their infants, and helps relieve the guilt associated with the preterm birth. Objective: The purpose of this study was to describe the meaning of milk for mothers who are providing milk for their very low birth weight (VLBW; < 1500 g) infants hospitalized in the neonatal intensive care unit (NICU). Methods: Using a qualitative descriptive design, in-depth semistructured interviews were conducted with 23 mothers of VLBW infants hospitalized in a level III NICU. Mothers were asked to share their perceptions about what providing milk meant to them. Results: Mothers had faith in the healing properties of their milk and equated providing milk with “giving life” to their infants, mitigating the effects of complications, keeping their infants healthy and stable, and helping themselves address the feelings of failure and guilt associated with the premature birth. Mothers’ faith in their milk to achieve these outcomes was a maternal motivator to continue pumping, even for mothers who had not intended to provide milk or who experienced the paradox of disliking pumping but wanting to provide their milk. Conclusion: The experiences of these mothers reflect the importance of acknowledging mothers’ faith in the healing properties of their milk as a motivating factor for sustaining lactation while coping with the stress and anxiety inherent during the infant’s NICU hospitalization.

Evaluating preterm infants with the Bayley-III: Patterns and correlates of development

This study investigates the Third Edition of the Bayley Scales of Infant and Toddler Development (Bayley-III) and: (1) early patterns of neurodevelopmental performance among preterm infants 8-12 months of age; and (2) correlations between known risk factors and neurodevelopmental outcome of preterm infants in this cohort. Mean Language Index (LI; 91±15) and Motor Index (MI; 94±17) were significantly lower than the Cognitive Index (CI; 102±15, p<.01). For the majority (53%) of infants, language development was their weakest domain; for another 39%, motor skills were the weakest area of development. Almost one-quarter (22%) of this cohort had mildly delayed language and motor skills, while 7% had significantly delayed language and motor skills. Regression models revealed severely abnormal head ultrasound significantly predicted MI, LI, and CI. Oxygen dependence at discharge predicted CI, LI, and race/ethnicity predicted LI, MI. Results support the addition of the Language Index to the newly revised Bayley-III Scales. Prediction models of developmental performance confirm known neonatal risk factors and reveal sociodemographic risk factors that call for additional research.

Depression, anxiety, and perinatal-specific posttraumatic distress in mothers of very low birth weight infants in the neonatal intensive care unit.

Objective: To compare the trajectories and determine the predictors of maternal distress defined as a continuous spectrum of symptomatology and elevated symptomatology, of depression, anxiety, and perinatal-specific posttraumatic stress (PPTS), in mothers of very low birth weight (VLBW) infants throughout the neonatal intensive care unit (NICU) hospitalization. Method: Sixty-nine mothers completed psychological questionnaires within the first month of their infants NICU hospitalization and again 2 weeks before NICU discharge. Multiple regression models determined maternal psychological, reproductive, sociodemographic, and infant medical predictors of maternal distress. Results: Perinatal-specific posttraumatic stress remained stable throughout the NICU hospitalization, whereas other aspects of distress declined. Previous psychological history and infant medical variables predicted higher PPTS but no other aspects of distress. Reproductive variables predicted anxiety and PPTS; history of fetal loss initially predicted lower PPTS but throughout hospitalization primipara status emerged as a predictor of higher anxiety and PPTS. Sociodemographic variables predicated initial, but not later, depressive distress. Conclusions: Psychological screening is important in the NICU. The PPTS profile suggests it may require distinct treatment. Primiparas should be targeted for intervention.

Maternal psychological distress and visitation to the neonatal intensive care unit.

To examine associations between maternal neonatal intensive care unit (NICU) visitation rates, maternal psychological distress (‘distress’) and preterm infant outcome post‐NICU discharge in a contemporary cohort of very low birthweight (VLBW) infants.

Cardiorespiratory events in extremely low birth weight infants: neurodevelopmental outcome at 1 and 2 years

Objective:To examine the association between cardiorespiratory events (CRE) and neurodevelopmental (ND) outcome at 8 and 20 months corrected age (CA) in a contemporary extremely low birth weight (ELBW )cohort.Study Design:Retrospective chart review of 98 ELBW infants born in 2009 to 2010 who completed ND assessments at 8 and 20 months CA. Neonatal, sociodemographic, CRE and ND data were collected. ND outcome measures included neurologic examination and results from the Bayley Scales of Infant and Toddler Development-III. Multiple regression analyses adjusted for the impact of neonatal risk factors on ND outcome.Result:After adjusting for neonatal and social variables, greater frequency of CRE was related to worse language scores at 8 months, while CRE of greater severity were related to worse language at 20 months CA.Conclusion:CRE in ELBW infants have impact on language development in the first two years of life.

Part C early intervention utilization in preterm infants: Opportunity for referral from a NICU follow-up clinic.

OBJECTIVE Early Intervention (EI) services promote development for preterm infants. In the state of Illinois, Child and Family Connections (CFC) is the intake agency that determines qualification for EI services. In Illinois, all extremely low birth weight (ELBW) infants are eligible for and referred to CFC at discharge from the Neonatal Intensive Care Unit (NICU). This study investigated: (1) patterns of CFC and EI enrollment, and; (2) predictors of CFC enrollment, need for CFC referral, and high EI therapy use among preterm infants seen in a NICU follow-up clinic. METHODS 405 preterm infants, including 169 ELBW infants, were seen in a NICU follow-up clinic at 4-, 8- and 20-months corrected age. CFC/EI data were collected at each visit. Multiple regression analyses adjusted for the effect of medical, sociodemographic and neurodevelopmental risk factors on CFC/EI outcome. RESULTS Despite the high rate of EI utilization and routine care by primary pediatricians, up to 28% of ELBW infants required a CFC referral from a NICU follow-up clinic. Medical and neurodevelopmental risk factors were associated with CFC enrollment while medical, sociodemographic and neurodevelopmental risk factors were associated with need for CFC referral. CONCLUSION NICU follow-up clinics facilitate appropriate CFC/EI services for preterm infants.

Neurodevelopmental impact of hydrocortisone exposure in extremely low birth weight infants: outcomes at 1 and 2 years

Objective:Postnatal steroids are used in neonatal intensive care units despite known side effects. Hydrocortisone (HC) use persists as it is believed to have less deleterious effects on neurodevelopmental (ND) outcome compared to other steroids. The literature is sparse with respect to the ND impact of HC use in recent years. Hence, we sought to examine the effect of HC use on ND outcome in a contemporary cohort of extremely low birth weight (ELBW) infants.Study Design:A total of 175 ELBW infants (86 HC exposed, 89 steroid naive) born in 2008 to 2010 were compared for mortality, morbidity and ND outcome at 8 and 20 months corrected age. Outcome measures included neurologic exam and results of the Bayley Scales of Infant and Toddler Development-III (BSITD-III). Multiple regression analyses adjusted for the effect of other risk factors on outcome.Result:Overall, 65 (75%) of the HC and 74 (83%) of the no-HC groups survived to discharge. HC infants were smaller (mean birth weight (BW) 719±127 g vs 837±99 g) and of lower gestational age (GA) (mean GA 26.0±1.7 weeks vs 27.5±1.8 weeks) compared to the no-HC group. Patients in the HC group were more likely to be a multiple, have a severely abnormal head ultrasound, bronchopulmonary dysplasia, retinopathy of prematurity, necrotizing enterocolitis and receive treatment for patent ductus arteriosus and hypotension than those in the no-HC group. Of the HC group, the mean age at treatment was 20±19 days, mean duration of treatment 49±37 days. At 8 months, the HC group had lower mean motor (87±18 vs 95±15, P=0.028) and fine motor (9±2.9 vs 10.5±2.6, P=0.005) and higher rate of subnormal motor (44 vs 15%, P=0.002) and fine motor scores (24 vs 6.5%, P=0.017). In regression analyses, HC exposure >7 days was significantly related to worse outcome on fine motor scores at 8 months while cumulative days of HC exposure was a predictor of worse outcome on language at 8 months and motor outcome at 20 months. Each additional day of HC exposure increased the odds of subnormal receptive and expressive language in the first year of life by 4 and 2%, respectively, and increased odds of subnormal motor function by 2% in the 2nd year of life.Conclusion:HC exposure for >7 days is associated with worse performance in fine motor skills in the first year of life, while cumulative HC exposure negatively impacts receptive and expressive language skills in the first year and motor skills in the second year of life after adjusting for neonatal and social risk factors.

Parental perception of child vulnerability among mothers of very low birth weight infants: psychological predictors and neurodevelopmental sequelae at 2 years

Objective:The objective of this study was to examine the impact of maternal psychological distress on the development of parental perception of child vulnerability (PPCV) in mothers of very low birth weight (VLBW) infants; and to examine the impact of PPCV on neurodevelopmental outcome in VLBW infants in the second year of life.Study Design:This is a prospective study of 69 mothers and their VLBW infants recruited from 2011 to 2012 for whom maternal psychological data were collected during the neonatal intensive care unit (NICU) hospitalization. Maternal PPCV was assessed at 4 months corrected age (CA). Neurodevelopmental outcome was assessed at 20 months CA. Regression analyses modeled the development of PPCV and the impact of PPCV on neurodevelopmental outcome.Results:PPCV at 4 months CA was predicted by maternal anxiety and history of previous fetal loss reported during the NICU stay. Higher PPCV at 4 months CA was associated with lower language scores at 20 months CA.Conclusion:Targeted interventions aimed at reducing PPCV in the NICU are supported.

A Multimodal Mindfulness Training to Address Mental Health Symptoms in Providers Who Care for and Interact With Children in Relation to End-of-Life Care

Aim: Medical providers may face unique emotional challenges when confronted with the suffering of chronically ill, dying, and bereaved children. This study assessed the preliminary outcomes of participation in a group-based multimodal mindfulness training pilot designed to reduce symptoms of burnout and mental health symptoms in providers who interact with children in the context of end-of-life care. Methods: A total of 13 medical providers who care for children facing life-threatening illness or bereaved children participated in a 9-session multimodal mindfulness session. Mental health symptoms and burnout were assessed prior to the program, at the program midpoint, and at the conclusion of the program. Results: Participation in the pilot was associated with significant reductions in depressive and posttraumatic stress disorder (PTSD) symptoms among providers (P < .05). Conclusion: Mindfulness-based programs may help providers recognize and address symptoms of depression and PTSD. Additional research is needed to enhance access and uptake of programming among larger groups of participants.