Neurodevelopmental care in the NICU

Statistical versus clinical significance for infants with brain injury: reanalysis of outcome data from a randomized controlled study

By adopting more appropriate statistical methods to appraise data from a previously published randomized controlled trial, the statistical and clinical significance of an intervention on the 18-month neurodevelopmental outcome of infants with suspected brain injury is evaluated. The intervention group (n = 32) receives extensive, individualized cognitive/sensorimotor stimulation by public health nurses while the control group (n = 30) receives standard follow-up care. At 18 months, 43 infants remain in the study (22 intervention and 21 control). The results indicate that there is a significant statistical change within groups and a clinical significance whereby more infants in the intervention group improve in mental, motor, and neurological functioning at 18 months compared to the control group. The benefits of looking at clinical significance from a meaningful aspect for practitioners are emphasized.

Cerebellar hemorrhage in extremely low birth weight infants: incidence, risk factors, and impact on long-term outcomes

Improvements in neuroimaging technology and techniques have contributed to the increased recognition of cerebellar hemorrhage (CBH) in the prererm infant. Studies have indicated that the extremely low birth weight (ELBW) infant (< 1,000 g) is at highest risk for this injury. Associated risk factors include a constellation of antenaral, intrapartum, and neonatal factors, with immaturity, fetal distress, and cardiorespiratory instability in the early neonatal course as significant contributors. The long-term impact of CBH for the ELBW infant is not fully understood, but recent reports suggest that, in addition to motor impairments, deficits in cognitive, language, and social-behavioral function are also apparent. This article reviews the current state of knowledge of cerebellar development, risk factors for injury, and long-term developmental consequences of injury. Implications for nursing practice, education, and research are discussed.

NICU lactation consultant increases percentage of outborn versus inborn babies receiving human milk

OBJECTIVE

To determine the effect of a dedicated lactation consultant (LC) on the percentage of neonates receiving any human milk in the neonatal intensive care unit (NICU) and at discharge over time.

STUDY DESIGN

Retrospective chart review of three time periods of 3 months each; Time period 1 (before LC hire), Time period 2 (T2; after LC arrival) and Time period 3 (subsequent period after T2).

RESULT

Percentage of infants receiving any HM during hospital stay and at discharge increased significantly over time after LC hire and with LC experience. Outborn (OB) infants receiving any HM in the NICU and at discharge increased over time, but there was no significant change for inborn infants, as the proportion receiving any HM remained consistently high over time.

CONCLUSION

Addition of a dedicated LC to the NICU increased the percentage of neonates receiving any HM, specifically in the OB population.

Sleep and kangaroo care: clinical practice in the newborn intensive care unit: where the baby sleeps

This article provides a review of a change in practice within a Level III neonatal intensive care unit setting. The use of skin-to-skin holding as a means to secure parents' attachment to their infant, and support their child's rest and recovery in the neonatal intensive care unit, has been recognized historically and supported by research in this practice. The importance of sleep to the infant's developmental outcome was recognized and the use of skin-to-skin holding as a means of increasing stable infant sleep and rest was implemented. The implementation was based on published research, current practice within the nursery, and staff and family discussions. Implementation of skin-to-skin holding earlier in the newborn's neonatal intensive care unit course was accomplished by increasing interactive education, support, and ongoing review of unit practices and outcomes. Education regarding sleep states and cues was a focus of the project and understanding infant sleep assisted the staff in recognizing levels of restful sleep or restless sleep in infants. The implications of sleep and infant success in achieving discharge to home allowed the staff to see not only their role in infant sleep but also the parents' role in their newborn infant's sleep and growth in the nursery.

A música como recurso no cuidado à criança hospitalizada: uma intervenção possível?

Trata-se de um estudo bibliográfico realizado a partir das bases de dados MEDLINE e LILACS e vias não-sistematizadas, no período de 1994 a 2004. Teve como objetivo analisar a produção bibliográfica da enfermagem pediátrica quanto à utilização da música como recurso terapêutico no espaço hospitalar, a fim de identificar o estado do conhecimento desta área nesse campo. Da análise do material empírico, emergiram três unidades de significados: o cenário, as intervenções e as repercussões. Os resultados evidenciaram os benefícios da música para a criança hospitalizada, seus familiares e equipe de saúde e constatou-se que este recurso pode ser utilizado no espaço hospitalar como uma intervenção de baixo custo, não-farmacológica e não-invasiva, promovendo um processo de desenvolvimento que visa à saúde da criança, da família e dos trabalhadores.

Early dyadic patterns of mother-infant interactions and outcomes of prematurity at 18 months

OBJECTIVE

With the increased survival of very preterm infants, there is a growing concern for their developmental and socioemotional outcomes. The quality of the early mother-infant relationship has been noted as 1 of the factors that may exacerbate or soften the potentially adverse impact of preterm birth, particularly concerning the infant's later competencies and development. The first purpose of the study was to identify at 6 months of corrected age whether there were specific dyadic mother-infant patterns of interaction in preterm as compared with term mother-infant dyads. The second purpose was to examine the potential impact of these dyadic patterns on the infant's behavioral and developmental outcomes at 18 months of corrected age.

METHODS

During a 12-month period (January-December 1998), all preterm infants who were <34 weeks of gestational age and hospitalized at the NICU of the Lausanne University Hospital were considered for inclusion in this longitudinal prospective follow-up study. Control healthy term infants were recruited during the same period from the maternity ward of our hospital. Mother-infant dyads with preterm infants (n = 47) and term infants (n = 25) were assessed at 6 months of corrected age during a mother-infant play interaction and coded according to the Care Index. This instrument evaluates the mother's interactional behavior according to 3 scales (sensitivity, control, and unresponsiveness) and the child's interactional behavior according to 4 scales (cooperation, compliance, difficult, and passivity). At 18 months, behavioral outcomes of the children were assessed on the basis of a semistructured interview of the mother, the Symptom Check List. The Symptom Check List explores 4 groups of behavioral symptoms: sleeping problems, eating problems, psychosomatic symptoms, and behavioral and emotional disorders. At the same age, developmental outcomes were evaluated using the Griffiths Developmental Scales. Five areas were evaluated: locomotor, personal-social, hearing and speech, eye-hand coordination, and performance.

RESULTS

Among the possible dyadic patterns of interaction, 2 patterns emerge recurrently in mother-infant preterm dyads: a "cooperative pattern" with a sensitive mother and a cooperative-responsive infant (28%) and a "controlling pattern" with a controlling mother and a compulsive-compliant infant (28%). The remaining 44% form a heterogeneous group that gathers all of the other preterm dyads and is composed of 1 sensitive mother-passive infant; 10 controlling mothers with a cooperative, difficult, or passive infant; and 10 unresponsive mothers with a cooperative, difficult, or passive infant. Among the term control subjects, 68% of the dyads are categorized as cooperative pattern dyads, 12% as controlling pattern dyads, and the 20% remaining as heterogeneous dyads. At 18 months, preterm infants of cooperative pattern dyads have similar outcomes as the term control infants. Preterm infants of controlling pattern dyads have significantly fewer positive outcomes as compared with preterm infants of cooperative pattern dyads, as well as compared with term control infants. They display significantly more behavioral symptoms than term infants, including more eating problems than term infants as well as infants from cooperative preterm dyads. Infants of the controlling preterm dyads do not differ significantly for the total development quotient but have worse personal-social development than term infants and worse hearing-speech development than infants from cooperative preterm dyads. The preterm infants of the heterogeneous group have outcomes that can be considered as intermediate with no significant differences compared with preterm infants from the cooperative pattern or the controlling pattern dyads.

CONCLUSION

Among mother-preterm infant dyads, we identified 2 specific patterns of interaction that could play either a protective (cooperative pattern) or a risk-precipitating (controlling pattern) role on developmental and behavioral outcome, independent of perinatal risk factors and of the family's socioeconomic background. The controlling pattern is much more prevalent among preterm than term dyads and is related to a less favorable infant outcome. However, the cooperative pattern still represents almost 30% of the preterm dyads, with infants' outcome comparable to the ones of term infants. These results point out the impact of the quality of mother-infant relationship on the infant's outcome. The most important clinical implication should be to support a healthy parent-infant relationship already in the NICU but also in the first months of the infant's life. Early individualized family-based interventions during neonatal hospitalization and transition to home have been shown to reduce maternal stress and depression and increase maternal self-esteem and to improve positive early parent-preterm infant interactions.

Neurophysiologic assessment of neonatal sleep organization: preliminary results of a randomized, controlled trial of skin contact with preterm infants

BACKGROUND

Sleep is important to brain organization, but few strategies to promote sleep among premature infants have been tested. Behaviorally based measures of sleep have shown increased quiet sleep (QS) and decreased active sleep (AS) during skin-to-skin contact (SSC) with the mother, but these results have not been confirmed with objective electroencephalographic/polysomnographic measures of sleep organization. Important differences exist between behavioral and electroencephalographic/polysomnographic definitions of sleep state.

METHODS

Data for the first 28 relatively healthy, preterm subjects of an ongoing randomized trial of one 2- to 3-hour session of SSC or incubator care between feedings are reported here. Infants were positioned prone, inclined, and nested in an incubator during the 2- to 3-hour pretest period, were fed, and then went into the test period of SSC or incubator care. Infants were left largely undisturbed throughout testing. A mixed-model regression analysis compared the test-pretest differences in outcome measures within and between groups.

RESULTS

Results showed that arousals were significantly lower in the SSC group, compared with the control group, for the entire study period and for test-pretest matched segments of QS and AS. Rapid eye movement was significantly lower for the SSC group for the study period and AS segments. Indeterminate sleep was significantly lower for the SSC group when confounding environmental variables were included in the regression analysis. When 4 subjects who experienced excessive ambient light levels during SSC were removed from analysis, QS increased during SSC.

CONCLUSIONS

The patterns demonstrated by the SSC group are analogous to more-mature sleep organization. SSC may be used as an intervention to improve sleep organization in this population of preterm infants.

Does a mother singing to her premature baby affect feeding in the neonatal intensive care unit?

Recent studies suggest that premature neonates exposed to music have reduced symptoms of stress, faster weight gain, and shorter neonatal intensive care unit (NICU) stays. This pilot study attempted to measure contingent effects of mothers' singing during feedings. Mothers sang to their babies during 2 of 4 feedings on 2 consecutive days, logging songs they sang, and subjectively evaluating each feeding. Infants' heart and respiration rates were recorded as well as duration of feeding and volume of fluid taken orally; feeding velocity and percent of feeding goal were calculated. In paired t tests, no significant benefits or deterrents assignable to the singing were observed.

Randomised trial of parental support for families with very preterm children: outcome at 5 years

AIMS

To test the effectiveness of a home based developmental education intervention in improving outcome at 5 years for very preterm infants.

METHODS

The Avon Premature Infant Project (APIP) is a randomised controlled trial in which the parents of 284 babies born <33 weeks gestational age received a developmental education programme, a social support intervention, or standard care. A term reference population was also recruited. This study reports outcomes at 5 years (mean age 58 months 15 days) for 187 (66%) of these children without disability. Outcomes were assessed using the British Ability Scales II for cognitive development, the Movement ABC for motor impairment, and the Child Behavior Checklist for behavioural problems.

RESULTS

Preterm infants showed poorer cognitive performance than their term peers. Mean (SD) general conceptual ability (GCA) scores were: Portage 99.2 (15.7); parent adviser 100.3 (14.8); preterm control 101.1 (15.0); term reference 107.2 (13.4). There were no significant differences between preterm groups in GCA scores indicating no effect of either intervention. Similarly, there was no significant effect of intervention on behavioural or motor outcomes. Further analyses, in which outcome data were adjusted for social factors, did not reveal any differences between the three preterm groups or by subgroups classified by a range of perinatal variables.

CONCLUSION

The small advantage shown at 2 years of age is no longer detectable at 5 years. These results question the effectiveness of early intervention in enhancing cognitive, behavioural, and motor function at 5 years.

Music as Therapy

Music is widely used to enhance well-being, reduce stress, and distract patients from unpleasant symptoms. Although there are wide variations in individual preferences, music appears to exert direct physiologic effects through the autonomic nervous system. It also has indirect effects by modifying caregiver behavior. Music effectively reduces anxiety and improves mood for medical and surgical patients, for patients in intensive care units and patients undergoing procedures, and for children as well as adults. Music is a low-cost intervention that often reduces surgical, procedural, acute, and chronic pain. Music also improves the quality of life for patients receiving palliative care, enhancing a sense of comfort and relaxation. Providing music to caregivers may be a cost-effective and enjoyable strategy to improve empathy, compassion, and relationship-centered care while not increasing errors or interfering with technical aspects of care.

Evidence-based design for infants and staff in the neonatal intensive care unit

Conscientious architects are becoming increasingly aware of the impact of design decisions on the sensory environment of the neonatal intensive care unit (NICU). This article addresses the relevance of theories of environmental psychology to NICU design. Design research on infants and staff in NICUs is summarized, and future research directions are identified.