Neonatal outcomes and its association among gestational diabetes mellitus with and without depression, anxiety and stress symptoms in Malaysia: A cross-sectional study.

OBJECTIVE: Prevalence of depression, anxiety and stress symptoms in gestational diabetes mellitus ranges from 10.2% to 39.9% based on previous studies in Malaysia. Presence of depression, anxiety or stress in pregnancy may increase the risk of neonatal morbidity and mortality. The aim of this study was to determine the prevalence of neonatal outcomes and its association among mothers with gestational diabetes mellitus with and without the presence of depression, anxiety and stress symptoms in Malaysia. DESIGN: This was a cross-sectional study. SETTING: Tertiary hospitals in Malaysia. PARTICIPANTS: Mothers with gestational diabetes mellitus (n = 418) who deliver their neonates at two major tertiary hospitals in Malaysia. MEASUREMENTS: Neonatal outcomes, such as low birth weight, preterm birth, macrosomia, metabolic and electrolyte disorders, neonatal respiratory distress and congenital anomalies were determined. FINDINGS: Prevalence of low birth weight in neonates born to mothers with gestational diabetes mellitus was 14.6%, followed by metabolic and electrolyte disorders 10.5%, preterm birth 9.1%, macrosomia 4.8%, neonatal respiratory distress 5.8% and congenital anomalies (2.4%). Among the adverse neonatal outcomes, neonatal respiratory distress was significantly associated with the presence of depression symptoms in mothers with gestational diabetes mellitus using univariate analysis (p = 0.010). After controlling for confounding factors, predictors for neonatal respiratory distress at delivery were the presence of depression symptoms in mothers with gestational diabetes mellitus (Adjusted OR = 3.87, 95% CI = 1.32-11.35), living without a husband (Adjusted OR = 9.74, 95% CI = 2.04-46.51), preterm delivery (Adjusted OR = 7.20, 95% CI = 2.23-23.30), caesarean section (Adjusted OR = 3.33, 95% CI = 1.09-10.15), being nulliparous and primiparous (Adjusted OR = 3.62, 95% CI = 1.17-11.17) and having family history of diabetes (Adjusted OR = 3.20, 95% CI = 1.11-9.21). KEY CONCLUSIONS: The findings of this study demonstrate the positive association of neonatal respiratory distress with the presence of depression symptoms in mothers with gestational diabetes mellitus. IMPLICATIONS FOR PRACTICE: It is therefore important to identify depression symptoms after a diagnosis of gestational diabetes mellitus in pregnant mothers is made to enable early referral and interventions.

Síndrome do desconforto respiratório agudo: como estão os pacientes após a unidade de terapia intensiva? / Acute respiratory distress syndrome: how do patients fare after the intensive care unit?

RESUMO Os pacientes com síndrome do desconforto respiratório agudo requerem estratégias ventilatórias que demonstraram ser importantes na redução da mortalidade em curto prazo, como ventilação protetora e ventilação em posição prona. No entanto, os pacientes que sobrevivem têm permanência prolongada, tanto na unidade de terapia intensiva como no hospital, e experimentam redução na satisfação global com a vida (independência, aceitação e perspectiva positiva), na saúde mental (ansiedade, depressão e sintomas de transtorno de estresse pós-traumático), na saúde física (estado físico, atividades da vida diária, fadiga e fraqueza muscular), na saúde social e na capacidade de realização de suas atividades sociais (amigos ou relações familiares, hobbies e atividades sociais).

ABSTRACT Patients with acute respiratory distress syndrome require ventilation strategies that have been shown to be important for reducing short-term mortality, such as protective ventilation and prone position ventilation. However, patients who survive have a prolonged stay in both the intensive care unit and the hospital, and they experience a reduction in overall satisfaction with life (independence, acceptance and positive outlook) as well as decreased mental health (including anxiety, depression and posttraumatic stress disorder symptoms), physical health (impaired physical state and activities of daily living; fatigue and muscle weakness), social health and the ability to participate in social activities (including relationships with friends and family, hobbies and social gatherings).

A case of infant delirium in the neonatal intensive care unit.

Infant delirium is an under-recognized clinical entity in neonatal intensive care, and earlier identification and treatment could minimize morbidities associated with this condition. We describe a case of a 6-month-old former 32 weeks gestation infant undergoing a prolonged mechanical ventilation course diagnosed with delirium related to the combination of his underlying illness and the use of multiple sedative and analgesic medications. Initiation of the atypical antipsychotic risperidone allowed for weaning from continuous infusions of benzodiazepines and opiods, and lower dosages of bolus-dosed sedation and analgesics. The patient experienced no adverse side effects from use of this neuroleptic.

Multiple Perspectives of Symptoms and Suffering at End of Life in the NICU.

BACKGROUND: Despite technological advances in the neonatal intensive care unit, not all infants survive. Limited research has focused on infants' symptoms and suffering at end of life (EOL) from multiple perspectives. PURPOSE: To compare retrospective parent report and electronic medical record (EMR) documentation of symptoms and to examine associations with parent perceptions of infants suffering at EOL. METHODS/SEARCH STRATEGY: Bereaved parents of 40 infants (40 mothers and 27 fathers) retrospectively reported on their perceptions of infant symptoms and suffering during the last week of life. EMRs were also reviewed. FINDINGS/RESULTS: Parents were asked about their observations of 23 symptoms. Within the 27 parental dyads, mothers reported 6.15 symptoms (standard deviation = 3.75), which was not significantly different from fathers' report of 5.67 symptoms (standard deviation = 5.11). Respiratory distress, agitation, and pain were most common according to mothers and EMR, whereas respiratory distress, agitation, and lethargy were most common according to fathers. Few differences were found between mothers, fathers, and EMRs. However, missing data (range: 0%-20%) indicated that some parents had challenges assessing symptoms. Parents reported that the worst symptom was respiratory distress. In addition, parents reported moderate infant suffering, which was correlated with the total number of symptoms. IMPLICATIONS FOR PRACTICE: Parents demonstrate awareness of their infant's symptoms at EOL, and these observations should be valued as they closely parallel EMR documentation. However, some parents did have difficulty reporting symptoms, highlighting the importance of education. IMPLICATIONS FOR RESEARCH: Future larger sample research should prospectively examine parent perceptions of infant symptom burden, suffering, and associations with other infant and parent outcomes (eg, decision making and grief).

Adult Outcomes After Newborn Respiratory Failure Treated With Extracorporeal Membrane Oxygenation.

OBJECTIVE: To describe the outcome of young adults treated for hypoxemic respiratory failure with extracorporeal membrane oxygenation as neonates. DESIGN: The study was designed as a multisite, cross sectional survey. SETTING: The survey was completed electronically or on paper by subjects and stored in a secure data base. SUBJECTS: Subjects were surviving neonatal extracorporeal membrane oxygenation patients from eight institutions who were18 years old or older. INTERVENTIONS: None. MEASUREMENTS AND MAIN RESULTS: A questionnaire modified from the 2011 Behavioral Risk Factor Surveillance System and the 2011 National Health Interview Survey with additional unique questions was completed by subjects. Results were compared to age-matched national Behavioral Risk Factor Surveillance System and National Health Interview Survey data. One hundred and forty-six subjects participated (8.9% of eligible candidates). The age at questionnaire submission was 23.7 ± 2.89 years. Subjects differed statistically from national cohorts by being more satisfied with life (93% vs 84.2%); more educated (some college or degree; 80.1% vs 57.7%); more insured for healthcare (89.7% vs 72.3%); less frequent users of healthcare in the last 12 months (47.3% vs 58.2%); more limited because of physical, mental, and developmental problems (19.9% vs 10.9%); and having more medical complications. Furthermore, learning problems occurred in 29.5% of the study cohort. The congenital diaphragmatic hernia group was generally less healthy and less well educated, but equally satisfied with life. Perinatal variables contributed little to outcome prediction. CONCLUSIONS: Most young adult survivors in this study cohort treated with extracorporeal membrane oxygenation as neonates are satisfied with their lives, working and/or in college, in good health and having families. These successes are occurring despite obstacles involving health issues such as asthma, attention deficit disorder, learning difficulties, and vision and hearing problems; this is especially evident in the congenital diaphragmatic hernia cohort. Selection bias inherent in such a long-term study may limit generalizability, and it is imperative to note that our sample may not be representative of the whole.

Frequency-modulated orocutaneous stimulation promotes non-nutritive suck development in preterm infants with respiratory distress syndrome or chronic lung disease.

OBJECTIVE: For the premature infant, extrauterine life is a pathological condition, which greatly amplifies the challenges to the brain in establishing functional oromotor behaviors. The extent to which suck can be entrained using a synthetically patterned orocutaneous input to promote its development in preterm infants who manifest chronic lung disease (CLD) is unknown. The objective of this study was to evaluate the effects of a frequency-modulated (FM) orocutaneous pulse train delivered through a pneumatically charged pacifier capable of enhancing non-nutritive suck (NNS) activity in tube-fed premature infants. STUDY DESIGN: A randomized trial to evaluate the efficacy of pneumatic orocutaneous stimulation 3 × per day on NNS development and length of stay (LOS) in the neonatal intensive care unit among 160 newborn infants distributed among three sub-populations, including healthy preterm infants, respiratory distress syndrome (RDS) and CLD. Study infants received a regimen of orocutaneous pulse trains through a PULSED pressurized silicone pacifier or a SHAM control (blind pacifier) during gavage feeds for up to 10 days. RESULT: Mixed modeling, adjusted for the infant's gender, gestational age, postmenstrual age and birth weight, was used to handle interdependency among repeated measures within subjects. A significant main effect for stimulation mode (SHAM pacifier vs PULSED orosensory) was found among preterm infants for NNS bursts per min (P=0.003), NNS events per min (P=0.033) and for total oral compressions per min (NNS+nonNNS) (P=0.016). Pairwise comparison of adjusted means using Bonferroni adjustment indicated RDS and CLD infants showed the most significant gains on these NNS performance indices. CLD infants in the treatment group showed significantly shorter LOS by an average of 2.5 days. CONCLUSION: FM PULSED orocutaneous pulse train stimuli delivered through a silicone pacifier are effective in facilitating NNS burst development in tube-fed RDS and CLD preterm infants, with an added benefit of reduced LOS for CLD infants.

Breastfeeding practices in mothers of high-respiratory-risk NICU infants: impact of depressive symptoms and smoking.

AIM: Mothers of infants in the neonatal intensive care unit (NICU) have very low breastfeeding rates and these high-respiratory-risk (HRR) NICU infants may benefit from breastfeeding through decreased risk for respiratory illnesses. This population's increased risk for maternal depression and high rates (22%) of maternal smoking may negatively affect breastfeeding. OBJECTIVE: This exploratory study investigated associations of breastfeeding with depressive symptoms and maternal smoking in mothers of HRR NICU infants (i.e. presence of one household smoker and birth weight <1500 g or mechanical ventilation ≥12 h). METHODS: Breastfeeding, depression and smoking data were collected from 104 mothers in the NICU following delivery. RESULTS: Fifty-five (52.9%) mothers reported breastfeeding, 39 (37.5%) had a Center for Epidemiological Studies Depression Scale (CES-D) score (≥16) suggestive of depression, and 36 (34.6%) reported smoking. Mothers with CES-D scores ≥16 were less likely to breastfeed compared to those with scores <16 (38.5% versus 61.5%; p = 0.02). Breastfeeding and smoking were not significantly associated (p < 0.10). Mothers of HRR infants with significant depressive symptoms who smoke have significantly lower breastfeeding rates (21%) than mothers who are not depressed and do not smoke (65%). CONCLUSIONS: Interventions to improve breastfeeding initiation and continuation that target depression and smoking are necessary.

Comparison of caretaker report and hands-on neurodevelopmental screening in high-risk infants.

Caretaker report in developmental screening of high-risk infants has not been investigated adequately. We compare a caretaker-completed neurodevelopmental prescreening questionnaire (NPQ) to a hands-on screener (Bayley Infant Neurodevelopmental Screener; BINS) and attempt to identify factors that influence agreement in a high-risk sample. From 1,436 infants drawn from 5 centers, 471 were prospectively evaluated at 6-months corrected age, 376 at 12-months, and 244 at 24-months. Fifty-five percent were male; 28% African American, 70% Caucasian, 3% other; M gestational age = 31.2 weeks, M birth weight = 1568 g. Caretakers completed the NPQ (based on the BINS) while watching a video depicting infants engaged in items. The BINS was subsequently administered. Sensitivity ranged from 80%-91%, specificity 57%-82%, and overall agreement 70%-83%, depending on age. Mean NPQ summary scores were lower than the BINS. Agreement varied depending on BINS risk status, being best in the high-risk group, and worst in the moderate risk group. Background variables had minimal impact at 6 and 12 months with BINS risk status being the primary influence; at 24-months, race, intraventricular hemorrhage, and respiratory distress syndrome were influential. Caretaker report is useful in a high-risk population, although the infant's neurodevelopmental status influences such early on; ethnic background and biomedical variables become more important at 2 years.

[Music therapy for prematures]. / Musiktherapie bei Frühgeborenen. Praktische Durchführung und mögliche Auswirkungen anhand eines Fallbeispiels.

BACKGROUND: More than ever before the neonatal care besides the medical and nursing work has to been balanced between protecting the child against over extension due to the concept of "minimal handling" and on the other hand the necessary fostering of the young patients psychic and sensomotor development during the long stationary treatment. In addition to known approaches of auditive stimulation as receptive music therapy a concept of active music therapy methods based on the Nordoff/Robbins creative music-therapy (University Witten/Herdecke) is presented in a case-report. PATIENT AND METHODS: The report describes in a single case-report the music-therapeutic work with a premature of the 23 + 3 (th) week of pregnancy at the neonatological unit of the Vestische Kinder- und Jugendklinik Datteln, Universität Witten/Herdecke. The main focus was the observation of the prematures reactions on specific synchronisation of motoric, sensor and acoustical stimulation. RESULTS: Positive reactions allow to presume the effectiveness of music therapy with early born children as they are already shown in clinical studies about receptive music therapy. On the level of involuntary motional actions in the area of head-, face- and hand movements increased directly reactions of awareness on the coordination of sensomotor and acoustical stimulation have been observed. Temporary increase of oxygen partial pressure and reduction of heart/pulse rate seem to cause positive physiological effects. CONCLUSIONS: Active music therapeutic treatment does not seem to be an other risk of over-tension for prematures, but offers through the coordination of different levels of perception an adequate development fostering stimulation.

Processing speed in the 1st year of life: a longitudinal study of preterm and full-term infants.

Processing speed was assessed at 5, 7, and 12 months in full-term and preterm infants (birth-weight < 1,750 g). Speed was gauged directly in a new task by presenting infants with a series of paired faces, one that remained the same across trials and one that changed; trials continued until infants showed a consistent novelty preference. At all ages, preterms required about 20% more trials and 30% more time than full-terms to reach criterion. Among preterms, slower processing was associated with greater medical risk (e.g., respiratory distress syndrome). Developmental trajectories for speed (and attention) were similar for both groups. Thus, the deficits in processing speed previously found for preterms in childhood are already present in the 1st year of life.

Effects of infant and caregiving conditions on an infant's focused exploration of toys.

An infant's exploration of toys, in the context of the mother's regulating actions, is a setting for cognitive and social development. The aim of this study was to examine the contribution of infant and caregiving conditions to the quantity of focused exploration of toys for 8-month-old infants. Infant biological conditions were gender and birth weight, including a range of both prematurely and term-born infants. The infant behavioural condition was responsiveness to care. Caregiving conditions included mother's education, the supportive, stimulating and sustaining quality of the home environment, and the attention-directing and -supporting behaviour of the mother during play. The direct and indirect effects of these conditions on focused toy exploration were modelled using multiple regression. The sample of 79 mother-infant dyads included 43 full-term infants and 36 premature infants. The mother's attention-directing behaviour was a significant negative predictor of focused toy exploration. Infant birth weight did not have a significant direct effect on focused toy exploration. Birth weight did not interact significantly with responsiveness to care or with any of the caregiving environment conditions to affect focused toy exploration. Further study of infant responses to the mother's attention-regulating and emotion-regulating behaviour during play is recommended to better understand how the caregiving environment supports or thwarts focused toy exploration.

Very-low-birthweight infants at seven years: an assessment of the health and neurodevelopmental risk conveyed by chronic lung disease.

To determine whether history of chronic lung disease (CLD) in children born at very low birthweight (VLBW) confers additional risk for impaired health, growth, and neurodevelopment, 17 VLBW children born in 1984 who had CLD (requiring supplemental oxygen more than 30 days after birth) in infancy and 28 VLBW children who did not have CLD were assessed at age 7 years. Assessments included a medical history, standard physical and neurological examinations, pulmonary-function tests, and tests of neuropsychological and psychoeducational functioning. Health status did not differ between the groups. In contrast, children with CLD did not perform as well in neuropsychological and psychoeducational assessments. Although CLD confers little added risk to health, it seems to add significantly to risks for poor school performance that are known to be associated with very low birthweight.

Making sense of randomization; responses of parents of critically ill babies to random allocation of treatment in a clinical trial.

Randomized controlled trials (RCTs) are widely accepted by the scientific community as the most rigorous way of evaluating interventions in health care. Although their central feature, random allocation of treatment, is generally seen as methodologically appropriate, its application has caused much debate amongst health professionals and ethicists. This paper describes the views of parents who consented that their critically ill newborn baby should be enrolled in a neonatal trial. In-depth interviews were used to determine their response to the trial and randomization. The nature of the trial was often poorly understood. The random basis of the allocation of treatment and the rationale behind this approach were also problematic issues. Some parents did not perceive a random element in the process at all. These findings advance understanding of the perceptions of trial participants and raise important issues for those concerned with RCTs. Greater understanding of participants' views provides the potential to improve the management of future trials and so the experience of those agreeing to take part.

Enhanced sucking engagement by preterm infants during intermittent gavage feedings.

Non-nutritive sucking (NNS) activities were recorded in preterm infants born at gestational age 32 weeks or less during nasogastric feedings. Six infants on intermittent nasogastric feeding schedules were tested with a pacifier in their mouth for three 5-minute periods (before, during, and after gavage feeding). Analysis of the recordings revealed that NNS activities increased markedly during the intermittent nasogastric feeding schedule. The overall proportions of sucking engagement, the mean duration of sucking burst, the mean number of sucks per burst, and the mean duration of individual sucks within a burst increased markedly during gavage feeding compared with both pre-test and post-test periods. NNS by a group of five infants on continuous nasogastric feedings was similar to the pre-test and post-test of the infants on the intermittent nasogastric feeding schedule. These results indicate that in the context of intermittent nasogastric feedings, NNS engagement in tube-fed infants depends on stomach cues and/or temperature changes associated with tube feedings.

The effects of neonatal jaundice and respiratory complications on learning and habituation in 5- to 11-month-old infants.

The influences of neonatal hyperbilirubinemia and respiratory complications were examined in 5- to 11-month-old infants in two studies. One study focused on habituation performance and the other on contingency learning. In both experiments, three neonatal jaundice conditions (no jaundice history, measured bilirubin, phototherapy) were crossed with two levels of neonatal respiratory risk (no oxygen intervention, oxygen intervention). For low respiratory risk subjects there were increasingly adverse effects for both habituation and learning the more severe the jaundice history. A complex pattern emerged for the high respiratory risk groups. Only for the learning task were the results consistent with a summative effect of neonatal jaundice and respiratory risk factors.

Memory and processing speed in preterm children at eleven years: a comparison with full-terms.

This study examined the effects of prematurity on 11-year-olds' performance on 2 specific aspects of cognition--memory and processing speed, using a new computer-administered battery, the Cognitive Abilities Test (CAT: Detterman). Preterms performed more poorly than their full-term controls on all memory tasks; this relative deficit was associated with the presence and severity of neonatal Respiratory Distress Syndrome (RDS). Preterms were also slower on selected aspects of processing speed but not on motor speed. Memory and processing speed, taken together, accounted for much of the 10-point difference in WISC-R IQ between groups.

The breathing bear: effects on respiration in premature infants.

The sleep states and the regularity of quiet sleep (QS) respiration were investigated in premature infants who were provided a "breathing" teddy bear. The bear (BrBr) is a source of optional rhythmic stimulation that reflects the breathing rate of the individual infant it is with. At 33 weeks CA, 19 premature infants were given a BrBr and 17 were given a nonbreathing bear (N-BrBr). At 35 weeks CA, and again at 45 weeks CA, a 1-2-h interfeed motility recording was obtained. These analog signals were scored for active sleep, QS, and wakefulness; and each 10-s epoch of QS was judged for regularity of respiration using a four-point rating scale. At 35 weeks, the BrBr babies showed slower and more regular respiration during QS. At 45 weeks, the BrBr babies showed more QS and less active sleep. At both ages, only the BrBr babies showed a correlation between respiratory regulatory and the amount of QS. The findings suggest facilitation of neurobehavioral development as well as entrainment from optional stimulation, which reflects one of the infant's own biological rhythms.