Motor performance in very preterm infants before and after implementation of the newborn individualized developmental care and assessment programme in a neonatal intensive care unit

Period prevalence of positional head deformations and implications for practice in a large tertiary neonatal unit

AIM

To establish the prevalence of positional head deformations (PHDs) within a neonatal unit (NU) setting, and to evaluate the subsequent impact that PHDs have on NU graduates and their families.

METHODS

A prospective audit was conducted over a six-week period within a tertiary NU (Brisbane, Australia). Eligible babies were measured weekly using a craniometer where presence, type and severity of PHD were determined. Univariate analysis was undertaken to establish differences in clinical characteristics between babies with, and without, the presence of PHD. A study-specific survey was completed by a separate set of families returning for outpatient follow-up services who represented similar clinical characteristics and risk factors for PHD.

RESULTS

Fifty-three babies were eligible for inclusion in the audit. PHDs were identified in 66% (n = 35) of the cohort, the most common being scaphocephaly (52.8%, n = 28). Within that, 46% (n = 13) were classed as mild, 25% (n = 7) were moderate and 29% (n = 8) were severe. Moderate correlation (r = 0.55) was found between severity of scaphocephaly, and length of time spent in an isolette. Of the 10 (66% response from 15 families) surveys completed, 80% of respondents perceived that their child's PHD had impacted their life.

CONCLUSIONS

Two-thirds of babies developed a PHD during their neonatal admission. Most families surveyed perceived this condition to have an impact on their lives beyond the confines of the nursery. Further research is needed to identify preventative interventions to decrease the prevalence and severity of this common condition.

A randomized-controlled trial of parent-administered interventions to improve short-term motor outcomes in hospitalized very low birthweight infants

BACKGROUND

Premature infants are at increased risk for cerebral palsy (CP). Early interventions with a motor focus and administered by parents may improve motor outcomes.

AIMS

Secondary study evaluating the short-term motor outcomes and risk for CP in very low birthweight (VLBW) infants randomized to multimodal interventions with a motor focus provided by parents versus usual care.

STUDY DESIGN

Randomized controlled trial (intervention vs. usual care (control group)).

SUBJECTS

Infants (<32 weeks' gestational age (GA) and/or <1500 grams birthweight) born between March 2019 and October 2020.

OUTCOME MEASURES

Short-term motor outcomes and risk for CP was evaluated using the Hammersmith Infant Neurological Evaluation (HINE, primary motor outcome), the General Movement Assessment (GMA) and the Test of Infant Motor Performance (TIMP) at 3 months' postmenstrual age (PMA).

RESULTS

70 participants were enrolled (GA 28.3±2.7 weeks, birthweight 1139.2±376.6 grams, 64.3% male). The in-person follow-up rate was 73%, lower than expected, in part due to COVID-19 restrictions, resulting in 25 infants (intervention) and 26 infants (control) with outcome data available for analysis. There was not a significant difference in the HINE, GMA or TIMP at 3 months' PMA between groups.

CONCLUSION

Multimodal interventions with a motor focus and provided by parents need further investigation to determine if they can improve short-term motor outcomes in VLBW infants. These interventions are evidence-based and the evaluation of broader implementation into routine care is also needed.

Compliance With Best Practice Guidelines for Neurodevelopmental Supportive Care in South Africa: A Situational Analysis

Neurodevelopmental supportive care provides preterm infants with evidence-based care to ensure the best possible neurological outcomes. The study aimed to determine the compliance of current nursing care practices with best practice guidelines by means of a situational analysis. The situational analysis was done in 2 cycles in the neonatal intensive care units (n = 25) of a private healthcare provider in South Africa. Structured observations were done in cycle 1 using the Implementation of Neurodevelopmental Supportive Care checklist. Cycle 2 comprised focus group discussions to verify findings from cycle 1. Seventeen conclusion statements were formulated, which were thematically combined to be presented as 9 categories: neonatal intensive care unit design, individualized care, family-centered care, infant positioning, handling techniques, environmental manipulation, pain management, knowledge of infant behavior, and feeding. The conclusion statements identified improvement opportunities in current practice and offer suggestions, which can be used to guide an implementation strategy for best practice guidelines of neurodevelopmental supportive care in the neonatal intensive care units of the private healthcare group in future. Addressing improvement opportunities in all the categories will ensure that all aspects of the guideline requirements are met, resulting in a comprehensive strategy improving practice and patient outcomes.

Neurocognitive impairment after neonatal sepsis: protocol for a systematic review and meta-analysis

INTRODUCTION

The effect of neonatal sepsis on the developing brain is not well documented. We aim to perform evidence synthesis to determine the outcome of neurodevelopmental impairment and intellectual disability among survivors of neonatal sepsis. The data gathered will inform on the long-term neurocognitive outcomes of neonates with sepsis and the measures used to document their developmental disability.

METHODS AND ANALYSIS

We will perform a search based on the following parameters: neonates and infants less than 90 days old diagnosed with sepsis who had neurocognitive outcomes or measures of developmental disability reported. We will search PubMed, Cochrane Central, Embase and Web of Science for articles in English language published between January 2010 and December 2019. Clinical trials and observational studies will be included. Two independent reviewers will screen studies for eligibility. Data extraction will then be performed using a standardised form. The quality of evidence and risk of bias will be assessed using Cochrane Collaboration's tool and Risk of Bias in Non-randomised Studies of Intervention (ROBINS-I). The results will be synthesised qualitatively and pooled for meta-analysis.

ETHICS AND DISSEMINATION

No formal ethical approval is required as there is no collection of primary data. This systematic review and meta-analysis will be disseminated through conference meetings and peer-reviewed publications.

PROSPERO REGISTRATION NUMBER

Registration submitted CRD42020164334.

Neuromotor and sensory development in preterm infants: prospective study

Aim

To investigate the relationship between motor and sensory development in the first 4 months of life in preterm infants born at 32 gestational weeks and below.

Material and Methods

The study consisted of 56 high-risk infants with a corrected age of 1 month who were born at 32 gestational weeks and stayed in the neonatal intensive care unit for at least 15 days. Neuro Sensory Motor Developmental Assessment and Infant Sensory Profile-2 were used for evaluation. These assessments were applied to preterm infants at the 1^st and 4^th months. The results of assessments were analyzed using the Wilcoxon test. The relationship between the results of motor and sensory assessments was analyzed using Spearman's correlation test.

Results

The mean gestational age of the infants was 29.58±2.09 weeks, their birth weights were 1233.87±251.22 grams, and their duration of stay in the neonatal intensive care unit was 26.48±9.58 days. There was a statistically significant difference between the Neuro Sensory Motor Developmental Assessment and Infant Sensory Profile-2 scores between the 1^st and 4^th months (p<0.05). It was found that there was a risk in terms of sensory development in 86-91% of the preterm infants at the 1^st month and in 69-85% at the 4^th month. There was moderate-strong degree of significant relationship between motor and sensory development.

Conclusion

Considering the findings of our study, preterm infants are at risk for motor and sensory development. There is, therefore, a need for future research to investigate the effect of early sensory-based intervention approaches on preterm infants.

Experience of neonatal intensive care unit nurses in providing developmentally-supportive care: A qualitative study

Many challenges have been noted in the implementation of developmentally-supportive care principles in neonatal intensive care units, despite evidence that adhering to such care principles achieves positive results for the neonate. The aim of this study was to explore and describe compliance in adhering to developmentally-supportive care principles implemented in one neonatal intensive care unit in South Africa. An exploratory design was used in this qualitative study with purposive sampling to select eligible neonatal intensive care registered nurses (n = 14) as participants. Participants all worked in a 10 bed neonatal intensive care unit at a large tertiary care public hospital. Six audio-recorded interviews were conducted, with recordings subsequently transcribed and analyzed. Three main themes were identified: value of developmentally-supportive care, nature of developmentally-supportive care, and barriers to developmentally-supportive care. One of the main themes had subthemes, which substantiated the findings, and included parent involvement, nurse engagement, and holistic care. Study outcomes offer insight into the development or revision of policies and practices, which are crucial when implementing developmentally-supportive care, particularly in resource-poor settings where challenges are magnified.

Targeted educational program improves infant positioning practice in the NICU

Quality problem or issue

Infant positioning may interfere with neuromotor development. Bedside education and Infant Positioning Assessment Tool (IPAT) improve nurses' and doctors' proficiency in applying proper infant positioning.

Initial assessment

Nursing compliance with proper positioning is suboptimal due to many factors. One factor was the inadequate knowledge and practice of infant positioning, since the baseline mean IPAT score was 3.4.

Choice of solution

Three experienced neonatal intensive care unit (NICU) nurses were chosen as position champions to help other NICU nurses apply proper positioning and monitor IPAT scores. Education and hands-on demonstration sessions were developed based on the observed baseline practice.

Implementation

Periodic education with hands-on demonstration was given to NICU nurses and residents. Infants' positions were objectively scored using IPAT. Two Plan, Do, Study and Act cycles were completed and adjustments were made based on each cycle's achieved results.

Evaluation

Mean IPAT scores increased from 3.4 at baseline and 6.3 in the second cycle to 7.3 in the third cycle of intervention.

Lessons learned

A systematic approach targeting infants' positioning succeeded in improving nurses' and residents' clinical performance. Not reaching significant change until after 18 months highlights the difficulty and complexity in changing behaviors.

Investigation of the Relationship Between Sensory Processing and Motor Development in Preterm Infants

OBJECTIVE

The aim of this study was to analyze the correlation between sensory processing and motor development in preterm infants.

METHOD

We included 30 preterm and 30 term infants with corrected and chronological ages between 10 and 12 mo. We used the Test of Sensory Functions in Infants to evaluate sensory processing and the Alberta Infant Motor Scale to evaluate motor development.

RESULTS

The Spearman correlation test indicated a strong positive relationship between sensory processing and motor development in preterm infants (r = .63, p < .001).

CONCLUSION

Given the relationship between sensory processing and motor development in the preterm group, the evaluation of sensory processing and motor development in preterm infants was considered necessary for the effective implementation of physiotherapy assessment and interventions.

Structured Educational Intervention Leads to Better Infant Positioning in the NICU

PURPOSE

The purpose is to test the effectiveness of an educational intervention in improving infant positioning because positioning may interfere with neuromotor development.

METHODS

A quality improvement (QI) project was initiated to increase knowledge and improve the compliance of nurses and physicians in infant positioning using the Infant Positioning Assessment Tool (IPAT). The project was part of Neonatal Individualized Developmental Care Assessment Program (NIDCAP) training. It included informal discussion and practice about infant positions.

MAIN OUTCOME VARIABLES

Staff knowledge, IPAT score.

RESULTS

Fifty-two pediatric residents and 39 NICU nurses participated in this project. The mean knowledge assessment test score improved significantly for both nurses (p < .0001) and residents (p < .0001) postintervention; IPAT scores increased significantly from 3.4 (±2. 5) to 8.1 (±2.7) (p < .001).

CONCLUSION

Nurses' education with hands-on practice improved infant positioning in the NICU; this may lead to fewer positional deformities and possibly an improved developmental outcome.

Individualized Developmental Care in the NICU: A Concept Analysis

BACKGROUND

Individualized developmental care (IDC) is a collection of evidence-based practices that include adapting care practices based on the infant's behavioral and developmental state, involving parents and families in the infant's care, and providing an environment that minimizes over stimulation of the infant.

PURPOSE

To clarify the definition of IDC in the neonatal intensive care unit (NICU) and to provide guidelines for implementation of IDC for healthcare professionals through a concept analysis.

METHOD/SEARCH STRATEGY

A literature review involving a search of multiple electronic databases from January 1982 to November 2016 was performed along with presentation of a model case and attributes of IDC.

CONCLUSIONS

This concept analysis defines and provides guidelines for implementing an individualized developmentally sound environment for infants born premature and their families.

IMPLICATIONS FOR PRACTICE

All NICUs need to strive to provide an environment that supports and promotes IDC. Education needs to be provided to healthcare providers and parents regarding IDC practices.

IMPLICATIONS FOR RESEARCH

Further research into short- and long-term outcomes of IDC is needed. Research into whether IDC is being implemented by NICUs is also needed.

Motor Development Interventions for Preterm Infants: A Systematic Review and Meta-analysis

CONTEXTS

Preterm infants are at an increased risk of neurodevelopmental delay. Some studies report positive intervention effects on motor outcomes, but it is currently unclear which motor activities are most effective in the short and longer term.

OBJECTIVE

The aim of the study was to identify interventions that improve the motor development of preterm infants.

DATA SOURCES

An a priori protocol was agreed upon. Seventeen electronic databases from 1980 to April 2015 and gray literature sources were searched.

STUDY SELECTION

Three reviewers screened the articles.

DATA EXTRACTION

The outcome of interest was motor skills assessment scores. All data collection and risk of bias assessments were agreed upon by the 3 reviewers.

RESULTS

Forty-two publications, which reported results from 36 trials (25 randomized controlled trials and 11 nonrandomized studies) with a total of 3484 infants, met the inclusion criteria. A meta-analysis was conducted by using standardized mean differences on 21 studies, with positive effects found at 3 months (mean 1.37; confidence interval 0.48-2.27), 6 months (0.34; 0.11-0.57), 12 months (0.73; 0.20-1.26), and 24 months (0.28; 0.07-0.49). At 3 months, there was a large and significant effect size for motor-specific interventions (2.00; 0.28-3.72) but not generic interventions (0.33; -0.03 to -0.69). Studies were not excluded on the basis of quality; therefore, heterogeneity was significant and the random-effects model was used.

LIMITATIONS

Incomplete or inconsistent reporting of outcome measures limited the data available for meta-analysis beyond 24 months.

CONCLUSIONS

A positive intervention effect on motor skills appears to be present up to 24 months' corrected age. There is some evidence at 3 months that interventions with specific motor components are most effective.

Support to mothers of premature babies using NIDCAP method: a non-randomized controlled trial

BACKGROUND

The Newborn Individualized Developmental Care and Assessment Program (NIDCAP) is based on preterm infant's observation during hospitalization and considers infant's behavior as the key to evaluate the level of neurobehavioral maturation.

OBJECTIVES

To evaluate the effectiveness of NIDCAP program on mother's support and infant development.

STUDY DESIGN

Non-randomized controlled study, including 43 infants of 32 weeks gestation receiving either a Standard Care (SC) or NIDCAP assessment. The Nurse Parent Support Tool (NPST) was given to mothers before discharge to evaluate the support given by NICU staff. Infants' motor, visual and auditory development was investigated by a neurofunctional assessment (NFA) at term and at 3 months. The effect of NIDCAP assessment on length of hospital stay and feeding status at discharge were also evaluated.

RESULTS

Mothers in the NIDCAP group awarded higher scores in the majority of the NPST items than mothers in the SC group. NFA at term resulted to be normal in a significant higher percentage of infants that underwent NIDCAP, while no difference could be detected at 3 months.

CONCLUSIONS

NIDCAP is an effective program to promote mothers' involvement in infants' care, that, in turn, could endorse infants' neurofunctional development in the short term.

A Narrative Synthesis of the Components of and Evidence for Patient- and Family-Centered Care

A narrative synthesis was conducted to determine typical patient- and family-centered care (PFCC) components and their link to outcomes in pediatric populations. 68 studies with PFCC interventions and experimental designs were included. Study features were synthesized based on 5 core PFCC components (i.e., education from the provider to the patient and/or family, information sharing from the family to the provider, social-emotional support, adapting care to match family background, and/or s decision-making) and 4 outcome categories (health status; the experience, knowledge, and attitudes of the patient/family; patient/family behavior; or provider behavior). The most common PFCC component was education; the least common was adapting care to family background. The presence of social-emotional support alone, as well as educational interventions augmented with shared decision-making, social-emotional support, or adaptations of care based on family background, predicted improvements in families' knowledge, attitudes, and experience. Interventions that targeted the family were associated with positive outcomes.

Compared outcomes of very preterm infants born in 2000 and 2005

AIM

To compare neonatal and 2-year outcomes in very premature infants born 5 years apart.

METHODS

Prospective observational study of infants born before 33 weeks' gestation in 2000 or 2005 admitted to a neonatal intensive care unit in France. We collected perinatal data and evaluated motor, cognitive, neurosensory and behavioural outcomes at 2 years of age.

RESULTS

  We included 170 infants in 2000 and 173 in 2005. The significant differences in neonatal outcomes were decreases in postnatal corticosteroid use and in percentage of infants with head circumference below the 3rd percentile on days 7 (25% vs. 13%) and 30 (30% vs. 17%). At 2 years of age, rates of follow-up were 87% in 2000 and 94% in 2005. The cerebral palsy rate was 6% in both cohorts. The overall rate of motor disabilities diminished from 30% (41/137) to 18% (26/142), and the rate of mild motor disabilities decreased from 24% to 12%. Rates of cognitive, behavioural and neurosensorial impairments were similar.

CONCLUSION

  Between 2000 and 2005, motor impairments at 2 years of age diminished in very preterm children (but not cerebral palsy rates). We observed a reduced use of postnatal corticosteroids and a decreased percentage of neonates with head circumference below the third percentile.

Family-centered developmental care practices and research: what will the next century bring?

Family-centered developmental care is an essential element of neonatal intensive care. It is of particular importance when the infant is vulnerable and at greater risk for poor outcomes complicated by a family unit that is easily challenged by the unique needs of the infant. Yet, all infants and their families deserve this philosophy of caregiving. Family-centered developmental care must continue to be tested through research to determine which interventions work, what does not work, and which interventions need further refinement. This article provides a brief history of where we have been in neonatal caregiving, provides definitions for family-centered developmental caregiving and offers some "predictions" about where these practices need to be in the next century. Research questions and strategies are also addressed. As we continue to forge ahead integrating this philosophy into the caregiving arena, it is important to remember that there are many unanswered questions.