Psychosocial parental support programs and short-term clinical outcomesin extremely low-birth-weight infants

GRACIELA B. NEARING1, ARIEL A. SALAS2, DEISE GRANADO-VILLAR3,

BARRY D. CHANDLER4, & AMED SOLIZ4

1Department of Psychiatry, Miami Children’s Hospital, Miami, FL, USA, 2Department of Pediatrics, Caja Petrolera de Salud, La Paz,

Bolivia, 3Department of Preventive Medicine, Miami Children’s Hospital, Miami, FL, USA, and 4Division of Neonatology, Miami

Children’s Hospital, Miami, FL, USA

AbstractObjective. To describe the association between an individualized psychosocial parental support (PPS) program and short-termclinical outcomes of extremely low-birth-weight (ELBW) infants admitted to the neonatal intensive care unit (NICU).

Methods. Medical records of ELBW infants (51000 g) hospitalized in the NICU at Miami Children’s Hospital between July2006 and June 2008 were reviewed. Outborn infants admitted during their first 72 h of life and discharged home were included.Parents were divided in two groups according to their participation status in the PPS program. Neonatal outcomes in both groupswere compared.

Results. Forty-one infants were included (n¼ 41). Mean gestational age was 26.7+2 weeks, and birth weight was 860+125 g.Median length of stay (LOS) was 96 days (quartile range: 76–112 days). PPS was provided to 33.3% of these infants’ parents. Themedian LOS in the PPS group was significantly lower than in control group (86 vs. 99 days; p5 0.05). No other differences inshort-term neonatal outcomes were found.

Conclusions. The addition of individualized psychosocial parent support programs to standard care in the NICU may reduce LOSin surviving infants discharged home. Further larger and randomized prospective studies are needed.

Keywords: Parental support programs, NICU psychological interventions, parental involvement, length of stay, preterm infants

Abbreviations: NICU¼ neonatal intensive care unit; PPS¼ psychosocial parental support; LOS¼ length of stay;ELBW¼ extremely low birth weight; CRIB¼ clinical risk index for babies; ROP¼ retinopathy of prematurity; NEC¼ necrotizingenterocolitis; IVH¼ intraventricular hemorrhage; BPD¼ bronchopulmonary dysplasia

Introduction

Advances in neonatal care have improved survival rates of

preterm infants. However, infants who survive have an

increased risk for medical, neurological, and long-term

developmental complications [1–4]. The risk increases sharply

with decreasing gestational age (GA) at birth [5].

The distress and challenges experienced by parents follow-

ing an unexpected premature birth of their infants [1,6–8]

require support during neonatal intensive care unit (NICU)

hospitalization [9] that sometimes may extend for several

months. Coping can be challenging under these circumstances

and frequently overwhelms parental resources [8,10].

Parental support can be provided either by organized

programs [8] or by psychosocial services in NICUs where

individualized interventions are designed according to specific

hospital settings [10–12]. Although systematic approaches to

provide this support have shown beneficial effects on infant

outcomes, they are not considered standard of care in most

NICUs. On the other hand, little is known about the use and

outcomes of individualized interventions taking place in

NICUs outside clinical trials. Furthermore, the role of parent

support and parental involvement in extremely low-birth-

weight (ELBW) infants remains unclear [8,13].

The objective of this study was to determine the association

between an individualized psychosocial parental support (PPS)

program and short-term clinical outcomes of ELBW infants

admitted to the NICU.

Methods

This retrospective study compared short-term outcomes of

ELBW infants (birth weight5 1000 g) according to parent

participation in an individualized PPS program during NICU

hospitalization.

(Received 16 November 2010; accepted 21 January 2011)

Correspondence: Graciela B. Nearing, PsyD, Department of Psychiatry, Miami Children’s Hospital, 3100 SW 62nd Avenue, Miami, Florida 33155, USA.

E-mail: gnearing@mindspring.com

The Journal of Maternal-Fetal and Neonatal Medicine, 2012; 25(1): 89–93

� 2012 Informa UK, Ltd.

ISSN 1476-7058 print/ISSN 1476-4954 online

DOI: 10.3109/14767058.2011.557790

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Settings

The NICU at Miami Children’s Hospital is a 39-bed unit that

serves as a regional, national, and international Level III

referral center, receiving critically ill infants from throughout

South Florida, as well as South and Central America and the

Caribbean.

Participants

Medical records of ELBW infants hospitalized in the NICU

between July 2006 and June 2008 were reviewed. Outborn

infants admitted during their first 72 h of life discharged home

were included. Exclusion criteria were major congenital

anomalies. Institutional review board approval was

obtained.

Data collection and definitions

Clinical data of selected infants were obtained from medical

records. Length of stay (LOS) in the hospital was defined as

number of days from admission to discharge. Days on

respiratory support were calculated based on total number

of days in which oxygen was provided, either by mechanical

ventilation or any other form of respiratory support. Bronch-

opulmonary dysplasia was diagnosed on the basis of the need

for supplemental oxygen at 36 weeks of corrected GA [14].

Intraventricular hemorrhage was classified as Grades 1–4

according to head ultrasound findings.

PPS program participation. The individualized PPS is offered

to all parents upon arrival by letter of introduction. During

hospitalization, parents are approached after morning rounds

for individual assessment of interventions needed, and

services are offered accordingly. Posters advertising weekly

parent workshops are also available in the unit. If a psychology

consult is requested by physicians, the PPS program is offered

in the interview. Participation is voluntary; thus, parents can

refuse help or not make use of help offered. Similarly,

enrolment into the program can occur at any time during

hospitalization. It consists of a person-to-person intervention

centered on helping mothers cope with their emotional

distress and understand their parenting role. The former is

addressed through psychotherapy and the latter by providing

information and techniques regarding developmental care.

This intervention is conducted by bilingual (Spanish/English)

psychology personnel and occurs at bedside and/or during

parent workshops. Topics are focused on bonding behaviors

to increase parent–infant interaction, such as appropriate

sensory stimulation, soothing the infant, reading the infant’s

cues, infant behavioral assessment, skin-to-skin contact,

breastfeeding practices, and massage therapy. In addition,

parent-to-parent interaction is encouraged during parent

workshops (once every three weeks for 2 h). Pre-and-post

tests are given to assess parents’ learning after workshops. For

study purposes, parents and their respective infants were

divided in two groups based on the information available

regarding their participation in the support program. Partici-

pation during the hospital stay was documented consistently

in the PPS group. For inclusion in this group, the following

criteria were considered: (1) early enrollment (514 days), (2)

three or more participations in parent workshops, and (3) at

least five individual therapies during hospitalization. The lack

of documented participation in activities detailed above was

classified as no support status (control group). Thus, the

control group included not only parents who did not receive

any psychological support but also parents who had an

inconsistent participation in the program (late enrollment,

participation in workshops but no individual therapies, few

individual therapies and no workshop assistance, etc.)

Information regarding parent participation in the PPS

program was analyzed independently. Likewise, parent sup-

port status did not influence clinical decisions because

physicians were unaware of the association under evaluation

due to the retrospective design of this study.

Parental involvement. Based on daily nursing reports, par-

ental involvement was defined as more than four visits in

different days over a 1-week period that included parent

presence at bedside with or without parent–infant interaction.

Statistical analysis

Continuous variables were compared using both the t-test and

Mann–Whitney test for normal and skewed distributions,

respectively. Proportions were compared by chi-square

statistics and Fisher’s exact test when appropriate. All data

were analyzed with SPSS 17.0 for Windows (SPSS Inc.,

Chicago, IL, USA).

Results

During the period of study, 97 ELBW outborn infants were

admitted to the NICU, but only 58 of them over their first

72 h of life. Nine of these infants died, 3 were discharged to

another health facility, and 46 were discharged home. Of this

group, three infants were excluded for major congenital

malformations and two for insufficient data on medical

records. Thus, 41 infants were included in the study

(n¼ 41). Mean GA in the entire group was 26.7+2 weeks,

and birth weight was 860+125 g. Median LOS was 96 days

(quartile range: 76–112 days). PPS as defined above was

provided to a third of these infants’ parents (33.3%). Clinical

and demographic characteristics of mothers and infants

included in the study are described in Table I. Sixteen

parents included in this study were single (39%), and nine

were adolescents (22%). No significant difference of these

variables between groups was found. The median LOS in the

PPS group was significantly lower than in the control group

(86 vs. 99 days). No other significant differences were found

between groups, except for a trend toward higher rates of

parental involvement in the PPS group.

Although PPS group showed a trend toward better parental

involvement (75% vs. 52%) as shown in Table I, no

independent effect of parental involvement on LOS was

found (p¼ 0.46).

Two-thirds of infants included in this study (65.9%) were

admitted from facilities located beyond the metropolitan area.

Only 52% of these infants received constant parental

involvement compared with 87.5% in the group of infants

transferred from nearby hospitals (p5 0.05). However, no

significant association between this variable and PPS partici-

pation was found. The proportion of parents living at a

significant distance from the hospital, outside the metropoli-

tan area, was comparable between groups (68.8% vs. 64%).

Discussion

In this report, we described short-term outcomes of critically

ill premature infants who survived to discharge and received

individualized PPS in addition to standard care in the NICU.

90 G. B. Nearing et al.

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In an attempt to have a clinically comparable group, only

ELBW infants were included in this study. As a result, short-

term clinical outcomes were quite similar between groups.

Infants in the PPS group had a shorter median LOS when

compared to the control group (86 vs. 99 days; p5 0.05).

Additionally, the PPS program was associated with a greater

proportion of parental involvement (75% vs. 52%). Since all

infants met the same criteria before being discharged home

and considering that comorbidity was comparable in both

groups, we speculate that shorter LOS in the PPS group was a

consequence of consistent psychosocial interventions.

Nevertheless, the group of parents who received regular

support represented only 33.3%. This finding is consistent

with the rates of parental participation reported in similar

interventions in other NICU studies [11]. While parents

experience different needs at different stages of their hospital

stay [15], mother–infant interaction is often ignored in today’s

NICUs [16], and this may disrupt or delay the formation of

attachment processes [17–20]. The ability to cope with

changing parental roles and emotional distress [1] and the

difficulties experienced during the establishment of an

appropriate parent–infant interaction [15] are situations that

must be addressed during the NICU stay since disruptive

experiences after birth may have a great impact on subsequent

neurobiological and behavioral development [7,21]. Critically

ill preterm infants are even at higher risk for disruption

because the development of maternal identity is considerably

delayed [22], and the readiness for motherhood is lower

among parents of preterm infants [16]. Attachment or

bonding is an individualized process [18,23]; therefore, parent

support programs that utilize only one type of intervention

may not be optimal for providing the range of support needed

during the NICU hospitalization of preterm infants [24].

Thus, individualized support programs may facilitate this

process [19]. These considerations highlight the diversity of

possible benefits on neonatal and maternal outcomes of an

individualized parent support program in the NICU. Neuro-

biological basis for some of the events described above have

been recently summarized [21,25].

Maternal mental health issues, such as anxiety, depression,

acute stress, and posttraumatic stress disorder affect nega-

tively bonding behaviors [6,7]. Consequently, psychotherapy

addressing these issues in NICU parents is also part of our

PPS program. Although these conditions have been associated

with nonadjustable variables such as marital status, ethnicity,

employment status, and education, they can also occur during

the postnatal period due to inadequate or restricted parent–

infant interaction [26]. In addition, psychological distress can

be more frequent and last longer in mothers of high-risk very

low-birth-weight infants [1].

One of the strengths of our study is that it included

critically ill ELBW infants transferred from other hospitals

with lower GAs at admission (two-thirds of them came from

facilities located beyond the metropolitan area). These are

recognized risk factors for both disrupted mother–infant

interaction and poor neonatal outcomes and are generally

exclusion criteria in clinical trials [8]. This fact helps to further

understand the significant reduction on LOS observed in our

study. Similarly, the trend toward better parental involvement

detected in the intervention group may also have contributed

to our findings since constant parental involvement is

associated with better adjustments in the transition to

motherhood [27] and stronger confidence and participation

in infants’ care at the time of discharge [8,28]. However,

parental involvement by itself did not show any benefit on

shortening LOS. We speculate that parental involvement with

knowledge about strategies to promote better parent–infant

interaction is more beneficial than sole presence at bedside.

Table I. Infant and maternal characteristics based on participation in the PPS program.

PPS group (n¼16) Control group (n¼25) p

Infant

Birth weight (g), mean+SD 872+125 852+128 0.63

Gestational age (week), mean+SD 26.4+1.7 26.9+2.2 0.44

Gender (male/female) (%) 50/50 52/48 0.91

Apgar Score, median (QR)

1st min 6 (3–7) 5 (2–7) 0.56

5th min 7 (6–8) 7 (5–8) 0.59

CRIB Score, median (QR) 4 (2–6) 4 (3–7.5) 0.60

Short-term complications (%)

IVH (Grade 3 or 4) 6.3 12 0.48

BPD (supplemental O2 at 36 week) 31.2 40 0.57

ROP (severe) 6.2 8 0.66

NEC (proven) 12.5 8 0.51

Days on respiratory support (days), mean+SD 59.4+23.6 69.2+26.7 0.26

Total weight gain during hospitalization (g), mean+SD 2050+653 2127+823 0.78

LOS (days), median (QR) 86 (69–102) 99 (86–118) 50.05

Mother

Maternal age (years) 27.7+6.1 26.8+7.8 0.70

Race (%)

Hispanic 50 40 0.39

Black 37.5 24

White 12.5 32

Others 0 4

Vaginal delivery (%) 37.5 32.0 0.72

Parental involvement (%) 75 52 0.13

QR: quartile range.

Psychosocial parental support programs in the NICU 91

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Auditory, tactile, visual, and vestibular stimulation of infants

have shown to reduce the length of hospitalization. The ability

of parents to elicit an appropriate behavioral response is

reassuring and may have significant benefits in parent–infant

interaction [29–30]. Beneficial effects on maternal and

neonatal outcomes of tactile-kinesthetic stimulation [26],

promotion of skin-to-skin contact [31], and breastfeeding

practices [32] can also be evoked to interpret the finding of

shortened LOS in the PPS group. Although these considera-

tions suggest that integrated interventions on developmental

care along with assistance to parents of high-risk infants in

mental health issues may have cumulative beneficial effects,

objective indicators for measurement of appropriate parent–

infant interaction have not yet been defined.

Regarding the limitations of this study, the retrospective

design along with the random selection of a reduced sample of

consecutive cases over a 2-year period are the major ones.

Although this affects the interpretation of a cause–effect

relationship, descriptive models help to establish trends and

associations in a field that has not yet been fully described

outside clinical trials. The lack of random allocation of

participants to either intervention or standard care is another

limitation of the study. An additional limitation is that many

of the interventions applied were difficult to quantify. Parental

involvement and mental-health issues in mothers were

subjectively evaluated. Similarly, since our program has an

individualized approach, we could not determine whether

some specific interventions were more beneficial than others.

Another potential limitation that should be noted is that social

characteristics were not recorded properly and could not be

analyzed as control variables. Finally, we could not determine

what caused exclusion of parents in this program.

Conclusions

Individualized psychosocial parent support during NICU

hospitalization of critically ill preterm infants seems to be

associated with shorter length of hospital stay in surviving

infants discharged home with comparable comorbidity. This

possible benefit of promoting better parental involvement and

increased parent–infant interaction should be evaluated in

other settings. Further larger prospective studies addressing

observational measures of parent–infant interactions along

with better description of mothers’ mental health status and

previous experiences in motherhood are crucial to validate

these preliminary findings.

Declaration of interest: The authors report no conflicts of

interest. The authors alone are responsible for the content and

writing of the paper.

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