[Sensory system development and the physical environment of infants born very preterm]

The effect of developmental care on the length of hospital stay and family centered care practice for very low birth weight infants in neonatal intensive care units: A cluster randomized controlled trial

BACKGROUND

Despite previous studies suggesting that developmental care can provide benign stimulation to promote neural development of newborns, more evidence is needed regarding the other clinical benefits of developmental care.

OBJECTIVE

To evaluate the effect of implementing developmental care on the length of hospital stay, the improvement of care practice in neonatal intensive care units, as well as the short-term outcome of very low birth weight infants.

DESIGN

Cluster-randomized controlled trial.

SETTING(S) AND PARTICIPANTS

From March 1, 2021 to March 1, 2022, 1400 very low birth weight infants were recruited from 14 tertiary neonatal intensive care units in China.

METHODS

We assigned 14 neonatal intensive care units to either developmental care or standard care. The length of hospital stay of the infants was the primary outcome analyzed at the individual level. Secondary outcomes were family centered care practice including parental involvement, the skin to skin care, exclusive breast milk, oral immune therapy and breastfeeding. The environmental management (noise and light) and the short-term outcomes were also evaluated.

RESULTS

The length of hospital stay for the developmental care group was 65 % as long as that for the control group (HR: 0.65, 95 % CI, 0.451-0936, p = 0.021). After controlling the covariables, the adjusted HR = 0.755 (95 % CI, 0.515 to 1.107, p = 0.150). When compared to the control group, the developmental care group had greater access to SSC, with 22 infants (3.8 %) in the developmental care group compared to 13 infants (1.7 %) in the standard care group (p = 0.013). A greater proportion of infants in the developmental care group were fed at the breast, than those in the standard care group (136 [23.6 %] vs 9 [1.1 %]; p = 0.029). Compared to the control group, exclusively breast milk was significantly more favorable in the developmental care group (435 [75.6 %] vs 114 [15.0 %]; p = 0.001). The difference remained significant even after adjusting for covariates. However, the rate of oral immune therapy and parental involvement was similar in the two groups. The average noise and light levels in the developmental care group were significantly lower than those in the standard care group. After adjusting for confounders, the difference remained significant. There were no significant differences among groups in the mortality and major morbidity.

CONCLUSIONS

Developmental care might have developed an accumulated effect over time on the length of hospital stay among very low birth weight infants. The implementation of developmental care can greatly improve family centered care practices and the neonatal intensive care unit environment.

REGISTRATION

ClinicalTrials.govNCT05166720. Registration date: 1 March, 2021.

[André Bullinger's contributions to the management of prematurity in neonatology]

Between 30 and 50 % of very premature babies have disorders that can affect their schooling, training and future life. Their origin is often multifactorial, and environmental, socioeconomic and family factors can influence the subsequent development of these children. Among these factors, the neonatal environment, which is generally very noisy and bright, as well as the numerous tactile solicitations, have been blamed. In 1978, the kangaroo method transformed this reality by improving the parent-baby relationship and reducing neonatal mortality. Since then, a trend has developed around developmental care with the Neonatal Individualized Developmental Care Assessment Program and the approach of André Bullinger.

Care with child development and André Bullinger's special look at prematurity

OBJECTIVE

To assess different ways of caring for preterm infants' development and for their families in neonatal units, with emphasis on the studies by André Bullinger.

DATA SOURCE

A review of the literature in the databases PubMed, SciELO, and the Cairn.info portal, which publishes reviews in human sciences in French. Also, the books and articles of André Bullinger, available only in French, were reviewed.

DATA SYNTHESIS

This review includes the Kangaroo Method, which is based on skin to skin contact and the encouragement of breastfeeding; the Newborn Individualized Developmental Care and Assessment Program (NIDCAP), based on the Synaptic Developmental Theory and aiming to positively change the neonatal environment, having the preterm newborn as the actor of their own development and the mother as a regulator; and the Bullinger Approach, which uses a sensory-motor perspective to approach child development, including preterm infants' development.

CONCLUSIONS

The Kangaroo Method has changed child developmental care in countries with limited financial resources. NIDCAP was shown to be efficient, although only a few long-term studies have been conducted on the subject. The Bullinger Approach is well diffused in European neonatal units, with promising results for the prevention of neurodevelopmental disabilities, especially those related to orality.

Very preterm infants displayed similar imitation skills to full-term infants at term equivalent age

AIM

Very preterm infants are exposed to an atypical environment that could alter their developmental trajectory. We aimed to examine neonatal imitation, a foundation of social cognition, in very preterm and full-term infants.

METHODS

In Strasbourg, France, between 2015 and 2018, we prospectively investigated the development of imitation skills. Very preterm (27 to 33 weeks of gestational age, n = 20) and full-term infants (n = 20) were enrolled using four gestures: tongue protrusion, mouth opening, sequential finger movements and hand movements. All testing were performed in infants at term-equivalent age. Two independent and blinded observers coded the behaviour of each infant on video recording. Facial expressions or hand movements, similar to the one presented, were quantified and classified according to their timing.

RESULTS

A total of 37 out of 40 infants imitated at least one gesture. The very preterm and term infants did not differ in the presence of imitation or its timing for the four gestures tested. The very preterm infants displayed more imitation abilities for sequential finger movement. Tongue protrusion and sequential finger movement were the particularly strong imitated gesture in both groups.

CONCLUSION

These findings are the first to show similar neonatal imitation in term and very preterm infants. Our results may support early parent-infant social interactions.

Pain Behavioural Response to Acoustic and Light Environmental Changes in Very Preterm Infants

Noise and high light illumination in the neonatal intensive care unit (NICU) are recognized as stressors that could alter the well-being and development of vulnerable preterm infants. This prospective observational study evaluated the pain behaviours of very preterm infants (VPIs) to sound peaks (SPs) and light levels variations (LLVs) in the NICU. We measured spontaneously occurring SPs and LLVs in the incubators of 26 VPIs over 10 h. Their behavioural responses were analysed through video recordings using the "Douleur Aigue du Nouveau-né" (DAN) scale. We compared the maximum DAN scores before and after environmental stimuli and the percentage of VPIs with a score ≥ 3 according to the type of stimuli. A total of 591 SPs and 278 LLVs were analysed. SPs of 5 to 15 dBA and LLVs significantly increased the maximum DAN scores compared to baseline. The occurrence of DAN scores ≥ 3 increased with both stressors, with a total of 16% of SPs and 8% of LLVs leading to quantifiable pain behaviour. Altogether, this study shows that VPIs are sensitive to SPs and LLVs, with a slighter higher sensitivity to SPs. The mechanisms leading to pain behaviours induced by noise and light changes should be evaluated further in the context of VPIs brain development. Our results provide further arguments to optimize the NICU sensory environment of neonatal units and to adapt it to the expectations and sensory abilities of VPIs.

Early discharge and hospital-assisted home care is associated with better neurodevelopmental outcome in preterm infants

AIMS

To compare hospital-assisted neonatal home care and standard hospital care for preterm newborns on neurodevelopment at 2 years corrected age, as well as duration of hospitalization, breastmilk rates, and readmissions before 1 year.

METHODS

This observational study enrolled 415 inborn neonates <34^{+ 6} weeks that received home care (2008 to 2015) in the French University Hospital of Toulouse and 3186 neonates from the national cohort of infants discharged in 2011 that received standard hospital neonatal care (EPIPAGE 2). Neurodevelopment at 2 years was assessed with the Ages and Stages Questionnaire-3 (ASQ-3).

RESULTS

At two years corrected age, infants in home care had 61% less risk of overall low ASQ ≤220 (OR = 0.4 [0.3-0.5], p < 0.001) and 31-80% less risk of low scores in four out of five domains compared to standard care. Home care was associated with shorter hospital stays (- 9 days; p < 0.001), higher breastmilk rates at final discharge (OR = 3.6 [2.8-4.6], p < 0.001 for singletons and OR = 2.3 [1.6-3.1], p < 0.001 for multiples), and more breastmilk feeding for at least six months (OR = 1.8 [1.3-2.3], p < 0.001 for singletons, OR = 3.6 [2.1-6.3], p < 0.001 for multiples). Readmissions also occurred less frequently with home care than with standard care, except for twins (OR = 0.7 [0.6-0.8], p < 0.001).

CONCLUSION

Hospital-assisted neonatal home care for preterm infants was associated with better neurodevelopment at 2 years corrected age, shorter duration of hospitalization, and higher rates of breastmilk feeding at 6 months.

Application of the Neonatal Behavioral Assessment Scale to Evaluate the Neurobehavior of Preterm Neonates

Background: The neonatal behavioral assessment scale (NBAS) was primarily developed to aid in the assessment of full-term neonates. The aim of this study was to detect if the NBAS was also valuable in the assessment of preterm neonates. Materials and Methods: We assessed 112 infants at a neonatal unit using the NBAS, 4th edition. The inclusion criteria included an oxygen saturation level between 88–95% and a heartrate of 100–205 beats per minute. Infant neurobehavior was assessed using the NBAS. Results: For full-term and preterm neonates, we observed that the NBAS enabled us to assess both groups of infants and gave relevant information pertaining to them. We found a significant correlation between the average week of gestation and response to touch, sensory input, peak of excitement, cost of attention, hand-to-mouth, and quality of alertness. Conclusions: The NBAS is a valuable scale for evaluating the neurobehavior of preterm neonates. The week of gestation at birth affects certain aspects of neurobehavior, such as response to sensory input, putting hand to mouth, peak of excitement, and cost of attention. The NBAS as an individually structured assessment may help in planning for early rehabilitation and intervention for this vulnerable population.

Changes of Infant- and Family-Centered Care Practices Administered to Extremely Preterm Infants During Implementation of the NIDCAP Program

Introduction: Many studies have evaluated the Neonatal Individualized Developmental Care and Assessment Program (NIDCAP), but few studies have assessed changes in infant- and family-centered developmental care (IFCDC) practices during its implementation. Objectives: The primary objective of this single center study was to investigate the impact of the implementation of the NIDCAP program on IFCDC practices used for management of extremely preterm infants (EPIs). The secondary objective was to determine during implementation the impact of this program on the short-term medical outcomes of all EPIs hospitalized at our center. Methods: All EPIs (<28 weeks gestational age) who were hospitalized at Strasbourg University Hospital from 2007 to 2014 were initially included. Outborn infants were excluded. The data of EPIs were compared for three time periods: 2007 to 2008 (pre-NIDCAP), 2010 to 2011, and 2013 to 2014 (during-NIDCAP implementation) using appropriate statistical tests. The clinical and caring procedures used during the first 14 days of life were analyzed, with a focus on components of individualized developmental care (NIDCAP observations), infant pain management (number of painful procedures, clinical pain assessment), skin-to-skin contact (SSC; frequency, day of initiation, and duration), and family access and involvement in the care of their children (duration of parental presence, parental participation in care). The short-term mortality and morbidity at discharge were evaluated. Results: We examined 228 EPIs who received care during the three time periods. Over time, painful procedures decreased, but pain evaluations, parental involvement in care, individualized observations, and SSC increased (all p < 0.01). In addition, the first SSC was performed earlier (p = 0.03) and lasted longer (p < 0.01). There were no differences in mortality and morbidity, but there were reductions in the duration of mechanical ventilation (p = 0.02) and the time from birth to first extubation (p = 0.02), and an increase of weight gain at discharge (p = 0.02). Conclusion: NIDCAP implementation was accompanied by progressive, measurable, and significant changes in IFCDC strategies. There were, concomitantly, moderate but statistically significant improvements in multiple important outcome measures of all hospitalized EPI.

[The discipline of nursing : Knowledge, teaching, and care]

In recent years, professional skills and the nursing profession in France have undergone major transformations. These have included the recognition of advanced nursing practice and its implementation in 2018, and the creation by the National Council of Universities in 2019 of a &#8220;Nursing&#8221; section (n&#176;&#160;92), which has paved the way for the development of research and teaching in nursing in an academic environment in France.To support these transformations, the Association de recherche en soins infirmiers (Arsi) (Nursing Research Association) has for several years been organizing seminars and symposia. The seminar &#8220;The discipline of nursing&#160;: Knowledge, teaching, and care,&#8221; held on November 16, 2019 in Paris, was a continuation of those organized in 2014 and 2016.This seminar focused on the acquisition of nursing knowledge, in particular through the analysis of clinical situations using two middle-range theories&#160;: comfort and symptom management.The first part of this article describes the objectives and the working methodology of the seminar. The second part provides a recap of the theoretical foundations, while the third and final part presents the results of what the workshops participants produced.

Pain, Parental Involvement, and Oxytocin in the Neonatal Intensive Care Unit

Preterm infants (PTI) typically experience many painful and stressful procedures or events during their first weeks of life in a neonatal intensive care unit, and these can profoundly impact subsequent brain development and function. Several protective interventions during this sensitive period stimulate the oxytocin system, reduce pain and stress, and improve brain development. This review provides an overview of the environmental risk factors experienced by PTI during hospitalization, with a focus on the effects of pain, and early maternal separation. We also describe the long-term adverse effects of the simultaneous experiences of pain and maternal separation, and the potential beneficial effects of maternal vocalizations, parental contact, and several related processes, which appear to be mediated by the oxytocin system.

[Music therapy in neonatalogy with premature babies and their parents]

Music therapy sessions in neonatal units, as part of a survey of practices, favoured the infant's physiological and behavioural stability as well as the parent-infant relationship throughout their time in hospital. Beneficial for the newborn, this concept, still a pioneering practice in neonatal units, could be combined with early developmental care intervention programmes.

Recommendations on the environment for hospitalised newborn infants from the French neonatal society: rationale, methods and first recommendation on neonatal intensive care unit design

AIM

Hospitalised newborn infants may be stressed due to inappropriate sensory stimuli and early separation from their families, that can negatively impact their neurodevelopment. The French Group of Reflection and Evaluation of the Environment of Newborns (GREEN) issues guidelines based on environmental neonatology and family-centred care. The first recommendation focuses on private family rooms versus large shared rooms.

METHODS

These guidelines are based on a systematic evaluation of the literature providing different grades of evidence. Internal and external reviews by multidisciplinary experts examined the scientific evidence of all recommendations. The literature search was performed for the period January 1, 2000 to January 1, 2016 with the keywords 'single room' or 'private room' and 'neonatal intensive care unit'.

RESULTS

A total of 25 studies were retained. Most studies reported a positive impact of private rooms on the health of newborn infants and satisfaction of families. Private rooms could lead to sensory deprivation if there is low parental involvement with limited presence and to reduced interaction among caregivers.

CONCLUSION

We recommend that neonatal units should mostly have private rooms. With this architectural design, we recommend supporting the staff's needs for changes in the organisation and philosophy of care and to provide improved family support.

Observational study found that even small variations in light can wake up very preterm infants in a neonatal intensive care unit

AIM

This prospective observational study evaluated the behavioural responses of very preterm infants to spontaneous light variations.

METHODS

We measured spontaneous light variations in the incubators of 27 very preterm infants, with a median gestational age of 28 weeks (range 26-31 weeks), over 10 hours. All of them had been admitted to the neonatal care unit of the Strasbourg University Hospital, France, between April 2008 and July 2009. Two independent raters examined changes in the infants' behavioural states using video recordings. The percentage of awakenings was recorded when there were light variations and during control periods with no changes.

RESULTS

We analysed 275 periods following light variations and 275 control periods. The overall percentage of awakenings was greater during periods following a change in light than during control periods (16.3% vs 11%, p = 0.03). The extent of light protection affected the percentage of awakenings. In mild light protection, there were more awakenings following changes in light than in control periods (25.6% vs 6.7%, p = 0.01). This difference was not found in high light protection.

CONCLUSION

Very preterm infants can be woken up by small variations in light, when the light protection in their incubator is insufficient.

The course and support of sensorimotor development in a premature infant

Prematurely born babies account for nearly 7% of all infants coming into the world, and there are more and more extremely small premature babies being born. A report covering 184 countries shows that each year, 14.9 million children are born ahead of time. Maintaining life is the fi rst task faced by the medical service. The issue regarding development and the future of these children is the next stage of interest for both doctors and a number of specialists from related fields. The aim of the study was to review literature concerning premature newborns in the fi eld of sensorimotor development within the fi rst years of life, taking into account the hazards and possible forms of early support. An attempt was made to present the current state of knowledge in the scope of recommended and used methods of conduct as well as to assess the long-term effects of undertaken interventions. A review of Polish-, English- and French-language literature was conducted, which concerned sensory motor development, introduction of early rehabilitation and support programmes for premature infants. Research papers and review works from the last 10 years included in databases (PubMed and websites of Polish medical publishing houses) were analysed. The works were searched using the following keywords: premature baby, sensorimotor development. The growing group of preemies requires adapted care. To counteract the indicated threats, a therapeutic intervention should be introduced precisely and in accordance with a child’s needs. There is a need to broaden knowledge about development in this group of children and to create a proven developmental support system that would be based on long-term research. Currently, support for babies born too early is heterogeneous, and the research carried out does not allow to design a single support model or clearly defi ned standards of conduct. premature infant, sensorimotor stimulation, rehabilitation 24 Jan. 2017; Accepted: 22 Nov. 2018

Very preterm infants can detect small variations in light levels in incubators

AIM

This prospective observational study was designed to improve our understanding of the responses of very preterm infants to light level variations in incubators and to evaluate what determined those reactions.

METHODS

The physiological responses of 27 very preterm infants were analysed following variations in the light level environments of their incubators over 10 hours. Heart and respiratory rates, systemic oxygen saturation and regional cerebral oxygen saturations were recorded using near-infrared spectroscopy, and the variation of each parameter was analysed.

RESULTS

We analysed 332 light level changes. Heart rate increased by 3.8 beats per minute (range -2.6 to 12.6), respiratory rate by six cycles per minute (-1.5 to 26) and regional cerebral oxygen saturation by 1.1% (-0.5% to 3.9%) (p < 0.05 each) when delta lux was over 50. Only respiratory rate decreased significantly, by -8.4 cycles per minute (-28 to -0.4), when delta lux was 50 or lower (p < 0.05). The initial level of illumination altered the very preterm infants' responses, with higher reactivity for higher ambient light levels.

CONCLUSION

Very preterm infants reacted to moderate variations in illumination in their incubator, within recommended ranges of light levels, suggesting that they may detect even small light level variations.

Hemisphere differences in speech-sound event-related potentials in intensive care neonates: associations and predictive value for development in infancy

Neurodevelopmental delays in intensive care neonates are common but difficult to predict. In children, hemisphere differences in cortical processing of speech are predictive of cognitive performance. We hypothesized that hemisphere differences in auditory event-related potentials in intensive care neonates are predictive of neurodevelopment in infancy, even in those born preterm. Event-related potentials to speech sounds were prospectively recorded in 57 infants (gestational age 24-40 weeks) prior to discharge. The Developmental Assessment of Young Children was performed at 6 and 12 months. Hemisphere differences in mean amplitudes increased with postnatal age (P < .01) but not with gestational age. Greater hemisphere differences were associated with improved communication and cognitive scores at 6 and 12 months, but decreased in significance at 12 months after adjusting for socioeconomic and clinical factors. Auditory cortical responses can be used in intensive care neonates to help identify infants at higher risk for delays in infancy.

The International Network for Evaluating Outcomes of very low birth weight, very preterm neonates (iNeo): a protocol for collaborative comparisons of international health services for quality improvement in neonatal care

BACKGROUND

The International Network for Evaluating Outcomes in Neonates (iNeo) is a collaboration of population-based national neonatal networks including Australia and New Zealand, Canada, Israel, Japan, Spain, Sweden, Switzerland, and the UK. The aim of iNeo is to provide a platform for comparative evaluation of outcomes of very preterm and very low birth weight neonates at the national, site, and individual level to generate evidence for improvement of outcomes in these infants.

METHODS/DESIGN

Individual-level data from each iNeo network will be used for comparative analysis of neonatal outcomes between networks. Variations in outcomes will be identified and disseminated to generate hypotheses regarding factors impacting outcome variation. Detailed information on physical and environmental factors, human and resource factors, and processes of care will be collected from network sites, and tested for association with neonatal outcomes. Subsequently, changes in identified practices that may influence the variations in outcomes will be implemented and evaluated using quality improvement methods.

DISCUSSION

The evidence obtained using the iNeo platform will enable clinical teams from member networks to identify, implement, and evaluate practice and service provision changes aimed at improving the care and outcomes of very low birth weight and very preterm infants within their respective countries. The knowledge generated will be available worldwide with a likely global impact.

Tactile sensory capacity of the preterm infant: manual perception of shape from 28 gestational weeks

OBJECTIVE

Recent studies have shown that from the postconceptional age of 33 weeks, preterm infants are able to memorize tactile information about the shape of an object by using their hands, and can detect differences with another shape. This study aimed to investigate tactile abilities earlier on in development, in very preterm and mildly preterm human infants.

METHODS

Infants were assigned to 2 groups according to postconceptional age: very preterm (before 32 weeks) and mildly preterm (from 32 to 33+6 weeks). The test consisted of the repeated presentation of an object (prism or cylinder) in the left hand. The experiment was conducted in 3 phases: habituation (repeated presentation of the same object), discrimination (presentation of a novel object), followed by recognition (presentation of the familiar object).

RESULTS

Forty-eight newborns were recruited (24 very preterm; 24 mildly preterm). During habituation, each infant showed a decrease in the holding time of the object. Then, when a novel shape was put into the preterm newborn's hand, holding time increased. Finally, when the familiar shape was presented again, the holding time decreased. Preterm infants can memorize by touch specific features that differentiate prism and cylinder shapes, discriminate between them, and recognize them after interference.

CONCLUSIONS

From 28 weeks, and from the first days of life, the preterm newborn is endowed with tactile sensory capacities. The tactile stimulations that are presented to preterm infants during their hospitalization should be adapted while respecting their sleep-wake rhythms.