A descriptive study of mothers' experiences feeding their preterm infants after discharge

[Experiences of parents of premature infants in their feeding journey]

Premature birth is an ordeal for parents, and can have repercussions on the bond of attachment. The risk of stress can be reduced by involving parents in care and feeding, and by encouraging their presence with their baby. The aim of the study was to understand parents' experience of their premature baby's feeding times. Eleven families were included. Parents' experiences differed according to their ability to engage in feeding patterns, influenced by their baby's state of health and immaturity, and by the medical environment. Many expressed the need for support in coping with emotional and practical challenges.

Maternal Reports of Preterm and Sick Term Infants' Settling, Sleeping and Feeding in the 9 Months after Discharge from Neonatal Nursery: An Observational Study

The effects of preterm birth, neonatal morbidities and environmental influences on infant sleep development is an important yet under-researched topic, with little known about normative sleep for infants born sick or preterm. The aim of this prospective, observational longitudinal study was to evaluate maternal perceptions and degree of bother with infant sleep behaviours and feeding outcomes across the first 9 months after discharge for sick/preterm infants cared for in the neonatal intensive care unit (NICU) and for healthy term-born infants. This paper reports outcomes for the sick/preterm cohort (I = 94) that were recruited from two NICUs in Perth, Western Australia. Total bother scores were on average 20.2% higher at 9 months than at two weeks post-discharge (p < 0.001). Increased night waking frequency, evening settling duration and crying duration were all positively associated with total bother scores. Maternal confidence scores were negatively associated with maternal bother scores; with each unit increase in confidence, maternal bother decreased by 8.5% (p < 0.001). Covariates such as birth gestation, breastfeeding status and multiple births were not associated with maternal bother. Families may benefit from additional support when experiencing increased night waking frequency and crying and settling durations in the first 9 months after discharge from NICU.

Understanding the Domains of Experiences of Black Mothers with Preterm Infants in the United States: A Systematic Literature Review

OBJECTIVE

To report the domains of Black mothers' experiences with preterm infants in the neonatal intensive care unit (NICU) and to determine the frameworks used.

METHODS

A systematic review of the literature using the PRISMA guideline was performed. An electronic database search of published literature between 2000 and 2022 was conducted based on predetermined search terms and parameters.

RESULTS

Twenty-seven articles met the inclusion and exclusion criteria. Eleven articles focused on feeding practices, ten reported on nursing/maternal care experiences, five reported mental health/social support, and only one focused on mother-infant relationships. Only five papers reported using any frameworks, comprising grounded theory framework (n = 2), theory of planned behavior (n = 1), research justice framework (n = 1), and the patient and public engagement protocol (n = 1).

DISCUSSION

A holistic approach to understanding the multifactorial experiences of Black mothers with preterm infants needs to be socio-culturally competent to ensure their diverse intersections and identities are accurately represented and understood. Rigorous research at the intersection of Black maternal health and the NICU hold promises for advancing maternal health equity in the United States.

After NICU discharge: Feeding and growth of low-income urban preterm infants through the first year

BACKGROUND

Little is known about preterm infant feeding and growth in the outpatient setting, and there are no standardized post-hospital discharge feeding guidelines. This study aims to describe post-neonatal intensive care unit (NICU) discharge growth trajectories of very preterm (<32 weeks gestational age (GA)) and moderately preterm (32-34 0/7 weeks GA) infants managed by community providers and to determine the association between post-discharge feeding type and growth Z-scores and z-score changes through 12 months corrected age (CA).

METHODS

This retrospective cohort study included very preterm infants (n = 104) and moderately preterm infants (n = 109) born 2010-2014 and followed in community clinics for low-income, urban families. Infant home feeding and anthropometry were abstracted from medical records. Repeated measures analysis of variance calculated adjusted growth z-scores and z-score differences between 4 and 12 months CA. Linear regression models estimated associations between 4 months CA feeding type and 12 months CA anthropometry.

RESULTS

Moderately preterm infants on nutrient-enriched vs. standard term feeds at 4 months CA had significantly lower length z-scores at NICU discharge that persisted to 12 months CA (-0.04 (0.13) vs. 0.37 (0.21), respectively, P = .03), with comparable length z-score increase for both groups between 4 and 12 months CA. Very preterm infants' 4 months CA feeding type predicted 12 month CA body mass index z-scores (β=-0.66 (-1.28, -0.04)).

CONCLUSION

Community providers may manage preterm infant post-NICU discharge feeding in the context of growth. Further research is needed to explore modifiable drivers of infant feeding and socio-environmental factors that influence preterm infant growth trajectories.

Parental Participation in Preterm Infant Feeding in the Neonatal Intensive Care Unit

PURPOSE

To identify factors associated with parental participation in the feeding care of hospitalized preterm infants and determine associations between parental participation in feeding and infant neurobehavioral outcomes.

STUDY DESIGN AND METHODS

Secondary analysis of data collected during a larger study of preterm infants. Parental participation in gavage and oral feeding was measured as a proportion of all feeding opportunities. Neurobehavioral outcomes were measured using a neurobehavioral assessment and feeding milestones. Other data were collected from the electronic health record.

RESULTS

Parental participation in feeding was low. There were associations between parental participation in gavage feeding and infant sex, insurance type, maternal race, infant gestational age at birth, and birthweight. There were associations between parental participation in oral feeding and infant sex, insurance type, maternal race, and study group. Greater parental participation in feeding was associated with earlier achievement of some feeding milestones.

CLINICAL IMPLICATIONS

Parental participation in feeding can decrease the time required for infants to achieve feeding milestones, possibly leading to decreased length of hospitalization. Nurses should encourage parents to participate in caregiving for their preterm infants. Interventions are needed to remove barriers to parental participation in caregiving.

‘They said, let’s teach you how you are going to care for the child at home…’: caregivers’ and healthcare worker’s perceptions and experiences of post-discharge preterm care in eastern Uganda

Background

Complications of prematurity are the leading cause of neonatal mortality, and the majority of these deaths occur in low and middle-income countries. Research in these settings has focused on improved outcomes for preterm infants in hospital settings, however, research into the continuation of preterm care in the home after discharge from a neonatal unit is limited. This study examines the experiences and perceptions of caregivers of preterm infants during the initial weeks following discharge from a neonatal unit in Uganda, and the views of healthcare workers (HCWs) on the ability of caregivers to cope.

Methods

This qualitative study used multiple data collection approaches, namely focus group discussions (FGDs), in-depth interviews (IDIs), field observations, and case studies to explore the perceptions and experiences of providing care to preterm infants post-discharge from a neonatal unit in eastern Uganda from the perspectives of caregivers and HCWs.

Results

We recruited 39 participants with a total of 35 separate sessions including 18 IDIs (12 caregivers and 6 HCWs), 3 FGDs (17 caregivers), and 4 case studies (14 separate IDIs over 5 weeks after discharge, three mothers, and one grandmother). IDIs and FGDs took place at the Mbale Regional Referral Hospital or in participants’ homes.

Key themes emerged; preparation for continuing care in the home, psychosocial challenges to providing preterm care in the home, barriers to continuing preterm care in the home, and suggestions for improvement of preterm care in the home. Caregivers had good knowledge and awareness about different aspects of preterm care. Following discharge, caregivers struggled to maintain quality care due to loss of continuous support from the neonatal team, feelings of anxiety and isolation, financial issues, and home responsibilities.

Conclusion

This study highlights multiple challenges to continuing preterm care in this Ugandan setting. Improved training and education for caregivers, especially in neonatal resuscitation, enhanced and continued support of the caregiver and infant in the home, and increased community involvement following discharge may all be key solutions. These findings are fundamental to improving care in the home for preterm infants in eastern Uganda and similar settings.

Risk Factors for Feeding and Swallowing Disorders in Very Low Birth Weight Infants in Their Second Year of Life

Background and Objectives: This study aimed to identify the prevalence of feeding and swallowing disorders (FSD) in very low birth weight (VLBW, 1500 g or less) infants in the first two years after discharge from the maternity hospital, their possible risk factors, and the consequences of them. Materials and Methods: A total of 117 preterm children with VLBW born between 2013 and 2015 were included. The data concerning possible FSD after discharge from the hospital were obtained through accessible medical documentation for the child and a short parental questionnaire. Results: FSD was reported in 32 (27.4%) infants following discharge from the hospital but in only five children (4.3%) at a mean age of four years. Four variables (birth gestational age less than 28 weeks, birth weight equal to or less than 1000 g, birth length below 33 cm, and start of oral feeding after the 34th gestational week) were identified as risk factors for FSD after discharge. However, only birth length remained a significant predictor after being included in a binary logistic regression model (p = 0.000). Abnormal oral sensitivity and a decrease in weight to under the 10th percentile were significantly more common in the FSD group at follow-up visits at the age of about 2 years. Conclusions: FSD was still present in more than one-quarter of VLBW infants after discharge from the maternity hospital but mostly disappeared within four years. A birth gestational age under 28 weeks, weight up to 1000 g, the late beginning of per oral feeding, and a birth length below 33 cm were determined to be significant predictive factors for FSD. Having a birth length below 33 cm was associated with an almost 6.5-fold increase in the odds of having persistent FSD after discharge from the hospital. FSD in the first years of life may have an impact on the child's further growth and development.

Demographic and clinical parameters are comparable across different types of pediatric feeding disorder

Knowledge and understanding of risk mechanisms associated with pediatric feeding disorder (PFD) remain limited. We aimed to investigate factors associated with PFD and their relation to specific PFD types according to the recent consensus WHO-based definition. We retrospectively reviewed the medical records of children with PFD and retrieved their demographic and clinical characteristics. Healthy age- and sex-matched children served as controls. Included were 254 children with PFD [median (interquartile range) age 16.4 (9.5-33) months at diagnosis] and 108 children in the control group [median age 24.85 (14.5-28.5) months]. According to the WHO-based definition, disturbances in oral intake were predominantly related to nutritional dysfunction in 118 (46.6%), feeding skill dysfunction in 83 (32.3%), medical conditions in 42 (16.7%) and psychosocial dysfunction in 11 (4.4%). In multivariate analysis, children with PFD had a higher risk for lower socioeconomic background (P < 0.01) and low birth weight (26.8% compared to 7.4%, P < 0.001). Moreover, significantly fewer children in the PFD group were breastfed (75% versus 89%, P = 0.003). There were no significant differences in any of those variables between PFD types. In conclusion, low socioeconomic status, lack of breastfeeding, and low birth weight were significantly more frequent in children with PFD. PDF manifest as multiple dysfunctions, thus highlighting the need to offer these children and their families multidisciplinary care.

Positive breastfeeding experiences and facilitators in mothers of preterm and low birthweight infants: a meta-ethnographic review

Background

Most qualitative research on breastfeeding the preterm or low-birthweight (LBW) infant has focused on negative insights; there are no comprehensive insights into how, when and why mothers experience positive breastfeeding experiences. We aimed to address this knowledge gap by exploring what characterizes and facilitates a positive breastfeeding experience in mothers of preterm and/or LBW infants.

Methods

A systematic review using meta-ethnographic methods was conducted. Search strategies involved a comprehensive search strategy on six bibliographic databases, citation tracking and reference checking. The analysis involved a reciprocal level of translation and a line of argument synthesis.

Results

Searches identified 1774 hits and 17 articles from 14 studies were included, representing the views of 697 mothers. A positive breastfeeding experience was identified as being ‘attuned’. Three themes and eight sub-themes were developed to describe what characterizes attuned breastfeeding. ‘Trusting the body and what it can do’, concerned how attuned breastfeeding was facilitated through understanding the bodily responses and capacity and feeling comfortable with holding the infant and to breastfeed. ‘Being emotionally present – in the here and now’ described the importance of feeling relaxed and reassured. ‘Experiencing mutual positive responses’, illuminated how attunement was related to feelings of mutuality - when the mother recognises the infant’s cues, responds to these signals and receives a positive response from the infant. The key factors to facilitate attuned breastfeeding were opportunities for prolonged close physical contact with the infant, positive relationships with and support from staff and peers, and being facilitated to breastfeed when the infant showed feeding cues.

Conclusions

This study provides new insights into what characterizes a positive breastfeeding experience and how staff can facilitate and enable mothers to achieve attuned breastfeeding. Improvements in units’ design, such as for rooming-in and having prolonged skin-to-skin contact, and care provided by knowledgeable, supportive and encouraging staff and peers, are crucial. The mother’s physical and emotional states and the infant’s behavioural responses and physiological signals should guide the process towards positive breastfeeding practices.

The relationship between maternal smartphone use, physiological responses, and gaze patterns during breastfeeding and face-to-face interactions with infant

Smartphone use during parent-child interactions is highly prevalent, however, there is a lack of scientific knowledge on how smartphone use during breastfeeding or face-to-face interactions may modulate mothers’ attentive responsiveness towards the infant as well as maternal physiological arousal. In the present study, we provide the first evidence for the influence of the smartphone on maternal physiological responses and her attention towards the infant during breastfeeding and face-to-face interactions. Twenty breastfeeding mothers and their infants participated in this lab study during which electrodermal activity, cardiograph impedance, and gaze patterns were monitored in breastfeeding and face-to-face interactions with three conditions manipulating the level of maternal smartphone involvement. We report that mothers’ gaze toward their infants decreased when breastfeeding while using the smartphone compared to face-to-face interaction. Further, we show that greater maternal electrodermal activity and cardiac output were related to longer maternal gaze fixation toward the smartphone during breastfeeding. Finally, results indicate that mothers’ smartphone addiction levels were negatively correlated with electrodermal activity during breastfeeding. This study provides an initial basis for much required further research that will explore the influence of smartphone use on maternal biobehavioral responses in this digital age and the consequences for infant cognitive, emotional, and social development.

Transition From Nasogastric Tube to Oral Feeding: The Role of Parental Guided Responsive Feeding

Background and Objective: Strategies to transition preterm infants from tube to oral feeding vary greatly and the transition may take days to weeks. The study objective was to evaluate the effect of parental guided responsive feeding (PGRF) on this transition. Methods: We conducted a randomized controlled trial on infants born at <32 weeks gestation. The PGRF intervention was performed by parents, and included feeding intervals and volumes which were guided by the infants' behavioral cues of hunger and satiety. If a minimum volume was not taken orally, an intermediate volume was supplemented via nasogastric tube. The control group was traditionally fed (TF), with pre-planned volumes of intake and at given scheduled intervals. Results: The study comprised 67 infants (PGRF 32, TF 35). PGRF infants reached full oral feeding within less days (median 2 vs. 8 days, p = 0.001), at an earlier age (median 34.28 vs. 35.14 weeks, p < 0.001), returned to baseline weight gain at 35 weeks (1.77 ± 0.70 vs. 1.25 ± 0.63 g/kg/day, p = 0.002), were discharged earlier (36.34 ± 0.6 vs. 36.86 ± 0.9 weeks, p = 0.001), were more likely to be fed by their parents (p < 0.001), and experienced less apnea/bradycardia events at 34 weeks (median 3.5 vs. 9 per week p = 0.047) compared to the TF infants. The regression model demonstrated that independent variables predicted 43.7% of the variance of time to full oral feeding [F _{(9, 65)} = 4.84 p < 0.001]. The only significant variable was feeding group (B = -6.43 p < 0.001); The PGRF infants were more likely to reach full oral feeding earlier. Conclusion: PGRF is safe, and associated with short-term advantages, higher parental engagement, and earlier discharge. Clinical Trial Registration: Identifier: SHEBA-12-9574-IM-CTIL; "Adjusted Individual Oral Feeding for Improving Short and Long Term Outcomes of Preterm Infants."

Caring for late preterm infants: public health nurses' experiences

BACKGROUND

Public health nurses (PHNs) care for and support late preterm infants (LPIs) and their families when they go home from the hospital. PHNs require evidence-informed guidelines to ensure appropriate and consistent care. The objective of this research study is to capture the lived experience of PHNs caring for LPIs in the community as a first step to improving the quality of care for LPIs and support for their parents.

METHODS

To meet our objectives we chose a descriptive phenomenology approach as a method of inquiry. We conducted semi-structured interviews with PHNs (n = 10) to understand PHN perceptions of caring for LPIs and challenges in meeting the needs of families within the community. Interpretative thematic analysis revealed PHN perceptions of caring for LPIs and challenges in meeting the needs of families within the community.

RESULTS

Four themes emerged from the data. First, PHNs expressed challenges with meeting the physiological needs of LPIs and gave voice to the resulting strain this causes for parents. Second, nurses conveyed that parents require more anticipatory guidance about the special demands associated with feeding LPIs. Third, PHNs relayed that parents sometimes receive inconsistent advice from different providers. Lastly, PHNs acknowledged that due to lack of resources, families sometimes did not receive the full scope of evidence informed care required by fragile, immature infants.

CONCLUSION

The care of LPIs by PHNs would benefit from more research about the needs of these infants and their families. Efforts to improve quality of care should focus on: evidence-informed guidelines, consistent care pathways, coordination of follow up care and financial resources, to provide physical, emotional, informational support that families require once they leave the hospital. More research on meeting the challenges of caring for LPIs and their families would provide direction for the competencies PHNs require to improve the quality of care in the community.

Implementing Co-Regulated Feeding with Mothers of Preterm Infants

PURPOSE

The purpose of this study is to describe implementation of the Co-Regulated Feeding Intervention (CoReg), when provided by mothers and guided by intervention nurses trained in methods of guided participation (GP). Co-regulated feeding intervention aims to prevent stress during feeding and ease the challenge very preterm (VP) infants experience coordinating breathing and swallowing during the early months. Guided participation is a participatory learning method to guide the complex learning required for mothers.

STUDY DESIGN AND METHODS

Sixteen mothers of 17 VP infants participated. Each mother received a median of five intervention sessions during the infant's transition to oral feeding. Intervention field notes, audio recordings of the sessions, and video recordings of the nurse-guided feedings were reviewed, organized, and content analyzed to evaluate implementation.

RESULTS

The co-regulated feeding intervention was well received by mothers; enrollment, participation, and retention rates were high. Most mothers chose to spread out the intervention sessions across the transition period. Scheduling sessions was the greatest barrier. Mothers had competing demands and infant readiness to eat could not be predicted. The top five issues identified as needing attention by the mother or nurse included reading cues, coregulating breathing, providing motoric stability, regulating milk flow, and providing rest periods. Main GP strategies included joint attention with the mother to the dyad's feeding challenges, auditory assessment of breathing and swallowing, and reflection with planning for future feedings using video playback.

CLINICAL IMPLICATIONS

Nurse presence while mothers feed affords rich opportunities to guide coregulated, cue-based feeding. Co-regulated feeding intervention would be enhanced if mothers are guided by the bedside nurse.

Parent, patient and clinician perceptions of outcomes during and following neonatal care: a systematic review of qualitative research

OBJECTIVE

Multiple outcomes can be measured in infants that receive neonatal care. It is unknown whether outcomes of importance to parents and patients differ from those of health professionals. Our objective was to systematically map neonatal care outcomes discussed in qualitative research by patients, parents and healthcare professionals and test whether the frequency with which outcomes are discussed differs between groups.

DESIGN

Systematic review of qualitative literature. The following databases were searched: Medline, CINAHL, EMBASE, PsycINFO and ASSIA from 1997 to 2017. Publications describing qualitative data relating to neonatal care outcomes, reported by former patients, parents or healthcare professionals, were included. Narrative text was analysed and outcomes grouped thematically by organ system. Permutation testing was applied to assess an association between the outcomes identified and stakeholder group.

RESULTS

Sixty-two papers containing the views of over 4100 stakeholders were identified; 146 discrete outcomes were discussed; 58 outcomes related to organ systems and 88 to other more global domains. Permutation testing provides evidence that parents, former patients and health professionals reported outcomes with different frequencies (p=0.037).

CONCLUSIONS

Parents, patients and health professionals focus on different outcomes when discussing their experience of neonatal care. A wide range of neonatal care outcomes are reported in qualitative research; many are global outcomes relating to the overall status of the infant. The views of former patients and parents should be taken into consideration when designing research; the development of a core outcomes set for neonatal research will facilitate this.

Preparing for post-discharge care of premature infants: Experiences of parents

OBJECTIVES

The study sought to describe the experiences of parents of premature children regarding discharge from the neonatal unit.

METHODS

This was a qualitative study, in which 10 semi-structured interviews were conducted with parents of premature infants upon discharge from the neonatal unit. Data were analyzed following principles of grounded theory; open and axial coding was performed.

RESULTS

The following categories emerged from the analysis of the information: feelings experienced upon discharge, and experience of the discharge as a process; the latter category clearly identified barriers and facilitators. The results highlight that the parents experience ambivalent feelings; joy is mixed with the fear of caring for a premature child at home.

CONCLUSIONS

For parents, discharge of premature children from the neonatal unit is a complex process during which conflicting feelings are experienced. Nursing must develop strategies to involve parents early in the care of their children during the hospital stay.

Postdischarge Feeding Interactions and Neurodevelopmental Outcome at 1-Year Corrected Gestational Age

OBJECTIVE

To determine the extent to which postdischarge feeding behaviors and interactions among caregiver-preterm infant dyads are associated with infant neurodevelopment at 1-year corrected gestational age (CGA).

STUDY DESIGN

We studied 119 preterm infants born <34 weeks gestation and <1750 g at birth, and their caregivers, enrolled in the Collaborative Home Infant Monitoring Evaluation with in-person feeding assessments according to the Nursing Child Assessment Feeding Scale (NCAFS) at 39-59 weeks postmenstrual age that completed Bayley Scales of Infant Development, Second Edition testing at 1 year CGA.

RESULTS

Mean ± SD gestational age was 29.6 ± 2.4 weeks, and birth weight was 1260 ± 320 g. After adjustment for maternal and infant demographics, gestational age at birth, discharge and birth weight, mode of infant feeding, and caregiver type during the postdischarge NCAFS assessment, overall NCAFS scores were positively associated with higher 1-year CGA Bayley mental developmental index (MDI) scores (for each 1 SD increase in overall NCAFS score, MDI increased by 2.8 [95% CI 0.7, 4.9] points). Among individual NCAFS domains, strongest effects were seen for caregiver responsiveness to infant distress, such that, compared with dyads having domain scores of 11 (highest possible score), the adjusted mean difference in MDI was 8.3 points (95% CI -15.2, -1.4) lower among dyads with scores <9.

CONCLUSIONS

Caregiver-preterm infant feeding interaction and caregiver responsiveness to preterm infant feeding distress were associated with preterm infant Bayley MDI at 1-year CGA. Caregiver-infant feeding interaction may represent a modifiable factor to improve the neurodevelopment of at-risk preterm infants.

Parental experience learning to feed their preterm infants

PURPOSE

Although extensive research has been conducted on preterm infant oral feeding, few investigations have examined parents' experiences learning to feed orally their preterm infant while in the neonatal intensive care unit (NICU). As such, the aim of this study was to explore parental learning experiences to gain a better understanding of the process parents use in learning to feed their preterm infant.

SUBJECTS

Parents included in the investigation were 18 years of age or older with a medically stable preterm infant who was less than 36 weeks' gestational age at birth, free of congenital malformations, and feeding orally.

DESIGN

This investigation used phenomenology to explore the depth and richness of parental experience with the process of learning to feed orally their preterm infant.

METHODS

Participants were recruited from a university-affiliated women's hospital with a level III NICU. Purposive sampling was used to ensure that all participants were familiar with the experience of interest. Data collection consisted of personal interviews, which were conducted in a private consultation room located within the NICU. In instances where both the infant's mother and father chose to participate, the interviews were conducted separately on the same day.

MAIN OUTCOME MEASURES

Twelve mothers and 8 fathers participated in semistructured interviews. For 8 mothers and 6 fathers, this was their first child. This was the first preterm infant for all participants. From the parental experience, the following 3 themes were identified: an emotional experience, learn as you go, and it is technical.

PRINCIPAL RESULTS

Parents noted that feeding encompassed both positive and negative emotions, that learning was a process that nurses played an instrumental role in, and that feeding a preterm infant could be very technical, requiring extra skills for feeding success.

CONCLUSIONS

Nurses can play a key role in helping parents learn by acknowledging both positive and negative feelings about the feeding process, recognizing parents' learning needs, and by teaching and demonstrating appropriate feeding techniques.

Communication about life-sustaining therapy: insights from the Adaptive Leadership Framework

OBJECTIVE

Effective provider and caregiver communication is central to quality care during treatment for life-threatening illnesses. The study aim was to analyze communication patterns between providers and a parent of an infant with a life-threatening disease using the Adaptive Leadership Framework, which is an activity that involves mobilizing others to adapt to a difficult situation.

METHOD

A secondary analysis was conducted on one case using 23 interviews with providers and mother of an infant diagnosed with Hurler's syndrome. The interviews focused on decision-making challenges in regard to the infant's treatment and were conducted over a 1-year period (pre-transplant, study entry, monthly, after a life-threatening event or substantial change in treatment and at 1-year post enrollment). Content analysis was used to identify and categorize communication patterns using concepts from the Adaptive Leadership Framework.

RESULTS

Infant illness events and parent-provider caregiving were chronicled across a 1-year trajectory. Despite the life-threatening nature of Hurler's disease, the parent and providers did not discuss palliative care or end-of-life. The parent sought direction and answers from the providers. The Adaptive Leadership Framework suggested how communication approaches were often mismatched with the needs of the parent.

DISCUSSION

The results of the study accentuate the need to improve communication between provider and parents about end-of-life for their child. Adaptive Leadership illuminates how providers can influence a parent's behavior when facing a challenging situation. This study suggests that Adaptive Leadership is a useful framework to guide research about healthcare communication in dealing with challenging issues.

Parents' perceptions regarding readiness for their infant's discharge from the NICU

PURPOSE

To identify what parents need to feel ready for the discharge of their infant from the neonatal intensive care unit (NICU).

DESIGN

Qualitative.

SAMPLE

20 parents of infants admitted to a Canadian Level III NI CU were interviewed (2011-2012) and asked to identify what they require to feel ready for discharge. Interview transcripts underwent qualitative content analysis to produce a descriptive summary of parents' perceptions of their needs.

RESULTS

Parents indicated a need for information and hands-on experience to enhance their readiness for discharge. Observations of their infant and of the NI CU environment impacted parents' perceptions of their infant's readiness for discharge, which influenced perceptions of their own readiness for discharge. Finally, parents require tailoring of information and experiences to meet the unique needs of their family.

The Alien Child: The Experience of Mothers of Hospitalized Premature Children

Objetivo: analizar el nacimiento de un niño prematuro y su posterior hospitalización en la Unidad de Cuidado Intensivo Neonatal, el cual casi siempre toma por sorpresa a sus padres, quienes a partir de ese momento se ven inmersos en una serie de situaciones que nunca consideraron en sus vidas y que determinan la relación con su hijo y su capacidad de cuidarlo. Método: para conocer las vivencias de las madres durante la gestación, el nacimiento y la hospitalización de su hijo prematuro se realizó un estudio fenomenológico con diez madres. Resultados: los hallazgos muestran que las mujeres vivieron la gestación como una sorpresa de corta duración y final inesperado, percibieron a su hijo distante y ajeno, lo cual es diferente a lo que viven las madres de niños nacidos sanos y a término. Las situaciones que las mujeres vivieron durante el nacimiento y la hospitalización de su hijo retardaron la apropiación del rol de madre cuidadora debido a las restricciones para estar a su lado en la UCIN y participar de su cuidado. Conclusión: estos hallazgos indican que es prioritario implantar estrategias institucionales de cuidado que propendan por la cercanía y el contacto madre-hijo como el cuidado canguro intrahospitalario.

Oral-motor function and feeding intervention

This article presents the elements of the Oral Motor Intervention section of the Infant Care Path for Physical Therapy in the Neonatal Intensive Care Unit (NICU). The types of physical therapy interventions presented in this path are evidence based as well as infant driven and family focused. In the context of anticipated maturation of suck-swallow-breathe coordination, the timing and methods for initiation of oral feedings and transition from gavage to full breast or bottle-feedings are presented with supporting evidence.

The development of a mother's internal working model of feeding

PURPOSE

The purpose of the study was to describe changes in a mother's early internal working model of infant feeding.

DESIGN AND METHODS

In this qualitative study, 12 maternal responses to the semi-structured internal working model interview were audio-recorded, once in the neonatal intensive care unit after infants began oral feeding and once 2 weeks post-discharge. Interviews were analyzed using directed content analysis.

RESULTS

A change between mothers' early and later nipple feeding experiences was identified.

PRACTICE IMPLICATIONS

Nurses and other clinicians can help mothers understand the infant's behaviors and focus on the infant's nutritional intake while simultaneously developing a relationship with the infant.

Estimated breastfeeding to support breastfeeding in the neonatal intensive care unit

OBJECTIVE

To evaluate the effects of estimated breastfeeding on infant outcomes in comparison to test weighing and to describe staff members' experiences of estimated breastfeeding as a method for supporting the transition from tube feeding to breastfeeding.

DESIGN

A mixed method evaluation.

SETTING

Neonatal Intensive Care Unit (NICU) in Sweden.

PARTICIPANTS

The study included 365 preterm (25(th)-36(th) gestational weeks) infants and 45 nurses or nurse assistants.

METHODS

A retrospective comparative medical record study was used to assess infant outcomes during a period of test weighing (196 infants) and again after the implementation of estimated breastfeeding (169 infants). A qualitative survey was conducted to explore the staff experiences of estimated breastfeeding.

RESULTS

No differences were found between groups regarding duration of tube feeding, length of hospital stay, gestational age, weight at discharge, and rate of any breastfeeding. Infants in the estimated breastfeeding group had a higher risk of not being exclusively breast milk fed than infants in the test-weighing group (OR = 2.76, CI [1.5, 5.1]). Staff perceived estimated breastfeeding as a more facilitative and less stressful method for mothers than test weighing. Some staff had difficulty following guidelines while simultaneously providing person-centered care.

CONCLUSIONS

Estimated breastfeeding is a nonintrusive and feasible method for assessing and supporting the transition from tube feeding to breastfeeding among preterm infants in a NICU. However, the increased risk for not being exclusively breastfed is of concern. Additional research is needed to assess whether this method is appropriate and feasible in varying contexts and cultures.

Psychometric testing of the modified breastfeeding self-efficacy scale (short form) among mothers of ill or preterm infants

OBJECTIVE

To psychometrically assess the modified Breastfeeding Self-Efficacy Scale-Short Form (BSES-SF) among mothers of ill or preterm infants.

DESIGN

Methodological study.

SETTING

Three neonatal intensive care units (NICUs) located in two hospitals in a central Canadian city.

PARTICIPANTS

One hundred forty-four (144) breastfeeding mothers of ill or preterm infants.

METHODS

Mothers completed the BSES-SF modified for mothers of ill or preterm infants, the Hill and Humenick (H&H) Lactation Scale, and demographic questions.

RESULTS

The Cronbach's alpha coefficient for internal consistency for the BSES-SF revised for mothers of ill or preterm infants was 0.88. Construct validity was assessed using comparison of contrasted groups (mothers who continued to breastfeed and those who discontinued) and correlation with the construct of maternal perceptions of insufficient milk supply. Support for predictive validity was demonstrated through significant mean differences between mothers who were breastfeeding (M = 83.44, SD = 8.23) and those who discontinued breastfeeding and breast pumping (M = 75.51, SD = 10.08) at 6-weeks post-infant hospital discharge.

CONCLUSION

Demographic response patterns suggest that the modified BSES-SF is a unique tool to identify breastfeeding mothers of ill or preterm infants at risk of prematurely discontinuing. This study provides evidence that the modified BSES-SF may be a valid and reliable measure of breastfeeding self-efficacy among a sample of mothers of ill or preterm infants.

Changes in Oral Feeding in Preterm Infants Two Weeks After Hospital Discharge

The purpose of this analysis was to measure changes in preterm infant feeding skill between discharge and two weeks post-discharge. Data were from two samples - 22 preterm infants who participated in a non-experimental study of feeding readiness and 63 preterm infants who participated in a study of four oral feeding approaches. Both studies were approved by the institutional review board; parents gave informed consent. The Early Feeding Skills Assessment (EFSA) was used to measure feeding skills. Data were analyzed descriptively and by ANOVA and regression. Analysis revealed that feeding skills changed selectively from discharge to post-discharge and that discharge skills were predictive of post-discharge skill. Changes that occur in feeding skills during the immediate post-discharge period have received little attention from researchers. The findings suggest that enhanced pre-discharge assessment and parent teaching maybe necessary to reduce reported parental stress associated with feeding the newly discharged infant and to promote a positive feeding experience.

Global health and neonatal nursing: a personal journey

The need for improvement of neonatal nursing care is a global issue. Neonatal nurses have an important role in optimizing these health outcomes for neonates and their families. This article describes the personal journey of one nurse and her mentee. It describes how a passion for neonates led to global policy work.

Mother-infant synchrony during infant feeding

PURPOSE

The purpose of this study was to test a coding system, the Maternal-Infant Synchrony Scale (MISS), for assessing synchrony of feeding interaction between a mother and her preterm infant. The secondary aim was to describe mother and preterm infant synchrony during feeding and the change over time.

METHODS

A descriptive, longitudinal design using data collected during an earlier study was employed, using a sample dataset from 10 mother-infant dyads that completed three data collection points. The Noldus Observer XT 8.0 (Noldus Information Technology b.v., 2006) was used for data review and coding. The MISS was created from pilot data and definitions further refined. The frequency of occurrence for select behaviors and the percentage of time behaviors occurred during the feeding and the changes in behaviors over the three observations periods were calculated.

RESULTS

The synchrony tool developed in this study demonstrates that changes occur in mother and infant behavior over time. Mothers were attentive and focused during feedings and monitored their infants' sucking intently but there was little interaction between the dyad. Infant attempts at interaction were greater than the mother attempts to engage her infant. The influence of infant maturation on feeding behaviors was evident across observations.

CONCLUSION

This study revealed behaviors that are descriptive of the interaction and can be used to develop interventions that would support the developing relationship. Use of the MISS with a larger sample size and a cohort of healthy, term newborns is needed to establish the MISS as a valid and reliable measure of synchrony.

The evidence base for the cues program for mothers of very low birth weight infants: an innovative approach to reduce anxiety and support sensitive interaction

Very low birth weight (VLBW) infants, born weighing less than 1,500 g, are at risk for several developmental problems. Consequently, there has been interest in developing intervention programs to prevent such problems. This article describes the empirical evidence that guided the development of an innovative, multicomponent intervention program for mothers of VLBW infants, as well as the program content and features. Based on the evidence, the program was designed to include six sessions and commence shortly after birth to reduce maternal psychological distress during the infant's hospitalization in the neonatal intensive care unit and to promote sensitive mother-infant interaction. The program incorporates various learning activities, including written materials, observational exercises, discussion, and video feedback.

Caregiving motivations and developmentally prompted transition for mothers of prematurely born infants

Parenting transition is a process prompted by infant developmental changes and may be defined by motivations for caregiving and the goals they indicate. Qualitative exploration of neonatal and 1-year feeding experience of 22 mothers of very-low-birth-weight infants revealed 3 types of caregiving-related motivations-nurturing, relating, and shaping quality of life. The clusters of motivations differed between ages and across mothers, suggesting transition in parenting reflective of both infant development and maternal goals. Study with a larger sample is needed to examine change in caregiving motivations and their function in characterizing parenting transitions.

Transition from hospital to home for parents of preterm infants

Research on the phenomenon of transition spans several decades. This article discusses the transition from hospital to home and the challenges parents of preterm infants experience during a neonatal intensive care unit stay and after discharge. The article explores the link between parental problems and rehospitalizations and the need for accurate measures of transitional concerns. An example of a theoretical model and instrument is described.

Encouraging breastfeeding: A relational perspective

Despite the WHO recommendations that babies should be breastfed exclusively for six months and thereafter for up to two years and beyond this pattern of feeding is far from the global norm. Although breastfeeding is triggered through biological mechanisms which have not changed with time, the perception of breastfeeding as a phenomenon is variable, as it not only reflects cultural values of motherhood but is also negotiable from the perspective of the individual. This paper argues that relationships are central to encouraging breastfeeding at an organisational, family and staff-parent level. This shifts our conceptualisations away from the primary focus of breastfeeding as nutrition which, in turn, removes the notion of breastfeeding as a productive process, prone to problems and failure.

Infant feeding in the neonatal unit

Infants admitted to a neonatal unit (NNU) are frequently unable to feed by breast or bottle because of ill health or prematurity. These infants require nutritional support until they can start oral feeding. Breastfeeding is advocated for these infants, and mothers are frequently encouraged to express breast milk to be fed via the enteral tube. However, by discharge, breastfeeding rates tend to be low. Oral feeding requires careful management, and although practices may vary because of clinical need, some may be informed by unit norms. There is limited evidence for effective breastfeeding support in this environment and little exploration of the effect of routine feeding decisions. This study aimed to explore feeding decisions and considered how these might affect outcomes. The staff in the two large urban NNUs who participated in the feeding decisions were interviewed and the data were analysed using a theoretical framework. Feeding decisions were made mainly by the unit staff, with limited parental involvement. Subsequent management varied, with differences being related to staff experience and beliefs, unit norms, parent's expectations and physical constraints within the unit. The staff were overtly supportive of breastfeeding, but the need to monitor and quantify milk intake may undermine breastfeeding. Furthermore, feeding breastfed infants during the mothers' absence was controversial and provoked debate. There is a need for clear guidelines and increased parental involvement in feeding decisions. Routine practices within the system may discourage mothers from initiating and persisting with breastfeeding. A change in unit culture is required to fully support the parent's feeding choices.

The Contribution of Infant, Maternal, and Family Conditions to Maternal Feeding Competencies

OBJECTIVE: Because little is known about the role of family problem-solving processes in the development of mothers' competencies in feeding a very low birth-weight (VLBW) infant, we explored the contribution made by the competence in negotiating displayed by a mother and family member as they jointly problem solve infant-care issues. The infant's neonatal biomedical condition, maternal depressive symptoms, and family poverty status may also contribute to feeding competencies. DESIGN: A sample of 41 mothers of VLBW infants from 2 longitudinal studies who were observed during feeding at 1 and 8 months infant postterm age, with a family member of their choosing, participated in a dyadic problem-solving exercise. We assessed maternal feeding competencies with the Parent-Child Early Relational Assessment (Clark, 1997) and dyadic negotiating competence using an observational scale from the Iowa Family Interaction Rating Scales (Melby & Conger, 2001). We classified infant condition through medical record audit. Maternal depressive symptoms were assessed with the Center for Epidemiologic Studies-Depression (CES-D) Scale (L. S. Radloff, 1977), and family poverty status was determined through the mother's report of family income. RESULTS: Mothers' feeding competencies, structured into 2 factors, Parental Positive Affective Involvement, Sensitivity, and Responsiveness (PPAISR) and Parental Negative Affect and Behavior (PNAB, scored in the direction of low negativity) were stable from 1 to 8 months, accounting for the entire set of predictor variables. Neonatal biomedical condition had no effect on either PPAISR or PNAB; depressive symptoms were negatively associated with PNAB at 8 months; poverty status negatively predicted both PPAISR and PNAB at 1 and 8 months; and negotiating competence of the mother-family member dyad was positively associated with PNAB at 1 month. CONCLUSIONS: Evidence that family poverty status and dyadic negotiating competence were both associated with maternal feeding competencies supports inclusion of these family-level variables in a model of feeding competencies. A mother's negotiating competence with another family member who takes a responsible role in infant care may support maternal feeding competencies during a VLBW infant's early weeks when parenting patterns are forming.

Human-milk feeding after NICU discharge

PURPOSE

Difficulty with breastfeeding is common, and challenges are particularly pronounced for mothers of ill or preterm infants. This study explores the breastfeeding experiences of mothers of these at-risk infants to determine their breastfeeding patterns and to better understand reasons they prematurely stop breastfeeding and/or human-milk feeding (HMF).

DESIGN

A qualitative, longitudinal, descriptive design was used.

SAMPLE

The sample consisted of 144 mothers whose preterm or ill infants were cared for in either an NICU or an intermediate care nursery in a large central Canadian city; 112 mothers completed data collection to six weeks after their infants were discharged from the hospital.

MAIN OUTCOME VARIABLE

The main outcome variable was continued breastfeeding or HMF of formerly ill or preterm infants at one and six weeks after their discharge from the hospital.

RESULTS

Of infants who were being fed mother's milk when discharged from the hospital, 71 percent continued to receive at least some mother's milk at six weeks after discharge. Mothers reported that their own physical and emotional problems, infant health concerns, and lack of time and support were reasons for discontinuing provision of human milk.

Discharge teaching in the NICU: are parents prepared? An integrative review of parents' perceptions

BACKGROUND

At the end of their infant's NICU stay, parents are expected to assume full responsibility for their infant's care. It is important to look at discharge practices from the parents' points of view to see whether our strategies are effective.

OBJECTIVES

Review the literature for studies that give insight into parents' perceptions of the discharge process in order to assist health care providers in evaluating the available research and to identify any gaps in the literature.

METHOD

A literature search was performed to identify published studies that discuss parental perceptions related to their preparedness for their infant's discharge home from the NICU.

RESULTS

Data from the parents' perspective were lacking. There are limitations in the data that are available. Parents are not prepared for discharge and have unanswered questions. Parental perceptions are different from health care professionals' perceptions.

DISCUSSION

The studies that have been done need to be repeated in different centers, with greater sample sizes, and with subjects of different cultures, ethnicities, and socioeconomic status. There is a need for more research into parental perceptions of preparedness for their infant's discharge and ways to increase parental preparedness for discharge home from the NICU.

Using evidence to improve care for the vulnerable neonatal population

The facilitation of evidence-based practice (EBP) in the clinical setting is important to ensure patients receive the best care possible. This article highlights changes in open visitation and feeding readiness practices that occurred in a Magnet-designated facility neonatal ICU. The examples demonstrate ways to bring evidence to the bedside within an environment that supports EBP at all levels of nursing leadership.

Assessing the feasibility and acceptability of an intervention to reduce anxiety and enhance sensitivity among mothers of very low birth-weight infants

PURPOSE

A pilot study was conducted to assess the feasibility and acceptability of an intervention program for mothers of very low birth-weight infants in the neonatal intensive care unit (NICU).

SUBJECTS

Thirty-three mothers of infants born weighing less than 1500 g.

DESIGN

A single-group, pretest-posttest design was used.

METHODS

Preintervention mothers completed self-report questionnaires and their interaction with their infant was observed. Mothers then received the intervention program. Mothers were assessed twice postintervention, first when the infant was 1/2 months old and again at 6 months. At the postintervention assessments, mothers completed the same questionnaires and interaction was observed.

MAIN OUTCOME MEASURES

Mothers completed the State-Trait Anxiety Inventory, the revised Parental Stress Scale: Neonatal Intensive Care Unit, the NICU Parental Beliefs Scale, and the Perinatal PTSD Questionnaire. Interactions between mothers and infants were rated by trained research staff using the Index of Parental Behaviour in the NICU. Postintervention mothers also responded to a questionnaire that assessed their perceptions of the intervention program.

RESULTS

It was feasible to enroll mothers because 62% of eligible mothers agreed to participate. However, 39% of mothers who enrolled withdrew. Most of the mothers who withdrew did so before even beginning the intervention, and many of these women were mothers of multiples. It was also feasible to provide the intervention because more than 80% of mothers who began the intervention received all 6 teaching sessions. Mothers found both the content and the format of the program to be acceptable. There were nonetheless several challenges in conducting an intervention study with mothers early in the NICU hospitalization.

CONCLUSIONS

The results of this pilot study are encouraging. It was found to be both feasible and acceptable to provide the intervention program to mothers during the NICU hospitalization. The effectiveness of this program needs to be assessed in a randomized controlled trial.