We admit babies to the Neonatal Intensive Care Unit (NICU), because they need specialized medical and nursing care. We recognize that, this can be a very stressful and confusing time for parents and family. Separation from your new baby is difficult . Understanding the needs of your baby will help you get through this difficult time.

1. How to Support & DealingHow to Support & Dealing
with parents in NICUwith parents in NICU
Dr.Osama Arafa Abd ELDr.Osama Arafa Abd EL
HameedHameed
M. B.,B.CH - M.Sc Pediatrics - Ph. D.M. B.,B.CH - M.Sc Pediatrics - Ph. D.
Pediatrics & NeonatologyPediatrics & Neonatology
ConsultantConsultant
Head of PediatricsHead of Pediatrics

3. Challenges to Parenting in the NICUChallenges to Parenting in the NICU
 Separation and distanceSeparation and distance
 Stress, anxiety, loss, fatigueStress, anxiety, loss, fatigue
 Infant appearance and behaviorInfant appearance and behavior
 Nursery appearance and policiesNursery appearance and policies
 Lack of privacy and controlLack of privacy and control
 Staff-parent interactionsStaff-parent interactions
 Financial concernsFinancial concerns
 Family issuesFamily issues

4. Parental Feelings After Preterm BirthParental Feelings After Preterm Birth
 GriefGrief
 FearFear
 HopeHope
 AngerAnger
 HelplessnessHelplessness
 Thinking about babyThinking about baby
continuallycontinually
 Loss of controlLoss of control
 Loss of role as decisionLoss of role as decision
maker and caregivermaker and caregiver
 AnxietyAnxiety
 HappinessHappiness
 ShockShock
 RestlessnessRestlessness
 EmptinessEmptiness
 DepressionDepression
 FrustrationFrustration
 DistressDistress
 Stress disordersStress disorders

6. Difficult Times in the NICUDifficult Times in the NICU
• Still unable to see babyStill unable to see baby
• First visit to the NICUFirst visit to the NICU
• Being discharged without babyBeing discharged without baby
• Difficult newsDifficult news
• TransitionsTransitions
• Discharge home with babyDischarge home with baby
• Death of baby in unitDeath of baby in unit

7. Parent Needs in the NICUParent Needs in the NICU (Cleveland,(Cleveland,
2008; Hurst, 2001)2008; Hurst, 2001)
 Accurate information and inclusion in theAccurate information and inclusion in the
infant's careinfant's care
 Vigilant watching over and protection ofVigilant watching over and protection of
the infantthe infant
 Contact with the infantContact with the infant
 Being positively perceived by the nurseryBeing positively perceived by the nursery
staffstaff
 Individualized careIndividualized care
 Therapeutic relationship with staffTherapeutic relationship with staff

8. Psychological Stress in NICUPsychological Stress in NICU
ParentsParents
 Parents of infants in the NICU are at increasedParents of infants in the NICU are at increased
risk of depression and stress disorders both duringrisk of depression and stress disorders both during
the infant’s hospitalization and in thethe infant’s hospitalization and in the
postdischarge periodpostdischarge period

Acute stress and distressAcute stress and distress

Posttraumatic stress disorderPosttraumatic stress disorder

AnxietyAnxiety

Depression/postpartum mood disordersDepression/postpartum mood disorders
(Beck, 2003; Groer et al, 2002; Howland et al, 2011; Padovani et al,
2009; Poehlmann et al, 2009; Shaw et al, 2009)

9. Stress and DistressStress and Distress
StressStress:: “...a physical, chemical, or“...a physical, chemical, or
emotional factor that causes bodily oremotional factor that causes bodily or
mental tension and may be recognized asmental tension and may be recognized as
a factor in disease causationa factor in disease causation.”.” (Merriam(Merriam
Webster's Collegiate Dictionary)Webster's Collegiate Dictionary)
DistressDistress:: adverse effects seen when aadverse effects seen when a
stress causing event has exceeded thestress causing event has exceeded the
human limits of stress tolerancehuman limits of stress tolerance

10. Consequences of StressConsequences of Stress
 During pregnancy = increase risk ofDuring pregnancy = increase risk of
preterm labor and birthpreterm labor and birth
 Postpartum: early stressful experiencesPostpartum: early stressful experiences
can subsequently affect parental attitudes,can subsequently affect parental attitudes,
behaviors and care giving relationshipbehaviors and care giving relationship
 Long term health risks for parents andLong term health risks for parents and
infantsinfants

11. Acute Stress DisorderAcute Stress Disorder
 Significant stressorSignificant stressor
 Initial "daze“ and disorientation, followedInitial "daze“ and disorientation, followed
by symptoms such as depression, anxiety,by symptoms such as depression, anxiety,
anger, despair, over activity, withdrawalanger, despair, over activity, withdrawal
 Usually diminishes after 24–48 hoursUsually diminishes after 24–48 hours

12. Critical Features of PostpartumCritical Features of Postpartum
Mood DisordersMood Disorders (Siegel, Gardner & Dickey, 2011)(Siegel, Gardner & Dickey, 2011)
 Over concern for the baby or excessiveOver concern for the baby or excessive
anxiety over the infant’s healthanxiety over the infant’s health
 Feelings of guilt , inadequacy,Feelings of guilt , inadequacy,
worthlessness, failure at mother hoodworthlessness, failure at mother hood
 Fear of losing control or “going crazy”Fear of losing control or “going crazy”
 Lack of interest in the babyLack of interest in the baby
 Fear of harming the babyFear of harming the baby
 ObsessionObsession

13. Post-traumatic Stress DisorderPost-traumatic Stress Disorder
(DSM-IV-TR)(DSM-IV-TR)
 Exposure to traumatic eventExposure to traumatic event
 Re-experiencing the event through intrusiveRe-experiencing the event through intrusive
thoughtsthoughts
 Avoidance of stimuli that represent the eventAvoidance of stimuli that represent the event
 Increased arousal after the event that was notIncreased arousal after the event that was not
present beforepresent before
 Duration of >1 monthDuration of >1 month
 Significant impairment in social or otherSignificant impairment in social or other
functioningfunctioning
 Reported among parents of VLBWReported among parents of VLBW

14. Post Traumatic Stress and NICUPost Traumatic Stress and NICU
FamiliesFamilies
 Wereszczak et al. (1997)Wereszczak et al. (1997)

Qualitative study of vividness of memories primaryQualitative study of vividness of memories primary
caregivers recall 3 years post preterm birth (n = 44)caregivers recall 3 years post preterm birth (n = 44)

Vivid memories related to infant appearance andVivid memories related to infant appearance and
behavior, pain, procedures, illness severity, andbehavior, pain, procedures, illness severity, and
uncertainty of outcomesuncertainty of outcomes
 Holditch-Davis et al (2003)Holditch-Davis et al (2003)

PTSD questionnaire and interview of 30 PT mothers atPTSD questionnaire and interview of 30 PT mothers at
6 mo corrected age6 mo corrected age

All had at least 1 PTSD symptom, 12 had 2, 16 had 3All had at least 1 PTSD symptom, 12 had 2, 16 had 3

PTSD symptoms associated with infant illness severityPTSD symptoms associated with infant illness severity

15. Post Traumatic Stress and NICUPost Traumatic Stress and NICU
FamiliesFamilies
 Pierrhumbert et al. (2003)Pierrhumbert et al. (2003)

PTSD questionnaire to parents (50 PT, 25 FT) at 6 moPTSD questionnaire to parents (50 PT, 25 FT) at 6 mo

67% of mothers of preemies vs. 6% controls exhibited67% of mothers of preemies vs. 6% controls exhibited
clinical post-traumatic reactionsclinical post-traumatic reactions

Intensity correlated with eating/sleeping problems ofIntensity correlated with eating/sleeping problems of
infantsinfants
 Kersting et al. (2004)Kersting et al. (2004)

PTS responses (scale) in 50 PT vs 30 FT mothers at 5PTS responses (scale) in 50 PT vs 30 FT mothers at 5
times from birth to 14 monthstimes from birth to 14 months

Higher rates and similar intensity of traumaticHigher rates and similar intensity of traumatic
symptoms in PT mothers at all time points to 14 monthssymptoms in PT mothers at all time points to 14 months

16. Post Traumatic Stress and NICUPost Traumatic Stress and NICU
FamiliesFamilies
 Shaw et al. (2009)Shaw et al. (2009)

Prevalence of ASD (birth) and PTSD 4 months after thePrevalence of ASD (birth) and PTSD 4 months after the
birth of PT or sick NB (n = 18)birth of PT or sick NB (n = 18)

33% of fathers, 9% of mothers met criteria for PTSD33% of fathers, 9% of mothers met criteria for PTSD

ASD symptoms correlated with PTSD and depressionASD symptoms correlated with PTSD and depression

Fathers: PTSD more delayed onset, greater risk by 4 moFathers: PTSD more delayed onset, greater risk by 4 mo
 Vanderbilt (2009)Vanderbilt (2009)

Assessment of postpartum acute PTS and depression inAssessment of postpartum acute PTS and depression in
59 NICU & 60 well NB mothers in first week after birth59 NICU & 60 well NB mothers in first week after birth

NICU mothers show increased symptoms of acute PTSNICU mothers show increased symptoms of acute PTS
stress and depression. 23% NICU and 3% well NBstress and depression. 23% NICU and 3% well NB
reached severity criteria for acute stress disorderreached severity criteria for acute stress disorder

17. Enhancing Parenting and Reducing StressEnhancing Parenting and Reducing Stress
 Emotional supportEmotional support
 Supportive environmentSupportive environment
 Understanding infant behavior and characteristicsUnderstanding infant behavior and characteristics
 Involvement in caregiving and decision makingInvolvement in caregiving and decision making
 Knowledge, sensitivity, skillsKnowledge, sensitivity, skills
 Skin to skin holding (kangaroo care)Skin to skin holding (kangaroo care)

18. Parent Emotional SupportParent Emotional Support (O’Donnell,(O’Donnell,
1996)1996)
 Help parents understand their responses andHelp parents understand their responses and
their partner’s responsestheir partner’s responses
 Provide information and empathyProvide information and empathy
 Assist in interpreting informationAssist in interpreting information
 Respond to all questions fully and openlyRespond to all questions fully and openly
 Support family from within their perspectiveSupport family from within their perspective
 Respect responsesRespect responses
 Repeat explanationsRepeat explanations
 Flexibility and availability to talk with family whenFlexibility and availability to talk with family when
they are readythey are ready

19. Supportive EnvironmentSupportive Environment
 Family centered careFamily centered care
 Continuity of careContinuity of care
 Parent to parent supportParent to parent support
 Partnering with parentsPartnering with parents
 Transition to homeTransition to home

21. Family-Centered CareFamily-Centered Care
 Supports development of parentalSupports development of parental
competencecompetence
 Focuses on:Focuses on:
 Identifying and building on individual andIdentifying and building on individual and
family strengthsfamily strengths
 Partnering and collaborating with parentsPartnering and collaborating with parents
 Empowering families so they can care forEmpowering families so they can care for
their infant in the NICU and at hometheir infant in the NICU and at home
(Griffin & Abraham, 2006; IFCC, 1998; Saunders et al., 2003)(Griffin & Abraham, 2006; IFCC, 1998; Saunders et al., 2003)

22. Key Components of Parent SupportKey Components of Parent Support
 Parents are respected and valued members ofParents are respected and valued members of
the health care teamthe health care team
 Parents and health professionals form effectiveParents and health professionals form effective
partnershipspartnerships
 The focus is on parental strengths; parentsThe focus is on parental strengths; parents
define their own needs and prioritiesdefine their own needs and priorities
(Hurst, 2001, 2006; Cooper et al, 2007; Gooding, 2008)(Hurst, 2001, 2006; Cooper et al, 2007; Gooding, 2008)

23. Key Components of Parent SupportKey Components of Parent Support
• All parents can give and receive; teach andAll parents can give and receive; teach and
learn; care and be cared forlearn; care and be cared for
• Parents are viewed in the context of theirParents are viewed in the context of their
families, neighborhoods or communitiesfamilies, neighborhoods or communities
• Parent support services are accessibleParent support services are accessible
• Information shared by parents is confidentialInformation shared by parents is confidential
(Hurst, 2001, 2006; Cooper et al, 2007; Gooding, 2008)(Hurst, 2001, 2006; Cooper et al, 2007; Gooding, 2008)

24. Promoting Parenting in the NICUPromoting Parenting in the NICU
• Provide support to parentsProvide support to parents
• Help parents identify and use supportHelp parents identify and use support
systemssystems
• Collaborate with families in planning andCollaborate with families in planning and
providing careproviding care
• Enhance the role of parents as advocatesEnhance the role of parents as advocates
for their infantfor their infant
• Empower parents to care for their infant,Empower parents to care for their infant,
participate in rounds, ask questions, meetparticipate in rounds, ask questions, meet
with the care team, etc.with the care team, etc.

30. EmpowermentEmpowerment
• To equip or supply with an ability; enableTo equip or supply with an ability; enable
• Helping processHelping process
• Caring presence building on parents strengthsCaring presence building on parents strengths
• Active participation with increasing controlActive participation with increasing control
• Sharing of knowledge and skillsSharing of knowledge and skills
• Partnership with mutual decisions, choices andPartnership with mutual decisions, choices and
responsibilityresponsibility
• Enabling or transferring power to the otherEnabling or transferring power to the other

31. Family Support and EmpowermentFamily Support and Empowerment
 Partnership between NICU care provider andPartnership between NICU care provider and
parent/family = interdependency andparent/family = interdependency and
collaborationcollaboration (Gibbins et al, 2008; Lawhon, 1997)(Gibbins et al, 2008; Lawhon, 1997)
 ““Unique and vital contribution of both the familyUnique and vital contribution of both the family
and the care provider to the infant’s health andand the care provider to the infant’s health and
well being”well being” (Gibbins et al, 2008)(Gibbins et al, 2008)
 Creating Opportunities for Parent EmpowermentCreating Opportunities for Parent Empowerment
(COPE)(COPE) (Melynk et al, 2006)(Melynk et al, 2006)

32. Kangaroo Care Parenting EffectsKangaroo Care Parenting Effects (Dodd,(Dodd,
2004; Feldman, 2004; Feldman & Eidelman, 2003; Ludington-Hoe et al, 20082004; Feldman, 2004; Feldman & Eidelman, 2003; Ludington-Hoe et al, 2008))
 Skin-to-skin contact between infant and parentSkin-to-skin contact between infant and parent
provides high levels of comfort to parentsprovides high levels of comfort to parents (Cooper(Cooper
et al, 2007)et al, 2007)
 Benefits to attachmentBenefits to attachment

Contingent stimulationContingent stimulation

Sensory environment of breastSensory environment of breast
 ParentalParental

Reduced anxiety, stressReduced anxiety, stress

Increased parental bonding and satisfactionIncreased parental bonding and satisfaction

Parent comfortParent comfort

33. Attachment Behaviors of Parents ofAttachment Behaviors of Parents of
NICU InfantsNICU Infants (Gale & Franck, 1998)(Gale & Franck, 1998)
 Eagerly performs caregiving activitiesEagerly performs caregiving activities
 Expresses pleasure in meeting infantExpresses pleasure in meeting infant
needsneeds
 Able to comfort infant when distressedAble to comfort infant when distressed
 Brings toys, other items to personalizeBrings toys, other items to personalize
infant’s spaceinfant’s space
 Makes personalized observations aboutMakes personalized observations about
infantinfant

34.  Offers suggestions and makes demands forOffers suggestions and makes demands for
personalized carepersonalized care
 Demonstrates advocacy behaviorsDemonstrates advocacy behaviors
 Feels knows and can care for infant better thanFeels knows and can care for infant better than
anyone elseanyone else
 Demonstrates consistent visiting and/or callingDemonstrates consistent visiting and/or calling
patternspatterns
 Questions focus on total infants, not onlyQuestions focus on total infants, not only
physiological parametersphysiological parameters
Attachment Behaviors of Parents ofAttachment Behaviors of Parents of
NICU InfantsNICU Infants (Gale & Franck, 1998(Gale & Franck, 1998

38. The Role of the Neonatal NurseThe Role of the Neonatal Nurse
•
Recognize and accept their role in dischargeRecognize and accept their role in discharge
managementmanagement
•
Work collaboratively with families in facilitatingWork collaboratively with families in facilitating
the transition to home from admission onwardthe transition to home from admission onward
•
Develop evidence-based practice guidelinesDevelop evidence-based practice guidelines
consistent with current knowledge and researchconsistent with current knowledge and research

39. Continuum of CareContinuum of Care
• Nurses link care across units, before admissionNurses link care across units, before admission
and after discharge, in hospital systems and withand after discharge, in hospital systems and with
external sites.external sites.
• Efforts focus on communication, information,Efforts focus on communication, information,
policies and practices.policies and practices.
• Each shift team should work with the next teamEach shift team should work with the next team
or provider to facilitate consistency andor provider to facilitate consistency and
continuity.continuity.

40. Parent EducationParent Education
• The nurse ensures that parents have theThe nurse ensures that parents have the
knowledge and skills they need for theknowledge and skills they need for the
infant’s transition to home.infant’s transition to home.
• The nurse individualizes teaching contentThe nurse individualizes teaching content
for each family based on the family’sfor each family based on the family’s
needs and priorities, which the family andneeds and priorities, which the family and
staff determine togetherstaff determine together (Griffin & Abraham, 2006).(Griffin & Abraham, 2006).
• Each family needs at least two caregivers.Each family needs at least two caregivers.
• As much teaching as possible shouldAs much teaching as possible should
occur before dischargeoccur before discharge (Broedsgaard & Wagner,(Broedsgaard & Wagner,
2005; Griffin & Abraham, 2006).2005; Griffin & Abraham, 2006).

41. Parent Education TopicsParent Education Topics

42. Feeding Topics for ParentFeeding Topics for Parent
EducationEducation
• Hunger and satiation cuesHunger and satiation cues
• Positioning, rooting and sucking reflexesPositioning, rooting and sucking reflexes
• Breaking suctionBreaking suction
• BurpingBurping
• Schedule vs. demandSchedule vs. demand
• Duration and volume of feedingsDuration and volume of feedings
• Latching on and letting downLatching on and letting down
• Formula typeFormula type
• Correct preparation of formulaCorrect preparation of formula

43. Choosing a Primary Care ProviderChoosing a Primary Care Provider
• Helping families select a primary care providerHelping families select a primary care provider
can:can:

Reduce anxietyReduce anxiety

Ensure that a provider is in place at theEnsure that a provider is in place at the
time of dischargetime of discharge

Allow provider involvement during theAllow provider involvement during the
discharge processdischarge process
• Nurses should encourage parents to meet withNurses should encourage parents to meet with
potential providers to help make their selection.potential providers to help make their selection.

44. BreastfeedingBreastfeeding
• In the first few weeks, regular and frequentIn the first few weeks, regular and frequent
pumping is important to establish milkpumping is important to establish milk
supplysupply (Isaacson, 2006; Spatz, 2004, 2006).(Isaacson, 2006; Spatz, 2004, 2006).
• Kangaroo careKangaroo care (Brodsky & Ouellette, 2008; Ludington-Hoe(Brodsky & Ouellette, 2008; Ludington-Hoe
et al., 2008; Nye, 2008; Spatz, 2006):et al., 2008; Nye, 2008; Spatz, 2006):

Promotes earlier breastfeeding and maternalPromotes earlier breastfeeding and maternal
milk supplymilk supply

Increases the number of mothers breastfeedingIncreases the number of mothers breastfeeding
at NICU dischargeat NICU discharge

Increases the duration of breastfeedingIncreases the duration of breastfeeding

45. BottlefeedingBottlefeeding
• Nurses should teach formula preparation,Nurses should teach formula preparation,
including mixing instructions and type of water toincluding mixing instructions and type of water to
use.use.
• The primary care provider needs to know waterThe primary care provider needs to know water
fluoride content to decide whether or not tofluoride content to decide whether or not to
supplement.supplement.
• Parents should clean utensils with hot, soapyParents should clean utensils with hot, soapy
water and a bottle and nipple brush; sterilizationwater and a bottle and nipple brush; sterilization
is not necessary.is not necessary.

46. Behavioral CuesBehavioral Cues
• Engagement cues (stability cues) indicate thatEngagement cues (stability cues) indicate that
the infant is coping well.the infant is coping well.
• Disengagement cues (stress or instability cues)Disengagement cues (stress or instability cues)
signal that the infant is becoming stressed orsignal that the infant is becoming stressed or
overloaded.overloaded.
• Parents, nurses and other care providers mustParents, nurses and other care providers must
be sensitive to infant cues and respondbe sensitive to infant cues and respond
appropriately.appropriately.

47. Engagement CuesEngagement Cues
• Relaxed tone with smooth movementsRelaxed tone with smooth movements
• Extremities flexedExtremities flexed
• Quiet, alert stateQuiet, alert state
• Animated face with bright eyesAnimated face with bright eyes
• Periodic eye contact with caregiverPeriodic eye contact with caregiver
• Hand-to-mouth movementsHand-to-mouth movements
• Turning toward a voiceTurning toward a voice
• SmilingSmiling
• Well-perfused, oxygenated appearanceWell-perfused, oxygenated appearance

48. Disengagement CuesDisengagement Cues
• Averted gazeAverted gaze
• Falling asleepFalling asleep
• YawningYawning
• Frowning orFrowning or
grimacinggrimacing
• ArchingArching
• Gagging, gruntingGagging, grunting
or sneezingor sneezing
• Hiccupping, spittingHiccupping, spitting
or gaggingor gagging
• Splayed fingersSplayed fingers
• CryingCrying
• Becoming pale,Becoming pale,
mottled or redmottled or red

49. Take Home MessageTake Home Message
 We admit babies to the Neonatal Intensive Care UnitWe admit babies to the Neonatal Intensive Care Unit
(NICU), because they need specialized medical and(NICU), because they need specialized medical and
nursing care.nursing care.
 We recognize that, this can be a very stressful andWe recognize that, this can be a very stressful and
confusing time for parents and family.confusing time for parents and family.
 Separation from your new baby is difficult .Separation from your new baby is difficult .
 Understanding the needs of your baby will help youUnderstanding the needs of your baby will help you
get through this difficult time.get through this difficult time.

50.  You may have many questions about the care yourYou may have many questions about the care your
baby will receive. We try to help answer many of thesebaby will receive. We try to help answer many of these
questions.questions.
 Our first priority is the care and health of your family.Our first priority is the care and health of your family.
 We want to work with you to meet your baby’s needs.We want to work with you to meet your baby’s needs.
Please ask questions or discuss concerns with yourPlease ask questions or discuss concerns with your
baby’s nurse or doctor.baby’s nurse or doctor.
 We want to make your baby’s stay with us as positiveWe want to make your baby’s stay with us as positive
as possible.as possible.

51. Selected ReferencesSelected References
 Ashton, M, Meagher-Stewart, D, et al. (2006). FamilyAshton, M, Meagher-Stewart, D, et al. (2006). Family
health nursing and empowering relationships. Pediatrhealth nursing and empowering relationships. Pediatr
Nurs, 32, 61-67Nurs, 32, 61-67
 Cooper, L.G., Gooding, J.S., et al. (2007). Impact of aCooper, L.G., Gooding, J.S., et al. (2007). Impact of a
Family-Centered Care Initiative on NICU Care, Staff andFamily-Centered Care Initiative on NICU Care, Staff and
Families. Journal of Perinatology, 27, S32-S37.Families. Journal of Perinatology, 27, S32-S37.
 Feeley, N., Zelkowitz, P. et al. (2011). PosttraumaticFeeley, N., Zelkowitz, P. et al. (2011). Posttraumatic
stress among mothers of very low birthweight infants at 6stress among mothers of very low birthweight infants at 6
months after discharge from the neonatal intensive caremonths after discharge from the neonatal intensive care
unit. Appl Nurs Res, 24, 114-117.unit. Appl Nurs Res, 24, 114-117.
 Feldman, R, Eidelman, A, et al. (2002). A comparison ofFeldman, R, Eidelman, A, et al. (2002). A comparison of
skin-to-skin (kangaroo) and traditional care, parentingskin-to-skin (kangaroo) and traditional care, parenting
outcomes and preterm infant development. Pediatrics,,outcomes and preterm infant development. Pediatrics,,
110-16-26.110-16-26.

52. Selected ReferencesSelected References
 Gibbins, S., et al. (2008). The universe of developmentalGibbins, S., et al. (2008). The universe of developmental
care, a new conceptual model for application in thecare, a new conceptual model for application in the
neonatal intensive care unit. Adv Neonat Care, 8, 141-neonatal intensive care unit. Adv Neonat Care, 8, 141-
148.148.
 Gooding, J.S., Cooper, L.G., et al. (2011). Family supportGooding, J.S., Cooper, L.G., et al. (2011). Family support
and family-centered care in the neonatal intensive careand family-centered care in the neonatal intensive care
unit: origins, advances, impact. Semin Perinatol, 35, 20-unit: origins, advances, impact. Semin Perinatol, 35, 20-
28.28.
 Howland, L.C., Pickler, R.H., et al. (2011). ExploringHowland, L.C., Pickler, R.H., et al. (2011). Exploring
biobehavioral outcomes in mothers of preterm infants.biobehavioral outcomes in mothers of preterm infants.
Am J Matern Child Nurs, 36, 91-97Am J Matern Child Nurs, 36, 91-97
 Lawhon, g. (1997). Proving developmentally supportiveLawhon, g. (1997). Proving developmentally supportive
care in the newborn intensive care unit: An evolvingcare in the newborn intensive care unit: An evolving
challenge. J Perinat Neonat Nurs, 10 (4), 48-61.challenge. J Perinat Neonat Nurs, 10 (4), 48-61.

53. Selected ResourcesSelected Resources
 Lefkowitz, D.S., Baxt, C. & Evans, J.R. (2010). PrevalenceLefkowitz, D.S., Baxt, C. & Evans, J.R. (2010). Prevalence
and correlates of posttraumatic stress and postpartumand correlates of posttraumatic stress and postpartum
depression in parents of infants in the Neonatal Intensivedepression in parents of infants in the Neonatal Intensive
Care Unit (NICU). J Clin Psychol Med Settings, 17, 230-Care Unit (NICU). J Clin Psychol Med Settings, 17, 230-
237.237.
 Ludington-hoe, S., Morgan, K. & Abouelfettoh, A. (2008). ALudington-hoe, S., Morgan, K. & Abouelfettoh, A. (2008). A
clinical guideline for implementation of kangaroo care withclinical guideline for implementation of kangaroo care with
premature infants of 30 or more weeks post-menstrual age.premature infants of 30 or more weeks post-menstrual age.
Adv Neonat Care, 8(Supplement),S3-S23.Adv Neonat Care, 8(Supplement),S3-S23.
 Melnyk, B.M., et al. (2006). Reducing premature infants'Melnyk, B.M., et al. (2006). Reducing premature infants'
length of stay and improving parents' mental healthlength of stay and improving parents' mental health
outcomes with the Creating Opportunities for Parentoutcomes with the Creating Opportunities for Parent
Empowerment (COPE) neonatal intensive care unitEmpowerment (COPE) neonatal intensive care unit
program: a randomized, controlled trial. Pediatrics, 118,program: a randomized, controlled trial. Pediatrics, 118,
e1414-e1427.e1414-e1427.

54. Selected ResourcesSelected Resources
 Moore, K.A., et al. (2003). Implementing potentiallyMoore, K.A., et al. (2003). Implementing potentially
better practices for improving family-centered care inbetter practices for improving family-centered care in
neonatal intensive care units: successes and challenges.neonatal intensive care units: successes and challenges.
Pediatrics,Pediatrics, 111(4 Pt 2), e450-460.111(4 Pt 2), e450-460.
 Shaw, R.J., et al. (2009). The relationship between acuteShaw, R.J., et al. (2009). The relationship between acute
stress disorder and posttraumatic stress disorder in thestress disorder and posttraumatic stress disorder in the
neonatal intensive care unit. Psychosomatics, 50, 131-neonatal intensive care unit. Psychosomatics, 50, 131-
137.137.
 Sweeney, M.M. (1997). The value of a family-centeredSweeney, M.M. (1997). The value of a family-centered
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