Shahirose Premji

Regional neonatal oral feeding protocol: changing the ethos of feeding preterm infants.

The Calgary Health Region Neonatal Oral Feeding Protocol is the culminating work of a broad range of healthcare professionals, including staff nurses, nurse practitioners, nurse educators, nurse managers, dietitians, lactation consultants, clinical nurse specialists, and occupational therapists. The protocol represents a synthesis of research evidence and expert opinion pertaining to the introduction and management of oral milk feedings for high-risk infants in the neonatal intensive care unit. This evidence-based neonatal oral feeding protocol is presented to share knowledge and skill required to create positive feeding experiences while assisting high-risk infants to achieve full oral feedings. Goals of this project include promoting consistent neonatal nursing feeding practices and changing the ethos in relation to feeding interactions between caregiver and infant in the neonatal intensive care unit. This culture change will assist nurses to identify what is unique about their professional practice, which is of particular importance given the skill mix resulting from hospital understaffing and a growing nursing workforce shortage.

A matched cohort study of feeding practice guidelines for infants weighing less than 1,500 g.

PURPOSETo evaluate the efficacy and safety of clinical practice guidelines (CPG) for the nutritional management of infants weighting <1,500 g SUBJECTSInfants weighing <1,500 g (n = 200) admitted to the NICU who had no major congenital anomalies were enrolled. DESIGN AND METHODSA before-and-after matched cohort study was conducted during 1996/1997 and 1998/1999 enrolling infants in a Standard Practice (SP) group and CPG group, respectively. Weight-stratified CPG were introduced between these 2 study periods. Data on the first 100 babies who could be matched for birth weight and gestational age were analyzed. Data collection continued until full feedings were established and tolerated for 48 hours or the infant was discharged from the hospital, whichever came first. PRIMARY OUTCOME MEASUREOf the 200 infants in the study (median gestational age 28 weeks), 142 infants attained full feedings. The median time to full feedings was 15 days in both groups, and a paired sample t test showed no significant difference between the 2 groups (P = 0.35). PRINCIPAL RESULTSNo statistically significant differences in the age of feeding commencement, number of feeding interruptions, days on total parenteral nutrition, days to regain birth weight, age at discharge, incidence of sepsis, hecrotizing enterocolitis, or use of erythromycin were found. CONCLUSIONSThe CPG was a safe alternative to standardize nutritional practices in the NICU. The lack of differences between groups shown in this study is likely related to gut immaturity limiting the infants response to changes in feeding practices, inconsistent use of the guidelines, confounding factors, the small sample size, or the similarity between SP and the CPG.

Perinatal Distress in Women in Low- and Middle-Income Countries: Allostatic Load as a Framework to Examine the Effect of Perinatal Distress on Preterm Birth and Infant Health

In low- and middle-income countries (LMIC), determinants of women’s and children’s health are complex and differential vulnerability may exist to risk factors of perinatal distress and preterm birth. We examined the contribution of maternal perinatal distress on preterm birth and infant health in terms of infant survival and mother–infant interaction. A critical narrative and interpretive literature review was conducted. Peer-reviewed electronic databases (MEDLINE, Embase, Global Health, CINHAL), grey literature, and reference lists were searched, followed by a consultation exercise. The literature was predominantly from high-income countries. We identify determinants of perinatal distress and explicate changes in the hypothalamic–pituitary–adrenal axis, sympathetic, immune and cardiovascular systems, and behavioral responses resulting in pathophysiological effects. We suggest cultural–neutral composite measures of allostatic mediators (i.e., several biomarkers) of maternal perinatal distress as objective indicators of dysregulation in body systems in pregnant women in LMIC. Understanding causal links of maternal perinatal distress to preterm birth in women in LMIC should be a priority. The roles of allostasis and allostatic load are considered within the context of the health of pregnant women and fetuses/newborns in LMIC with emphasis on identifying objective indicators of the level of perinatal distress and protective factors or processes contributing to resilience while facing toxic stress. We propose a prospective study design with multiple measures across pregnancy and postpartum requiring complex statistical modeling. Building research capacity through partnering researchers in high-income countries and LMIC and reflecting on unique ethical challenges will be important to generating new knowledge in LMIC.

A review of postpartum depression, preterm birth, and culture.

Postpartum depression (PPD) varies worldwide and is considered a serious issue because of its devastating effects on mothers, families, and infants or children. Preterm birth may be a risk factor for PPD. In 2005, the global incidence of preterm birth was estimated to be 9.6%, and of these births, 85% occurred in Africa and Asia. Among Asian countries, Pakistan has a preterm birth rate of 15.7% and the highest prevalence rate of PPD (63.3%). A literature review was therefore undertaken to better understand the potential contribution of preterm birth to PPD and to identify gaps in the scientific literature. Limited studies compare prevalence rates of PPD in mothers of full-term infants and mothers of preterm infants. Furthermore, meta-analyses examining predictors of PPD have not included preterm birth as a variable. The interrelationship between preterm birth and PPD may be explained by early parental stress and mother-infant interaction among mothers of preterm infants. Culture plays an important role in shaping communication between mothers and their infants and defines social support rituals that may or may not mediate PPD. More research is needed to provide evidence for practice.

The association between parity, infant gender, higher level of paternal education and preterm birth in Pakistan: a cohort study

BackgroundHigh rates of antenatal depression and preterm birth have been reported in Pakistan. Self reported maternal stress and depression have been associated with preterm birth; however findings are inconsistent. Cortisol is a biological marker of stress and depression, and its measurement may assist in understanding the influence of self reported maternal stress and depression on preterm birth.MethodsIn a prospective cohort study pregnant women between 28 to 30 weeks of gestation from the Aga Khan Hospital for Women and Children completed the A-Z Stress Scale and the Centre for Epidemiology Studies Depression Scale to assess stress and depression respectively, and had a blood cortisol level drawn. Women were followed up after delivery to determine birth outcomes. Correlation coefficients and Wilcoxon rank sum test was used to assess relationship between preterm birth, stress, depression and cortisol. Logistic regression analysis was used to determine the key factors predictive of preterm birth.Results132 pregnant women participated of whom 125 pregnant women had both questionnaire and cortisol level data and an additional seven had questionnaire data only. Almost 20% of pregnant women (19·7%, 95% CI 13·3-27·5) experienced a high level of stress and nearly twice as many (40·9%, 95% CI 32·4-49·8%) experienced depressive symptoms. The median of cortisol level was 27·40 ug/dl (IQR 22·5-34·2). The preterm birth rate was 11·4% (95% CI 6·5-18). There was no relationship between cortisol values and stress scale or depression. There was a significant positive relationship between maternal depression and stress. Preterm birth was associated with higher parity, past delivery of a male infant, and higher levels of paternal education. Insufficient numbers of preterm births were available to warrant the development of a multivariable logistic regression model.ConclusionsPreterm birth was associated with higher parity, past delivery of a male infant, and higher levels of paternal education. There was no relationship between stress, and depression, cortisol and preterm birth. There were high rates of stress and depression among this sample suggesting that there are missed opportunities to address mental health needs in the prenatal period. Improved methods of measurement are required to better understand the psychobiological basis of preterm birth.

Geophagy practices and the content of chemical elements in the soil eaten by pregnant women in artisanal and small scale gold mining communities in Tanzania

BackgroundGeophagy, a form of pica, is the deliberate consumption of soil and is relatively common across Sub-Saharan Africa. In Tanzania, pregnant women commonly eat soil sticks sold in the market (pemba), soil from walls of houses, termite mounds, and ground soil (kichuguu). The present study examined geophagy practices of pregnant women in a gold mining area of Geita District in northwestern Tanzania, and also examined the potential for exposure to chemical elements by testing soil samples.MethodWe conducted a cross sectional study using a convenience sample of 340 pregnant women, ranging in age from 15–49 years, who attended six government antenatal clinics in the Geita District, Tanzania. Structured interviews were conducted in June-August, 2012, to understand geophagy practices. In addition, soil samples taken from sources identified by pregnant women practicing geophagy were analysed for mineral element content.ResultsGeophagy was reported by 155 (45.6%) pregnant women with 85 (54.8%) initiating the practice in the first trimester. A total of 101 (65%) pregnant women reported eating soil 2 to 3 times per day while 20 (13%) ate soil more than 3 times per day. Of 155 pregnant women 107 (69%) bought pemba from local shops, while 48 (31%) consumed ground soil kichuguu. The estimated mean quantity of soil consumed from pemba was 62.5 grams/day. Arsenic, chromium, copper, iron, manganese, nickel and zinc levels were found in both pemba and kichuguu samples. Cadmium and mercury were found only in the kichuguu samples. Based on daily intake estimates, arsenic, copper and manganese for kichuguu and copper and manganese for pemba samples exceed the oral Minimum Risk Levels designated by the U.S. Agency for Toxic Substance and Disease Registry.ConclusionAlmost 50% of participants practiced geophagy in Geita District consistent with other reports from Africa. Both pemba and kichuguu contained chemical elements at varying concentration, mostly above MRLs. As such, pregnant women who eat soil in Geita District are exposed to potentially high levels of chemical elements, depending upon frequency of consumption, daily amount consumed and the source location of soil eaten.

Prenatal Maternal Anxiety as a Risk Factor for Preterm Birth and the Effects of Heterogeneity on This Relationship: A Systematic Review and Meta-Analysis

Background. Systematic reviews (SR) and meta-analyses (MA) that previously explored the relationship between prenatal maternal anxiety (PMA) and preterm birth (PTB) have not been comprehensive in study inclusion, failing to account for effects of heterogeneity and disagree in their conclusions. Objectives. This SRMA provides a summary of the published evidence of the relationship between PMA and PTB while examining methodological and statistical sources of heterogeneity. Methods. Published studies from MEDLINE, CINAHL, PsycINFO, and EMBASE, until June 2015, were extracted and reviewed. Results. Of the 37 eligible studies, 31 were used in this MA; six more were subsequently excluded due to statistical issues, substantially reducing the heterogeneity. The odds ratio for PMA was 1.70 (95% CI 1.33, 2.18) for PTB and 1.67 (95% CI 1.35, 2.07) for spontaneous PTB comparing higher levels of anxiety to lower levels. Conclusions. Consistent findings indicate a significant association between PMA and PTB. Due to the statistical problem of including collinear variables in a single regression model, it is hard to distinguish the effect of the various types of psychosocial distress on PTB. However, a prenatal program aimed at addressing mental health issues could be designed and evaluated using a randomised controlled trial to assess the causal nature of different aspects of mental health on PTB.

Transitions in the early-life of late preterm infants: vulnerabilities and implications for postpartum care.

The focus of this article is on the transition of late preterm infants from hospital to home. The current state of literature related to mortality, morbidities, emergency department visits, and rehospitalization underscores the vulnerability of late preterm infants following discharge from hospital. Universal provision of postpartum care to late preterm infants is viewed as an environmental support intended to facilitate transition of these vulnerable infants from hospital to home. Gaps in provision of postpartum care of late preterm infants are situated within the discussion of guidelines and models of postpartum care (home vs clinic) of late preterm infants.

Breastfeeding the late preterm infant: experiences of mothers and perceptions of public health nurses

BackgroundThe promotion and maintenance of breastfeeding with late preterm infants (LPIs) remain under examined topics of study. This dearth of research knowledge, especially for this population at-risk for various health complications, requires scientific investigation. In this study, we explore the experiences of mothers and the perceptions of public health nurses (PHNs) about breastfeeding late preterm infants in Calgary, Alberta, Canada.MethodsWe used an exploratory mixed methods design with a convenience sample of 122 mothers to gather quantitative data about breastfeeding. We collected qualitative data by means of individual face-to-face interviews with 11 mothers and 10 public health nurses. Data were collected from April 2013 to June 2014. We then employed an interpretive thematic analysis to identify central themes and relationships across narratives.ResultsWe collected 74 complete data sets about breastfeeding. During the first 6–8 weeks postpartum, 61 mothers breastfed their infants. Of these, 51 partially breastfed and 10 exclusively breastfed. For qualitative purposes, the researchers interviewed 11 mothers with late preterm babies and three themes emerged: significant difficulty with breastfeeding, failing to recognize the infant’s feeding distress and disorganized behavior, and the parental stress caused by the multiple feeding issues. The public health nurses’ comments reinforced and expanded on what the mothers reported. The themes for the nurses included: challenges with initiating breastfeeding, challenges during breastfeeding, and the need for stimulation during breastfeeding.ConclusionMothers face challenges when breastfeeding their late preterm infants and public health nurses can guide them through this experience. Families with a late preterm infant need to be informed about the challenges associated with breastfeeding a late preterm infant. It is necessary for all health care professionals to receive proper training on safe and effective breastfeeding of late preterm infants. It is essential for public health nurses to communicate effectively with families of late preterm infants to provide anticipatory guidance about potential challenges and strategies to resolve any breastfeeding problems.

Sociocultural influences on newborn health in the first 6 weeks of life: qualitative study in a fishing village in Karachi, Pakistan

BackgroundGiven regional variability and minimal improvement in infant mortality rates in Pakistan, this study aimed to explicate sociocultural influences impacting mothers’ efforts to maintain or improve newborn health.MethodsWe used a qualitative phenomenological approach. A total of 10 mothers and 8 fathers from a fishing village in Karachi, Pakistan were purposefully sampled and interviewed individually. A focus group was undertaken with four grandmothers (primary decision makers). Transcripts were independently reviewed using interpretive thematic analysis.ResultsA multigenerational approach was used in infant care, but mothers did not have a voice in decision-making. Parents connected breast milk to infant health, and crying was used as cue to initiate feeding. Participants perceived that newborns required early supplementation, given poor milk supply and to improve health. There were tensions between traditional (i.e., home) remedies and current medical practices. Equal importance was given to sons and daughters.ConclusionFindings suggest that social and cultural influences within families and the community must be considered in developing interventions to improve newborn health. Introducing non-breast milk substances into newborn diets may reduce the duration of exclusive or partial breastfeeding and increase risks to infant health.