Association of Neonatal Pain-Related Stress and Parent Interaction With Internalizing Behaviors Across 1.5, 3.0, 4.5, and 8.0 Years in Children Born Very Preterm

Abstract

ImportanceInternalizing (anxiety and/or depressive) behaviors are prevalent in children born very preterm (24-32 weeks’ gestation). Procedural pain-related stress in the neonatal intensive care unit (NICU) is associated with long-term internalizing problems in this population; however, whether positive parenting during toddlerhood attenuates development of internalizing behaviors across childhood is unknown.ObjectiveTo investigate whether neonatal pain-related stress is associated with trajectories of internalizing behaviors across 1.5, 3.0, 4.5, and 8.0 years, and whether supportive parenting behaviors and lower parenting stress at 1.5 and 3.0 years attenuate this association.Design, Setting, and ParticipantsIn this prospective longitudinal cohort study, preterm neonates (born at 24-32 weeks’ gestation) were recruited from August 16, 2006, to September 9, 2013, with follow-up visits at ages 1.5, 3.0, 4.5, and 8.0 years. The study was conducted at BC Women’s Hospital, Vancouver, Canada, with recruitment from a level III neonatal intensive care unit and sequential developmental assessments performed in a Neonatal Follow-up Program. Data analysis was performed from August to December 2021.Main Outcomes and MeasuresParental report of child internalizing behaviors on the Child Behavior Checklist at 1.5, 3.0, 4.5, and 8.0 years.ResultsA total of 234 neonates were recruited, and 186 children (101 boys [54%]) were included in the current study across ages 1.5 (159 children), 3.0 (169 children), 4.5 (162 children), and 8.0 (153 children) years. After accounting for clinical factors associated with prematurity, greater neonatal pain-related stress was associated with more internalizing behaviors across ages (B = 4.95; 95% CI, 0.76 to 9.14). Higher parenting stress at age 1.5 years (B = 0.17; 95% CI, 0.11 to 0.23) and a less supportive parent environment (less sensitivity, structure, nonintrusiveness, nonhostility, and higher parenting stress; B = −5.47; 95% CI, −9.44 to −1.51) at 3.0 years were associated with greater internalizing problems across development to age 8.0 years.Conclusions and RelevanceIn this cohort study of children born very preterm, exposure to repetitive neonatal pain-related stress was associated with persistent internalizing behavior problems across toddlerhood to age 8.0 years. Supportive parenting behaviors during early childhood were associated with better long-term behavioral outcomes, whereas elevated parenting stress was associated with more child anxiety and/or depressive behaviors in this population. These findings reinforce the need to prevent pain in preterm neonates and inform future development of targeted parent-led behavioral interventions.

Fostering Resilience to Very Preterm Birth Through the Caregiving Environment

“…However, the communication abilities, atypical behavior, and regulation systems of very preterm-born children can affect the quality of these interactions. McLean et al found at 3 years, but not 1.5 years, children exhibited lower parent-reported internalizing behaviors related to supportive parenting interactions, even after accounting for child behavior in parent-child interactions in a teaching task.…”

“…6 Several factors contribute to the traumatic stress experienced by parents of preterm infants in the NICU; however, the most stressful aspects of the NICU experience reported by parents were the physical separation from their infant and their feelings of a loss of control and helplessness in their inability to shield their infant from the numerous painful procedures. 7 The findings of McLean et al 4 show that reduced parental stress and sensitive supportive parenting may temper the association between the effects of neonatal pain-related stressors in the NICU and internalizing behaviors throughout early and middle childhood. Therefore, interventions that help reduce stress should be part of postnatal care for mothers of very preterm children.…”

“…Preterm birth is increasing worldwide, but most studies on very preterm infants have involved White Western populations. The cohort in the study by McLean et al was predominantly a more mature, well-educated sample of parents (60% White and 84% with partial or complete university degree or postgraduate degree) with universal access to health care. Culture, poverty, and maternal mental well-being strongly influence parenting; therefore, more research is needed to determine who and under what social and psychological circumstances parents of children born very preterm require parenting support.…”

“…Emerging evidence suggests that maternal sensitivity is a long-term resilience factor in the development of internalizing problems in early adolescence in very preterm children. 3 McLean et al 4 provide further evidence that supportive parenting of infants born very preterm is associated with more optimal emotional outcomes across early and middle childhood. They report the findings from a prospective, longitudinal cohort study of 186 very preterm neonates (24-32 weeks' gestational age) recruited from the level III neonatal intensive care unit (NICU) at BC Women's Hospital in Vancouver, Canada.…”

Association of Neonatal Midazolam Exposure With Hippocampal Growth and Working Memory Performance in Children Born Preterm

“…Preterm born children (n = 234) were originally enrolled in a larger longitudinal study that examined the long-term effects of neonatal pain-related stress on the neurodevelopment of children born very preterm (24–32 weeks' gestation), who were admitted to the Level III neonatal intensive care unit (NICU) at British Columbia's Women's Hospital from 2006 to 2013. 19 Data from a subset of the neonatal cohort were reported previously. 20 A total of 142 preterm born children returned for MRI scans and neuropsychological follow-up testing at the University of British Columbia (2015–2022).…”