The NICU during COVID-19 Pandemic: Impact on Maternal Pediatric Medical Traumatic Stress (PMTS).

OBJECTIVE: The objective of this paper was to assess how hospital and outpatient clinic policies changes due to the coronavirus disease 2019 (COVID-19) pandemic impact pediatric medical traumatic stress (PMTS) symptoms in mothers of newborns admitted in a neonatal intensive care unit (NICU). STUDY DESIGN: Observational case-control study included the comparison between mothers of infants admitted in the NICU at birth during the COVID-19 pandemic and mothers of infants admitted in the NICU before the COVID-19 pandemic. The control group was selected matching 1:1 with the study group for the following infants' clinical variables: gender, type of pathology, gestational age, weight at birth, day of recovery, ventilator time days, and associated malformations. The Italian version of the Impact of Event Scale-Revised (IES-R) was used as a measure of PMTS. RESULT: Mothers of the study group (50) scored significantly higher than mothers of the control group on three of four scales of IES-R ("IES-R total": F = 6.70; p = 0.011; IES-R subscale "intrusion": F = 7.45; p = 0.008; IES-R subscale "avoidance": F = 8.15; p = 0.005). A significantly higher number of mothers in the study group scored above the IES-R total clinical cut-off compared with mothers of control group (72 vs. 48%; Chi2 = 6.00; p = 0.012). CONCLUSION: The COVID-19 pandemic acted as superimposed stress in mothers of newborns admitted in the NICU at birth determining high levels of PMTS. Clinicians and researchers should identify and implement novel strategies to provide family-centered care during the COVID-19 pandemic and beyond. KEY POINTS: · COVID-19 acted as superimposed stress on NICU population.. · PMTS in mothers got significantly worse during the COVID-19 pandemic.. · Alert on long-term consequences on child development..

Pediatric medical traumatic stress (PMTS) in parents of newborns with a congenital anomaly requiring surgery at birth.

BACKGROUND: Pediatric medical traumatic stress (PMTS) is a psychological and physiological response of children and their families to pain, serious illness, and invasive medical procedures. We aimed to apply the PMTS model to parents of newborns operated at birth for a congenital malformation and to identify clinical and sociodemographic risk factors associated with PMTS symptoms at 6 months. METHODS: We designed a cross-sectional study to assess PMTS symptoms (avoidance, arousal, reexperiencing) in parents of six months children operated on for a congenital anomaly, with the Italian version of the Impact of Event Scale - Revised (IES-R). RESULTS: One-hundred-seventy parents form the object of the study. Eighty-two parents (48.2%) fell over the clinical cut-off. Ventilatory time (p = 0.0001), length of hospital stay (p = 0.0001), associated anomalies (p = 0.0002), medical devices at discharge (p = 0.0001) and Bayley motor scale (p = 0.0002) were significantly correlated with IES-R Total and Subscale Scores. Multivariate linear regression showed length of hospital stay and number of associated anomalies as significant predictors of IES-R Scores. CONCLUSIONS: Regardless the type of anomaly and sociodemographic factors, it is the clinical history of the child which seems to predict the severity of PMTS symptoms in this population of parents. PMTS represents a useful model to describe the psychological reactions of parents of newborns operated at birth for a congenital malformation. NICU and outpatient pediatric staff should be aware of risk factors to identify families who may request early multidisciplinary interventions since the first admission. LEVEL OF EVIDENCE: Prognosis study, level II.

Fixed the gap, solved the problem? Eating skills in esophageal atresia patients at 3 years.

Although eating problems have been described as long-term morbidities of esophageal atresia (EA), there have been few studies exploring eating outcomes in children born with EA as primary aim. Parents of children operated on for EA in our Institution from January 2012 to January 2016, answered a telephone structured interview developed specifically to conduct the present study, assessing eating skills at 3 years of age. Clinical data were collected from children's medical records. Parents (45 mothers and 6 fathers) of 51 children (male = 34; female = 17) with a median age of 3.5 years form the object of the study. Considering eating problems, parents reported that 23 children (45%) still have episodes of choking during meals at 3 years of age, 9 (45%) of these have more than one episode a week, and 19 parents (39%) reported higher levels of anxiety during mealtimes. Forty-four children (86%) were described by their parents as able to eat alone, 32 (65%) accepted all food textures and 45 (90%) was described as curious about food (3 years). Forty-three (86%) parents let their children eat with other people. Correlations showed that weaning age was significantly associated with number of dilatations (rs = 0.35, P = 0.012), days of mechanical ventilation (rs = 0.40, P < 0.001), and presence of gastrostomy tube at discharge (rs = 0.45, P < 0.001). Chewing age resulted associated with number of dilatations (rs = 0.34, P < 0.01) and days of mechanical ventilation (rs = 0.38, P < 0.01). Presence of choking episodes was associated with curiosity about food (rs = 0.29, P < 0.05), while frequent choking episodes were associated with higher parental anxiety during mealtimes (rs = 0.45, P < 0.05). In order to prevent delay in the achievement of eating developmental milestones in children operated on of EA, we advocate a dedicated preventive intervention from birth to follow-up.

Couples Facing the Birth of a Newborn with a Congenital Anomaly: PTSD Symptoms in the First Year.

OBJECTIVE: The objective of this study was to assess the presence of posttraumatic stress disorder (PTSD) symptoms in parental couples of newborn requiring early surgery at 6 and 12 months after birth. STUDY DESIGN: A longitudinal study was set up from January 2014 to June 2015. As a measure of PTSD, we used the Italian version of the Impact of Event Scale-Revised (IES-R). RESULTS: Thirty-four couples form the object of the study. At 6 months, half of mothers (52.9%) and fathers (44.1%) reported traumatic stress symptoms above the clinical cutoff. Percentages remained stable at 12 months. When parental gender and length of follow-up were compared with two-factor analysis of variance, none had an impact on IES-R score, nor an interaction between these factors was found. A significant correlation of IES-R total score was present within the couple both at 6 and 12 months (6 months-r: 0.6842, p < 0.0001 and 12 months-r: 0.4045, p = 0.0177). CONCLUSION: Having a child with a repaired malformation represents a complex prolonged stressful situation with persistent burden for both parents who are at high risk of developing PTSD symptoms.

Does Ventilatory Time Retain Its Validity in Predicting Neurodevelopmental Outcome at Two Years of Age in High-Risk Congenital Diaphragmatic Hernia Survivors?

Objective To evaluate if in high-risk non-extracorporeal membrane oxygenation (ECMO)-treated congenital diaphragmatic hernia (CDH) survivors, ventilatory time (VT) is correlated to and can be used as clinical marker of neurodevelopmental delay at 2 years of age. Study Design Cohort study was conducted between 2008 and 2012. Mental, motor, and language development were assessed by the Bayley Scales of Infant and Toddler Development III. The correlation between VT and neurodevelopmental outcome (NDO) was analyzed using Pearson's test. Receiver operating characteristic (ROC) analysis was performed to determine the accuracy and best cutoff value of VT to predict the risk of neurodevelopmental delay. Statistical significance was set at p < 0.05. Results A total of 49 patients form the subject of this study. VT during first admission was inversely correlated with cognitive (r = -0.4116; p = 0.0033), motor (r = -0.4241; p = 0.0024), and language development (r = -0.3564; p = 0.0119). Using ROC curve analysis, VT was a significant predictor for neurodevelopmental delay in the cognitive (area under the curve [AUC]: 0.864, sensitivity: 100; specificity: 66.67; p < 0.0001) and motor (AUC: 0.902; sensitivity: 100; specificity: 73.17; p < 0.0001) scales, but not in the language scale. The best cutoff value for both scales was 9 days. Conclusion Within a population of high-risk non-ECMO-treated CDH survivors, VT appears to retain its validity as a clinical marker of adverse NDO in cognitive and motor domains.

Seeing Their Children in Pain: Symptoms of Posttraumatic Stress Disorder in Mothers of Children with an Anomaly Requiring Surgery at Birth.

Objective Assess the presence of posttraumatic stress disorder (PTSD) symptoms in mothers of newborns requiring early surgery. Study Design Mothers of newborns operated on for a congenital anomaly underwent a semi-structured interview on their experience 6 months postpartum. Interviews were audiotaped, transcribed verbatim, and analyzed for symptoms of the three major criteria of PTSD: re-experiencing, avoidance, and heightened arousal. Results A total of 120 mothers took part in the study; their children were affected by one of the following congenital anomaly: esophageal atresia (n = 29); congenital diaphragmatic hernia (n = 38); midgut malformations (n = 38); and abdominal wall defects (n = 15). Two mothers did not show any symptoms; 12 mothers (10%) had one posttraumatic symptom, 77 (64.2%) had two, and 29 (24.2%) had three. Overall, 106 mothers (88.4%) presented at least two symptoms. Conclusion PTSD can be considered a useful model to describe and comprehend mothers' reactions in this specific population. Preventive interventions and dedicated follow-up program should be offered to these families.

Neurodevelopmental Outcome in High-Risk Congenital Diaphragmatic Hernia Patients: An Appeal for International Standardization.

BACKGROUND: Since mortality in congenital diaphragmatic hernia (CDH) is decreasing, morbidity such as neurodevelopmental outcome is becoming increasingly important. OBJECTIVES: We evaluated neurodevelopmental outcome in high-risk CDH patients treated according to the CDH EURO Consortium standardized treatment protocol. METHODS: This observational, prospective cohort study was conducted in two European centers. Neurodevelopment of 88 patients (Rotterdam n = 49; Rome n = 39) was assessed at 12 and 24 months with the Bayley Scales of Infant Development (BSID)-II-NL (Rotterdam) or BSID-III (Rome). Data of the centers were analyzed separately. RESULTS: Cognition was normal in 77.8% of children from Rotterdam and in 94.8% from Rome at 12 months, and in 70.7 and 97.4%, respectively, at 24 months. Motor function was normal in 64.3% from Rotterdam and in 81.6% from Rome at 12 months and in 45.7 and 89.8%, respectively, at 24 months. Longer length of hospital stay (LoS) was associated with worse cognitive outcome and motor function; LoS, low socioeconomic status, and ethnicity were associated with lower cognition. CONCLUSIONS: At 2 years, most CDH patients have normal cognition, but are at risk for motor function delay. Due to differences in outcomes between centers, careful interpretation is needed before conclusions can be drawn for other centers. Future multicenter collaboration should not only focus on standardization of postnatal care, but also on international standardization of follow-up to identify risk factors and thereby reduce morbidity.

Factors affecting short-term neurodevelopmental outcome in children operated on for major congenital anomalies.

PURPOSE: Identify clinical and socio-demographic risk-factors affecting short-term neurodevelopmental outcome (NDO) in children operated on for abdominal and thoracic congenital anomalies (CA). METHODS: Prospective cohort observational study on newborns operated on for non-cardiac major CA. Evaluations were conducted at 6 and 12 months of age. Univariate linear regression and multivariate regression were conducted to analyze the impact on NDO of clinical and sociodemographic variables. Infants were evaluated with the Bayley Scales of Infant and Toddler Development-3rd Edition. RESULTS: One-hundred-fifty-five children were enrolled. They were affected by the following anomalies: Esophageal Atresia (N=41), Congenital Diaphragmatic Hernia (N=42), Midgut Malformations (N=34), Abdominal Wall Defects (N=18), Colorectal Malformations (N=20). There were no statistically significant differences among the five groups of CA as to NDO. Variables which reached statistical significance at multivariate regression (p≤0.001) at 6 and 12 months as to cognitive and motor development were: ventilatory time, associated malformations, medical appliances for feeding, number of surgery and length of hospital stay. CONCLUSIONS: On the average, children born with CA show a NDO within normal range. The identified risk-factors could prompt health care professionals to conduct a close surveillance on most vulnerable children giving them the best chance to reach their full potential.

Neurodevelopmental outcome in congenital diaphragmatic hernia survivors: role of ventilatory time.

BACKGROUND: Neurodevelopmental impairment is one of the most significant morbidities among CDH survivors. PURPOSE: Assess correlation between ventilatory time (VT) and short-term neurodevelopmental outcome in congenital diaphragmatic hernia (CDH) survivors. METHODS: A prospective longitudinal study was conducted between 2008 and 2012. Assessment of mental and motor development was performed at 6 and 12months by Bayley Scales of Infant and Toddler Development - 3rd Edition (BSID-III). ROC curve analysis was used. RESULTS: Forty-two subjects were included in the study. There was a significant inverse correlation between neurodevelopment at 6 and 12months and VT during first admission (p<0.0001). VT predicting the risk of moderate (BSID-III <85) and severe (BSID-III <70) delay was 13 and 28days, respectively (area under the curve - delay <85: 6months mental 0.943 and motor 0.992; 12months mental 0.877 and motor 0.925; delay <70: 6months mental 0.934 and motor 0.943; 12months mental 0.906 and motor 0.975; p<0.0001). CONCLUSIONS: VT should be considered an important marker to identify subjects at risk for short-term neurodevelopmental delay in CDH survivors. Early follow-up intervention therapy should be activated in every baby with a history exceeding 13days of VT.

Surgical gastrointestinal anomalies including diaphragmatic hernia: Does type of anomaly affect neurodevelopmental outcome?

OBJECTIVE: To describe short-term neurodevelopmental outcome of infants operated on for congenital anomalies (CA) and assess the impact of type of CA on the outcome. STUDY DESIGN: From 2008 to 2010 newborns operated on for CA were enrolled in a cross-sectional follow-up study including three distinct groups: infants of 6 months (group A), infants of 12 months (group B), and children of 24 months (group C). Each group was divided into five subgroups: (1) esophageal atresia; (2) congenital diaphragmatic hernia; (3) midgut malformations; (4) abdominal wall defects; (5) colorectal malformations. Each group of patients underwent a neurodevelopmental evaluation with Bayley III. RESULTS: In all, 150, 156, and 84 babies were enrolled in groups A, B, and C, respectively. Mean (standard deviation) Mental Scale score was 94.65 (8.75), 98.76 (11.03), and 100.60 (12.04) in groups A, B, and C. Mean (standard deviation) Motor Scale score was 96.89 (11.62), 99.23 (14.83), and 103.60 (12.90) in groups A, B, and C. No significant differences were found among the five subgroups considered. CONCLUSION: Regardless of type of malformation, short-term neurodevelopmental outcome of children with gastrointestinal anomalies including diaphragmatic hernia falls within normal range, suggesting that neither being born with a CA nor its type is per se a risk factor for neurodevelopmental delay.

Lack of institutional pathways for referral: results of a survey among pediatric surgeons on prenatal consultation for congenital anomalies.

OBJECTIVE: This paper aimed to assess pathways through which pediatric surgeons receive couples for prenatal consultation after prenatal diagnosis. METHOD: A questionnaire was mailed to pediatric surgical centers to assess the following: (1) surgical caseload per year; (2) number of centers in which prenatal consultation is offered; (3) presence of a 'structured' prenatal consultation clinic; (4) number of consultations per year; (5) pathways for referral to the pediatric surgeon; and (6) the availability of psychological counseling. RESULTS: Response rate was 81%, (42/52 centers). Thirty-eight centers (93%) offered prenatal consultation. Seven centers (18%) reported to have a 'structured' clinic in terms of time and location. In 13 centers (34%), 1-9 consultations were carried out, from 10 to 19 in 18 centers (47%), from 20 to over 50 in 7 centers (18%). In 34 centers, internal referrals from the obstetric departments were counseled, and in 28 centers, there were also external referrals. Eleven centers reported that couples were self-referred. Information regarding prenatal counseling was available on the institutional website in 10/38 (26%) centers. Psychological counseling was available in 36 centers. CONCLUSION: Despite the fact that the majority of pediatric surgical centers provides prenatal consultation, caseloads are very variable as are referral modalities.

Communication with parents in neonatal intensive care.

The psycho-relational problems in Neonatal Intensive Care Units (NICU) are complex and multifaceted and have only recently been properly addressed. Some specific factors make communication in NICU particularly problematic; the baby's clinical condition, the emotional and working conditions of the medical staff, the emotional state of the parents and the setting of the NICU and the interaction of multiple professional figures with the parents. The purpose of communication in NICUs is not only to inform parents of their child's clinical condition; the medical and nursing staff must also educate and guide parents so that they can actively participate in caring for their child and become true "partners" with the medical team in the decision-making process. Furthermore, the staff must also use their communication skills to understand and contain the anxieties and emotions of parents, supporting and comforting them through the most critical moments of their child's illness and possibly even bereavement. Given the number and complexity of the interpersonal exchanges that take place in the NICU, the risk of misunderstanding, misinterpretation and conflict is high. One could say that the interpersonal aspect is an area where the risk of iatrogenesis is elevated. It is recognized that poor staff-family interactions not only reflect negatively on the baby's care and are a source of distress and discontent for the parents, but are also a major cause of medico-legal litigation and increase the incidence of "burnout". Therefore, specific training of the staff in communication is essential if the optimal results, obtained through modern technology, are not to be invalidated.

Is counselling for CCAM that difficult? Learning from parental experience.

OBJECTIVE: Cystic adenomatoid malformations (CCAM) are relatively rare developmental abnormalities of the lung. Despite outcome is usually benign, parents often exhibit high anxiety level. The purpose of the present study was to collect parents'subjective experience of communication of diagnosis when expecting a fetus with CCAM. METHODS: In the period ranging between 2004 to 2007 all couples referred to our hospital for prenatal suspicion of CCAM, were contacted to participate in the study by means of a questionnaire. RESULTS: Twenty-seven couples returned fully completed questionnaire and form the object of this study. 13/27 couples were recommended pregnancy termination.MAJOR RISKS PRESENTED WERE: fetal distress (27/27), intrauterine death (16/27), death at birth (12/27).THE MOST DISTRESSING MOMENTS WERE: communication of diagnosis and the time lag between communication of diagnosis and consultation with the surgeon. CONCLUSIONS: Despite CCAM carries a favourable prognosis, couples often appear to receive incomplete information with risk of fetal distress and demise prevailing over survival rate and long term outcome. To provide the couple with the most accurate information concerning the anomaly and the associated prognosis to make informed decision a referral to a tertiary pediatric surgery unit should be made as soon as possible.

When uncertainty generates more anxiety than severity: the prenatal experience with cystic adenomatoid malformation of the lung.

AIM: To assess reasons for higher levels of anxiety generated by prenatal counselling of a condition with good outcome such as cystic adenomatoid malformation (CCAM) of the lung compared to a life-threatening malformation such as congenital diaphragmatic hernia (CDH). MATERIALS AND METHODS: The Spielberger State-Trait Anxiety Inventory (STAI-S) was used to measure anxiety in two groups of mothers carrying a fetus with the respective malformation. RESULTS: Forty-four mothers completed the questionnaire (CCAM, n=21 and CDH, n=23). Before consultation, the mean STAI-S scores in the CCAM group (44.80+/-5.92) and in CDH group (44.05+/-4.96) were not significantly different but was significantly reduced in both groups after consultation (CCAM 44.80 vs. 41.60, P=0.014 and CDH 44.05 vs. 34.35, P=0.0001). The groups were not significantly different regarding gestational age at diagnosis. CONCLUSIONS: After initial prenatal counselling, uncertainty about prenatal outcome and lack of defined management plans in CCAM seems to be more important than higher mortality rate occurring in CDH.

Mothers' adaptation to antenatal diagnosis of surgically correctable anomalies.

OBJECTIVE: To assess the applicability of Drotar model when the diagnosis of congenital malformation is made antenatally. METHODS: In a 3-year period (2000-2003) fifty mothers, counselled for fetal malformations amenable to surgical correction at birth, were interviewed. Statistical associations were sought between each stage of the adaptation process and type of anomaly, gestational age at diagnosis, maternal age, educational background and previous miscarriage. Emotional experience at each stage was studied as dichotomous variables. RESULTS: Fetuses were affected by the following anomalies: abdominal wall defects (11), intestinal atresia (14) and diaphragmatic hernia (25). All mothers experienced stage one, two and three. No association was found between anger, type of anomaly, maternal age, educational background, and age at diagnosis. On the contrary, such association was statistically significant for previous miscarriage. Thirty-nine mothers reached the adaptation stage while none of them experienced that of reorganization. CONCLUSION: Despite significant differences, the adaptation process proposed by Drotar to describe parents reactions is applicable in prenatal age.

Congenital intestinal anomalies, neonatal short bowel syndrome, and prenatal/neonatal counseling.

BACKGROUND: Short bowel syndrome (SBS) is a severe malabsorption caused by bowel loss. Congenital intestinal anomalies (CIA) detectable by prenatal ultrasound as jejunoileal atresia, meconium peritonitis, complicated meconium ileus, and fetal volvulus can be responsible for SBS. AIMS: This study aims to investigate either frequency of SBS or the morbidity in CIA population during the first admission. MATERIAL AND METHODS: Records of CIA treated from 1997 to 2003 were reviewed. The prenatal ultrasound findings were correlated with SBS. Student's t and chi(2) tests were performed to analyze epidemiological data, growth at discharge, sepsis, liver disease, catheter-related complications, motor developmental delay, and hospital stay in CIA with and without SBS. RESULTS: Forty-four CIA: SBS developed in 43%, ranging from 83% in volvulus to 0% in complicated meconium ileus. Thirty-six prenatal diagnoses: a strong correlation with SBS was observed in isolated dilated bowel (58%). In SBS neonates, birth weight, gestational age, and growth at discharge were statistically lower, whereas sepsis, motor delay, and hospital stay were statistically higher. CONCLUSIONS: Many neonates with CIA detectable by prenatal ultrasound develop SBS. Short bowel syndrome presents a significant higher morbidity. The counseling should stress the frequent association between CIA and SBS as well as the significant morbidity in SBS.

False-positive rate in prenatal diagnosis of surgical anomalies.

BACKGROUND/PURPOSE: Technical refinements and increasingly sophisticated equipment have led to higher sensitivity in prenatal diagnosis of congenital malformations; however, such progress may be accompanied by decreased specificity. The aim of this study is to evaluate evolution of prenatal diagnosis from the first sonographic suspicion of fetal anomaly until after delivery (diagnosis confirmed, resolution before birth, healthy baby, or affected with different disorder) to document rate of false-positive (FP) results. METHODS: Retrospective review of prenatal ultrasound examinations performed at our institution between 2000 and 2002 was conducted. The series includes pregnancies referred to our department after detection of thoracic and abdominal anomalies at routine obstetrical sonography and with a follow-up comprising at least the first 6 months of life. Urologic malformations were excluded. Those fetuses who proved healthy at birth were considered FP results. RESULTS: One hundred fifty-seven fetuses/neonates underwent complete follow-up. Prenatal diagnosis of esophageal atresia resulted in 3 (27%) of 11 FPs. Finding of dilated bowel, isolated or associated with hyperechogenicity or ascites, was not predictive of small bowel obstruction in 7 (41%) of 17 fetuses. No FPs were found with regard to abdominal wall defects (8 gastroschisis and 26 omphaloceles, all confirmed at birth). Concerning thoracic malformations, no FPs were seen among the 28 cases of congenital diaphragmatic hernia, whereas diagnosis of lung malformation presented a specificity of 97% (1/28 FP). Ovarian cysts accounted for an FP rate of 17% (4/23 FPs). Overall, a percentage of FP of 12% (6/50) was seen in 2000, of 11% (5/44) in 2001, and 9% (6/63) in 2002, with no statistically significant difference. CONCLUSIONS: Because of the high FP rate regarding some particular anomalies, unnecessary psychological burden to prospective parents may ensue. This issue should be dealt with in future prospective studies.

Antenatal diagnosis of diaphragmatic hernia: parents' emotional and cognitive reactions.

PURPOSE: The aim of this study was to assess parent's emotional and cognitive reactions to the prenatal diagnosis of diaphragmatic hernia in their prospective children. METHODS: A survey was conducted by means of a questionnaire. In the period ranging from 1997 to 2002, 40 couples in whom an established diagnosis of diaphragmatic hernia was made in their fetus were seen for prenatal consultation at a tertiary referral center. RESULTS: Overall response rate was 93% (37 couples). Mean period since diagnosis for compilation of the questionnaire was 2 weeks. Mean gestational age at diagnosis was 25 weeks (range, 16 to 35 weeks). All parents lacked prediagnostic knowledge of diaphragmatic hernia and consider a single consultation with the paediatric surgeon inadequate to have a clear understanding of the anomaly. Only 1 mother and 1 father reported they understood all the information given by the surgeon. The most frequent (75%) feeling during and after the consultation was fear. Most parents (70%) referred to the intense emotions as the factor that made it difficult to follow the surgeon's explanations as well as to ask questions. CONCLUSIONS: Because of the incompatibility of emotional distress and optimum learning, impairment of early comprehension of information about diaphragmatic hernia is unavoidable. Therefore, we believe that follow-up antenatal consultations and provision of written and visual illustration are extremely important to facilitate informed choices.