The United States of America (USA or U.S.A.), commonly known as the United States (US or U.S.) or America, is a country primarily located in North America. The third-largest country in the world by land and total area,^[c] the U.S. is a federal republic of 50 states, with its capital in a separate a federal district, and 326 Indian reservations that overlap with state boundaries. It also has five major unincorporated territories, and seven undisputed plus four disputed Minor Outlying Islands.^[i]. It shares land borders with Canada to its north and with Mexico to its south and has maritime borders with several other countries.^[j] With a population of over 334 million,^[k] it is the third-most populous country in the world. The national capital is Washington, D.C., and its most populous city and principal financial center is New York City.

Healthcare in the United States is largely provided by private sector healthcare facilities, and paid for by a combination of public programs, private insurance, and out-of-pocket payments. The U.S. is the only developed country without a system of universal healthcare, and a significant proportion of its population lacks health insurance.

The U.S. healthcare system has been the subject of significant political debate and reform efforts, particularly in the areas of healthcare costs, insurance coverage, and the quality of care. Legislation such as the Affordable Care Act of 2010 has sought to address some of these issues, though challenges remain.

https://en.wikipedia.org/wiki/United_States

• GLOBAL PRETERM BIRTH RATES – USA
• Estimated # of preterm births: 9.56 per 100 live births
• (Global Average: 10.6)
• Source- WHO 2023- https://ptb.srhr.org/https://www.who.int/news/item/06-10-2023-1-in-10-babies-worldwide-are-born-early–with-major-impacts-on-health-and-survival

COMMUNITY

The 2024 Mom and Baby Action Network Summit Igniting Impact Together: Nurturing Collaborative Solutions

June 10 & 11, 2024    Marriott Marquis Chicago, Illinois

The 2024 Mom and Baby Action Network Summit will be a multi-day, multi-track, in-person conference to bring together existing and prospective M-BAN members, community partners, funders, philanthropists, and March of Dimes mission staff to learn, network, celebrate, be inspired, commit, and take action to advance equity in maternal and infant health.

https://www.marchofdimes.org/our-work/mom-and-baby-action-network#:~:text=The%202024%20Mom%20and%20Baby%20Action%20Network%20Summit%20will%20be,take%20action%20to%20advance%20equity

LET”S FOCUS ON PREVENTION

Foods we eat are covered in plastics that may be causing a rise in premature births, study says

By Sandee LaMotte, CNN – 02:23 – Source: CNN

Premature births are on the rise, yet experts aren’t sure why. Now, researchers have found synthetic chemicals called phthalates used in clear food packaging and personal care products could be a culprit, according to a new study.

Past research has demonstrated that phathalates — known as “everywhere chemicals” because they are so common — are hormone disruptors that can impact how the life-giving placenta functions. This organ is the source of oxygen and nutrients for a developing fetus in the womb.

“Phthalates can also contribute to inflammation that can disrupt the placenta even more and set the steps of preterm labor in motion,”said lead author Dr. Leonardo Trasande, directorof environmental pediatrics at NYU Langone Health.

“Studies show the largest association with preterm labor is due to a phthalate found in food packaging calledDi(2-ethylhexyl) phthalate, or DEHP,” Trasande said. “In our new study, we found DEHP and three similar chemicals could be responsible for 5% to 10% of all the preterm births in 2018. This could be one of the reasons why preterm births are on the rise.”

The5% to 10% percentagetranslated into nearly 57,000 preterm births in the United States during 2018, at a cost to society of nearly $4 billion in that year alone, according to the study, published Tuesday in the journal Lancet Planetary Health.

“This paper focused on the relationship between exposure to individual phthalates and preterm birth. But that’s not how people are exposed to chemicals,” said Alexa Friedman, a senior scientist of toxicology at the Environmental Working Group, or EWG, in an email.

“Every day, they’re often exposed to more than one phthalate from the products they use, so the risk of preterm birth may actually be greater,” said Friedman, who was not involved in the study.

The American Chemistry Council, an industry trade association for US chemical companies, told CNN the report did not establish causation.

“Not all phthalates are the same, and it is not appropriate to group them as a class. The term ‘phthalates’ simply refers to a family of chemicals that happen to be structurally similar, but which are functionally and toxicologically distinct from each other,” a spokesperson for the council’s ’s High Phthalates Panel wrote in an email.

‘Everywhere chemicals’

Globally, approximately 8.4 million metric tons of phthalates and other plasticizers are consumed every year, according to European Plasticisers, an industry trade association.

Manufacturers add phthalates to consumer products to make the plastic more flexible and harder to break, primarily in polyvinyl chloride, or PVC, products such as children’s toys.

Phthalates are also found in detergents; vinyl flooring, furniture and shower curtains; automotive plastics; lubricating oils and adhesives; rain and stain-resistant products; clothing and shoes; and scores of personal care products including shampoo, soap, hair spray and nail polish, in which they make fragrances last longer.

Studies have connected phthalates to childhood obesity, asthma, cardiovascular issues, cancer and reproductive problems such as genital malformations and undescended testes in baby boys and low sperm counts and testosterone levels in adult males.

“The Consumer Product Safety Commission no longer allows eight dif­ferent phthalates to be used at levels higher than 0.1% in the manufacture of children’s toys and child care products,” Trasande said. “However, not all of the eight have been limited in food packaging by the FDA (US Food and Drug Administration).”

In response to governmental and consumer concerns, manufacturers may create new versions of chemicals that no longer fall under any restrictions. Take DEHP, for example, which has been replaced by newer phthalates called di-isodecylphthalate (DiDP), di-n-octyl phthalate (DnOP), and diisononyl phthalate (DiNP).

Are those safer than the original? That’s not what scientists say they typically discover as they spend years and thousands of dollars to test the newcomers.

“Why would we think that you can make a very minor change in a molecule you are manufacturing and the body wouldn’t react in the same way?” asked toxicologist Linda Birnbaum, former director of the National Institute for Environmental Health Sciences, as well as the National Toxicology Program. She, too, was not involved in the paper.

“Phthalates should be regulated as a class (of chemicals). Many of us have been trying to get something done on this for years,” Birnbaum said in an email.

Even more dangerous swaps

The new research used data from the National Institutes of Health’s Environmental influences on Child Health Outcomes, or ECHO, study, which investigates the impact of early environmental influences on children’s health and development. In 69 sites around the country, expectant mothers and their newborns are evaluated and provide blood, urine and other biological samples to be analyzed.

The team identified 5,006 pregnant mothers with urine samples that tested positive for different types of phthalates and compared those with the baby’s gestational age at birth, birthweight and birth length.

Data was also pulled from the 2017-2018 National Health and Nutrition Examination Survey, a government program that assesses the health and nutritional status of Americans using a combination of interviews, physical examinations and laboratory analysis of biological specimens.

After analyzing the information, Trasande and his coauthors were able to confirm past research showing a significant association of DEHP with shorter pregnancies and preterm birth.

Interestingly, however, the research team found the three phthalates created by manufacturers to replace DEHP were actually more dangerous than DEHP when it came to preterm birth.

“When we looked further into these replacements, we found even stronger effects of DiDP, DnOP and DiNP,” Trasande said. “It took less of a dose in order to create the same outcome of prematurity.”

Dangers of prematurity

A birth is considered preterm if it occurs before 37 weeks of gestation — a full-term pregnancy is 40 weeks or more. Because vital organs and part of the nervous system may not be fully developed, a premature birth may place the baby at risk. Babies born extremely early are often immediately hospitalizedto help the infant breathe and address any heart, digestive and brain issues or an inability to fight off infections.

As they grow up, children born prematurely may have vision, hearing and dental issues, as well as intellectual and developmental delays, according to the Mayo Clinic. Prematurity can contribute to cerebral palsy, epilepsy,and mental health disorders such as anxiety, bipolar disorder and depression.

As adults, people born prematurely may also have higher blood pressure and cholesterol, asthma and other respiratory infections and develop type 1 and type 2 diabetes, heart disease, heart failure or stroke.

All of these medical expenses add up, allowing Trasande and his coauthors to estimate the cost to the US in medical care and lost economic productivity from preterm births to be “a staggering $3.8 billion,” said EWG’s Alexa Friedman.

“But the real cost lies in the impact on infants’ health,” Friedman said.

For second year in a row, US gets D+ grade for high preterm birth rate: ‘There’s so much work to be done’

There are additional steps one can take to reduce exposure to phthalates and other chemicals in food and food packaging products, according to the American Academy of Pediatrics’ policy statement on food additives and children’s health.

“One is to reduce our plastic footprint by using stainless steel and glass containers, when possible,” said Trasande, who was lead author for the AAP statement.

“Avoid microwaving food or beverages in plastic, including infant formula and pumped human milk, and don’t put plastic in the dishwasher, because the heat can cause chemicals to leach out,” he added. “Look at the recycling code on the bottom of products to find the plastic type, and avoid plastics with recycling codes 3, which typically contain phthalates.”

https://www.cnn.com/2024/02/06/health/preterm-birth-phthalates-study-wellness/index.html

Olivia Rodrigo – Vampire (Live From iHeartRadio Jingle Ball 2023)

     Olivia Rodrigo

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The 3 NEONATAL (cyanotic) CARDIAC emergencies you NEED to know

Tala Talks NICU 6,508 views Dec 19, 2022 Cardiac

You are about to attend a delivery of a prenatally diagnosed cardiac patient: when do you need to immediately alert the cardiologists/ transport team/ cardiac surgeons? We discuss 3 cardiac lesions which may need immediate intervention.

Dr. Tala is a board-certified neonatologist and has worked in busy level III and IV units for the past 15 years. She has won multiple teaching awards throughout her time as a neonatologist.

HEALTHCARE PARTNERS

Neurodevelopmental, Mental Health, and Parenting Issues in Preterm Infants

Abstract

The World Health Organization in its recommendations for the care of preterm infants has drawn attention to the need to address issues related to family involvement and support, including education, counseling, discharge preparation, and peer support. A failure to address these issues may translate into poor outcomes that extend across the lifespan. In this paper, we review the often far-reaching impact of preterm birth on the health and wellbeing of the parents and highlight the ways in which psychological stress may have a negative long-term impact on the parent-child interaction, attachment, and the styles of parenting. This paper addresses the following topics: (1) neurodevelopmental outcomes in preterm infants, including cognitive, sensory, and motor difficulties, (2) long-term mental health issues in premature infants that include elevated rates of anxiety and depressive disorders, autism, and somatization, which may affect social relationships and quality of life, (3) adverse mental health outcomes for parents that include elevated rates of depression, anxiety, and symptoms of post-traumatic stress, as well as increased rates of substance abuse, and relationship strain, (4) negative impacts on the parent-infant relationship, potentially mediated by maternal sensitivity, parent child-interactions, and attachment, and (5) impact on the parenting behaviors, including patterns of overprotective parenting, and development of Vulnerable Child Syndrome. Greater awareness of these issues has led to the development of programs in neonatal mental health and developmental care with some data suggesting benefits in terms of shorter lengths of stay and decreased health care costs.

1.Introduction

Global estimates of preterm (<37 weeks gestation) and low birth weight (LBW) infants range from 15–20% of all live births. Infants in this category have a two- to 10-fold higher risk of mortality than the term and normal birth weight infants and are at greater risk of medical complications and developmental problems including growth failure and developmental disabilities. Preterm birth rates decreased between 2007–2014 but have increased since that date with one in 10 babies in the US being born prematurely. Rates of prematurity and low birth weight vary depending on race and ethnicity with higher rates in Black women .

While much attention has been focused on the medical and developmental issues of preterm infants, an appreciation of the psychological impact of the preterm birth and the neonatal intensive care unit (NICU) experience on the parents has been less well studied. This is reflected in the hospital NICU practices that have emphasized interventions to improve infant outcomes rather than the psychological health of the parents. However, the recent World Health Organization Recommendations for Care of the Preterm or Low-Birth-Weight Infant [3] have drawn attention to the need to address the issues related to family involvement and support including education, counseling, discharge preparation, and peer support.

The birth and hospitalization of a preterm or LBW infant in the NICU is typically an unexpected and traumatic experience for parents. Parents frequently report feelings of guilt, anxiety, and sadness about the loss of the “perfect” child. Sources of stress include aspects of the NICU environment, unexpected physical characteristics and behaviors of the infant, difficult interactions with NICU staff, and the inability to take on the expected parenting role. The psychological models used to explain parental reactions include those of grief and loss, but also the trauma model, in which the baby’s preterm birth is experienced as a traumatic event.

In this paper, we review the often far-reaching impact of preterm birth on the health and wellbeing of the parents and highlight the ways in which psychological stress may have a negative long-term impact on parent-child interaction, attachment, and styles of parenting. A failure to recognize these issues may translate into poor outcomes that may extend across the lifespan.

2. Neurodevelopmental Outcomes

To provide a context to the impact of preterm birth, we start with a review of neurodevelopmental outcomes in the preterm infants. As improvements in survival have occurred among preterm infants, focus has shifted somewhat from preventing mortality to reducing neurodevelopmental impairment [5,6]. In the second half of gestation, brain volumes increase over 10-fold, making this a particularly vulnerable stage for neurological injury and disordered development . The brains of preterm infants over time may show poor oligodendrocyte maturation, delayed myelination and neurite formation, and glial activation . Rates of cognitive, motor, and sensory impairments are higher among preterm born than term born children and have been studied extensively. The highest rates of impairment occur among the most premature, although even late preterm and early term born children may have outcomes below term norms. In a meta-analysis of studies performed after 2000, the rates of cognitive and motor delays were found in roughly 16% and 20% of preterm born children with mild delays being more frequent than moderate to severe delays. Among those extremely preterm (EPT: born at less than 28 weeks gestation) and very preterm (VPT: born between 28–31 weeks gestation), the rates are higher and estimated to be 52% and 24%, respectively, in an international cohort .

It is important to note that challenges exist in interpreting the existing data regarding neurodevelopmental outcomes due to a variation in the individual center approaches to high-risk infants , varying definitions of impairment in the literature, changes in testing models, and a limited predictability of early-stage testing to predict school age outcomes . There is a relative paucity of data on neurodevelopmental outcomes up to school age with some concern that early estimates of cognitive and motor impairment may underestimate issues identifiable at later ages. In addition, the post discharge care environment may have a profound impact on the developmental trajectories, particularly for the highest risk infants.

Specific neurodevelopmental challenges among former preterm children include abnormalities of motor, cognitive, and sensory capabilities. A composite of these three factors, often a combination of Bayley Scales of Infant Development (BSID) cognitive and motor scores and sensory impairment data, is commonly used as a primary outcome in neonatal research but misses other important challenges faced by preterm born children. Social, attentional, executive function, and communication skills may be undermeasured, either due to a test construct or the age of administration, but may represent more important functional and life-impacting issues to children and families. Attention has been brought by former NICU families on the need to include factors valued by the family, or those themselves who were born preterm, in the delineation of research outcomes.

Motor disturbances were among the earliest described and may encompass both cerebral palsy (CP), and movement disorders. The rates of CP have fallen in recent years with an estimate of 6.8% in preterm born children, down from previous estimates of ~11% in more historical cohorts. Higher rates of CP are found in EPT-born children but have similarly fallen from estimates of ~14% to 10%. The rates of overall motor delay are higher than of CP, being up to 44% of EPT children and 16% of VPT children with moderate to severe delays in 11% and 6%, respectively. Although movement disorders may be ameliorated by therapies, some may have a significant impact on daily living activities and are associated with an increased risk of reading and attention issues, speech and language impairment, and social-emotional problems.

Sensory impairments, including profound hearing and vision impairment, are less frequent than cognitive and motor delays but may have important long-term consequences for the preterm infant. Bilateral hearing impairment requiring intervention occurs in 1–9% of preterm infants. As auditory input is important for language development, a failure to recognize and mitigate the deficits may have a significant impact on functional abilities and academic performance. Visual impairments, including acuity, convergence, and strabismus issues, are also more common in preterm infants and may lead to academic challenges .

Cognitive disabilities represent the most common neurodevelopmental impairment and may include difficulties in executive function, language processing, and working memory. The rates of cognitive neurodevelopmental impairment are more common in EPT children with a pooled prevalence of 29% in recent studies, and 10.9% being moderate or severe. VPT children in this same review had a 14% rate of cognitive impairment with 5.8% being moderate or severe. Language skills are often commonly affected with VPT children who are eight times more likely to exhibit a poorer language trajectory during development. IQ scores are 12–13 points lower than term infants in VPT born children [38] and up to 25 points lower for children born less than 26 weeks gestation.

Intelligence tests may fail to detect other issues that are important to cognitive function, including executive function, and a collection of abilities related to goal-direction and adaptive behavior. The included domains are working memory, impulse control, cognitive flexibility, planning, and organization. EPT children have higher rates of executive dysfunction at school age, particularly in working memory, planning, and organization. Working memory, in particular, is a strong, independent predictor of academic achievement, even after accounting for IQ. Attention disorders are more common among preterm infants and may significantly impact academic performance. VPT children have shown higher levels of attention problems, social impairment, and compromised communication skills than their term born counterparts .

3. Speech and Language Delays

Children born preterm demonstrate an increased risk for poor outcomes in language development. Early difficulties with language have been documented across all degrees of prematurity, including among children born extremely preterm, moderately and late preterm, late preterm, and preterm or at a low birthweight. Children born preterm display difficulties on the measures of receptive language , expressive language, receptive and expressive language considered together , and articulation. While an extensive literature documents the challenges that children born preterm experience with the acquisition of language skills, there is a paucity of research that has investigated how to mitigate the risk of prematurity on language development during the earliest opportunity to intervene—in the NICU environment. More research is needed on NICU-based language interventions to provide children born preterm with a robust foundation from which to build language competence.

4. Infant Mental Health Outcomes

Children born preterm demonstrate a heightened risk for a wide range of mental health and neurodevelopmental conditions. A variety of psychobiological factors have been implicated in the development and maintenance of these conditions. An appreciation of both the risk for and complexity of psychiatric and neurodevelopmental concerns can support the delivery of effective, tailored care to children born preterm.

4.1. Internalizing and Externalizing Disorders

Children born preterm may display behavioral difficulties as they progress through childhood, however, research findings in the literature are mixed. Several unique behavioral profiles have been detected. Some children born preterm may show the highest levels of behavioral problems in the period between two and three years of age. However, Bosch and colleagues found limited behavioral challenges among two-year-olds with a history of preterm birth. Some children born preterm may show few externalizing and internalizing behaviors, with relatively more internalizing behaviors as they age.

Variables that account for the outcomes in behavioral concerns include gestational age, skin-breaking procedures and morphine administration in the NICU, maternal depression, parenting stress, caregiver hostility, parental view of child vulnerability, and socioeconomic status. The emerging research has focused on investigating the neural correlates of behavioral difficulties of the children born preterm. Results from Gilchrist and colleagues have revealed that decreased neural network integration is linked to greater internalizing challenges when children are seven years of age.

Heightened risk for psychiatric disorders has been reported in the literature, although findings have been inconsistent. Among three- to six-year-olds, late preterm birth has been shown to relate to elevated odds of developing an anxiety disorder. Late preterm birth has also been linked to elevated teacher reports of attention and internalizing concerns at six years. Individuals born preterm display 1.5–2.9 times greater odds of developing depression, 2.7–7.4 times greater odds of developing bipolar disorder, and 1.6–2.5 times greater odds of developing psychosis. The findings from Upadhyaya et al. similarly demonstrate heightened risk for depression between the ages of 5 and 25 years in individuals born preterm. A history of preterm birth has also been found to relate to elevated odds of psychiatric hospitalization later in life. Lower gestational age has been found to be linked to higher odds of psychiatric hospitalization. However, in a report from Burnett and colleagues on adolescents, mood and anxiety disorders were present at comparable levels between subjects who had been born preterm and subjects who served as controls.

4.2. Social Relationships and Autism

The extant literature has demonstrated a link between a history of preterm birth and social functioning. At seven to nine months of age, children born preterm demonstrate lowered social attentional preference relative to children born full term, although this difference is no longer present at five years. Preterm birth is also related to an elevated risk for autism spectrum disorder (ASD). One report indicates a prevalence rate of ASD of 28–40% in a local sample of adolescents with a history of preterm birth. Research from Chang and colleagues has demonstrated that earlier gestational age is linked with an elevated risk for ASD. Among the children with ASD, the children born preterm show poorer nonverbal behaviors but better socioemotional reciprocity and peer relationships relative to the children born full term. The candidate etiological pathways for the onset of ASD in children born preterm are underlying inflammatory and genetic processes.

4.3. Somatization

Given that children born preterm undergo a multitude of painful procedures over the course of a NICU admission, it is critical to understand the degree to which early, concentrated experiences of pain are related to later pain processing and management. Grunau and colleagues have found that young children with a history of extremely low birth weight and preterm birth demonstrate clinically elevated levels of somatization. Variables that have been found to relate to somatization in the children born preterm include family relations, maternal sensitivity, and NICU admission history.

4.4. Quality of Life

Quality of life is an important consideration when caring for infants born preterm who have a greater likelihood of enduring the painful and extensive medical interventions from the earliest moments of life. An examination of the quality of life of individuals born preterm has resulted in mixed findings, depending in part on the source of data and the age of the subjects. The parents of children born preterm have indicated a lower quality of life for their children at 10 years of age as compared to the parents of children born full-term. Subject- and caregiver assessment of quality of life has demonstrated a less favorable quality of life relative to the controls at 13 and 26 years. On the other hand, Roberts and colleagues reported that adolescents with a history of extremely preterm or extremely low birth weight have quality of life ratings that are comparable to control peers. Similarly, adults with a history of moderately preterm birth demonstrate a quality of life that is similar to their peers with a history of full-term birth.

The early life experiences of children born preterm, and their families may contribute to cascading consequences in the areas of mental health and neurodevelopment. It is important to recognize that the etiology of psychiatric and neurodevelopmental conditions is often multifactorial, encompassing factors across the social and biological realms. A keen understanding of the key factors and processes that contribute to the differences in development can facilitate the development of interventions that ameliorate the impact of preterm birth and promote child and family well-being. Parental and child health are inextricably linked. In order to support the development of children, clinical attention should also address the needs of parents.

5. Parental Mental Health Outcomes

When considering mental health issues related to preterm birth, it is important to take into account the impact on parents. For many parents, an infant’s admission to the NICU can evoke feelings of shock, guilt, fear, sadness, and helplessness. In summarizing the NICU parent experience, Miles categorized stressors for NICU parents into four categories: (1) the infant’s appearance and behaviors, (2) the sights and sounds in the NICU, (3) parental relationship and communication with staff, and (4) parental role alteration. NICU parents are faced with seeing their sick infant exposed to intensive medical intervention in an unfamiliar environment, while simultaneously learning how to effectively communicate with staff, and to trust in one’s own abilities as a parent. If unaddressed, the mental health sequelae of these stressors can disrupt a parent’s ability to be present and engaged in their infant’s care, potentially causing a negative impact on both the short-term and long-term child-parent relationship, child developmental outcomes, and overall parent mental health.

5.1. Grief and Loss

Experiences of grief and loss are also commonly reported by NICU parents. For NICU parents, the time around the end of their infant’s life can be especially challenging due to issues related to decision making, saying goodbye to their infant, and making preparations for after the death. In addition, NICU parents have reported experiencing anticipatory grief, or the psychological challenges associated with hoping for the infant’s survival while simultaneously preparing for their death. Ambiguous loss is also commonly reported by NICU parents, including feelings of loss related to important milestones or experiences such as the imagined pregnancy or birth, having a baby shower, or being able to hold one’s baby immediately after birth. Additionally, the developmental trajectories of infants in the NICU related to prematurity or other complex medical needs can often be very different than what a parent imagined for their child, themselves, and their family.

5.2. Depression

Despite what can often be a very vulnerable time for all new parents, stressors unique to the NICU experience likely contribute to the higher reported rates of depression among NICU parents when compared to the general population. For example, when compared to the parents of full-term infants, the parents of very premature infants reported much higher rates of depression shortly after birth. Moreover, while approximately one in seven mothers and one in 10 fathers in the general population experience postpartum depression, this number may be as high as four in 10 mothers of preterm infants. With reported feelings of inadequacy, helplessness, and guilt, depressive symptoms have been found in as many as 38% of all NICU parents, often with depressive symptoms decreasing over time.

5.3. Anxiety and Traumatic Stress

In addition to symptoms of depression, parental stressors associated with an infant’s NICU admission have been reported to lead to increased rates of parental anxiety and traumatic stress. Malouf and colleagues found that among NICU parents, 41.9% reported experiencing anxiety, and 39.9% experienced post-traumatic stress. Critical medical diagnoses such as prematurity, traumatic birth experiences, and witnessing infants receive intensive medical intervention can lead to higher rates of anxiety and traumatic stress that may meet criteria for acute stress disorder or post-traumatic stress disorder (PTSD). Commonly reported traumatic stress symptoms include symptoms of arousal and intrusion, as well as either a difficulty leaving the infant’s bedside or an avoidance of the NICU. Despite remaining higher than the general population of parents, NICU parent reports of anxiety and traumatic stress have also been found to decrease over time. Lefkowitz and colleagues found that while 35% of mothers and 24% of fathers met the criteria for acute stress disorder a few days after their infant’s NICU admission, when screened 30 days later, 15% of mothers and 8% of fathers went on to meet the criteria for PTSD.

5.4. Substance Use

In the United States, every 25 min a baby is born who will experience symptoms of Neonatal Abstinence Syndrome (NAS) due to the discontinuance of in-utero exposure to substances. Parents of these children are often forced to find ways to cope with their infant’s prolonged NICU admission, as well as with managing their own psychological adjustment and substance use. While little is known about the link between traumatic stress and substance use in NICU parents specifically, the literature suggests that the prevalence of PTSD among those with substance use disorders can range from 25.3% to 49%. In addition to potentially suffering from the biopsychosocial consequences of addiction, a newborn’s withdrawal symptoms and need for intensive and sensitive care can cause a parent distress, guilt, and create challenges for a parent’s ability to bond and connect with their baby.

5.5. Relationship Strain

Parenting a child with a serious or chronic illness increases the risk for breakups or divorce. The relationship strain experienced by NICU parents can be especially challenging because the infant has never left the hospital and parents have yet to experience their baby on their own and may be excluded from care. The differences in coping styles, gender roles and expectations, and communication styles can add additional stress for parents. For example, some fathers are forced to return to work while also feeling responsible for caring for the mother, the newborn baby, and older children. In addition, many NICU hospitalizations can last for months at a time, placing increased strain on the parents to make arrangements for other children and to navigate a return to work, potentially causing parents to be separated from each other for long periods of time. The social and emotional strain placed on NICU parents can persist after discharge and have lasting effects on family relations, including the critical parent-infant relationship and attachment.

6. Parent-Infant Relationship and Attachment

The quality of caregiving relationships during infancy and early childhood has significant and lasting psychological and biological impacts on the developing child. The parent-infant relationship is one of the infant’s most proximal environmental exposures, and preterm infants are considered to be neurologically and biologically more vulnerable to their environmental exposures, hence, it is critical to understand the barriers and challenges in developing optimal relationships in the NICU parents and infants. Prematurity, particularly when leading to a NICU admission, can cause a disruption in the normal process of parent-infant bonding. Preterm infants are less interactive, less alert and, and more easily dysregulated, and as a result their parents can have a harder time reading their cues. NICU admission leads to parent-infant separation and makes it challenging, and at times impossible, for parents to hold their infant and to help soothe or regulate them when in distress. The parents of preterm infants also experience higher rates of psychiatric distress and can experience lower parental self-efficacy (parent’s self confidence in being able to carry out their parental role) which can add to their difficulties in bonding with their infant.

The parent-infant relationship is complex and multidimensional. Maternal sensitivity (defined as the mother’s ability to detect, interpret, and respond to their infant’s emotional and physical needs ), the quality of the parent-infant interactions, and the patterns of attachment are among the main dimensions studied in both the general and the preterm parent-infant population. Sensitive parenting and high-quality parent-infant interactions are associated with better neurocognitive, socioemotional, and language development, and higher academic achievement later in childhood in preterm infants. Inversely, less sensitive parenting has been associated with an increase in externalizing behaviors in early childhood, and in particular, in those preterm infants who experience higher levels of distress in infancy. Drawing on this literature and our general understanding of the effects of the parent-infant relationship in full-term infants, higher levels of parental sensitivity and higher quality of parent-infant interactions are thought to be protective factors in the face of the increased developmental risks that preterm infants face.

Given the importance of high-quality parent-infant relationships in the NICU population and the many challenges these infants and parents face in establishing an optimal bond in the beginning, many researchers have looked at the various aspects of the parent-infant relationship in this population to discern if there are any differences when compared to the general population. The results are heterogenous and difficult to interpret. The heterogeneity in the results is likely due to several factors: (1) as mentioned above, the parent-infant relationship is complex and multidimensional and therefore, different studies have looked at different aspects of this relationship, and even those that have looked at the same dimension, at times, have used different assessment tools and methods, (2) among preterm infants there is a significant diversity in terms of the degree of prematurity, medical comorbidities, and the length of stay in the NICU, all of which can affect the quality of the parent-infant relationship, (3) NICUs and the supportive/therapeutic services they offer (family based developmental care practices, mental health services, psychosocial support services, etc.) differ widely, (4) factors such as race, ethnicity, and psychosocial adversity play an important role in the quality of the care patients receive and in their outcomes, and (5) differences in the study designs in terms of the timeline of assessments, and whether the study is longitudinal vs. cross sectional, and if longitudinal the follow up timelines can all create a heterogeneity in the findings. Here, we summarize some of the findings on the three core dimensions of the preterm parent-infant relationship.

6.1. Preterm Parent-Child Interactions

The majority of the studies that look at the preterm infant behavior have found preterm infants to be less interactive, less responsive, and to demonstrate less positive affect. However, some studies found no differences between the preterm and full-term infant behaviors and a small number of studies found mixed results, or more favorable infant behavior among the preterm infants. It is important to note that the degree of prematurity, other medical comorbidities, pain and distress, or sedation can all impact the degree of a preterm infant’s responsiveness and engagement in dyadic interactions. A larger number of studies have looked at the maternal interactive patterns in the mothers of preterm infants. The findings here are more heterogeneous and therefore, it is not easy to draw any universal conclusions based on these studies. About half the studies have shown less favorable maternal interactive patterns such as lower sensitivity, more controlling and intrusive behavior, and lower responsiveness. There are, however, studies that show higher levels of attunement and maternal sensitivity, and responsiveness in the mothers of preterm infants, and a fair number of studies that have found no statistically significant differences between these mothers and the mothers of full-term infants. Finally, a smaller subset of studies has looked at the quality of the dyadic interaction in the preterm population. About half of these studies have found a lower quality of dyadic interactions in these mothers and infants. These studies have found less dyadic coregulation, less cooperation, synchrony, and positive affect in the preterm mothers and infants. Others have found no statistically significant differences, although the majority of the studies that found no differences were performed when infants were six months or older.

Looking at the findings of the research on preterm parent-infant interaction highlights the fact that preterm mothers and infants constitute a heterogeneous population. There are differences in the infants’ medical condition and birth weight, parents bring their own varying psychosocial and personal backgrounds and histories of trauma or adversity, and the NICUs differ significantly in terms of the resources (including early screening, psychological support, and interventions) that they provide. The timing of assessment can significantly affect the findings: while preterm infants are less interactive and neurologically premature, in many cases they eventually catch up with their full-term counterparts. Similarly, during the early postpartum period and the NICU admission, many parents experience higher degrees of psychological distress and uncertainty about their infant’s developmental and medical outcomes. Therefore, depending on the population studied and considering the variations in methodological designs discussed earlier, it is not surprising to see the heterogeneity in the findings.

Nevertheless, a number of points can be more definitely concluded based on these studies: (1) preterm infants, in particular very preterm and extremely preterm infants and those with medical complications, contribute substantially less to the dyadic interactive flow and use different ways of communicating their needs and distress. This in turn, can affect parental interactive patterns with these infants, (2) there are subsets of vulnerable groups among parents of the preterm infants when it comes to parental sensitivity and interactive style. Some of the factors leading to vulnerability are better known, however, we need to better understand which parental and infant factors can lead to an increased vulnerability in developing optimal parent-infant interactions in the preterm population, and (3) preterm infants and their parents may undergo periods during which the quality of their interactions are more challenged (including during the NICU stay, the immediate period post-discharge, and the times when there are medical crises or complications). These periods of increased vulnerability need to be better studied and understood.

6.2. Preterm Parent-Infant Attachment

Another important framework to assess the parent-infant relationship is through attachment classification. Attachment theory and science describe the role that parents play for their infants in making them feel safe, secure, and protected. Children who consistently receive sensitive, loving, and responsive parenting are able to use their parents as a safe haven when feeling in danger and a secure base from which to explore their environment. These children develop what is classified as a secure attachment. Unlike children who develop secure attachment, those who develop insecure attachment often are faced with inconsistent or distant, insensitive, or unresponsive caregiving. Broadly, the insecurely attached children are divided into the anxious-ambivalent group (children who have received an inconsistent quality of responsiveness and sensitivity and therefore act in ambivalent ways toward their caregivers) and the anxious-avoidant group (children who have received an insensitive, unresponsive, and absent caregiving who are unable to use their caregiver as a safe haven or a secure base). A fourth category of disorganized attachment was later added to this classification. Children who have disorganized attachment style often have caregivers who are at times frightening or frightened due to their own significant history of unresolved trauma. These children do not have an identifiable pattern of relating to their caregivers at times of separation, reunion, or distress. Even though a disorganized attachment is the only category that is directly associated with later psychopathology, insecure attachment styles are also associated with problematic patterns of emotional regulation, interpersonal, and academic skills. The gold standard for the assessment of attachment style is the Strange Situation Protocol (SSP) which is often used when the infant is nine to 18 months old.

Many of the studies that have looked at the preterm infant’s attachment styles have reported higher rates of insecure attachment in this group compared to the full-term infants. Studies have also found higher rates of disorganized attachment. However, these findings are not consistent, and some research has not demonstrated any statistically significant difference in the rates of the various categories of attachment styles between the preterm and full-term infants and their caregivers. Looking more closely at some studies, there are again subpopulations of preterm infants who might be at a higher risk of developing insecure or disorganized attachment styles: VLBW infants, infants with respiratory illness, those with longer lengths of hospitalization, and children with more significant developmental delays. These findings highlight the importance of understanding the infant, parental, and environmental factors that can impede or promote the child’s attachment to their caregiver. Identifying the infants and parents who are biologically, medically, developmentally, or psychologically at risk of developing insecure or disorganized attachment styles can help us tailor interventions and support systems specific to their needs.

7. Impact on Parenting

In addition to the impact of preterm birth on the attachment and parent-child interactions, it is important to consider how these early life experiences for both parent and child affect parenting behaviors. Parents have a critical impact on an infant’s learning and development through parenting interactions. Parental emotional trauma during a neonatal intensive care unit (NICU) admission often has a significant impact on the parents’ mental health and distorted parental perceptions of their child’s vulnerability (PPCV). This impacts their parenting styles and can result in a style of overprotective parenting. NICU parents are at a high risk for developing increased PPCV. Parents of preterm infants had significantly higher PPCV for their healthy children at age 36–42 months old compared to healthy term infants. Sixty four percent of the mothers of ex-premature infants viewed their children as vulnerable in one study. Additionally, about 83% of mothers who experienced significant emotional trauma during the NICU stay also say they have distorted vulnerability views of their infants. It has been found that the medical complexity of the infants does not correspond with the PPCV ratings, and that NICU parents have high ratings of PPCV compared to healthy term infants.

The effects of increased PPCV on the parents and child can persist after the infant’s discharge from the NICU, such as compromises in optimal parenting skills and stunted learning and developmental outcomes for the child. This is described in the concept of Vulnerable Child Syndrome (VCS). Green et al. first described the theory that VCS affected parents with children whose ages and diagnoses varied, but that a fear for the child’s survival persisted even after the resolution of a traumatic health event. This fear led to increased PPCV and then overprotective parenting skills. The final common point was associated poor outcomes for the child’s behavior, social skills, over somatization of bodily symptoms, school problems, health care utilization, and psychological problems. In 2015, Horwitz et al. developed a theoretical model specifically for VCS in NICU children and showed that the maternal responses and sequelae to traumatic events, maternal dysfunctional coping methods to trauma, and the levels of family support were most influential in the development of VCS, per a multi-regression analysis model. Hoge et al. have further explored the concept of utilizing trauma-informed cognitive behavioral therapy models to predict the risk and progression of the development of VCS.

The reported incidence of VCS in the general pediatrics literature has been around 10–21%; however, the incidence in the NICU families is unknown. Given that the risk factors of anxiety, depression, trauma, and distorted views of vulnerability are high in this population, more so than the general population, it could be assumed that the incidence is at least as high as in the general population, and likely higher. Thus, it is important to support the NICU parents during the infant’s hospital stay by finding ways to ameliorate their ability to effectively cope with the emotional trauma during, and after a NICU admission, and help them have realistic and healthy perceptions of their child for the future.

Cognitive behavioral therapy (CBT) could be an effective mode of treatment to prevent VCS in the NICU population. Manualized CBT has been shown to be feasible to address concepts of PPCV and VCS in the NICU parents of premature infants with very high parental satisfaction. These parents have expressed stories of utilizing the techniques and improving situations once discharged from the NICU. Ongoing analysis is underway to assess the effects on PPCV scores and long-term outcomes of the children.

8. Discussion

With increased rates of survival of preterm infants, attention is now being focused on the long-term issues affecting both infants and their caregivers. These include not only chronic medical complications and neurodevelopmental delays, but also the parenting and mental health issues that have been referenced above. For many parents, the trauma of a preterm birth may have a lifelong impact, not only on styles of attachment and parenting approaches, but also on their own mental health and well-being.

Interest in these issues has led to the growth of new specialties, including neonatal mental health and developmental care. While still a relatively young field, it is fortunate that researchers are starting to develop a number of effective and evidence-based interventions that have the potential to improve both the infant and parent outcomes. These include: (1) developmental care interventions involving measures to reduce infant pain and stress, sensory interventions to stimulate development, and educational interventions that teach parents how to recognize their infant’s developmental needs and foster healthy parenting skills, (2) interventions that include parent-infant psychotherapy that address the relationship and interactions between the parent and infant with the goal of fostering parental sensitivity and engagement, and (3) interventions directed specifically at the parents to address parental stress and trauma.

Although these interventions have proven efficacy and long-term benefits, access to psychological and developmental care services is not uniform across the NICUs. Even in those hospitals that fund psychological services, there are often gaps and disparities in their implementation and utilization based on cultural and systemic variables. In part, these gaps exist due to the absence of robust mental health screening for parents. Although many obstetrical programs now offer screening for depression, it is rare for the NICUs to routinely screen parents of preterm infants, in particular, the non-birth parents who may be equally impacted by the birth trauma. In addition, access to follow-up mental health care after the infants are discharged is often variable and, in many cases, completely absent. Similarly, preventative mental health care in the prenatal period is generally not available even in well-funded academic programs.

Looking forward, there is a strong need for research and program development in the areas of neonatal mental health and developmental care. Although there is some data that has shown shorter lengths of stay and decreased health care costs, there has been no systematic evaluation of the risks associated with not offering early intervention or the potential benefits of providing these services. Patterns of overprotective parenting and symptoms of VCS, for example, as described above, have been linked with the overutilization of healthcare services in pediatric care, as well as increased rates of somatization, which also burden the healthcare system. However, without robust evidence to demonstrate the financial benefits of early childhood and parent interventions, it will be difficult to convince both hospital programs and insurance companies to provide adequate mental health care and parent support. Future research would do well to demonstrate the benefits of mental health and developmental care interventions for the well-being of infants, families, and the health care systems that serve them.

Source: https://www.mdpi.com/2227-9067/10/9/1565

Gravens By Design: “Hands-Off” and “Hands-On” Care in the NICU: Can They Coexist and be Mutually Reinforcing in the NICU of the Future?

Robert White, MD

In this decade, we have witnessed the steady growth of both “hands-off” and “hands-on” care in the NICU. While at first glance, these would seem to be competing concepts—and indeed, they have been in many respects in the early part of this decade. Experience with both concepts has grown, and now a new factor has emerged—artificial intelligence (AI), which may help us find a way to realize the benefits of both strategies while avoiding most of their downsides.

I will define “hands-off” care as the intent to avoid stress in high risk newborns whenever possible by limiting any “unnecessary” (a concept mostly in the eye of the beholder since there is a paucity of data available to define this) sensory input, to include not only touch but also visual and auditory stimuli. This concept was born out of an era in the early days of NICU care when infants were subjected to excessive stimuli of all sorts—except for human contact, which was extremely restricted.

I will define “hands-on” care as the effort to keep babies in the arms of a parent or surrogate as much as possible, even very soon after birth and even if receiving intensive care in the form of endotracheal intubation, umbilical vessel catheterization, and other similar invasive measures. This, too, can be seen as a reaction to the minimal access given to parents in the early days of NICU care but obviously with a much different philosophy to the “hands-off” approach. Both strategies are intended to minimize the stress on the newborn so they can thrive, but through entirely different methods.

Both “hands-off” and “hands-on” care have advocates who have produced strong scientific evidence that their approach has led to better outcomes than in previous eras. Intraventricular hemorrhage (IVH) prevention protocols embrace a number of “hands-off” practices and, when bundled together, have been shown to reduce the incidence of IVH. (1) However, there is little evidence that any individual component of the bundle (such as minimal touch or continuous dim lighting) is essential to the success of the bundle. In many NICUs, most components of these bundles are continued well beyond the time frame used in the studies to show benefits for IVH prevention; in particular, infants on ventilatory assistance are often kept on “minimal stress” precautions for weeks or months. Notably, one characteristic of these protocols, formal or informal, depending on the NICU, is that parents are given limited opportunities to hold their babies while they are on ventilatory assistance.

On the other hand, proponents of “zero separation” have shown that even the highest-risk infants can be safely held by their parents and exposed to various auditory and visual stimuli in the first days of life, with outcomes comparable to the most cautious NICU protocols. (2) A third trend has emerged, that of AI, although it has yet to have practical applications in the NICU with respect to these challenges. Can we project how each of these well-intentioned strategies might play out in the coming two or three decades (the typical lifespan of a NICU), so that someone currently planning a new NICU will create an environment of care that gives its babies, families, and caregivers the maximal benefit of all of these trends? Let us start with basic goals, which I suggest can be identified as follows:

 • Support infant homeostasis to the greatest degree possible in order to optimize growth, development, and healing.

 • Optimize parent-infant interaction to the greatest degree possible. 

• Provide caregivers with as much information as possible to guide their care, packaged and processed, to maximize the accuracy and thoroughness of medical decision-making.

 In today’s NICU, “hands-off” and hands-on” strategies are intended to support homeostasis, thereby minimizing stress and its related complications, although they seek to achieve that goal through very different methods. Could AI help here? Perhaps so— one of AI’s most obvious uses would be detecting imperceptible changes and trends in a patient’s status and either alerting a caregiver or implementing a change in clinical support according to the given directions. Consider, for example, our current method of adjusting ventilatory support for a very preterm infant in the first days of life. In the first era of neonatology, we adjusted oxygen input based on visual assessment of color and frequent arterial blood gases; we adjusted ventilator settings based on those same blood gases and ancillary tests such as chest X-rays. With the advent of transcutaneous O2 saturation and pCO2 monitors, we obtained real-time continuous data, occasionally confirmed with much less frequent blood gases, but usually could make adjustments in oxygen concentration and ventilator settings based on the transcutaneous information. It is only a matter of time before AI can receive that same information as well as data from the ventilator itself and, based on parameters determined by the clinician, make adjustments in ventilator settings continuously, still with intermittent adjustments in either actual settings or the parameters being used by AI by clinicians as they see fit.

One can imagine a similar strategy being employed to manage continuous drips to support blood pressure or blood glucose. It is perhaps a little more of a stretch to imagine how sensory input could also be managed with the help of AI. However, let us agree that the goal should be to minimize noxious stimuli and maximize nurturing stimuli. We must only identify how we judge an infant’s response to a given environmental input to determine whether it should be limited or encouraged. It is very likely that we already have access to continuous data, such as heart rate, cerebral oxygenation, and brain wave activity, which can be used for this purpose once we learn how to train an AI helper properly.

If AI could provide directed, automatic intervention as well as alert clinicians to times when an infant needed more direct attention, it should be possible to put an infant in the arms of his/her parents with the assurance that homeostasis would be maintained or the clinician alerted when that was not possible within the parameters selected. In this future, but perhaps not too distant scenario, babies could be safely in the arms of a parent or surrogate most of the time.

What impact would this next era of care have on NICU design? First —and we are probably already there—NICUs will not need to be constructed with “line of sight” considerations in which nurses would have direct visibility of their baby’s bed. All the information once gained by this design consideration is now available through the interlinking of monitors, cameras, and personal communication devices. This does not mean that nurses will not have direct contact with their patients; their bedside duties will remain, but when they are away from the bedside, they will still receive all the information they need about their patient’s status electronically. Second, it is likely that we can customize each infant’s immediate environment—lighting, auditory, temperature, humidity, etc.—to their specific need, rather than using a “one size fits all” approach that we have been forced to use until now. Third, if we can safely provide care to babies while they are being held for extended periods, we can design our NICUs in a way that fully supports a parent or parents who want to essentially live with their baby during the NICU stay, and therefore create patient rooms and support spaces that welcome families as an integral part of our care team, rather than as visitors.

 It will be a brave new world, but babies will get even better care while minimizing stressors for caregivers and families. The NICUs that do this best will be designed with these changes in mind.

https://neonatologytoday.net/newsletters/nt-jan24.pdf

PREEMIE FAMILY PARTNERS

Perspectives on Parenting in the NICU Advocacy, Support, and Partnership

Barnes, Jessica MSN, RN, RNC-NIC, NPD-BC; Vance, Ashlee J. PhD, MA, RN, RNC-NIC

Advances in Neonatal Care 24(1):p 1-3, February 024. | DOI: 10.1097/ANC.0000000000001144

Supporting parenting in the neonatal intensive care unit (NICU) is one of the most challenging but rewarding aspects of patient care in neonatal nursing. As nurses, we are uniquely positioned to offer support, advice, and guidance in the transition to parenthood. Yet, sometimes parents perceive us as “gatekeepers” to their newborn rather than facilitators of access. As the neonatal nursing community works to improve care for all patients, parenting in the NICU is one element of care that needs to remain at the forefront. Consider the following experience of a parent, who has been on “both sides” of the incubator as a NICU nurse and then a NICU parent.

OUR STORY

After 12 years working in high-risk perinatal care and level III NICUs, I found myself on the other side of the bed, watching my child received the same care I had provided countless times to other babies and their families. Instead of guiding a parent through one of the most challenging and difficult experiences of their lives, I was the one now in need of support and guidance. My daughter, Aurelia, was born in August 2022 at 27 weeks 5 days of gestation, after a placental abruption, which began at home. On the night Aurelia was born, I woke up to a significant amount of blood that quickly increased. I immediately sensed what was happening. As my husband was speeding to the hospital through overnight construction traffic, I was acutely aware of what laid before us. If we both survived, our whole family was facing months of uncertainty, anxiety, and separation. I wept for my baby, myself, my husband, and my 2 other children at home. How were we going to do this?

I delivered Aurelia at the hospital where I worked for 10 years—with much of that time spent in their large, high-acuity level III NICU. Although I was no longer working in that unit, I called the NICU charge nurse from the L&D waiting room and explained our situation. Even though she did not know who I was, I told her to prepare for a STAT 27-weeker and I needed to know which provider was on call. She cautiously gave me details about the delivery team and assured me they were getting a space ready for my baby.

The nurse in labor and delivery triage kept telling me everything was going to be okay while trying to find Aurelia’s heart tones. After the third time, I asked her to stop saying it was okay. I knew this was a preterm abruption and nothing about this situation was okay. I needed to hear my baby’s heartbeat and get to the OR as quickly as possible. I needed to know she was still alive, and we both needed to be saved. I thought of my 2 boys at home and wanted so badly to be able to see them again. I wanted my baby to survive despite all the potential challenges ahead of her.

OUR PRIVILEGE

I want to pause here and take a moment to acknowledge the immense privilege I carried with me into our NICU stay. Not only did I have experience and knowledge of the NICU environment and the medical care necessary for my baby’s survival, but my positionality as a White woman with adequate employment and good insurance. We had a good support network providing childcare so that my husband and I could be in the NICU daily. Additionally, I had already established care with a therapist, who was also a NICU parent, as we embarked on our own NICU journey. I had so many moments sitting at Aurelia’s bedside thinking about my struggles and wondering if I was struggling this much, despite my privilege, how much more challenging it must be for other families. If it’s this hard for me, I can’t imagine how other families did it.

During the first few days of our hospitalization, I tried to be “easy” parent. Because of my experience, I knew we had a long stay ahead of us, and I didn’t want to develop a reputation. I accommodated the nurses, thought of their tasks and schedules before my own, and felt the constant tension of wanting to interject when it wasn’t the way I would have done it. This all changed for me after Aurelia’s first bath.

I coordinated with the nurse to be present for Aurelia’s first bath at 3 am on her fourth day of life while I was still inpatient. That night, I fell deep asleep for the first time since she was born, and I woke up in a panic at 03:09, knowing immediately that I might have missed my window. I rushed to the NICU as quickly as I possibly could, considering my postpartum, postoperative recovery. I arrived at her bed at 03:14 to her nurse putting away the plastic bath basin. She turned to me and said, “We said three o’clock.” Those 4 words completely shattered me, and I felt an intense wave of grief flood me. I sat down at her bedside and cried the hardest I had ever cried in my life. It was in this moment that I realized being the “good parent” or “easy parent” was not meeting my needs nor my daughter’s. Aurelia may have been taken out of my body, but here in the NICU, I felt like she was not mine. I was at the mercy of the nurses, doctors, respiratory therapists, and countless other people overseeing her care. I was outnumbered and terrified; all my previous experience did not prepare me for this moment.

IMPORTANCE OF PRESENCE

Missing Aurelia’s first bath put everything into perspective for me. I was/am her mother; that’s who she needed me to be, her advocate. I would do whatever it took to be heard and supported. One of the most frustrating experiences during her NICU stay was the constant reminder to “just be her mom right now.” When I heard comments like this, what I understood the team to be saying was, “Don’t ask too many questions. Just sit quietly. I’ll let you know when you can interact with her.”

The irony is that while they were telling me to be her mother, there were more moments when the opportunity to be her mother was not possible or taken from me. It is a mother’s job to bathe, hold, feed, and care for her infant, but in the NICU, those activities often require permission: to be given permission from the “gatekeepers.” The conflict between my personal and professional understanding of the situation further complicated my traumatic experiences. I knew as a professional that there were legitimate reasons for some of the responses I was given, but as a mother, there was nothing any of the nurses could say that I would find acceptable. I was trying to be her mother, yet it was so hard! There were so many competing interests: how do I integrate my knowledge as a mother and my experience as a nurse?

So, I decided to be myself and lean into the duality of my role as Aurelia’s mom and as a NICU professional. I was authentic and honest with the team. I started with transparent communication despite it being perceived as negative. Some offered a sympathetic ear and a shoulder to cry on, others seemed to take it personally and tried to appeal to my sense of “knowing better.” When offered unsolicited advice, I would remind them that my experience was unique and valid. The times that I felt the most supported as her mother were when I was able to express my authentic emotions about what was happening—the everchanging mixture of pride, fear, love, anger, and gratitude I felt at any given moment. A few colleagues were consistent sources of support. They provided meals, acknowledged the disappointment, stress, and grief we were experiencing while also celebrating every weight gain, skin-to-skin session, and successful eating experience. I will forever be grateful for their kindness and support.

IMPORTANCE OF PARENTING AND PRESENCE

Parental–infant separation is inherently traumatic. Human beings are social beings that need human connection to thrive and so the effect of being separated from and not able to hold your baby after birth is a common source of trauma reported by former NICU parents, which also increases their risk for developing posttraumatic stress disorder. When an emergency and the need for life-saving care disrupts the bonding process, the sequela of events that follow can negatively impact parents and infants. Postpartum Support International lists NICU admission as an example of trauma and risk for developing postpartum posttraumatic stress disorder (P-PTSD). Symptoms include “intrusive re-experiencing of a past traumatic event… flashbacks or nightmares, avoidance of stimuli associated with the event … persistent increased arousal (irritability, difficulty sleeping, hypervigilance, exaggerated startle response), anxiety and panic attacks, feeling a sense of unreality and detachment.” The American Psychiatric Association estimates 17% of parents experience P-PTSD or birth-related trauma—a number that only includes those who meet clinical criteria for diagnosis as many more parents experience P-PTSD symptoms.⁴ But what many former NICU parents will tell you, is that even after leaving the NICU, the NICU never really leaves you. NICU parents remain at risk for developing P-PTSD up to a year after their infant’s discharge. Every noticeable difference from your baby gets mentally tagged and then the worry sets in wondering if it was connected to their birth. Is this her normal or is it because she was born early or in the NICU? These lingering questions make it even harder to process the trauma exposure from the NICU. I have always been a strong advocate of trauma-informed care (TIC) and have integrated TIC principles into every class I teach as a neonatal clinical nurse educator. I remember telling my therapist during one of our virtual sessions, as I sat in my car in between care times, that I felt like I was disassociating—like I was watching a movie about the NICU as if it was happening to some other family. Again, all my professional experience and training couldn’t have possibly prepared me for this traumatic experience, even though I knew what to expect from the environment. Even the most clinically benign NICU admission can be traumatic, and processing that trauma takes time.

During our NICU journey, I experienced the effects of toxic positivity, which I had not recognized before. Toxic positivity is defined as “dismissing negative emotions and responding to distress with false reassurances rather than empathy.”⁶ When people are uncomfortable or are unsure of what to say, they often rely on vague or empty statements. The team kept telling me over and over to “be grateful,” “this will all be over soon,” or “at least she’s growing/doing well/not requiring a lot of respiratory support.” My reaction to these comments highlighted how dismissive they were and reminded me of all the times I said similar things to other parents. For example, during her first and only septic workup, I was told “Hey! It’s her first one. It’s not a NICU stay without a workup or two. I’m surprised it hasn’t happened already” and while I understood this sentiment as a professional, as a parent, it shattered my emotional composure. It was one of our worst days in the NICU, and these comments did nothing to validate or acknowledge the worry and fear we were feeling.

In short, I learned language matters. If nothing else changes in your clinical practice after reading this or other articles, other than removing the phrase “at least” in your communication with parents, then that will be a win for me. Even though I was deeply grateful that this was only her first workup and that she was getting the right care at the right time, I was still upset about the pain my daughter was feeling and concerned about implications of the results. Multiple things can be true at once: parents can be grateful, disappointed, scared, and angry at the same time. Statements that are dismissive of parents’ emotions and concerns can further exacerbate their traumatic experience and distrust of providers. Given the focus of individualizing care for infants, we must also acknowledge and individualize the emotional support provided to parents and not be dismissive of their experience.

VALIDATION AND EMOTIONAL SUPPORT

In healthcare, we often focus on the short-term outcomes. Nowhere is that truer than the NICU. We celebrate every discharge and pat ourselves on the back for a job well done of getting a baby home. We reminisce about former patients and enjoy seeing holiday cards and getting updates at return visits or reunions, but so much more could be done to connect us with the lived experiences of our patients and their families as they navigate the transition to parenthood in an unfamiliar environment. The care we provide today potentially impacts every one of their tomorrows. Why wouldn’t we want to support their family’s transition to home in the best way possible? In sum, Aurelia’s 75-day stay in the NICU was clinically uneventful. I owe that in part to the high-quality care she received, but I also believe our consistent presence in the NICU as her parents played a protective role in her outcomes. Validation fosters resilience and resilience mitigates the impact of trauma. My hope in sharing my experience is to empower more NICU professionals to choose to foster resilience in our patients and their families.

We hope that this special series, Parenting in the NICU, offers new insights, challenges conventional practices in the NICU, and sparks a desire to promote care that values and validates the parent’s role in the care of their child during a NICU hospitalization. Let’s meet parents where they are at, knowing the lasting impacts our choices have on their transition to parenthood.

https://journals.lww.com/advancesinneonatalcare/fulltext/2024/02000/perspectives_on_parenting_in_the_nicu__advocacy,.1.aspx

2024 NCH NICU Reunion

NCH·Feb 1, 2024

New Funding Supports “Care for NICU Families” Research and Program

October 26, 2023

Interdisciplinary Collaborative Receives $4 Million Cooperative Agreement from the CDC to Improve Postpartum Care In and Beyond the Neonatal Intensive Care Unit

Chapel Hill, NC, October 2023 – The University of North Carolina at Chapel Hill’s Department of Pediatrics and Collaborative for Maternal and Infant Health, along with Reaching Our Sisters Everywhere, the University of California San Francisco’s School of Nursing and subject matter collaborative partners, have received a $4 million Cooperative Agreement from the Centers for Disease Control and Prevention (CDC) to Advance Best Practices to Improve Postpartum Care In and Beyond the Neonatal Intensive Care Unit (“Care for NICU Families”).

Collaborative partners include Mighty Little Giants, Breast Friends Lactation and Support Services, the 4th Trimester Project, Bellamy Management Consultants, Narrative Nation, the National Institute for Children’s Health Quality, the National Perinatal Association, Postpartum Support International, the Association of Women’s Health, Obstetric and Neonatal Nurses, Sabia Wade, and Heather Burris.

Care for NICU Families

The team will build a national partnership guided by community and diverse lived experience voices to develop a set of Best Practices for Postpartum NICU Care along with co-created tools and strategies to support model care. They will share what they learn across NICUs, professional and community networks nationwide, and provide technical assistance to groups who are ready to make change. This will lead to increased awareness and use of effective data-informed clinical care and public health resources and interventions, as well as increased capacity to implement clinical and public health approaches to improve outcomes for postpartum people.

Co-Principal Investigator (Co-PI) Dr. Ifeyinwa Asiodu highlights that “The long-term goal of this important project is to eliminate perinatal health disparities and improve postpartum health and wellbeing during NICU stays through the transition to home. Continuity of care, including addressing the physical and mental health needs of the postpartum person and family, is critical to improving care for NICU families.“

The United States has one of the highest rates of maternal mortality and morbidity among wealthy countries (32.9 deaths per 100,000 birth) with unacceptable inequities due to historic and structural racism: Black birthing people experience a rate of maternal mortality 2.6 times higher than those who are White. “We know from previous research that mothers with infants in a NICU are more likely to have experienced a birth-related trauma, have depression/anxiety, lack access to basic care, have a chronic health condition, experienced a cesarean birth, and/or a blood transfusion, than mothers whose infants do not have a NICU stay,” Co-PI Dr. Sarah Verbiest underscored. Dr. Verbiest also directs the Jordan Institute for Families at the UNC School of Social Work which focuses on building economic and social supports for families with young children.

“NICUs are designed to address infant health, and they often do not accommodate the needs of postpartum people who are recovering from childbirth,” states Co-PI Dr. Wayne Price. NICU families describe challenges with basic practical needs, such as NICU visitor restrooms without menstrual products, going without meals to avoid leaving the infant bedside, and not taking pain medication / pulling over on the side of the road to sleep because there was no place to rest while visiting the NICU. He furthers, “Care for NICU Families” will increase awareness, resources, interventions, and capacity to make changes for NICU families on their postpartum journeys.”

Co-PI Dr. Kimarie Bugg concludes, “The “Care for NICU Families” team believes that better care for NICU postpartum parents will lead to improvements in outcomes for mothers and their babies by reducing maternal mortality and morbidity, increasing infant access to human milk, addressing maternal mental health and trauma, and providing NICU and community-based resources and social supports.”

You can learn more about the “Care for NICU Families” work at NewMomHealth.com/care-for-nicu-families.

https://www.med.unc.edu/pediatrics/2023/10/new-funding-care-for-nicu-families/

INNOVATIONS

Premature births can be predicted at 23 weeks using ultrasound

Chad Van Alstin | January 24, 2024 | Health Imaging | Womens Imaging

After more than 20 years of research between University of Illinois Chicago and University of Illinois Urbana-Champaign, a new method for measuring a woman’s risk of delivering a baby prematurely has been developed. 

By using quantitative ultrasound to measure microstructural changes in the cervix, clinicians can accurately predict the risk of a premature birth as early as 23 weeks into a pregnancy.The research is published in  the American Journal of Obstetrics & Gynecology Maternal Fetal Medicine.

Currently, assessing the risk of a premature birth—which occurs in 10%-15% of pregnancies, according to the study authors—requires some guesswork based on symptoms and a patient’s previous history. Now, with ultrasound, providers will be able to make a more grounded assessment, regardless of a patient’s symptoms or previous pregnancies. 

“Today, clinicians wait for signs and symptoms of a preterm birth,” study lead author Barbara McFarlin, a professor emeritus of nursing at the University of Illinois Chicago, said in a statement. “Our technique would be helpful in making decisions based on the tissue and not just on symptoms.”

The study was conducted on 429 women who gave birth without induction at the University of Illinois Hospital, all of whom were given quantitative ultrasounds prior to birth. However, instead of simply analyzing the pictures, researchers read radio frequency data from the scans to assess tissue characteristics. 

The women in the study were assessed for their risk based on two separate hospital visits where sonograms were performed. The risk assessment took into consideration a patient’s medical history as well as the results of the ultrasounds.

Based on symptoms and patient history alone, the best predictive model for a premature pregnancy had an estimated receiver operating characteristic area under the curve of 0.56 ± 0.03. However, after the two visits where quantitative ultrasound was utilized, the predictive model showed a significant improvement (likelihood ratio test, p < 0.01), with the area under the curve reaching 0.69 ± 0.03.

Ultrasounds earlier in pregnancy also showed a modest improvement over a clinical examination of history and symptoms (0.63 ± 0.03). Notably, this improvement  was seen as early as 23 weeks. Because the method allows for premature births to be more accurately predicted, it may reduce the number of premature babies and save lives, the researchers said, as clinicians will now have a larger window to administer treatments and monitor a fetus.

A method 22 years in the making

The quest to develop a better way to predict premature births began when McFarlin was working as a sonographer and midwife. Noticing there were differences in the appearance of the cervix in women who went on to deliver preterm, she became interested in researching what this could mean when she was a PhD student at the University of Illinois Chicago in 2001.

She partnered with University of Illinois Urbana-Champaign professor Bill O’Brien, who was studying ways to use quantitative ultrasound data in healthcare. Together, their research discovered that changes in the cervix could predict a premature birth, and quantitative ultrasound waves are able to measure those changes. 

This study found that using quantitative ultrasound works. However, more research is being done to further improve its accuracy. 

https://healthimaging.com/topics/medical-imaging/womens-imaging/premature-births-can-be-predicted-23-weeks-using-ultrasound

Doug Campbell MD | Time to rethink how we help babies breathe | Delphi 2023

The Incubator Channel
Oct 12, 2023

 

Dr. Campbell is a neonatologist at the Hospital for Sick Children and the Director of the NICU & Deputy Chief Pediatrics at St. Michael’s Hospital in Toronto Canada. He has varied research interest and has been a positive presence for neonatology on social media over the years. This year at Delphi, Dough spoke to us about a new way to ventilate neonates using non-invasive negative pressure ventilation.

RECAP Preterm – Improving the quality of life of children and adults born very preterm

Jul 13, 2021

Normal human pregnancy lasts 40 weeks. However, every 10th baby is born preterm, which means before 37 weeks of pregnancy. Very preterm birth is defined as birth before 32 weeks and affects about 1 – 2% of all babies, that is over 50,000 babies per year in Europe.

Improvements in care during pregnancy and during the neonatal period have increased survival. However, very preterm survivors face greater risks of physical and mental health problems that can affect their participation in everyday activities.

It is thus important to identify children who are at risk of health and developmental difficulties and to find treatments or factors in the environment that protect them against adverse outcomes and build on their strengths.

The EU-funded RECAP preterm Data Platform brings together data from more than 20 population-based very preterm cohorts, meaning studies that enroll very preterm infants at birth and follow them up into childhood and adulthood.

The platform will provide access to over 20.000 variables hosted across Europe. The data from the cohorts are kept securely in each institution, but new software allows for non-disclosive and safe data analysis across the cohorts.

This Data Platform presents exciting opportunities to make optimal use of all available data to generate new knowledge about the consequences of preterm birth.

RECAP preterm aims to improve the health, development, and quality of life of children and adults born very preterm and their parents. RECAP preterm does so by identifying core risk and protective factors for development and suggesting policy recommendations for optimal care and support that can make a difference for each and every person born preterm throughout childhood, adolescence and adulthood.

In the RECAP Preterm on-line summer school you are able to learn about existing cohorts, new research studies using the platform and their findings on children and adults born very preterm.

The school will also provide information on how to implement a collaborative research protocol, including the ethical and legal requirements, data harmonisation, the technological aspects of storing and sharing data, and analytic approaches and software.

If you are interested in more information or would like to develop a project on our platform, please see the RECAP Preterm website for more information.

GLOBAL RESEARCHERS

I WAS A NICU BABY AND IT CHANGED MY PERSPECTIVE OF MOTHERHOOD

January 05, 2024 By Allison Thommen

When my mom was diagnosed with HELLP syndrome while she was pregnant with me, her prognosis was not good. In 1989, birth at 35 weeks was considered risky and both of them were nervous to become parents in such an uncertain way. That level of prematurity was considered high risk.

My dad was asked which one of us he would rather the medical team focus their life-saving attention on if it came to it. He is a doctor, so his response was simple.

“You’ll come get me before something happens to either of them.”

On May 29th, 1989, I was born at 35w6d and was immediately snuggled by my perfectly healthy mom. We both made it through her labor without any major complications.

I spent a total of 10 days in the NICU and my parents are adamant that my first years were no different than the two full-term siblings who followed me.

The medical field has progressed so much since then.

I’ve been witness to the NICU graduations of babies born at 23 and 24 weeks while I worked in a NICU as a dietitian. The joy of watching those babies leave our unit is something I will never forget.

My perspective on the NICU and premature babies shifted when I became a mother.

I learned to cling to my daughters’ great health and never take for granted the blessing that is. I was once the baby with an uncertain future and that worry shadowed my parents’ first moments as mom and dad. I will never take for granted the easy pediatrician appointments and clean bills of health.

I cannot imagine the worry, fear, and uncertainty of the journey of a NICU mom.

Just because I didn’t walk that road in my own journey in motherhood doesn’t mean that I don’t want to understand yours.

I want your story…I want your worries…I want your trust that I will do what it takes to help you.
I want you to reach out to me when you need a friend…I want you to know that I think about you often…I want you to know that I pray for you and your baby(ies).

Prematurity remains the leading cause of death in children under the age of 5. We have come so far, and yet have so very far to go.

On every day, but especially on World Prematurity Day, I want to take a moment to celebrate all those moms who have walked that unknown path in the NICU and the years beyond it, to sing praises for all those babies that were born far too early who fought like crazy to be here today, to pray for the babies who are fighting their battles now, to thank the partners and medical professionals who supported a mom healing from delivery while caring for her baby(ies), and to lift up in prayer the babies born beyond what our medical expertise can help.

We are honored to know you, to support you, to love you, and to lift you up by any means necessary.

You are strong…You are brave…You are the best mother.

https://www.preeclampsia.org/our-stories/i-was-a-nicu-baby-and-it-changed-my-perspective-of-motherhood

What Growth Mindset Means for Kids | Rebecca Chang | TEDxYouth@Jingshan

TEDx Talks
Mar 25, 2019
In this talk, Rebecca shares the process of joining the Student Counsel (STUCO) at her elementary school. She discusses her feelings when she was forced to take on this challenge by her mother and how she was able to shift her anger into a growth mindset. Student at Shekou International School (SIS). This talk was given at a TEDx event using the TED conference format but independently organized by a local community.
Learn more at https://www.ted.com/tedx

Introduction to Youth Participatory Action Research (YPAR)

   SchYPAR     Sep 1, 2023

This short introduction to youth participatory action research (YPAR) facilitated by Dr. Alexandrea Golden of the University of Memphis was created by the Center for Urban Education at Cleveland State University as part of its School-Based YPAR program. Visit http://www.schypar.org for more information and resources on how to do YPAR in schools.

The Pencil’s Tale – a story that everyone should hear

Dare To Do       Aug 28, 2023

a short but beautiful story for life 🙂

BEST BANZAI PIPELINE OF 2024 SO FAR!!!

   #banzaipipeline Oahu Surf Films  #northshore

Monday January 22nd The best of 2024 by far. The word is out. Monday morning Surfers from around O’ahu and Pros in town for the Lexus Pipeline Pro awoke to a perfect Big Pipeline. It doesn’t get any better than this. I counted a total of 7 broken boards between 8-11am. Sit back and grab some popcorn for the intro as no one was seriously hurt but lots of people paid their dues.

Pakistan, officially the Islamic Republic of Pakistan, is a country in South Asia. It is the fifth-most populous country, with a population of over 241.5 million, having the largest Muslim population as of 2023.Islamabad is the nation’s capital, while Karachi is its largest city and financial centre. Pakistan is the 33rd-largest country by area, being the second largest in South Asia. Bounded by the Arabian Sea on the south, the Gulf of Oman on the southwest, and the Sir Creek on the southeast, it shares land borders with India to the east; Afghanistan to the west; Iran to the southwest; and China to the northeast. It shares a maritime border with Oman in the Gulf of Oman, and is separated from Tajikistan in the northwest by Afghanistan’s narrow Wakhan Corridor.

Pakistan is a middle power nation, and has the world’s sixth-largest standing armed forces. It is a declared nuclear-weapons state, and is ranked amongst the emerging and growth-leading economies, with a large and rapidly-growing middle class. Pakistan’s political history since independence has been characterised by periods of significant economic and military growth as well as those of political and economic instability. It is an ethnically and linguistically diverse country, with similarly diverse geography and wildlife.

The healthcare delivery system of Pakistan  is complex because it includes healthcare subsystems by federal governments and provincial governments competing with formal and informal private sector healthcare systems. Healthcare is delivered mainly through vertically managed disease-specific mechanisms. The different institutions that are responsible for this include: provincial and district health departments, parastatal organizations, social security institutions, non-governmental organizations (NGOs) and private sector. The country’s health sector is also marked by urban-rural disparities in healthcare delivery and an imbalance in the health workforce, with insufficient health managers, nurses, paramedics and skilled birth attendants in the peripheral areas. Pakistan’s gross national income per capita in 2021 was $4,990 and the total expenditure on health per capita in 2021 was Rs 657.2 Billion, constituting 1.4% of the country’s GDP. The health care delivery system in Pakistan consists of public and private sectors. Under the constitution, health is primarily responsibility of the provincial government, except in the federally administered areas. Health care delivery has traditionally been jointly administered by the federal and provincial governments with districts mainly responsible for implementation. Service delivery is being organized through preventive, promotive, curative and rehabilitative services. The curative and rehabilitative services are being provided mainly at the secondary and tertiary care facilities. Preventive and promotive services, on the other hand, are mainly provided through various national programs; and community health workers’ interfacing with the communities through primary healthcare facilities and outreach activities. The state provides healthcare through a three-tiered healthcare delivery system and a range of public health interventions. Some government/ semi government organizations like the armed forces, Sui Gas, WAPDA, Railways, Fauji Foundation, Employees Social Security Institution and NUST provide health service to their employees and their dependents through their own system, however, these collectively cover about 10% of the population. The private health sector constitutes a diverse group of doctors, nurses, pharmacists, traditional healers, drug vendors, as well as laboratory technicians, shopkeepers and unqualified practitioners.

Source:https://en.wikipedia.org/wiki/Pakistan

• GLOBAL PRETERM BIRTH RATES – Pakistan
• Estimated # of preterm births: 14.3 per 100 live births
• (USA 9.56-Global Average: 10.6)
• Source- WHO 2023- https://ptb.srhr.org/https://www.who.int/news/item/06-10-2023-1-in-10-babies-worldwide-are-born-early–with-major-impacts-on-health-and-survival

COMMUNITY

AKU neonatologists contribute to Pakistan guidelines for newborn care

Healthcare workers being trained across the country

Nov 20, 2023

Eight faculty members from Aga Khan University out of a total of 55 national and international neonatologists have contributed to the 352-page first National Guidelines for Small and Sick Newborn Care at Primary and Secondary Healthcare Facilities in Pakistan.

Ten percent of neonatal deaths globally take place in Pakistan. The guidelines will be used to train primary and secondary healthcare workers, paediatricians and neonatologists in Pakistan with the goal of lowering these mortality rates.

“Ten percent of neonatal deaths globally take place in Pakistan.”

The guidelines were the initiative of Pakistan’s Ministry of National Health Services, Regulations & Coordination, and have been supported by the Neonatology Group of Pakistan Pediatric Association (PPA), UNICEF, Pakistan and WHO, Pakistan.

Prof Sabina Durrani, the director-general of the Population Program Wing at the Ministry of National Health Services, Regulations and Coordination, Pakistan has said that these guidelines will be disseminated at and followed in all primary and secondary level healthcare facilities in Pakistan which will contribute to the achievement of SDG 3.2. The high rate of preterm babies and slow decline in neonatal mortality are key concerns towards achieving SDG 3.2. The major proportion of our neonatal mortality is from primary or secondary healthcare facilities.

AKU’s Dr Muhammad Sohail Salat led the effort from Sindh and his concerted follow-up with the team and his commitment to the project have resulted in these much-needed guidelines. From Aga Khan University these are the contributing authors:

• Distinguished Professor Zulfiqar A. Bhutta
• Associate Professor of Paediatrics Muhammad Sohail Salat
• Associate Professor of Paediatrics Khalil Ahmad
• Assistant Professor of Paediatrics Ali Shabbir Hussain
• Assistant Professor of Paediatrics Adnan Mirza
• Assistant Professor of Paediatrics Muhammad Hussain Shah
• Assistant Professor of Paediatrics Vinod Kumar
• Senior Instructor & Neonatologist Waqar Hussain Khawaja

The manual provides national standards and protocols to guide clinicians, administrators and teams working across maternity and neonatal services. These guidelines will standardize the development of neonatal units at secondary level hospitals and quality management of small and sick newborns in them.

The chapters include guidance on setting up a neonatal unit at a secondary level healthcare facility. The guidelines even specify dress codes, effective handwashing in Neonatal Units, hands-on techniques of Neonatal Resuscitation and Neonatal Transport.

These guidelines will be updated every two to three years. Work started in May-June 2022 and the book was published by July 2023. Over 100 trainers have been trained so far (Nov 2023) with pre- and post-workshop testing. The three-day sessions are divided into covering Neonatal resuscitation, Essential newborn care, Prevention of infections, Neonatal transport, Oxygen therapy, NIV, nHFT, nCPAP, CMV, Approach to respiratory failure. Workshops on Non-Invasive Ventilation, Kangaroo Mother Care and Neonatal Resuscitation have been held.

The guidelines have been edited by Prof. Khalid N. Haque, Visiting Professor of Neonatal Medicine, University of Child Health Sciences, The Children’s Hospital, Lahore, Former Professor and Reader in Neonatal Medicine, University of London, Consultant Neonatologist, Director of Research and Development, Epsom & St Helier University Hospitals Trust, London, UK.

Dr Muhammad Sohail Salat commented, “We are hopeful that the guidelines and effective training will serve to standardise the quality and level of new-born care in primary and secondary healthcare facilities across the country.”​

https://www.aku.edu/news/Pages/News_Details.aspx?nid=NEWS-003166#:~:text=Healthcare%20workers%20being%20trained%20across%20the%20country&text=Eight%20faculty%20members%20from%20Aga,Secondary%20Healthcare%20Facilities%20in%20Pakistan.

Strengthening neonatal and obstetric healthcare in the war-affected regions of Ukraine (October 2023)

By Milena Chodola and Dorota Zadroga – October 02, 2023

For 12 months, the Polish Medical Mission conducted a program in Ukrainian neonatology hospitals aimed at improving the standard of maternal and newborn care, training medical personnel in European standards and the latest national guidelines for patient care, including in wartime conditions.

Within the framework of the project “Strengthening neonatal and obstetric healthcare in the war-affected regions of Ukraine” which lasted from September 2022 to the end of August 2023, the Polish Medical Mission equipped neonatal intensive care units in 10 hospitals in Ukraine with specialized medical equipment – neonatal resuscitation stations, patient monitors and dual-syringe infusion pumps. The project was implemented in hospitals in the following cities: Kyiv, Dnipro, Chernihiv, Kharkiv, Chernivtsi, Zaporizhzhia, Poltava and Lviv. In its implementation, the Polish Medical Mission cooperated with the Association of Neonatologists of Ukraine, the Ukrainian NGO “Early Birds,” the National Health Service of Ukraine and the Ministry of Health of Ukraine.

At each of the 10 hospitals, PMM conducted monthly in-person sessions for patients to raise their awareness about patient rights, newborn care and caring for well-being, supplemented by regular online sessions. These sessions also discussed changes in the operation of hospitals and medical services due to the war in Ukraine, available medical packages within the National Health Service of Ukraine, and options for psychological support. Patients admitted that, despite sometimes being in the hospital for several weeks, they often had no knowledge of how the National Health Service of Ukraine’s packages functioned, how to be treated at the state’s expense, and their rights and options for psychological support. Doctors from 10 project hospitals also participated in training sessions on patient rights in Ukraine. At these trainings, doctors also learned about the issue of patient rights in the European Union. This is an important issue for Ukrainian hospitals in the context of Ukraine’s introduction of more EU solutions and practices into the Ukrainian system on the way to receiving membership in the European Union. Medical staff from the 10 participating hospitals were also trained in doctor-patient communication, including under wartime conditions. The trainings also included recommendations on the well-being of medical personnel, counteracting professional burnout and maintaining a work-life balance. The training and session program on patient rights were supervised and coordinated by patient rights experts Oleksandra Balyasna and Yevgeniya Kubakh.

As part of the strengthening of professional competence, the medical staff of the aforementioned hospitals took part in four-day in-person medical training courses on neonatal intensive care, post-intensive care and various perinatal problems of newborns and premature infants, among others. The training program was developed on the basis of European neonatal treatment standards, the latest international research, but also on the basis of the latest national clinical guidelines, and is designed to update and expand doctors’ knowledge and promote good practice in Ukraine. During the medical training sessions at each hospital, the trainers, together with the medical staff, discussed and tried to work out solutions to the current challenges of a particular hospital – concerning both difficult clinical cases at a particular hospital and working under wartime conditions. The medical training program as well as its coordination in hospitals was supervised by medical experts, Prof. Tetiana Znamenska and Prof. Olga Vorobiova. At the beginning and end of the training, the doctors filled out anonymous knowledge tests – the results show that about 95% of the participating doctors increased their level of knowledge in the topics covered in the trainings.

During monitoring visits that the trainers conducted several months after the training, they undertook to identify problems that may have gone undetected during medical training, and reassessed the level of doctors’ knowledge using a test of the knowledge gained during medical training. The trainers also analyzed in detail the work of neonatology departments in terms of adherence to national guidelines, international recommendations and clinical protocols, reviewed department reports with indicators and statistics (number of patients, morbidity, mortality, length of stay in hospitals), and assessed the quality of neonatal care, including premature and sick newborns. They also discussed the organization of primary and specialized care, taking into account the conditions of individual hospitals. On the basis of this detailed analysis and audit, the trainers jointly gave a rating to each hospital and made recommendations for further professional development of doctors and for improving the operation of hospitals under wartime conditions (preserving the availability and continuity of care for newborns and pregnant and post-partum women). After summarizing and approving the results of the assessment, the medical trainers, together with the staff of the hospital in question, developed an action plan for the hospitals and individual departments (including neonatal intensive and post-intensive care, labor and delivery, and postpartum). Each hospital received an individually prepared plan.

Hospital administration representatives from 10 facilities indicated in their reports after medical monitoring that the project’s activities helped ensure the necessary standards of patient care and reduce mortality in the unit during the reporting period. For example, at a hospital in Poltava, mortality in the neonatal intensive care unit decreased by 5.8 times during the reporting period. In one hospital in Dnipro, on the other hand, the mortality rate and treatment time in the neonatal intensive care unit decreased almost 2 times during the reporting period. At a hospital in Chernihiv, morbidity and mortality among premature babies in the neonatal intensive care unit decreased thanks to modern medical equipment received under the project – the morbidity rate fell by 8%, and the mortality rate fell by 5%.

In an effort to reach a larger audience, including those outside the 10 participating hospitals, on the Ukrainian medical online platform the Polish Medical Mission published a comprehensive course on patient rights, doctor-patient communication and preventing professional burnout for medical professionals, as well as a webinar on patient rights, well-being and neonatal care for patients from across Ukraine. Prominent Ukrainian experts were invited to participate in these events, including the head of the National Health Service of Ukraine, who spoke about available neonatology and obstetrics services during the war. It will also be used in the next year of the ongoing second edition of the project to support neonatology in 10 more hospitals in new locations in Ukraine.

Key statistics of the project:

– 1,717 female patients attended sessions conducted in 10 hospitals in both in-person and online formats, as well as a webinar for female patients from across Ukraine.

– 78 stationary awareness-raising sessions for female patients on patient rights, newborn care, doctor-patient communication, changes in the functioning of hospitals and medical services due to the war in Ukraine, and opportunities for psychological support.

– 2578 newborns had benefited from medical equipment purchased under the project by the end of August.

– 346 doctors from the 10 hospitals participating in the project took part in medical training, and 160 in training on patient rights.

– 995 doctors from across Ukraine took a course on patient rights registered with the Ministry of Health of Ukraine, conducted online on a Ukrainian medical platform, passed the test, received a certificate and credits from the Ministry of Health of Ukraine.

– During medical monitoring, 94.42% of medical professionals trained at medical training courses showed improvement in patient care.

– 8 live online trainings on patient rights, doctor-patient communication and preventing professional burnout for medical workers from 10 hospitals. They were attended by 160 health workers.

– 10 individual plans were developed to improve the operation of hospitals and individual departments under wartime conditions.

– 1 live webinar on the popular Ukrainian medical platform Medvoice for patients from across Ukraine.

Source:https://reliefweb.int/report/ukraine/strengthening-neonatal-and-obstetric-healthcare-war-affected-regions-ukraine-october-2023

A nonprofit is racing to get its portable baby incubators into Israel and Gaza as crisis deepens

By Parija Kavilanz, CNN – October 27, 2023

New York CNN — 

Jane Chen is racing against the clock, again. She knows well how every minute that passes is crucial for a new life that emerges prematurely into the world in the most vulnerable of circumstances — in the midst of war, in the aftermath of a natural disaster or in a remote village far away from a medical center.

Acutely aware of the deepening crisis between Israel and Gaza, Chen is mobilizing her team at Embrace Global, a nonprofit she co-founded to help save babies’ lives, in a way that’s become second nature to her.

Embrace, based in San Francisco, California, makes low-cost portable baby incubators that don’t require a stable electricity supply.

The Embrace incubator resembles a sleeping bag, but for a baby. It’s a three-part system consisting of an infant sleeping bag, a removable and reusable pouch filled with a wax-like phase-change material which maintains a constant temperature of 98 degrees F for up to eight hours at a stretch when heated, and a heater to reheat the pouch when it cools.

Chen said the pouch requires just a 30-minute charge to be fully ready for reuse. “This is really ideal for settings that have intermittent access to electricity, which is a lot of places where we work in the world,” she said.

According to the UN Population Fund (UNFPA), an estimated 50,000 pregnant women currently reside in Gaza, 5,500 of whom are due to give birth in the coming month.

The stats are startling to Chen, who is bracing for a swell of need there. She’s learned how access to incubators becomes critical in conflict areas through the organization’s efforts to donate 3,000 Embrace incubators with the help of UNICEF to doctors and hospitals in Ukraine where a war with Russia rages on. The nonprofit also sent the devices to Turkey and Syria after devastating earthquakes there earlier this year.

Medical experts point to elevated stress as a potentially serious factor that could trigger preterm deliveries in these situations.

“There’s been plenty of data that show stress not only causes preterm birth but also low-birth-weight,” said Dr. Veronica Gillispie-Bell, an obstetrician-gynecologist and associate professor with Ochsner Health in New Orleans, Louisiana

In general, babies born preterm or before 37 weeks, have difficulty maintaining their body temperature, said Bell. “Specifically, if we are speaking of disasters…. in my own experience of being here during [Hurricane] Katrina, in those very stressful situations, we have seen an uptick during those times in preterm birth and low birth weight,” she said.

Chen said the pouch requires just a 30-minute charge to be fully ready for reuse. “This is really ideal for settings that have intermittent access to electricity, which is a lot of places where we work in the world,” she said.

In general, babies born preterm or before 37 weeks, have difficulty maintaining their body temperature, said Bell. “Specifically, if we are speaking of disasters…. in my own experience of being here during [Hurricane] Katrina, in those very stressful situations, we have seen an uptick during those times in preterm birth and low birth weight,” she said.

Because preterm and low-birth-weight babies don’t have as much body fat, it’s harder for them to maintain their body temperature, which for a healthy baby is between 96.8 and 99.5 degrees F, she said. “The lower it is below that, the more oxygen and energy they need to stay warm. So they would have use even more energy.”

In both cases of preterm and low-birth-weight infants, quick and constant access to an incubator is vital.

From Ukraine to Gaza

In Ukraine, Chen said doctors have indicated that preterm births are on the rise across the country at the same time that intermittent power outages have made the use of conventional incubators very challenging. Several doctors and nurses, she said, also must consistently take babies and mothers to basement shelters as bombings continue.

Dr. Halyna Masiura, a general practitioner, is experiencing this first hand at the Berezivka Primary Healthcare Center in the Odesa region of Ukraine.

“Half of the babies being born in this area need more care,” Masiura told CNN. “They are being born early and with low birth weight. When air raids happen, we all have to go into shelters.” Masiura said her staff members have been relying on donated Embrace incubators for babies born with a birth weight of 2 kg (4 lbs.) and up.

In the Palestinian exclave of Gaza, Israel has instructed more than half of the more than 2 million residents in the north to evacuate to the southern region ahead of an anticipated ground operation in Gaza by the Israel Defense Forces (IDF) in response to Hamas’ deadly October 7 attack on Israel.

That attack killed more than 1,400 people.

In Gaza, where half of the overall population are children, access to medical aid, food, water, fuel, electricity and other normal daily necessities of life have evaporated in recent days amid sustained Israeli bombardment.

Over the weekend, after days of a complete siege of the exclave by Israel, the first trucks reported to be carrying medicine and medical supplies, food and water entered Gaza on Saturday.

For Chen, the most pressing problem is to figure out how to get the incubators to where they are most needed on the ground there. “As we did for Ukraine, we’re looking for partnerships with organizations that can get into the region effectively and also for funding,” she said. As a nonprofit, Chen said donations are sought through GoFundMe and a mix of individual donors, foundations and corporate donations.

Her team is working on a partnership with a humanitarian relief organization to respond in Gaza. “We’re also reaching out to organizations in Israel to assess the need for our incubators there,” she added.

A couple of hundred incubators are ready to immediately be sent to Israel and Gaza. Said Chen, “Depending on the need, we would go into production for more. But the big question is, can we get into those areas? We don’t want to ship products and then have them sit there.”

From a classroom idea to real-world solution

Linus Liang, along with Chen, was among the original team of graduate students at Stanford University who, as part of a class assignment in 2007, were given a challenge to develop a low-cost infant incubator for use in developing countries.

Liang, a software engineer who had already created and sold two gaming companies by then, was intrigued. “This class deliberately brought together people from different disciplines – law, business, medical school, engineers – to collaborate to solve world problems,” he said.

“Our challenge was that about 20 million premature and low-birth-weight babies are born globally every year,” he said. “Many of them don’t survive, or if they do, they live with terrible health conditions.”

The reasons why came down to factors such as a shortage of expensive conventional incubators or families living far away from medical centers to access quickly for their newborns.

The team formed their company in 2008 and then took a few years to engineer and produce the solution, with Liang and Chen both moving to India for a few years to get it off the ground and market test it there. Chen said the incubators, made in India, underwent rigorous testing and are CE certified, a regulatory standard that a device must meet to be approved for use in the European market and in Asia and Africa.

“We chose that route instead of seeking FDA approval because the need really is outside of the US,” said Liang. The cost per incubator is about $500, including cost of the product, training, distribution, shipping, implementation, monitoring and evaluation, said Chen. That compares to as much as $30,000 or more per conventional incubators, she said.

Chen estimates some 15,000 babies benefited from Embrace incubators in 2022.

Not just wars

Dr. Leah Seaman has been using Embrace incubators for three years in Zambia. Seaman is a doctor working in pediatrics for the last 12 years, including six years focusing on neonatal care at the Kapiri Mposhi District Hospital in the Central Province of Zambia.

Seaman has also been busy setting up a new specialized neonatal ward in the rural district hospital. “When I first came to Zambia, we had one old incubator that would draw a lot of power,” she said. “We often struggle with power cuts here, so even the voltage can be too low for the incubator to function well. Having enough space to set up conventional incubator was an issue as well.”

So she reached out to Chen in late 2020 after researching solutions that would work for the specific conditions in Zambia.

“In Zambia, 13% of births are premature, and that’s not even including low-birth-weight babies born at term,” she said. “We needed an effective solution.”

Embrace Global donated 15 incubators to the hospital. The new neonatal ward, set to open this month, is built around the Embrace incubator stations with Kangaroo mother care, or skin to skin contact between mother and baby.

“Last year we had 800 babies through the ward and maybe half of them used the Embrace incubator,” said Seaman. “This year we’ve had over 800 already. We haven’t asked for any conventional incubators because from 1 kg (2.2 lbs) and above, the Embrace incubator does the work.”

Because of their heavy use, Seaman said the main challenge with the incubators is making sure that the heating pad is kept warm and reheated in a timely manner. “We’ve built a mattress station where we will be teaching the new mothers how to do that,” she said.

“Why do we keep babies warm? It’s not just a nice thing. It literally does save lives,” Seaman said.

Source:https://www.cnn.com/2023/10/25/business/baby-incubators-israel-gaza/index.html

Asim Azhar & Shae Gill – Bulleya (Official Video)

      Asim Azhar

5,017,656 views May 29, 2023 #Bulleya #AsimAzhar #ShaeGill

Asim Azhar & Shae Gill collaborates for the first time. Presenting the official video of “Bulleya” A song about peace, harmony & love 🤍🎶 This is definitely going straight into your daily travel playlist.

Why Infant Deaths are Rising in 2023

For the first time in two decades, infant mortality is on the rise in the United States. The nation already struggles with a higher infant mortality rate than many other developed countries. Moreover, like other countries, the United States has recently charted higher rates of low birthweight and preterm births. Nevertheless, new data from the CDC clearly illustrate the factors driving infant deaths – and give powerful clues about how to prevent them. Infant Mortality Data:

Between 2021 and 2022, the United States saw a 3% climb in its infant mortality rate. That raises infant fatalities to 5.6 per 1,000 live births. In a nation that welcomes 3.7 million babies each year, this means that more than 18,000 newborn lives were lost last year.

Babies of color face a higher risk of death:

A Black infant born in America is about twice as likely as a white infant to die in the first year of life. Native American infants and babies born before 37 weeks of gestation experienced the starkest change in mortality over the past few years.

Reversing the Trend:

The CDC cites two primary causes of infant mortality: maternal complications and bacterial meningitis. However, the “cause of death” alone paints an incomplete picture. The factors driving changes in infant survival, especially the disparities in maternal and infant health, are complex and multifaceted.

Consider that Black, Alaskan Native, Native Hawaiian, and Native American women are far more likely than white women to face fetal death, preterm births, stillbirths, and low-birthweight babies. These same groups have higher rates of pregnancies for which they receive no prenatal care and have higher incidences of maternal mortality.

The trend suggests that lack of access to adequate prenatal care and interventions contributes to the rise in infant deaths. The COVID-19 pandemic, which reduced hospital visits and led some clinics to close, also deepened healthcare inequalities.

Better access to care could not only save infants but also reduce pregnancy-related maternal death.

Reducing infant mortality, therefore, will require targeted policy interventions. Policymakers, healthcare professionals, and communities can unite around policy initiatives that bolster maternal and prenatal health services and education.

One example is the Black Maternal Health Momnibus Act of 2023, which aims to address the maternal health crisis in the United States. The legislation provides critical funding to address social determinants of health, enhance data collection processes, improve access to maternal mental health care, and promote maternal vaccinations to protect the health of moms and their babies.

All expectant mothers, regardless of their demographic background, should have access to timely and comprehensive prenatal care. By prioritizing maternal health care and addressing disparities in access, policymakers, advocates, and providers can work toward a healthier, more equitable future for mothers and babies alike”.

Source:https://neonatologytoday.net/newsletters/nt-dec23.pdf

HEALTHCARE PARTNERS

Cardiac Corner: Critical Physiological Principles when Caring for Babies with Congenital Heart Diseases

Gil Wernovsky, MD; Benjamin Hopkins, OMSIV (Discussant)

In this month’s edition of Cardiac Corner, I would like to discuss some critical physiological principles necessary for all those caring for babies with congenital heart disease. There are three broad concepts which determine chamber and great artery pressures, as well as direction of shunting

• A hole of any significant size equalizes the pressure on both sides of the hole.

• “Holes” equalize pressure, but do not determine the direction of shunting 1. Blood rolls “downhill”.

• The differences in the vascular resistance determine the direction of shunting  2. Blue is better than gray.

• A “low” oxygen saturation with normal cardiac output typically results in improved oxygen delivery than a “normal” oxygen saturation with low systemic blood flow

 Let me get into this distinction in more detail. It is not uncommon at the bedside to confuse the crucial distinctions between pressure and resistance. When discussing “holes” such as atrial septal defects, ventricular septal defects, patent ductus arteriosus, and AP window, etc., it is essential to remember that the pressures are equal on either side of the hole, particularly at the ventricular and great vessel levels. Therefore, it is also vital to understand the strict definition of pulmonary hypertension: a mean pressure in the pulmonary artery greater than 25 mmHg. Thus, in all patients with a large VSD and with a large patent ductus arteriosus, the pulmonary artery pressure is at the systemic level. Thus, there is “pulmonary hypertension.” I will get into this in more detail below

The second rule, blood rolls downhill, involves resistance, not pressure. For example, in a baby with a ventricular septal defect, blood will shunt, in most situations, from the left ventricle to the low-resistance pulmonary circuit via the right ventricle. This results in a left to right shunt, pulmonary congestion, and no hypoxemia. If pulmonary vascular resistance is high, or there is an obstruction to pulmonary blood flow, as in Tetralogy of Fallot, blood may go from the right ventricle to the left ventricle, where there is less resistance to flow.

Number three, “blue is better than gray,” is the physiologic principle most frequently quoted when discussing complex physiology with my NICU colleagues. By that, we mean that the delivery of oxygen, is more important than the oxygen saturation via pulse oximetry (which, of course, is the percent of hemoglobin, which is bound to oxygen). Indeed, if cardiac output is normal and carrying capacity (hemoglobin) is normal, oxygen saturations in the 60s and 70s, even if sustained, will not result in tissue ischemia, metabolic acidosis, or, importantly, neurologic injury. It is beyond the scope of this article to discuss all of the details of every congenital heart problem. Still, in general, not all oxygen saturations that are “higher” are “better.”

The next concept that I’d like to discuss is “shunting.” This, by convention in most NICUs, refers to shunting in only one direction, right to left, resulting in hypoxemia, and may be labeled “PPHN”. This can easily be determined by pulse oximetry. However, the degree of left-to-right shunting cannot be quantified at the bedside but may result in significant clinical illness.

I think of “shunting” associated with hypoxemia in two broad categories. The most common scenario in the NICU is interpulmonary shunting, where the blood returning from the pulmonary veins is not fully saturated; this is due to lung disease, pneumothorax, pleural effusion, atelectasis, etc. Intracardiac shunting, however, results in systemic hypoxemia due to systemic venous return bypassing the pulmonary circulation through an intracardiac or great vessel connection. So, in a hypoxemic newborn with congenital heart disease, it is important to distinguish systemic hypoxemia due to an intrapulmonary shunt, intracardiac shunt, or both.

Finally, “pulmonary hypertension” is a frequently misused term, and I wonder if we will ever get it out of our lexicon. In my world as a congenital cardiologist, pulmonary hypertension needs to be divided into two categories: pulmonary hypertension due to elevated pulmonary vascular resistance (such as seen in PPHN, diaphragmatic hernia, and meconium aspiration), and pulmonary hypertension due to the connection of the ventricles or the great vessels by “holes” (Rule #1), and differences in resistance (Rule #2). For example, echo reports may report “elevated right ventricular and pulmonary artery pressure,” which may be assumed by the bedside team that the pressure is elevated due to elevated resistance (“PPHN”), with institution of pulmonary vasodilation. However, it may also be due to Intracardiac or great vessel communications – a very important distinction for management.

As a parting comment, systemic hypoxemia without alveolar hypoxia does NOT cause an elevated pulmonary vascular resistance or “worse PPHN” – otherwise, all babies with intracardiac shunts from congenital heart disease would have elevated pulmonary vascular resistance! It is alveolar hypoxia which causes elevations in pulmonary vascular resistance, sometimes severe, and should be treated with usual ventilatory maneuvers, inhaled nitric oxide, ECMO, etc. If a baby has hypoxemia with no lung disease, increasing oxygen, non-invasive or invasive mechanical ventilation is likely to do more harm than good.

Source:https://childrensnational.org/visit/find-a-provider/gil-wernovsky

NICU Nurses Have ‘Something Special’ | Jan, 15, 2024 | News 19 This Morning

WHNT News 19   Jan 15, 2024

Do you believe in angels? What about miracles? Some say they’ve seen both in the Regional Neonatal Intensive Care Unit at Huntsville Hospital for Women and Children.

So Many Babies”: An interview with author and neonatologist Susan Landers, MD

Jul 8, 2023 #theartofmedicine #podcastsonamazonmusic

It’s a pleasure to welcome Susan Landers, MD, to The Art of Medicine with Dr. Andrew Wilner. Dr. Landers is a retired neonatologist and author of the memoir, “So Many Babies.” After four years of medical school, three years of pediatric residency, and three years of neonatology fellowship, Dr. Landers worked as a neonatologist for 34 years. She has many stories to tell! In “So Many Babies,” Dr. Landers tells the stories of many of her tiny patients and their distraught and devoted families. She also shares the challenges she faced as a full-time working Mom. Dr. Landers tried desperately to balance her dedication to her patients and academic career with the roles of wife and mother to three children. She learned that working full-time, producing scholarly publications, teaching medical students and residents, providing optimal patient care, and raising a family can be too much for one person to do simultaneously. The lessons she learned may help young physicians, nurses, and other career-minded professionals succeed in their careers and family life. You can find “So Many Babies” on Amazon and in my library.

PREEMIE FAMILY PARTNERS

How to support your premature child at school

The Smallest Things  Jul 20, 2023

A webinar from The Smallest Things premature baby charity and the University of Leicester for parents and carers who want to help their prematurely born children at school. • Hear from leading academics including Professor Samantha Johnson on the latest research findings into educational needs and how schools can support premature children • Receive practical advice and resources to help you advocate for your child and ask their school to become Prem Aware • Watch teachers from Prem Aware schools explain why they took the three steps to achieve the Prem Aware Award and how it’s making a difference to their communities • Listen to an adult born prematurely and a parent of premature children talk about their experiences of the education system.

Lullaby-Playing Pacifier Helps Premature Babies Thrive | UCLA Health Newsroom

UCLA Health – Feb 11, 2019

Babies who are born premature often struggle with feeding and the reflex to suck, breathe and swallow, which is pivotal for their development. And when parents watch their premature newborns in the neonatal intensive care unit (NICU), they often feel helpless. Now, researchers with the music therapy program at UCLA Mattel Children’s Hospital are testing whether an unusual device, which plays a lullaby recorded by the baby’s parents when a baby successfully sucks on the connected pacifier, can empower parents by helping them bond with their babies — and strengthen the babies by improving their oral abilities, which play a crucial role in the ability to feed. A family with triplets participated in the research and used the pacifier-activated lullaby (PAL) device to aid in their babies’ development.

Seeking Local Parent /Patient support? EFCNI provides contact information for International and National  Parent and Patient Organizations.

Parent and Patient Organisations

International Organizations

• INTERNATIONAL COUNCIL OF MULTIPLE BIRTH ORGANISATIONS / ICOMBO
• INTERNATIONAL FEDERATION OF SPINA BIFIDA AND HYDROCEPHALUS / IFSBH
• INTERNATIONAL PATIENT ORGANISTION FOR PRIMARY IMMUNODEFICIENCIES / IPOPI
• 57 Countries are listed with  identified patient/parent organizations

ENTER HERE

Source:https://www.efcni.org/parent-and-patient-org-2/

Early body contact develops premature babies’ social skills

November 30, 2023  Karolinska Institutet

Summary:

Skin-to-skin contact between parent and infant during the first hours after a very premature birth helps develop the child’s social skills. The study also shows that fathers may play a more important role than previous research has shown.

Skin-to-skin contact between parent and infant during the first hours after a very premature birth helps develop the child’s social skills. This is according to a new study published in JAMA Network Open by researchers from Karolinska Institutet and others. The study also shows that fathers may play a more important role than previous research has shown.

In current practice, very premature babies are usually placed in an incubator to keep them warm and to stabilize them during the first hours after birth.

In the “Immediate parent-infant skin-to-skin study” (IPISTOSS), 91 premature babies born at 28 to 33 weeks were randomized to either traditional care in an incubator or immediate skin-to-skin contact with one of the parents.

The study has generated several results that show, among other things, that immediate skin-to-skin contact is safe for babies and beneficial for their cardiorespiratory stabilization and temperature maintenance, and that it is perceived as valuable by the parents.

Now, as part of this study, the researchers have also studied the social development at four months of age of 71 of these premature babies.

The children were randomly assigned to receive either standard care in an incubator or to receive care resting on one of their parents’ breasts, either the mother’s or the father’s, for the first six hours after birth.

“What is new about our study is that we also allowed the fathers to have skin-to-skin contact immediately after the birth. In most previous studies, it is the mother who is the primary caregiver, but in our study it was the fathers who had the most skin-to-skin contact,” says Wibke Jonas, midwife, senior lecturer and associate professor at Karolinska Institutet’s Department of Women’s and Children’s Health, as well as research leader and last author of the study.

“The study has identified fathers as a previously untapped resource that really has an important function in having immediate skin-to-skin contact with their infant if the mother is not available,” says Siri Lilliesköld, PhD student at the same department and specialist nurse in neonatal care, and first author of the study.

After four months, the social interaction between mother and infant was filmed and assessed by two psychologists who did not know which infant had received early skin-to-skin contact and which had not.

The quality of the interaction was measured according to the Parent-Child Early Relational Assessment (PCERA) scale, where different elements are graded between one and five, with one being cause for concern and five being very good quality.

The infants who received immediate skin-to-skin contact had significantly better results in a subscale measuring the infant’s communicative and social skills.

On the five-point scale, their average score was closer to four, while the infants cared for according to current practice were just above three.

“What you could see was that the infants in the skin-to-skin group had slightly better communication skills, they were a bit more social and happier,” says Wibke Jonas.

Premature babies have developmental challenges as they grow up and need a lot of support.

Even though medical developments have come a long way, the care of these babies still needs to be developed, the researchers say.

“If we combine the immediate medical care of the very premature babies with a relatively simple intervention such as skin-to-skin contact, it has effects on the infants social skills,” says Jonas Wibke and continues.

“Previous studies have shown that premature babies perform slightly poorer when socially interacting, for example, they do not give as clear signals in the interaction with their mothers. The closeness between babies and their parents at birth may therefore stimulate later interaction and thus the development of the infant.”

The benefits of immediate skin-to-skin contact are so clear that both Wibke Jonas and Siri Lilliesköld believe it should be introduced now in Swedish neonatal care.

And this work is already underway, they say.

‘We have worked very actively to minimize separation between infants and parents in general, and now we have the evidence to do the same with these very premature babies,” says Siri Lilliesköld.

The research team will continue to report on the development of the infants at 12 and 24 months.

The study is a collaboration between researchers from Karolinska Institutet and the University Hospital of Stavanger, Norway, and the University of Turku, Finland. The research was funded by, among others, the Swedish Research Council, Region Stockholm and Stiftelsen Barnavård. The researchers declare that there are no conflicts of interest.

Source:https://www.sciencedaily.com/releases/2023/11/231130113047.htm

INNOVATIONS

Two-Year Autism Risk Screening and 3-Year Developmental Outcomes in Very Preterm Infants

Coral L. Shuster, PhD¹; Stephen J. Sheinkopf, PhD²; Elisabeth C. McGowan, MD^1,3; et alJulie A. Hofheimer, PhD⁴; T. Michael O’Shea, MD⁴; Brian S. Carter, MD⁵; Jennifer B. Helderman, MD, MS⁶; Jennifer Check, MD⁶; Charles R. Neal, MD, PhD⁷; Steven L. Pastyrnak, PhD⁸; Lynne M. Smith, MD⁹; Cynthia Loncar, PhD³; Lynne M. Dansereau, MSPH¹; Sheri A. DellaGrotta, MPH¹; Carmen J. Marsit, PhD¹⁰; Barry M. Lester, PhD^1,3

Key Points

Question  How are screening examinations using a 2-stage parent-report autism risk screening tool at 2 years of age associated with 3-year developmental and behavioral outcomes among infants born very preterm?

Findings  In this longitudinal cohort study of 467 infants born less than 30 weeks’ gestation, children who screened positive on the 2-stage parent-report autism risk screening tool at age 2 years were significantly more likely to have cognitive, language, and motor delay as well as internalizing, externalizing, and autism-related behavior problems at age 3 years.

Meaning  Study results suggest use of the 2-stage parent-report autism risk screening tool for behavior problems and overall developmental delays for infants born very preterm, regardless of future autism diagnosis.

Abstract

Importance  Use of the Modified Checklist for Autism in Toddlers, Revised With Follow-Up, a 2-stage parent-report autism risk screening tool, has been questioned due to reports of poor sensitivity and specificity. How this measure captures developmental delays for very preterm infants may provide support for continued use in pediatric care settings.

Objective  To determine whether autism risk screening with the 2-stage parent-report autism risk screening tool at age 2 years is associated with behavioral and developmental outcomes at age 3 in very preterm infants.

Design, Setting, and Participants  Neonatal Neurobehavior and Outcomes for Very Preterm Infants was a longitudinal, multisite cohort study. Enrollment occurred April 2014 to June 2016, and analyses were conducted from November 2022 to May 2023. Data were collected across 9 university-affiliated neonatal intensive care units (NICUs). Inclusion criteria were infants born less than 30 weeks’ gestational age, a parent who could read and speak English and/or Spanish, and residence within 3 hours of the NICU and follow-up clinic.

Exposures  Prematurity and use of the 2-stage parent-report autism risk screening tool at age 2 years.

Main Outcomes and Measures  Outcomes include cognitive, language, motor composites on Bayley Scales for Infant and Toddler Development, third edition (Bayley-III) and internalizing, externalizing, total problems, and pervasive developmental disorder (PDD) subscale on the Child Behavior Checklist (CBCL) at age 3 years. Generalized estimating equations tested associations between the 2-stage parent-report autism risk screening tool and outcomes, adjusting for covariates.

Results  A total of 467 children (mean [SD] gestational age, 27.1 [1.8] weeks; 243 male [52%]) were screened with the 2-stage parent-report autism risk screening tool at age 2 years, and outcome data at age 3 years were included in analyses. Mean (SD) maternal age at birth was 29 (6) years. A total of 51 children (10.9%) screened positive on the 2-stage parent-report autism risk screening tool at age 2 years. Children with positive screening results were more likely to have Bayley-III composites of 84 or less on cognitive (adjusted odds ratio [aOR], 4.03; 95% CI, 1.65-9.81), language (aOR, 5.38; 95% CI, 2.43-11.93), and motor (aOR, 4.74; 95% CI, 2.19-10.25) composites and more likely to have CBCL scores of 64 or higher on internalizing (aOR, 4.83; 95% CI, 1.88-12.44), externalizing (aOR, 2.69; 95% CI, 1.09-6.61), and PDD (aOR, 3.77; 95% CI, 1.72-8.28) scales.

Conclusions and Relevance  Results suggest that the 2-stage parent-report autism risk screening tool administered at age 2 years was a meaningful screen for developmental delays in very preterm infants, with serious delays detected at age 3 years.

Source:https://jamanetwork.com/journals/jamapediatrics/article-abstract/2812810

Quality of inpatient care of small and sick newborns in Pakistan: perceptions of key stakeholders

Nousheen Akber Pradhan, Ammarah Ali, Sana Roujani, Sumera Aziz Ali, Samia Rizwan, Sarah Saleem, Sameen Siddiqi 

Abstract

Background

In LMICs including Pakistan, neonatal health and survival is a critical challenge, and therefore improving the quality of facility-based newborn care services is instrumental in averting newborn mortality. This paper presents the perceptions of the key stakeholders in the public sector to explore factors influencing the care of small and sick newborns and young infants in inpatient care settings across Pakistan.

Methods

This exploratory study was part of a larger study assessing the situation of newborn and young infant in-patient care provided across all four provinces and administrative regions of Pakistan. We conducted 43 interviews. Thirty interviews were conducted with the public sector health care providers involved in newborn and young infant care and 13 interviews were carried out with health planners and managers working at the provincial level. A semi-structured interview guide was used to explore participants’ perspectives on enablers and barriers to the quality of care provided to small and sick newborns at the facility level. The interviews were manually analyzed using thematic content analysis.

Findings

The study respondents identified multiple barriers contributing to the poor quality of small and sick newborn care at inpatient care settings. This includes an absence of neonatal care standards, inadequate infrastructure and equipment for the care of small and sick newborns, deficient workforce for neonatal case management, inadequate thermal care management for newborns, inadequate referral system, absence of multidisciplinary approach in neonatal case management and need to institute strong monitoring system to prevent neonatal deaths and stillbirths. The only potential enabling factor was the improved federal and provincial oversight for reproductive, maternal, and newborn care.

Conclusion

This qualitative study was insightful in identifying the challenges that influence the quality of inpatient care for small and sick newborns and the resources needed to fix these. There is a need to equip Sick Newborn Care Units with needed supplies, equipment and medicines, deployment of specialist staff, strengthening of in-service training and staff supervision, liaison with the neonatal experts in customizing neonatal care guidelines for inpatient care settings and to inculcate the culture for inter-disciplinary team meetings at inpatient care settings across the country.

Source:https://bmcpediatr.biomedcentral.com/articles/10.1186/s12887-021-02850-6

Seven simple innovations that could save the lives of two million pregnant women and babies

MATERNAL HEALTH – BEATRIZ LECUMBERRIPATRICIA R. BLANCO– Madrid – SEP 13, 2023

A study by the Bill and Melinda Gates Foundation states that the world is experiencing an epidemic of maternal and child mortality

Seven medical innovations or treatments, most of them inexpensive and easy to implement, could significantly reduce maternal and infant deaths around the world, particularly in sub-Saharan Africa and South Asia. This is the conclusion of the 2023 Goalkeepers Report published by the Bill and Melinda Gates Foundation this Tuesday. “By making new innovations accessible to those who need them most, 2 million additional lives could be saved by 2030 — and 6.4 million lives by 2040,” estimates the philanthropic organization in its annual report, which focuses on maternal and child mortality, whose progress has become stagnant since 2016 and even increased in some countries, including the United States.

Among these innovations are the rapid diagnosis of postpartum hemorrhage, an intravenous infusion of iron against anemia, a probiotic supplement for babies, antenatal corticosteroids (anti-inflammatories) for women who will give birth prematurely, azithromycin (an antibiotic) to prevent infections, and an AI-enabled ultrasound device to monitor high-risk patients in low-resource places.

In 2015, world leaders agreed on 17 Sustainable Development Goals with an eye toward 2030. The year 2023 marks the halfway point to achieving those goals and, in the case of maternal, child and neonatal mortality, the data indicate that there is still a long way to go. The goal was to end all preventable child deaths by 2030 and reduce maternal mortality to 70 out of every 100,000 births, but that has not happened. Every day, 800 women around the world die from reasons related to pregnancy and childbirth. That is, one every two minutes. According to the UN, 70% of these deaths occur in sub-Saharan Africa. In addition, every year approximately five million children die before their fifth birthday, and nearly two million more are stillborn.

This happens despite the fact that there has never been so much scientific knowledge on maternal and child health: “Researchers have learned more about the health of mothers and babies over the past 10 years than they did in the century before that,” the report states. The problem is that the solutions do not reach those who need them most. The authors even speak of an “epidemic” of maternal and child mortality, and not only in low-income countries: in the United States, for instance, mortality among Black mothers has doubled since 1999. “American women are more than three times more likely to die from childbirth than women in almost every other wealthy country. But, as I noted earlier, the biggest crisis is among Black and Indigenous women,” writes Melinda French Gates.

In the 2000s, indicators of human well-being such as poverty or education improved substantially, and it was precisely maternal and child health what made the most progress. This was possible, in part, because several international organizations had set ambitious goals; these, however, were curtailed after 2016 and ended up stagnating with the arrival of the Covid-19 pandemic. In some countries, like Venezuela or the United States, the situation has even worsened, according to the report.

Three low-cost lifesavers

According to Melinda French Gates, three inexpensive innovations can prevent thousands of women in low- and middle-income countries from dying during pregnancy and childbirth: a new treatment for postpartum hemorrhage, the use of the antibiotic azithromycin to prevent infections, and intravenous infusions of iron for cases of anemia.

Postpartum hemorrhage (PPH), which occurs when a woman loses more than half a liter of blood within 24 hours of childbirth, is the number one cause of maternal death. The World Health Organization (WHO) estimates that it affects 14 million women a year, killing 70,000, particularly in low-income countries. In impoverished countries, the main problem is realizing that a significant loss of blood is taking place. In many places this is only estimated visually, and thousands of women die without receiving the treatment that could save them.

The Gates Foundation proposes a simple, low-cost way to assess this blood loss: a calibrated obstetric drape that looks like a V-shaped plastic bag, which is hung on the edge of the patient’s bed so the blood falls into it and rises like the mercury in a thermometer. That is a quick visual gauge that can alert healthcare personnel in time. Furthermore, instead of sequentially applying the five treatments to stop bleeding (uterine massage, oxytocic drugs, tranexamic acid, IV fluids and genital-tract examination), they propose grouping them all together. In a study called E-MOTIVE, Nigerian obstetrician-gynecologist Hadiza Galadanci and a team of researchers from four African countries with a high maternal mortality rate found that using the drapes and following the updated guidelines managed to decrease cases of severe bleeding by a remarkable 60%.

Another of the proposed changes is the treatment of anemia, which affects 37% of pregnant women (although in some areas of the world, such as South Asia, it can go up to 80%) and increases the chances of hemorrhage during childbirth. Diagnosing it during pregnancy is essential, but instead of treating it with oral iron supplements that must be taken for 180 days, Bosede Afolabi, a Nigerian obstetrician and researcher, is working to implement a promising new intervention in her country: a single intravenous infusion of iron that takes 15 minutes and can replenish a woman’s iron reserves during pregnancy.

Another of the main causes of maternal mortality is infection. In recent years, researchers have discovered that one of the most promising new ways to prevent infections during pregnancy is one of the most used antibiotics in the world: azithromycin. In a trial carried out in sub-Saharan Africa, it reduced cases of sepsis (an extreme inflammatory reaction) by one third.

“These breakthroughs aren’t silver bullets on their own — they require countries to keep recruiting, training, and fairly compensating health care workers, especially midwives, and building more resilient health care systems. But together, they can save the lives of thousands of women every year,” reflects Melinda French Gates.

The baby knowledge boom

“Over the past decade, the field of child health has moved faster and farther than I thought I’d see in my lifetime,” writes Bill Gates, highlighting the launch of three Gates Foundation programs to carry out research on the deaths of children and newborns, in order to prevent them: CHAMPS (Child Health and Mortality Prevention Surveillance); PERCH, which analyzes the causes of childhood pneumonia; and GEMS, for diarrheal diseases.

Ten years ago, he explains, “any record of a child’s death would generally list one of the four most common causes: diarrhea, malnutrition, pneumonia, or premature birth.” However, he continues, “each was a vast ocean of different illnesses, with scores of different causes and cures. Pneumonia, for example, is linked to more than 200 types of pathogens.”

The collection of data carried out in recent years — taking blood and tissue samples from children who had died and comparing cases — has revealed that some pathogens were less likely than expected, such as the one that causes whooping cough, while others were more common, such as Klebsiella, which is more difficult to treat. The new information about this last bacteria “is leading doctors to change what antibiotics they use,” explains Bill Gates. This is what he refers to as the baby knowledge boom. “Thanks to studies like CHAMPS, GEMS and PERCH, the medical field has begun to understand precisely when and why some babies are dying, which allows them to keep others alive,” he stresses.

Another example that Gates highlights is how doctors help premature babies breathe by giving antenatal corticosteroids (ACS) to pregnant mothers who are going to give birth prematurely. According to the foundation’s calculations, “ACS could save the lives of 144,000 infants in sub-Saharan Africa and South Asia by 2030 and nearly 400,000 by 2040.” Probiotic supplements with bifidobacteria (bacteria that live in the digestive system and help break down milk sugars) also reduce the risk of death or serious illness in premature babies.

Source:https://english.elpais.com/international/2023-09-13/seven-simple-innovations-that-could-save-the-lives-of-two-million-pregnant-women-and-babies.html

Unlocking Potential: The Early Stages of Preemie Education Programming – A Journey of Growth and Exploration

Every preemie represents a world of untapped potential, and preemie education programs are at the forefront of pioneering innovative approaches. These programs are breaking away from traditional teaching methods, placing a strong emphasis on adaptability and forward-thinking to cater to each child’s unique needs. Envision a classroom where lessons seamlessly blend with sensory experiences, social interactions, and progressive challenges. In an ideal learning/teaching environment education is far from a one-size-fits-all model; it’s a journey of individual resonance, finely tuned for every individual learner.

Within this promising new educational frontier targeting the needs and  great potentialities of prematurely born children, and as research continues, we can anticipate the expansion of such programs over time. With increased understanding and ongoing innovation, we can look forward to the implementation of more of these tailored educational approaches, ensuring that every preemie has the opportunity to thrive and reach their full potential.

Preemie education programming isn’t a fanciful educational approach; it’s a pragmatic response to unique challenges. It signifies the resilience of preemies, the creative expertise of teachers, the importance of tailored learning, and a cooperative effort that benefits both learners, educators, and their support systems. Our education-focused journey is in its early stages, and the possibilities are vast, inviting our creativity, knowledge, and most of all, engagement.

Preemie Chat – Catriona Ogilvy – on January 14 at 1 pm EST

Following the successful introduction of the UK Prem Aware Award, helping teachers to support the needs of children born prematurely in school, this presentation will highlight the lasting journey and impact of premature birth, with a specific focus on education and learning.  While being born premature does not mean that a child will have special educational needs, it does increase the chances. It is essential therefore that parents and teachers alike are aware of the potential difficulties and become equipped to meet these needs. This presentation will examine this topic and discuss what more we can do to support the long-term outcomes of children born early.

Preemie babies become capable adults when grown up, new study confirms

New research shows that extremely prematurely born adults are transitioning to adult life similarly to their term-born peers.22 DECEMBER 2023 RESEARCH AND CLINICAL TRIALS | NICU

New evidence from a world-leading Victorian study following premature babies into adulthood shows that babies born before 28 weeks’ gestation are doing surprisingly well as young adults in their twenties.

In a paper published in PEDIATRICS, new data released from the Victorian Infant Collaborative Study (VICS) 1991-92 cohort reveals insights from the 25-year point of the long-term study.

The study, co-led by the Royal Women’s Hospital and Murdoch Children’s Research Institute (MCRI), shows that extremely prematurely born adults are just as likely to have completed secondary school, be in paid work, and be in a romantic relationship, compared to their peers born at full term.

Dr Lauren Pigdon, Research Officer at MCRI, analysed the new data from the unique Australian geographic cohort who were recruited at birth and followed for 25 years.

“A strength of this study is that it represents the earliest survivors of the post-surfactant era to navigate the transition into adulthood and fills a gap in knowledge,” Dr Pigdon said.

The introduction of exogenous surfactant in the early 1990s was a game changer in treating respiratory distress syndrome in newborn intensive care. Since then, there has been a dramatic rise in survival of infants born extremely preterm (younger than 28 weeks’ gestation) or with extremely low birthweight (less than 1000g).

With increased survival rates of even the tiniest babies, concerns arose that these tiny babies might have increased chances of health and developmental problems as children and adults. And that this may in turn have an impact on their transition into adult life. But is this true?

Professor Jeanie Cheong, Consultant Neonatologist at the Women’s and Co-Group Leader of the Victorian Infant Brain Studies group at MCRI.

“Our data paints a positive and encouraging picture,” Dr Pigdon said. “There were minimal group differences in self-reported general interpersonal relationships, satisfaction with different aspects of life, and current smoking behaviour.”

However, Professor Jeanie Cheong, Consultant Neonatologist at the Women’s and Co-Group Leader of the Victorian Infant Brain Studies group at MCRI, said there were some differences between the groups.

“More adults born extremely preterm had their main income source from government financial assistance and more had not yet moved out of the parental home compared with their peers born full term,” Professor Cheong said.

“Data from the past 25 years has allowed us to look at how, over time, care has improved for Victoria’s youngest and most vulnerable patients,” Professor Cheong said.

“While survival rates have gone up, we now also know that these babies have the chance to become fully functional members of our society.

“Findings from our study are relevant when counselling families after their baby is born, to put into perspective what the long-term outcomes may mean for their child.”

Meet Duane: 

Duane has certainly grown up since he was born extremely premature at 26 weeks’ gestation in March 1992. He weighed only 886 grams at birth.

“I was so tiny that my father’s wedding ring could fit all the way up my arm to my shoulder,” Duane remembers.

After a happy and normal childhood, Duane completed high school and became a competitive slalom skier, trying out for the Australian National Team. While he is an experienced downhill racer avoiding major obstacles, Duane faced a few health issues and injuries in his early 20s.

Duane is now a professional skiing and snowboard instructor. He follows the snow seasons and enjoys living and working abroad. He spent a long time in Austria, where he completed a sports diploma in Innsbruck, and now speaks German fluently.

Currently, Duane is keen for his torn ACL in the knee to heal. Then he plans to hit the slopes again and has offers to work in the USA, Japan, and Europe.

Source:https://www.thewomens.org.au/news/prem-babies-become-capable-adults-when-grown-up-new-study-confirms

This Is The Way We Go To School By Edith Baer, Book Read Aloud, Book about Transportation

J&D Play Fun

What are all the ways we can go to school around the WORLD, watch and find out! SUBSCRIBE for more books! This is another of D’s school books with FCA.

Surfing clubs at Mubarak Village Beach

Yasir Jawed   Nov 25, 2022     MUBARAK VILLAGE BEACH

The coastal belt of Pakistan has one of the best beaches in the World. In today’s vlog, we are going to be surfing at Mubarak village beach. Surfing is a sport that is not popular in Pakistan like other water sports but there are people who love to surf in Pakistan, we will meet the surfing community of Rehman Goth @Surfers of Bulleji and another group resident of Mubarak Village. I’d like to appreciate the efforts and support of Dr. Aftab Ahmed Siddiqui who has been supporting the fishing community of Mubarak village he has provided them the equipment, accessories training to encourage them to do this sport. Moreover, I am thank full to Mr. Murtaza Sabir Ali for engaging me in such activities, I am sure the bond is getting stronger day by day. For me Surfing was entirely new but since I love water sports, it was a great experience for me. My son 9 years old and my friend Khalil also enjoyed the day by far. Special thanks to Team @shaharyarkhanvlogs & Team @PakistanwithFarhanAli because of the fellow content creators we had extreme fun. Thanks to @Atiq a professional surfer from Rehman Goth, I wish he becomes a star in the sports one day.