Neonatal, Paediatric

and Child Health Nursing

Official Journal of Australian College of Children & Young People’s Nurses,
Australian College of Neonatal Nurses, Neonatal Nurses College Aotearoa and
Nurses for Children and Young People of Aotearoa

Vo lu me 15 Nu mb er 3 – Novemb er 2 0 1 2

IN THIS ISSUE . . .

Guest editorial
Happy mum! Happy child! Happy family!
Eimear Muir-Cochrane

Understanding child mental health consultation

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Lucie Zwimpfer and Dawn Elder

Surviving postnatal depression:

the male perspective
Elaine Bennett and Dawson Cooke

Perinatal mental health, antidepressants and

neonatal outcomes: findings from the Longitudinal
Study of Australian Children
Andrew J Lewis, Megan Galbally and Catherine M Bailey

Print Post Publication

No. PP 602669/00702
ISSN 1441-6638
 Editorial Board Neonatal, Paediatric
Editor
Professor Linda Johnston RN PhD
Associate Editor ACCYPN
and Child Health Nursing
Alison Hutton RN, PhD
Associate Editor ACNN Volume 15 Number 3 – November 2012
Victoria Kain
Associate Editor NNCA
Annette Dickinson PhD
Associate Editor NCYPA Official journal of the
Ruth Crawford
Section Editors Australian College
Cochrane Nursing Care Field
Carmel Collins RN, RM, PhD
of Children & Young
Trudi Mannix RN, RM, EdD People’s Nurses
Statistics Advisor www.accypn.org.au
Dr Sandra Pereira, PhD
Journal Management Board
Melissah Burnett
Becky Conway
Jennifer Fraser
Australian College of
Gill Lewis Neonatal Nurses
Trudi Mannix (Chair)
Pam Nicol (Secretary)
www.acnn.org.au
Jane Pope
Jenny Richards D R $RWHDUR
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Neonatal Nurses College

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All correspondence to

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and Child Health Nursing Aotearoa  &ROOHJH

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School of Nursing and Midwifery D
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Medical Biology Centre

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The journal will endeavour to reflect this diversity by its content.
Neonatal, paediatric and child health nursing have many different
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In addition to clinically oriented material, including research, the journal
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Volume 15 Number 3 – November 2012 2


Guest editorial
Happy mum! Happy child! Happy family!
Professor Eimear Muir-Cochrane
Chair of Nursing (Mental Health), School of Nursing and Midwifery, Flinders University, SA
Email eimear.muircochrane@flinders.edu.au www.flinders.edu.au
Depressive disorders account for close to 41.9% of the
disability from neuropsychiatric disorders among women
compared to 29.3% among men. Gender differences occur
particularly in the rates of common mental disorders –
depression, anxiety and somatic complaints. These disorders,
in which women predominate, affect approximately one
in three people in the community and constitute a serious
public health problem. Unipolar depression, predicted to be
the second leading cause of global disability burden by 2020,
is twice as common in women. Depression is not only the
most common women’s mental health problem but may be
more persistent in women than men. Awareness, education
and training in mental health for all health professionals can
encourage specialist clinicians to work collaboratively rather
than in isolation, providing comprehensive care to women
and their families, with a clearer understanding of the role
and function of mental health services and clinicians within
them.
Within this context, it is my great pleasure to pen the editorial
for this special edition on mental health! Previously, it was
believed that pregnancy itself was a protective factor against
poor mental health, but this has now been discredited and
clinical guidelines for perinatal care have been developed in
a number of countries. In Australia, for example, in 2011 the
Department of Health and Ageing published Clinical Practice
Guidelines for Depression and Related Disorders in the Perinatal
Period for clinicians providing care to pregnant women.
However, the provision of comprehensive psychosocial
assessment has raised debate due to the need for increased
resources in the education and training of clinicians.
Nevertheless, mental health care in the perinatal period is
receiving the attention such care deserves and has resulted
in the establishment of nurse practitioner (maternal mental
health) roles within maternal care settings.
The articles in this special edition provide a bird’s eye view of
Referencing for Neonatal, Paediatric and Child Health Nursing
Guidelines for Authors appear on our website: <http://www.npchn.com>. One important point to note is that NPCHN uses the
Vancouver system. To see how to do it, open: http://www.ncbi.nlm.nih.gov/books/bv.fcgi?rid=citmed.TOC&depth=2
Please note that these sites say that either numbers in brackets or superscript can be used. NPCHN USES SUPERSCRIPT ONLY.
Papers will not be accepted unless the Vancouver system is used correctly.
Volume 15 Number 3 – November 2012
N EON ATAL, PAED I ATRI C AN D C H I LD H EALT H NU R S I NG
a range of research pertinent to maternal mental health care.
The paper by O’Kane et al. is concerned with the need for
networking and collaboration between primary care and
specialist mental health clinicians. Consultation liaison is
discussed as a model to effectively care for children and young
people with mental health problems. Zwimpfer and Elder
present a psychoanalytic approach to the management of
psychic pain in infants in paediatric intensive care units. Vocal
soothing is suggested as a potentially effective, non-invasive
technique. The use of this form of therapeutic communication
via infant-directed speech can be utilised by both clinical staff
and parents as a pain reduction technique. Bennett and Cooke
provide a unique perspective on the experiences of male
partners of women with postnatal depression. This grounded
theory study provides practical strategies for men by men to
increase social contact and seek help from friends as well as
communicate openly with partners. The paper by Lewis et al.
presents significant findings about the Longitudinal Study
of Australian Children (LSAC) within the context of the 12%
of mothers experiencing maternal depression. This study
adds to the burgeoning evidence that antenatal depression
is associated with a complex set of associated risks for the
unborn child. Fascinating and insightful stuff!
I trust these papers are pertinent to your ongoing professional
development and raise awareness about mental health issues
for women and their families
References
New Perinatal Health Guides for Clinicians (2012). Available at http://
www.health.gov.au/internet/ministers/publishing.nsf/Content/
mr-yr12-mb-mb033.htm?OpenDocument&yr=2012&mth=04
Accessed 25 September 2012.
WHO Gender and Women’s Health. Available at http://www.who.
int/mental_health/prevention/genderwomen/en/ Accessed 30
September 2012.
1
N E ON ATA L , PA ED IAT R IC A ND CH ILD H EALTH NU RSING

Understanding child mental health consultation from the

perspective of primary health care professionals
Deb O’Kane *
Flinders University, School of Nursing and Midwifery, GPO Box 2100, Adelaide, SA 5001, Australia
Email debra.okane@flinders.edu.au

Pat Barkway
Flinders University, SA

Eimear Muir-Cochrane
Flinders University, SA

* corresponding author

Abstract
Aim To explore the understanding of mental health consultation and its utilisation from the perspective of primary care workers
working with children and young people who experience mental health issues.
Background Recognition of mental health consultation is respected and advocated as a way forward to support those
professionals who may not necessarily have the training or understanding of child mental health issues, yet come across them
frequently as part of their daily practice. Little is known, however, about how primary care professionals understand or utilise
mental health consultation.
Design A qualitative research design informed by phenomenology.
Methods: School nurses (n=6) were purposively sampled. Semi-structured interviews were undertaken, facilitated by the use of
open-ended questions. All interviews were audio-recorded and transcribed, followed by vigorous thematic analysis.
Results Five overarching themes were identified from the data. These included: communication; crisis identification; hindrances;
resources; and expectations. Each main theme consisted of several sub-themes relating to issues of professional identity; blurring
of professional boundaries; constraints such as time management and workload; and the participant’s own needs, including self-
confidence and educational needs.
Conclusions and implications for clinical practice When utilised, mental health consultation proved effective in supporting the
participants to address the mental health needs of children and young people; however, there are several factors such as lack
of resources, differing perceptions of mental health consultation and personal challenges that prevent full engagement. This
research contributes to existing knowledge by advocating that all individuals participating in mental health consultation should
be encouraged to embrace the practice and understand what it actually means within the context of their own discipline.
Keywords Child, consultation, mental health, phenomenology, primary care, support.

What is known about this topic What this paper adds

• T he importance of mental health consultation has
become widely accepted in Australia, particularly
within adult emergency departments. One could argue,
however, that this is not the case in children’s services,
with mental health consultation still used on an ad
hoc basis by primary care professionals. Factors that
influence this may be that primary care workers do
not understand what mental health consultation is
or how it can be utilised in their work. Furthermore,
the literature to date on mental health consultation
appears to devote attention to the process and theory
of consultation rather than describing the dynamics and
perceptions from those using it. Thus, it is believed that
a lack of literature on mental health consultation for
primary care workers working with children and young
people indicated the current understanding in the area
is incomplete.
• T he findings have highlighted that, despite the general
agreement between professionals working with children
experiencing mental health issues that mental health
consultation is needed, it appears difficult to put into
practice in a consistent manner due to the different
perceptions people have of it and how it can be used
in the first instance. Though it is not within the scope of
this research to stipulate a model of consultation, it has
highlighted that individual, organisational and external
system-level factors all contribute to the success of
mental health consultation.

2 Volume 15 Number 3 – November 2012


Declarations
Conflict of interest None
Funding None
Ethics Flinders University Social and Behavioural Ethics
Committee
Contributions Concept of study DO, data collection DO,
written by DO and edited by PB and EMC.
Background
The last decade has seen an increasing focus on child mental
health worldwide with Australia clearly calling for those
working with children and young people to take more
notice of a child or young person’s mental health needs1. In
Australia, as internationally, figures reveal 14–20% of children
and young people experience mental health problems that in
turn creates more demand for professionals to act in response
to these needs2. Strategies such as prevention, promotion
and early identification provide a perfect vehicle to address
the issue and inevitably lead to better health outcomes later
on in life3-7. This, however, demands far greater coordination
and cooperation within an interagency framework1 than seen
previously and is often dependent on the level of training,
support and consultation a professional receives if it is to be
effective8.
The paucity of resources, fragmentation of services and lack
of available professionals specifically trained in the area of
child and adolescent mental health cannot meet the high
demand of services required, thus waiting lists are often
the norm of community services9. One way to address these
issues and support the needs of children and young people
is the commitment to multi-agency working relationships,
both from the specialist Child and Adolescent Mental
Health Services (CAMHS) professionals and other agencies,
particularly in primary health care. One example of this is to
promote the use of mental health consultation. Mental health
consultation involves those who have specialist knowledge
and skills in child mental health to offer regular consultation
to those primary health workers who are struggling with the
demands of the child and family and often feel ill equipped
to manage the issues1,9,10.
The concept of mental health consultation is not new.
Since Gerard Caplan’s seminal work from the 1960s11 it
has gained considerable popularity, as has the nature and
definition of its adaptation to suit certain contexts and the
different professional groups using it. Despite various guises,
recognition of the influence of mental health consultation and
importance in service delivery is respected and advocated as
a way forward to support the increasing mental health issues
being experienced in today’s society12. Offering a logical
approach mental health consultation helps to support those
professionals who may not necessarily have the training or
understanding of mental health issues yet come across them
frequently as part of their daily practice. Such professionals
including paediatric nurses, child and family health workers,
Volume 15 Number 3 – November 2012
N EON ATAL, PAED I ATRI C AN D C H I LD H EALT H NU R S I NG
social workers, and teachers who are in key positions to
recognise problems at their onset and implement strategies
to alleviate them at an early stage with support from specialist
child and adolescent professionals via the process of mental
health consultation.
Caplan’s original model of mental health consultation was
used broadly as a working model for the purpose of this
research, despite some literature stating a "fresh look" is
required13. However, a literature search provided very little
in terms of evidence or description of evolving models in the
area of CAMHS, whereas Caplan’s model was clearly visible in
the literature over decades as providing a strong influence
shaping consultation practice11,14-17.
Caplan’s model18 is based on four different types of
consultation, namely: Client Centered Case; Consultee
Centered Case Consultation; Program Centered and
Administrative Consultation. With policy driving professionals
to incorporate health prevention, education and early
intervention as strategies to meet the unmet needs of
young people and their families experiencing mental health
problems, client-centred case consultation was utilised to
define mental health consultation for the purpose of the
research.
According to Caplan17, client-centred mental health
consultation involves two or more participants with one of the
participants (consultant) offering a sound knowledge base to
empower and support the other participant(s) (consultee)
to work with a client they have responsibility for, in this case
a child, young person or family. Shared problem solving,
an equal partnership and the opportunity to remediate
and/or prevent a mental health problem become the core
components to the process, though in the last few years
there has been dispute over whether Caplan’s model is in fact
advocating for the consultant (expert) to work with the case
through the consultee (non-expert) rather than supporting
and enabling the consultee to work within their own context
of practice19.
The consultee profits from the relationship in such a way that
future problems may be responded to more effectively and
handled with more confidence and skill. The consultant or
the service they represent profits from the relationship via
the opportunity to implement early interventions, thereby
reducing referrals in the long term12. This inadvertently also
releases CAMHS staff to work with those clients deemed to
have mental health problems more serious in nature and can
in fact speed up access to specialist services if necessary12.
Mental health consultation liaison services in emergency
departments has evolved with consultation-liaison nursing
roles, specifically developed to support other non-mental
health professionals in managing mental health problems
in their department20-22. Yet, mental health consultation in
CAMHS is not taken up as much as one would hope or
presume23. One possible reason for this could be that though
the importance of consultation may be widely accepted, the
3
N E ON ATA L , PA ED IAT R IC A ND CH ILD H EALTH NU RSING
lack of a clear definition, or a framework for implementation,
and poor understanding of factors that may impact on its
development are still little understood in the child adolescent
context. Furthermore, the majority of publications relating
to mental health consultation appear to concentrate on the
process and theory aspect of it rather than describing the
practical elements such as the dynamics and perceptions of
it from a professional’s perspective.
Methodology
Design
The research methodology was informed by interpretive
phenomenology. Exploring the lived experience of a lived
or social phenomenon and revealing the meaning behind it
suited the aims of the research to explore the understanding
of the phenomenon – mental health consultation and its
utilisation from the perspective of primary care workers24-25.
Participants reflected on the mental health consultation they
received in their professional practice in order to explore how
it was interpreted, defined and described.
Semi-structured interviews, which included open-ended
questions were conducted with six professionals who
managed a significant number of children or young people
with mental health issues in their daily practice, yet had
little or no training in mental health. The participants were
purposively sampled from nurses working within a school
environment, based on international literature recommending
schools as being ideally placed to recognise and support
mental health issues26-28.
Data collection and analysis
Interviews varied from 45 to 60 minutes They were audio-
recorded, transcribed and analysed to discover the meaning
of mental health consultation for those nurses working
within a school environment.
Data collated provided a rich and detailed account of how
the participants understood mental health consultation in
the context of their own practice. Despite the complexity
of the data, following vigorous thematic analysis using
Burnard’s29 stage-by-stage process, various connections or
clusters emerged. These clusters were condensed and refined
into five major themes with underlying sub-themes. In the
Table 1. Results of thematic analysis – themes and subthemes.
Communication Crisis identification Hindrances
Working relationships/ Risk assessment/ Time constraints and
collaborative practice crisis identification workload of school
nurses
Working towards the Risk taking/clinical CAMHS waiting lists
same goals (goal setting) judgement
Role clarity Containment/ Professional identity
managing a case and role conflict (fear
of role expansion)
Responsibility of the
problem
4 Volume 15 Number 3 – November 2012
process of consolidating the findings and beginning the
process of analysis, links and tenuous connections further
emerged, intertwining some of the sub-themes; therefore,
the themes cannot be fully grasped in isolation but must
be viewed and understood within the context of the whole
phenomena.
Ethical approval was obtained from the University’s Social
and Behavioural Ethics Committee and safety of the data
and other ethical issues such as anonymity/confidentiality,
informed consent, maintenance of dignity and benefit to risk
ratio, were addressed accordingly within the study30-31.
Results
Five overarching themes and several sub-themes were
identified from the data. These included: communication;
crisis identification; hindrances; resources; and expectations
(Table 1).
Theme: Communication (Box 1)
Findings indicated there was a major gap in communication
between the service requiring consultation and the service
offering consultation. The participants wished to ensure
communication was clear and open between the consultee
(themselves) and the consultant. However, they felt that at
times some information was not filtering through to them
and, therefore, inhibited collaborative practice. Feelings of
frustration due to misunderstanding and miscommunication
based on people’s expectations and understanding of the
consultation process were common and resulted in negative
experiences for the participants. Similarly, ignorance and
lack of understanding or respect for each other’s roles, skills
and unique competencies complicated the communication
process further, leaving some participants unwilling
to maintain a working relationship. When a consultative
relationship was established, it was a priority for the
participants to not only set and plan goals but to clarify
each other’s role in planning care. This provided something
tangible that could be used in practice; however, false
expectations of each other and different agendas left some
feeling there was an expectation for them to take on more
work than they were able to.
Resources Expectations
The need Advice, support and encouragement
for practical
solutions
Training/ Expertise/knowledge
education
Offloading baggage/supervision
Increase in confidence

Box 1
“We should be working together, sorting things out as
a team, with both sides having an equal voice but the
reality is that we’re not that good at it.”
"We are all on different sides of the fence. CAMHS, me, the
teachers, the social services. We all have our own agenda
even though we say we want what’s best for the child.
We do, but only if it means we don’t have to do any extra
work. So we nod at each other and look like we have an
agreed plan of action but then go and do what fits in best
with our role. It's lip service ”
“We all hopefully are working towards the same goals.
It’s just difficult if I don’t understand what the other goal
is or what people are talking about. People forget school
nurses don’t have any mental health training and yet
because we’re in the midst of it on a day-to-day basis it's
presumed we know all about it.”
Theme: Crisis identification (Box 2)
Participants described feeling completely out of their depth,
both in knowledge and experience when faced with mental
health issues. A fear of a wrong word or a wrong action
triggering an unwanted behaviour was often cited. Other
feelings of not being able to contain the situation, it getting
"out of control", and feeling "helpless" were common phrases
used, causing distress in both the workplace and home life for
some participants.
Mental health consultation was seen as an avenue to remove
this stress or contain the case (usually identified as young
people exhibiting suicidal or self-harming behaviour) to a
level they felt comfortable with via direct action from the
CAMHS team, yet one participant was genuinely surprised
that CAMHS did not appear as concerned about a specific
case as she was. On the other hand, one participant actively
used mental health consultation, but described the resulting
stress of implementing a technique she was uneasy with, and
the fear of reprisal if it had not been successful, was too great
for her to contemplate doing it again.
Education and, in particular, risk assessment tools were
identified as useful in terms of knowing when to refer further
but most made it evident that the pressure they endured on
a daily basis was well beyond their role and didn’t want this
complicated further by having to do risk management. Risk
management, therefore, was perceived as something that
CAMHS should undertake.
Volume 15 Number 3 – November 2012
N EON ATAL, PAED I ATRI C AN D C H I LD H EALT H NU R S I NG
Box 2
“It’s hard sometimes. You know like when I’m desperately
concerned about somebody but I never know if that’s me
or whether I should contact somebody. Sometimes what
I think is a real, real biggy, you know like, somebody
saying they’re going to kill themselves, CAMHS don’t
seem that concerned and I wonder why.”
“It’s very scary sometimes to know what to do or what
to say. I had a young girl last year. She kept wanting to
see me but then would never turn up at the agreed time.
She used to turn up without fail just as I’d be leaving
and, well, well, I’d end up dropping everything else to
see her. You know, I was always concerned she would
kill herself. I was discussing it in consultation and got
told that I should stick to boundaries. Something about
therapeutic boundaries. I did and it worked – she turned
up on time the next time but what if she hadn’t? What
then? Don’t think I can go through that again. The
stress.”
“When a family has a crisis, we’re the ones holding it in
the interim cos of the year's waiting list or whatever and
it’s very, very difficult for us to deal with.”
Theme: Hindrances (Box 3)
"Hindrances" refer to identified obstacles to be overcome in
order to access and maintain regular consultation. Evident
in the findings were practical resource issues such as time
constraints (workload), funding, and location, all of which had
a profound influence on the attendance rate of participants.
Participants acknowledged their workload felt too
overwhelming to spend time on something that they didn’t
fully understand and where they were uncertain about
how it would benefit them. There was a clear directive that
unless the consultant had a "quick-fix" that would ultimately
help them out, for example, helping their client to be seen
immediately or not be placed on a waiting list, then mental
health consultation was an unnecessary aspect in their
valuable time.
Of interest was that what first appeared to be a hindrance
to implementing consultation can also be argued by those
who actively engaged in consultation as an advantage. Not
dismissing the fact of time constraints and busy workloads
for participants, the participants who actively engaged in
consultation found the process of consultation enabled them
to manage their time more successfully. One participant
reported that, prior to consultation, incidents where she had
initially spent many hours reflecting on the best course of
action, once given the opportunity to discuss it, she felt more
able to deal with future problems efficiently and effectively
5
N E ON ATA L , PA ED IAT R IC A ND CH ILD H EALTH NU RSING
in a timely manner, freeing her up to participate in other
activities. In a similar vein, two of the participants believed
consultation was an invaluable support mechanism whilst
their client was on the waiting list.
Box 3
“Time is always a problem. We all have really heavy
workloads, are overstretched and they want us to attend
a meeting that may or may not be useful to us. I don’t
think so.”
“What’s the point in going? I went once and came away
with more work to do when all I wanted was to maybe
move the kid further up the waiting list. The only advice
I got was suggestions on how to work more with him;
that’s more of my time.”
“I’ve been doing this job for eight years and it’s not
what I signed up for. I’m a school nurse not a bloody
psychologist.”
Theme: Resources (Box 4)
Most participants expressed a desire to develop a repertoire
of resources they could use in practice. Education to
extend their knowledge, either through formal or informal
training, was perceived a priority. Within this, some spoke
of requiring practical tools they can use in daily practice
rather than in-depth knowledge about specific mental
illness. One significant finding suggested group mental
health consultation as far more advantageous than individual
consultation as it provided the opportunity to listen and learn
from other’s case discussions.
Box 4
“A few more lectures and training sessions would be
great, but sometimes I just go to the meetings cos just
chatting about different things and listening to others
helps”
“I’m just thinking of one most recent one we had
last month. There was a practical teaching about
assessment. If it’s an eating disorder or anything else,
you know, to make sure we’re asking the right questions,
to know what to look for cos obviously we’re not mental
health trained and could miss out things. We did a
checklist of key questions to ask really. Which was really
useful.”
“We have practical problems, we need practical
solutions. Something we can do. When have these kids
and families crying out for help. We need something
we can do with them, not just someone to talk to but
someone who can show us what to do.”
6 Volume 15 Number 3 – November 2012
Theme: Expectations (Box 5)
Expectations of what the participants perceived mental
health consultation to offer were articulated through their
description of hopes and/or beliefs. Some expected to be
given advice including recommendations, suggestions,
guidance and instructions to foster skill development and
self-confidence, whereas others spoke of needing verbal
reassurance that they were "doing OK". Once reassurance
was given emotions such as relief, increased confidence
and a sense of achievement were common features in the
findings. On the other hand, some expected the opportunity
to "offload", meaning that the consultant would be available
to listen to all of the participant’s issues, problems and
dilemmas in the workplace. Descriptions of needing time
for themselves, or having someone to turn to when they
were feeling isolated or overwhelmed, appeared a common
feature. A feeling of immense relief and "lightening the load"
gives the impression of a great weight or burden (often
described as stress) being lifted. Being able to talk in this
manner facilitated the participants to not only cope better
in their practice area but in their personal lives too. Examples
of this include improved sleep patterns and reduced anxiety.
Box 5
“I try my best, but sometimes I haven’t a clue. Having
somebody specialised in mental health is handy, especially
if I’ve come to the end of my limits of what I can do within
a school and I’m looking for more expertise, more for the
family, for the kid."
“Often you feel as if you’re floundering out here on your
own. Having someone who I could just go blah, blah, blah
to would be wonderful.”
“Well it gets it off my chest straight away, it stops me going
home thinking about it. Once I’ve offloaded, I can sleep at
night.”
“I feel swamped at times, and having some "me" time really
helps. I’m not sure if that’s what it's supposed to be for, but
it helps me clear my head.”
Discussion
This qualitative study aimed to investigate how professionals
working directly with children and young people understand
and use mental health consultation offered by CAMHS.
Using general nurses who work within school settings as a
representative population, the results contribute towards
a greater knowledge base of how primary care workers
understand mental health consultation. Of most significance
is that of social and professional identity relating to how
individuals identify themselves within a profession32-33. The
findings identified how the nurse’s sense of professional

identity shapes who they are in the world of child mental
health practice and, in turn, how they felt the need to
protect their established professional identity. In accepting
the norms, values and rules that characterise their role as
a general nurse working within a school environment, any
changes to this role can cause discomfort and uncertainty.
Having to consider and explore issues of mental health
practice can become a threat to this core professional identity
and result in feelings of powerlessness, anger, confusion and
feeling deskilled. As Harmer33 points out, expansion of roles
and lack of clear boundaries between professionals can only
lead to a further sense of losing their professional identity
whereas others perceived the role expansion as a gain34
believing the value and benefit of attending mental health
consultation far outweighed the negative aspects.
Blurring of professional boundaries is a key factor
regarding whether the participants understood mental
health consultation as favourable or unfavourable. Clear
parameters are needed to establish what each person will
contribute to the care of the identified case under discussion
in consultation, thus creating transparent boundaries for
successful joint working as advocated by the Australian Infant,
Child, Adolescent and Family Mental Health Association
(AICAFMHA)1. However, this does not assist those participants
who feel overworked and resentful when asked to become
involved with mental health issues. For instance, the feelings
of being overwhelmed by a predominance of mental health
issues can result in a desire to defend "one’s turf", with a fear
that a blurring of the roles may result in a loss of professional
identity as already discussed.
The findings both identified constraints that were real and
perceived. For instance, it is a real issue that despite having
clear directives of using mental health consultation, few
resources are allocated to assist with the time and workload
this creates. The participants, as with most workers in the
primary care field, are under increasing pressure to take more
onto their workload, so finding time to attend consultation
often loses priority35. Only when national and local services
support primary care professionals with appropriate resources
will mental health consultation in primary health care truly
be effective. In acknowledging this constraint, it also can be
argued that even though participants discussed the issue of
workload pressure, those who actively engaged in mental
health consultation were able to articulate how attending
consultation actively reduced their workload in the longer
term by alleviating the stress of having to manage complex
mental health issues in an isolated manner.
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N EON ATAL, PAED I ATRI C AN D C H I LD H EALT H NU R S I NG
It is interesting to note the participants' understanding of
what constituted mental health consultation. Rather than
focus on the mental health needs of the child or young
person, there was a definite focus on each participant’s
own needs. Colloquial terms such as "offloading" used
by participants within the interviews could be argued to
have many similarities with clinical supervision rather than
mental health consultation. "Offloading" conveys a personal
motive, such as accessing support for personal emotional
wellbeing, though it is difficult to ascertain whether this also
incorporates the practice of self-reflection as a quality tool
to improve practice. Though clinical supervision recognises
that often personal issues can affect work practice and
sometimes cannot be ignored, when the focus becomes more
about the supervisee rather than a practice issue, a strong
recommendation to seek personal counselling is usually
recommended. The fact the consultant would highly likely
be trained in mental health and skilled in counselling may
misguide the consultee to assume consultation was for this
purpose. Salmon and Rapport36 found similar findings in their
research on multi-agency working relationships, reporting
that when some professionals felt unsupported and were
receiving inadequate supervision within their own agencies,
meetings set up for case consultation appeared to turn into
personal supervision. This begs the question of what kind of
support the participants were expecting and how this then
affected their understanding of mental health consultation,
despite consultation, clinical supervision and "offloading"
being three very different concepts. As support comes in
a variety of forms37, part of the process of understanding
mental health consultation is determining what type of
support is required and if consultation is the correct forum to
receive it. Regardless of this, anecdotally it could be argued
that those primary care professionals who attend mental
health consultation are, in fact, providing a better service to
the client by actively engaging in the process (whatever their
understanding) as they themselves feel supported.
Feeling overwhelmed by mental health issues and requests
from the consultant to be actively involved in interventions
could go some way to explain levels of resistance seen in
the findings. A lack of confidence, of not knowing what
appropriate action to take, often instigated feelings of
helplessness and being "out of their depth", whereas, for those
who used consultation, a greater sense of self-confidence
emerged, trusting their ability to perform. This demonstrates
self-awareness and an emerging sense of professional
development through reflective practice. If primary care
workers can be educated that mental health consultation
can have a positive impact on practice, then perhaps the
7
N E ON ATA L , PA ED IAT R IC A ND CH ILD H EALTH NU RSING
negative aspects of it, and the assumption that it is inherently
not worth partaking in, can be challenged. Stakeholders must
also play their part in allowing primary care professionals to
actively engage in mental health consultation by recognising
the gap between the desire to expand the professional role
and the realities of workload and clinical capacity38.
Also related to issues of confidence, emerged the participants'
lack of an appropriate knowledge base from which to work. In
this small study there was a belief confidence increased due
to an increased ability to identify mental health problems via
having undertaken the appropriate training. In 2006, Watson
reported that the biggest component of mental health
consultation for paediatric wards soon became teaching
and education with staff demonstrating a commitment
and awareness of their educational needs39. Likewise, the
participants were clearly able to identify their learning needs
with strong enthusiasm for any future training on offer.
Sharrock et al.20 advocate that education topics offered
should be negotiated and selected from the requests of the
primary care staff and should include both written and critical
reflection scenarios to improve the expertise of the staff.
Current reforms in Australia suggest that mental health
professionals will take on more consultative and educative
roles in addition to their usual clinical care roles4. Although
targeting education makes practical sense, it also raises
concerns that those least motivated for further education
may be those whose skills are in most need of improvement.
Regardless of this, upskilling and supporting the primary
care workforce, such as school nurses, is a logical solution to
addressing the increasing prevalence of mental health issues
in children and young people.
Limitations
Although qualitative research allows the development of
rich description, the use of a small, purposive sample of
participants, all employed in one local area, means the study
is not without limitations. These include external validity
and the generalisability of the study. It is acknowledged the
research is unlikely to be wholly representative of a school
nurse population or other primary care workers and any
inferences made are purely speculative. The focus of this
small-scale study was to identify and explore the experiences,
opinions and perceptions of school nurses in order to develop
rich description, rather than use sampling techniques that
support generalisability of the findings.
Conclusion
This research contributes to existing knowledge about
mental health consultation by advocating that all individuals
8 Volume 15 Number 3 – November 2012
participating in mental health consultation should be
encouraged to embrace the practice and understand what
it actually means within the context of their own discipline.
From this, primary care workers are then able to develop,
maintain or rework their professional working identity to
prepare them for the reality of consultation practice in their
everyday working life. Acknowledging and accepting mental
health consultation is an important practice for primary
care workers in Australia will go some way towards dealing
with the rising prevalence rates of mental health problems
in children and young people1. Therefore, it is imperative
that clear processes and structures are established to
enhance not only mental health consultation but any multi-
agency working relationships. Working across professional
agencies will continue to become an increasing part of those
individuals who work directly and indirectly with mental
health issues. Developing and implementing guidelines will
be one way to support this.
In order to address barriers that may hinder the uptake of
mental health consultation decision-makers in all service
systems should match current rhetoric about implementing
it as a preventative strategy by considering appropriate
and realistic processes about how it can be incorporated
into the existing workforce structure. The provision
of sustainable financial resources such as staff training,
time, interprofessional education, evaluation strategies
and research will go some way towards achieving this.
Organisations can ensure a culture that supports effective
mental health consultation by encouraging all stakeholders
are included in the development and implementation of
future policies, particularly in relation to role responsibilities,
developing values, structures and processes, ensuring a
balanced delivery of care and resources as needed
This research has demonstrated that mental health
consultation is multifaceted, consisting of several elements
that can promote or hinder its success in practice.
Identification of an effective and comprehensive model
could guide flexible, innovative and complete mental health
consultation tailored to meet the needs of primary care
professionals. Thus there is a need to develop, pilot and
evaluate a consistent, systematic model to be able to support
primary care workers and, thereby, children and young
people with mental health issues.
References
1. Australian Infant, Child, Adolescent and Family Mental Health
Association (AICAFMHA). Improving the mental health of infants,
children and adolescents in Australia. Position Paper of the
AICAFMHA; 2011.

2. Australian Bureau of Statistics (ABS). National Survey of Mental
Health and Wellbeing of Australians: Summary of Results. Canberra:
ABS; 2008.
3. Council of Australian Governments (COAG). National action plan on
mental health 2006–2011. Canberra: Commonwealth of Australia;
2006.
4. Commonwealth of Australia. Fourth national mental health plan—
An agenda for collaborative government action in mental health
2009–2014. Canberra: Department of Health and Ageing; 2009.
5. Council of Australian Governments (COAG). Investing in the early
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Commonwealth of Australia; 2009. Available at: http://www.coag.
gov.au/ Accessed 28 March 2012.
6. Council of Australian Governments (COAG). Protecting children is
everyone’s business. National framework for protecting Australia’s
children 2009–2020, Canberra: Commonwealth of Australia; 2009.
7. American Academy of Child and Adolescent Psychiatry. Improving
mental health services in primary care: reducing administrative
and financial barriers to access and collaboration. Paediatrics 2009;
123:1248–1251.
8. Department of Health. National Service Framework for Children,
young people and maternity services. London: Department of
Health; 2004.
9. CAMHS Review. Children and Young People in Mind: The Final
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Children, Schools and Families; 2008.
10. National Public Health Partnership (NPHP). Healthy Children –
Strengthening Promotion and Prevention Across Australia:
Developing a National Public Health Action Plan for Children
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11. Erchul WP. Gerald Caplan: A Tribute to the Originator of Mental
Health Consultation. J Educ Psychol Consult 2009; 19(2):95–105.
12. Bryant J, Forster J, McNamara P, Sharrock J. You are not alone.
Results of the 2005 Australian consultation liaison nurses survey.
The Australian College of Mental Health Nurses Consultation –
Liaison Special Interest Group; 2007.
13. Southall A. Consultation in child and adolescent mental health.
London: Radcliffe Publishers; 2005.
14. Green B, Everhart M, Gordon L, Gettman M. Characteristics of
Effective Mental Health Consultation in Early Childhood Settings:
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2006; 26(3):142–152.
15. Larney R. School-based consultation in the United Kingdom:
Principles, practice and Effectiveness. School Psychology
International 2003; 24(5):5–19.
16. Athanasiou M, Geil M, Hazel C, Copeland E. Teacher and school
psychologist perceptions of school-based consultation: Using
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17. Caplan G, Caplan RB, Erchul WP. Caplanian mental health
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18. Caplan G. The Theory and Practice of Mental Health Consultation.
London: Tavistock Publications; 1970.
19. Jones S. Good practice: Consultation to a primary care team. In:
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health. London: Radcliffe Publishers; 2005.
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20. Roberts D. Working models for practice. In: S Regal & D Roberts,
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Professionals. Edinburgh: Harcourt Publishers; 2002.
21. Sharrock J, Grigg M, Happell B, Keeble-Devlin B, Jennings S. The
mental health nurse: a valuable addition to the consultation-liaison
psychiatry team. Int J Ment Health Nurs 2006; 15(35):35-43.
22. McNamara P, Bryant J, Forster J, Sharrock J, Happell B. Exploratory
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Nurs 2008; 17:189–196.
23. O’Kane D. Consultation: a phenomenological study of school
nurses' understanding of mental health consultation by child and
adolescent mental health nurses. MA thesis. Flinders University;
2009.
24. Flood A. Understanding phenomenology. Nurse Researcher 2020;
17(2):7–15.
25. Barkway P (in press). Research for Health Professionals. Ch 6. In:
P Barkway. Psychology for Health Professionals. Sydney: Elsevier.
26. National Institute for Health & Clinical Excellence (NICE). Promoting
Children’s Social and Emotional Wellbeing in Primary Education.
London: NICE; 2008.
27. National Institute for Health & Clinical Excellence (NICE). Social and
Emotional Wellbeing in Secondary Education. London: NICE; 2009.
28. Braddick F, Carral V, Jenkins R, Jane-Llopis E. Child and Adolescent
Mental Health in Europe: Infrastructures, Policy and Programmes.
Luxembourg: European Communities; 2009.
29. Burnard P. A Method of Analysing Interview Transcripts in
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30. Polit DF, Beck C. Essentials of Nursing Research: Methods, Appraisal
and Utilisation. 6th ed. Philadelphia: Lippincott Williams & Wilkins;
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31. Aita M, Richer MC. Essentials of research ethics for health care
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32. Adams K, Hean S, Sturgis P, McLeod Clark J. Investigating the factors
influencing professional identity of first year health and social care
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33. Hamer V. Are nurses blurring their identity by extending or
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34. Holbeche L. Understanding Change: Theory, Implementation and
Success. Butterworth Heinemann; 2006.
35. Ball J. School Nursing in 2009: Results from a Survey of RCN
Members working in School. London: Royal College of Nursing;
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36. Salmon G, Rapport F. Multi-agency voices: A thematic analysis
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37. Pryjmachuk S, Graham T, Hadad M. School nurse’s perspective on
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E, Harrington R. Primary mental health workers in child and
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settings. Paediatric Nursing 2006; 18(1):30–3.
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Talking to and being with babies: the nurse–infant

relationship as a pain management tool

Lucie Zwimpfer *
Department of Paediatrics and Child Health, University of Otago, PO Box 7343, Wellington, New Zealand
Email lucie.zwimpfer@xtra.co.nz Tel +64 4 385 5999 extension 5062 Fax +64 4 385 5898

Dawn Elder
University of Otago, Wellington, New Zealand
* corresponding author

Abstract
Introduction The field of infant mental health stresses the importance of attuned caregiver–infant interactions for the
development of healthy emotional regulatory capacities in infants.
Background "Talking to" and "being with" infants as part of their neonatal care has been identified as an important aspect of pain
management. However, the use of the voice and emotional presence alone have not been widely studied.
The thesis of this paper Talk and emotional presence are key elements of the psychoanalytic approach to managing psychic
pain. Some of the tools of the analyst–infant relationship may be useful for nurses to use with infants during painful and stressful
procedures.
Discussion We propose a model of nurse vocal soothing that may be an effective non-pharmacological pain management
technique in the neonatal intensive care unit (NICU). If a nurse is to offer their voice and emotional presence to an infant during
a procedure as a pain management tool, they need to be in an attuned state, thinking about the infant and "being with" the
infant emotionally.
Conclusion This discussion paper considers the rationale for investigating the effectiveness of attuned, empathic vocal soothing
on preterm infant stress.
Implications for clinical practice If attuned, empathic vocal soothing is found to be an effective mitigator of preterm infant stress
then this will provide evidence for a relationship-based, non-pharmacological, cost-effective intervention that would enable the
infant’s emotional needs to be met more effectively in the NICU.
Keywords Neonatal nursing, relationship-based care, procedural pain management, vocal soothing, empathy, psychoanalysis.

What is known about this topic What this paper adds

• T alking to infants and offering them a human presence
during painful procedures has been identified in the
medical literature as being important to neonatal care.
• T his paper offers a psychoanalytic viewpoint of the
nurse–infant relationship, specifically the aspects of
"talking to" and "being with" babies. A model of attuned
vocal soothing as a pain management tool during painful
procedures is proposed.

Declarations Introduction
Competing interests Nil. Infant exposure to pain and stress is associated with adverse
physical and emotional outcomes1-5 and later behavioural
Funding Nil. and emotional problems2. Preterm infants are not exempt.
Ethical approval Not applicable. For infants born at or less than 32 weeks gestation, poorer
Guarantor LZ cognition and motor function at 8 and 18 months is
independently associated with the number of exposures to
Contributorship LZ – main composition of the manuscript,
skin-breaking procedures during their time in the neonatal
DE – critical revision of the manuscript and supervisor of PhD unit6. For these reasons, researchers and clinicians have
project. sought to develop effective pharmacological and non-
Acknowledgements We would like to thank the staff and pharmacological methods to manage pain for preterm
families of the NICU that continue to support this study. infants7.

10 Volume 15 Number 3 – November 2012


The field of infant mental health, with its focus on infant
research, neuroscience and relationship-based interventions,
stresses the importance of attuned caregiver–infant
interactions for the development of healthy emotional
regulatory capacities in infants.
"Talking to" and "being with" infants as part of their
neonatal care has been identified as an important aspect
of pain management8,9. However, although the use of non-
pharmacological strategies for managing infant pain is well
established, the use of the voice alone has not been as widely
studied.
"Talking to" and "being with" infants are key aspects of the
parent–infant relationship and also of the analyst–infant
relationship in some parent–infant psychotherapies10-12. This
paper will discuss the importance of relationships for infant
development and suggest that knowledge gained from the
exploration of psychoanalytic treatment for infants may
be useful for the nurse–infant relationship in the neonatal
intensive care unit (NICU). A model of nurse vocal soothing
will be presented, which is underpinned by the psychoanalytic
concept of containment.
Background
The importance of relationships
There is good evidence available that relationships with
adults are critical to facilitate the growth of healthy infant
brains that are able to manage stress13. It is in moments
of stress that the infant most needs the support of an
adult caregiver to help them regulate their emotional state.
When infants are attended to and soothed by an adult
caregiver, their ability to do this for themselves is facilitated
through development of the neural pathways for emotional
regulation. When this does not happen, the infant is at risk
of adverse mental health sequelae later in life13. Emotional
regulation thus depends on having an emotionally available
adult who can tune in and communicate with the infant.
Because the NICU is increasingly being seen as a place not
just for the physical care of the infant, but also their emotional
and developmental care, relationship-based care practices
have been developed and are now a routine component of
neonatal care in many units14.
Relationship-based care in the NICU
Relationship-based care practices in the NICU include the
Neonatal Individualized Care and Assessment Programme
(NIDCAP) and infant-led singing. The NIDCAP approach
focuses on planning individualised care based on observations
of the infant’s behaviour, thereby recognising the infant as a
person with goals and facilitating the development of a
caregiver relationship with the infant15. Numerous studies
have now been published reporting favourable outcomes for
infants using this approach16-18. It is, however, an expensive
programme to implement fully18.
Infant-led singing is an approach in which the infant is offered
improvised, infant-led singing, within an attuned relationship,
to facilitate self and mutual regulation19. The spontaneous
nature of the singing means that the therapist is led by the
infant’s immediate responses and aims to connect with the
infant’s emotional experience19. This is seen to be particularly
important given the hospital experience being largely non-
contingent with the infant’s psychological needs19.
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N EON ATAL, PAED I ATRI C AN D C H I LD H EALT H NU R S I NG
The unifying philosophy of these approaches is that the
infant is regarded as an individual with emotional as well as
physical needs. Relationship-based care practices, such as
sensorial saturation, have also been shown to be effective in
managing pain and stress9. The aim of sensorial saturation
is to distract the infant’s senses so that pain has less chance
of being perceived centrally20. Bellieni and colleagues have
studied the effectiveness of sensorial saturation extensively
and have refined the technique in the "Triple T intervention"
using touch, taste and talk as the distractors9. This technique
has been shown to be effective in reducing behavioural and
physiological expressions of neonatal pain9.
In reviewing this approach, Bellieni found that the "taste"
intervention, oral glucose, was the critical component of
their distraction intervention and without this component
found touch and talk alone were ineffective21. A caveat to
this finding is that the measures they used were purely
behavioural. It would have been interesting to examine
whether effects on physiological measures such as heart
rate variability, respiratory rate and variability or salivary
cortisol may have been demonstrated in the absence of a
behavioural effect. Also the particular kind of talk offered to
the infants during the sensorial saturation intervention is not
fully described other than to say that the words used should
be gently but firmly spoken20.
Bellieni et al. suggest that an important aspect of sensorial
saturation is that the baby should feel accompanied by
a human presence during the painful procedure21,22. The
importance is stressed of the caregiver being caring and
attentive and it is argued that effective treatment of neonatal
pain can only be realised when the infant is seen as a person
and, as such, treated with both dignity and empathy9,22,23.
These aspects of the nurse–infant relationship, "talk" and
"human presence", have, therefore, been identified in the
medical literature as being relevant to medical care. But
does it matter what sort of "talk" nurses use with their
infant patients? Also what kind of human presence might
be required for the effective soothing of neonatal pain and
stress?
The thesis of this paper
Talk and emotional presence are key elements of the
psychoanalytic approach to managing psychic pain. Firstly
some of the tools of the analyst–infant relationship that may
be useful for nurses to use with infants during painful and
stressful procedures in NICU will be described. Secondly, a
model of nurse vocal soothing that may be an effective non-
pharmacological pain management technique in NICU will
be proposed.
Discussion
The field of psychoanalysis has long been interested in
the impact of relationships on mental health and theories
have been proposed that describe how relationships with
primary caregivers (external environment) meet an infant’s
experience (internal environment) to co-create the infant’s
emerging sense of self.
Parent–infant psychotherapeutic approaches are generally
aimed at recognising and soothing the emotional expressions
11
N E ON ATA L , PA ED IAT R IC A ND CH ILD H EALTH NU RSING
of the infant. While some therapists may do this by focusing on
helping the parents to "talk to" and "be with" their infant24-26,
others "talk to" and "be with" the infant directly10,11,27.
The approach of psychoanalyst Johan Norman was to focus
on the help the therapist could offer directly to the infant11.
Three important features of his technique, as described by
Salomonsson28, are that:
1. The analyst seeks to establish a therapeutic relationship
with the baby.
2. 
The analyst assumes the infant will use his primary
intersubjectivity29 (an innate capacity to relate to other
humans) to obtain containment30.
3. The analyst assumes that the baby processes the non-
lexical aspect of interactions.
These will be discussed in turn to consider how they may be
relevant for use in the NICU.
The analyst seeks to establish a therapeutic relationship
with the baby
Preterm infants may spend up to three or four months in
the NICU, where there are fewer opportunities for intimate
interaction with their primary caregiving parents. In the
physical and often emotional absence of parents in the NICU,
nurses frequently take on the role of primary caregiver for
their young patients. The nurse works directly with the infant
and takes overall responsibility for their physical care. She or
he is important to the baby.
The analyst assumes the infant will use their primary
intersubjectivity to obtain containment
Preterm infants seek communication and comfort
from caregivers: that is anyone who offers them care.
Even preterm infants are born with an innate primary
intersubjectivity, ready to relate to other human beings and
expecting a response to their bids for communication31,32.
Infant researcher Colwyn Trevarthen suggests that
it does not necessarily have to be the biological mother
that meets the needs of the infant and that infants are
born ready to have their needs met by any sympathetic
adult willing and able to enter their emotional world32.
Within psychoanalysis, the school of object relations
is particularly concerned with the relationships, real and
imagined, between infants and their primary caregivers.
Theorists within this school of thought stress the importance
of primary caregivers for helping infants manage "big
feelings", both joyful and painful30,33,34. This process is often
described as "containment"30.
Psychoanalyst Wilfred Bion suggested that in infancy we have
many raw feelings and experiences, but they cannot be made
sense of without a container, without someone else who can
"metabolise" them for us and give them back in a digested
form30. It is a bit like the albatross that chews the fish for their
babies then regurgitates it in a way that is digestible to the
chicks. Bion said that in this way, through the receiving of
thought about thoughts, we develop the capacity to think
ourselves30. The infant has the emotional experience, the
parent recognises it, accepts it and reassures the infant that it
is a valid feeling to have and they are not alone.
12
When Bellieni et al. suggested the importance of human
presence alongside the infant during painful procedures an
empathetic presence was presumed21,22. In order for a mother
to be able to offer containment to her infant, Bion suggested
that she needed to be in a state of reverie, a sort of daydream
state, where she is emotionally open to receiving the infant’s
communications, both good and bad30. He postulated that
this state of being attuned allows the mother to more
accurately understand the infant. It would not be practical
for nurses to enter a state of reverie with every infant in
their care; however, tuning into the infant during a painful
experience would be achievable. Studies have demonstrated
that interventions can be more effective when the clinician
focuses their attention on the infant35. Anand et al. stress
the importance of clinicians working in the NICU expressing
empathy and love for their patients and suggest that this is
crucial to "maximise the benefits" of evidence-based medical
interventions to reduce stress8. Clinicians are urged to be
like secure mothers who are sensitive and responsive to the
infant’s needs8.
The analyst assumes that the baby processes the non-
lexical aspect of interactions
The assumption here is that, although infants do not
understand the actual words spoken to them, they do
understand the emotional intention behind the words. If this
is the case, then there may be therapeutic value in nurses
offering vocal soothing to infants under stress. This vocal
soothing would need to be truthful, that is, recognise and
name the infant experience, in order to be meaningful to
the infant and help them feel understood and reassured and,
therefore, contained.
Infants prefer infant-directed speech to adult-directed
speech36. Infant-directed speech, also known as "motherese"
(although it can be offered by anyone) is characterised by
longer sounds in the words, higher pitch, more variation
in the pitch and repetition37. The falling and rising pitch
contours depend on whether the infant is being soothed
(falling) or whether their attention is being attracted (rising)38.
Because of these cadences in the speech, infants can sense
the emotions being conveyed39.
If nurses are to offer their voice and emotional presence to an
infant during a procedure as a pain management tool, they
need to be in an attuned state, thinking about the infant and
"being with" the infant emotionally. Nurses who speak to their
colleagues while carrying out a painful procedure on an infant
are physically present with the infant during the procedure
but not emotionally present. When nurses say to infants in
their care "it doesn’t hurt" or "nothing is happening", the
infant’s experience is, in fact, being minimised or denied and
the nurse is clearly neither emotionally present with the infant
nor attuned to what they are experiencing. Containment
is only possible if the caregiver is open to receiving and
accepting the infant’s communications and, in particular,
their level of stress. The psychotherapeutic viewpoint is that
the human presence is about "being with" and "thinking
about" the infant emotionally not just physically.
In a recent observational study, we found that despite
speaking regularly to their colleagues, nurses did not often
Volume 15 Number 3 – November 2012

offer vocal soothing to infants during a heel prick procedure40.
Also, despite being recommended as a standard of care in the
NICU there was limited use of other non-pharmacological
interventions to relieve pain during the procedure40. Others
have reported that despite much research demonstrating the
effectiveness of these techniques, general implementation
of pain management programmes appears to be limited
internationally41.
It is not likely that nursing staff deliberately withhold pain
relief from their patients. However, to be available to talk
to infants during a painful procedure, a nurse needs to be
attuned to the reality of the painful experience. This, in itself,
can be an emotionally taxing thing to do. It is possible that
psychological protective mechanisms of which the nurse is
not likely to be fully conscious, minimise the perceived effect
of the painful procedure on the infant and, therefore, in turn,
lead to the underuse of pain management techniques in the
nursery. More research is required to establish whether this is,
in reality, a barrier to the use of these techniques.
A model of nurse vocal soothing
Bringing together these elements of "talking to" and "being
with" an infant, a model of nurse vocal soothing is proposed. If a
nurse is emotionally available to the infant’s communications
and conveys this to the infant through an attuned, empathic
voice, similar to "motherese", it is hypothesised that the infant
may achieve containment. In this way, the nurse is responsive
to the infant’s communications in the moment, leaving the
infant feeling that they are accompanied in their pain and,
therefore, soothed.
The words used by the nurse are a critical component of this
communication. They must be truthful and used in context
to help the infant feel that their experience has been well
understood. One way to ensure this is to consider the steps
suggested for procedural pain management by Halimaa42:
1. Creating an environment that is favourable to effective
pain management.
2. Safe preparation of the infant for the procedure.
3. Pain alleviation during the procedure.
4. Restoring the infant’s sense of security after the procedure.
These steps can be understood in terms of vocal soothing.
Firstly, offer a warning about what is about to happen, then
talk the infant through the procedure and finally have a time
of debriefing afterwards. The aim is to accompany an infant
through their experience from the start to the finish: to see
it from their point of view, to offer warning or preparation
about what is to come, to be aware of how the infant is
feeling during the procedure and then to have a review of
what has happened before moving on to the next task. Pain
management as a process can enhance the emotional health
of the infant through making the experience meaningful to
them. Someone is thinking about them and how they are
feeling and the infant is aware of this.
During this process the nurse must be attuned to the
experience of the infant. They need to feel both empathic and
confident that the infant will tolerate the procedure well and
recover well from any temporary stress that they experience.
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N EON ATAL, PAED I ATRI C AN D C H I LD H EALT H NU R S I NG
The essence of the theory of containment is that when an
infant feels that a stronger other person understands how
they are feeling and remains calm and supportive, it will be
reassuring and soothing for the infant.
Further research is needed to determine whether nurse-
provided vocal soothing and emotional availability can be
experienced as soothing by infants during painful procedures.
Studies such as this will make important contributions to the
literature on both empathy and pain management techniques
in the NICU.
Conclusion
This discussion paper has considered the rationale for
investigating the effectiveness of attuned, empathic vocal
soothing on preterm infant stress. It has been proposed that
some of the elements of the parent–infant and analyst–infant
relationship can be reproduced in a nurse–infant relationship
and that this may be of benefit to the emotional development
of the preterm infant being cared for in the NICU.
Implications for practice
If attuned, empathic vocal soothing is found to be an effective
mitigator of preterm infant stress then this will provide
evidence for a relationship-based, non-pharmacological,
cost-effective intervention that may mean that the infant’s
emotional needs are met more effectively in the NICU.
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2. Anand KJS, Scalzo FM. Can adverse neonatal experiences alter
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3. Grunau R. Early pain in preterm infants: A model of long-term
effects. New York, NY, ETATS-UNIS: Elsevier; 2002.
4. Ozawa M, Kanda K, Hirata M, Kusakawa I, Suzuki C. Influence of
repeated painful procedures on prefrontal cortical pain responses
in newborns. Acta Paediatr. 2011;100(2):198–203.
5. Winberg J. Do neonatal pain and stress program the brain’s response
to future stimuli? Acta Pædiatr. 1998;87(7):723-5.
6. Grunau RE, Whitfield MF, Petrie-Thomas J, Synnes AR, Cepeda IL,
Keidar A et al. Neonatal pain, parenting stress and interaction, in
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preterm infants. Pain. 2009;143(1–2):138–46.
7. Pillai Riddell RR, Racine NM, Turcotte K, Uman LS, Horton RE, Din
Osmun L, Ahola Kohut S, Hillgrove Stuart J, Stevens B, Gerwitz-Stern
A. Non-pharmacological management of infant and young child
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2012 Feb 20]. Available from: http://www.mrw.interscience.wiley.
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8. Anand KJS, Hall RW. Love, pain, and intensive care. Pediatr.
2008;121(4):825–7.
9. Bellieni CV, Tei M, Coccina F, Buonocore G. Sensorial saturation for
infants’ pain. J Matern Fetal Neonatal Med. 2012;25 Suppl 1:79–81.
10. Acquarone S. Infant–Parent Psychotherapy: A Handbook. London: H.
Karnac (Books) Ltd; 2004.
11. Norman J. The Psychoanalyst and the baby: A new look at work with
infants. Int J Psychoanal. 2001;82(1):83–100.
12. Norman J. Transformations of early infantile experiences: A 6-month-
old in psychoanalysis. Int J Psychoanal. 2004;85(5):1103–22.
13. Schore AN. The experience-dependent maturation of a regulatory
system in the orbital prefrontal cortex and the origin of
developmental psychopathology. Dev Psychopathol. 1996;8:59–87.
14. Legendre V, Burtner PA, Martinez KL, Crowe TK. The evolving
practice of developmental care in the neonatal unit: A systematic
review. Phys Occup Ther Pediatr. 2011;31(3):315–38.
15. Als H, Gilkerson L. The role of relationship-based developmentally
supportive newborn intensive care in strengthening outcome of
preterm infants. Semin Perinatol. 1997;21(3):178–89.
16. Als H, Duffy FH, McAnulty GB. Effectiveness of individualized
neurodevelopmental care in the newborn intensive care unit (NICU).
Acta Pædiatr. 1996;85:21–30.
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17. Als H, Duffy FH, McAnulty GB, Rivkin MJ, Vajapeyam S, Mulkern RV
et al. Early experience alters brain function and structure. Pediatr.
2004;113(4):846–57.
18. Westrup B, Sizun J, Lagercrantz H. Family-centered developmental
supportive care: a holistic and humane approach to reduce stress
and pain in neonates. J Perinatol. 2007;27(S1):S12–S8.
19. Shoemark H. Infant-directed singing as a vehicle for regulation
rehearsal in the medically fragile full-term infant. Aust J Mus Ther.
2006;17:54–63.
20. Bellieni CVC, Buonocore GG, Nenci AA, Franci NN, Cordelli DMD,
Bagnoli FF. Sensorial saturation: an effective analgesic tool for
heel-prick in preterm infants: a prospective randomized trial. Biol
Neonate. 2001;80(1):15.
21. Bellieni CVC. Effect of multisensory stimulation on analgesia in term
neonates: A randomized controlled trial. Pediatr Res. 2002;51(4):460–
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22. Bellieni CVC, Bagnoli FF, Buonocore GG. Alone no more: pain in
premature children. Ethics & Med. 2003;19(1):5.
23. Bellieni CVC. Pain definitions revised: newborns not only feel pain,
they also suffer. Ethics & Med. 2005;21(1):5.
24. Baradon T, Broughton, C, Gibbs, I, Joyce, A & Woodhead, J. The
practice of psychoanalytic parent-infant psychotherapy – claiming
the baby. London: Routledge; 2005.
25. Cohen NJ. Watch, wait, and wonder: Testing the effectiveness of a
new approach to mother-infant psychotherapy. Infant Ment Health
J. 1999;20(4):429–51.
26. Fraiberg S. Ghosts in the nursery: A psychoanalytic approach to the
problems of impaired infant-mother relationships. J Am Acad Child
Psychiatry. 1975;14(3):387.
27. Thomson-Salo F. Recognizing the infant as subject in infant-parent
psychotherapy. Int J Psychoanalysis. 2007;88(4):961–79.
28. Salomonsson B. Baby worries: A randomised controlled trial of
mother-infant psychoanalytic treatment. Stockholm: Karolinska
Institutet; 2010.
29. Trevarthen C, Aitken KJ. Infant intersubjectivity: Research, theory,
and clinical applications. J Child Psychol Psychiatr. 2001;42(1):3–48.
30. Bion WR. Learning from experience. London: Karnac Books; 1962.
31. Aitken KJ, Trevarthen C. Self/other organization in human
psychological development. Dev Psychopathol. 1997;9(04):653–77.
32. Trevarthen C. Intrinsic motives for companionship in understanding:
Their origin, development, and significance for infant mental health.
Infant Ment Health J. 2001;22(1–2):95–131.
33. Ogden T. The Matrix of the Mind. Object Relations and the
Psychoanalytic Dialogue. London: H Karnac (Books) Inc; 1992.
34. Winnicott D. The maturational processes and the facilitating
environment: Studies in the theory of emotional development.
London: Karnac Books Ltd; 1990.
35. Ventegodt S, Merrick J. Clinical holistic medicine: Applied
consciousness-based medicine. ScientificWorldJournal. 2004;4:96–9.
36. Cooper RP, Aslin RN. Preference for infant-directed speech in the first
month after birth. Child Dev. 1990;61(5):1584–95.
37. Trainor LJ. Infant preferences for infant-directed versus noninfant-
directed playsongs and lullabies. Infant Behav Dev. 1996;19(1):83–
92.
38. Fernald A. Prosody in speech to children: Prelinguistic and linguistic
functions. Ann Child Dev. 1991;8:43–80.
39. Caron AJ, Caron RF, MacLean DJ. Infant discrimination of naturalistic
emotional expressions: The role of face and voice. Child Dev.
1988;59(3):604–16.
40. Zwimpfer L, Wiltshire, E. & Elder, D. Talking to Babies: A baseline study
of vocal soothing by neonatal nurses during painful procedures. J
Paediatr Child Health. 2012;48(Suppl 1):8–81.
41. Spence K, Henderson-Smart D. Closing the evidence-practice gap
for newborn pain using clinical networks. J Paediatr Child Health.
2011;47(3):92–8.
42. Halimaa S-L. Pain management in nursing procedures on premature
babies. J Adv Nurs. 2003;42(6):587–97.

Special Issue November 2013 –

Call for papers
Health promotion or harm minimisation for children and young people has an important role in policy and
practice. This special issue aims to explore this topic in relation to community and acute initiatives, service delivery
and policy within the contexts of infants, children and young people. The special issue will be published in
November 2013.
We welcome a broad spectrum of scholarly papers, based on research, systematic review or service evaluation, that
extend the knowledge base of effective health promotion and are relevant to nursing practice for this group.
Topics may include the following, although this list is not exhaustive:
• Models/frameworks for health promotion care for children and young people
• Outcomes of acute or community care
• Prevention and population health
• Promoting healthy lifestyles
• Supporting children and young people with chronic disease
All papers should be submitted through the Cambridge Manuscript Management System and the standard
guidance for authors should be used: http://www.npchn.com/
We ask all authors to identify the paper as being for the mental health special issue by using the initials “HP” in the
title of their paper (e.g. “HP: The role of the school-based counsellor in early identification of mental health issues“).
The deadline for receipt of papers is 26 April 2013.
All papers will be subjected to the journal’s usual double-blind peer-review process as set out in the guidance for
authors. Should there be too many papers accepted following peer-review for the space available in the special
issue, then these papers will be published in subsequent issues of Neonatal, Paediatric and Child Health Nursing.
Associate Professor Jodi Shaefer, Guest Editor, and Professor Linda Johnston, Editor
Online submission
Submit your paper to Neonatal, Paediatric and Child Health Nursing: http://www.npchn.com/

14 Volume 15 Number 3 – November 2012

 N EON ATAL, PAED I ATRI C AN D C H I LD H EALT H NU R S I NG

Surviving postnatal depression: the male perspective

Elaine Bennett *
Director Services, Education & Research, Ngala, Perth, WA, Australia
9 George St, Kensington, WA 6151, Australia
Tel + 61 8 9368 9368 Email ejbennett@ngala.com.au

Dawson Cooke
Fatherhood Educator – HeyDadWA, Ngala, Perth, WA

* corresponding author

Abstract
Aim The study aim was to hear the male voice describing the experience of postnatal depression (PND) and to develop a
conceptual framework, which would explain this experience.

Background Given the relatively large body of research on the nature of PND from the woman’s perspective and the general
movement towards family-centred practice, it seemed timely to undertake a study that concentrated on the male experience of
having a partner with PND.

Method Seven men whose partners were currently experiencing, or who had recently experienced moderate to severe PND,
participated in unstructured interviews. Grounded theory methodology was used to explore the male experience of living with
a partner suffering from PND.

Results Data analysis revealed four categories in the process of living through the experience of a partner’s PND: "out of control",
"coming to the realisation", "making sense of it", and "the road to recovery". The core variable, "surviving PND" integrates the
categories and encapsulates the process of transition experienced by the men.

Conclusions The consequences of "surviving PND" are explained by the men as both losses and gains. For some men there was
a sense of vulnerability and emotional drain because they had poured so much energy and self into the women and their needs
for recovery. "Surviving PND" also had significant impact on the relationship, both in a positive and negative way. In addition, all
men developed an increased understanding and gained personal insight into themselves, their partner and people in general.

Implications for clinical practice This research increases our understanding of the male experience of PND and may be drawn
on to inform the practice of nurses and other health care or early parenting professionals.

Keywords Postnatal depression, perinatal mental health, father.

What is known about this topic What this paper adds

• T he impact of perinatal mental health distress has far- • A
 n increased understanding of the male experience of
reaching effects on the woman, partner, child and family. PND.
• R
 esearch and services addressing PND often neglects to • I nforms the practice of nurses and other health and early
consider the role or experience of male partners. parenting professionals.
• M
 en who have a partner with PND have an increased risk • A
 n increased knowledge of strategies the men identified
of depression. as being necessary to survive PND.

Declarations
Contributorship EB undertook study as part of Master of
Nursing thesis1. DC contributed to current literature and
co-writing of article.
Ethical approval Approval for the research project was given
by the University of Tasmania, Ethics Committee. Approval
Number H4022.
Competing interests Nil.
Introduction
Childbirth and early parenting services generally focus on the
needs of the mother and her child, with minimal attention
given to the needs or influences of the child’s father. This
practice continues in spite of evidence that has clearly shown
the importance of the father’s role in child development2
and the couple's relationship3. One particular circumstance,
in which there is good reason to consider the father’s
experience, is when a mother has symptoms of postnatal
depression (PND). This situation poses significant challenges
to the couple, the family and the child’s development.

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N E ON ATA L , PA ED IAT R IC A ND CH ILD H EALTH NU RSING
Recruitment and engagement of new fathers in parenting
research is understandably difficult, given the demands of
caring for young children4. Nevertheless, there is a need
for greater understanding of fathers’ experiences during
this critical period for families and children, so services
and health professionals can be appropriately skilled and
easily accessible. Alienation of fathers can compound any
reluctance they may have to engage with services and
opportunities to address any family relationship difficulties
may be missed.
Background
The diagnosis of PND is classified as a major depressive
episode commencing within four to six weeks of delivery5,6,
depending on the criteria used. More commonly, the term
is used to describe many distressing and often disabling
feelings (usually self-reported with a screening checklist),
and is experienced by up to 20% of women up to one year
following childbirth7,8. In addition to identifying depressed
mood or anhedonia (first criteria of a major depressive
episode), PND is generally accepted to also include possible
symptoms of anxiety, panic, self-blame and difficulty with
coping7.
Although the prevalence of diagnosable PND is difficult
to determine and controversial9,10, maternal depressive
symptoms are widely recognised as a significant health
problem, not only for the mother, but also for their partner,
the child, other family members and the wider community11.
An Australian study12, conducted over 11 years, identified the
effects on children with mothers suffering from moderate
to severe depression, as behavioural disturbances, lowered
intellectual functioning and poorer reading ability. More
generally, unipolar major depression is considered the
leading contributor to the burden of disease in middle and
high-income countries13.
Early parenting research, antenatal education and clinical
practice with new parents have only recently begun to address
issues associated with fathers14. Positive father involvement
has been found to positively influence all family members'
health outcomes15, and fathers can play a moderating role
in either reducing or exacerbating some of the adverse
effects of PND16. For men themselves, it is also the case that
the transition to fatherhood has potential for both personal
development or reward17,18, and significant stress19.
Given these potential difficulties, risks and opportunities for
fathers with a partner with PND, greater consideration of the
father is warranted when providing care of a mother with
PND. This study of men’s experience of having a partner with
PND set out to explore both the positive and the challenging
aspects of a particularly difficult time for the whole family.
Men’s experience of having a partner with PND
Recent quantitative studies of the influence of maternal PND
on the male partner have found a range of associated risks for
men, including increased depression20,21, parenting stress21,
16
problem fatigue20 and having less optimal interaction with
their infant21. In addition, recent meta-analysis has indicated
a prevalence of paternal depression in excess of 10% in the
three- to six-month postnatal period, with a moderate positive
correlation between maternal and paternal depression22.
These findings are of particular concern because of the
association between paternal depression and an increased
risk of children’s behavioural and emotional problems23,24.
A limited amount of qualitative research has been published
on the experience of men whose partners were diagnosed
with PND. An Australian study25 used focus groups to
evaluate an intervention for PND, which included the male
partners. These men reported feeling isolated from their
family members, feeling helpless and stigmatised, and that
they experienced their partners’ PND as overwhelmingly
frustrating. They also expressed struggling with the changing
role and expectations of fathers in society. In contrast, the
men’s experience of the group treatment programme was
very favourable and valued.
An American phenomenological study26 with fathers reported
similar themes of difficulty such as stress and loss of control
as a result of their partner’s PND. In addition, they reported
altered views of their partner and changes to the relationship,
as well as anger at their inability to “fix the problem”. A
more positive response to PND was found in men’s sense
of increased responsibility, although this feeling was also
expressed as a pressure to make sacrifices and manage the
situation.
A pilot study in Canada identified a number of support needs
from fathers with partners who had experienced PND27.
These fathers also reported many difficulties, which included
fear or worry for their partner and uncertainty about their
relationship. Their main barrier to support was reported as
the difficulty of finding supportive professional or informal
PND resources. These fathers acknowledged that their own
lack of awareness or knowledge of PND was a barrier to
accessing support. Also, the feeling of being excluded by a
health professional or the stigma related to PND were said to
contribute to their resistance to seek help.
Although these studies identify a range of men’s experiences
in the situation of a partner with PND, research is required
to better understand the processes behind men’s views on
living with PND, explain how this experience changes over
time, and develop a conceptual framework to describe this
experience.
Method
Grounded theory underpinned this research using
a recognised approach by Strauss and Corbin28 in order
to see and explain the world from the eyes of the male
participants. Grounded theory research "emphasises how
people view their circumstances, how they interact, and how
these processes change"29. The task for the researcher is to
discover and conceptualise complex interactional processes30
using a rigorous method of analysing data, which results in
Volume 15 Number 3 – November 2012

a theoretical explanation about a particular phenomenon31.
The understanding that occurs from this process permits
the development of relevant interventions in the social
environment under consideration.
Grounded theory uses a "bottom-up approach" to develop a
theory which is relevant to everyday people. This differs from
a theory that is developed in isolation, then tested and often
imposed on people so that it does not make sense to the
world in which people live30.
The purpose of the researcher using a grounded theory
method is "to explain a given social situation by identifying
the core and subsidiary processes operating in it"32. The core
process is the guiding principle, which then links most of the
other processes occurring in the network of data. A resulting
theory explains the social situation under investigation. In
this study, men sharing common circumstances, namely
having a partner with PND, experience shared meanings and
behaviours, which are explained by the resulting theory.
Design of the study
In this study, seven men who had a partner who had
experienced moderate to severe PND were interviewed. To
supplement data collected from the interviews, theoretical
support and depth was drawn from existing literature.
This process led to the development of a more complete,
substantive grounded theory. Participants were fathers from
an homogenous group, ranging in age from 27 to 42 years
and with one to four children. They all had what they
described as "good" relationships with their partners and
their partner was receiving or had received either individual
or group support, or both, for PND.
Ethics
Approval for the study was obtained via the University Higher
Research Ethics Committee. The men made contact with the
researcher and were sent an information sheet with details of
the study and a consent form. The researcher made contact
with the men after receiving consent to be involved in the
study.
Data collection and analysis
Following the recruitment process, there was an initial round
of one-hour interviews with five of the men. These five men
were interviewed again in a second round to seek feedback
on the developed theory. Following the second round of
interviews the researcher determined that categories were filled
and that no further participants were necessary. Two different
men were interviewed to consolidate the theory and confirm
the accuracy of the researcher’s interpretation of the data.
From the beginning of this study, data were carefully coded
and were subject to constant comparative analysis to ensure
the emerging theory was grounded in the study data. The final
check of accuracy came from the participants themselves33.
Grounded theory methodology relies on constant or
"continuous comparative analysis" of the data (p. 21)34. Every
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N EON ATAL, PAED I ATRI C AN D C H I LD H EALT H NU R S I NG
piece of data was compared with other pieces of data
so that similarities and differences in phenomena were
distinguished28,35,36. There was not a linear series of steps but
rather a matrix of processes going on at once. The researcher
examined the data after the first interview, and then began to
code and categorise it33.
Maxwell and Maxwell (cited in33,34,37) have described five steps
for analysis of data, which guided this study: the collection
of empirical data; concept formation; concept development;
concept modification and integration; and production of the
research report.
Establishing trustworthiness
Trustworthiness38 establishes rigour and confidence in the
research. Three of the techniques by Lincoln and Guba38
were adopted for this study as criteria for establishing
trustworthiness: credibility, dependability and confirmability.
These were achieved through spending time with the
participants until no new ideas were forthcoming and further
checking with two more male participants who had not been
involved in the first two rounds of interviews. Peer debriefing
was also used after each interview to ensure adherence
to the codes and reflection on the interview process. The
researcher kept detailed records of the process of the research
involving journals, analytical notes and memos. Following the
interviews, literature was used to reinforce what the men
were saying in order to contribute to the development of the
conceptual framework.
Results: four categories
Four major categories evolved from the data: "out of control’"
"coming to the realisation", "making sense of it", and "the road
to recovery".
Out of control
The men described an initial process where they felt "utterly
helpless", because they felt they had lost control of their life.
This phase was fraught with contradictions because of many
external pressures; having "to hold it together" and at the
same time feeling "out of control". In the words of one man:
It was like being in a situation where you had no control over
it … like a storm had hit … with no control over it. You are in
a situation that you totally don’t know what to do. You were
lacking understanding of it, of what was happening.
Coming to the realisation
The "out of control" category led into a "coming to the
realisation" that something was wrong and that help was
needed. Over a period of time the men realised that there
were more than adjustment issues to contend with following
the birth of their baby. The men were questioning their
relationship, whether having had a baby was a mistake, or
whether something terrible was wrong with their partner.
During this phase the men may have been told their wives
had PND, and for some men it took a while for this to register,
while for others it did not:
17
N E ON ATA L , PA ED IAT R IC A ND CH ILD H EALTH NU RSING
I started coming to the realisation that that’s what it was
and that seemed to make me feel a lot more comfortable
about it. And realising it was a health problem and not
a personality problem made me feel better about our
marriage.
Making sense of it
"Making sense of it" was a process for the man of working
through what the term PND meant and attributing some
meaning to the situation they were in. The men now
attempted to involve other people in some way, even if it just
meant talking to their colleagues about the situation. The
label of PND assisted them to put a name to the condition
for themselves and also assisted them to explain it to others.
This period during the transition gave them strength to keep
going, even though the "going was tough", but it also meant
that they denied their own needs in order to survive.
I don’t need to say that PND is a difficult thing to understand
and initially accept. I found that when the illness was
explained it was easier for me. But lots of patience was
essential – patience is the main ingredient … which is
needed to deal with the healing process.
The road to recovery
The "road to recovery" was a period of time when the men
began to feel hope that their partners were beginning to
overcome PND. They saw a definite improvement in their
partner and sensed they had a direction for themselves,
particularly with the type of support they were giving to
their partner. They also saw the value of support from others,
including professionals, and the effect that this had on the
women. The effect of the process so far began to take its toll
with most men, as they felt the emotional drain and had to
cope with relapses along the way.
At the times when I am looking after the kids and need to
cope I can operate quite efficiently, but at times when that’s
not necessary I don’t know what to do. When the pressure
starts to come off I think what am I, how am I supposed to
relate to people?
Knowing about PND validated it and I knew that suddenly
I had a purpose to what I was doing and I started to learn
ways to deal with it for myself and for our family. There was
a point to that now because I knew that there would be an
end to this illness. We could control it.
Discussion
"Surviving postnatal depression" was a dynamic process
for the men, moving from "out of control" through to "the
road to recovery". The core variable or central phenomenon
of "surviving PND" captures this transitional process. In a
grounded theory analysis the core variable can be explained
in a story line28. The men’s experience of PND occurred over
a period of time as demonstrated by the four categories
that emerged from the data: "out of control", "coming to the
realisation", "making sense of it", and "the road to recovery".
The core variable, "surviving PND", incorporates the four
categories and provides the linkage between them.
18
"Surviving" was defined by the men in this study as a process
of continuing to exist and living beyond the life of the event
of PND, in spite of a difficult transition period. One man
described it as:
... it just feels like you’ve weathered this enormous storm and
you sort of, it’s in the past but the effects of it still buffets you
a bit, but you know you’ve survived.
The distress that results from an unanticipated event varies
with each individual. The feelings of surviving experienced by
the men were initially ones of helplessness, confusion, shock
and anxiety39,40. As the process of surviving continued, the
men experienced a "non-emotional survival state"41, which
was described as "rock solid" and which assisted them to
remain focused on the task of caring. As the woman improved
there was an "emotional drain" experienced because of
the man’s vulnerability at this time. One of the emotions
experienced was guilt, which is discussed in the literature
as "survivor guilt"42,43. The men felt guilty for experiencing
sadness, anger, tiredness, lack of motivation, anxiety and
anger, as well as for wanting to take care of their own needs.
Raphael41 points out that surviving a personal disaster "is not
forgotten but stays with the individual as a reference point in
his existence" (p. 351).
The positive aspects described by the men were an increase
in understanding and personal insight. All men felt they
had a clearer understanding of PND and the impact it has
on the family. They also appeared to have developed a
depth of personal insight into the experience that they had
encountered. The insight extended to their relationship with
their partner and child/ren, their general understanding of
parenting, and the disruption an adjustment crisis such as
PND can cause.
Probably just the fact that after going through it and
understanding it and being happy with the third baby
now, and knowing the things and I’m probably more
understanding because at the time I probably wasn’t.
I think we both probably have become more tolerant of
people generally, I don’t quite know why, but we’ve also
become especially more tolerant of people with mental
illness, not so much tolerant, more understanding.
Looking through a periscope – “surviving PND”
A conceptual framework is "developed by the researcher
through identifying and defining the concepts of interest and
proposing relationships among them" (p. 98)44. The conceptual
framework of this study depicted the male experience of
having a partner with PND. It illustrated the transition process,
characterised by overwhelming helplessness and constant
engagement in trying to support a partner who is struggling.
For the men, PND meant both changes to their relationship
and the development of new aspects of their relationship. It
also meant a reassessment of their lives prior to them being
able to move on. The core variable, which integrates these
categories and captures the central phenomenon of the male
experience is "surviving PND"
Volume 15 Number 3 – November 2012

The conceptual framework can be described by the analogy
of looking into a periscope. The periscope differs from
using a telescope or binoculars where the viewer is out in
the open and exposed. The significance of the concealed
or protected position of the person using the periscope is
twofold. Firstly, PND is often kept a family secret for some
time before it is revealed and, secondly, some men find
emotional experiences difficult to discuss openly.
Just as the periscope is able to bring distant objects into focus,
the men in this study viewed their experience of PND from a
distance and, by telling their story, were able to bring into
focus their perceptions of their experience. The onset of PND
is insidious, with the men feeling helpless, confused and "out
of control" as they watch someone they love change in front
of their eyes. The men are led into "coming to the realisation"
that something is wrong and that help is needed. They
gradually commence "making sense of it" through support
from others and remaining "solid" through the difficult
times. As the head of the periscope scans the horizon, the
view changes and another aspect of the transition process is
revealed. "The road to recovery" usually occurs where there is
a sense of beginning to "see the light at the end of the tunnel"
or a direction for themselves together with their partner.
The experience of "surviving PND" meant that there were
consequences or effects of having lived through a partner
experiencing PND. These consequences were dependent
on three factors: the severity of their partners’ PND, the
experience of the recovery period, and their current situation
in relation to the recovery. For most men there were many
losses and only a few gains in the experience, and the further
they moved away from the experience, the easier it was
to view it. When looking through a periscope, sometimes
there can be weather conditions that affect the viewing.
Consequences are like these weather conditions – they
sometimes affect the way the experience is perceived.
Relevance to practice
This research increases our understanding of the male
experience of PND for this group of men and may be drawn
on to inform the practice of nurses and other health care or
early parenting professionals. The study has implications for
practice, particularly in relation to the strategies the men
identified as being necessary to survive PND.
The conclusions drawn from this study can be presented as
a series of propositions (Table 1), which largely relate to the
process of "surviving PND". These are supported by strategies
for themselves and health care providers that the men in the
study identified as being helpful.
Limitations
One limitation to the study relates to the small number
of participants. Although qualitative research provides the
reader with a depth of understanding of the subject area, its
small sample size means that the study is not generalisable
to a larger group. The second limitation could be the gender
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N EON ATAL, PAED I ATRI C AN D C H I LD H EALT H NU R S I NG
Table 1. Concluding propositions.
Strategies identified by men for men
Accept support from others and share experiences, which validate
and normalise PND.
Time-out for self allows the man to gain perspective of the situation
and to revitalise.
Seeking professional assistance allows the man to clarify and
offload about the situation.
Open communication assists the couple to take control of the
situation.
Emotional support and involvement in parenting and household
tasks by the man increases the feeling of support for the woman.
Strategies identified for health care providers
Increased community awareness of PND will assist to reduce the
stigma associated with this mental health issue.
The practice of nurses and other health professionals requires
a family perspective and inclusion of the male partner in the
management of PND.
of the primary researcher. Being a female, the researcher
interpreted the meaning of the participant experience from
a female rather than from a male perspective. This limitation
was minimised by returning to the participants to validate
the findings of the research.
Conclusion
This study provided a conceptual framework for understanding
the experience of men who have partners with PND. The
analysis showed that the experience of "surviving PND"
involved significant distress for the man as he strived to move
through the transition process and regain control of his life
and his family situation.
The analogy of looking into a periscope was used for the
conceptual framework. As the man looked through the
eyeglass there is a picture of the process experienced from
a distance. Reflecting mirrors or prisms bring the experience
into focus. As the head of the periscope rotates across the
horizon, it views the experience from being "out of control"
to "the road to recovery". Sometimes "weather conditions"
influence the view, as the consequences of surviving PND
influence the man’s perception of his experience.
In the initial stages, the men in this study felt "out of
control" because their partner appeared to be gradually
becoming a different person. They began to "realise" that
something was wrong and that help was needed. Trying to
"make sense" of the situation occurred where they tried to
engender support from others and to find out what PND
meant. "The road to recovery" began when they saw their
partner beginning to improve and this gave them a sense of
direction. Consequences of "surviving PND" were felt by the
men and described in terms of losses and gains.
This research increases our understanding of the male
experience of PND for this group of men and may be drawn
on to inform the practice of nurses and other health care or
19
N E ON ATA L , PA ED IAT R IC A ND CH ILD H EALTH NU RSING
early parenting professionals. The study has implications for
practice, particularly in relation to the strategies the men
identified as being necessary to survive PND.
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Perinatal mental health, antidepressants and neonatal

outcomes: findings from the Longitudinal Study of
Australian Children

Andrew J Lewis *
Associate Professor, School of Psychology, Faculty of Health, Deakin University, Melbourne, VIC, Australia
Tel + 61 3 9244 6774 Email Andrew.Lewis@deakin.edu.au

Megan Galbally
Head of Unit, Perinatal Mental Health Unit, Mercy Hospital for Women

Catherine M Bailey
Research Fellow, School of Psychology, Faculty of Health, Deakin University

* corresponding author

Abstract
Background This study presents findings on the characteristics of women who used antidepressants in pregnancy and how such
mothers compare to depressed and non-depressed mothers in terms of their demographics and health across pregnancy. We
also present findings on the birth outcomes for these three groups of women.

Methods Data were drawn from the first wave of the Longitudinal Study of Australian Children (LSAC). This study examined
n=5,107 infants, who were assessed in their first year. Mothers reported antidepressants as a prescribed medicine over their
pregnancy.

Results In this nationally representative study, the 2.1% of Australian women who indicated that they took antidepressants
during their pregnancy also took more general medications, were more likely to smoke and drink alcohol during pregnancy,
and also reported higher depression scores at wave one and more infant sleep problems than the non-depressed control group.
Infants exposed to antidepressants showed reduced length at birth.

Conclusions Antidepressant use during pregnancy in Australian women is reasonably prevalent. Caution in prescription is
needed given that adverse child developmental outcomes have not been ruled out by existing studies. The current findings
point to the complexity of multiple in utero exposures from smoking, alcohol, depression and antidepressants impacting on child
developmental outcomes. Clinical guidelines are needed to provide optimal clinical care for infants who were exposed in utero
to antidepressants.

Keywords Depression, antidepressants, alcohol, smoking, pregnancy, neonatal outcomes.

What is known about this topic What this paper adds

• W
 ith increasing awareness and detection of perinatal
depression there has also been a sharp increase in rates
of pharmacological treatment of pregnant women over
the last decade in the USA and Canada. However, rates of
prescription in Australia have not been established.
• P
 renatal exposure to antidepressants has been
associated with neonatal discontinuation symptoms
and an increase in some birth complications, lower
gestational age and lower birth weight.
• H
 owever, untreated antenatal depression is associated
with poor child developmental outcomes and poor
maternal outcomes.
• 2
 .1% of Australian women used antidepressants during
their pregnancy and also used more general medications
and were more likely to smoke and drink alcohol during
pregnancy than depressed women or healthy women.
• A
 ntenatally depressed women show a complexity of
multiple in utero exposures each of which may impact on
neonatal outcomes.
• C
 aution in prescription is needed given that long-term
adverse child developmental outcomes have not been
ruled out and clear clinical guidelines are needed to
provide optimal clinical care for neonates who were
exposed in utero to antidepressants.

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Introduction quality, it is difficult to run such studies with large sample

sizes. This may introduce bias within the sampling, lack of
Approximately 12% of new mothers experience a major
control for covariates and insufficient power to detect subtle
depressive episode1. Maternal depression is the most common
but still clinically significant effects. In particular, these smaller
complication of childbirth in Western societies. Depression
studies of neonatal birth outcomes have suffered from a lack
impacts on a mother’s state of mind, her enjoyment of
of control for exposure to alcohol and smoking. Therefore,
pregnancy and motherhood and on the functioning of
a second methodology is frequently used which gathers
the family as a whole. Maternal depression in the perinatal
complementary information from large population studies
period has been repeatedly shown to be associated with
such as the current use of the Longitudinal Study of Australian
poorer pregnancy outcomes for mothers and for the child2,3
Children (LSAC). Antidepressant exposure is measured along
and impact on a child’s social, emotional and cognitive
with a large range of other possible exposures and in the
development4,5.
context of many other developmental factors in a large and
It is essential that midwives, obstetricians and GPs assess for nationally representative sample. This allows the effects of
antenatal and postnatal depression in women6. However, as a antidepressant exposure to be distinguished not only from
result of increasing awareness of the importance of treating a non-exposure group of mothers, but also from mothers
antenatal depression, there has been a sharp increase in who are antenatally depressed but elected not to take
rates of pharmacological treatment7,8. In a large, population- antidepressants. It also enables the confounding effects of
based study of health data, Oberlander found that rates other exposures to be controlled in the data analysis.
of prescription in British Columbia had increased over the
Using three groupings of pregnant mothers: taking
period from 1998 to 2001 from 2.3% to 5.0%9. More recent
antidepressants, depressed and non-depressed controls, the
studies in the United States have found that the rate of
current paper reports prevalence of antidepressant exposure
prescription in pregnancy has more than doubled, with rates
and characteristics of these three groups. Using propensity
between 7.6% and 13.4%7,8. Relatively little is known about
score matching of groups to control for covariates, we then
the characteristics of mothers who take antidepressants
examined whether in utero exposure to antidepressants
during pregnancy, and there is only a small but growing would be associated with poorer neonatal birth outcomes in
body of literature on the outcomes for neonates, infants and terms of gestation, weight, length and head circumference.
children who were exposed in utero to antidepressants.
Method
More specifically, the growing literature on neonatal
Study design and sample
outcomes raises a number of questions about the safety
Data were drawn from the first wave of the LSAC, an
of antidepressants in pregnancy10. Oberlander found that
ongoing, nationally representative study of the growth and
selective serotonin reuptake inhibitor (SSRI)-exposed infants
development of Australia’s children. The sampling design
had significantly lower birth weight and gestational age than
and method have been described in a previous technical
non-exposed infants and that there was a higher incidence of
paper14. LSAC used a two-stage cluster sampling design
neonatal respiratory distress, jaundice, and feeding problems
with Australian postcodes (stratified by state of residence
in the exposed group9. Our own study found prenatal
and urban versus rural status) as primary sampling units.
exposure to antidepressants was associated with neonatal
Secondary sampling units were infants born between March
discontinuation symptoms following in utero exposure11 and
2003 and February 2004, who were enrolled in the Australian
an increase in birth complications, lower gestational age and
Medicare database, excluding some very remote postcodes.
lower birth weight12.
Random selection of infants within each postcode produced
The evidence concerning the impact on neonatal, infant
a cohort aged between three and 19 months, with all birth
and child outcomes following antidepressant exposure is
months represented. Of those selected infants who were
based on two complementary research methods13. Smaller
able to be contacted, 5,107 took part in the first wave
clinical studies are able to follow mothers prospectively
of LSAC in 2004 (64.2% response rate). This sample was
across multiple time points, commencing in early pregnancy,
generally representative of all Australian infants, although
gathering information on specific types of antidepressants,
those with two-parent households, English-speaking and
severity of depression, medication dose and timing of foetal
highly educated parents were slightly over-represented13.
exposure. Such studies often measure neonatal and child
outcomes using high-quality standardised measures and Data were collected from the child’s primary caregiver via
examine outcomes at multiple time points across the child’s face-to-face interview with a trained researcher. The child’s
development. However, precisely because of their high mother was the primary caregiver in 98.6% of cases13. After

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each interview, both primary and secondary caregivers
completed a self-report questionnaire. The study was
approved by the Australian Institute of Family Studies Ethics
Committee, and a parent provided written informed consent
for every participant.
Design
The sample for this analysis was limited to infants for whom
the primary caregiver was the child’s biological mother. There
were three available depression variables in the first wave
of LSAC: Depressed for two weeks or more in the last year,
Depressed for two years or more, and the K6 Depression
Scale. The Edinburgh Post Natal Depression Scale (EPDS) was
not used in the first wave since the study design required a
repeated measure applicable to both parents and repeated
across the child’s development. The variable “Depressed
for two years or more” was chosen as indicating an overall
tendency to depression, and was therefore the measure most
likely to report depression in pregnancy.
Mothers were categorised into three groups for the purposes
of this analysis: (1) those who took antidepressants during
pregnancy; (2) those who did not take antidepressants during
pregnancy and reported depression for two or more years; and
(3) those who did not take antidepressants during pregnancy
and did not report depression for two or more years (control
group).
Measures
Demographic data. Mothers reported the child’s gender and
age, their own age, marital status, employment status, and
education status. Social disadvantage was measured using
the census-based Socio-Economic Indexes for Areas (SEIFA).
Predictor and outcome variables. Antidepressant use during
pregnancy: Mothers were asked, "What prescribed medicines
or tablets were taken? Antidepressants (yes/no)". Depression
during pregnancy: Mothers were asked, “Have you ever had
two or more years in your life when you have felt depressed
or sad most days, even if you felt OK sometimes? (yes/no)".
Child growth. Mothers were asked the weight of the baby at
birth, weeks of gestation, and to consult maternal and child
health records for the child’s length and head circumference
at birth.
Other exposures during pregnancy. A number of other exposures
were recorded including smoking, alcohol consumption and
other medications taken during pregnancy. Information
collected on drinking patterns was combined into a total
score indicating average daily alcohol consumption during
pregnancy, and then converted into a categorical variable: Did
not drink during pregnancy, or drank one or more standard
drinks per day. Mothers were asked about any cigarette
smoking. The number of cigarettes smoked on average per
day was converted into a categorical variable: Smoked more
or less than five cigarettes per day during pregnancy. Mothers
were questioned about whether they had taken antibiotics,
asthma medication, nausea medication, blood pressure
tablets, iron tablets, heartburn medicines, thyroid medicines,
other prescriptions medicines, over the counter medicines
and painkillers during pregnancy. These yes/no questions
were converted into a continuous variable measuring general
medication intake.
Statistical analysis
All analyses were performed using SPSS version 18 (SPSS Inc,
Chicago, Ill). Sample weights were used in all analyses. There
was less than one per cent missing data for parity, marital
status, school completion, work status, mothers’ age, SEIFA
disadvantage, combined medications and antidepressants
taken during pregnancy. There was 22% of missing data for
both alcohol and cigarette usage, and 17% for depressed
two years or more. Demographic variables were investigated
using the frequency function, and one-way ANOVAs were
performed.
In order to account for potentially confounding variables,

Table 1. State of residence by antidepressant medication during pregnancy.

Anti-D No anti-D Total

# (%) # (%) #

New South Wales 27 (1.6) 1690 (98.4) 1717

Victoria 31 (2.4) 1263 (97.6) 1294
Queensland 13 (1.3) 960 (98.7) 973
South Australia 14 (3.9) 342 (96.1) 356
Western Australia 18 (3.7) 474 (96.3) 492
Tasmania 2 (1.6) 120 (98.4) 122
Northern Territory 0 (0) 53 (100.0) 53
Aust. Capital Territory 3 (3.4) 86 (96.6) 89
Total 108 (2.1) 4988 (97.9) 5096

Note: Anti-D=Indicated antidepressant was used in pregnancy.

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N E ON ATA L , PA ED IAT R IC A ND CH ILD H EALTH NU RSING
propensity scores were created using the logistic regression
(binary logistic) function15. Any cases with missing data on
the variables used were removed before the propensity score
matching was conducted. The dataset was split in order to
compare group one with group two, and group one with
group three. The closest propensity scores were chosen for
each of the available scores from group one, for groups two
and three and the datasets were then merged. One-way
ANOVAs were rerun on groupings based on the propensity
score matched dataset, which effectively controlled for
confounding variables.
Results
Prevalence rates
Prevalence rates for the two variables: depressed for two
years or more and whether antidepressant medication was
taken during pregnancy were calculated. Overall, 15.6%
of the sample indicated that they had been depressed for
two years or more, and there was no significant statistical
differences between depression rates by states (x2=8.93 (7),
p=.26). Prevalence rates for antidepressant medication during
pregnancy by state are displayed in Table 1. Overall, 2.1% of
the sample indicated that they were taking antidepressants
at some time during pregnancy. Table 1 suggests that some
states appear to be prescribing antidepressants in pregnancy
at higher rates than other states (x2=19.05 (7), p=.008).
Western Australia has one of the lowest depression rates at
12.7%, compared to other state; however, it has one of the
highest rates of antidepressant medication prescription at
3.7%. South Australia (3.9%) and the ACT (3.4%) also have
relatively high rates of prescription, whilst NSW has relatively
low rates at 1.3%. Sample sizes for some states were very low,
and percentage rates need to be treated with caution.
Analyses of metropolitan versus non-metropolitan rates of
depression and antidepressant medication indicated that
there were no significant statistical differences for either
rate (x2=1.83 (1), p=.176). The rate of depression in the
metropolitan sample was 16.2%, and in the non-metropolitan
sample, 14.5%.
Study group characteristics
The study groups were calculated from the above depression
and antidepressant medication variables. Group one was all
mothers who had taken antidepressants (108 (2.1%)), group
two was mothers who indicated that they had been depressed
for two or more years but not taken antidepressants during
pregnancy (602 (11.8%)), and group three, the control group,
was mothers who indicated they have not been depressed
for two years or more, and had not taken antidepressant
medication during pregnancy (3534 (69.2%)). Missing data on
the depression variable accounted for 861 cases (16.9%). The
24
mothers in the antidepressant group were different from the
other two groups across a number of domains.
Demographic differences: the antidepressant group were
most likely to be employed full-time at wave one while the
depressed group were least likely to be married at wave
one, least likely to be either full- or part-time employed and
had the lowest SEIFA scores, indicating higher disadvantage.
Comprehensive demographic description of this sample has
been presented in a previous publication16.
Mental health differences: The three groups had significantly
different scores at wave one on the post-partum measure
of depression (K6) (F=231.13 (2, 4165), p<.001). Ratings of
depression in the first year post-partum were highest for the
antidepressant group (M=6.55, SD=4.65), slightly lower for the
depressed group (M=5.98, SD=4.60) and lowest for the control
group (M=3.06, SD=3.03).
Other exposures: As compared to the control group, mothers
who were depressed tended to smoke more (five cigarettes
or more per day) during pregnancy (OR=2.54, 95% CI 2.03,
3.17). However, women who took antidepressants were
considerably more likely to smoke during their pregnancy
than controls (OR=3.41, 95% CI 2.21, 5.27). A different pattern
emerged in terms of drinking one or more glasses of alcohol
per week during pregnancy. No significant difference was
found in the odds comparing drinking between control and
depressed women (OR=0.95, 95% CI 0.72, 1.26) nor between
control and women taking antidepressants (OR=1.21, 95% CI
0.68, 2.15).
We calculated a measure of the combined number of
other prescription and over the counter medications taken
across pregnancy. Here we found that the three groups
were significantly different F=17.66 (2, 4226), p<.001.
The antidepressant group had the highest index of other
medication usage (M=2.19, SD=1.18) while the mean of the
depressed (M=1.61, SD=1.12) and control group (M=1.61,
SD=.95) was roughly equal.
Sleep patterns of infants: When asked during the first year
post-partum whether their child had any sleep problems,
again, there were notable differences between the groups.
The lowest rate of sleep problems was in the control group
(51.3%). Children whose mothers had taken antidepressants
were most likely to have sleep problems (OR=1.68, 95%
CI 1.13, 2.51) as compared to the control group. However,
the depressed group was also more likely to report child
sleep problems than controls (OR=1.35, 95% CI 1.13, 1.61),
although the depressed and antidepressant group did not
significantly differ from one another in terms of their odds of
reporting sleep problems.
Volume 15 Number 3 – November 2012
 N EON ATAL, PAED I ATRI C AN D C H I LD H EALT H NU R S I NG

Table 2. One-way ANOVAs for weight at birth in grams, length and head circumference at birth in centimetres, and gestation in
weeks by study group, full sample.

N* Mean SD 95% CI for M f (df) p

Weight at birth 2.64 (2, 4218) 0.07
Anti-D 106 3324.0 532.61 3221.7 – 3426.4
Depressed 595 3370.0 591.02 3322.5 – 3417.6
Control 3520 3414.5 571.44 3395.6 – 3433.4
Total 4222 3405.9 573.53 3388.6 – 3423.2

Length at birth 6.21 (2, 4041) 0.002**

Anti-D 101 49.39 2.98 48.80 – 49.98
Depressed 559 50.26 3.09 50.00 – 50.51
Control 3383 50.41 2.93 50.31 – 50.50
Total 4044 50.36 2.96 50.27 – 50.45

Head circumference at birth 1.71 (2, 3928) 0.18

Anti-D 98 34.31 1.61 33.99 – 34.63
Depressed 542 34.64 1.80 34.49 – 34.79
Control 3290 34.64 1.72 34.58 – 34.69
Total 3930 34.63 1.73 34.57 – 34.68

Gestation in weeks 2.04 (2, 4203) 0.13

Anti-D 106 38.70 2.04 38.30 – 39.08
Depressed 597 39.07 2.10 38.90 – 39.23
Control 3504 39.11 2.09 39.04 – 39.18
Total 4207 39.09 2.09 39.03 – 39.16

* variability in the N is due to sample weighting, and a small amount of missing data in the antidepressant group.
** partial eta squared (effect size) =0.003, very small.

Neonatal outcomes
In order to investigate whether children in the different
depression group categories had different birth outcomes
on weight, height, head circumference and gestation length,
one-way ANOVAs were performed and are presented in
Table 2. There was a tendency for infants of mothers who
took antidepressants in pregnancy to be slightly lighter than
infants in the other two groups; however, this did not reach
statistical significance. Infants from this group are, on average,
91 grams lighter than the control group and 46 grams lighter
than the depressed group. Infants in the antidepressant
group are, on average, 1.02 cm shorter than the control
group, and 0.87 cm shorter than the depressed group;
however, there was almost no difference between groups
on head circumference. Infants in the antidepressant group
had slightly shorter gestation, being born at around 2.7 days
earlier than the control group, and 2.6 days earlier than the
depressed group. Only length reached significant statistical
difference between groups: F=6.21 (2, 4041), p=.002, partial
eta squared =.003 (small effect size).
cases which best matched to the antidepressant group were
selected in order to form a depressed group_PSM (n=206) and
the control group_PSM (n=208). Previously examined variables
were then examined to determine the match between the
original antidepressant group and the two new groups using
chi-square and one-way ANOVA tests (Married p=0.80; Full-
time work: p=0.91; Not completed school: p=0.42; Cigarette
smoking: p=.28; Alcohol: p=.74; SEIFA disadvantage: p=.82;
Combined medications: p=.14). The matching procedure
appeared to be successful since none of the examined
variables showed statistically significant between group
differences.
One-way ANOVAs were then rerun for birth weight, length,
head circumference and gestation comparing the original
antidepressant group to the new PSM groups and these
results are presented in Table 3. The antidepressant group was
still on average slightly lower in weight than the depressed
group_PSM and the control group_PSM. Length was again the
only test that reached statistical significance, F=3.57 (2, 512),
p=.03, partial eta squared=0.014, a small effect size.

In order to control for a range of possible confounders, Discussion

propensity score matching was conducted. Using a matching Our study found that 2.1% of Australian women reported
value on the propensity score a group of approximately 200 antidepressant use during pregnancy, which is a prevalence

Volume 15 Number 3 – November 2012 25

N E ON ATA L , PA ED IAT R IC A ND CH ILD H EALTH NU RSING

Table 3. One-way ANOVAs for weight at birth in grams, length and head circumference at birth in centimetres, and gestation in
weeks by study group; propensity scored matched sample.

N* Mean SD 95% CI for M f (df) p

Weight at birth 1.35 (2, 517) 0.26
Anti-D 106 3324.1 532.61 3221.7 – 3452.0
Depressed PSM 208 3432.4 614.34 3348.5 – 3516.4
Control PSM 206 3415.1 535.49 3341.6 – 3488.7
Total 521 3403.4 568.20 3354.5 – 3452.4
Length at birth 3.57 (2, 512) 0.03**
Anti-D 101 49.39 2.98 48.80 – 49.98
Depressed PSM 208 50.31 3.22 49.87 – 50.75
Control PSM 206 50.23 2.72 49.85 – 50.60
Total 515 50.09 3.00 49.83 – 50.35
Head circumference at birth 1.80 (2, 508) 0.17
Anti-D 98 34.30 1.61 33.99 – 34.63
Depressed PSM 208 34.70 1.86 34.44 – 34.95
Control PSM 206 34.63 1.59 34.41 – 34.84
Total 512 34.60 1.71 34.45 – 34.75
Gestation in weeks 2.17 (2, 517) 0.12
Anti-D 106 38.70 2.04 38.30 – 39.09
Depressed PSM 208 39.10 2.02 38.83 – 39.38
Control PSM 206 39.16 1.78 38.91 – 39.40
Total 520 39.04 1.94 38.88 – 39.21

* variability in the N is due to sample weighting, and a small amount of missing data in the Antidepressant group. PSM = propensity
score matched grouping.
** partial eta squared (effect size) =0.013, small.

rate lower than current estimates in the United States and
Canada. Rates of prescription were highest in South Australia
and Western Australia despite low to moderate overall levels of
depression. This state-wide variance may suggest differences
in service provision, access to specialist prescribing or
different perceptions amongst prescribing doctors as to the
indications for prescription of antidepressants to pregnant
women. Another consideration here is that there may be less
access to psychological interventions in South Australia and
Western Australia.
The current findings add to the growing evidence that
antenatal depression is associated with a complex set of
foetal exposures. As compared to both the depressed and
the non-depressed group, women who took antidepressants
also took more medications in general and were more likely
to smoke during pregnancy. A study using the Swedish Birth
Registry found women on antidepressants in pregnancy
had a threefold increase in rates of smoking17 consistent
with the current finding. While several previous studies have
found smoking is significantly associated with depression
in pregnancy18,19 our study was able to show that higher
rates of smoking are specifically associated with the use of
antidepressants, as distinct from the report of depression
per se. The most likely explanation is that women taking
antidepressants are presenting with more severe levels of
depression. Further studies of antidepressant exposure in
pregnancy need to examine the confounding effect of in
utero exposure to smoking, which would appear to be
correlated with antenatal depression. It is possible that prior
findings of an impact of antidepressant exposure on neonatal
growth and development are moderated by smoking in
depressed women.
Despite the use of antidepressant medication, this group
reported higher depression scores measured by the K6 in the
post-partum period. A recent study by Yonkers et al. found
there was no difference in risk of a major depressive episode
in those who took antidepressant medication compared
to those who discontinued20. However, an earlier study by
Cohen et al. found antidepressant medication in pregnancy
significantly decreased the risk of relapse3. This may reflect
the differences in the samples recruited. The Cohen et al.
study population had more severe depression and were
recruited through psychiatric services compared to a general
obstetric population for Yonkers et al.’s study. Fournier et al.
in a recent meta-analysis of adult patients with depression
found that antidepressant treatment was more effective
in those with more severe illnesses21. A limitation of this
current study is a lack of measure of severity of depression

26 Volume 15 Number 3 – November 2012


in pregnancy, although these findings clearly point to the
urgent need to thoroughly investigate the treatment efficacy
of antidepressants for both antenatal and postnatal maternal
depression.
Another interesting finding was that mothers taking
antidepressants and those depressed but not taking
antidepressants reported more infant sleep problems than
the non-depressed control group. Therefore, that either
antidepressant exposure or antenatal depression may have
an impact on neonatal sleep regulation cannot be discounted
and deserves further investigation.
While the current study overcomes some of the limitations of
prior case-control studies by making use of a larger population
dataset, it also suffers from a number of limitations which are
common in population studies. Antidepressant exposure
is defined by a single self-reported item, and outcomes are
reported via maternal report. It is also notable that a clinical
interview was not used to supplement the K6 or self-reported
depression as a screening measure due to the inherent
restrictions of a large study. However, the advantage of large
sample size and broad coverage of developmental domains
in the current study allowed for a full range of covariates to
be controlled for in the analysis.
Conclusion
Caution needs to be exercised in prescription of
antidepressants to pregnant women given that there is a
growing body of evidence of adverse child developmental
outcomes using a variety of different methods. The current
findings suggest that clinicians need to be aware that women
presenting with antenatal depression are also more likely to
use a range of other medications and smoke. This may imply
the need for additional professional advice, intervention and
public health campaigns to reduce the prevalence of such
a wide range of foetal exposures. Our findings regarding
neonatal outcomes add to a growing body of literature which
suggests that specific clinical recommendations are required
for the effective medical management of antidepressant-
exposed neonates.
Acknowledgements
This paper uses unit record data from Growing Up in Australia,
the Longitudinal Study of Australian Children. The study is
conducted in partnership between the Department of
Families, Housing, Community Services and Indigenous
Affairs (FaHCSIA), the Australian Institute of Family Studies
(AIFS) and the Australian Bureau of Statistics (ABS). The
findings and views reported in this paper are those of the
authors and should not be attributed to FaHCSIA, AIFS or the
ABS. The authors would like to thank Katherine Scalzo and
Lynne Millar for their assistance with data management.
Volume 15 Number 3 – November 2012
N EON ATAL, PAED I ATRI C AN D C H I LD H EALT H NU R S I NG
References
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2. Austin MP, Kildea S, Sullivan E. Maternal mortality and psychiatric
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2;186(7):364–7.
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Altshuler LL et al. Relapse of depression during pregnancy following
antidepressant discontinuation: a preliminary prospective study.
Arch Womens Ment Health. 2004 Oct;7(4):217–21.
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6. Buist A, Bilszta J, Milgrom J, Barnett B, Hayes B, Austin MP. Health
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al. Use of antidepressant medications during pregnancy: a multisite
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antidepressants in pregnancy. Am J Obstet Gynecol. 2007
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9. Oberlander TF, Warburton W, Misri S, Aghajanian J, Hertzman C.
Neonatal outcomes after prenatal exposure to selective serotonin
reuptake inhibitor antidepressants and maternal depression using
population-based linked health data. Arch Gen Psychiatry. 2006
Aug;63(8):898-906.
10. Galbally M, Snellen M, Walker S, Permezel M. Management of
antipsychotic and mood stabilizer medication in pregnancy:
recommendations for antenatal care. Aust N Z J Psychiatry. 2010
Feb;44(2):99–108.
11. Galbally M, Lewis AJ, Lum J, Buist A. Serotonin discontinuation
syndrome following in utero exposure to antidepressant
medication: prospective controlled study. Aust N Z J Psychiatry.
2009 Sep;43(9):846–54.
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at birth and one month postpartum following in utero exposure
to antidepressant medication. Aust N Z J Psychiatry. 2010
May;44(5):482–7.
13. Galbally M, Snellen M, Lewis AJ. A review of the use of
psychotropic medication in pregnancy. Current Opinion in
Obstetrics and Gynecology. 2011;Publish Ahead of Print:10.1097/
GCO.0b013e32834b92f3.
14. Soloff C, Lawrence D, Johnstone R. LSAC technical paper no. 1:
Sample design. Melbourne, Australia: Australian Institute of Family
Studies. 2005.
15. Rubin DB. Estimating Causal Effects from Large Data Sets Using
Propensity Scores. Annals of Internal Medicine. 1997 October 15,
1997;127(2):757–63.
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19. Pritchard CW. Depression and smoking in pregnancy in Scotland. J
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27
N E ON ATA L , PA ED IAT R IC A ND CH ILD H EALTH NU RSING
Cochrane Nursing Care Column
Editors Carmel Collins RN, RM, NICC, BSocSc, GDipPH, PhD
and Trudi Mannix RN, RM, NICC, BN(Ed), MN(Child Health),
EdD
Each issue of the journal features a summary of a Cochrane
Review relevant to neonatal, paediatric or child health
nursing. This is an initiative of the Cochrane Nursing Care
Network (CNCN). If you would like to be involved in writing
a summary, please contact the section editors Carmel Collins
(carmel.collins@health.sa.gov.au) or Trudi Mannix (trudi.
mannix@flinders.edu.au)
What is a Cochrane Review?
Cochrane Reviews help us to ‘make sense’ of often large
amounts of evidence for and against health care treatments
and practices. They are specifically designed to help clinicians,
patients and policy makers make choices regarding health
care interventions. Most Cochrane Reviews are based on
randomised controlled trials, but other types of study designs
may also be taken into account.
Cochrane summaries are based on new and updated
systematic reviews published in The Cochrane Library.
The summary must be read in conjunction with the full
review when making decisions. The authors’ conclusions are
summarised but have not been reinterpreted.
How do I access the full review?
Complete reviews are published monthly by the Cochrane
Library and are available at http://www.thecochranelibrary.
com/
Cochrane Review Summary
Intravenous in-line filters for preventing morbidity
and mortality in neonates
Clinical context
Nosocomial infection is a major problem in neonatal care
settings and is responsible for significant morbidity and
mortality. Infants requiring intravenous (IV) therapy are at risk
for catheter-associated septicaemia.
In-line IV filters are used to retain particles which may
contaminate IV fluids, such as bacteria, endotoxins, antibiotics,
glass and rubber. They have been used extensively in the adult
population since the 1960s, and now their use is increasing in
the care of neonates being treated with IV therapy. While the
use of in-line IV filters has been shown to shorten hospital
stay, reduce the incidence of phlebitis and reduce health care
costs in adults, they are not without their problems. There
28
have been reports of filters blocking, which means that the
IV line may need to be disconnected and hence increase the
potential for infection. Any contamination introduced below
the level of the filter cannot be contained by the filter. In
addition, some solutions cause the flow rate to slow. Since
there have been mixed findings about the protection offered
by IV in-line filters, a systematic review of the literature was
necessary to guide clinical practice for hospitalised neonates.
There are two main IV filter sizes. The 0.22 micron filter
is used for aqueous solutions, and the 1.2 micron filter is
recommended for larger molecule solutions such as lipids.
The aim of this Cochrane Review was to determine the effect
on neonatal morbidity and mortality of in-line IV filters.
Inclusion criteria
Studies
Randomised, or quasi-randomised controlled trials.
Participants
Neonates receiving IV infusions during the neonatal period.
Intervention
In-line IV filter versus placebo or no filter.
Outcomes
The primary outcomes included mortality, proven septicaemic
infection, and positive bacterial or fungal blood culture.
The secondary outcomes included localised phlebitis, the
number of days of cannula patency, number of catheters
inserted, suspected septicaemic infection, local or systemic
thrombus, proven or suspected necrotising enterocolitis;
periventricular leukomalacia or cystic changes in the
periventricular areas, neurodevelopment up to two years
corrected age, financial costs, and length of stay in hospital.
Pre-specified sub-group analysis included the type of filter
(0.22, 0.12 micron) and IV line (central or peripheral), the
gestation of the infant, and the type of IV fluid.
Results
Four randomised controlled trials with 704 neonates (range
63 to 442) were included in the review. All four trials aimed to
compare the use of a 0.22 micron in-line filter (intervention)
with no filter. Three of the trials changed the IV administration
set every 96 hours in the intervention group compared to
daily in the control, and one trial changed both intervention
and control sets daily.
Risk of bias
The methodological quality of the trials was limited. Only
one trial was randomised, with the remaining three quasi-
randomised using alternate allocation. A placebo was not
used in any of the trials and, therefore, the intervention was
not blinded nor was the outcome assessment. All infants
Volume 15 Number 3 – November 2012

were included in the primary outcome analysis except for
one trial where 13% of participants were excluded after
randomisation due to incomplete data.
Effects of intervention
Of the two studies in which mortality data were recorded,
there was no statistically significant difference in mortality
between infants in the control or intervention groups
[Summary RR 0.87 (95% CI 0.52 to 1.47), RD -0.01 (95% CI
-0.06 to 0.04)].
There was no statistically significant difference found in
proven sepsis in the two trials in which this was reported
[Summary RR 0.86 (95% CI 0.59 to 1.27), RD -0.02 (95% CI
-0.09 to 0.04)].
Three trials reported localised phlebitis and no statistically
significant difference was found between treatment and
control [Summary RR 1.22 (95% CI 0.40 to 3.77), RD 0.01 (95%
CI -0.05 to 0.08)]. Only one small trial (n=63) of the three
trials that reported duration of cannula patency showed an
increase in the median patency duration in the treatment
group compared to the control (49 hours versus 59 hours,
P<0.05). There was no significant difference found in the
two trials that reported the number of catheters inserted
during the neonate’s hospitalisation. In the one trial that
reported suspected septicaemic infection, local thrombosis
and proven necrotising enterocolitis, no differences between
the intervention and control was found.
None of the trials reported on systemic thrombus, suspected
necrotising enterocolitis, periventricular leukomalacia or
neurodevelopment outcomes.
Because the IV sets were changed less frequently for infants
in the intervention groups with filters in their IV sets in three
of the included trials, financial savings were recorded in those
trials.
SAVE THE DATE
ACCYPN Conference 2013; in association with the
4th International Congress in Paediatric Nursing
CONNECTING in children and young people's health care
24–27 August 2013, Melbourne Convention & Exhibition Centre
The theme of the ACCYPN Conference is CONNECTING in children and young people’s health care. The conference program will explore
innovative strategies to promote excellence in children and young people’s nursing across the continuum of care; advance nursing practice
in clinical care, education, management and research using innovation, new technologies and evaluation; and create an international forum
for the exchange of evidence-based practices and solutions among nurse researchers, clinicians, educators, policy makers and managers.
Volume 15 Number 3 – November 2012
N EON ATAL, PAED I ATRI C AN D C H I LD H EALT H NU R S I NG
Authors’ conclusions
Implications for practice
The authors concluded that although cost savings can be
made with the use of in-line IV filters due to less frequent
changing of IV sets, there is not enough evidence to
recommend their use for reducing morbidity or mortality in
neonates.
Implications for research
There is a need for more research to determine if the use of
the 0.22 micron filter and the 1.2 micron filter has any impact
on the rates of necrotising enterocolitis, periventricular
leukomalacia, local or systemic thrombus and local phlebitis
in term and preterm infants.
Summarised from:
Foster JP, Richards R & Showell MG. Intravenous in-line
filters for preventing morbidity and mortality in neonates.
Cochrane Database of Systematic Reviews 2006, Issue 2. Art.
No.: CD005248. DOI: 10.1002/14651858.CD005248.pub2.
Publication status and date: Edited (no change to conclusions),
published in Issue 9, 2011. Review content assessed as up-to-
date: 8 June 2011.
Summary prepared by:
Trudi Mannix RN, RM, NICC, BN(Ed), MN(Child Health), EdD
Flinders University School of Nursing and Midwifery,
Flinders University, Bedford Park, SA
Email: trudi.mannix@flinders.edu.au
Carmel Collins RN, RM, NICC, BSSc, GDPH, PhD
Child Nutrition Research Centre, Women’s and Children’s
Health Research Institute, Flinders Medical Centre and
Women’s and Children’s Hospital, Adelaide, SA
Email carmel.collins@health.sa.gov.au
A Member of the Cochrane Nursing Care Field (CNCF)
The call for abstracts is now open.
Key dates:
Now! – Call for abstracts opens
31 January 2013 – Call for abstracts closes
14 March 2013 – Notification of acceptance
30 June 2013 – Early bird registration closes
For more information:
http://www.accypnconf.com.au