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

Early Intervention for Preterm Infants and Their Mothers: A Systematic Review

This systematic review evaluates the efficacy of various early interventions on maternal emotional outcomes, mother-infant interaction, and subsequent infant outcomes during neonatal intensive care unit admission and postdischarge. Key interventions associated with outcomes in both the neonatal intensive care unit and postdischarge (ie, home) settings are summarized. A comprehensive search of peer-reviewed randomized controlled trials involving early interventions for infants and their mother published between 1993 and 2013 in the electronic databases PubMed, CINAHL, EMBASE, PsychINFO, and Cochrane was undertaken. Methodological quality was assessed using the PEDro scale to evaluate internal and external validity of the study. Twelve randomized controlled trials were included in the review, and all used some form of parenting education. The interventions had limited effects on maternal stress and mother-infant interaction and positive effects on maternal anxiety, depressive symptoms, and maternal coping. There were positive effects on infants' short-term outcomes for length of stay and breast-feeding rate. Positive and clinically meaningful effects of early interventions were seen in some physiological/psychological outcomes of mothers and preterm infants. It is important for nurses to foster close mother-infant contact and increase maternal competence during and after the infant's hospitalization period.

Posttraumatic Stress in Mothers While Their Preterm Infants Are in the Newborn Intensive Care Unit: A Mixed Research Synthesis

In this mixed research synthesis on posttraumatic stress in mothers related to their preterm infants' stay in the newborn intensive care unit (NICU), we synthesized and integrated a total of 37 studies, 25 of which were quantitative and 12 were qualitative studies. The prevalence rates of NICU mothers with elevated posttraumatic stress symptoms ranged from 18% in the United States to 81% in Turkey. Nine of the 12 studies testing interventions to decrease mothers' stress related to their NICU experiences reported significant results. Content analysis of the qualitative studies' findings revealed 5 themes: stark contrast to images of joyous motherhood, cultural overlay, issues of ownership and control, support, and learning to be a NICU mother.

Trauma-informed care in the newborn intensive care unit: promoting safety, security and connectedness

Both babies and their parents may experience a stay in the newborn intensive care unit (NICU) as a traumatic or a 'toxic stress,' which can lead to dysregulation of the hypothalamic-pituitary-adrenal axis and ultimately to poorly controlled cortisol secretion. Toxic stresses in childhood or adverse childhood experiences (ACEs) are strongly linked to poor health outcomes across the lifespan and trauma-informed care is an approach to caregiving based on the recognition of this relationship. Practitioners of trauma-informed care seek to understand clients' or patients' behaviors in light of previous traumas they have experienced, including ACEs. Practitioners also provide supportive care that enhances the client's or patient's feelings of safety and security, to prevent their re-traumatization in a current situation that may potentially overwhelm their coping skills. This review will apply the principles of trauma-informed care, within the framework of the Polyvagal Theory as described by Porges, to care for the NICU baby, the baby's family and their professional caregivers, emphasizing the importance of social connectedness among all. The Polyvagal Theory explains how one's unconscious awareness of safety, danger or life threat (neuroception) is linked through the autonomic nervous system to their behavioral responses. A phylogenetic hierarchy of behaviors evolved over time, leveraging the mammalian ventral or 'smart' vagal nucleus into a repertoire of responses promoting mother-baby co-regulation and the sense of safety and security that supports health and well-being for both members of the dyad. Fostering social connectedness that is mutual and reciprocal among parents, their baby and the NICU staff creates a critical buffer to mitigate stress and improve outcomes of both baby and parents. Using techniques of trauma-informed care, as explained by the Polyvagal Theory, with both babies and their parents in the NICU setting will help to cement a secure relationship between the parent-infant dyad, redirecting the developmental trajectory toward long-term health and well-being of the baby and all family members.

EXCLUSIVE BREASTFEEDING AND MATERNAL SELF-EFFICACY AMONG WOMEN OF INTIMATE PARTNER VIOLENCE SITUATIONS

ABSTRACT This study aims to evaluate the practice of breastfeeding among women in intimate partner violence situation during the current pregnancy for the duration of exclusive breastfeeding, the level of self-efficacy in breastfeeding, related factors from the beginning, the establishment of breastfeeding and early weaning. Cross-sectional study. 63 women in intimate partner violence situation in the current pregnancy participated, identified by survey in antenatal service. Data collection was performed in the prenatal and postpartum period. We used a questionnaire to identify the intimate partner violence, the Breastfeeding Self-Efficacy Scale and medical record information. The average days of exclusive breastfeeding was 19.08. There was no statistically significant association between the duration of exclusive breastfeeding at 30 and 70 days postpartum and intimate partner violence and care practices with level of self-efficacy to breastfeed. We found association between the type of breastfeeding at 30 and 70 days postpartum and better conditions vital of newborns with level of self-efficacy to breastfeed.

Developing family-centred care in a neonatal intensive care unit: an action research study protocol

AIM

The aim of this study was to develop, implement and evaluate evidence-based family-centred interventions and to promote parental involvement in the care of infants in neonatal intensive care.

BACKGROUND

Parental involvement in the care of their infants in Neonatal Intensive Care Units leads to improved neonatal outcomes. Although research identifies the benefits of individual interventions to promote family-centred care, little is known about how they might be implemented in everyday practice.

DESIGN

Participatory action research.

METHODS

Funding commenced in January 2015. The study comprises three phases: (i) Exploration: Baseline measures of staff and parental satisfaction with care and parental stress will be obtained using validated survey instruments. Baseline infant data includes breast feeding and skin-to-skin contact. Staff focus groups and interviews will provide insight into the context of parental involvement and perceived barriers to change. Parent focus groups and diaries will provide insight into factors influencing parental involvement in care. The data will inform the development of the evidence-based intervention; (ii)

INTERVENTION

Three action research cycles and ongoing data collection from parents and staff will inform the further development of the intervention and change process; (iii)

EVALUATION

Baseline measures will be repeated to identify changes. Focus groups and interviews with staff and parents will provide insight into their perceptions of the success of the initiative in promoting family-centred care.

DISCUSSION

This study will contribute new knowledge about approaches to actively involve parents in the care of their infant on neonatal intensive care units. Greater understanding of the impact of family-centre care on staff and parents will be gained with the potential to inform future policy and practice.

The role of peer support in the development of maternal identity for "NICU Moms"

OBJECTIVE

To examine first-time neonatal intensive care unit (NICU) mothers' perceptions of the initial effect and stress of their birth experiences and hospitalizations of their infants and what facilitated or hindered the development of their maternal roles within the context of the NICU.

DESIGN

A qualitative descriptive design.

SETTING

A 57-bed, tertiary NICU in Chicago.

PARTICIPANTS

Twenty-three mothers of very low birth weight (VLBW) infants hospitalized in the NICU.

METHODS

Participants were a subset of a larger longitudinal mixed-method study of psychological distress in 69 mothers of VLBW infants. Mothers were interviewed using an adaptation of the Clinical Interview for Parents of High-Risk Infants (CLIP) approximately 6 weeks after the births of their infants. Data were analyzed using conventional content analysis.

RESULTS

Mothers characterized the infants' births and hospitalizations as a time of overwhelming change culminating in a new perspective on life. Primary themes were loss, stress and anxiety, adapting, resilience, peer support, and "I'm a NICU Mom." Mothers rated peer support as the most facilitative and supportive aspect of developing the maternal role in the NICU.

CONCLUSION

Peer support and role modeling by NICU-based breastfeeding peer counselors helped the mothers throughout every stage of their infants' hospitalizations, from giving them hope, to helping them begin to develop maternal identity, to providing anticipatory guidance about taking their infants home. Talking points are provided for nurses who work in NICUs without dedicated peer support to help mothers establish a healthy mother/infant relationship.

Maternal attention and preterm infant feeding

PURPOSE

The purpose of this study was to explore the relationships among the mother's internal working model of feeding, attentional process, feeding behaviors, and responsiveness accounting for maternal psychological distress, which may contribute to preterm infants' feeding difficulties.

DESIGN AND METHODS

In this descriptive study, 21 mother-preterm infant dyads were videotaped during feeding.

RESULTS

Surprisingly, the internal working model of feeding was a significant negative predictor of maternal feeding behaviors and maternal attention. All other correlations were non-significant.

CONCLUSIONS

Given the early timing of the data collection, it is possible that mothers had not developed a frame of reference of their infant as a person. Research to help further understand factors and timing affecting maternal feeding behaviors is needed.

Mother-infant interaction improves with a developmental intervention for mother-preterm infant dyads

While premature infants have a high need for positive interactions, both infants and their mothers are challenged by the infant's biological immaturity. This randomized clinical trial of 198 premature infants born at 29-34 weeks gestation and their mothers examined the impact of the H-HOPE (Hospital to Home: Optimizing the Infant's Environment) intervention on mother-premature infant interaction patterns at 6-weeks corrected age (CA). Mothers had at least 2 social environmental risk factors such as minority status or less than high school education. Mother-infant dyads were randomly assigned to the H-HOPE intervention group or an attention control group. H-HOPE is an integrated intervention that included (1) twice-daily infant stimulation using the ATVV (auditory, tactile, visual, and vestibular-rocking stimulation) and (2) four maternal participatory guidance sessions plus two telephone calls by a nurse-community advocate team. Mother-infant interaction was assessed at 6-weeks CA using the Nursing Child Assessment Satellite Training-Feeding Scale (NCAST, 76 items) and the Dyadic Mutuality Code (DMC, 6-item contingency scale during a 5-min play session). NCAST and DMC scores for the Control and H-HOPE groups were compared using t-tests, chi-square tests and multivariable analysis. Compared with the Control group (n = 76), the H-HOPE group (n = 66) had higher overall NCAST scores and higher maternal Social-Emotional Growth Fostering Subscale scores. The H-HOPE group also had significantly higher scores for the overall infant subscale and the Infant Clarity of Cues Subscale (p < 0.05). H-HOPE dyads were also more likely to have high responsiveness during play as measured by the DMC (67.6% versus 58.1% of controls). After adjustment for significant maternal and infant characteristics, H-HOPE dyads had marginally higher scores during feeding on overall mother-infant interaction (β = 2.03, p = 0.06) and significantly higher scores on the infant subscale (β = 0.75, p = 0.05) when compared to controls. In the adjusted analysis, H-HOPE dyads had increased odds of high versus low mutual responsiveness during play (OR = 2.37, 95% CI = 0.97, 5.80). Intervening with both mother and infant is a promising approach to help premature infants achieve the social interaction patterns essential for optimal development.

Acupuncture for anxiety in lactating mothers with preterm infants: a randomized controlled trial

The purpose of this study was to evaluate the effect of acupuncture versus placebo acupuncture on anxiety in lactating mothers with preterm infants. A parallel, randomized, patient-assessor blind, placebo-controlled trial was conducted in a tertiary school hospital in Londrina, Brazil, between 2011 and 2012. Mothers (n = 29) with very low birth weight infants born at this institution were randomly assigned to two treatment groups: acupuncture, AG (n = 14), or placebo acupuncture, PG (n = 15). Treatment sessions occurred once a week, using 5 Chinese auricular points unilaterally. The primary outcome measure was STAI-State scores, and secondary outcome measure was salivary cortisol levels. Both measures were collected before and after treatment and submitted to a blind assessor. Before-after treatment mean difference in STAI-State scores was observed in both groups (AG = 8.71 and PG = 8.20), not statistically significant (P = 0.888), although within group analysis was significant for both groups (P < 0.005). Salivary cortisol levels did not change after treatment in both groups (P = 0.480). There was no correlation between STAI and salivary cortisol results. At infant's hospital discharge, 76% subjects were breastfeeding exclusively. There was no difference between real and placebo acupuncture for anxiety in mothers with preterm infants.

Early educational and behavioral RCT interventions to reduce maternal symptoms of psychological trauma following preterm birth: a systematic review

Early behavioral and educational interventions have been developed to reduce maternal symptoms of psychological trauma (depression, anxiety, parenting stress, acute stress disorder, and posttraumatic stress disorder) following preterm birth (PTB). Aims of this systematic review were to critically assess study methodology and provide a synthesis of existing randomized control trial (RCT) interventions and to estimate effects of the interventions in reducing the maternal symptoms across studies. Four electronic databases were systematically searched to locate relevant RCTs using preestablished eligibility criteria. Data from 8 qualifying RCTs were synthesized. Two reviewers independently assessed study methodology using appraisal checklists. Considerable heterogeneity precluded calculation of pooled estimates. There is evidence that mothers of very preterm infants of low-birth-weight experience major depression for up to 12 months following PTB. Sound interventions implemented during and following infant hospitalization and grounded in coping and self-regulation had a small to moderate effect in reducing maternal depression and anxiety and parenting stress for up to 2 months and 12 months respectively. Clinicians can use existing evidence to help guide best practices. Future high-quality RCTs and meta-analysis require that researchers improve study methodology and include analysis of data on maternal hormonal stress and history of psychological symptoms including during the pregnancy.