NEONATOLOGY Peer Reviewed Research, News and Information TODAY in Neonatal and Perinatal Medicine Volume 14 / Issue 12 | December 2019
Abstracts from National Perinatal Association 2019 The Neonatal Intensive Care Unit Directory - Annual Conference on April 3-5, 2019 in New Web Resources Providence, RI: Improving Access to Scott Snyder, MD ...... Page 83 Perinatal Care: Confronting Disparities Genetics Corner: Genetic Counseling and Family and Inequities in Maternal-Infant Health Erika Goyer Screening after Prenatal Diagnosis Of Hypoplastic ...... Page 4 Left Heart Syndrome: Is It Warranted? Fellow Column: Quality Improvement Initiative: Robin Clark, MD and Nivedita Rajakumar, MA, MS ...... Page 86 Reducing the Interval from Birth to NICU Admission From The National Perinatal Information Center: and Initial Blood Glucose Determination in Very Low Do You Know Your Community? NICU Care within Birth Weight (VLBW) Infants Aleksandra M. Adamczak, MD, Christian Castillo, MD, Vishakia Nanda, MD the Lens of Social Determinants of Health ...... Page 23 Elizabeth Rochin, PhD, RN, NE-BC ...... Page 89 A Mom’s Grief from the Loss of Her Baby Babies Benefit When Mom Eats More Seafood Is Unique and Profound Susan Hepworth and Mitchell Goldstein, MD Alison Jacobson ...... Page 93 ...... Page 27 Clinical Pearl: “This is a Great Idea, Medical Legal Forum – Use and Abuse of the So Let’s Just Do It”: Implementation Science Apgar Score Joseph R. Hageman, MD, Gilbert Martin, MD and Jonathan Fanaroff MD, JD ...... Page 98 ...... Page 33 Letters to the Editor Respiratory Care and its Impact on Mitchell Goldstein, MD responds as Editor-in-Chief Neurodevelopmental Outcomes: What’s Good, ...... Page 103 What’s Bad, and How Can We Do Better Erratum Rob Graham, R.R.T./N.R.C.P...... Page 104 ...... Page 39 Upcoming Meetings Coping with Infant Illness in the NICU ...... Page 106 During the Holiday Season Neonatology Today: Navy C. Spiecker, BA, Pamela A. Geller, Ph.D., & Chavis A. Patterson, Ph.D...... Page 46 Subscriptions and Contact Information Weight-Based Approach to Phototherapy ...... Page 106 Initiation in Preterm Infants Editorial Board Shabih Manzar, MD ...... Page 110 ...... Page 54 Neonatology and the Arts Looking Ahead - 2020 Federal Health Policy Outlook Herbert Vasquez, MD Darby O’Donnell, JD ...... Page 112 ...... Page 59 Instructions for Manuscription Submission Neonatal Coding and Documentation: The History ...... Page 112 Gilbert I Martin, MD Neonatology Today is Still Going to the Birds ...... Page 65 Holiday Cheer Medical News, Products & Information Mitchell Goldstein, MD Compiled and Reviewed by Mitchell Goldstein, MD ...... Page 113 ...... Page 68
NEONATOLOGY TODAY Loma Linda Publishing Company © 2006-2019 by Neonatology Today A Delaware “not for profit” 501(c) 3 Corporation. Published monthly. All rights reserved. c/o Mitchell Goldstein, MD ISSN: 1932-7137 (Online), 1932-7129 (Print) 11175 Campus Street, Suite #11121 All editions of the Journal and associated Loma Linda, CA 92354 manuscripts are available on-line: Tel: +1 (302) 313-9984 www.NeonatologyToday.net [email protected] www.Twitter.com/NeoToday NT INOMAX® (NITRIC OXIDE) GAS, FOR INHALATION Because Every Moment Counts
L INCL INC INC AL UD LL LUD LL LU ’S ED S A E S A DE IT * IT’ D IT’ D INOmax IN YOUR Total Care® CONTRACT in your A complete system with comprehensive care is included NO EXTRA COST contract in your INOmax Total Care contract at no extra cost.
When critical moments arise, INOmax Total Care is there to help ensure your patients are getting uninterrupted delivery of inhaled nitric oxide. 2017 EMERGENCY 1 1 LL INCLU LL INCLU • Over 18 years on market with over 700,000 patients treated A DE A DE DELIVERIES INCL T’S D T’S D • Continued innovation for delivery system enhancements L INCL LL UD I I DRUG & DEVICEAL UD S A E ’S ED IT’ D • Emergency deliveries of all INOmax Total Care components within hours† IT IN YOUR • Live, around-the-clock medical and technical support and training 2,700+IN YOUR IN YOUR CONTRACT • Ongoing INOMAX® (nitric oxide) gas, for inhalation reimbursement CONTRACT CONTRACT NO EXTRA assessment and assistance included in your INOMAX contract COST NO EXTRA NO EXTRA (Note: You are ultimately responsible for determining the appropriate COST COST reimbursement strategies and billing codes)
Indication INOMAX is indicated to improve oxygenation and reduce • In patients with pre-existing left ventricular dysfunction, the need for extracorporeal membrane oxygenation in INOMAX may increase pulmonary capillary wedge term and near-term (>34 weeks gestation) neonates pressure leading to pulmonary edema. with hypoxic respiratory failure associated with clinical or • Monitor for PaO₂, inspired NO₂, and methemoglobin echocardiographic evidence of pulmonary hypertension during INOMAX administration. in conjunction with ventilatory support and other • INOMAX must be administered using a calibrated appropriate agents. INOmax DSIR® Nitric Oxide Delivery System operated IN YOUR Important Safety Information by trained personnel. Only validated ventilator systems CONTRACT • INOMAX is contraindicated in the treatment of neonates should be used in conjunction with INOMAX. dependent on right-to-left shunting of blood. • The most common adverse reaction is hypotension. • Abrupt discontinuation of INOMAX may lead to increasing You are encouraged to report negative side effects of pulmonary artery pressure and worsening oxygenation. prescription drugs to the FDA. Visit MedWatch or • Methemoglobinemia and NO₂ levels are dose dependent. call 1-800-FDA-1088. Nitric oxide donor compounds may have an additive Please visit inomax.com/PI for Full Prescribing effect with INOMAX on the risk of developing Information. methemoglobinemia. Nitrogen dioxide may cause airway inflammation and damage to lung tissues.
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LL INCLU Mallinckrodt, the “M” brand mark and the Mallinckrodt Pharmaceuticals logo are trademarks of S A DE a Mallinckrodt company. Other brands are trademarks of a Mallinckrodt company or their respective owners. IT’ D © 2018 Mallinckrodt US-1800073 August 2018
N INC INC LL I CLU LL LUD LL LUD S A DE S A E S A E IT’ D IT’ D IT’ D IN YOUR IN YOUR CONTRACT IN YOUR CONTRACT CONTRACT ® ADVERSE REACTIONS INOmax (nitric oxide gas) Because clinical trials are conducted under widely varying Brief Summary of Prescribing Information conditions, adverse reaction rates observed in the clinical trials of a drug cannot be directly compared to rates in the clinical trials of INDICATIONS AND USAGE another drug and may not re ect the rates observed in practice. Treatment of Hypoxic Respiratory Failure The adverse reaction information from the clinical studies does, INOmax® is indicated to improve oxygenation and reduce the need for however, provide a basis for identifying the adverse events that extracorporeal membrane oxygenation in term and near-term (>34 appear to be related to drug use and for approximating rates. weeks) neonates with hypoxic respiratory failure associated with Controlled studies have included 325 patients on INOmax doses clinical or echocardiographic evidence of pulmonary hypertension of 5 to 80 ppm and 251 patients on placebo. Total mortality in in conjunction with ventilator support and other appropriate agents. the pooled trials was 11% on placebo and 9% on INOmax, a CONTRAINDICATIONS result adequate to exclude INOmax mortality being more than INOmax is contraindicated in neonates dependent on right-to-left 40% worse than placebo. shunting of blood. In both the NINOS and CINRGI studies, the duration of hospitalization WARNINGS AND PRECAUTIONS was similar in INOmax and placebo-treated groups. Rebound Pulmonary Hypertension Syndrome following Abrupt From all controlled studies, at least 6 months of follow-up Discontinuation is available for 278 patients who received INOmax and Wean from INOmax. Abrupt discontinuation of INOmax may lead to 212 patients who received placebo. Among these patients, worsening oxygenation and increasing pulmonary artery pressure, there was no evidence of an adverse effect of treatment on the i.e., Rebound Pulmonary Hypertension Syndrome. Signs and need for rehospitalization, special medical services, pulmonary symptoms of Rebound Pulmonary Hypertension Syndrome include disease, or neurological sequelae. hypoxemia, systemic hypotension, bradycardia, and decreased In the NINOS study, treatment groups were similar with respect to cardiac output. If Rebound Pulmonary Hypertension occurs, reinstate the incidence and severity of intracranial hemorrhage, INOmax therapy immediately. Grade IV hemorrhage, periventricular leukomalacia, cerebral Hypoxemia from Methemoglobinemia infarction, seizures requiring anticonvulsant therapy, pulmonary Nitric oxide combines with hemoglobin to form methemoglobin, hemorrhage, or gastrointestinal hemorrhage. which does not transport oxygen. Methemoglobin levels increase In CINRGI, the only adverse reaction (>2% higher incidence on with the dose of INOmax; it can take 8 hours or more before steady- INOmax than on placebo) was hypotension (14% vs. 11%). state methemoglobin levels are attained. Monitor methemoglobin and adjust the dose of INOmax to optimize oxygenation. Based upon post-marketing experience, accidental exposure to nitric oxide for inhalation in hospital staff has been associated If methemoglobin levels do not resolve with decrease in dose or with chest discomfort, dizziness, dry throat, dyspnea, discontinuation of INOmax, additional therapy may be warranted and headache. to treat methemoglobinemia. DRUG INTERACTIONS Airway Injury from Nitrogen Dioxide Nitric Oxide Donor Agents Nitrogen dioxide (NO2) forms in gas mixtures containing NO and O2. Nitrogen dioxide may cause airway in ammation and damage to Nitric oxide donor agents such as prilocaine, sodium lung tissues. nitroprusside and nitroglycerine may increase the risk of developing methemoglobinemia. If there is an unexpected change in NO concentration, or if the 2 OVERDOSAGE NO2 concentration reaches 3 ppm when measured in the breathing circuit, then the delivery system should be assessed in accordance Overdosage with INOmax is manifest by elevations in with the Nitric Oxide Delivery System O&M Manual troubleshooting methemoglobin and pulmonary toxicities associated with inspired NO . Elevated NO may cause acute lung injury. section, and the NO analyzer should be recalibrated. The dose of 2 2 2 Elevations in methemoglobin reduce the oxygen delivery INOmax and/or FiO2 should be adjusted as appropriate. capacity of the circulation. In clinical studies, NO2 levels >3 ppm Worsening Heart Failure or methemoglobin levels >7% were treated by reducing the dose Patients with left ventricular dysfunction treated with INOmax of, or discontinuing, INOmax. may experience pulmonary edema, increased pulmonary capillary Methemoglobinemia that does not resolve after reduction wedge pressure, worsening of left ventricular dysfunction, systemic or discontinuation of therapy can be treated with intravenous hypotension, bradycardia and cardiac arrest. Discontinue INOmax vitamin C, intravenous methylene blue, or blood transfusion, based while providing symptomatic care. upon the clinical situation. INOMAX® is a registered trademark of a Mallinckrodt Pharmaceuticals company. © 2018 Mallinckrodt. US-1800236 August 2018 Abstracts from National Perinatal Association 2019 Annual Conference on April 3-5, 2019 in Providence, RI: Improving Access to Perinatal Care: Confronting Disparities and Inequities in Maternal-Infant Health
Erika Goyer, Family Advocate ed States. Zika virus infection of pregnant es promote improvements in monitoring women places their infants at risk for con- pregnancy and infant outcomes that in- tracting congenital Zika syndrome, charac- form clinical guidance and public health terized by brain malformations, other birth response. The National Perinatal Association defects, and concurrent developmental (NPA)is an interdisciplinary organiza- delays. Zika virus was monitored glob- Implications for Practice tion that strives to be a leading voice for ally as an emerging infectious disease. In perinatal care in the United States. Our 2017, epidemiological response to Zika Actively engaging a Zika Clinical Cham- diverse membership is comprised of virus infection showed more immune re- pion at each of the nine delivery hospitals healthcare providers, parents & caregiv- sponse and less acute disease, neces- in the Philadelphia area has been crucial ers, educators, and service providers, sitating changing protocols in screening, to active surveillance, data collection and all driven by their desire to give voice to testing and clinical management. Approxi- management, as well as referral to local and support babies and families at risk mately 12% of Philadelphia’s 1.5 million services and effective patient follow-up. across the country. residents routinely travel to their home Utilizing a home visiting strategy allows countries, many of which are or were en- PDPH and clinicians to engage client fami- Members of the NPA write a regular demic for Zika virus infection. Potential ex- lies both in the home and in the provider’s peer-reviewed column in Neonatology posure to Zika virus posed a great risk for facility. Today. Zika virus infection in the individual, sexual partner(s), and possible vertical transmis- ______sion to the newborn. NPA2019-2
Content/Action Bryant
The Philadelphia Department of Health Meeting NICU Moms Where they Are: Un- (PDPH) utilized an ecological approach to derstanding and Improving Postpartum provide active surveillance of Zika-associ- Health Care for Mothers of Medically Frag- ated birth defects, analysis and reporting ile Infants of surveillance data and systems, engage- ment and referral services for families RESEARCH affected by maternal Zika infection, long- term follow-up of children born to moth- Introduction: Mothers of medically fragile ers infected with Zika virus, and capacity infants (MMFI) face a host of challenges building among clinical partners in recog- following childbirth. Compared to mothers nizing and supporting families at risk for of well babies (MWB), MMFIs have a great- NPA2019-1 Zika virus infection. er burden of chronic disease and are at increased risk for mental health problems, Surveillance and Care Management of Lessons Learned while at the same time are navigating the Zika Virus-Affected Families in Philadel- health care system on behalf of their medi- phia (2016-2019) This model of care focuses on multidisci- cally complex infant and managing their plinary and multi-level interventions in re- own postpartum recovery. The neonatal Rachel Blumenfeld, MPH, Sharon Starr, sponse to the Zika virus outbreak. Phila- intensive care unit (NICU) parenting expe- MSN, RN, Mariah Menanno delphia identified 41 mothers on the U.S. rience has been fairly well researched but Zika Pregnancy Registry, per the Centers comparably limited information is available INNOVATIVE MODELS OF CARE for Disease Control and Prevention inclu- focusing on NICU mothers’ postpartum re- sion criteria guidelines, with 32 completed Background covery, health needs, and access to ser- live births. Collaboration between the fields vices for her own well-being. Using quan- of public health, medicine, nursing, envi- titative and qualitative methods, our work Since 2015, Zika virus has affected popu- ronmental professionals, and community- lations worldwide throughout the Caribbe- focused on identifying MMFI postpartum based education and outreach influenced health conditions, needs and concerns, an, Central and South America, Southeast Zika virus responses for surveillance and Asia, and small areas of the southern Unit- and health care services received in the 90 patient care management. These respons- days following delivery, as well as health
NEONATOLOGY TODAYtwww.NeonatologyToday.nettDecember 2019 4 care systems-related barriers to care, with supported the idea of a postpartum nurse an eye to improving access to care for rounding on them in the NICU. Health sys- mothers of medically fragile infants in the tems barriers identified by key informants Additional limited results of study findings postpartum period. included: limited awareness of services have been shared at ACOG, SMFM, and provided by other units resulting in an as- AMCHP. Methods: We conducted a retrospective sumption that MMFI needs are being met cohort study of mothers of live-born infants by other providers; lack of clarity across ______born at the NC Women’s Hospital from types of providers as to who is responsible July 1, 2014 to June 30, 2016 (n=6,849) to for providing care for MMFI; and scarce re- NPA2019-3 measure prevalent conditions, health care sources. Key informants voiced an aware- Downtin utilization, and receipt of recommended ness of the unique needs of MMFI and services. We defined MMFI as mothers of expressed interest in exploring alternative Collaborative Psychological Services in infants with a total neonatal intensive care models of care delivery such as MMFI-as- the NICU: Caring for the Care Teams unit and pediatric critical care unit length of signed patient navigator or a nurse check- stay ≥3 days. We defined MWB as moth- ing in on moms. MMFI and key informants INNOVATIVE MODELS OF CARE ers of infants who were not admitted to an alike suggested systems improvements intensive care unit and were discharged to including NICU-based mental health and Background home. Over the course of a year, from April medical health care and access to a place 2017 to June 2018, we conducted in-depth to rest (e.g. a nap room). Stanford University’s Lucile Packard Chil- interviews with 44 adult English-speaking dren’s Hospital (LCPH) currently has a 40- MMFIs and more than 50 key stakeholders Discussion: Despite evidence of greater bed level IV neonatal intensive care unit who provide services to or have knowledge prevalence of chronic conditions and post- (NICU). In 2017, the child and adolescent about the health care needs of these wom- partum morbidity, MMFI reported little at- psychiatry department partnered with the en (e.g. postpartum and NICU nurses, lac- tention paid to their postpartum health neonatology department to create a 1-year tation specialists, hospital administrators), needs from medical professionals. They clinical child psychology postdoctoral fel- to identify maternal health needs, barriers described significant need for mental lowship. The fellowship was designed to and facilitators to accessing services, and health care in particular, coupled with chal- establish a dedicated psychiatry/psychol- suggested systems improvements. lenges in accessing that care. Similarly, ogy service specific to the NICU and allow key informants described a fragmented specialized training in perinatal mental for Results: We found that mothers with in- system that result in lack of clarity about the NICU fellow. Through that fellowship, fants in the NICU have a greater burden who is responsible for providing care for the fellow worked to modify an evidence- of chronic disease and postpartum morbid- NICU moms, suggesting a need to clarify based psychotherapy intervention that ity than mothers of well babies. Compared roles and identify a provider designated was originally designed for individual psy- to MWB, MMFI were more likely to have a for MMFI during their NICU stay. The chotherapy with mothers of premature in- BMI >30 (35% vs. 25% MWB) and chronic overwhelming drive of NICU moms to be fants. The intervention was modified and is hypertension (17% vs. 7%). MMFI were at the baby bedside further suggests the currently being used to address the needs also more likely to undergo general anes- need to build access to care in the con- of mothers in group-format who are exhib- thesia for delivery (8.6% vs. 0.9% MWB), text of the NICU stay, particularly for MMFI iting symptoms of trauma, anxiety and de- undergo hysterectomy (1.6% vs. 0.1%) whose home communities are great dis- pression. and to have had a blood transfusion (5.7% tances from the NICU. As MMFI cannot, vs. 2.2%). Thirty-two percent experienced or will not, seek care away from baby, an Within a year of establishing the NICU psy- gestational hypertension or preeclamp- alternative is to meet them where they are chology fellowship, families began receiv- sia compared to 12% of MWB, and more and bring the care to them. One possible ing mental health screening, psychological than half of MMFI were recovering from model is to assign a postpartum nurse to evaluation, bedside follow-up, and individ- a cesarean section while caring for their round on mothers in the NICU, a sugges- ual and family therapy from the NICU fel- infant in the NICU (54% vs. 24% MWB). tion that was met with strong support by low and psychology/psychiatry attendings. Some key elements that MMFI identified MMFI interviewees and interest by key in- Additionally, mothers of premature infants as part of their postpartum NICU experi- formants. System-level challenges such as receive the group-based trauma-focused ence include: significant social-emotional- billing and payment procedures and staff- psychotherapy intervention. However, mental health needs and difficulty access- ing structure would need to be addressed support services for NICU residents, fel- ing mental health services and support; to support such a model of care. Meeting lows, and nurses continued to be an area unmet practical needs causing significant NICU moms where they are holds great of needed growth. burden, such as lack of a place to sleep promise for improving access to health while visiting the NICU, lack of childcare care and addressing the unique needs of Action for other children, and parking difficulties; mothers of medically fragile infants. and an overriding desire to be at baby The 2018-2019 NICU psychology fellow at bedside coupled with the minimization of Previously Presented LPCH collaborated with the NICU social their own health needs so as to attend to work intern to begin addressing the needs baby. While MMFI described confidence in Study and results previously described in of NICU nurses and trainees. Through how their babies were cared for, they re- poster presentation at the Association of meetings and thoughtful discussions with ported that there was no one checking on Maternal Child Health Programs (AMCHP) a neonatology attending, nursing manage- their own health and their needs, beyond annual conference in March 2019. ment, a nurse educator, a neonatal nurse being asked a generic “How are you do- practitioner, the fellow and intern were ing?”. They described a lack of connection AMCHP Poster Title: The New Mother able to pilot a NICU service for nurses and to health care and support services where Friendly NICU: Understanding and Im- trainees. This poster will outline the work- (near the NICU) and when (urgently) they proving the Postpartum Experience for flow for those meetings and provide a brief needed it. When asked, MMFI strongly Mothers of Medically Fragile Infants overview of the initial NICU staff and train-
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© 2019 Respiralogics, GaleMed. All rights reserved. ee support services at this hospital. Robin Bisgaard, Sharon Sossaman, Jera- conducted a process of co-design with my Sossaman, Anne Shamiyeh, Kathryn healthcare professionals and parents of Lessons Learned Millar, Tanya Johnston, Rebecca Kriz, Di- former preterm infants to adapt and imple- ana Cormier MPH RNC-NIC, Priscilla Joe, ment FICare in California. Using user- This poster will discuss lessons learned Nicole Hansen, Holly Christensen, Nadia centered design principles and practices, through meeting with the identified depart- Tsado, Pallavi Bekal, Samantha Ngo, Yao we co-designed a new mobile enhanced ment representatives including addressing Sun. adaptation of the FICare model, called ‘m- barriers to providing supports for union FICare’, to extend the support for families nurses, timelines need for establishing INNOVATIVE MODELS OF CARE to those who cannot be physically present care, providing culturally-informed care in in the NICU during daytime hours. We also the NICU, psychological impact of trauma Background: Extensive research has developed an innovative approach to the on NICU staff and families, and common shown that an integrated person- and fam- conduct of NICU clinical research in part- topics and themes requested by the train- ily-centered approach to healthcare (FCC) nership with families. ees and nurses. leads to better outcomes for babies and families. This approach is endorsed by the The We3health mobile app is a secure, Implications for Practice World Health Organization and many other HIPAA compliant, mobile app co-designed national and international groups. FCC is with parents to increase access and qual- NICU nurses and trainees often choose particularly important for small and sick ity of parent support to enable greater in- their specialty because they have a pas- newborns. Yet most Neonatal Intensive volvement in their infant’s care planning sion for helping infants and their families Care Units (NICUs) lack the policies, re- and caregiving. The We3health app also through challenging times. Working in the sources and structures needed to ensure facilitates parent tracking of data for re- NICU can be rewarding. Staff and trainees FCC is consistently practiced and parents search and NICU quality improvement. may end their day knowing that they posi- have the support they need to become We also co-developed a parent mentor tively impacted a family or families through competent and confident caregivers for program that serves all preterm parents their direct care or indirect interactions. their babies. and aims to increase access and depth The NICU can also be an emotionally per- of involvement for parents who live at a plexing experience for staff and trainees. Family Integrated Care (FICare) trans- distance from the NICU or are from under- The goals of this project were to: 1) identify forms the culture of the NICU by training served communities. Finally, we imple- needs of NICU staff and trainees, 2) estab- and supporting parents to be their baby’s mented and are evaluating the mFICare lish the appropriate support services, and primary caregiver and a partner in the care model in California NICUs. 3) implement those services. This poster team. A cluster randomized trial of FICare will discuss the feedback from NICU staff (O’Brien et al. 2017) showed better growth Lessons Learned: Co-design is an ex- and trainees to help other hospitals ex- for infants and increased rates of breast- tremely useful strategy for increasing pa- plore supporting the psychosocial needs of feeding. It also showed decreased stress tient and family involvement and there are their NICU nurses and trainees to improve levels for parents. Notably, all FICare in- a number of challenges and opportunities outcomes for women, infants, and their tervention NICUs continued to practice FI- in implementing co-design, depending on families. Care after the trial was completed. the context. These include negotiating the scope of the work and how best to meet ______Content/Action: While the FICare out- the needs of the main stakeholder groups, comes are significant and show promise, NPA2019-4 i.e., parents and NICU health profession- adaptation may be needed for the US als. A mutual deep understanding of each context – most notably to because many Co-Designing Mobile Technology and stakeholder group’s main challenges and parents do not have parental leave and developing empathy are key to success Care Delivery to Improve Family Integrat- are unable to be physically present in the ed Care in NICUs of the co-design approach. Parents have NICU to the same degree as participants amazing insights that substantially im- Linda Franck, Brittany Lothe, Scott Bolick, in the Canadian-led trial. Therefore, we prove research design and implementa-
Newly-Validated Online NICU Staff Education Caring for Babies and their Families: Providing Psychosocial Support to NICU Parents
based on the “Interdisciplinary Recommendations for Psychosocial Support for NICU Parents.”
Contact [email protected] for more information.
Brought to you by a collaboration between National Perinatal Association Patient + Family Care Transform Your NICU Preemie Parent Alliance www.mynicunetwork.com
NEONATOLOGY TODAYtwww.NeonatologyToday.nettDecember 2019 7 tion. Ongoing attention and recalibration tunity to generate research questions and Introduction: Family Integrated Care (FI- is essential to maintain equity in imple- consensus priorities from women at high Care) is a novel package of evidence- mentation and avoid creating or worsening risk for preterm birth from three centers in based interventions that enables parents disparities in access and quality of care. California using the Research Prioritization to more effectively become primary care- True co-creation requires give-and-take. by Affected Communities (RPAC) protocol givers for their preterm infants in the neo- Parents are impatient for change, and that (Franck, et al. 2018). natal intensive care unit (NICU). As part of is good - and challenging - for traditional a multi-site trial of FICare in California, a research. Context: Participants included Parent Cli- mobile application (We3health app) was nician Advisory Board (PCAB) members developed to support families during their Implications for Practice: Parent and from PTBi-CA’s Newborn Family Research NICU stay. Because FICare strongly pro- healthcare professional co-design is a Collaborative located in San Francisco, motes kangaroo care (KC), We3health powerful approach to addressing access Oakland, and Fresno, California. PCAB includes a module for tracking KC. This and equity issues in patient and family members include neonatal intensive care analysis describes relationships between care delivery and in research. unit (NICU) professionals and parents of parent and infant characteristics and KC former NICU infants. RPAC was conduct- activity recorded in We3health. Previously presented at the Institute for ed separately at each site, and collabora- Patient and Family Centered Care Inter- tively at the network level to generate the Method: Parents of preterm infants <33 national Conference, Baltimore, MD, June top two priorities. weeks gestation enrolled in the baseline 2018, and at the March of Dimes California (usual care) phase of the study completed Annual Conference, Irvine, CA, November PCAB participants were racially and eth- an online survey and used We3health to 2018. nically diverse. Each site generated be- record frequency, duration and subjective tween 50 and 80 original research ques- experience with KC from the time of study ______tions and reached consensus on research enrollment until discharge. priorities. Priority similarities and differenc- NPA2019-5 es were noted across sites. The top pri- Results: To date, 66 parents (61 mothers; orities across all sites, determined by con- 5 fathers) from three of the NICUs com- Collaborative research priority setting by sensus, included postnatal interventions pleted both survey and We3health data parents of preterm infants and neonatal to improve transition from NICU to home, for analysis. KC frequency was unrelated intensive care unit professionals follow-up support after discharge, and in- to parent race, gender, prior NICU or child Linda Franck PhD RN, Kathryn Millar RN fant development and/or family wellbeing. hospitalization, infant gestational age or MPH, Dawn Gano MD MAS, Rebecca Kriz Participants felt empowered, developed a length of NICU stay. RN MS, Diana Cormier DNP APRN-CNS sense of community with the group, and increased engagement in research. Parents able to see their infant within 1 MPH RNC-NIC, Priscilla Joe MD, Nicole hour of birth reported KC on a larger pro- Hansen RN, Holly Christensen RN, Nadia Practice Application: The RPAC protocol portion of days during their infant’s hospi- Tsado BA, Pallavi Bekal MS, Samantha enabled rapid generation of research pri- talization compared with parents who first Ngo MPH MSW. orities among diverse parents of preterm saw their infant 1-24 or >24 hours after Introduction: Community-based partici- infants from communities that have often birth, after controlling for GA (Figure 1, patory research improves the relevance not been engaged in research and clini- p=.004). This difference in KC frequency and application of research findings to af- cians who care for their babies. The results likely accounted for longer mean durations fected communities. Little is known about of this research prioritization process have of KC day across the infant’s hospitaliza- research priorities of parents and clinicians informed the research agenda within our tion, controlling for GA (Figure 2, p=.021). who care for preterm infants. Since preterm network to ultimately promote health eq- Accounting for the differences in KC fre- birth disproportionately affects communi- uity and improved outcomes for premature quency, however, there was no difference ties of color, understanding their perspec- infants. in mean KC duration on the days KC was tives is necessary to achieve health equity reported based on when parents first saw Previously presented at the Preterm Birth their infant. in research. The UCSF California Preterm Initiative Annual Symposium, Kigali, Rwan- Birth Initiative’s (PTBi-CA) community ad- da, October 2018, and at the American Parents able to hold their baby within 24 visory boards provided the unique oppor- Public Health Association Annual Meeting, hours after birth also reported KC on a San Diego, CA, November 2018. larger proportion of days, after controlling (Figure 1, p=.012), and a slightly longer ______mean duration of KC per day of the infant’s NICU stay (p=.060). Note that only 9 of the NPA2019-6 23 parents who held their baby within 24 hours were among the 23 who first saw Relationship between kangaroo care activ- their infant within 1 hour. ity during neonatal intensive care unit hos- pitalization and early parent-infant contact Discussion: Early parent-infant contact within 24 hours of birth is an important fac- Linda Franck PhD RN, Caryl Gay, PhD, tor influencing KC frequency and duration. Rebecca Kriz RN MS, Robin Bisgaard, Evidence-based, protocol driven quality RN, Dawn Gano MD MAS, Diana Cormier improvement strategies are urgently need- DNP APRN-CNS MPH RNC-NIC, Priscilla ed to improve early parent-infant contact Joe MD, Kathryn Millar RN MPH, Nicole for preterm infants. Hansen RN, Holly Christensen RN, Nadia Tsado BA, Pallavi Bekal MS, Samantha Previously presented at the International Ngo MPH MSW, Yao Sun, MD PhD. Conference on Kangaroo Mother Care,
NEONATOLOGY TODAYtwww.NeonatologyToday.nettDecember 2019 8 Bogota, Colombia, November, 2018. death syndrome, sepsis, necrotizing en- in policies which do not optimize health terocolitis, diabetes, asthma, and obesity. outcomes. Restrictive breastfeeding prac- ______Available evidence is unclear regarding tices for women who use marijuana which whether infants who were already exposed do not utilize an individualized, shared de- NPA-2019-7 to THC in utero would be worse off with cision-making approach are neither medi- continued exposure through breastmilk vs. cally sound nor ethically justified, and may Breastfeeding and Marijuana Use: An Eth- with increased risks associated with formu- disproportionately undermine the health ical Analysis of Current Practice la feeding. (2) Women who do not breast- of underserved women and infants. Un- Research Submission for National Perina- feed have increased risk of cardiovascular biased, culturally-informed and evidence- tal Association 2019 Conference disease, reproductive cancers, diabetes, based counseling would promote open pa- depression and unintended pregnancy, all tient-provider communication may improve major sources of morbidity and mortality long-term health. for U.S. women. Marijuana use is highest Marielle S. Gross, MD, MBE1, Carla Bos- among underserved minority women who ______sano, MD2, Nadine Rosenblum, RN, IB- disproportionately suffer from the health CLC3, and Lorraine Milio, MD, MPH2 consequences that breastfeeding may mit- NPA-2019-8 igate, and who are especially vulnerable to Johns Hopkins Berman Institute of Bioeth- punitive damages (e.g., criminal charges Breastfeeding and Marijuana Use: An Ethi- ics, Johns Hopkins School of Medicine, related to drug use or Child Protective cal Analysis of Current Practice and Johns Hopkins Hospital3; Baltimore, Services involvement). Maternal desire to Research Submission for National Perina- Maryland bond with her infant through breastfeed- tal Association 2019 Conference ing, cultural norms, values, and social Introduction: U.S. guidelines recommend pressures, and the financial burden of for- Marielle S. Gross, MD, MBE1, Carla Bos- breastfeeding women avoid marijuana mula all may exacerbate the harm of tell- sano, MD2, Nadine Rosenblum, RN, IB- given concerns about infant neurodevel- ing women to avoid breastfeeding. (3) The CLC3, and Lorraine Milio, MD, MPH2 opment. Unfortunately, this has resulted in national recommendation that women who many physicians and hospitals prohibiting breastfeed should avoid marijuana is inter- Johns Hopkins Berman Institute of Bioeth- women who use marijuana from breast- preted by some physicians and hospitals ics, Johns Hopkins School of Medicine, feeding despite inconclusive evidence of as a policy that women who use marijuana and Johns Hopkins Hospital3; Baltimore, harm and well-known benefits of breast- should not breastfeed. This practice fails Maryland feeding. Meanwhile, marijuana use is in- to account for the risks of avoiding breast- creasing among reproductive-aged wom- feeding for both infants and women, pos- Introduction: U.S. guidelines recommend en, and complex personal/socioeconomic sibly exaggerating the strength of available breastfeeding women avoid marijuana factors affect feeding choices. We assess evidence about harms from breastmilk given concerns about infant neurodevel- evidence and ethical justification for cur- THC exposure, and thus may not optimize opment. Unfortunately, this has resulted in rent practice. health outcomes. In addition to potentially many physicians and hospitals prohibiting exacerbating existing health disparities, women who use marijuana from breast- Methods: We review: (1) Harm to infants this practice may be unjust if women who feeding despite inconclusive evidence of from breastmilk marijuana exposure vs. screen positive for THC during pregnancy harm and well-known benefits of breast- avoiding breastfeeding, (2) Maternal health are told they are ‘not allowed’ to breast- feeding. Meanwhile, marijuana use is in- and psychosocial considerations, and (3) feed regardless of whether they are ac- creasing among reproductive-aged wom- Current practices in light of principles of tively using at time of delivery. Given the en, and complex personal/socioeconomic beneficence, justice, and autonomy. clinical equipoise regarding the best feed- factors affect feeding choices. We assess ing method for infants whose mothers use evidence and ethical justification for cur- Results: (1) First, delta-9-tetrahydrocan- marijuana, particularly if they were already rent practice. nabinol (THC) is excreted in breastmilk exposed to THC in utero, and the large and limited data (three studies with hu- range in frequency/intensity of maternal Methods: We review: (1) Harm to infants man subjects and three animal studies) marijuana use, an individualized, shared from breastmilk marijuana exposure vs. suggest neurobehavioral changes among decision-making approach is appropriate. avoiding breastfeeding, (2) Maternal health infants whose mothers use marijuana Furthermore, a woman’s autonomy may and psychosocial considerations, and (3) during breastfeeding, though effects of in be compromised if crucial postpartum lac- Current practices in light of principles of utero vs. breastmilk exposure are difficult tation support is withheld while she is in the beneficence, justice, and autonomy. to distinguish and interpretation is limited hospital postpartum or if she is concerned by socioeconomic and other confound- that breastfeeding against recommenda- Results: (1) First, delta-9-tetrahydrocan- ers. There are also concerns that mari- tions may jeopardize custody of her infant. nabinol (THC) is excreted in breastmilk juana use negatively impacts safe infant and limited data (three studies with hu- care and that the average concentration Discussion: Ultimately, failure to account man subjects and three animal studies) of THC in marijuana has increased in the for risks of avoiding breastfeeding for in- suggest neurobehavioral changes among years since the relevant studies were com- fants and women, with attention to epide- infants whose mothers use marijuana pleted. Meanwhile, avoiding breastfeeding miology of marijuana use and breastfeed- during breastfeeding, though effects of in increases infants’ risk of sudden infant ing-associated health effects, may result utero vs. breastmilk exposure are difficult
NEONATOLOGY TODAYtwww.NeonatologyToday.nettDecember 2019 9 to distinguish and interpretation is limited marijuana use, an individualized, shared feel they have adequate skills to communi- by socioeconomic and other confound- decision-making approach is appropriate. cate with distressed and anxious parents. ers. There are also concerns that mari- Furthermore, a woman’s autonomy may Subsequently, this skill deficit increases juana use negatively impacts safe infant be compromised if crucial postpartum lac- staff's own stress and can contribute to care and that the average concentration tation support is withheld while she is in the on-the-job burnout. Additionally, as more of THC in marijuana has increased in the hospital postpartum or if she is concerned NICUs are moving towards providing the years since the relevant studies were com- that breastfeeding against recommenda- model of family-integrated care, roles of pleted. Meanwhile, avoiding breastfeeding tions may jeopardize custody of her infant. NICU care providers are changing towards increases infants’ risk of sudden infant forming a more egalitarian partnership with death syndrome, sepsis, necrotizing en- Discussion: Ultimately, failure to account parents and encouraging greater involve- terocolitis, diabetes, asthma, and obesity. for risks of avoiding breastfeeding for in- ment of parents at their baby's bedside. Available evidence is unclear regarding fants and women, with attention to epide- This paradigm shift calls for new skill de- whether infants who were already exposed miology of marijuana use and breastfeed- velopment among multidisciplinary staff. to THC in utero would be worse off with ing-associated health effects, may result continued exposure through breastmilk vs. in policies which do not optimize health Objective with increased risks associated with formu- outcomes. Restrictive breastfeeding prac- la feeding. (2) Women who do not breast- tices for women who use marijuana which This study sought to determine whether feed have increased risk of cardiovascular do not utilize an individualized, shared de- NICU staff would demonstrate improved disease, reproductive cancers, diabetes, cision-making approach are neither medi- knowledge and attitudes about their ability depression and unintended pregnancy, all cally sound nor ethically justified, and may to provide psychosocial support to parents major sources of morbidity and mortality disproportionately undermine the health as a result of taking an online education for U.S. women. Marijuana use is highest of underserved women and infants. Un- course. among underserved minority women who biased, culturally-informed and evidence- disproportionately suffer from the health based counseling would promote open pa- Design consequences that breastfeeding may mit- tient-provider communication may improve long-term health. This was a time series pre/posttest com- igate, and who are especially vulnerable to parison of responses provided to a 33-item punitive damages (e.g., criminal charges ______survey among NICU staff before and after related to drug use or Child Protective taking an online education course on pro- Services involvement). Maternal desire to NPA-2019-9 viding psychosocial support to parents. bond with her infant through breastfeed- Content in the 7-hour course covered the ing, cultural norms, values, and social Improving Staff Knowledge and Attitudes categories as described in the “Interdisci- pressures, and the financial burden of for- towards Providing Psychosocial Support plinary Recommendations for the Psycho- mula all may exacerbate the harm of tell- to NICU Parents through an Online Edu- social Support of NICU Parents” (Hall and ing women to avoid breastfeeding. (3) The cation Course Hynan, J Perinatol, 2015). national recommendation that women who breastfeed should avoid marijuana is inter- Institutions: St. John’s Regional Medical Setting preted by some physicians and hospitals Center, Oxnard, CA, USA; University of as a policy that women who use marijuana Mississippi Medical Center, Jackson, MS, Two NICUs participated in this project: St. should not breastfeed. This practice fails USA. John’s Regional Medical Center (SJRMC), to account for the risks of avoiding breast- a 16-bed Level III community NICU with feeding for both infants and women, pos- Authors: SL Hall MD; ME Famuyide MD; 250 admissions annually, and The Univer- sibly exaggerating the strength of available S Mosher RN, MHA; TA Moore RN, PhD; sity of Mississippi Medical Center (UMMC), evidence about harms from breastmilk K Sorrells BSFCS; CA Milford EdS; J Craig a level IV academic NICU with 102 beds. THC exposure, and thus may not optimize PhD, MBA, OTRL, CNT; SN Saxton PsyD. health outcomes. In addition to potentially Participants exacerbating existing health disparities, Introduction this practice may be unjust if women who Staff at both NICUs, including physicians, screen positive for THC during pregnancy Provider-parent communication is a criti- nurses, occupational therapists, and social are told they are ‘not allowed’ to breast- cal determinant of how NICU parents cope workers, were invited to take the online feed regardless of whether they are ac- with their situation and of how satisfied course and participate in the study. tively using at time of delivery. Given the they are with their overall experience and clinical equipoise regarding the best feed- with the care their infant received. NICU Methods ing method for infants whose mothers use parents desire and benefit from psychoso- marijuana, particularly if they were already cial support from staff, and yet are not al- Participants provided demographic infor- exposed to THC in utero, and the large ways satisfied with the communication and mation, then took a 33-item survey before range in frequency/intensity of maternal support they receive in the NICU. Many (pretest) and after (posttest) taking the neonatologists and neonatal nurses do not comprehensive course called “Caring for
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NEONATOLOGY TODAYtwww.NeonatologyToday.nettDecember 2019 10 Babies and Their Families” using a Likert Methods: The present online survey NPA2019-11 scale of 1-6 (1 = strongly disagree, 6 = study includes women from diverse back- strongly agree). Pre- and posttest scores grounds (N = 825; Age: 18 - 66 years, M = Supporting LGBQ/T Families were analyzed using non-parametric 31.87, SD = 8.69) who have experienced a paired t-tests. pregnancy loss at some point in their life- Rachel Hess, MS, Postpartum Doula time. By utilizing social media platforms, a Results large proportion of minority women were Background: included in the sample (N = 391; 47.40%). Of the 114 staff who registered for the In my practice, I’ve had requests by provid- Participants reported whether fertility ers to learn how to offer truly respectful and course, 87.9% were nurses with a mean of treatment was used to achieve the index 9.6 years of NICU service. All survey items competent care. In my work with LGBQ/T pregnancy, and self-reported causal attri- families, ever single family has encoun- showed posttest mean scores higher than butions of their most recent loss using the pretest mean scores; in 30/33 (90.9%) tered some form of oppression and/or dis- Pregnancy Loss Attributional Question- crimination due to their LGBQ/T identity these differences were significant, p< naire. Examples from this questionnaire 0.05. Night shift staff and staff with shorter during the perinatal period. The research include, If I were a different age, this loss backs up this anecdotal experience. periods of NICU service had lower pretest might not have happened; Others deserve scores on several items; these differences to be a parent more than I did, which helps were eliminated on the posttest. Educa- In a study about lesbian mothers, Dr. to explain why I had the loss; and If I rested Gregg writes: “In all studies reviewed, re- tional needs for staff were identified on more, the loss might not have happened. both the pretest and posttest. searchers reported that lesbian women seeking maternity care experienced some Results: Descriptive statistics indicate Discussion amount of heteronormativity or homopho- that, on average, women’s most recent bia in their health care encounters.” (“The pregnancy loss occurred 4.21 + 3.55 years This education course was highly effective Health Care Experiences of Lesbian Wom- prior to the time of survey completion (N en Becoming Mothers,” by Isabel Gregg, in improving staff knowledge and attitudes = 825). Further, 5.78% of participants (n = about how to support NICU parents, and Nursing for Women’s Health, February 48) reported that they used fertility treat- 2018 Volume 22, Issue 1, Pages 40–50). in eliminating differences between day ment to achieve the pregnancy that was and night staff, and between those with lost. Independent t-tests were conducted shorter vs. longer periods of service in Additionally, transgender and gender non- to determine which causal attributions conforming individuals experience a great the NICU. Areas in need of further educa- (e.g., external attribution, internal charac- tion were identified. Ninety percent of par- deal of oppression and discrimination when terological attribution, or internal behavior- attempting to access health care. “One- ticipants would recommend the course to al attribution) were more prevalent among their peers. Results are most applicable to third (33%) of those who saw a health care women who experienced a pregnancy loss provide in the past year reported having nurses, who represented the majority of following fertility treatment compared to participants. at least one negative experience related women who experienced a loss without to being transgender, with higher rates for ______fertility treatment. Results indicated that people of color and people with disabilities. women who underwent fertility treatment This included being refused treatment, NPA-2019-10 were more likely to attribute their loss to verbally harassed, or physically or sexu- their age, t(668)= -2.49, p=.013, and lack ally assaulted, or having to teach the pro- Causal attributions of pregnancy loss of rest, t(668)= -2.33, p=.020. Further, vider about transgender people in order to amongst women who experienced fertility women who underwent fertility treatment get appropriate care. In the past year, 23% treatment were more likely to report that the loss of respondents did not see a doctor when was related to punishment for “the per- they needed to because of fear of being Alison R. Hartman, B.A., Victoria Grun- son I am,” t(668)= -1.92, p=.056, and that mistreated as a transgender person, and berg, M.S., & Pamela Geller, Ph.D. “others deserve to be a parent more than I 33% did not see a doctor when needed be- did,” t(668)= -2.79, p=.005. cause they could not afford it. (2015 U.S. Introduction: One in four women in U.S. Transgender Survey, Executive Summary, will experience a pregnancy loss during Discussion: Findings indicated that wom- December 2016, page 8) their lifetime. Many women who experi- en who underwent fertility treatment were ence a pregnancy loss attribute the loss to more likely to blame their age and lack of Content/Action: their own behaviors or character; that is, rest for the loss. Notably, these women they blame themselves. Self-blame is also were also more likely to endorse that they In this interactive workshop, participants common among women who experience were less deserving of parenthood and will explore the basics of LGBQ and infertility, and is associated with adverse that the loss was a form of punishment. Transgender identities. We will also gain psychosocial consequences including an Women who undergo fertility treatment a deeper understand of the barriers to increased suicide risk and decreased rela- and experience pregnancy loss may be care LGBQ/T families face. There will be tionship satisfaction. It remains unclear as at increased risk for negative psychoso- research presented on the experiences to whether women who have experienced cial sequelae due to elevated feelings of LGBQ/T individuals have with the medi- pregnancy loss after conceiving with fer- self-blame. It is important that healthcare cal community in general and we will dis- tility treatment attribute the cause of their providers, clinicians, and researchers cuss how this could impact families in the loss differently than women who have ex- be aware of the role of self-blame within perinatal period. There will also be ample perienced a pregnancy loss without under- these reproductive life events to facilitate time and activities for participants to ex- going fertility treatment. The current study psychoeducation and open communica- amine and explore their own potential was conducted to examine whether wom- tion with patients. biases. Participants will have a deeper en who underwent fertility treatment tend understanding of structural, cultural, and to blame themselves for their loss more ______interpersonal homophobia/transphobia/ often than women who did not. oppression and how it affects LGBQ/T
NEONATOLOGY TODAYtwww.NeonatologyToday.nettDecember 2019 11 families when accessing care. Teaching PPD affects between 13% and 19% per- study. methods include, but are not limited to, cent"We ofare new concerned mothers that (Mann, being Gilbody,born really & Furthermore, early mental health support for Data Collection and Measures definingextremely terms low birthand levels weight survivorsof oppression who areas Adamson,small and being 2010), exposed with much to all higher the stresses rates well as activities brainstorming oppression among Black women reaching upward of born at 2.2 pounds or less, and their parents associated with preterm birth can lead to an Participants were first provided a total of incould perinatal also prove care. beneficial. Participants will have a 38%amplification (Gress-Smith, of normal J. L., Luecken,stresses L.that J., deeper understanding of the range of LG- Lemery-Chalfant,predispose people to K., develop & Howe, depression R, 2012; and three questionnaires in a private office. The BTQThe identities, study, published families, October terms, 3, and2017 poten in The- Keefeanxiety et later al., in 2015). life," said Davis Van Lieshout.and Townsend first questionnaire asked for demographic tialJournal needs of during Child thePsychology childbearing and Psychiatry,years. (2005) almost 25% (7.5 million) of Black information including age, education, num- looked at the impact of mental health risk AmericansHe recommended have beenfuture diagnosedresearch focus with on a ber of children, welfare services, psychi- Learning:factors on Extremely Low Birth Weight mentalthe timing illness and typeand ofBlack supports women for risk are factors at a atric history, employment status, income preemies during childhood and adolescence. higherthat would risk of createdevelopment. better mental health and marital status. The second measure- Participants will reflect on their own work, outcomes in preemies. ment,NEONATAL a pre-test /post-test NURSE questionnaire, how"In terms they of may major perpetuate stresses in structural childhood op and- Gavin et al (2005) posit that 10% to 15% was createdPRACTITIONER by the PI to test subjects’ pression,adolescence, and pretermwhat they survivors can do appear to change to be ofThe new study mothers was supported will experience by grants PPD. from Lack the baseline and post intervention knowledge theirimpacted materials/practices more than those to born be culturallyat normal ofCanadian support, Institutes distress, of lower Health economic Research staand- of PPD. The 4-minute video intervention competent.birth weight," We said will Ryan do this J. byVan exploring Lieshout, tus,the U.S. along National with elevated Institute of PPD Child symptoms, Health and highlight the signs and symptoms of PPD. Assistant Professor of Psychiatry and Human Development. St. Agnes Hospital, a large, gender-neutral language in a variety of sometimes results in an increased risk The third instrument, Inventory of Attitudes ways.Behavioral We will neurosciences brainstorm gendered at McMaster lan- towards Seeking Mental Health Services University and the Albert Einstein/Irving forAdditional poor pregnancyauthors on the outcomes study came including from the community teaching hospital guage used in perinatal work, look at their (IATSMHS) (MacKenzie, Knox, Gekoski, Zucker Chair in Neuroscience. pretermdepartments birth ofamong psychiatry Black women.and behavioral Black in Baltimore, Maryland is own materials and practice making them womenneurosciences; have double pediatrics, the risk and of white psychology, wom- & Macaulay, 2004) was used to measure more"If we inclusive. can find We meaningful will also role-play interventions inter for- enneuroscience for preterm and births behavior and atlow McMaster. birth weight subjects’recruiting attitudes aboutfor amental full-time health ser - view/classExtremely usingLow Birthgender Weight neutral survivors language. and (Orr, James, & Blackmore, 2002). The vices. IASMHS is a 24-item measure with I theirwork parents,to create we a cansafe improve learning the environ lives of- increased risk for preterm and low birth threeneonatal subscales: nurse Psychological practitioner openness, mentpreterm where survivors participants and potentially can understand prevent the weightRapid Whole-Genome births among BlackSequencing women of NICU con- help-seekingto work propensity,rotating anddays indifference and thedevelopment depth of biases of depression and the structural and anxiety na -in tributesPatients to Is the Useful high and rate Cost-Effective of infant mortality/ - to stigma. Subjects indicate their level of tureadulthood." of trans/bio/homophobia. Participants deathsFindings within Reported the first at ASHG year 2017of life. Annual Knitzer, agreementnights within eachthe statementNICU, well using a will have an opportunity to ask questions, Theberge,Meeting and Johnson (2008) found that 5-pointbaby Likert nursery scale (rangeand attendingis from 0 to 4, examineThe study their utilized experiences, the McMaster and Extremely under- infants with mothers who are depressed 0=disagree, 4=agree). standLow Birth the difference Weight Cohort, between which includes intent a and mayRapid experience whole-genome loss ofsequencing early connections (WGS) of deliveries. St. Agnes has a group of 179 ELBW survivors and 145 normal acutely ill Neonatal Intensive Care Unit impact. and may develop decreased sensitivity, Knowledge of Postpartum Depression by birth weight controls born between 1977 and (NICU) patients in the first few days of life Pre-testlevel and 3A Post-test NICU staffed by a 1982, which has 40 years' worth of data. attentiveness,yields clinically and useful cognitive diagnoses stimulation. in many Plan for Action: Likewise, children whose mothers experi- group of four neonatologists cases, and results in lower aggregate costs To test the hypothesis that viewing the The study showed that although these encethan thedepression current standard are also of at care, high according risk for Participants will walk away with an un- psychopathology. “Youand Are an Not experienced Alone” video interventiongroup derstandingpreemies were of not how necessarily to make exposed their work to a to findings presented at the American Society would improve knowledge pre-test (M = culturallylarger number humble, of risk anti-biased, factors compared and what to of Human Genetics (ASHG) 2017 Annual 4.07,of SDNNPs. = 2.02) and knowledge post-test their normal birth weight counterparts, these MethodsMeeting in Orlando, FL. resourcesstresses appeared and information to have a theygreater need impact to (M = 5.48, SD = 1.88) with Black women a follow up with and continue to learn. paired sample t-test was conducted. The on their mental health as adults. ResearchShimul Chowdhury, Design PhD, FACMG, Clinical Please send CVs to: Laboratory Director at the Rady Children's hypothesis was found statistically signifi- ______Besides bullying by peers and a small circle of ThisInstitute study for is Genomic an exploratory Medicine, pre-test and and his cant (p Karen< .000). Broderick, MD friends, researchers looked at a number of post-testcolleagues survey focused design. their analysis Black female on a broad pa- NPA2019-12other risk factors, like maternal anxiety or tientsswath wereof NICU recruited patients with for flierswhom athat genetic were [email protected] Towards Seeking Mental Health depression and family dysfunction. provideddiagnosis to themmight when help theyinform checked treatment in for Services by Pre-test and Post-test Providing education on PPD in a hospital theirdecisions prenatal and visitdisease or uponmanagement. admission They to setting"We believe may beit may a good be helpful way to to help monitor wom and- postpartum,studied thelabor, clinical and delivery utility units. and To test the hypothesis that the “You Are Not enprovide become support more foraware the ofmental the signs health and of cost-effectiveness of sequencing infants and Alone” video intervention would influence symptomsmothers of of preemies, PPD in particular, as for the Sampletheir parents. attitudes pre-test (M = 27.11, SD = 11.97) purposes of this study, they were the primary and attitudes post-test (M = 30.47, SD = Kendracaregiver," Flores said Carter Van Lieshout. The"Newborns study often was conducteddon't fit traditional using methods a con- 10.81) held by subjects, a paired sample venienceof diagnosis, sample as (N they = 43)may of present postpartum with t-test was done. No significant difference Introduction/Background"There can also be family strain associated Blacknon-specific women. symptoms . Inclusion or criteria display included: different between attitudes towards seeking mental with raising a preemie and all the related signs from older children," said Dr. According to Keefe, Brownstein-Evans, (a) English speaking Black women, (b) health services for PPD pre-test and post- medical care, which can lead to difficulties. 18Chowdhury. years of age In ormany older, such (c) pregnant cases, he or test (p = 0.75) was found. Lane,Support Carter, for the and family Polmanteer in a variety (2016) of forms re- explained, sequencing can pinpoint the cause postpartum women, and (d) women who searchmight also on be postpartum beneficial." depression (PPD) of illness, yielding a diagnosis that allows Discussion has increased substantially, however the self-identifydoctors to modify as Black. inpatient Exclusion treatment criteria and included: Women who had experienced populationThe paper being builds studiedon previous for research postpartum that resulting in dramatically improved medical The results suggested that providing edu- identified that ELBW survivors have an miscarriages,outcomes in both fetal the demises,short- and andlong-term. stillborn depression has been mostly White wom- cation on PPD in a hospital setting may be enincreased with access risk of to mental mental illness health in adulthood. services. deaths. Prisoners and hospital employees were also excluded from participation in a good way to help women become more
The 37th Annual Advances in Care Conference – Advances in Therapeutics and Technology March 24-28, 2020; Snowbird, UT
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NEONATOLOGY TODAY t www.NeonatologyToday.net t March 2018 21 NEONATOLOGY TODAYtwww.NeonatologyToday.nettDecember 2019 12 aware of the signs and symptoms of PPD. from a family member, or from a commu- Black women gaining education on signs nity organization. Some are following with OPIOIDS and NAS and symptoms may help them reach out their own therapist. All reported coming to When reporting on mothers, babies, for help the moment they start noticing clinic because this was a service for their and substance use symptoms of PPD. The results indicated child. However, when they were offered in- LANGUAGE MATTERS that the intervention did not influence dividual therapy, most declined. the participants’ attitude towards seeking I am not an addict. Current interdisciplinary NICU model high- mental health services as hypothesized. I was exposed to substances in utero. The results further suggested that there is lights the need for an integrative approach I am not addicted. Addiction is a set of a grave need for the creation of interven- to mental health screening starting earlier behaviors associated with having a Substance Use Disorder (SUD). tions that could positively influence Black with mothers of high risk infants, such as in women’s attitudes towards seeking servic- the NICU. This would decrease stigma and I was exposed to opioids. es. In Conclusion, current results suggest resistance to treatment. While I was in the womb my mother and I that cultural differences and beliefs sys- shared a blood supply. I was exposed to ______the medications and substances she tems may play a small but significant role used. I may have become physiologically in influencing Black women’s attitudes in dependent on some of those substances. seeking mental health services and future NPA2019-13 research is therefore encouraged to better NAS is a temporary and Improving Access to Perinatal Care: Con- treatable condition. determine the role of diversity in the utiliza- fronting Disparities and Inequities in Ma- tions of mental health services. There are evidence-based pharmacological ternal-Infant Health and non-pharmacological treatments for Neonatal Abstinence Syndrome. ______My mother may have a SUD. NPA2019-12 Legnetto She might be receiving Medication-Assisted Treatment (MAT). My NAS may be a side NICU and Beyond- Assessment and Inter- effect of her appropriate medical care. It is Background: As part of an initiative to re- not evidence of abuse or mistreatment. vention for Infants and their Parents. form the Medicaid system in New York My potential is limitless. Kgomez State, in 2014 over 8 billion dollars were reinvested into the NYS Medicaid system I am so much more than my NAS diagnosis. My drug exposure will not NICU and Beyond: Assessment and Inter- to address various aspects of health care. determine my long-term outcomes. vention for Infants and their Parents. A portion of these funds have been used to But how you treat me will. When you invest in my family's health fund projects that work towards promoting and wellbeing by supporting Research shows high emotional distress integrated delivery of services, preparing Medicaid and Early providers for Value Based Payment (VBP) Childhood Education you in parents during their newborn’s NICU can expect that I will do as (Newborn Intensive Care Unit) stay, result- and using patient centered approaches to well as any of my peers! ing in 20-30% diagnosable mental health health care delivery. Many of these proj- disorders in the first year. Parents experi- ects focus on improving maternal and in- ence grief, anxiety, fear and guilt. Early de- fant health outcomes, as these groups Learn more about make up a large portion of Medicaid en- Neonatal Abstinence Syndrome tection and intervention improves mental at www.nationalperinatal.org health, parent-infant attachment, and can rollees. significantly reduce adverse childhood ex- periences. In NYS, premature birth is the leading model serves as a roadmap of how to cause of death in infants and affects 1 out implement program and policy changes We report on an interdisciplinary outpatient of every 10 babies born. In Central New than can help practices improve screening NICU follow up clinic model we developed York (CNY), the premature birth rates per for these factors during the prenatal care at the UMass Medical School in Worces- county range from 7.6% to 12.5%, and period. It provides risk assessment tools, ter, MA, to screen for maternal depression have shown no significant change in the educational materials, policy templates, while providing medical and developmen- past 10 years. In September 2017, St. Jo- information on reimbursement and VBP, a tal evaluations of their infants. seph’s Health, a hospital located in Syra- quality improvement plan and a system to cuse, NY received grant funds to develop screen, make referrals and follow up part This weekly clinic includes a child psy- and promote a program that focuses on of the routine practice and sustainable. chologist, a neurodevelopmental pediatri- reducing the rate of premature births in six The model of care is the focal point of our cian and a physical therapist. Infants are CNY counties. The program partners with provider toolkit, which features additional evaluated using the Mullen Scales of Early participating birthing hospitals and outpa- educational materials and risk prevention Learning, or the Newborn Behavior Obser- tient obstetrical care providers to address resources. All information is available on vation, and physical therapy evaluation. four specific risk factors associated with our website as well. Infants receive a developmental and neu- premature birth: tobacco use, alcohol and rologic examination. Mothers are asked substance use, stress and oral care by en- Our team has formal contracts with 12 about post-partum stressors, depression suring evidence-based screening tools are birthing hospitals and outpatient prenatal and/or anxiety. built into the medical record. care providers and continues to meet with and sign on potential partners. We have Over the course of 10 months, we evalu- Content/Action: Our Preemie Prevention gained support from over 40 state and lo- ated 80 infants and their mothers. Majority team has developed a Clinical Standards cal community based organizations, gov- of infants were in early intervention (80%). Educational Protocol Model of Care to ernment entities and additional businesses Mothers reported feeling overwhelmed address comprehensive screening prac- including health departments, third party while their infant was in the NICU. About tices by making system changes. Follow- payors, pharmacies and pharmaceutical half of them reported receiving support ing Medicaid and ACOG guidelines, this companies. Several of these organiza-
NEONATOLOGY TODAYtwww.NeonatologyToday.nettDecember 2019 13 tions have agreed to post the program’s Implications for Practice: In creating this in a sample of neonates with dual MAT and educational “posterzine”, a patient-friendly educational model of care, we have come psychotropic medication exposure born to graphic that highlights risk factors that can across three significant implications for mothers seeking outpatient MAT for opioid lead to a preterm birth and how to address practice. First, the process of screening, use during pregnancy. each one. Kinney Drugs, a local pharmacy educating and referring to additional treat- chain, has posted the posterzines in all of ment needs to be a part of any health care Method: Retrospective medical chart re- their locations and the Onondaga County appointment for any woman of childbear- view was conducted for women undergoing Health Department has posted these in ing age and/or those who are trying or prenatal care at a multifaceted substance their public breastfeeding pods across the are currently pregnant. Women who are abuse treatment clinic and their newborns county. Our posterzine has been featured engaging in or exposed to risky behaviors (N = 460). Medical chart abstraction in- on a local news media segment during and environments should be supported, cluded information regarding demograph- premature awareness month and used as educated and if needed referred, to aid in ics, MAT, pregnancy/childbirth characteris- a marketing and educational piece at sev- increasing their own health and decrease tics, and neonatal medical care. Maternal eral events including the 2018 NYS Fair. negative health risks to their baby. This is characteristics: majority Caucasian (90%), In November 2018, our team organized extremely important for women who have unmarried (77%), insured through Medic- and held an educational conference titled, language or cultural barriers, as this may aid (91%); Mage = 28 years. Infant char- Healthy Moms, Healthy Babies: Your role be one of the only times she seeks health acteristics: Mgestational age at birth = 38 in Preemie Prevention with speakers from care and can be helped. A health care pro- weeks. Psychotropic medications: SSRIs, NYSDOH, parent and partnering organi- vider, especially a nurse educator or social benzodiazepines, Clonidine. Outcome zations, vendors and audience attendees worker, can be a very influential part of her variables of interest included NICU admis- of 80+ from CNY and adjacent counties. support system. sion, diagnosis of NAS, days until onset of Speakers at the conference focused on: NAS, maximum Finnegan score, median Current status of Maternal-Infant Mortality Second, screening for women of child- neonatal morphine dose, and if the infant in NYS, Obstetrics and Value Based Pay- bearing age and/or those who are trying was discharged home with the mother. ments, Clinical approach to better birthing or are currently pregnant needs to be uni- outcomes and sharing positive practice versal, regardless of age, race, ethnicity, Results: About half the sample had a psy- outcomes from using our model of care. socioeconomic status or any other po- chiatric diagnosis documented in preg- tentially distinguishing characteristic. This nancy (54%) and 51% of participants were Lessons Learned: The concern of prema- is important in establishing and ensuring prescribed a psychotropic medication. In ture birth is one that involves much more health equity for all patients and avoiding general, there were no differences be- than just these four risk factors. Through bias or discrimination. All women should tween women who had a psychiatric diag- our developmental research and many be provided the same level and courteous- nosis and/or were prescribed psychotro- conversations with nurses, clinicians and ness of care. pic medication and those women without health care professionals, we have found psychiatric diagnosis/medication. Women that in addition to these social risk factors, Finally, after performing these screening who took benzodiazepines during preg- women and families are faced with several practices, comprehensive documentation nancy gave birth to infants who needed a other clinical, societal, environmental and must be kept in the medical record. Com- higher morphine dose (M = .11, SD = .28) other issues that could lead to a prema- prehensive and accurate documentation is than infants without benzodiazepine expo- ture birth. Therefore, one of the lessons important for compliant health care prac- sure (M = .07, SD = .09), t(423) = 2.70, learned is that addressing premature birth tices. Building reportable fields is crucial p = .007, 95% CI -.08, -.01. Infants with should start when a woman is considering for internal and external auditing and will benzodiazepine exposure also had higher becoming pregnant, so as to asses her be used in the future for reimbursement for maximum Finnegan scores (M = 11.20, SD current way of life and connect her with services. = 3.50) than those without exposure (M = any needed clinical or community services 10.36, SD = 3.83), t(399) = 2.04, p = .008, before pregnancy. ______95% CI -1.66, -.03.
In talking with many providers and office NPA2019-14 Discussion: Having a documented psychi- staff, we came across a few reoccurring is- atric diagnosis and/or treatment with psy- sues. The first issue being that there are Neonatal outcomes following dual expo- chotropic medication was not associated so many patient education materials in sure to medication assisted treatment for with any neonatal outcomes. However, circulation, it is difficult to find time to re- opioid use disorder and psychotropic med- benzodiazepine use, either prescription search the “best” for an office and to use to ication in utero or illicit, appeared to be associated with more severe NAS requiring more intensive correspond with provider teachings. In ad- A. Meyer, M. Sharp,, PhD, M. Prasad, DO, dition, we found a second issue to be that NICU intervention. This information may MPH, C. Lynch, PhD, MPH, K. Carpenter, help MAT and general obstetric provid- patient education was not being fully done Ph.D. after screening because providers did not ers counsel mothers regarding the risks know where to send patients for additional Introduction: Medication assisted treat- of benzodiazepine use during pregnancy. and follow up care. Learning these lessons ment (MAT) for opioid use disorder (OUD) MAT programs should regularly screen for early on in developing our model of care, decreases the risk and severity of neona- psychotropic medication use and incorpo- gave us time to compile comprehensive tal abstinence syndrome (NAS) compared rate education into standard practice. and commonly used materials (and create to illicit exposure to opioid drugs. Concur- ______our own posterzine) and a list of referring rent prenatal exposure to psychotropic providers and community based organi- medications and MAT may be associated NPA2019-15 zations, specific to each risk factor, addi- with more severe NAS, including longer tional area of need and geographical loca- duration of opioid treatment, withdrawal PSS:NICU - Understanding aspects of tion. These materials and information was symptoms, and total hospital stay. The Postpartum Stress shared and well received from providers. purpose of this study was to examine NAS
NEONATOLOGY TODAYtwww.NeonatologyToday.nettDecember 2019 14 Chavis Patterson, PhD, Director of Psy- PSS:NICU is a validated survey which high parental stress. Using this informa- chosocial Services, Division of Neonatolo- asks parents to rate their level of stress as- tion, we will create a strategic program to gy, The Children's Hospital of Philadelphia, sociated with 37 items in four categories: help parents cope with NICU stress and Assistant Professor of Clinical Psychology sights and sounds of the NICU, the baby’s measure whether such intervention can in Psychiatry, Department of Psychiatry, appearance, parental role, and staff com- successfully mitigate risk for Perinatal Perelman School of Medicine at the Uni- munication. Responses were recorded on Mood and Anxiety Disorders (PMADS). versity of Pennsylvania a 5 point likert type scale (1 = not at all stressful, 5 = extremely stressful). ______Pamela Geller, PhD, Associate Professor of Psychology and Interim Director of Clini- Our goal was to identify specific environ- NPA2019-16 cal Training, Drexel University, Research mental contributors and then address Associate Professor of Obstetrics and them through later programing – psycho- Supporting Parent-Infant Bonding and Pa- Gynecology, Drexel University College of education, exposure, coping strategies. rental Mental Health Medicine, Co-Director of Drexel’s Mother Baby Connections Program Lessons Learned Gabrielle R. Russo, B.S. and Pamela A. Geller. Ph.D. Katherine Guttmann, MD, MBE, Fellow, Overall, 45% of responses were reported Neonatal-Perinatal Medicine, Division of as either very or extremely stressful. Par- Introduction: The first year of human life Neonatology, The Children’s Hospital of ents reported the highest levels of stress involves substantial physical, emotional, Philadelphia relating to “The appearance of my baby” and social development. An infant is in- and “Relationship with infant and parental fluenced significantly by their immediate John Chuo, MD, MS, Neonatologist, Divi- role.” In the subcategory of “The appear- social environment and caregivers. Par- sion of Neonatology, The Children’s Hos- ance of my baby”, over 25% of parents ents can facilitate growth and demonstrate pital of Philadelphia, Associate Professor found the following items to be very or emotion regulation and social interactions of Clinical Pediatrics, Perelman School of extremely stressful: Being separated from for their children. Therefore, the health of Medicine at the University of Pennsylvania my baby (50%), Not feeding my baby my- the parent-infant relationship and substan- self (26%), Not being able to care for my tial parent-child interactions are crucial for Background baby myself (24%), Not being able to hold maximizing exploration and learning op- my baby when I want (39%), Feeling help- portunities for the child. Parenting an infant in the Neonatal Inten- less and unable to protect my baby from sive Care Unit (NICU) is often distressing, pain (46%), Feeling helpless about how to Previous studies have evaluated the rela- as parents must navigate the challenges help my baby during this time (45%). For tionship between satisfaction with social of complex medical systems and begin the subcategory of “The appearance of support and mental health. For example, to develop their parental identities. For my baby”, 25% or more parents reported social support from partner and peers many, this experience is accompanied by that the following items were stressful: was negatively associated with mother’s severe psychological distress. Parents When my baby looked to be in pain (47%), postpartum depression (Dennis & Letour- are at heightened risk for adverse mental When my baby looked sad (33%), Tubes neau, 2007) and dissatisfaction with social health outcomes, including depression, and equipment on or near my baby (25%), support from parents was positively cor- anxiety, and post-traumatic stress. The Bruises, cuts or incisions on my baby related with maternal postpartum depres- rate of Perinatal Mood and Anxiety Dis- (27%), and My baby's unusual or abnor- sion scores (Heh et al., 2004). Additionally, orders (PMADS) for mothers and fathers mal breathing pattern (31%). One sub- prior research has assessed the relation- who have a baby in the NICU (up to 70% question in the Sight and Sounds category ship between parental mental health and & 70%, respectively) is significantly higher that scored above 25% was The sight of parent-infant bonding; Parfitt, Pike, and when compared to those who do not have having a machine breathe for their baby Ayers (2013) observed an association be- a child in the NICU (10-20% & 10-14%, (27%). tween parental prenatal anxiety as well as respectively). These responses continue father’s postnatal depressive symptoms beyond the NICU hospitalization experi- Surprisingly, parents were not very or ex- and poor parent-baby interaction. Notably, ence (Holditch-Davis et al, 2003; Shaw et tremely stressed by The unusual color of Lutz et al. (2012) observed an interac- al, 2006) and are known to be risk factors my baby (19%), The small size of my baby tion effect of informational social support for disruption in the parent-infant relation- (4%), or Seeing needles and tubes put on maternal-child interactions for mothers ship, and delays in infant development. in my baby (21%). Parents were also not with high levels of stress. Thus, evidence very or extremely stressed by the staff be- suggests reason to investigate the role that Content/Action haviors and communication or the Sights increased social support may play in pro- and Sounds in the unit. moting parent-infant bonding. The current In an effort to parse out and explore spe- study seeks to understand this relationship cific NICU environmental features contrib- Implications for Practice and extend current knowledge regarding uting to the emotional stressors parents this concept in order to stimulate clinical face, we administered the Parent Stress The intent of this abstract is to identify as- practice for parents’ mental health, directly Scale, NICU version (PSS:NICU). The pects of the NICU experience that cause impacting the mental and physical health
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NEONATOLOGY TODAYtwww.NeonatologyToday.nettDecember 2019 15 of their child. The current study will also self-report survey. The self-report mea- Qualitative investigation of characteristics consider relationship satisfaction which sures included in this study assess par- of social support related to traumatic child- has been shown to play a crucial role in the ent-infant bonding, satisfaction with social birth mental health of parents, where decreased support, depressive symptoms, anxiety relationship satisfaction may be a common symptoms, parental stress, and relation- Meghan Sharp, PhD, Burklee Bradley, BA, predictor of poor mental health (Dudley et ship satisfaction. The relationship between Christyn Dolbier, PhD al., 2001). Additionally, evidence suggests parent-infant bonding and satisfaction with a positive association between parental re- social support will be analyzed. Depres- Introduction: About half of women report lationship satisfaction and the parent-child sion, anxiety, and parental stress will be dissatisfaction with their childbirth expe- relationship (Erel & Burman, 1995). examined as potential mediators. Parents rience, and some women appraise their of 3 to 12-month-old infants with a current childbirth as a traumatic event. Traumatic Finally, in order to thoroughly address fac- romantic partner, all in cohabitation, will childbirth appraisal is associated with post- tors impacting parental-child interactions, it be eligible to complete the 110-item sur- partum emotional distress that can inter- is critical to measure a parent’s perception vey administered on Amazon Mechanical fere with mother-infant interaction. While of their child’s temperament. As described Turk with compensation provided. Primary postpartum social support may provide a by DiLalla and Jones (2000), infant tem- and secondary hypotheses will be ana- buffer against distress, negative social in- perament is based on the behaviors and lyzed using a series of linear and multiple teractions may have the opposite effect. reactions of infants to life events. A great regressions. Participants will be workers The purpose of this study was to explore deal of research has shown significant as- of Amazon Mechanical Turk (MTurk) and women’s descriptions of their traumatic sociation between parental behavior and recruited through the TurkPrime website. childbirth and types of childbirth-specific parental mental health with infant tempera- The study will be posted on TurkPrime and postpartum social support. ment (Whiffen & Gotlib, 1989; Greenwell, distributed throughout the months of Janu- 2015). In fact, negative infant tempera- ary and February. Data collection will con- Method: Women who had given birth in ment at 8 weeks was significantly asso- clude, and results will be analyzed in the the prior year (N = 129) were recruited via ciated with not only maternal postpartum month of March. social media for an online study regarding depression, but poorer face-to-face inter- difficult childbirth experiences. The major- actions between infant and mother (Mur- Results: It is expected that more satisfac- ity was White (84%), married (76%), em- ray et al., 1996). It is hypothesized that: tion with social support will be correlated ployed (56%), and had private insurance with and predict higher quality bonding (69%). Participants typed responses in an 1) A direct relationship exists between between parents and infants. Additionally, open-ended format to prompts to describe satisfaction with social support and results are expected to show that parental their difficult childbirth, identify childbirth parent-infant bonding, mental health mediates this relationship, characteristics that contributed to trauma specifically, that having greater satisfac- appraisal, and to describe positive, nega- a) Greater satisfaction with so- tion with social support results in more tive, and hoped-for social support related cial support is associated with a positively rated mental health, ultimately to childbirth. healthier bond between parent leading to higher quality parent-infant and infant. bonding. Finally, it is expected to be shown Results: Common themes identified in dif- that positively rated mental health will be ficult childbirth descriptions and trauma b) Satisfaction with social support associated with better perceived infant appraisal included medical characteristics from partner has a stronger asso- temperament. of childbirth (e.g., emergent C-section, 83- ciation with parent-infant bonding 92%), elevated perception of risk (e.g., than does satisfaction with social Discussion: Studying the relationship be- nursing staff rushing, 25-40%). Dissatis- support from others. tween a parent’s satisfaction with social faction with healthcare support (e.g., per- support and the health of the parent-infant ceived negative comments from medical 2) Parent mental health mediates the bond within the first year postpartum may providers) was reported by 26% of partici- relationship between satisfaction provide valuable insights. For example, if a pants in their difficult childbirth description, with social support and parent-infant direct relationship is found to exist, it would but only 4-6% of trauma characteristics. bonding: support the need to evaluate the parent’s Women reports positive reactions to emo- social support network and parent-infant tional (73%) and tangible (15%) support a) Greater satisfaction with social related to birth. Negative social interac- support is associated with better bonding in addition to parental mental mental health. health following the birth of a child. Few studies have analyzed the relationships b) More positively scored mental between the current variables. The current health is associated with a health- study builds upon and extends the current ier parent-infant bond. literature as it is the first study to attempt to distinguish a direct association between 3) Parental mental health is associated satisfaction with social support and parent- with more parental perceptions of in- infant bonding. Previous studies have pri- fant temperament: marily assessed heterosexual mothers, making the proposed project unique in that a) More positively scored mental fathers and individuals who are members health is associated with more of a non-heterosexual couple are eligible positive perceptions of infant tem- for participation. perament. ______Methods: The current study has a cross- sectional design consisting of one online NPA2019-17
NEONATOLOGY TODAYtwww.NeonatologyToday.nettDecember 2019 16 tions were described as minimizing (23%), utilizing Parents as Teachers (PAT) as personally insulting (e.g., commenting on an educational model and activities were maternal age, 28%), blaming the mother measured using the Wheel of Interven- (14%), dismissing the mother’s needs tions defined by the Minnesota Depart- (10%), and lack of support from medical ment of Health. professionals (10%). Women reported that A collaborative of professional, clinical, they wished they had received better post- Lessons Learned community health, and family support organizations improving the lives of partum emotional support (40%), greater premature infants and their families through explanation/understanding of childbirth The results of this study show that 21 cli- education and advocacy. events (17%), and more support from ent families were engaged in services medical professionals (17%). using Parents as Teachers model or PAT health topics. Thirteen clients declined Conclusions: Several themes related to home visiting services. Engaging clients medical care were common in descrip- in home based services enhanced Zika tions of difficult and traumatic childbirths. related surveillance and collaboration be- These themes are reflected in participants’ tween clients, their primary providers, and descriptions of negative social interactions the health department. related to birth and types of support they would have liked to receive, in retrospect. Implications Women’s accounts can inform recom- Utilizing a home visiting strategy allowed The National Coalition for Infant mendations for peripartum doctor-patient Health advocates for: communication. This information may be client families to engage in family supports for their children and connect parents and Access to an exclusive human milk particularly useful for obstetric providers diet for premature infants children with their community. Parents as caring for women who have high risk preg- Increased emotional support resources nancies or deliveries that require escalat- Teachers model is a valuable strategy for for parents and caregivers suffering from PTSD/PPD ed medical intervention. educating families while screening for de- velopmental and other needs. The Wheel Access to RSV preventive treatment for all premature infants as indicated on the ______of Interventions provides a unique method FDA label of measuring process outcomes. Active Clear, science-based nutrition guidelines NPA2019-18 surveillance was enhanced with this col- for pregnant and breastfeeding mothers laboration. Safe, accurate medical devices and Utilizing Evidence to Develop a Home Vis- products designed for the special iting Program for Zika Virus Affected Fami- ______needs of NICU patients lies NPA2019-19 www.infanthealth.org Sharon Starr, MSN, RN, Rachel Blumen- Partnering with patient advocacy groups to feld, MPH, Mariah Menanno the ideation of solutions for challenges fac- identify challenges and solutions for post- ing those affected by PPD. Four meetings partum mental health care. Background were held with 31 patient advocates/advo- cacy groups in Baltimore, Chicago, Hous- In 2016, Zika virus affected populations Marjorie Stewart-Hart1, Emily Gusse1, Zo ton, and San Francisco, with participants throughout the Caribbean, Central and Ratansi2, Chris Zealey2, Devra T. Dens- from the surrounding geographic areas. South America and small areas of south- more1 Each meeting included a one-on-one infor- ern United States. Zika infection of preg- mation sharing session and a group work nant women places infants at risk for con- Affiliations: 1 Sage Therapeutics, Inc., session. These sessions were focused on genital Zika syndrome characterized by Cambridge, MA, USA; 2 Sixsense Strat- the following questions: 1. What can be brain malformations, other birth defects, egy Group, Toronto, ON, CA done to reduce/eliminate the stigma as- and concurrent developmental delays. sociated with PPD? 2. What can be done Zika was monitored as an emerging infec- Abstract Category: Innovative Models of to improve the collaboration amongst Ad- tious disease. Approximately 12% of Phil- Care vocacy Groups, Providers, Government, adelphia’s 1.5 million residents routinely Background: Postpartum depression is the etc.? 3. What can be done to ensure that travel to their countries of origin, many of most common complication of childbirth. programs, tools, services, communication, which are Zika endemic countries, risking In the United States, estimates of new etc. serve the needs of the diverse popula- Zika virus infection of the individual or the mothers experiencing symptoms of PPD tion of women and families that are impact- sexual partner and possible vertical trans- vary by state from 8-20%, with an overall ed by PPD? 4. What can be done to better mission to the newborn. average of 11.5%, and in the absence of reach women and families in rural and/or Action universal screening, approximately 50% underserved communities? 5. What can of PPD cases may go undiagnosed. Addi- be done to improve screening and diagno- The Philadelphia Department of Health tionally, it has been reported that approxi- sis of PPD? 6. What can be done to im- (PDPH) provided surveillance of Zika- mately 50% of women receiving referrals prove a PPD patient’s ability/opportunity to associated birth defects as well as fam- for perinatal mental health services do not connect with care providers? and 7. What ily support services. Mothers of the U.S. receive care. is needed to support the effectiveness and Zika Pregnancy Registry were engaged development of Patient Advocacy Organi- in home visiting activities for education, Content/Action: This presentation will illus- zations? developmental screening, and support in trate the positive outcomes resulting from caring for themselves and their offspring. engagement with the postpartum depres- Lessons learned: The home visiting program was developed sion (PPD) advocacy community, including
NEONATOLOGY TODAYtwww.NeonatologyToday.nettDecember 2019 17 The learnings from these meetings pro- parties involved-regardless of the above of babywearing increases oxytocin levels, vided key insights into to the needs of PPD mentioned factors. In my experience as which supports connectedness, bonding, patients and their advocates. These meet- an expecting mom, I found there was not and love. Especially when taking into con- ings also demonstrated how, through lis- much access to information about ways to sideration the fact that infant abuse and tening and tapping into the strength, spirit care for my babies that would safely meet shaken baby syndrome are overwhelm- and determination of advocates, we can all three of our needs while positively sup- ingly caused by the inability to calm a unlock solutions for the challenges fac- porting my transition into my new role as crying baby, it is evident that baby carrier ing the PPD community. Major learnings their mother. education has a role to play in increasing focused on: how to improve collaborative the likelihood that caregivers will respond care, ensure that programs/tools/services Content: more sensitively and appropriately to their meet diverse patient needs, and how best baby’s needs. to interact with patient advocacy organiza- In this presentation, I will share how the tions. benefits of regular baby carrier access and Lessons Learned: usage can help bridge the gap created by Implications for Practice: health disparities and inequities. I will high- Promoting the use of baby carriers can be light how this culturally historic practice can an effective way to confront health dispari- The learnings from these meetings pro- improve the infant and parent’s health and ties and inequities during the perinatal time vided key insights into to the needs of PPD well-being as evidenced through attach- period and beyond. In this presentation, I patients and their advocates. Sharing the ment theory and the theory of psychoso- will share how having my twin babies so information gathered from these meetings cial development. I will address the public close to me decreased the severity of my is an important step towards establishing health benefits that naturally occur when own perinatal mood and anxiety disorders greater collaboration between patients, using an infant carrying device. Further- while promoting an unbreakable bond with patient advocates, health care provid- more, I will share the specific ways baby- my daughters. Babywearing made it pos- ers, and other organizations to enhance wearing empowered me as a new mother sible for my babies to sleep peacefully on postpartum mental health care and make and how it supported me during the transi- me while I tended to the daily demands of a difference in the lives of moms, babies tion into my new life after the birth of my my adult life, thus building my confidence and families. Fostering such coordinated twins in ways that would have otherwise as a mother and in my abilities to care for action and collaborative care may be one been unobtainable. them. This hands-free caregiving option way to enhance postpartum mental health also helped me exceed my breastfeeding care. The mother's chest is the natural habitat goal of 2 years. Most importantly, baby- for her newborn during the transition to be- wearing helped me maintain my sanity ______ing outside of her womb. Infant carrying during difficult life situations and circum- devices bring babies back to that habitat, stances. The close contact facilitated by NPA2019-20 and can be used with skin-to-skin con- the baby carrier played the most significant tact or a clothed baby. Babywearing is role in allowing me to thrive as a mother, Baby Carriers: Bridging the Gap of Health the best way to ensure baby and mom- or which in turn helped my girls thrive and Disparities for Mothers and Babies any emotionally involved caregiver- con- find their own confidence and indepen- tinue to reap the benefits of kangaroo care dence when they were ready. Tello and close contact over the first few years, Background: which is a crucial time for baby’s social, In addition to describing my personal ex- emotional, and cognitive development. periences as a mother of twin girls, now The transition into parenthood can be pre- 5.5 years old- and still tandem worn-, I will pared for, but the course of events can- Some of the benefits for babies include share how my journey has influenced my not always be predicted. When looking at greater physiologic stability, more regu- passions and why this work is so impor- the bigger picture there is no doubt that lar sleep patterns, improved weight gain, tant. My current work involves empower- socioeconomic and sociocultural factors and more successful breastfeeding rates.* ing new and expecting moms during their (i.e. family stability, access to resources, Babies who are carried in an infant car- transition into motherhood through the use academic competency, ethnicity, etc.) rier are more easily soothed, more likely of baby carriers in a way that will positively play a role in the staggering rates of ma- to be calm and less likely to cry because impact her infant’s socioemotional and ternal and infant health issues. Forming they are with a familiar adult. They become cognitive development. healthy bonds and secure attachments one unit with their caregiver and can feel with babies early in life will positively im- and hear the familiar heartbeat, breath- Implications for Practice: ing pattern, movements and voice while pact their development, while decreasing Babywearing is a practice being adopted stress on new parents. Access to baby still leaving caregivers hands free. Addi- tionally, because the baby is so close, the by a growing number of parents world- carriers and best practices education can wide. Both healthcare providers and par- help decrease health disparities because caregiver is likely to talk to baby, stimulat- ing brain development and enhancing lan- ents should have a better understanding they facilitate hands-free, close contact of this growing phenomenon, its impact on and meets the evolutionary needs of all guage nutrition. The physical closeness
NEONATOLOGY TODAYtwww.NeonatologyToday.nettDecember 2019 18 public health issues, and the infant’s social, emotional, and cogni- tive development. All those involved in infant care should have a better understanding about the benefits of utilizing baby carriers and be aware of the best practices. Evidence that babywearing can positively support maternal and infant health and develop- ment is mounting and deserves more research. Implementing ac- cess, education, and the regular use of baby carriers will not only help address current public health and other maternal-infant re- lated concerns, but it can also help positively influence the health and development of generations to come.
*Source: Kangaroo Care -Cleveland Clinic
Note: This presentation was previously given at the 2017 National Perinatal Association Conference, and discussed how babywear- ing my twins positively impacted my perinatal mental health and transition into motherhood. It has since been updated to include information that focuses on how babywearing can support overall mental and public health for both infants and parents.
______
NPA2019-21
Development and Implementation of a Postpartum Depression Screening Program in the Neonatal Intensive Care Unit.
Angela Vaughn RN, NNP-BC
Background:
Postpartum depression (PPD) is an unexpected complication of pregnancy (Association of Women's Health & Neonatal Nurses, 2015). Risk factors associated with PPD include: prior history of depression anxiety, unplanned pregnancy, disadvantaged so- cioeconomic status, difficult relationships and recent stressful life events (Hawes, McGowan, O'Donnell, Tucker, &Vohr, 2016). The exact cause of PPD is unknown but thought to be a multi- factorial dyad of physical and emotional changes (Ugarte et al., 2017). Rapid decline of estrogen, progesterone, and increase of circulating autoimmune thyroid antibodies are physical changes following childbirth thought to be attributed to PPD development. (Beil,2017). Emotional components of PPD include mood swings, sleep deprivation, exhaustion, physical discomfort associated with postpartum recovery and difficulty with self-identity (Dunlop, Logue, & Thorne, 2016).
Untreated postpartum depression negatively effects maternal/ child health. Prior to PPD identification and treatment, mothers experience dysfunction of maternal/infant bonding, poor nutrition, relationship challenges and poor healthcare compliance (Farhat, Saeidi, Mohammadzadeh, & Hesari, 2015). Infants and children born to mothers with untreated PPD experience longer lengths of hospitalization, bonding/attachment issues, abnormal sleep patterns, poor growth, developmental delay and behavior disor- ders of childhood (Ward, Kanu, & Robb, 2017). The Centers for Disease Control and Prevention estimate 10-15% of childbearing women will develop PPD (American Academy of Pediatrics. aap. org (2015); Hawes, McGowan, O'Donnell, Tucker, & Vohr, 2016). The incidence of PPD increases to approximately 40% in mother’s whose infants are admitted to the Neonatal Intensive Care Unit (NICU) (Cherry, Blucker, Thornberry, Heatherington, & McCaffree, 2016).Postpartum depression screening improves identification, referral and treatment for mothers and is recommended by key national women and infant organizations (American College of Obstetricians and Gynecologist, 2015; Association of Women's Health & Neonatal Nurses, 2015; Earls, 2010).In addition to PPD screening, national organizations recommend PPD referral, treat-
NEONATOLOGY TODAYtwww.NeonatologyToday.nettDecember 2019 19 ment and follow-up program development in facilities providing sis plans should be in place. care to women and infants. Supporting the evidence-based PPD screening recommendations published by key professional orga- Implications for Practice: nizations aimed at women, infants and children, I propose devel- oping and implementing a PPD screening program for use in the Development of PPD screening programs and screening for PPD NICU. in the NICU has short and long-term benefits for the NICU patient and family. Maternal and infant health suffers from undiagnosed Content/Action: PPD. Infants admitted to the NICU are at risk for neurodevel- opmental delay, difficulty feeding, poor weight gain and lengthy Unrecognized postpartum depression has long-term adverse hospitalization due to prematurity. Mothers of infant’s in the NICU effects for infant growth and development. The American Acad- are at increased risk for PPD. Early recognition of PPD prompts emy of Pediatrics (AAP) periodicity schedule includes a series maternal treatment, improves maternal/infant bonding, infant nu- of well-child screening and assessments designed to foster the trition, family relationships and overall healthcare compliance. parent and provider relationship while focusing on disease pre- (Farhat, Saeidi, Mohammadzadeh, & Hesari, 2015). Infants and vention, tracking growth and development and addressing health children born to mothers with treated PPD experience shorter and wellness concerns from infancy through adolescents. During lengths of hospitalization, improved bonding/attachment issues, the one-month, two-month, four-month and six-month well-child predictable sleep patterns, improved growth, and less incidence screening assessments the AAP recommends universal PPD of developmental delay and behavior disorders of childhood. screening. Well child visits in a Pediatricians office are ideal for PPD screening due to the established primary care provider re- ______lationship and congruency with the onset of PPD. Some infants require prolonged hospitalization and remain admitted to the Neo- NT natal Intensive Care Unit (NICU) and are not eligible to attend well-child visits with a Pediatrician during one or more of the AAP Corresponding Author recommended PPD screening intervals. Although well-child visits are ideal for screening most mothers for PPD screening, the NICU mother, who has a 40% risk of PPD, lacks access to AAP recom- mended universal screening since their infant will not attend rou- tine well-child until post NICU discharge. Early detection of PPD improves maternal and infant outcomes. Overlooking the AAP PPD screening recommendations for NICU mothers with infants Erika Goyer who remain hospitalized potentially increases long-term mater- nal and infant health complications. In response to the AAP PPD Family Advocate screening recommendations, this practice improvement strategy Director of Communications, utilized the Plan-Do-Study-Act method to develof postpartum National Perinatal Association depression screening program including: postpartum depression Co-Chair NPA 2019 conference education for staff, implementation of PPD screening at intervals [email protected] recommended by the AAP, providing referral resources for moth- ers with positive PPD screens and following up with mothers who were provided with referral resources while their infant remains in the NICU. Lessons Learned: Postpartum Revolution Navigating PPD can be a complicated and lengthy process. @ANGELINASPICER Successful implementation of a PPD screening programs in the NICU requires a multidisciplinary team approach. It is important to identify key members of the teams to serve as champions to improve program compliance and acceptance. Program barriers were present due to PPD screening of NICU mothers who are no longer a patient of the facility. Who is responsible for referral, screening, treatment and where should results be documented. Additionally, all mother’s will not agree to PPD screening and cri- New subscribers are always welcome! NEONATOLOGY TODAY To sign up for a free monthly subscription, just click on this box to go directly to our subscription page
NEONATOLOGY TODAYtwww.NeonatologyToday.nettDecember 2019 20
Time interval from birth to NICU admission and initial blood glucose level Peer Reviewed
in Very Low FellowBirth Column: Weight (VLBW) Infants. Quality Improvement Initiative: Reducing the Interval le sandrafrom Birth da c a to NICU Admission hristian and Initial astillo Blood Glucose isha ha anda e art ent ofDetermination eonatology in Very ohn Low . Birth toger Weight r. os ital (VLBW) Infants of oo ounty hicago Aleksandra M. Adamczak, MD, Christian Castillo, MD, Vishakia Nanda, MD
At the John H. Stroger Hospital’s NICU and Perinatal Center, Very “It is critical that neonatologists, Low Birth (VLBW) infants are at risk for hypoglycemia for various reasons including decreased glycogen stores owing to prematu- and those in training to become rity or being small for gestational age at birth. One of the goals of the “Golden Hour” is to decrease the occurrence of hypoglyce- neonatologists, realize the impact that a PROBLEM RESULTSmia (Accucheck of 40 mg/dL or 2.mM) by the prompt institution NICU experience can have on a family- of intravenous glucose and fluid supplementation within the first hour of life. The admission of an infant to the NICU is a complex -both the infant, the infant’s parents procedure affected by the duration of resuscitation, comorbidities • Ourof the a erage infants requiring ad ission procedures soon after ti e birth, the distancefro irthindividually to and as in a couple, and infant the in the last year is in. he esti ated distance et een la or and deli ery and in our • ohn . troger os ital is one of the erinatal centers of the delivery site from the NICU, and mode of transfer. It was observed previously that any delay in the time of admission to the entire family—and that the potential hos italNICU appearedis a outto increase the likelihood eters. of an infant experienc e - ha eadverse noticed developmental that all outcomes the cases for ith se ere hy oglyce ia glucose g dl has an ad ission ti e to of ore than in hicago llinois. ing hypoglycemia. the infant and adverse mental health inWe fro sought to irth.document the ifty relationship ercent between the time of of delivthose- cases had at in of life and of cases has access in ore than an hour. ll of our cases of • infants are at ris of hy oglyce ia for arious reasons ery and admission time and its relation to the occurrence of hypo- outcomes for parents are well-described hy oglyce iaglycemia in VLBW infants. We g dl conducted a retrospective has reviewan ad ission ti e fro irth a erage of . in. including decreased glycogen stores. One of the “golden hour” of time of delivery to time of admission (in minutes) and the occur- and documented” rence of hypoglycemia in our high-risk population. We analyzed data for the 12 months of 2018 in terms of the time of admission goals is to decrease the occurrence of hy oglyce ia y and occurrence of hypoglycemia. Our goal of an admission time to encourage prompt the admission process. This Quality Assur- of <30 minutes from birth and initiation of initial Accucheck deter- ance program has the approval of the Neonatology faculty and i le enting strategies to o tain access and initiate mination and institution of intravenous dextrose in water fluids is key nursing leaders to achieve this quality improvement. 30 minutes or less for 2019 and 2020. To assist in achieving this goal, we implemented a 20 minute after birth alert (or warning) Our average admission time from birth to NICU in VLBW infants intra enous fluids ithin first hour of life. in the last year is 29 min. The distance between most deliveries • he rocess of ad ission of a neonate to is co le • Table 1. Time between birth and admission to and is affected y duration of resuscitation co or idities of the NICU in VLBW from January 2018 to December infant distance fro la or and deli ery to and ode of 2018 per quarters. trans ort. e ha e noticed that if ti e of ad ission fro irth is Average time to NICU • Figure 1. Graph showing average NICU admission time per quarter and average e tended the chances of hy oglyce ia increase. admission IVF time and % low Accu-check.