Neonatal physiological and behavioral stress during neurological assessment

Establishing Normative Values for Healthy Term Infant Feeding Performance: Neonatal Eating Assessment Tool-Mixed, Oral Feeding Scale, and Early Feeding Skills Assessment

PURPOSE

Infants with perceived feeding problems are frequently referred for assessment of their feeding abilities. However, little is known regarding how healthy nondysphagic infants perform on commonly used assessments, making determination of impairment difficult. The aim of this investigation was to elucidate the characteristics of healthy term infant feeding performance using three commonly employed clinical assessments: Neonatal Eating Assessment Tool-Mixed (NeoEat-Mixed), Oral Feeding Scale, and Early Feeding Skills (EFS).

METHOD

In this prospective case-control study, we recruited 30 infants without feeding impairments to undergo video-monitored bottle feeds under their normal feeding conditions. Caregiver perception of infant feeding was evaluated using the NeoEat-Mixed. Milk ingestion was monitored real time using the Oral Feeding Scale for rate of milk transfer and modified proficiency as characterized by the total volume consumed out of the total volume the caregiver provided. Videos were analyzed by two speech pathologists using the EFS assessment. Descriptive statistics were used to characterize performance.

RESULTS

Participants underwent feeding monitoring at an average chronological age of 4 ± 2 months. Caregivers primarily reported normal, nonconcerning feeding patterns across all of the NeoEAT-Mixed outcomes. Infants consumed milk at an average rate of transfer of 7 ± 3 ml/min, a modified proficiency of 50 ± 21%, and achieved the highest OFS score of 4 (93%, n = 28). The majority of infants scored the best EFS score (mature-3) as it related to the absence of color changes during the feed (97%, n = 29), although commonly scored in the worst EFS score (immature-1) in their presentation of one or more compelling stress cues (63%, n = 19).

CONCLUSION

Establishing healthy term infant normative values for commonly used feeding assessments is critical in accurately distinguishing infants with feeding impairments from those with normal developmental variants.

Reconceptualizing Somatic Dysfunction in the Light of a Neuroaesthetic Enactive Paradigm

Background: Palpatory findings are considered a central element of osteopathic practice, especially when associated with a patient's altered regulative functions than with named somatic dysfunctions. Although osteopathic theories for somatic dysfunction could be plausible, the clinical applicability of the concept is debated, especially because it is largely related to simple cause-effect models of osteopathic care. In contrast to a linear kind of diagnosis of a "tissue as a producer of symptoms", this perspective article aims to provide a conceptual and operational framework in which the somatic dysfunction evaluation process is seen as a neuroaesthetic (en)active encounter between osteopath and patient. Subsections relevant to the subject: To summarize all concepts of the hypothesis, the enactive neuroaesthetics principles are proposed as a critical foundation for the osteopathic assessment and treatment of the person, specifically addressing a new paradigm for somatic dysfunction. Conclusions, and future directions: The present perspective article represents a proposition to blend technical rationality informed by neurocognitive and social sciences, and professional artistry clinical experience informed by traditional tenets, to overcome the controversy around somatic dysfunction, rather than dismissing the concept.

Acoustic conditioning of the neonatal incubator compartment: Improvement proposal

The objective of this work focuses on the study of the main sources of noise associated with incubators and the acoustic effects that derive from them. The method that has been established is based on tests carried out under different operating conditions of the incubators. Noise levels are analyzed under different boundary conditions (Neonatal ICU and "Controlled environment rooms"). Under normal operating conditions, the levels inside the incubator are around 56 dB (A), values that exceed the maximum limits recommended by the American Academy of Pediatrics. The scope of this study is to evaluate the existing noise levels in the incubator and analyze possible design improvements. The study was carried out in the hospitals of Cádiz, Huelva, and Malaga.

The impact of parental contact upon cortical noxious-related activity in human neonates

BACKGROUND

Neonates display strong behavioural, physiological and cortical responses to tissue-damaging procedures. Parental contact can successfully regulate general behavioural and physiological reactivity of the infant, but it is not known whether it can influence noxious-related activity in the brain. Brain activity is highly dependent upon maternal presence in animal models, and therefore this could be an important contextual factor in human infant pain-related brain activity.

METHODS

Global topographic analysis was used to identify the presence and inter-group differences in noxious-related activity in three separate parental contexts. EEG was recorded during a clinically required heel lance in three age and sex-matched groups of neonates (a) while held by a parent in skin-to-skin (n = 9), (b) while held by a parent with clothing (n = 9) or (c) not held at all, but in individualized care (n = 9).

RESULTS

The lance elicited a sequence of 4-5 event-related potentials (ERPs), including the noxious ERP (nERP), which was smallest for infants held skin-to-skin and largest for infants held with clothing (p=0.016). The nERP was then followed by additional and divergent long-latency ERPs (> 750 ms post-lance), not previously described, in each of the groups, suggesting the engagement of different higher level cortical processes depending on parental contact.

CONCLUSIONS

These results show the importance of considering contextual factors in determining infant brain activity and reveal the powerful influence of parental contact upon noxious-related activity across the developing human brain.

SIGNIFICANCE

This observational study found that the way in which the neonatal brain processes a noxious stimulus is altered by the type of contact the infant has with their mother. Specifically, being held in skin-to-skin reduces the magnitude of noxious-related cortical activity. This work has also shown that different neural mechanisms are engaged depending on the mother/infant context, suggesting maternal contact can change how a baby's brain processes a noxious stimulus.

PREDICTIVE VALUE OF THE GENERAL MOVEMENTS ASSESSMENT IN PRETERM INFANTS: A META-ANALYSIS

Objective:

To discuss the predictive value of the General Movements Assessment for the diagnosis of neurodevelopment disorders in preterm newborns.

Data source:

We conducted a systematic literature review using the following databases: Scientific Electronic Library Online (SciELO), National Library of Medicine, National Institutes of Health (PubMed), and Excerpta Medica Database (EMBASE). The articles were filtered by language, year of publication, population of interest, use of Prechtl’s Method on the Qualitative Assessment of General Movements, and presence of variables related to the predictive value. The Quality Assessment of Diagnostic Accuracy Studies 2 was used to assess the methodology of the included studies. Sensitivity, specificity, Diagnostic Odds Ratio, positive and negative likelihood ratio, and parameter of accuracy were calculated.

Data synthesis:

Six of 342 articles were included. The evaluation of Writhing Movements is a good indicator for recognizing cerebral palsy, as it has high values for the sensitivity and accuracy parameters. The evaluation of Fidgety Movements has the strongest predictive validity for cerebral palsy, as it has high values in all measures of diagnostic accuracy. The quality assessment shows high risk of bias for patient selection and flow and timing of the evaluation. Therefore, the scale has potential to detect individuals with neurodevelopment disorders. However, the studies presented limitations regarding the selection of subjects and the assessment of neurological outcomes.

Conclusions:

Despite the high predictive values of the tool to identify neurological disorders, research on the subject is required due to the heterogeneity of the current studies.

Neurobehavior of preterm infants from 32 to 48 weeks post-menstrual age

AIM

Evaluate prospectively the neurobehavior of preterm infants (PT).

STUDY DESIGN

Cohort of PT (gestational age(GA) <32weeks), evaluated biweekly from 32 to 48 weeks post-menstrual age (PMA) by NICU Network Neurobehavioral Scale (NNNS). Scores were compared by repeated Measures ANOVA. Scores of PT were compared to those of full-term infants, matched for gender by ANOVA.

RESULTS

39 PT (mean ± SD: GA 29.2 ± 2.0 weeks; birthweight 1100 ± 331g) were studied. As PMA progressed, PT showed increasing scores in habituation, attention, arousal, regulation, maneuvers for orientation, quality of movements and hypertonicity, and decreasing scores in excitability, lethargy, non-optimal reflexes, asymmetry, hypotonicity, and signs of stress/withdrawal. At 40 weeks PMA, PT were similar to term neonates assessed in the first days of life, except for less habituation, regulation capacity and excitability, and more hypotonia.

CONCLUSION

At 40 weeks PMA, PT reached the performance of full-term neonates evaluated in the first days of life in most neurobehavior domains.

Early developmental assessment with a short screening test, the STEP, predicts one-year outcomes

OBJECTIVE

To evaluate the Specific Test of Early Infant Motor Performance (STEP), a rapid screening test of preterm infants at risk for developmental delay.

STUDY DESIGN

We prospectively studied 23 preterm infants' performance on the STEP and the Test of Infant Motor Performance (TIMP) at term and 3 months, and on the Bayley-III at 12 months. We investigated the psychometric qualities of the STEP and determined STEP cutoff scores for low and high-performing infants.

RESULTS

STEP scores at term and 3 months strongly correlate with 12-month Bayley-III gross motor and cognitive scaled scores, while TIMP scores did not. The STEP showed excellent reliability and required 6-10 min to administer.

CONCLUSION

STEP is a short, easy to administer, early developmental assessment with unique scoring that emphasizes qualitative and quantitative aspects of muscle tone in movements and predicts 12-month Bayley gross motor and cognitive scaled scores.

Effects of bathing interval on skin condition and axillary bacterial colonization in preterm infants

AIM

The objective of this study was to evaluate the effects of preterm infant bathing periods on skin condition and axillary skin colonization.

BACKGROUND

Reducing the frequency of bathing in preterm infants is beneficial in reducing the risk of hypothermia and exposure to stress from frequent nursing contacts.

METHODS

The subjects of this study were observed at The V hospital at the C University in South Korea between December 2012 and August 2013. A total of 32 preterm infants were included and were randomly assigned to two different bathing intervals; every four days (n=16) and the other every two days (n=16) bathing groups. A neonatal skin conditions were assessed on a daily basis, whereas, axillary skin colonization was measured every eight days before bathing. Data was analyzed via the SPSS program with a non-inferiority test, t-test, chi-square test, Fisher's exact test, and paired t-test.

RESULTS

Mean differences of skin condition between the four-day bathing and two-day bathing groups were 0.065 and the 97.5% one-sided confidence limit was 0.196 (less than the non-inferiority margin, 0.3). There were no statistically significant differences in skin condition and axillary skin colonization between the two groups (p>0.05).

CONCLUSION

The interval of bathing for preterm infants can be changed from every two days to every four days without increasing the incidence of skin condition problems or axillary skin colonization. Less-frequent bathing may decrease the chance of physiological instability caused by the caring process, while providing them with a better environment for growth and development.

A Systematic Review of the Predictive Validity of Neurobehavioral Assessments During the Preterm Period

AIMS

For high-risk newborns, early assessment of neurobehavior that accurately predicts neurodevelopmental outcome is the first step towards determining early intervention needs. This study reviews systematically the validity of neurobehavioral assessments administered to premature newborns before term-equivalent age to predict long-term neurodevelopmental outcome.

METHODS

A systematic literature search of CINAHL, EMBASE, MEDLINE, PubMed, Web of Science, PsychInfo, Cochrane Library databases was conducted. PRISMA and COSMIN guidelines were followed.

RESULTS

Five assessments and 11 studies were identified: (a) Neonatal Behavioral Assessment Scale (NBAS); (b) Test of Infant Motor Performance (TIMP); (c) General Movements (GMs); (d) Neurobehavioral Assessment of the Preterm Infant (NAPI); (e) Neonatal Oral Motor Assessment Scale (NOMAS). Predictive validity estimates were variable. The GMs and TIMP showed the strongest associations with neurodevelopmental outcome. Threats to validity included small sample size, sample bias, limited reliability testing.

CONCLUSIONS

Five neurobehavioral measures have established predictive validity for the assessment of premature newborns while they reside in the NICU. Although the GMs and TIMP have the strongest evidence, further higher quality research is required. New methods of testing should be developed that provide accurate prediction and minimize the potential stress induced during developmental assessments.

Physiological stress responses in infants at 29-32 weeks' postmenstrual age during clustered nursing cares and standardised neurobehavioural assessments

OBJECTIVE

To compare the physiological stress responses of infants born <30 weeks' gestational age when undergoing clustered nursing cares with standardised neurobehavioural assessments in neonatal nurseries.

DESIGN/METHODS

Thirty-four infants born <30 weeks' gestation were recruited from a tertiary neonatal intensive care unit. Heart rate (HR) and oxygen saturation were recorded during clustered nursing cares and during standardised neurobehavioural assessments (including the General Movements Assessment, Hammersmith Neonatal Neurological Examination and Premie-Neuro Assessment). Two assessors extracted HR and oxygen saturations at 5 s intervals, with HR instability defined either as tachycardia (HR >180 beats per minute (bpm)) or bradycardia (HR <100 bpm). Oxygen desaturations were defined as SpO₂<90%. Physiological stability was compared between nursing cares and neurobehavioural assessments using linear (for continuous outcomes) and logistic (HR instability and oxygen desaturation) regression.

RESULTS

Compared with clustered nursing cares HR was lower (mean difference -5.9 bpm; 95% CI -6.5 to 5.3; P<0.001) and oxygen saturation higher (mean difference 2.4%; 95% CI 2.1% to 2.6%; P<0.001) during standardised neurobehavioural assessments. Compared with clustered nursing cares neurobehavioural assessments were also associated with reduced odds of tachycardia (OR 0.44, 95% CI 0.22 to 0.86), HR instability (OR 0.43, 95% CI 0.22 to 0.85) and oxygen desaturation (OR 0.43, 95% CI 0.26 to 0.70).

CONCLUSIONS

Standardised neurobehavioural assessments are associated with less physiological stress than clustered nursing cares in infants aged 29-32 weeks' postmenstrual age, and are therefore possible without causing undue physiological disturbance in medically stable infants.

Early Initiation of Newborn Individualized Developmental Care and Assessment Program (NIDCAP) Reduces Length of Stay: A Quality Improvement Project

Infants born at ≤32weeks gestation are at risk of developmental delays. Review of the literature indicates NIDCAP improves parental satisfaction, minimizes developmental delays, and decreases length of stay, thus reducing cost of hospitalization. Half (50.6%) of the infants admitted to this 84-bed Level IV Neonatal Intensive Care Unit (NICU) with a gestational age of ≤32weeks were referred for NIDCAP. The specific aims of this quality improvement project were to 1) compare the age at discharge for infants meeting inclusion criteria enrolled in NIDCAP with the age at discharge for those eligible infants not enrolled in NIDCAP; and 2) investigate the timing of initiation of NIDCAP (e.g., within six days of admission) on age at discharge. During the 12month period of data collection, infants enrolled in NIDCAP (M=27.85weeks, SD=1.86) were 2.02weeks younger than those not enrolled in NIDCAP (M=29.87weeks, SD=2.49), and were 2.32weeks older at discharge (M=38.28weeks, SD=5.10) than those not enrolled in NIDCAP (M=35.96weeks, SD=5.60). Infants who enrolled within 6days of admission were discharged an average of 25days sooner (p=0.055), and at a younger post-menstrual age (by 3.33weeks on average), than those enrolled later (p=0.027).