The Prevalence of PTSD of Mothers and Fathers of High-Risk Infants Admitted to NICU: A Systematic Review

Abstract

Admission of a preterm or sick full-term infant to the neonatal intensive care unit (NICU) is a stressful experience for parents. Indeed, the ‘NICU experience’ may constitute a traumatic event for parents, distinct from other birth-related trauma, leading to significant and ongoing posttraumatic stress disorder (PTSD) symptoms. However, the rates at which this outcome occurs are not well understood. This review aimed to identify the prevalence of PTSD in mothers and fathers of high-risk infants admitted to the NICU, specifically focusing on the NICU experience as the index trauma. The PRISMA-P: Preferred Reporting Items for Systematic Review and Meta-Analysis Protocols were used to conduct this review. We searched PsycINFO, PubMed, Scopus, EMBASE, Web of Science, ProQuest Dissertations and Theses databases, and reference lists of included articles (1980–2021). Two independent reviewers screened titles and abstracts and conducted the full-text screening assessment. Of the 707 records identified, seven studies met the inclusion criteria. In this systematic review, PTSD symptomatology was assessed by self-report measures rather than a clinical interview. We identified significant variations in the methodologies and quality between studies, with a wide variation of reported prevalence rates of PTSD of 4.5–30% in mothers and 0–33% in fathers. Overall, the findings indicate that up to one-third of parents experience PTSD symptomatology related to the NICU experience. These results emphasize the importance of universal routine antenatal and postnatal screening for symptoms of PTSD to identify parents at risk of distress during the NICU experience and after discharge.

Trial registration: The study protocol was registered with Prospero registration number CRD42020154548 on 28 April 2020.

Appendices

Appendix 1: Search Terms

(Information Sources PsycINFO, 1980 to November to 26 November 2021)
Search number	Query	Results
4	((("Stress Disorders, Post-Traumatic"[Mesh] OR "PTSD"[tiab] OR "post-traumatic stress disorders"[tiab] OR "post-traumatic stress disorder"[tiab] OR "posttraumatic stress disorders"[tiab] OR "posttraumatic stress disorder"[tiab] OR PTSS[tiab] OR "post-traumatic stress symptomatology"[tiab])) AND ((('Intensive Care'[tiab] OR 'neonatal intensive care’[tiab] OR 'Intensive Care Units[tiab] OR 'nicu'[tiab])) AND (('Intensive Care'[tiab] OR 'neonatal intensive care’[tiab] OR 'Intensive Care Units[tiab]OR 'nicu'[tiab])))) AND (('infant'[tiab] OR ‘newborn’[tiab] OR ‘neonate’[tiab] OR ‘prematurity’[tiab] OR ‘low birth weight’[tiab] OR ‘Hospitalised infant’[tiab]))	67
3	('infant'[tiab] OR ‘newborn’[tiab] OR ‘neonate’[tiab]OR ‘prematurity’[tiab] OR ‘low birth weight’[tiab] OR ‘Hospitalised infant’[tiab])	406,709
2	(('Intensive Care'[tiab] OR 'neonatal intensive care’[tiab] OR 'Intensive Care Units[tiab]OR 'nicu'[tiab])) AND (('Intensive Care'[tiab] OR 'neonatal intensive care’[tiab] OR 'Intensive Care Units[tiab]OR 'nicu'[tiab]))	171,848
1	("Stress Disorders, Post-Traumatic"[Mesh] OR "PTSD"[tiab] OR "post-traumatic stress disorders"[tiab] OR "post-traumatic stress disorder"[tiab] OR "posttraumatic stress disorders"[tiab] OR "posttraumatic stress disorder"[tiab] OR PTSS[tiab] OR "post-traumatic stress symptomatology"[tiab])	51,250

Appendix 2: Summary of Characteristics of Studies

First Author/Year/Country/Design	Sample (n) size	Parents age (mean)	Gestational age weeks (mean)	Infant’s weight g (mean)	Outcome measures	Clinical cut-off	PTSD event specified	Timepoints (postpartum)	Prevalence of probable PTSD (n, %)	Findings
Barr, 2012, Australia; Prospective cohort study	Couples (n = 67)	Fathers 33.5 Mothers 31.0	> 34	NR	PCL-S DSM-IV (Self-report)	≥ 44	NICU Experience re-experiencing (“Repeated, disturbing memories, thoughts, or images of your NICU experience?”); avoidance (“Avoid thinking about or talking about your NICU experience or avoid having feelings related to it?”); and hyperarousal (“Being ‘super alert’ or watchful on guard?”)	13 months	Nil (0) Fathers 6 (4.5%) Mothers	4.5% of mothers and no fathers met clinical cut-off for PTSD. Mothers who met the clinical cut-off for PTSD had a previous history of ASD. There was a relationship between PTSD and chronic guilt with guilt-proneness and fear of death as a predictor of psychological distress
Galpin, 2013, United Kingdom; Cross-sectional Correlational study	Fathers (n = 30) Mothers (n = 53)	Fathers 31 Mothers 31 (Median)	Range 30–36	Range 1500–3500	IES-R DSM-IV (Self-report)	33	The experience of having a premature baby hospitalized on the neonatal unit	4–8 weeks post-discharge	1 (3%) Fathers 10 (19%) Mothers	19% of mothers and 3% of fathers met the clinical cut-off for probable PTSD. This study demonstrated positive correlations between PTSD and Post traumatic growth
Lefkowitz, 2010, United States of America; Prospective study	Fathers (n = 25) Mothers (n = 60)	Fathers 33 Mothers 29	Range < 30 and ≥ 30	NR	PCL DSM-IV (Self-report)	One or more re-experiencing symptoms, three or more avoidance symptoms, and two or more arousal symptoms over the past month	Their infant's admission to the NICU	T2— ≥ 30 days post-admission (Median days 33)	2 (8%) Fathers 9 (15%) Mothers	15% of mothers and 8% of preterm infants' fathers met the clinical cut-off for PTSD. Positive correlations of PTSD included a family history of depression, anxiety, serious mental illness, and ASD
Lotterman, 2019, United States of America; Longitudinal study	Mothers (n = 76)	32.45	33.53	NR	PCL DSM-IV (Self-report)	38	During hospitalization	T2—6 months	15.8% Mothers	At 6 months, 15.8% of mothers of preterm infants met the clinical cut-off for symptoms of PTSD. There were no differences in symptoms at baseline and again at 6 months
Schecter, 2020, United States of America; Longitudinal prospective study	Mothers Fathers (n = 80)	NR	29% Extremely Preterm (< 28) 33% Very Preterm (28 to < 32) 38% Moderate to Late Preterm (33 to 37 weeks) 9% Full-term (> 37 weeks)	NR	PCL-C DSM-IV (Self-report)	> 30	First day in the NICU and first week in the NICU	< 1 year and > 1 year	9% Fathers 17% Mothers	17% of mothers and 9% of fathers met the clinical cut-off for symptoms of PTSD at 12 months follow-up. There were no statistical differences in PTSD symptoms across gestational age or in mothers or fathers
Shaw, 2009, United States of America; Prospective study	Mothers Fathers (n = 18)	Fathers 37 Mothers 33.96	30.89	1664.39	DTS DSM-IV (Self-report)	38 and 39	Their reactions to having an infant hospitalized in the NICU	T2—4 months	2 (33%) Fathers 1 (9%) Mothers	33% of fathers and 9% of mothers met the clinical cut-off for symptoms of PTSD at 4 months. Significant correlations were found between ASD and PTSD
Shaw, 2013, United States of America; Longitudinal study	Mothers (n = 50)	Mothers 32.7	31.9	1757	DTS DSM-IV (Self-report)	≥ 40	During or after having an infant in the NICU	T2—1 month after discharge from hospital	15 (30%) Mothers	30% of mothers of preterm infants met the clinical cut-off for probable PTSD. Correlations of PTSD include ASD, dysfunctional coping, and years of education

1. The prevalence of PTSD of mothers and fathers of high-risk infants admitted to NICU: a systematic review. Clinical Child and Family Psychology Review.
2. Lisa McKeown Queensland Health Lisa.mckeown@health.qld.gov.au.
3. NR not reported, n number, g grams, % percentage. Measures: DTS Davidson Trauma Scale for DSM-IV (Davidson et al., 1997), IESR The Impact of Event Scale: Revised (Weiss & Marmar, 1997), PCL The PTSD Checklist (Weathers et al., 1993), PCL-C PTSD Checklist for DSM-IV-Civilian (Weathers et al., 1993), PCL-S PTSD Checklist for DSM-IV (Weathers et al., 1993).

Appendix 3: PRISMA 2020 Checklist

Section and topic	Item #	Checklist item	Location where item is reported
TITLE
Title	1	Identify the report as a systematic review	1
ABSTRACT
Abstract	2	See the PRISMA 2020 for Abstracts checklist	1
INTRODUCTION
Rationale	3	Describe the rationale for the review in the context of existing knowledge	4
Objectives	4	Provide an explicit statement of the objective(s) or question(s) the review addresses	5
METHODS
Eligibility criteria	5	Specify the inclusion and exclusion criteria for the review and how studies were grouped for the syntheses	5 and 7
Information sources	6	Specify all databases, registers, websites, organizations, reference lists, and other sources searched or consulted to identify studies. Specify the date when each source was last searched or consulted	5
Search strategy	7	Present the full search strategies for all databases, registers and websites, including any filters and limits used	Appendix 1
Selection process	8	Specify the methods used to decide whether a study met the inclusion criteria of the review, including how many reviewers screened each record and each report retrieved, whether they worked independently, and if applicable, details of automation tools used in the process	6
Data collection process	9	Specify the methods used to collect data from reports, including how many reviewers collected data from each report, whether they worked independently, any processes for obtaining or confirming data from study investigators, and if applicable, details of automation tools used in the process	6–7
Data items	10a	List and define all outcomes for which data were sought. Specify whether all results that were compatible with each outcome domain in each study were sought (e.g., for all measures, time points, analyses), and if not, the methods used to decide which results to collect	6–7
	10b	List and define all other variables for which data were sought (e.g., participant and intervention characteristics, funding sources). Describe any assumptions made about any missing or unclear information	6–7
Study risk of bias assessment	11	Specify the methods used to assess risk of bias in the included studies, including details of the tool(s) used, how many reviewers assessed each study and whether they worked independently, and if applicable, details of automation tools used in the process	7
Effect measures	12	Specify for each outcome the effect measure(s) (e.g., risk ratio, mean difference) used in the synthesis or presentation of results	6–7
Synthesis methods	13a	Describe the processes used to decide which studies were eligible for each synthesis (e.g., tabulating the study intervention characteristics and comparing against the planned groups for each synthesis (item #5))	6–7
	13b	Describe any methods required to prepare the data for presentation or synthesis, such as handling of missing summary statistics, or data conversions	6–7
	13c	Describe any methods used to tabulate or visually display results of individual studies and syntheses	6–7
	13d	Describe any methods used to synthesize results and provide a rationale for the choice(s). If meta-analysis was performed, describe the model(s), method(s) to identify the presence and extent of statistical heterogeneity, and software package(s) used	N/A
	13e	Describe any methods used to explore possible causes of heterogeneity among study results (e.g., subgroup analysis, meta-regression)	N/A
	13f	Describe any sensitivity analyses conducted to assess robustness of the synthesized results	N/A
Reporting bias assessment	14	Describe any methods used to assess risk of bias due to missing results in a synthesis (arising from reporting biases)	7
Certainty assessment	15	Describe any methods used to assess certainty (or confidence) in the body of evidence for an outcome	N/A
RESULTS
Study selection	16a	Describe the results of the search and selection process, from the number of records identified in the search to the number of studies included in the review, ideally using a flow diagram	7 and Fig. 1
	16b	Cite studies that might appear to meet the inclusion criteria, but which were excluded, and explain why they were excluded	7
Study characteristics	17	Cite each included study and present its characteristics	Table 1
Risk of bias in studies	18	Present assessments of risk of bias for each included study	7
Results of individual studies	19	For all outcomes, present, for each study: (a) summary statistics for each group (where appropriate) and (b) an effect estimate and its precision (e.g., confidence/credible interval), ideally using structured tables or plots	N/A
Results of syntheses	20a	For each synthesis, briefly summarize the characteristics and risk of bias among contributing studies
	20b	Present results of all statistical syntheses conducted. If meta-analysis was done, present for each the summary estimate and its precision (e.g., confidence/credible interval) and measures of statistical heterogeneity. If comparing groups, describe the direction of the effect	N/A
	20c	Present results of all investigations of possible causes of heterogeneity among study results	8
	20d	Present results of all sensitivity analyses conducted to assess the robustness of the synthesized results	N/A
Reporting biases	21	Present assessments of risk of bias due to missing results (arising from reporting biases) for each synthesis assessed	Figure 2
Certainty of evidence	22	Present assessments of certainty (or confidence) in the body of evidence for each outcome assessed	N/A
DISCUSSION
Discussion	23a	Provide a general interpretation of the results in the context of other evidence	9
	23b	Discuss any limitations of the evidence included in the review	10
	23c	Discuss any limitations of the review processes used	10
	23d	Discuss implications of the results for practice, policy, and future research	9–10
OTHER INFORMATION
Registration and protocol	24a	Provide registration information for the review, including register name and registration number, or state that the review was not registered	1, 5
	24b	Indicate where the review protocol can be accessed, or state that a protocol was not prepared	5
	24c	Describe and explain any amendments to information provided at registration or in the protocol	5
Support	25	Describe sources of financial or non-financial support for the review, and the role of the funders or sponsors in the review	10
Competing interests	26	Declare any competing interests of review authors	10
Availability of data, code and other materials	27	Report which of the following are publicly available and where they can be found: template data collection forms; data extracted from included studies; data used for all analyses; analytic code; any other materials used in the review	10

1. From Page et al. (2021)
2. For more information, visit: http://www.prisma-statement.org/