Improving child and family outcomes following complicated births requiring admission to neonatal intensive care units

This paper reviews current research regarding the impact of birth complications, such as preterm labour, on parents and the nuclear family system. Specifically, how parents cope with the neonatal intensive care unit (NICU) experience and the associated decision-making tasks required during complicated births will be investigated. Consequences of poor adaptation to prematurity for the parent, family and infant relationships will also be discussed. The importance of informed decision-making, perceived control, self-esteem and the benefits of certain strategies, such as kangaroo care (skin-to-skin contact), in the facilitation of greater levels of attachment and improved relationships, will be highlighted. The paper concludes with suggestions for future research areas to focus on finding better ways to prepare and support parents in these situations, thus improving the quality of relationships between parents and with their child.

Maternal and neonatal influences on, and reproducibility of, neonatal aortic pulse wave velocity

Aortic pulse wave velocity (aPWV), a noninvasive measure of vascular stiffness, is an independent predictor of cardiovascular disease both before and in overt vascular disease. Its characteristics in early life and its relationship to maternal factors have hardly been studied. To test the hypothesis that infant aPWV was positively related to maternal anthropometry and blood pressure (BP) at 28 weeks gestation, after adjusting for neonatal anthropometry and BP, 148 babies born in Manchester were measured 1 to 3 days after birth. A high reproducibility of aPWV, assessed in 30 babies within 3 days of birth, was found with a mean difference between occasions of –0.04 m/s (95% CI: –0.08 to 0.16 m/s). Contrary to our hypothesis, a significant inverse relation was found between neonatal aPWV (mean: 4.6 m/s) and maternal systolic BP (mean: 108.9 mm Hg; r=–0.57; 95% CI: –0.67 to –0.45) but not maternal height nor weight. Neonatal aPWV was positively correlated with birth length, birth weight, and systolic BP. In multiple regression, neonatal aPWV remained significantly inversely associated with maternal systolic BP (adjusted ß coefficient: –0.032; 95% CI: –0.040 to –0.024; P<0.001), after adjustment for maternal age, birth weight, length, and neonatal BP (all independently and positively related to aPWV) and for gestational age, maternal weight, and height (unrelated). These results suggest that infant aPWV may be a useful index of infant vascular status, is less disturbing to measure than infant BP, and is sensitive to the gestational environment marked by maternal BP.

Parenting a preterm infant: experiences in a regional neonatal health services programme

In an Australian regional health service, parents’ experiences of the neonatal intensive care (NICU), neonatal nurseries and a community discharge programme were investigated. Parents from 12 families participated in an in-depth interview. Three themes captured a partial, yet significant, view of these parents’ experiences as they strived to develop their identity and competence as parents. The findings are explored as they reveal issues associated with the provision of family centred, developmental care in neonatal services. Opportunities for nurses in this context to expand and clarify their role in ways that are responsive to parenting needs are discussed.

Support needs of parents of sick and/or preterm infants admitted to a neonatal unit

Background: The sudden unexpected delivery of a preterm infant is a shock to parents with studies confirming the importance of providing them with nursing support. The purpose of this descriptive study was to identify the type and level of support that nurses provided to the parents of sick and/or preterm infants. It also investigated whether parents were satisfied with the support provided by nursing staff.
Method: A convenience sample of 112 parents in an Australian tertiary neonatal unit were invited to complete the ‘Nurse Parent Support Tool’ (NPST), which is a 21-item questionnaire. The NPST consists of four domains: emotional, informational, appraisal and instrumental support. A second tool was used to assess parents’ satisfaction with the nurse to parent support.
Results: Instrumental support had the highest mean score for both nurse to parent support at 4.51 (out of 5) and 4.36 (out of 5) for satisfaction. The mean score for nursing support was 4.21 followed by parental satisfaction with nurse to parent support which was 4.16. In contrast, emotional support had the lowest mean score for both nurse to parent support at 3.94 and 3.97 for satisfaction. Parents indicated that they needed further support with lactation, breastfeeding and assistance with parenting skills.
Conclusion: Overall, the results from the study indicated that parents’ perception of nursing support was positive and that parents were highly satisfied with the nursing support provided in the neonatal unit. However, some attention needs to be given to providing more support and information on breastfeeding and parenting skills.

Support needs of parents of sick and/or preterm infants admitted to a neonatal unit

The sudden unexpected delivery of a preterm infant elicits many emotional responses from parents, with studies confirming the importance of providing parents with nursing support. The purpose of this study was to measure parents' perception of the type and level of support that nurses provided in an Australian neonatal unit, and to determine the extent to which parents were satisfied with the support currently provided. A convenience sample of 112 parents in an Australian tertiary neonatal unit were invited to complete the nurse parent support tool (NPST), which is a 21-item questionnaire used to measure the level of nursing support. The NPST consists of four domains -emotional, informational, appraisal and instrumental support. A second tool was used to assess parent satisfaction with nurse-to-parent support. A total of 62 parents completed the NPST and satisfaction tool.

Results showed that instrumental support had the highest mean score for both nurse-to-parent support 4.51 (out of 5) and 4.36 for satisfaction. The mean score for nursing support was 4.21 followed by satisfaction with nurse-to-parent support at 4.16. In contrast, emotional support had the lowest mean score for both nurse-to-parent support at 3.94 and 3.97 for satisfaction. Parents indicated that they needed further support with lactation, breastfeeding and assistance with parenting skills. Overall, results indicated that parent perception of nursing support was positive and that parents were highly satisfied with the nursing support provided in the neonatal unit. However, some attention needs to be given to providing more support and information on breastfeeding and parenting skills.

Angiotensin II receptor imbalance associated with neonatal cardiac growth restriction is a prelude to adult cardiac hypertrophy

The Hypertrophic Heart Rat (HHR) displays spontaneous cardiomyocyte hypertrophy in association with an apparent reduction in myocyte number in adulthood. This suggests the possibility of reduced hyperplasia or increased apoptosis during early cardiac development. The angiotensin AT1 and AT2 receptor subtypes have been implicated in both cellular growth and apoptosis, but the precise mechanisms are unclear. The aim of this study was to determine the relationship between cardiac AngII receptor expression levels and neonatal cardiomyocyte growth and apoptotic responses in the HHR compared with the Normal Heart Rat (NHR) control strain. Cardiac tissues were freshly harvested from male HHR and NHR at several developmental stages (p2 and 4, 6, 8, 12wks). HHR cardiac weight indices were considerably smaller than NHR at day 2 (4.330.19 vs 5.010.08 mg/g), but ‘caught-up’ to NHR by 4 weeks (5.100.15 vs 5.160.11 mg/g). By 12 weeks, HHR hearts were 27% larger than NHR. Tissue AT1A and AT2 mRNA expression levels were quantified by real-time RT-PCR. Relative to NHR, HHR neonatal hearts exhibited a 4.6-fold higher AT2/AT1 mRNA expression ratio. Cultured neonatal cardiomyocytes were infected with AT1A and/or AT2 receptor-expressing adenoviruses to achieve a physiological level of receptor expression (150 fmol receptor protein/mg total cell protein). In addition, to emulate receptor expression in neonatal HHR hearts, cells were co-infected with AT1A and AT2 receptors at a 4:1 ratio. Apoptosis incidence was studied by morphological analysis after 72 hours exposure to 0.1 M AngII. When infected with the AT1A receptor alone, a higher proportion of HHR myocytes appeared apoptotic than NHR (22.7 4.1% vs 1.1 0.6%, P 0.001). This implies that intrinsic differences predispose HHR cells to accentuated AT1-mediated apoptosis. Interestingly, the bax-1/bcl-2 mRNA expression ratio was significantly higher (50%) in HHR neonatal hearts. When cells were co-infected with AT1A and AT2 receptors, evidence of apoptosis in HHR cells virtually disappeared (0.4 0.1%). These findings suggest a novel capacity of AT2 receptors to counteract accentuated AT1A receptor-induced apoptosis in the HHR in early cardiac growth.

Neonatal growth outcomes at birth and one month postpartum following in utero exposure to antidepressant medication

Objective: There is evidence of increasing prescription of antidepressant medication in pregnant women. This has arisen from the recognition of the importance of treating maternal depression. This must be balanced, however, with information on outcomes for infants and children exposed to antidepressants in pregnancy. The aim of the present study was to examine whether neonatal outcomes including gestational age at birth, neonatal growth outcomes at birth and then at 1 month postpartum were altered by in utero exposure to antidepressant medication using a prospective and controlled design.

Method: A prospective case–control study recruited 27 pregnant women taking antidepressant medication and 27 matched controls who were not taking antidepressant medication in pregnancy at an obstetric hospital in Melbourne, Australia. Of the 27 women taking medication, 25 remained on medication in the third trimester. A purpose-designed self-report questionnaire and the Beck Depression Inventory-II were completed in pregnancy, after birth and at one month postpartum. In addition information was collected on exposed and non-exposed infants including Apgar scores, birthweight/length/head circumference and gestational age at birth. Weight/length/head circumference was again collected at 1 month of age.

Results: Infants exposed to antidepressants in utero were eightfold more likely to be born at a premature gestational age, had significantly lower birthweight and were smaller in length and head circumference than non-exposed infants. There was no association between birth outcomes and maternal depression. At 1 month, the difference in weight in the exposed group became significantly greater than the control group.

Conclusion: Antidepressant exposure in utero may affect gestational age at birth and neonatal outcomes independently of antenatal maternal depression. Further studies are needed to examine whether these findings vary according to the type of antidepressant prescribed and follow up growth and development in exposed infants beyond 1 month.

Contribution of stretch to the change of activation properties of muscle fibers in the diaphragm at the transition from fetal to neonatal life

The transition from fetal to postnatal life involves clearance of liquid from the lung and airways, and rapid formation of a functional residual capacity. Despite the importance of the diaphragm in this process, the impact of birth on the mechanical and functional activity of its muscle fibers is not known. This study determined the contractile characteristics of individual “skinned” diaphragm fibers from 70 days (0.47) gestation to after birth in sheep. Based on differential sensitivity to the divalent ions calcium (Ca²⁺) and strontium (Sr²⁺), all fibers in the fetal diaphragm were classified as “fast,” whereas fibers from the adult sheep diaphragm exhibited a “hybrid” phenotype where both “fast” and “slow” characteristics were present within each single fiber. Transition to the hybrid phenotype occurred at birth, was evident after only 40 min of spontaneous breathing, and could be induced by simple mechanical stretch of diaphragm fibers from near-term fetuses (∼147 days gestation). Both physical stretch of isolated fibers, and mechanical ventilation of the fetal diaphragm in situ, significantly increased sensitivity to Ca²⁺ and Sr²⁺, maximum force generating capacity, and decreased passive tension in near-term and preterm fetuses; however, only fibers from near-term fetuses showed a complete transition to a “hybrid” activation profile. These findings suggest that stretch associated with the transition from a liquid to air-filled lung at birth induces physical changes of proteins determining the activation and elastic properties of the diaphragm. These changes may allow the diaphragm to meet the increased mechanical demands of breathing immediately after birth.

Researching maternal, neonatal and child health service use in rural and pastoralist Ethiopia: A key informant research approach

Like many nations in sub-Saharan Africa, Ethiopia has both a high neonatal mortality rate and maternal mortality ratio and is unlikely to meet Millennium Development Goals 4 and 5 by 2015. This working paper examines how Key Informant Research (KIR) in rural and pastoralist Ethiopia will identify facilitators and barriers to the use of maternal, neonatal and child health services. The methodology is informed by Participative Ethnographic Evaluation Research (PEER) and Key Informant Monitoring (KIM). Key Informant Research (KIR) training will provide research skills to Health Extension Workers (HEWs) and Non-government organisation (NGO) staff to enable them to develop research questions, collect data and participate in preliminary data analysis. This will enable the identification of strategies that improve the identification of risk, enhance early referral, increase access, affordability and acceptability of skilled birthing services in rural and pastoralist Ethiopia.