Early discharge of preterm infants needing limited special care, followed by domiciliary nursing care

The aim of this study was to evaluate the effect of early discharge, followed by domiciliary nursing care, on infant health and utilization of health services in preterm infants still in need of special care (mainly gavage feeding). In total, 88 infants who were physiologically stable, but in need of further special care such as gavage feeding, were allocated to an early discharge group (EDG = 45 infants) and offered home visits by a nurse backed up by a neonatologist, or to a control group offered standard neonatal care (CG = 43 infants). Infants in the EDG spent 30.6 d (mean) in hospital after birth compared with 46.3 d in the CG (p = 0.003). On average, the domiciliary nurse spent 10.4 h with each family in the EDG, including a median number of 5 home visits, scheduled telephone contact and travelling time. The infants had a mean of 1.7 scheduled visits and 0.4 unscheduled visits to the neonatal ward. The domiciliary nurse received a mean of 0.9 telephone calls from the parents. When the period of domiciliary care in the EDG (post-conceptional age 35.9-38.7 wk) was compared with the corresponding time in hospital in the CG (post-conceptional age 35.6-38.6 wk), no statistical differences were observed in infant health, surgical procedures or medication. However, a reduced incidence of respiratory infections was observed in the EDG (6 versus 16 infants; p = 0.02). Nine infants in the EDG were re-hospitalized. The two groups did not differ in the numbers of rehospitalizations and non-elective contacts with the health services during the first year after discharge. In conclusion, early discharge of preterm infants still requiring special care, followed by domiciliary nursing care, was associated neither with an increased utilization of health services after discharge, nor with infant morbidity after discharge. More information on safety is needed before widespread early discharge can be advocated.     

Maternal participation in the care of the high risk infant: follow-up evaluation

Fifty mothers of high risk infants admitted to the Neonatal Special Care Unit were followed up to the postnatal age of 2.5 mo +/- 15 days. Twenty five mothers (Group I) had stayed in the nursery with the infant for a period of 4.8 +/- 4.6 days until the discharge of the infant, providing expressed milk and participating in the non-specialised care of the infant. The other 25 mothers (Group II) remained separate from their babies for the duration of the latter's stay in the hospital although some of the mothers did come off and on to give expressed human milk and at times handle their infants. Family features such as parental age, educational and occupational status, and presence of residential elder women, were similar in the two groups. Infant characteristics too, such as sex, birth weight, and early neonatal morbidity were also comparable. Operative deliveries and maternal problems were as expected more in the separated group. The duration of the infants' hospital stay was also more in the latter (9.5 +/- 3.5 vs 6.3 +/- 3.9 days; p greater than 0.05). Subsequent to their discharge, mothers who had stayed with the infant identified the following benefits of their stay--acquiring of knowledge relevant to infant care especially hygiene (19) and their personal involvement in the care of their infant (12), both of which they said increased their self confidence in looking after the babies after discharge, and provision of breast milk round the clock (17).(ABSTRACT TRUNCATED AT 250 WORDS)     

The impact of individual room on rehospitalization and health service utilization in preterms after discharge

Abstract Aim: To compare individual room implemented family-centred care to classical designed neonatal intensive care unit and find out its effect on rehospitalization and application to health services in preterm infants after discharge. Methods: Mothers whose infants were born before 34 gestational weeks and hospitalized for at least one week in the NICU were enrolled in the study. Mothers who were hospitalized with their preterm infants in individual rooms (Group I) were compared with mothers who were not hospitalized with their preterm infants (Group II). After the third postdischarge month, groups were compared for their rates of phone consultations to physician/hospital, acute care applications, rehospitalization and parent's perception of child's vulnerability. Results: Although demographic and medical information did not indicate any differences between the groups, the mean number of acute care visits (p = 0.046), the median number of phone consultations (p = 0.001) and rehospitalization rate (12.9% vs. 34.5%, p < 0.05) were significantly higher in Group II. The anatomical problems, such as inguinal hernia and retinopathy of prematurity, were the main recorded causes in Group I whereas problems related to prematurity like feeding difficulties were dominating in Group II. Conclusion: The availability of individual rooms that allows maternal presence and participation during the hospitalization of the mother's preterm infant, is correlated with lower rates of rehospitalization and healthcare applications.     

A controlled trial of skin-to-skin contact in extremely preterm infants

BACKGROUND: Extremely preterm birth, even in the absence of significant neurological impairment, is associated with altered pain responses and impaired memory and behaviour. Preterm birth increases the risk of maternal depression and may impede the development of the mother-infant relationship, factors that in turn are also associated with impaired infant outcome. Mother-infant skin-to-skin contact has been recommended as a simple means of ameliorating these effects. METHODS: We conducted a pragmatic, prospective, controlled, intention-to-treat trial in two neonatal intensive care units. Infants born below 32 weeks gestation were recruited within the first week after birth and assigned to a control group receiving standard care, or an intervention group in which mothers were encouraged to provide a session of skin-to-skin contact once daily for 4 weeks. We assessed infant behaviour at time of discharge from hospital, responses to immunisation at 4 and 12 months of age, and memory, behaviour and development at 1 year corrected (postmenstrual) age. Indices of maternal depression, stress, anxiety, lactation performance and infant interaction were assessed at time of infant discharge, 4 months and 1 year. RESULTS: No significant difference was identified in any infant or maternal measure at any time point. CONCLUSIONS: Mother-infant skin-to-skin contact after extremely preterm birth results in neither benefit nor adverse consequences. Although there is no reason to dissuade mothers who wish to provide STS contact, we are unable to recommend resource allocation for the implementation of STS programmes for extremely preterm infants in a neonatal intensive care unit setting.     

Early and Late Discharge after Hospital Birth: Breastfeeding

Breastfeeding was studied among women discharged early and late after normal delivery in a hospital. Early discharge was defined as leaving the hospital 24–48 h after delivery in combination with domiciliary visits, and late discharge as the regular hospital postpartum care (mean 6 days). 164 women interested in participating in the early discharge study were randomly allocated in late pregnancy to a group offered early discharge (Experimental group = EG) or a group offered the traditional later discharge (Control group = CG). After medical exclusions and non-medical withdrawals, 50 mother-infant couples remained in EG and 54 in CG. Regular breastfeeding at 6 months after birth was reported by 63% of the multiparae in EG and 41% in CG ( p =0.06). Thirty-three per cent of the primiparae in each group were still breastfeeding at 6 months. 2% of the infants in EG and 72% in CG received supplementary breastmilk at least once during their first week of life. Infants discharged early were breastfed more often on the 2nd (NS), 3rd ( p <0.05) and 4th day ( p <0.001) after birth, compared with infants who stayed longer in hospital. There were no statistically significant differences between EG and CG women in their experiences of success in breastfeeding according to daily records from the first 14 days after the birth.     

Parental perceptions of infant vulnerability in a preterm sample: prediction from maternal adaptation to parenthood during the neonatal period

The present longitudinal study of African-American mothers of preterm infants tested the hypothesis that the quality of maternal adaptation to parenthood before infant discharge from the hospital is predictive of maternal perceptions of infant vulnerability later in the infant's first year. As hypothesized, perceptions of infant vulnerability at 3 to 4 months of infant corrected age were predicted by two theoretically relevant measures of maternal adaptation in the neonatal period: mothers' perceptions of their neonates as lethargic and unresponsive to mothers' bids and by low maternal self-efficacy beliefs about feeding the infant. Neonatally obtained maternal self-inefficacy beliefs about their ability to feed the infant in particular proved to be quite robust in predicting mothers' later perceptions of infant vulnerability. Findings collectively suggest that careful attention to the manner in which mothers of preterm infants adapt to parenthood, even before infant hospital discharge, can help clinicians identify mothers at particularly high risk of developing perceptions of infant vulnerability later in the infant's first year. Implications for intervention are discussed.     

Early and late discharge after hospital birth: breastfeeding

Breastfeeding was studied among women discharged early and late after normal delivery in a hospital. Early discharge was defined as leaving the hospital 24-48 h after delivery in combination with domiciliary visits, and late discharge as the regular hospital postpartum care (mean 6 days). 164 women interested in participating in the early discharge study were randomly allocated in late pregnancy to a group offered early discharge (Experimental group = EG) or a group offered the traditional later discharge (Control group = CG). After medical exclusions and non-medical withdrawals, 50 mother-infant couples remained in EG and 54 in CG. Regular breastfeeding at 6 months after birth was reported by 63% of the multiparae in EG and 41% in CG (p = 0.06). Thirty-three per cent of the primiparae in each group were still breastfeeding at 6 months. 2% of the infants in EG and 72% in CG received supplementary breastmilk at least once during their first week of life. Infants discharged early were breastfed more often on the 2nd (NS), 3rd (p less than 0.05) and 4th day (p less than 0.001) after birth, compared with infants who stayed longer in hospital. There were no statistically significant differences between EG and CG women in their experience of success in breastfeeding according to daily records from the first 14 days after the birth.     

Cot-nursing using a heated, water-filled mattress and incubator care: a randomized clinical trial

AIMS: To evaluate the thermal responses and weight gain in preterm infants nursed in a cot on a heated, water-filled mattress (HWM) compared with infants receiving care in an air-heated incubator and to compare mothers' stress, anxiety levels and perceptions of their infants in the two groups. METHODS: Stable preterm infants weighing 1300 to 1500 g were enrolled, being randomly allocated to either the study group (n = 41) receiving care in a cot on an HWM, or the control group (n = 33) receiving incubator care. The mean daily body temperature and episodes of cold stress and hyperthermia were recorded. Weight gain (g kg(-1) body weight d(-1)) was also calculated. The mothers completed questionnaires on their perceptions of their infants, and their anxiety and stress levels before randomization, and 2-3 wk later during the trial. RESULTS: The mean body temperature was similar for the first week of the trial (study group 36.9 degrees C vs controls 36.9 degrees C). There were no significant differences in the incidence of cold stress, while more hyperthermic episodes were seen in the study group (p = 0.03). There were no significant differences in weight gain during the first (study group 21.4 g vs controls 19.6 g) or second weeks of the trial (study group 20.5 g vs controls 19.2 g). Neonatal morbidity did not differ between the groups. There were no differences in mothers' perceptions of their babies, or feelings of stress or anxiety. CONCLUSION: There were no differences between infants cot-nursed on an HWM and those receiving incubator care, with the exception of episodes of high temperature. The results suggest that the HWM may be used safely for low-weight preterm infants.     

Mothers' perception of Newborn Individualized Developmental Care and Assessment Program (NIDCAP) as compared to conventional care

BACKGROUND: Family-centred care according to the Newborn Individualized Developmental Care and Assessment Program (NIDCAP) has been reported to positively influence family function. The aim was to examine if NIDCAP affects the views of prematurely born infants' mothers regarding maternal role, perception of the infant and the neonatal care. METHOD: Preterm infants with gestational age <32 weeks were randomly assigned to receive either care based on NIDCAP (n=12) or conventional neonatal care (n=13), forming two comparable groups with respect to gestational age, birth weight, female/male ratio, and initial illness severity. A questionnaire was designed to evaluate various aspects of the mothers' attitudes and apprehension of their maternal role, perception of their infant and the neonatal care. The questionnaire was validated and given to the mothers when the infants reached 36 weeks postmenstrual age (PMA). RESULTS: Ten mothers in each group replied to the questionnaire. The mothers in the NIDCAP-group perceived more closeness to their infants than did the control mothers (p=0.022) and this feeling demonstrated no significant correlation to the infant's gestational age, weight at birth or severity of illness. Furthermore, the mothers in the NIDCAP-group tended to rate the staff's ability to support them in their role as a mother somewhat higher (p=0.066), but at the same time they expressed more anxiety than did the control mothers (p=0.033). CONCLUSION: Early intervention according to NIDCAP seems to facilitate a feeling of closeness between the mother and her premature infant regardless of the infant's birth weight or health status. The higher level of anxiety in the mothers in the NIDCAP-group, may mirror that the mothers in the NIDCAP-group had already bonded to their infants during the hospital stay.     

Factors associated with successful establishment of breastfeeding in very preterm infants

Aim: To describe feeding practices at hospital discharge in relation to characteristics of the very preterm infants (VPI) and their mothers. Methods: Design. Prospective hospital‐based registration of very preterm infants born with a gestational age ≤32 weeks in Denmark during 2004–2008. Subjects. Healthy mothers and VPI without diseases causing eating disabilities at discharge. Results: A total of 478 VPI were registered. At discharge, 60% were exclusively breastfed, 35% were exclusively bottlefed, and 5% were both breast‐ and bottle‐fed. Mothers of high social class (p = 0.000) and ‘not smoking’ (p = 0.003) were significantly more often breastfeeding their preterm infant(s) at discharge. Single births infants tended more often to be breastfed (p = 0.09). Infant age at discharge and duration of hospitalization did not influence breastfeeding at discharge. Increase in weight z‐score from birth to discharge was largest in the bottlefeeding‐group compared with the breastfeeding‐group (p = 0.000) probably as a result of feeding practice the last week(s) of hospitalization. Conclusion: Breastfeeding can successfully be established in very preterm infants. Mothers of low social classes, smokers, multiple birth and very preterm infants with low weight for age may need extra attention in breastfeeding establishing policies.     

Increasing breast milk production for premature infants with a relaxation/imagery audiotape

Many women whose premature infants are hospitalized in a newborn intensive care unit choose to express breast milk for their babies. Yet anxiety, fatigue, and emotional stress are powerful inhibitors of lactation. To facilitate the breast-feeding experience, intervention mothers were given a 20-minute audio cassette tape based on relaxation and visual imagery techniques. At a single follow-up expression of milk at the hospital approximately 1 week after enrollment, they expressed 63% more breast milk than a randomized group of control mothers. The fat content of the breast milk in the two groups was not significantly different. Among a small group of mothers whose infants were receiving mechanical ventilation, the increase in milk volume compared with that of control mothers was 121%. Longer-term effects of the relaxation/imagery approach (such as extending the duration of breast-feeding or reducing parental stress after hospital discharge) and the physiologic basis for the increased volume of expressed milk (improved milk production v more efficient milk ejection) are appropriate topics for future research.     

A neonatal early discharge and home support programme: Shifting care into the community

Objective: The Neonatal Early Discharge and Family Support Programme (NEDP) was an initiative aimed at providing extended care for families whose infants had required neonatal special care, thereby allowing earlier discharge.
Methodology: Two groups of families were examined; one before and one after the instigation of the NEDP. Hospital and community service usage and psychosocial effects were examined.
Results: Families who received support were able to be discharged earlier and rooming-in was unnecessary as support was provided at home. Visits to family doctors for mothercraft issues were less frequent. Transport of babies from the Level 3 nursery to other nurseries in order to be closer to home was also provided by the nursing team, saving on ambulance costs and freeing their time for emergencies. There was no increase in maternal anxiety and infants were less difficult in the patient group.
Conclusions: NEDP and family support programme is a worthwhile extension of neonatal intensive care.     

Pre-discharge anxiety among mothers of well newborns: prevalence and correlates

OBJECTIVE: To explore the prevalence and correlates of maternal postpartum anxiety. METHODS: 422 of 973 invited mothers (43%) were screened for anxiety before hospital discharge with the State-Trait Anxiety Inventory (STAI). Recent medical and social life events, stress, resiliency (mastery, social support, and marital satisfaction), length of stay, discharge readiness, anticipatory medical care, and history of psychiatric illness and depression were assessed by questionnaire and medical record review. RESULTS: 24.9% of mothers had moderate and 1% severe anxiety. Higher anxiety was observed among young, unmarried, primiparous mothers with male infants, and anxiety correlated with medical and negative social life events, stress, history of depression, and duration of postpartum stay. Inverse correlations were observed with maternal education and household income, pregnancy planning, prenatal class attendance, infant healthcare provider identification, and with all resiliency factors. In multivariate models, pre-discharge anxiety was significantly associated with medical life events and the maternal perception of perinatal stress, and negatively associated with mastery, marital satisfaction, and choice of infant healthcare provider. CONCLUSION: Moderate maternal anxiety is common prior to perinatal hospital discharge, especially among women with low mastery and marital satisfaction, stressful perinatal courses, and failure to identify an infant healthcare provider.     

Focused breastfeeding counselling improves short‐ and long‐term success in an early‐discharge setting: A cluster‐randomized study

Length of postnatal hospitalization has decreased and has been shown to be associated with infant nutritional problems and increase in readmissions. We aimed to evaluate if guidelines for breastfeeding counselling in an early discharge hospital setting had an effect on maternal breastfeeding self‐efficacy, infant readmission and breastfeeding duration. A cluster randomized trial was conducted and assigned nine maternity settings in Denmark to intervention or usual care. Women were eligible if they expected a single infant, intended to breastfeed, were able to read Danish, and expected to be discharged within 50 hr postnatally. Between April 2013 and August 2014, 2,065 mothers were recruited at intervention and 1,476 at reference settings. Results show that the intervention did not affect maternal breastfeeding self‐efficacy (primary outcome). However, less infants were readmitted 1 week postnatally in the intervention compared to the reference group (adjusted OR 0.55, 95% CI 0.37, ?0.81), and 6 months following birth, more infants were exclusively breastfed in the intervention group (adjusted OR 1.36, 95% CI 1.02, ?1.81). Moreover, mothers in the intervention compared to the reference group were breastfeeding more frequently (p < .001), and spend more hours skin to skin with their infants (p < .001). The infants were less often treated for jaundice (p = 0.003) and there was more paternal involvement (p = .037). In an early discharge hospital setting, a focused breastfeeding programme concentrating on increased skin to skin contact, frequent breastfeeding, good positioning of the mother infant dyad, and enhanced involvement of the father improved short‐term and long‐term breastfeeding success.     

Kangaroo care for the preterm infant and family

Kangaroo care (KC) is the practice of skin-to-skin contact between infant and parent. In developing countries, KC for low-birthweight infants has been shown to reduce mortality, severe illness, infection and length of hospital stay. KC is also beneficial for preterm infants in high-income countries. Cardiorespiratory and temperature stability, sleep organization and duration of quiet sleep, neurodevelopmental outcomes, breastfeeding and modulation of pain responses appear to be improved for preterm infants who have received KC during their hospital stay. No detrimental effects on physiological stability have been demonstrated for infants as young as 26 weeks’ gestational age, including those on assisted ventilation. Mothers show enhanced attachment behaviours and describe an increased sense of their role as a mother. The practice of KC should be encouraged in nurseries that care for preterm infants. Information is available to assist in developing guidelines and protocols.     

The impact of neonatal unit policies on breast milk feeding at discharge of moderate preterm infants: The EPIPAGE‐2 cohort study

Facilitating factors and barriers to breast milk feeding (BMF) for preterm infants have been mainly studied in very preterm populations, but little is known about moderate preterm infants. We aimed to analyze hospital unit characteristics and BMF policies associated with BMF at discharge for infants born at 32 to 34 weeks' gestation. EPIPAGE‐2, a French national cohort of preterm births, included 883 infants born at 32 to 34 weeks' gestation. We investigated kangaroo care in the first 24 hr, early involvement of parents in feeding support, volume of the unit, BMF information given to mothers hospitalized for threatened preterm delivery, protocols for BMF, presence of a professional trained in human lactation, unit training in neurodevelopmental care, and regional BMF initiation rates in the general population. Multilevel logistic regression analysis was used to investigate associations between unit policies and BMF at discharge, adjusted for individual characteristics and estimating odds ratios (ORs) and 95% confidence intervals (CIs). Overall, 59% (490/828) of infants received BMF at discharge (27% to 87% between units). Rates of BMF at discharge were higher with kangaroo care (adjusted OR 2.03 [95% CI 1.01, 4.10]), early involvement of parents in feeding support (1.94 [1.23, 3.04]), unit training in a neurodevelopmental care programme (2.57 [1.18, 5.60]), and in regions with a high level of BMF initiation in the general population (1.85 [1.05, 3.28]). Creating synergies by interventions at the unit and population level may reduce the variability in BMF rates at discharge for moderate preterm infants.     

Safe discharge of the late preterm infant

Late preterm infants are infants who are premature, but often mature enough to be managed in settings and with treatment plans appropriate for term newborns. They are arbitrarily defined as infants born at gestational ages of 34, 35 and 36 weeks. Late preterm infants have more problems with adaptation than term infants, and may require neonatal intensive care and prolonged admission. However, those who do not may, appropriately, be triaged to mother-baby care in a low-risk nursery setting. Special attention must be offered to the late preterm infant in ensuring adequate thermal homeostasis and the establishment of successful feeding before discharge. In particular, care must be taken to ensure that these babies do not experience severe late hyperbilirubinemia, which characteristically occurs in the breastfeeding late preterm infant at four to five days of age and is not always predictable by routine bilirubin screening before 48 h of age. Discharge of a late preterm infant places particular demands on the community; accessible facilities for retesting, re-evaluation and readmission must be made available by the discharging institution.     

'Facilitated tucking by parents' in pain management of preterm infants-a randomized crossover trial

BACKGROUND: There is a need for a safe and effective non-pharmacological pain management method for preterm infants. The parents could be given an active role in the pain management which may help the parents to cope with the stress related to painful situations of the infant. AIMS: To examine the effectiveness of a method called 'facilitated tucking by parents' (a parent holds the infant in a flexed position) in pain management during endotracheal/pharyngeal suctioning of preterm infants. In addition, the parental perception of the method was studied. STUDY DESIGN: A randomized crossover trial. SUBJECTS: Twenty preterm infants with one of their parents participated in the study. Infants' gestational age ranged from 24 to 33 (median 28) weeks and postnatal age from 6 to 37 days (median 15 days). OUTCOME MEASURES: The primary outcome was the Neonatal Infant Pain Scale (NIPS) score. Heart rate and oxygen saturation were recorded. Parents completed a questionnaire about their perception of the procedure. RESULTS: The highest NIPS score was median 3 (range from 2 to 6) using 'facilitated tucking by parents' and median 5 (range from 2 to 7) without tucking during suctioning (p < 0.001). The infants calmed down more quickly after 'facilitated tucking by parents' (5 s vs. 17 s, p = 0.024). Nineteen out of twenty parents preferred facilitated tucking during suctioning compared to control care. CONCLUSIONS: Facilitated tucking by parents is an effective and safe pain management method during suctioning of preterm infants. This study shows that parents can be given an active role in the pain care of their preterm infants.