Parsing the relations between SES and stress reactivity: examining individual differences in neonatal stress response

In an effort to further delineate the reported relations between socioeconomic status (SES) and stress reactivity in children, associations between three domains of perinatal risk: socio-demographic, obstetrical complications, and maternal psychological factors during the perinatal period, and cortisol and behavioral reactivity were examined in 100 healthy African American neonates whose families resided in low-income environments. Behavioral and cortisol response to a heel stick and the Neonatal Behavioral Assessment Scale (NBAS) was measured within the first 2 days of life. Significant associations were found between socio-demographic risk, obstetrical complications, and maternal psychological factors and neonatal behavior and cortisol in the context of the NBAS; few significant associations were found in the context of the heel stick. Greater magnitude of perinatal risk was associated with both higher and lower than average neonatal stress reactivity. The results provide preliminary data on the types of perinatal experiences that may have significant effects on stress reactivity in humans, especially in the context of families living in poverty. Application of these data to the hypothesis that prenatal stress results in programming of the fetal/neonatal stress response system is discussed.     

早发型重度子痫前期的诊疗决策

早发型重度予痫前期可采取保守治疗恰当延长孕龄,减少因胎儿不成熟导致的围生儿死亡。但对妊娠28周～32周以前者的保守治疗,应采取非常慎重的态度,可以预期结局作为临床决策依据,恰当把握终止妊娠的时机与指征,达到提高胎儿有效成活率,避免孕产妇终末脏器不可逆损害,降低孕产妇病死率与婴幼儿死亡及病残率,减轻家庭和社会负担的目的。     

Mental health policy and the psychiatric inpatient care of children

Recent changes in psychiatric inpatient treatment of children and youth are placed in the more general context of, first, the inpatient treatment of adults and, second, multiple public policies affecting children. For adults, the experimental evidence shows that the majority of psychiatric inpatients could be treated in programs outside the hospital more effectively and less expensively. For children, no such data base exists. Contrary to policy intent, between 1980 and 1985 inpatient care of children and youth increased substantially in residential treatment centers, private psychiatric hospitals, and scatter hospitals (general hospitals without any formal specialized units). Thus, psychiatric inpatient care of children and youth is increasing, dramatically so at largely uninvestigated and more expensive sites. The failure of children's mental health policy is placed in the context of the multiple policy failures for children regarding health, welfare, education, and housing. Recent positive efforts by federal agencies are described, but the need is great for data on efficacy and cost-effectiveness of inpatient treatment of children.     

Making Sense of Suffering and Death: How Health Care Providers’ Construct Meanings in a Neonatal Intensive Care Unit

Biomedical technology has progressed at a pace that has created a new set of patient care dilemmas. Health care providers in intensive care units where life-sustaining therapies are both initiated and withdrawn encounter clinical scenarios that raise new existential, theological, and moral questions. We hypothesized that there might be broad patterns in how such staff understand these questions and make sense and meaning from their work. Such meaning making might be the key to working with the critically ill and dying while helping to create and sustain a meaningful context for personal living. This article presents themes evident in an in depth analysis of open-text responses to a spiritual and religious questionnaire survey completed by staff in one neonatal intensive care unit. The data reveal the central roles of perceived infant suffering and death in these providers’ work experience and details how they understand the ultimate meaning of the suffering and death. We investigate patterns in how different providers articulate their individual attributes and motivations for working in intensive care. We found a surprising range of religious, spiritual, existential, and other meaning-making systems that underpin how staffs understand their work and how, certain of them, even define their purpose in life as caring for critically ill infants and their families.Wendy Cadge received her Ph.D. in sociology from Princeton University. She is currently an Assistant Professor of Sociology at Bowdoin College and a Robert Wood Johnson Foundation Scholar in Health Policy Research at Harvard University. Her research examines a range of topics related to religion in contemporary American life including religious pluralism, religion & immigration, religion & sexuality, and religion & the arts. Her first book is titled, Heartwood: the First Generation of Theravada Buddhism in America (Chicago: University of Chicago Press, 2005). Dr. Cadge’s current research focuses on the history, presence, and significance of religion and spirituality in American hospitals. Elizabeth A. Catlin is a senior faculty neonatologist at the Massachusetts General Hospital (MGH) in Boston and an Associate Professor of Pediatrics, Harvard Medical School. Dr. Catlin completed general pediatric training at Tufts University School of Medicine, Boston, followed by subspecialty training in neonatal–perinatal medicine at Brown University School of Medicine, Providence, Rhode Island. Dr. Catlin served as Chief of Neonatology at MGH from 1992 to 2004. She completed a Kenneth B. Schwartz Foundation fellowship in Clinical Pastoral Education in 1999. Dr. Catlin has a long-standing interest in spiritual distress, tragic decision-making, suffering, bereavement, and religious components of patient care in neonatal intensive care. Correspondence to Elizabeth A. Catlin, ecatlin@partners.org.     

Macropremies: underprivileged newborns

The focus of neonatal intensive care has been on very low birthweight infants, who comprise only 1.4% of neonates. Too little attention is paid to moderately preterm infants that we call macropremies or moderately low birthweight infants (MLBW, with birthweights 1500-2500 grams). Admitting over half MLBW infants to normal nurseries presumes that they have few needs and an excellent prognosis similar to fullterm newborns. It does not take into account the macropremie's vulnerability to complications of prematurity due to immature organ systems. Obstetricians are increasingly willing to deliver these infants prematurely for signs of fetal distress. As many as 25% of children with cerebral palsy referred to a disability clinic in Paris were MLBW, with hypoxic-ischemic-inflammatory associated disorders in one-third. The majority of MLBW infants who required neonatal intensive care at a tertiary care center in Baltimore had complications of prematurity: 47% had respiratory problems, 20% had feeding intolerance and 9% had hypoglycemia. MLBW infants comprise 5-7% of the neonatal population but account for 14% of neonatal deaths, 18-37% of children with cerebral palsy and 7-12% of children with mental retardation. Increasing the level of neonatal care for the macropremie's transition to extrauterine life would be economically feasible if it prevented as few as 30% of cases of major disability. A change in attitude towards this low risk (but not risk free) group of MLBW infants will both reduce morbidity and improve their health and neurodevelopmental outcome. It includes: 1) Providing an intermediate level of neonatal care for a short duration, with close monitoring and prompt intervention as needed, and 2) Neonatal neurodevelopmental screening to allow focused neurodevelopmental followup of MLBW infants with abnormalities.     

Relations between neonatal states and 8-month developmental outcome in preterm infants

This study investigated longitudinal relations between measures of neonatal state behavior and developmental outcome in a sample of preterm infants (N = 16). Results indicate that irritability/reactivity in the neonatal period is positively associated with Bayley scores and exploratory play at 8 months. Conversely, neonatal alertness was not associated with these developmental measures. These preliminary findings, based on a small sample, are discussed in the context of preterm function.     

The National Commission on AIDS

A decade after the first cases were recognized in the United States, AIDS continues to vex policymakers and fascinate the public. It has been said that AIDS acts as a prism, refracting a spectrum of controversial topics. For bioethicists, these topics include: equity in the allocation of resources for treatment and research; forgoing life-sustaining care and proxy decision making; informed consent in the context of HIV testing and screening; the ethical duties of health care workers to provide care for persons with HIV disease; and competing obligations of health care professionals to patients and to third parties who may be put at risk.     

Caring fathers in the Netherlands

Data from two studies on heterosexual men and their care work at home are discussed. Five groups of fathers are distinguished. They range from the traditional father (hardly any care work within the home) to the very caring father (who does at least as much as his wife). What makes the difference between these five groups of men? Measures at three levels have been studied: present social context, value orientation, and family of origin of the fathers. Measures at the first and second levels seem to be the most important. The role of the female partner is also discussed. Caring men do not report a lesser degree of well-being, including the quality of their relationship.     

Extremely Preterm Birth Outcome: A Review of Four Decades of Cognitive Research

Premature birth incidence and survival rates are increasing steadily due to advances in obstetric and neonatal intensive care. Those born at the limits of viability are highly at-risk of adverse neurocognitive function over their lifespan, leading to current controversy regarding aggressive resuscitation efforts for these extremely preterm children. However, data from earlier generation cohorts who were born in substantially different eras of neonatal intensive care cannot be relied on to predict outcome of today’s newborn. Our review by the crucial variable of birth cohort year shows a changing developmental trajectory in which today’s extremely preterm survivor is likely to have fewer severe medical complications, better neurological outcomes, and fewer adverse cognitive late effects. Such data further underscore the importance of concurrently considering medical, familial, socioenvironmental, and neurobiological factors in combination with individual neonatal intensive care center protocols when studying outcomes of the preterm child. This complex, interrelated range of factors directly affects the immature, rapidly developing premature brain. However, ongoing surveillance to detect subsequent delay or impairment and to apply interventional strategies early in the developmental course holds promise for further enhancement of functional outcome.     

The relation between length of hospitalization and the mental and physical development of preterm infants

Longitudinal pilot data from 10 preterm infants showed that a longer length of hospitalization in the neonatal intensive care unit was reliably related to poorer mental and physical development at 24 months of age. Less realistic mothers' perceptions of their infants behaviors were also related to poorer physical development scores.     

My <Emphasis Type="Italic">Ishvara</Emphasis> is Dead: Spiritual Care on the Fringes

Human suffering speaks differently to different lived contexts. In this paper, I have taken a metaphoric representation of suffering, Ishvara, from the lived context of a Hindu immigrant woman to show that suffering is experienced and expressed within one’s lived context. Further, a dominant narrative from her world is presented to show that the same lived context can be a resource for spiritual care that could reconstruct her world that has fallen apart with a suffering experience. Having argued that suffering is experienced and expressed within one’s lived context, and that lived context could be a resource, in this paper I present that spiritual care is an intervention into the predicaments of human suffering and its mandate is to facilitate certain direction and a meaningful order through which experiences and expectations are rejoined. Finally, I observe that spiritual care is an engagement between the lived context where suffering is experienced and the spiritual experience and orientation of the caregiver.     

The detection and management of mental health disorders in pediatric primary care

We reviewed the literature on the detection and management of mental health disorders within the context of pediatric primary care. Pediatricians have displayed a low sensitivity and high specificity in research investigating the detection of mental health impairment in children. Active management efforts characterize approaches to identified cases with more recently trained primary care pediatricians displaying a wider range of skills in managing mental health disorders. Few efforts have been made by pediatric psychologists to develop strategies for enhancing detection rates and management or to empirically evaluate the integration of pediatric psychology services into the primary care context. A conceptual model of factors influencing detection rates and ongoing management of mental health disorders within pediatric primary care is presented. Recommendations are made for more direct involvement of pediatric psychologists within the primary care context.     

Dimensions of naturally occurring mother-infant separations during the first year of life

The goals of this paper are (1) to introduce a methodology developed to study mother-infant separations that occur in the context of normal family life, including but going beyond separations associated with maternal employment; (2) to present illustrative data that describe the range of separations experienced by one sample of infants; and (3) to demonstrate how a focus on specific underlying dimensions results in a more precise characterization of the separation experience. It is necessary to identify the specific dimensions on which mother-infant separations vary in order to clarify which aspects of separation are relevant to child outcome. Detailed histories of mother-infant separations and concomitant substitute care during the first year of life were obtained by interview from 144 middle-class mothers of first-born infants. Far from being an unusual event, separation from mother was a normal experience during infancy for this sample. Six types of separation were identified, the majority of which have not been studied previously. Analyses indicated that naturally occurring mother-infant separations can be differentiated statistically and compared in terms of amount of separation, stability of care, characteristics of caregivers, and characteristics of the substitute care setting.     

Child Saving and the Emergence of Vocational Psychology

Vocational psychology emerged at the beginning of the 20th in a context of social and political change known as the “progressive era.” A popular progressive theme was “child saving,” a movement that expressed concern for the physical, educational, emotional, and social well-being of children and adolescents. Vocational guidance was one manifestation of this and served as the foundation for the emergence first of vocational psychology and later of counseling psychology. The concern for and care of youth was gradually replaced by the professionalization of psychology that over time has changed the focus and direction of vocational psychology.     

The Effect of Spiritual Self-care Training on the Quality of Life of Mothers of Preterm Infants: A Randomized Controlled Trial

The present study was carried out with the aim of determining the effect of spiritual self-care training on the quality of life of mothers of preterm infants. This trial was carried out on 60 mothers with premature infants. Mothers were randomly divided into two intervention and control groups. Training for increasing awareness about the condition of the infants was carried out in both groups. In the intervention group, spiritual self-care training was also done. Data were completed in both groups before, immediately after, and two weeks after the intervention by using the standard WHO quality of life questionnaire. Data were analysed using statistical tests, including ANOVA and Repeated Measures. The results showed that the average quality of life of mothers under study was significantly different at different points of measurement in the intervention group (first, second, and third time-points) (P = 0.016). An increase was observed in the intervention group at the second time-point compared to the first time-point (84.2–88.4, P < 0.001) and in the third time-point compared to the first time-point, (87.9), which was also statistically significant (P < 0.001). According to the results of post hoc tests, there was a decrease in quality of life in the control group at the second time-point compared to the first time-point and the average score of mothers decreased from 82.9 to 75.3, which was statistically significant (P < 0.001). Spiritual self-care training can increase the quality of life and can be used as a form of holistic nursing care for mothers with premature infants in neonatal intensive care units.

     

Heidegger in the township

Imagine Heidegger in a township. Imagine you are able to translate his concept of ‘care’ to ‘the people’. Would they agree that in their ordinary experience people care? I argue not and contend that, instead, they would choose the term ‘struggle’. I analyse experiential aspects of ordinary life in the context of the township, which involves a significant part of people around the world, in order to argue that, at least in such contexts, it is a more common experience for people to struggle than to care. In this way I hope to show how a phenomenological analysis of everyday life experience such as Heidegger's can contribute to the understanding of contextual issues, but also how a context can induce the introduction of new concepts of thinking.     

Preterm outcomes research: a critical component of neonatal intensive care

While early preterm outcome studies described the lives of preterm survivors to justify the efforts required to save them, subsequent studies demonstrated their increased incidence of cerebral palsy, mental retardation, sensory impairments, minor neuromotor dysfunction, language delays, visual-perceptual disorders, learning disability and behavior problems compared to fullterm controls. Because infants born at the lower limit of viability require the most resources and have the highest incidence of neurodevelopmental disability, there is concern that resources have gone primarily to neonatal intensive care and are not available for meeting the followup, health, educational and emotional needs of these fragile infants and their families. Despite many methodological concerns, preterm outcome studies have provided insight into risk factors for and causes of CNS injury in preterm infants. Nevertheless, it remains difficult to predict neurodevelopmental outcome for individual preterm infants. Perinatal and neonatal risk factors are inadequate proxies for neurodevelopmental disability. Recent randomized controlled trials with one to five year neurodevelopmental followup have provided valuable information about perinatal and neonatal treatments. Recognizing adverse longterm neurodevelopmental effects of pharmacological doses of postnatal steroids is a sobering reminder of the need for longterm neurodevelopmental followup in all neonatal randomized controlled trials. Ongoing longterm preterm neurodevelopmental studies, analysis of changes in outcomes over time and among centers, and evaluation of the longterm safety, efficacy and effectiveness of many perinatal and neonatal management strategies and proposed neuroprotective agents are all necessary for further medical and technological advances in neonatal intensive care.     

“Who Cares for the Children?” Lessons from a Global Perspective of Child Care Policy

We present the argument that the meaning of child care and the policies that address it are explicitly linked with national ideologies, work force participation, economic success, and child outcomes. The relationship between family and child care policies is cyclical in nature, with a nation’s ideology and vision of family often driving child care policies, while child care policies in turn drive and support a nation’s ideology. We examine the interrelatedness of child care policy and national ideologies of family in selected industrialized countries. Specifically, this paper first defines child care policy and discusses the national ideological frameworks that provide the impetus for child care policy formation and implementation. Second, the paper explores current child care policies and their connection to the historical and political context of several countries within, including France, Germany, Japan, South Korea, Belgium, the Nordic countries, and the United States. Lastly, recommendations are offered for the future of child care policy development with specific recommendations for child care policy development in the United States.     

Child care effects in context: quality, stability, and multiplicity in non-maternal child care arrangements during the first 15 months of life

Main and interactive effects of child care quality, stability, and multiplicity on infants' attachment security, language comprehension, language production, and cognitive development at 15 months were examined using data from the National Institute of Child Health and Human Development (NICHD) Study of Early Child Care. Thirty-nine percent of the infants in this sample experienced arrangement change, and 46% experienced multiple concurrent arrangements during the first 15 months. As in previous studies, concurrent quality, average quality, and quality slope significantly predicted cognitive and language development. There was some evidence that certain forms of unstable child care--including nonfamilial change, familial to nonfamilial change, and within-home to out-of-home change--were associated with poorer language development. Multiple child care arrangements involving family members positively predicted language comprehension; multiple care involving a mix of family and non-relative caregivers negatively predicted language comprehension. Interactions among variables exhibited "effects in context." That is, under conditions of low or moderate quality in the primary care arrangement, the use of fewer multiple arrangements was associated with higher language scores; under conditions of high primary care quality, the use of more multiple arrangements was associated with higher language scores.