Given the importance of the close contact and interaction described in establishing parent-child relationships under normal circumstances, it is not surprising that parents of premature or sick infants requiring care in the neonatal intensive care unit (NICU) experience anxiety and stress. Singer and associates17 showed that at 1 month of age, one third of mothers of very low birth weight infants had clinically significant symptoms of general distress, with 13% having severe signs. Of mothers of term infants at the same age, 17% reported mild distress and 1% had severe symptoms. By 2 years of age, the mothers of infants with very low birth weight without complications had similar measures of distress as term mothers, whereas mothers of infants who had chronic lung problems continued to show psychological distress. A meta-analysis of 14 qualitative studies11 found mothers overall felt alienated because of separation from their infant and reported a sense of depression, powerlessness, and despair. The mothers explained the need to have closeness and proximity and belonging to their infant. When these needs were met, the mothers became more responsible, confident, and familiar with their fragile infant. Parents who live a distance from perinatal care centers may experience additional separation because of the necessity of transporting their child to a regional NICU. If the infant must be transferred to another hospital, it is important that parents be given a chance to see and touch the infant and take a picture before transfer occurs, receive contact information for the other hospital, and accompany the infant whenever possible.14 Transporting the mother afterward for postpartum care is beneficial; however, financial barriers and lack of insurance provider coverage are problems in some areas. Parents of transported infants often describe the separation in terms of loss, and may experience a grief response even when the condition of the infant is not serious. After the initial transport, parents living far away have continued difficulty visiting their infant and may be helped with access to overnight accommodations. The NICU environment can be challenging for parents. There are many rules to follow, and parents are still excluded in many NICUs from important activities such as nursing shift changes or multidisciplinary rounds. Parents may be asked to leave the NICU for procedures on their infants, or in open units, to leave when procedures are necessary on other infants in the same area. Many parents report not feeling like their infant’s parent until the infant is discharged home.4 The design of the NICU impacts outcomes for patients and families. Emphasis on family-centered care has promoted design of single-patient rooms rather than the traditional open-bay NICUs to better include families during rounds and to provide space for parents to stay overnight. One of the first demonstrations that direct parent care may be beneficial for premature infants during the intermediate or convalescent period before discharge was reported by Forsythe.7 Infants cared for in living/sleeping units by their parents with a small group of consistent neonatal nurses had decreased length of hospital stay, fewer rehospitalizations, reduced visits to emergency departments, and reduced parental anxiety. Subsequent studies continue to show benefits for infants cared for in single rooms, benefits that include lower sound levels, improved parental involvement and perceived privacy by parents, and reduced infection rates compared with those cared for in shared rooms.16 Melnyk and associates10 evaluated parents of premature infants 26 to 34 weeks’ gestational age in an educational-behavioral intervention program (Creating Opportunities for Parent Empowerment or COPE) and found that mothers in the intervention group exhibited significantly less stress while their infant was in intensive care and less depression and anxiety at 2 months’ corrected age compared with mothers in the control group. In addition, infants in the intervention group had a 4-day shorter length of stay (mean 35 vs. 39 days) compared with control infants. A meta-analysis of interventions for parents to improve developmental outcomes for preterm infants found significant reduction in maternal anxiety and depressive symptoms and positive effects on parental self-efficacy.2 Interventions included psychosocial support, parent education, and/or therapeutic developmental interventions targeting the infant; the positive effects seen in the psychosocial aspects of these mothers implicate mental health services for families in the NICU as an important adjunct to routine care. These studies suggest that simple interventions may ameliorate problems of parenting associated with neonatal intensive care and may promote the health and development of children born prematurely. See Chapter 67. The most immature neonates will spend as long as 3 to 4 months in the NICU and are subjected to a variety of environmental influences in that time. Current research is focused on optimizing environmental factors in the NICU, particularly light, sound, tactile stimulation, and sleep, and investigating how modifications to the environment can impact both short-term medical and long-term neurodevelopmental outcomes (see Chapters 36, 37, and 38). In the late 1970s, Als and colleagues1 introduced a systematic approach of developmentally supportive care for preterm infants that instructs parents in the care of their infant by teaching them to read their infant’s cues, understand the infant’s unique strengths and needs, and respond appropriately. The Newborn Individualized Developmental Care and Assessment Program (NIDCAP) approach involves an assessment of each infant on a daily basis by trained observers, which is used in conjunction with the parents and direct care providers to individualize care based on various infant behaviors. A Cochrane meta-analysis published in 200618 of five randomized controlled trials of NIDCAP showed reduced incidence of moderate to severe chronic lung disease and necrotizing enterocolitis, and improved family and neurodevelopmental outcomes at 6 months. The Newborn Individualized Developmental Care and Assessment Program is resource-consuming, labor-intensive, and expensive both to implement and maintain because it requires developmental specialists, regular formal assessments, and training of nursing staff. A more recent systematic review of 11 primary and 7 secondary studies, including 627 preterm infants, did not find any evidence that NIDCAP improves long-term neurodevelopmental or short-term medical outcomes.12 Developmentally supportive care has become the standard of care in many nurseries, in many cases without full integration of NIDCAP, and the effects of specific components of NIDCAP are not known.
Attachment Challenges with Premature or Sick Infants
Premature or Sick Infants
Interventions for Premature or Sick Infants and Their Parents
Individualized Developmental Care
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Attachment Challenges with Premature or Sick Infants
