Information Order for Periviable Counseling: Does It Make a Difference?

OBJECTIVES: To examine whether the order of presenting survival vs disability information, with or without the description of infant neonatal intensive care unit (NICU) experiences would influence treatment choice during hypothetical periviable birth counseling. STUDY DESIGN: An internet sample of childbearing-aged women (n = 839) viewed a pictograph displaying the chances of survival and a pictograph on the chances of disability for a baby resuscitated during the periviable period. The sample was randomized to the order of pictographs and level of description of infant NICU experiences. Participants selected between intensive care or comfort care and reported their personal values. RESULTS: The order of the information influenced treatment choices (P = .02); participants were more likely to choose intensive care if they saw the survival pictograph first (70%) than the disability pictograph first (62%). Level of description of premature infant NICU experiences did not influence treatment choice (P = .92). Participants who valued sanctity of life, autonomy in making decisions, who were more religious, and had adequate health literacy were more likely to choose intensive care. Such participant characteristics had greater explanatory power than the experimental manipulations. CONCLUSIONS: Subtle differences in how information is presented may influence critical decisions. However, even among women with the same values, diversity in treatment choice remains.

Black Women and the Preemie Prep for Parents (P3) Program: Exploratory Analysis of a Clinical Trial.

Background: The smartphone Preemie Prep for Parents (P3) program was developed to address the gap in prenatal education of preterm birth in high-risk pregnancies. Despite a higher incidence of preterm birth, Black women are less likely to receive prenatal education. Methods: Pregnant women with medical conditions that predisposed them to preterm birth were randomized to receive the P3 program or links to American College of Obstetricians and Gynecologists webpages (control). The P3 group received periodic text messages, starting as early as 18 weeks gestational age, each with a link to a short, animated educational video. Participants completed the Parent Prematurity Knowledge Questionnaire, PROMIS Anxiety scale, and a feedback survey. This is a subgroup analysis of the Black, non-Hispanic participants in the P3 trial. Results: Of the 26 Black non-Hispanic women enrolled, the P3 group (n=14) had higher knowledge scores than the control group (n=12), 67.5% correct vs. 43.6% (difference 24.0; 95% CI, 7.4 to 40.6), without experiencing an increase in anxiety. More P3 participants reported discussing preterm birth with their partner (100%) than control participants (57%; difference 43; 95% CI, 6 to 80). Conclusions: The P3 program appears to be an effective method of providing preterm birth education to Black pregnant women.

Smartphone-Based Video Antenatal Preterm Birth Education: The Preemie Prep for Parents Randomized Clinical Trial.

Importance: Preterm birth is a leading cause of infant mortality and child morbidity. Preterm birth is not always unexpected, yet standard prenatal care does not offer anticipatory education to parents at risk of delivering preterm, which leaves parents unprepared to make health care choices during the pregnancy that can improve survival and decrease morbidity in case of preterm birth. Objective: To evaluate the effect of the Preemie Prep for Parents (P3) program on maternal knowledge of preterm birth, preparation for decision-making, and anxiety. Design, Setting, and Participants: Recruitment for this randomized clinical trial conducted at a US academic medical center took place from February 3, 2020, to April 12, 2021. A total of 120 pregnant persons with a risk factor for preterm birth were enrolled between 16 and 21 weeks' gestational age and followed up through pregnancy completion. Intervention: Starting at 18 weeks' gestational age, P3 program participants received links delivered via text message to 51 gestational age-specific short animated videos. Control participants received links to patient education webpages from the American College of Obstetricians and Gynecologists. Main Outcomes and Measures: At 25 weeks' gestation, scores on the Parent Prematurity Knowledge Questionnaire (scored as percent correct), Preparation for Decision Making Scale (scored 0-100), and Patient-Reported Outcomes Measurement Information System (PROMIS) Anxiety computerized adaptive test. Analysis was based on an intention to treat. Results: A total of 120 pregnant participants (mean [SD] age, 32.5 [4.9] years) were included in the study; 60 participants were randomized to each group. Participants in the P3 group scored higher than those in the control group on knowledge of long-term outcomes at 25 weeks (88.5% vs 73.2%; estimated difference, 15.3 percentage points; 95% CI, 8.3-22.5 percentage points; P < .001). Participants in the P3 group reported being significantly more prepared than did participants in the control group for neonatal resuscitation decision-making at 25 weeks (Preparation for Decision Making Scale score, 76.0 vs 52.3; difference, 23.7; 95% CI, 14.1-33.2). There was no difference between the P3 group and the control group in anxiety at 25 weeks (mean [SE] PROMIS Anxiety scores, 53.8 [1.1] vs 54.0 [1.1]; difference, -0.1; 95% CI, -3.2 to 2.9). Conclusions and Relevance: In this randomized clinical trial, pregnant persons randomly assigned to the P3 program had more knowledge of core competencies and were more prepared to make decisions that affect maternal and infant health, without experiencing worse anxiety. Mobile antenatal preterm birth education may provide a unique benefit to parents with preterm birth risk factors. Trial Registration: ClinicalTrials.gov Identifier: NCT04093492.

Readiness of obstetric professionals to inform parents regarding potential outcome of premature infants.

Parents often regard obstetric professionals as an important source of information regarding prematurity. However, there is no information regarding the readiness of these obstetric professionals to inform expectant parents of the potential outcomes of premature infants. Using a self-report questionnaire, we determined the knowledge of obstetric professionals regarding outcomes of premature infants, and gauged their confidence in providing this information to expectant parents. Some 50% of obstetric professionals reported that they 'struggle to answer parental questions' regarding premature infants. The majority of obstetric professionals correctly identified potential morbidities of prematurity, but compared to neonatal professionals, they were less likely to discuss this information with parents. When they do provide information to parents, obstetric professionals were least likely to discuss neurological morbidities. Our study has identified an important barrier to the effective transfer of neonatal outcomes information to expectant parents. This limitation requires further investigation and intervention.

Effectiveness of Digital Multimedia Educational Aids Produced by Intensive Care Unit Providers.

Multimedia improves understanding of information. Professionally developed digital multimedia educational modules are expensive. We tested educational modules developed by a medical student without extensive multimedia production training. The modules were developed with neonatologist collaboration, uploaded to YouTube, and presented via iPad to neonatal intensive care unit family members who were ≥ 18 years, English literate, and unexposed to topic they were reviewing. Thirty-six participants viewed the modules once and then answered topic-specific key questions. Thirty of 36 (83%) of the participants answered 4/4 (100%) of questions correctly and 6/36 (17%) answered three-fourths (75%) correctly, demonstrating success of the educational modules. Health care workers can economically create effective digital multimedia educational materials without extensive training.

Video Education in Early Pregnancy and Parent Knowledge of Neonatal Resuscitation Options: A Secondary Analysis of a Randomized Clinical Trial.

This secondary analysis of a randomized clinical trial investigates the proportion of correct answers on neonatal resuscitation options among parents after seeing a video on these options.

Informing and educating parents about the risks and outcomes of prematurity.

The current process of educating and informing parents of the concerns and outcomes of premature infants is suboptimal, mostly because of modifiable factors. Proven methods to improve the transference of information are underused. In most institutions, the task to inform and educate parents is left to individual providers. Effective parent-clinician communication depends collectively on parents, clinicians, and the health care systems. Efforts must focus on improving communication and not on decreasing information provided to parents. If done successfully, we might find new and worthy allies in the trenches of the NICU.

Variations among US hospitals in counseling practices regarding prematurely born infants.

OBJECTIVE: We studied several counselor-independent elements of prenatal counseling regarding prematurely born infants. Elements studied include: indications to offer counseling, clinical settings in which counseling is offered, personnel assigned to counsel, availability of tools to assist counseling and post-counseling documentation requirements. METHOD: As the study aimed to explore system-based practices and not counselor-based practices, we surveyed Neonatal Intensive Care Unit medical directors. RESULT: Responses were received from 352 hospitals (53%) in 47 states. Analysis was based on responses from the 337 hospitals that routinely counseled women anticipating a premature birth. In 299 (≈ 90%) hospitals, counseling was primarily performed by neonatal professionals. Premature labor was the most common indication to offer counseling; however, in 54 hospitals most counseling was offered before labor and based on maternal risk factors for preterm delivery. In nearly all (99.7%) hospitals information was provided verbally and face-to-face; a third of the hospitals also provided written information. For non-English-speaking Hispanic patients, 208 (62%) of the hospitals had certified hospital-based Spanish interpreters. Five (1%) hospitals provided specialized training to the designated prenatal counselors. The upper gestational age eligible for counseling at all 337 hospitals included 33 weeks; in 134 hospitals, gestational age of <23 weeks was not eligible for counseling. CONCLUSION: Antenatal parental counseling for premature delivery is a widely practiced intervention with substantial system-based variability in execution. Interventions and strategies known to improve overall counseling effectiveness are not commonly utilized. We speculate that guidelines and tool-kits supported by Pediatric and Obstetric professional organizations may help improve system-based practices.

Advances in the diagnosis and management of persistent pulmonary hypertension of the newborn.

Rapid evaluation of a neonate who is cyanotic and in respiratory distress is essential for achieving a good outcome. Persistent pulmonary hypertension of the newborn (PPHN) can be a primary cause or a contributing factor to respiratory failure, particularly in neonates born at 34 weeks or more of gestation. PPHN represents a failure of normal postnatal adaptation that occurs at birth in the pulmonary circulation. Rapid advances in therapy in recent years have led to a remarkable decrease in mortality for the affected infants. Infants who survive PPHN are at significant risk for long-term hearing and neurodevelopmental impairments, however. This review focuses on the diagnosis, recent advances in management, and recommendations for the long-term follow-up of infants who have PPHN.

Polymorphism of tumor necrosis factor-alpha and risk and severity of bronchopulmonary dysplasia among very low birth weight infants.

BACKGROUND: Preterm infants with bronchopulmonary dysplasia (BPD) exhibit prolonged elevation of inflammatory indices in their tracheal aspirates. Tumor necrosis factor-alpha (TNF-alpha) is a central mediator of the inflammatory response. The adenine-containing alleles of TNF-alpha-308 and lymphotoxin-alpha+250 have been associated with increased levels of TNF-alpha, whereas the adenine allele of TNF-alpha-238 produces lower levels of TNF-alpha after stimulation. High levels of TNF-alpha may promote chronic inflammation by overwhelming counter-regulatory mechanisms and may lead to the development of BPD. Low levels of TNF-alpha may decrease the risk and/or severity of BPD. OBJECTIVE: To determine whether alleles of TNF-alpha play a role in the susceptibility and/or severity of BPD among very low birth weight infants. METHODS: Infants with birth weights of < or =1250 g were included. Genotypic analyses (polymerase chain reaction-restriction fragment length polymorphism assays) were performed with DNA extracted from whole-blood samples. RESULTS: Infants who developed BPD (fraction of inspired oxygen at postconceptional age of 36 weeks of >0.21, n = 51) had a younger gestational age (mean +/- SD: 27 +/- 4 vs 29 +/- 2 weeks) and lower birth weight (853 +/- 184 vs 997 +/- 193 g) than did infants without BPD (n = 69). The genotypic distributions of lymphotoxin-alpha+250 and TNF-alpha-308 were comparable among the groups of infants. However, the AA and GA TNF-alpha-238 genotypes were much less likely to occur among infants with BPD than among infants without BPD. The adenine allele of TNF-alpha-238 was absent among infants with severe BPD and occurred significantly less often among infants with moderate or severe BPD, compared with infants with mild BPD. The number of adenine alleles of TNF-alpha-238 was correlated inversely with the severity of BPD (r = -.341). CONCLUSION: The adenine allele of TNF-alpha-238 may reduce the risk and severity of BPD.

Tumor necrosis factor-alpha allele lymphotoxin-alpha+250 is associated with the presence and severity of placental inflammation among preterm births.

Histologic inflammation of placenta has been associated with increased risk for bronchopulmonary dysplasia and periventricular leukomalacia among preterm infants. Tumor necrosis factor-alpha (TNF-alpha) plays a central role in the regulation of inflammation. Some alleles of TNF (LT-alpha+250, TNF-alpha-308, and TNF-alpha-238) have been associated with susceptibility and/or severity of many diseases characterized by inflammation and/or involving the immune system. To determine whether alleles of TNF-alpha affect the risk and/or the severity of chorioamnionitis, we examined the placentas of 101 preterm births (birth weight