Shame, Suffering, and Believing in the Family: The Experiences of Grandmothers of a Grandchild With a Developmental Delay or Disability in the Context of Chinese Culture.

Grandparents are primary resources of caregiving support for parents worldwide, regardless of the cultural background. In Chinese societies, grandmothers often fill the role of supportive caregiver. However, a knowledge gap in the literature exists about how Chinese culture influences caregiving for grandmothers of grandchildren with a disability, particularly in Taiwan. This phenomenological study explored the lived experience of grandmothers caring for a grandchild with a developmental delay or disability in the context of Chinese culture. Twenty-five grandmothers were interviewed. When grandmothers learned of their grandchild's disability, they experienced suffering, which was compounded by the stigma attached to persons with a disability in Chinese cultures, and they also experienced shame and fear of social rejection. Grandmothers' belief in the importance of family gave meaning to their suffering and prompted them to find new ways to deal with everyday difficulties. These findings can guide nurses and health care professionals responsible for supporting grandmothers caring for a child with a disability in the context of Chinese culture.

The attitudes of neonatal professionals towards end-of-life decision-making for dying infants in Taiwan.

The purposes of research were to describe the neonatal clinicians' personal views and attitudes on neonatal ethical decision-making, to identify factors that might affect these attitudes and to compare the attitudes between neonatal physicians and neonatal nurses in Taiwan. Research was a cross-sectional design and a questionnaire was used to reach different research purposes. A convenient sample was used to recruit 24 physicians and 80 neonatal nurses from four neonatal intensive care units in Taiwan. Most participants agreed with suggesting a do not resuscitate (DNR) order to parents for dying neonates (86.5%). However, the majority agreed with talking to patients about DNR orders is difficult (76.9%). Most participants agree that review by the clinical ethics committee is needed before the recommendation of 'DNR' to parents (94.23%) and nurses were significantly more likely than physicians to agree to this (p=0.043). During the end-of-life care, most clinicians accepted to continue current treatment without adding others (70%) and withholding of emergency treatments (75%); however, active euthanasia, the administration of drug to end-of-life, was not considered acceptable by both physicians and nurses in this research (96%). Based on our research results, providing continuing educational training and a formal consulting service in moral courage for neonatal clinicians are needed. In Taiwan, neonatal physicians and nurses hold similar values and attitudes towards end-of-life decisions for neonates. In order to improve the clinicians' communication skills with parents about DNR options and to change clinicians' attitudes for providing enough pain-relief medicine to dying neonates, providing continuing educational training and a formal consulting service in moral courage are needed.

To explore the neonatal nurses' beliefs and attitudes towards caring for dying neonates in Taiwan.

(1) To explore attitudes and beliefs of neonatal nurses toward nursing care for dying neonates; (2) to estimate the influence of neonatal nurses' personal and professional characteristics on their attitudes towards end-of life care for dying infants. A cross-sectional design was used. A questionnaire was used to collect data from 80 neonatal nurses. Research setting was four level III NICUs at four medical centers around the central region of Taiwan. Research participants were neonatal nurses who had worked for at least 1 year in one of level III NICUs and had been directly involved with the care of dying infants. Research participants were 80 neonatal nurses (response rate 100 %). Research findings identified eight barriers hindering neonatal palliative care practice. These barriers were insufficient communication due to the lack of an in-service educational program; the lack of available counseling help for neonatal clinicians; inability to express personal opinions, values and beliefs towards neonatal palliative care; insufficient staffing; the lack of unit policies/guidelines for supporting palliative care; the technological imperative; parental demands and personal beliefs about death and previous experience caring for dying infants. Further studies are needed to explore each barrier and to provide in-service neonatal palliative care educational programs that are needed to decrease these barriers.

Relationships between environmental stressors and stress biobehavioral responses of preterm infants in NICU.

Although research has demonstrated that the neonatal intensive care unit (NICU) is a stressful environment for preterm and high-risk infants, little research validates the suspected relationships between infant biobehavioral responses and environmental stress in the NICU. This exploratory study examined the relationship between environmental stress and biobehavioral responses of preterm infants. The study used a repeated-measures research design to examine research variables in one group of preterm infants. Measurements of research variables were recorded every 2 minutes during two 60-minute observation periods for each research day (1 hour in the morning and 1 hour in the afternoon) and conducted over 2 days. A convenience sample of 37 preterm infants was recruited from 2 medical centers in Taiwan. A total of 4164 observations were made and recorded during the study. There was a statistically significant (P < .05) relationship between environmental stressors and changes in physiological signals. There were also statistically significant (P < .05) relationships between environmental stress and some specific stress behaviors. This research is applicable to neonatal clinical practice because it demonstrates the importance of recognizing the preterm infant's biological stress responses to environmental stressors, allowing for early interventions to reduce the possibility of more serious physiological or pathological changes in the status of the preterm infant.

An outbreak of enterovirus 71 in a nursery.

In this article we report a nosocomial outbreak of enterovirus 71 (EV71) in a newborn nursery and describe the clinical presentations of infected infants. Community outbreaks of EV71 are quite common in epidemic areas, but a nosocomial outbreak of EV71 is a rare occurrence. A total of 7 out of 19 infants (37%) had symptoms. All infants had poor activity, 6 (86%) had fever, 4 (57%) had drowsiness, 3 (43%) had diarrhoea, and 2 (29%) had oral ulcers. Four infants (57%) suffered from encephalitis. There were no deaths. EV71 was isolated from 3 (43%) of the young infants, while all were positive when tested for EV71 using a reverse transcription polymerase chain reaction. A sequence analysis of the EV71 partial gene revealed a 98.6-100% nucleotide similarity. Control measures included staff hand washing, disinfecting all materials exposed to potentially infected biological fluid, increasing staff hygiene precautions in the kitchen, and using a different basin for bathing each baby. We conclude that it is difficult to diagnose EV71 infection in young infants by clinical presentation alone and, similar to other enteroviruses, EV71 can spread efficiently amongst young infants in a nursery unit.

Prediction for developmental delay on Neonatal Oral Motor Assessment Scale in preterm infants without brain lesion.

BACKGROUND: Preterm infants often have difficulty in achieving a coordinated sucking pattern. To analyze the correlation between preterm infants with disorganized sucking and future development, weekly studies were performed of 27 preterm infants from initiation of bottle feeding until a normal sucking pattern was recognized. METHODS: A total of 27 preterm infants without brain lesion participated in the present study. Neonatal Oral Motor Assessment Scale (NOMAS) was utilized to evaluate the sucking pattern. Infants who were initially assessed as having disorganized sucking on NOMAS and regained a normal sucking pattern by 37 weeks old were assigned to group I; infants with a persistent disorganized sucking pattern after 37 weeks were assigned to group II. The mental (MDI) and psychomotor (PDI) developmental indices of Bayley Scales of Infant Development, second edition were used for follow-up tests to demonstrate neurodevelopment at 6 months and 12 months of corrected age. RESULTS: At 6 months follow up, subjects in group I had a significantly higher PDI score than group II infants (P= 0.04). At 12 months follow up, group I subjects had a significantly higher score on MDI (P= 0.03) and PDI (P= 0.04). There was also a higher rate for development delay in group II at 6 months (P= 0.05). CONCLUSION: NOMAS-based assessment for neonatal feeding performance could be a helpful tool to predict neurodevelopmental outcome at 6 and 12 months. Close follow up and early intervention may be necessary for infants who present with a disorganized sucking pattern after 37 weeks post-conceptional age.

The association of macronutrients in human milk with the growth of preterm infants.

BACKGROUND: Breast milk is the optimal choice for feeding premature babies. However, the prevalence rate of extrauterine growth restriction in preterm infants remains high. OBJECTIVES: The purpose of this study was to analyze the macronutrients present in human milk and the correlation with the growth of in-hospital preterm infants. METHODS: This prospective study is based on data from 99 in-hospital preterm infants younger than 37 weeks of gestational age on an exclusively human milk diet. Infants who had previously received parenteral nutrition were eligible, but they had to have reached full enteral feeding at the time that the samples were taken. A total of 3282 samples of raw human milk or donor pasteurized milk were collected. The levels of lactose, protein, fat, and energy in the samples were measured using a Miris human milk analyzer. The primary outcome was weight growth velocity (g/kg/day) which was obtained using two-point approach. RESULTS: The mean (±standard deviation) macronutrient composition per 100 mL of milk was 7.2 (±0.3) g of lactose, 1.1 (±0.2) g of true protein, 3.5 (±0.9) g of fat, and 66.9 (±6.5) kcal of energy. The protein concentration in human milk had a positive, significant correlation with body weight gain, with a coefficient of 0.41 (p < 0.001). After adjusting for gestational age, postmenstrual age, small-for-gestational age, intraventricular hemorrhage, patent ductus arteriosus or congestive heart failure, duration of total parenteral nutrition support, bottle feeding or use of orogastric tube, and ventilator support, total daily protein intake was associated with body weight growth (p < 0.001). CONCLUSION: Both the protein concentration in human milk and the daily total protein intake had a positive correlation with the body weight gain of premature infants. Routine analysis of breast milk and individualized fortification might be indicated to optimize the growth of preterm infants.

Knowledge and attitudes of pediatric clinicians regarding pediatric pain management.

BACKGROUND: The professional knowledge and personal attitudes of pediatric clinicians regarding pediatric pain are the most important factors impacting pediatric pain relief care. Few studies have investigated the knowledge and attitudes regarding pediatric pain management of clinicians in Taiwan. PURPOSE: Research purposes were to evaluate the knowledge and attitudes of pediatric clinicians regarding pain management and to describe the barriers of applying pain management across pediatric and neonatal settings. DESIGN AND METHODS: A cross-sectional descriptive comparative design was used. Pediatric clinicians from two medical centers and three general hospitals in Taiwan were recruited to complete a questionnaire. RESULTS: A total of 264 clinicians participated. On 33 questions measuring knowledge of pain management, the average correct response rate was 23.67. A significantly positive relationship was identified between clinicians' knowledge and prior training experience. Professional degree attainment significantly impacted clinicians' attitudes about pediatric pain management. Clinicians at pediatric wards showed more positive attitudes than did clinicians at either pediatric intensive care units or neonatal intensive care units. Five barriers to pediatric pain management were found. CONCLUSION: The findings of this study suggest that pediatric clinicians in Taiwan need further education regarding pediatric pain management. This study will also helpful in implementing multidisciplinary pediatric pain management programs to improve the quality of pediatric practice in pediatric care settings of hospitals.

Relationships between environmental stressors and stress biobehavioral responses of preterm infants in NICU.

Although research has demonstrated that the neonatal intensive care unit (NICU) is a stressful environment for preterm and high-risk infants, little research validates the suspected relationships between infant biobehavioral responses and environmental stress in the NICU. This exploratory study examined the relationship between environmental stress and biobehavioral responses of preterm infants. The study used a repeated-measures research design to examine research variables in one group of preterm infants. Measurements of research variables were recorded every 2 minutes during two 60-minute observation periods for each research day (1 hour in the morning and 1 hour in the afternoon) and conducted over 2 days. A convenience sample of 37 preterm infants was recruited from 2 medical centers in Taiwan. A total of 4164 observations were made and recorded during the study. There was a statistically significant (P < .05) relationship between environmental stressors and changes in physiological signals. There were also statistically significant (P < .05) relationships between environmental stress and some specific stress behaviors. This research is applicable to neonatal clinical practice because it demonstrates the importance of recognizing the preterm infant's biological stress responses to environmental stressors, allowing for early interventions to reduce the possibility of more serious physiological or pathological changes in the status of the preterm infant.

Risk factors for postdischarge growth retardation among very-low-birth-weight infants: A nationwide registry study in Taiwan.

BACKGROUND: Very-low-birth-weight (VLBW) infants have a high risk of postdischarge growth retardation (GR). Continued GR might exert negative long-term effects on their health. This study examined the prevalence and the risk factors for postdischarge GR among VLBW infants in Taiwan. METHODS: Nationwide data from the Taiwan Premature Infant Follow-up Network between 2007 and 2011 were analyzed. Infants with a gestational age (GA) < 37 weeks and birth body weight (BBW) < 1500 g were enrolled. They were followed up after discharge at the corrected ages of 6, 12, and 24 months. Associations between postdischarge GR at the follow-ups and possible risk factors were analyzed. RESULTS: The prevalence of postdischarge GR among 2124 VLBW infants was 17.3%, 19.4%, and 13.8% at the corrected age (CA) of 6, 12, and 24 months, respectively. The significant perinatal factors of postdischarge GR were being small for gestational age (SGA) and extremely low birth weight (ELBW). ELBW infant with extra-uterine growth retardation (EUGR) at discharge or longer length of hospital stay (LOS) had poorer growth outcomes. Among non-ELBW infants, EUGR at discharge and surgical necrotizing enterocolitis (NEC) were the main influencing factors of unfavorable growth outcomes. RDS with surfactant therapy had a positive effect of postdischarge growth outcomes in ELBW infants. CONCLUSION: Postdischarge GR is still a serious problem in Taiwan. Being SGA and ELBW and EUGR were significant risk factors for postdischarge GR throughout the first two years of life in VLBW infants. An integrated and organized team for postdischarge care as well as scheduled follow-ups, detailed nutritional education, and thorough inspection are necessary.

Correction: Post-discharge body weight and neurodevelopmental outcomes among very low birth weight infants in Taiwan: A nationwide cohort study.

[This corrects the article DOI: 10.1371/journal.pone.0192574.].

Acute encephalitis with refractory, repetitive partial seizures.

BACKGROUND: Acute encephalitis with refractory, repetitive partial seizures (AERRPS) is a new epileptic syndrome described by Sakuma in Japan in 2001. The clinical manifestations, neuroimaging findings and outcome of AERRPS in Taiwan have not been reported. METHODS: From 2000 to 2006, we collected cases that fulfilled the diagnostic criteria of AERRPS and analyzed the clinical course, virology, medication, electroencephalographic findings, neuroimaging characters and prognosis retrospectively. RESULTS: Fourteen children aged from 1 year and 2 months to 15 years and 6 months were enrolled. They presented with prodromic symptoms including fever (n=13, 92.9%), upper respiratory tract infection symptoms (n=12, 85.7%) and gastrointestinal tract discomfort (n=6, 42.9%). Seizures occurred 3-14 days after antecedent symptoms with patterns of generalized tonic-clonic seizures, focal seizures or myoclonic seizures. The seizures were refractory to combinations of antiepileptic drugs (AEDs). Prolonged fever (n=14, 100.0%), hypersensitivity to AEDs (n=11, 78.6%) and liver function impairment (n=8, 57.1%) were noted during the period of hospitalization. The follow-up EEG findings were similar to those of initial findings including epileptiform discharges and/or generalized background slow waves. Initial brain MRI scans were normal but later showed focal or multifocal abnormal signal intensity followed by generalized brain atrophy in more than 50% of cases. The general prognosis was poor with variable psychomotor retardation and persistence of refractory epileptic seizures. CONCLUSIONS: The similarities of the clinical features support AERRPS as a new epileptic syndrome. More study is needed to specify the etiology of the syndrome as the first step for more effective treatment.

Related factors in using a free breastfeeding hotline service in Taiwan.

AIMS: This study aimed to examine the use of a free hotline service for breastfeeding mothers in Taiwan. Specific attention was given to the accumulated consultation time and to investigate the trends and reasons that prompted people to contact the service. BACKGROUND: Breastfeeding can be a difficult time for mothers, especially during the first two weeks after birth. It has been suggested that a telephone hotline service may be helpful for breastfeeding mothers. DESIGN: In this quantitative study data, including the demographic data and the problems of consultations, were gathered from callers during August 2003 to August 2005. RESULTS: Of the 2445 callers, 935 made subsequent calls (38.2%). Approximately 25.25 calls were answered each day by two specially-trained staff according to an answering book. The mean consultation time for single first-call was 21.82 minutes and for one subsequent-call was 15.87 minutes. Perceived insufficient milk supply (30%) and returning to work (21%) were the top two reasons for a first-call. If callers' problems were about babies' sickness, perceived insufficient milk supply, babies' body weight gain and supplement issues, the accumulated consultation time would last longer. More than half (53.3%; 1303/2445) of callers made the first-call during the first month after birth, followed by 23.2% (566/2445) during babies' age between one and three months old. CONCLUSION: The telephone hotline service for breastfeeding mothers in Taiwan was well used during the two year period of this study. Many mothers used the service repeatedly for a variety of reasons. RELEVANCE TO CLINICAL PRACTICE: Recommendations for breastfeeding support strategies for the professionals include category of common breastfeeding problems by different stages after birth. This study supports the establishment of free hotline services may encourage greater empowerment in breastfeeding mothers. Future studies are required to examine client satisfaction of the telephone service.

Community-based epidemiological study on breastfeeding and associated factors with respect to postpartum periods in Taiwan.

AIMS: To explore the prevalence of breastfeeding in different geographical areas and identify the factors influencing breastfeeding practices during in-hospital stay and at one, four and six months postpartum in Taiwan. BACKGROUND: The national data on prevalence for breastfeeding patterns are still unknown. DESIGN: Community-based epidemiological survey design. METHODS: A total of 12,201 women were sampled from the birth registration and surveyed between June-October 2004. Data were collected through a computer-assisted telephone interview at four different postpartum periods. Logistic regression modelling was applied to determine factors influencing breastfeeding patterns and postpartum time-specific odds ratios. RESULTS: Rates of breastfeeding practices were 29.4, 33.2, 16.9 and 13.1% for in-hospital stay, the first-, fourth- and sixth-month postpartum respectively. Mother's intention to breastfeed was the most important factor to lengthen breastfeeding practices over time. The effect of an advocate programme in the hospital was significantly associated with breastfeeding only at the time of in-hospital stay. Age, family support and singleton were found to be significantly related to the continuation of breastfeeding at the fourth month postpartum. Employment status was significantly associated with the termination of breastfeeding, particularly at the later postpartum period. Geographical variation in breastfeeding practices within the first month postpartum was identified. In contrast, ethnic variation was more apparent at the later postpartum period. CONCLUSIONS: This large-scale study revealed a significantly decreasing trend after one month postpartum of breastfeeding rate in each geographical area of Taiwan. Factors associated with women's decision and continuation on breastfeeding patterns tended to be dependent on the time-specific postpartum period and varied between geographical areas. RELEVANCE TO CLINICAL PRACTICE: If breastfeeding rates are to increase, more attention should be paid to establish early breastfeeding and counter the negative influences of factors within the social environment.

Neurodevelopmental outcomes of infants with very low birth weights are associated with the severity of their extra-uterine growth retardation.

BACKGROUND: For infants with very low birth weights (VLBW), their neurodevelopmental outcomes are thought to be associated with extra-uterine growth retardation (EUGR). In this study, based on a single institute, we analyzed the association between different levels or severity of EUGR of VLBW infants and their neurodevelopmental outcomes later at a corrected age of 24 months. METHODS: This is a hospital-based retrospective cohort study. The severity of EUGR was classified into three categories according to the z-score of discharge weight: z < -2.0, <-2.5, and <-3.0. The outcomes were assessed using the Bayley Scales of Infant Development-II (BSID-II) at a corrected age of 24 months. We then estimated the association of EUGR with low mental developmental index (MDI) or low psychomotor developmental index (PDI). Multiple logistic regression and stratified analyses were used to adjust for the possible confounding factors. RESULTS: In total, 224 VLBW infants were enrolled in this study from 1997 to 2006. In the univariate analysis, EUGR for weight at discharge from hospital was associated with MDI <85 at the corrected age of 24 months, and this association was related to the severity of EUGR (z < -2.5, OR: 1.92 (1.04-3.53); z < -3.0, OR: 2.83 (1.26-6.36)). In addition, the relationship was not confounded by gender nor small for gestational age. The stratified analysis against hemodynamic significant patent ductus arteriosus also revealed that EUGR was an independent predictor for neurodevelopmental outcomes. CONCLUSION: In VLBW preterm infants, EUGR was significantly associated with low MDI scores assessed at a corrected age of 24 months. Early evaluation and recognition of EUGR should be emphasized when caring for preterm infants.

Correction: Post-discharge body weight and neurodevelopmental outcomes among very low birth weight infants in Taiwan: A nationwide cohort study.

[This corrects the article DOI: 10.1371/journal.pone.0192574.].

Post-discharge body weight and neurodevelopmental outcomes among very low birth weight infants in Taiwan: A nationwide cohort study.

BACKGROUND: Premature infants are at high risk for developmental delay and cognitive dysfunction. Besides medical conditions, growth restriction is regarded as an important risk factor for cognitive and neurodevelopmental dysfunction throughout childhood and adolescence and even into adulthood. In this study, we analyzed the relationship between post-discharge body weight and psychomotor development using a nationwide dataset. MATERIALS AND METHODS: This was a nationwide cohort study conducted in Taiwan. Total of 1791 premature infants born between 2007 and 2011 with a birth weight of less than 1500 g were enrolled into this multi-center study. The data were obtained from the Taiwan Premature Infant Developmental Collaborative Study Group. The growth and neurodevelopmental evaluations were performed at corrected ages of 6, 12 and 24 months. Post-discharge failure to thrive was defined as a body weight below the 3rd percentile of the standard growth curve for Taiwanese children by the corrected age. RESULTS: The prevalence of failure to thrive was 15.8%, 16.9%, and 12.0% at corrected ages of 6, 12, and 24 months, respectively. At corrected ages of 24 months, 12.9% had low Mental Developmental Index (MDI) scores (MDI<70), 17.8% had low Psychomotor Developmental Index (PDI) scores (PDI<70), 12.7% had cerebral palsy, and 29.5% had neurodevelopmental impairment. Post-discharge failure to thrive was significantly associated with poor neurodevelopmental outcomes. After controlling for potential confounding factors (small for gestational age, extra-uterine growth retardation at discharge, cerebral palsy, gender, mild intraventricular hemorrhage, persistent pulmonary hypertension of newborn, respiratory distress syndrome, chronic lung disease, hemodynamic significant patent ductus arteriosus, necrotizing enterocolitis, surfactant use and indomethacin use), post-discharge failure to thrive remained a risk factor. CONCLUSION: This observational study observed the association between lower body weight at corrected age of 6, 12, and 24 months and poor neurodevelopmental outcomes among VLBW premature infants. There are many adverse factors which can influence the neurodevelopment in NICU care. More studies are needed to elucidate the causal relationship.

Hyperekplexia (startle disease) mimicking neonatal seizures: report of one case.

Herein we report a case of a male infant with hyperekplexia. He was born after an uneventful pregnancy to healthy unrelated parents. At 2 days, he began to have frequent episodes of apnea accompanied with generalized tonic posture. Phenobarbital had been prescribed for the suspicion of neonatal seizures. However, the attack frequency remained the same. Clonazepam and clobazam were prescribed under the impression of hyperekplexia after the infant reached one month, and the apnea attacks quickly decreased. The startle reaction to tapping of the nasal bridge persisted at the age of 2 years. His growth and development were compatible with his age. A timely diagnosis in cases of hyperekplexia is crucial because affected neonates are at risk of sudden death from apnea.

Reduced nosocomial infection rate in a neonatal intensive care unit during a 4-year surveillance period.

BACKGROUND: Hospital-acquired infections are a leading cause of morbidity and mortality in neonatal intensive care units (NICU). The aim of the study was to investigate the change of nosocomial infection rate in a NICU during a 4-year surveillance period. METHODS: We investigated the changes in nosocomial infection rates, infection sites, and microorganism species in a NICU before and after the unit was moved to a new location, extending from November 2008 to October 2012.The new facility was opened on November 1, 2010 and the old NICU was closed on the same day. In the meantime, three catheter-based bundles were implemented in the new NICU and all intensive care units in our hospital due to the new policy. Data collection was performed by independent, experienced infection control nurses. RESULTS: A total of 512 neonates were admitted to the NICU and enrolled in this study. There were 242 infants who were admitted to the old NICU, and 270 infants in the new facility. During the study period, the rate of infection episodes decreased from 19.0% to 11.1% (P = 0.01). Additionally, the average hospital-acquired infection rate decreased from 6.26 cases per 1000 patient-days to 4.09 cases per 1000 patient-days (P = 0.03). The most common infection site was blood stream infection, which decreased from 8.3% to 3.7% (P = 0.03). The total catheter-related infection rates of the blood stream, lower respiratory tract, and urinary tract decreased from 13.6% to 5.9% (P = 0.003). Klebsiella pneumonia, E. coli, Methicillin-resistant Staphylococcus aureus (MRSA), and Coagulase-negative Staphylococci (CoNS) were the most frequently found pathogens in the old NICU, whereas MRSA, CoNS, E. faecalis, and A. baumannii were the most frequently found pathogens in the new NICU. CONCLUSION: The change in the environment and implementation of device bundles in the NICU might be associated with the nosocomial infection rate.