Experiences of Parents Whose Newborns Undergo Hypothermia Treatment Following Perinatal Asphyxia

Uncertainties in the NICU: a scoping review to inform a tailored taxonomy

Our objective was to conduct a scoping review of the literature to inform a modified taxonomy of uncertainty in the NICU, for the purpose of better identifying and defining different experiences of uncertainty for parents and medical teams. We conducted a systematic literature search for studies examining an element of uncertainty in the NICU. Data extraction was guided by Han's taxonomy of uncertainty and a thematic analysis informed the modified taxonomy. We included 55 articles, leading to three major alterations of Han's taxonomy. We believe this modified taxonomy of uncertainty in the NICU provides a more nuanced understanding of the specific uncertainties faced in this context, leading to a better understanding of the different needs of families and medical teams. It also highlights the need for targeted strategies to further explore and manage these uncertainties.

A Pilot Randomized Control Trial of Holding During Hypothermia and Effects on Maternal and Infant Salivary Cortisol Levels

BACKGROUND

The lack of physical contact during therapeutic hypothermia (TH) is challenging for parents of newborns with hypoxic ischemic encephalopathy. Holding is often avoided due to concerns for effects on infant temperature and for dislodging equipment.

PURPOSE

We assessed the effect of holding during TH on maternal and infant salivary cortisol levels and on infant vital signs.

METHODS

Prospective crossover study with infants randomized to a 30-minute session of holding on day-2 versus day-3 of TH. "No-holding" occurred on the alternate day at the same time. Pre- and post-holding salivary cortisol levels were compared between holding and no-holding conditions. Vital signs were collected at 2-minute intervals. Data was analyzed using mixed-effects models.

RESULT

Thirty-four mothers and infants were recruited. The median gestational age was 39 weeks, 16 (94%) had moderate encephalopathy and all were on morphine during TH. Salivary cortisol levels decreased after holding for infants on day-2 ( P = .02) and mothers on day-2 and day-3 ( P = .01). Infants held on day-2, but not on day-3, had lower heart rates, respiratory rates, and mean arterial pressures. Temperature and oxygen saturations were stable on both days.

IMPLICATIONS FOR PRACTICE AND RESEARCH

We demonstrate positive effects of holding during TH as evidenced by lower salivary cortisol for both mother and infant and decreased heart rate, respiratory rate, and blood pressure for the infant on day-2. Further research is needed to replicate these results, to understand the lack of infant response on day-3 and to assess correlation with cumulative morphine exposure.

Communicating with Parents About Therapeutic Hypothermia and Hypoxic Ischemic Encephalopathy: Integrating a Palliative Care Approach into Practice

Parents of newborns with hypoxic ischemic encephalopathy (HIE) can face communication challenges in the neonatal intensive care unit. Both specialty palliative care and primary palliative care trained clinicians can assist parents as they navigate traumatic experiences and uncertain prognoses. Using evidence-based frameworks, the authors provide samples of how to communicate with parents and promote parent well-being across the care trajectory. The authors demonstrate how to involve parents in a shared decision-making process and give special consideration to the complexities of hospital discharge and the transition home. Sustained investment to guide the development of effective communication skills is crucial to support families of infants with HIE.

Parent-infant closeness and care practices during therapeutic hypothermia in Swedish neonatal intensive care units

OBJECTIVES

The aim of this study was to investigate care practices among Neonatal Intensive Care Units (NICU) providing Therapeutic hypothermia (TH), and more specific to investigate staff's experiences of parental participation, presence, and possibilities of being close with their infant during TH.

METHODS

A descriptive, qualitative, and quantitative study. All Swedish NICUs providing TH (n = 10) participated. Data were collected during January-April 2021 via a questionnaire followed by a semi-structured interview with the registered nurse and the neonatologist responsible for TH at each unit. Descriptive statistics were calculated, and a qualitative content analysis was performed.

RESULTS

All NICUs allowed parents unlimited stay with their infants and were keen to support parental presence, which was a prerequisite for promoting parent-infant closeness. Standardized routines regarding the infants' care space and course of action were described as time-efficient and staff-saving, which freed up time to focus on the families.

CONCLUSION

Standardized routines regarding the care space setup and the medical and caring approach, as well as the NICU environment and practices around the families, can promote or curb the possibilities of parent-infant closeness. Well-established care practices and good environmental conditions with flexibility regarding the family's needs are therefore required.

Remote Monitoring for Seizures During Therapeutic Hypothermia in Neonates With Hypoxic-Ischemic Encephalopathy

Importance

Neonates with hypoxic-ischemic encephalopathy (HIE) undergoing therapeutic hypothermia (TH) frequently experience seizures, which are associated with adverse outcomes. Efforts to rapidly identify seizures and reduce seizure burden may positively change neurologic and neurodevelopmental outcomes.

Objective

To describe the onset, treatment, and evolution of seizures in a large cohort of newborns with HIE during TH assisted by a telehealth model and remote neuromonitoring approach.

Design, Setting, and Participants

This was a prospective, observational, multicenter cohort study performed between July 2017 and December 2021 in 32 hospitals in Brazil. Participants were newborns with HIE meeting eligibility criteria and receiving TH. Data were analyzed from November 2022 to April 2023.

Exposure

Infants with HIE receiving TH were remotely monitored with 3-channel amplitude-integrated electroencephalography (aEEG) including raw tracing and video imaging, and bedside clinicians received assistance from trained neonatologists and neurologists.

Main Outcomes and Measures

Data on modified Sarnat examination, presence, timing and seizure type, aEEG background activity, sleep-wake cycling, and antiepileptic drugs used were collected. Descriptive statistical analysis was used with independent t test, χ2, Mann-Whitney test, and post hoc analyses applied for associations.

Results

A total of 872 cooled newborns were enrolled; the median (IQR) gestational age was 39 (38-40) weeks, 518 (59.4%) were male, and 59 (6.8%) were classified as having mild encephalopathy by modified Sarnat examination, 504 (57.8%) as moderate, and 180 (20.6%) as severe. Electrographic seizures were identified in 296 newborns (33.9%), being only electrographic in 213 (71.9%) and clinical followed by electroclinical uncoupling in 50 (16.9%). Early abnormal background activity had a significant association with seizures. Infants with flat trace had the highest rate of seizures (58 infants [68.2%]) and the greatest association with the incidence of seizures (odds ratio [OR], 12.90; 95% CI, 7.57-22.22) compared with continuous normal voltage. The absence of sleep-wake cycling was also associated with a higher occurrence of seizures (OR, 2.22; 95% CI, 1.67-2.96). Seizure onset was most frequent between 6 and 24 hours of life (181 infants [61.1%]); however, seizure occurred in 34 infants (11.5%) during rewarming. A single antiepileptic drug controlled seizures in 192 infants (64.9%). The first line antiepileptic drug was phenobarbital in 294 (99.3%).

Conclusions and Relevance

In this cohort study of newborns with HIE treated with TH, electrographic seizure activity occurred in 296 infants (33.9%) and was predominantly electrographic. Seizure control was obtained with a single antiepileptic drug in 192 infants (64.9%). These findings suggest neonatal neurocritical care can be delivered at remote limited resource hospitals due to innovations in technology and telehealth.

Psychiatric Symptoms, Posttraumatic Growth, and Life Satisfaction Among Parents of Seriously Ill Infants: A Prospective Case-Controlled Study

We evaluated psychiatric symptoms, posttraumatic growth, and life satisfaction among the parents (n = 34) of newborns (n = 17) requiring therapeutic hypothermia or urgent surgery (interest group). Our control group included 60 parents of healthy newborns (n = 30). The first surveys were completed soon after diagnosis or delivery and the follow-up surveys 1 year later (participation rate 88% in the interest group and 70% in the control group). General stress was common in both groups but was more prevalent in the interest group as were depressive symptoms, too. Anxiety was more common in the interest group, although it showed a decrease from the baseline in both groups. Life satisfaction had an inverse correlation with all measures of psychiatric symptoms, and it was lower in the interest group in the early stage, but similar at 12 months due to the slight decline in the control group. Mothers in the interest group had more anxiety and depressive symptoms than fathers in the early stage. Mothers had more traumatic distress than fathers at both time points. Half of the parents experienced substantial posttraumatic growth at 12 months. In conclusion, the serious illness of an infant substantially affects the well-being of the parents in the early stages of illness and one year after the illness.

The Postpartum Specific Anxiety Scale: Confirmatory factor analyses and relationships with birth experience

The Postpartum Specific Anxiety Scale [PSAS] was developed and validated as a research tool with a four-factor structure; with predictive validity corroborated in studies examining infant-feeding and maternal bonding outcomes. The PSAS has not been examined in relation to birth experiences. We aimed to confirm the PSAS four-factor structure and examine these domains of anxiety in relation to subjective and objective birth experiences. Postpartum mothers (≤ 12-months; N = 500) completed the PSAS alongside measures of subjective birth satisfaction and objective obstetric interventions/complications. Confirmatory factor analyses [CFA] tested eight models, theoretically derived from the preceding exploratory work. Structural equation modelling [SEM] tested associations between each PSAS factor and birth experience variables in the best-fitting model. An identical 51-item four-factor model fits the data well. SEM analyses revealed associations between lower perceptions of quality of intrapartum care and increased maternal competence and attachment anxieties, practical infant care anxieties, and infant safety and welfare anxieties. High subjective stress and negative emotional response to labour were associated with increased psychosocial adjustment to motherhood anxieties. Specific associations were found between neonatal care unit admission and practical infant care anxieties; and infant asphyxia and infant safety and welfare anxieties. Findings confirm construct and convergent validity of the four-factor PSAS and its use in measuring postpartum anxiety. Unique associations were also identified, indicating specific subjective and objective experiences occurring during birth may elicit a differential anxiety response, in that they are related to specific forms of postpartum anxiety which occur during the first postpartum year.

Supporting families in their child's journey with neonatal encephalopathy and therapeutic hypothermia

Neonates and families face challenges in hypothermic therapy, including trauma to parents, extreme emotions, and unfamiliarity with the medical system. Communication is an essential element to supporting parents while their children are in the NICU, and beyond, building the foundation for the ongoing relationship the family has with the medical system. Significant consideration needs to be given to the critical element of integrating the family into the care of a baby being treated with therapeutic hypothermia. Clinicians can promote healing of accumulated traumas of parents through ensuring parent's emotional safety, facilitating a trusting relationship, and promoting parent empowerment. Connecting parents with resources, especially peer support, is an essential part of a hospital stay. In this chapter, we explore best practices to support families during and after hypothermic therapy.

Nursing care in therapeutic hypothermia in neonates with hypoxic-ischaemic encephalopathy. Review of the literature

INTRODUCTION

Hypoxic-ischaemic encephalopathy is one of the main causes of neurological damage in the new-born. Therapeutic hypothermia is the current treatment to reduce mortality and disability in new-borns with this condition.

OBJECTIVE

To identify nursing care in new-borns with severe to moderate EHI, treated with active therapeutic hypothermia.

MATERIALS AND METHODS

A review of the scientific literature was carried out in different databases (PubMed, Lilacs, IBECS, Cinhal, OvidSP, Cuiden, Embase and Cochrane Plus) over the last five years. The documentary assessment was carried out by peers and the quality was evaluated using the CEBM and GRADE scales.

RESULTS

Of the 22 articles selected and reviewed, it is evident that therapeutic hypothermia is effective in reducing the mobility and mortality of neo-nates with hypoxic-ischaemic encephalopathy. Nursing care during hypothermia treatment focuses on four basic pillars: general care for stabilisation of the new-born, preparation of the material, administration of medical treatment in all its phases and emotional support of the family.

CONCLUSIONS

Therapeutic hypothermia is effective in reducing the sequelae and mortality of neonates with hypoxic-ischaemic encephalopathy. Nursing care is essential throughout the treatment, in the early detection of complications in the infant and psychological support for parents. It is essential for nurses to receive training in this care.

When all I wanted was to hold my baby-The experiences of parents of infants who received therapeutic hypothermia

AIM

The knowledge is limited about how parents experience the time when their infant is receiving therapeutic hypothermia (TH) after severe perinatal asphyxia. The aim of this study was to explore parents' experience of closeness and involvement in their infant's care while in the neonatal intensive care unit (NICU) with their newborn undergoing TH.

METHODS

Face-to-face, semi-structured interviews were conducted with parents (n = 11) whose infants (n = 8, aged 3-5 years at the time of the study) underwent TH at a level III Swedish NICU during 2013-2016. The interviews were analysed using qualitative content analysis.

RESULTS

All the parents shared the trauma of being both physically and psychologically separated from their infant. They all described a need for information and emotional support, and reported that the NICU staff had influenced the extent to which they as parents had been able to be near and actively participate in the care. Parents described the wish to be closer to their infant and to be more actively involved in their infant's care.

CONCLUSION

Strategies to enable parent-infant closeness and active guidance from staff might help alleviate the emotional stress of parents and promote their participation during TH.

Parental viewpoints and experiences of therapeutic hypothermia in a neonatal intensive care unit implemented with Family-Centred Care

AIMS AND OBJECTIVES

To explore parental experiences of therapeutic hypothermia (TH) in their newborn infant suffering from hypoxic ischaemic encephalopathy following perinatal asphyxia.

BACKGROUND

Since more than a decade, newborn infants are treated with TH following perinatal asphyxia to reduce mortality and disabilities and to improve neurological outcome. The infants' body temperature is lowered to 33.5°C for 72 hr, and the infant is usually cared for in an open incubator. The parents are not able to hold their infant skin to skin, which risks causing emotional reactions in parents and a loss of normal parent-infant bonding.

DESIGN

A qualitative descriptive design using semi-structured interviews.

METHODS

Up to 7 months after the event, interviews were conducted with 14 parents of seven infants who had received TH in a neonatal intensive care unit (NICU) in Sweden. The interviews were transcribed and analysed using framework approach. Findings were reported following the Standard for Reporting Qualitative Research (SRQR) checklist.

RESULTS

From the interviews, an overall theme was found: Transition through a life-altering time, and three categories: (a) trepidation about prognosis, (b) transitioning into parenthood supported by the caring philosophy of family-centred care (FCC) and (c) rewarming as a milestone.

CONCLUSIONS

Parental experiences of TH are based on the immediate emotions and stress of uncertainty of the infant's prognosis. The values of FCC in the NICU append a natural transitioning into parenthood by parental involvement in nursing care and decisions. The rewarming of the infant is seen as a restart to more or less normal circumstances from the critical period of delivery and TH.

RELEVANCE FOR CLINICAL PRACTICE

The management of NICUs should update the awareness of and deepen knowledge about FCC. The emphasis ought to be on adequate information about TH and the values of FCC to parents in the NICU context.

Nursing care in therapeutic hypothermia in neonates with hypoxic-ischaemic encephalopathy. Review of the literature

INTRODUCTION

Hypoxic-ischaemic encephalopathy is one of the main causes of neurological damage in the new-born. Therapeutic hypothermia is the current treatment to reduce mortality and disability in new-borns with this condition.

OBJECTIVE

To identify nursing care in new-borns with severe to moderate hypoxic-ischaemic encephalopathy, treated with active therapeutic hypothermia.

MATERIALS AND METHODS

A review of the scientific literature was carried out in different databases (PubMed, Lilacs, IBECS, Cinhal, OvidSP, Cuiden, Embase and Cochrane Plus) over the last five years. The documentary assessment was carried out by peers and the quality was evaluated using the CEBM and GRADE scales.

RESULTS

Of the 22 articles selected and reviewed, it is evident that therapeutic hypothermia is effective in reducing the mobility and mortality of neo-nates with hypoxic-ischaemic encephalopathy. Nursing care during hypothermia treatment focuses on four basic pillars: general care for stabilisation of the new-born, preparation of the material, administration of medical treatment in all its phases and emotional support of the family.

CONCLUSIONS

Therapeutic hypothermia is effective in reducing the sequelae and mortality of neonates with hypoxic-ischaemic encephalopathy. Nursing care is essential throughout the treatment, in the early detection of complications in the infant and psychological support for parents. It is essential for nurses to receive training in this care.

Maternal holding during therapeutic hypothermia for infants with neonatal encephalopathy is feasible

AIM

Concerns for infant destabilisation often prohibit parental holding of infants during therapeutic hypothermia (TH). We assessed the feasibility of maternal holding during TH, as the inability to hold can impede bonding.

METHODS

Vital signs were assessed in stable infants before, at two-minute intervals during and 30 minutes after a single 30-minute holding session. The infant remained on the blanket throughout holding, and both infant and blanket were placed into the mother's arms on top of a thin foam insulating barrier. Mothers and nurses were surveyed about their experience.

RESULTS

Ten infants undergoing TH for neonatal encephalopathy had no equipment malfunctions or dislodgement. The mean temperature was 33.4°C prior to and 33.5°C (p = 0.18) after holding. There was no significant bradycardia (heart rate <80 beats per minute), hypotension (mean arterial pressure <40 mm Hg) or oxygen desaturation (<93%). Nurses either strongly agreed (75%) or agreed (25%) with the statement 'After assisting with the holding protocol, I feel that holding during cooling is safe'. Mothers (100%) strongly agreed that other parents would benefit from holding.

CONCLUSION

In a small sample of ten stable infants treated with TH for neonatal encephalopathy, holding resulted in no adverse events and positive feedback from mothers and nurses.

Parental perceptions of neonatal therapeutic hypothermia; emotional and healing experiences

Introduction: Parents of infants who undergo therapeutic hypothermia experience emotional challenges that have not been fully characterized. Comprehensive understanding of the parental experience of hypothermia is needed to provide better care to the family of the infant. This study aimed to improve the understanding of the parental emotional experience of therapeutic hypothermia in the Neonatal Intensive Care Unit (NICU).Methods: Semistructured interviews were conducted in a group setting with parents matched into groups according to the severity of the infant's presenting encephalopathy. The interviews were transcribed and coded into principal and additional subthemes.Results: Families of 15 infants, who were between 2 months and 2 years at the time of the interview, participated. Infants had a mean gestational age of 40.0 weeks and 11 (73%) were male. Eleven (73%) were transferred from other hospitals following birth and eight (53%) had seizures. Emotional Experiences was a principal theme and included subthemes of traumatic experiences, Loss of normalcy, and Separation of parent and infant. The birth was frequently described as traumatic with descriptions of chest compressions, excessive blood loss and infants not crying. Trauma was also described in the parental observations of the shivering hypothermic infant. Parents highlighted the loss of normalcy in terms of their expected birth narrative and the loss of the early opportunity to breastfeed and hold their infant. Parents reported that the physical separation imposed by hypothermia adversely impacted their ability to bond with their infant. Healing Experiences was the other principal theme with subthemes identified as Incorporation of parents into NICU care, Reclaiming parenthood and Support from other hypothermia families. Parents reported feeling a connection to their infant when they were involved in medical rounds and when asked to participate in routine care of their infant. Occasionally, parents strongly advocated for their own participation in a particular aspect of their infant's care such as a diaper change and this was perceived as reinforcing their role as parent. Lastly, parents requested greater access to peer support from parents who had experienced therapeutic hypothermia.Conclusion: Parents of infants treated with hypothermia reported the experience of their unexpected adverse delivery and their baby subsequently being treated with therapeutic hypothermia as traumatic. This trauma can be compounded by the pale, still and shivering appearance of their newborn and the delay in bonding as a result of physical separation during hypothermia treatment. Parents described feeling connected to their infant in the context of performing routine care activities and desired greater access to peer support. The themes reported in this study could be used to inform high level NICU care and raise provider awareness of the parent experience.

Exploring parent expectations of neonatal therapeutic hypothermia

OBJECTIVE

We aimed to assess the parent experience of therapeutic hypothermia (TH), specifically focusing on unmet expectations.

STUDY DESIGN

Open-ended questions were used in a focus group setting. We employed an inductive approach to develop thematic content from the transcribed recordings.

RESULTS

30 parents of infants treated with TH participated. Within the principal theme of managing expectations, four sub-themes emerged. These included parental concerns about morphine use; specifically the association of morphine with end-of-life care and addiction. Parents perceived their role as key in the decision to implement TH and were emotionally burdened by this during and after TH. Parents recall intense fear for the infant's immediate survival and were not sufficiently reassured regarding survival. Parents also experience ongoing uncertainties about the long-term prognosis after TH.

CONCLUSION

The identification of these four areas in which parents have unmet expectations is important in order to improve the delivery of care.

Exploring Parent Experience of Communication About Therapeutic Hypothermia in the Neonatal Intensive Care Unit

BACKGROUND

The unique communication challenges faced by parents of infants undergoing therapeutic hypothermia have not been well characterized.

PURPOSE

To develop awareness of communication challenges experienced by families of infants treated with therapeutic hypothermia.

METHODS

Semistructured interviews were conducted in a group setting with parents matched into groups according to the severity of the infant's presenting encephalopathy. The interviews were transcribed and coded into principal and additional subthemes.

RESULTS

Thirty adults were interviewed including 15 mothers, 12 fathers, 2 grandmothers, and 1 grandfather. The 15 infants were between 2 and 24 months of age at the time of the interviews. The principal theme of communication included the following 3 subthemes; transparency, consistency, and delivery style. Parents reported a strong desire for improved early and transparent communication about therapeutic hypothermia, particularly during transfer from an outside hospital. Parents also reported a preference for consistent communication and highlighted parental touch of the hypothermic infant, obstetrical nurse-to-neonatal intensive care unit nurse communication, and parent and visitor presence in the infant's room as areas in need of greater communication consistency. Parents valued direct and compassionate communication styles that excluded medical jargon.

IMPLICATIONS FOR PRACTICE

All providers can implement recommendations for communication to parents of infants treated with therapeutic hypothermia by increasing transparency, developing greater consistency in the communication delivered, and employing a direct and compassionate style to improve the parental experience of therapeutic hypothermia.

IMPLICATIONS FOR RESEARCH

Further investigation is needed into the specific challenges parents face with a lack of transparent communication prior to the transfer of an infant for therapeutic hypothermia.

No question too small: development of a question prompt list for parents of critically ill infants

OBJECTIVE

To develop a question prompt list tailored to the needs of parents of critically ill infants at risk of neurodevelopmental impairment.

STUDY DESIGN

Question content was derived from audio-recorded neonatal intensive care unit family meetings and interviews with parents of infants treated with therapeutic hypothermia. Question content was refined using clinician focus groups. Acceptability testing was performed with parents and clinicians caring for infants in the neonatal intensive care unit.

RESULTS

All clinicians and parents found the QPL content acceptable. Parents universally endorsed that the question prompt list was useful to them and would help them prepare for a meeting with their infant's healthcare team.

CONCLUSION

This question prompt list, designed for parents of critically ill infants, is acceptable to parents and clinicians, and can be used in the acute neonatal course to facilitate parent engagement in family meetings.

Parental perceptions of hypothermia treatment for neonatal hypoxic-ischaemic encephalopathy

AIMS

Hypothermia Treatment (HT) is now the standard care for neonatal hypoxic-ischaemic encephalopathy (HIE). We conducted a survey to explore parental perceptions of HT as there is little information about this in the current literature.

METHODS

Postal questionnaire survey included families (n = 51) whose babies received HT at Princess Anne Hospital, Southampton, UK, with 23 questions covering communication, clinical management, follow-up, and care in general. Statistical analysis of descriptive and analytical tests were done using Minitab 16.

RESULTS

The response rate was 60.8%. All parents had concerns amongst which perceptions of pain and distress were described by 41%. Temporary concerns about bonding were common (83.8%), more so in babies transferred from other hospitals (p = .04). Only 61.3% felt they had a good understanding of HT. The need for improvements in the quality (71%) and frequency of communication (48.3%) were also highlighted.

CONCLUSIONS

Parents were worried about pain and distress, bonding and about outcomes after HT. Consistency in communication, regular updates, involvement of parents in decision making, strong support mechanisms and balanced discussions about long term outcomes at an early stage are of high importance to families whose babies undergo HT.

Survey of Neonatal Intensive Care Unit Nurse Attitudes Toward Therapeutic Hypothermia Treatment

BACKGROUND

The traumatic experiences of parents of babies treated with therapeutic hypothermia (TH) have been described. No research has assessed neonatal intensive care unit (NICU) nurse experience in providing care to hypothermic babies and emotional support to their parents.

PURPOSE

To assess NICU nurse attitudes to the provision of TH with respect to perceptions about baby pain/sedation, need for nurse and parent education, decision making about initiation of TH, and barriers to best care.

METHODS

A survey was electronically sent to 219 nurses at 2 affiliated academic level III NICUs: 1 rural and 1 urban location. There were 17 questions where responses were selected from a preset list and 7 opportunities for nurses to provide free text responses.

FINDINGS

The response rate was 38% (N = 83). Overwhelming similarities between the urban and rural institutions were found with NICU nurses expressing understanding of the indications for initiating TH, agreement that TH improves long-term outcomes and that the benefits of TH outweigh the risks. Nurses at the urban institution more frequently expressed concerns surrounding inadequate treatment of baby pain/sedation, and nurses at both institutions strongly emphasized the need for more nurse and parent education about TH and improved timeliness of decision making for initiation of TH.

IMPLICATIONS FOR PRACTICE

NICU nurses specifically want to learn more about outcomes of babies after treatment with TH and feel that parents need more education about TH.

IMPLICATIONS FOR RESEARCH

Research is urgently needed to better understand the implications of TH treatment for parent-baby bonding.

Parent Experience of Neonatal Encephalopathy

We aimed to characterize the parent experience of caring for an infant with neonatal encephalopathy. In this mixed-methods study, we performed semistructured interviews with parents whose infants were enrolled in an existing longitudinal cohort study of therapeutic hypothermia between 2011 and 2014. Thematic saturation was achieved after 20 interviews. Parent experience of caring for a child with neonatal encephalopathy was characterized by 3 principal themes. Theme 1: Many families described cumulative loss and grief throughout the perinatal crisis, critical neonatal course, and subsequent missed developmental milestones. Theme 2: Families experienced entangled infant and broader family interests. Theme 3: Parents evolved into and found meaning in their role as an advocate. These data offer insight into the lived experience of parenting an infant with neonatal encephalopathy. Primary data from parents can serve as a useful framework to guide the development and interpretation of parent-centered outcomes.

Impact of perinatal asphyxia on parental mental health and bonding with the infant: a questionnaire survey of Swiss parents

OBJECTIVE

To compare current mental health symptoms and infant bonding in parents whose infants survived perinatal asphyxia in the last 2 years with control parents and to investigate which sociodemographic, obstetric and neonatal variables correlated with parental mental health and infant bonding in the asphyxia group.

DESIGN

Cross-sectional questionnaire survey of parents whose children were registered in the Swiss national Asphyxia and Cooling register and of control parents (Post-traumatic Diagnostic Scale, Hospital Anxiety and Depression Scale, Mother-to-Infant Bonding Scale).

RESULTS

The response rate for the asphyxia group was 46.5%. Compared with controls, mothers and fathers in the asphyxia group had a higher frequency of post-traumatic stress disorder (PTSD) symptoms (p<0.001). More mothers (n=28, 56%) had a symptom diagnosis of either full or partial PTSD than controls (n=54, 39%) (p=0.032). Similarly, more fathers (n=31, 51%) had a symptom diagnosis of either partial or full PTSD than controls (n=19, 33%) (p=0.034). Mothers reported poorer bonding with the infant (p=0.043) than controls. Having a trauma in the past was linked to more psychological distress in mothers (r=0.31 (95% CI 0.04 to 0.54)) and fathers (r=0.35 (95% CI 0.05 to 0.59)). For mothers, previous pregnancy was linked to poorer bonding (r=0.41 (95% CI 0.13 to 0.63)). In fathers, therapeutic hypothermia of the infant was related to less frequent PTSD symptoms (r=-0.37 (95% CI -0.61 to -0.06)) and past psychological difficulties (r=0.37 (95% CI 0.07 to 0.60)) to more psychological distress. A lower Apgar score was linked to poorer bonding (r=-0.38 (95% CI -0.64 to -0.05)).

CONCLUSIONS

Parents of infants hospitalised for perinatal asphyxia are more at risk of developing PTSD than control parents.

Communication Challenges in Neonatal Encephalopathy

BACKGROUND

Families must process complex information related to neonatal encephalopathy and therapeutic hypothermia.

METHODS

In this mixed methods study, semi-structured interviews were performed with parents whose infants were enrolled in an existing longitudinal cohort study of therapeutic hypothermia between 2011 and 2014.

RESULTS

Thematic saturation was achieved after 20 interviews. Parental experience of communicating with clinicians was characterized by 3 principle themes. Theme 1 highlighted that a fragmented communication process mirrored the chaotic maternal and neonatal course. Parents often received key information about neonatal encephalopathy and therapeutic hypothermia from maternal clinicians. Infant medical information was often given to 1 family member (60%), who felt burdened by the responsibility to relay that information to others. Families universally valued the role of the bedside nurse, who was perceived as the primary source of communication for most (75%) families. Theme 2 encompassed the challenges of discussing the complex therapy of therapeutic hypothermia: families appreciated clinicians who used lay language and provided written material, and they often felt overwhelmed by technical information that made it hard to understand the "big picture" of their infant's medical course. Theme 3 involved the uncertain prognosis after neonatal encephalopathy. Parents appreciated specific expectations about their infant's long-term development, and experienced long-term distress about prognostic uncertainty.

CONCLUSIONS

Communicating complex and large volumes of information in the midst of perinatal crisis presents inherent challenges for both clinicians and families. We identified an actionable set of communication challenges that can be addressed with targeted interventions.

Ensuring Quality in the NICU: Translating Research Into Appropriate Clinical Care

Since the Institute of Medicine's landmark report To Err Is Human, extensive efforts to improve patient safety have been undertaken. However, wide-scale improvement has been limited, sporadic, and inconsistent. Implementation of evidence-based interventions remains a challenge, resulting in unwarranted variations in care. Three main categories of problems in healthcare delivery are defined as overuse, underuse, and misuse of medical services, resulting in inappropriate care, inefficiencies, and poor quality. Although broad acknowledgement that these categories of quality problems exist, there are limited standards for measuring their overall impact. This article aims to discuss the important role of implementation science in advancing evidence-based practice, using neonatal therapeutic hypothermia for the treatment of hypoxic-ischemic encephalopathy as an exemplar for examining appropriateness of care.

Maternal experiences of caring for an infant with neurological impairment after neonatal encephalopathy in Uganda: a qualitative study

PURPOSE

The study investigated maternal experiences of caring for a child affected by neurological impairment after neonatal encephalopathy (NE) ("birth asphyxia") in Uganda.

METHODS

Between September 2011 and October 2012 small group and one-on-one in-depths interviews were conducted with mothers recruited to the ABAaNA study examining outcomes from NE in Mulago hospital, Kampala. Data were analysed thematically with the aid of Nvivo 8 software.

FINDINGS

Mothers reported caring for an infant with impairment was often complicated by substantial social, emotional and financial difficulties and stigma. High levels of emotional distress, feelings of social isolation and fearfulness about the future were described. Maternal health-seeking ability was exacerbated by high transport costs, lack of paternal support and poor availability of rehabilitation and counselling services. Meeting and sharing experiences with similarly affected mothers was associated with more positive maternal caring experiences.

CONCLUSION

Mothering a child with neurological impairment after NE is emotionally, physically and financially challenging but this may be partly mitigated by good social support and opportunities to share caring experiences with similarly affected mothers. A facilitated, participatory, community-based approach to rehabilitation training may have important impacts on maximising participation and improving the quality of life of affected mothers and infants. Implications for Rehabilitation Caring for an infant with neurological impairment after NE in Uganda has substantial emotional, social and financial impacts on families and is associated with high levels of emotional stress, feelings of isolation and stigma amongst mothers. Improved social support and the opportunity to share experiences with other similarly affected mothers are associated with a more positive maternal caring experience. High transport costs, lack of paternal support and poor availability of counselling and support services were barriers to maternal healthcare seeking. Studies examining the feasibility, acceptability and impact of early intervention programmes are warranted to maximise participation and improve the quality of life for affected mothers and their infants.

Sleep-wake cycling in a neonate admitted to the NICU: a video-EEG case study during hypothermia treatment

This retrospective case study describes the sleep-wake cycles of an infant in the neonatal intensive care unit. We analyzed video-electroencephalographic recording of the term infant monitored during treatment with therapeutic hypothermia for hypoxic-ischemic encephalopathy. The continuous video-electroencephalographic recording over a 4-day period also allowed us to describe the following dimensions of daily care in relation to the infant's sleep-wake states: (1) handling by professional and parent caregivers and (2) stress, pain, and analgesia. Physical contact constituted 17% to 36% of each 24-hour period. The infant's care was fragmented, with a mean of 3 to 4 physical contacts per hour. As a result, the structure of infant sleep was altered by the increased amount of awake and quiet sleep. The number of painful procedures ranged from 5 to 24 per day. Nurses were the main care providers. Parents had more contact after the infant was rewarmed. This case study suggests that neonatal intensive care unit infants are exposed to frequent handling and stress as well as altered sleep. The cumulative negative impact of frequent handling and sleep fragmentation may go unnoticed by caregivers focused on episodes of care. Continuous video-electroencephalographic monitoring is a useful tool for longitudinal evaluation of infant sleep and responses to caregiving in the neonatal intensive care unit.

Becoming a parent to a child with birth asphyxia-From a traumatic delivery to living with the experience at home

The aim of this study is to describe the experiences of becoming a parent to a child with birth asphyxia treated with hypothermia in the neonatal intensive care unit (NICU). In line with the medical advances, the survival of critically ill infants with increased risk of morbidity is increasing. Children who survive birth asphyxia are at a higher risk of functional impairments, cerebral palsy (CP), or impaired vision and hearing. Since 2006, hypothermia treatment following birth asphyxia is used in many of the Swedish neonatal units to reduce the risk of brain injury. To date, research on the experience of parenthood of the child with birth asphyxia is sparse. To improve today's neonatal care delivery, health-care providers need to better understand the experiences of becoming a parent to a child with birth asphyxia. A total of 26 parents of 16 children with birth asphyxia treated with hypothermia in a Swedish NICU were interviewed. The transcribed interview texts were analysed according to a qualitative latent content analysis. We found that the experience of becoming a parent to a child with birth asphyxia treated with hypothermia at the NICU was a strenuous journey of overriding an emotional rollercoaster, that is, from being thrown into a chaotic situation which started with a traumatic delivery to later processing the difficult situation of believing the child might not survive or was to be seriously affected by the asphyxia. The prolonged parent-infant separation due to the hypothermia treatment and parents' fear of touching the infant because of the high-tech equipment seemed to hamper the parent-infant bonding. The adaption of the everyday life at home seemed to be facilitated by the follow-up information of the doctor after discharge. The results of this study underline the importance of family-centered support during and also after the NICU discharge.