Developmental patterns of physiological response to a multisensory intervention in extremely premature and high-risk infants

Interdisciplinary collaborative eye examinations to protect preterm infant neurodevelopment: a quality improvement project

Introduction

Infants born <31 weeks gestational age with birth weight ≤ 1,500 grams receive routine eye examinations to screen for Retinopathy of Prematurity (ROP) while in the Neonatal Intensive Care Unit (NICU) to help prevent vision threatening complications; however, preterm infants' sensory systems are underdeveloped, and repeated exposure to painful stimuli is associated with worse developmental outcomes.

Methods

An interdisciplinary NICU team designed a collaborative eye exam model (CEEM) incorporating best practice recommendations for infant pain control during exams. Pain scores and vital signs were recorded before, during, and after exams. Two sets of mixed-effects regression models with a random intercept on infants were established to investigate relationships between the intervention, birth gestational age (BGA), postmenstrual age (PMA), and outcomes associated with painful stimuli. Survey feedback was elicited from NICU stakeholders about the CEEM.

Results

Thirty standard of care (SC) and 35 CEEM exams of 37 infants were included in final analysis. In infants of the same BGA, the number of desaturation events was significantly reduced in the CEEM group (p = 0.003) and became 1.53 times smaller with each additional week of BGA (p = 0.009). Probability of heart rate recovery within 15 min lowered significantly in the CEEM group (p = 0.04). In SC or CEEM or between infants of the same PMA, no differences were observed for bradycardia, heart rate range, chance of heart rate recovery, or pain scores. Increases in tachycardia (p < 0.001) events and desaturations p = 0.006 were discovered in the CEEM group. When considering interaction effects, the CEEM appeared to reduce the number of desaturations to a greater degree for infants at earliest BGAs with attenuation of this effect with greater BGA. Regarding PMA, bradycardia and tachycardia events were reduced for infants across PMAs in the CEEM, but the effect for tachycardia improves with age, while the effect for bradycardia diminishes with age. Stakeholders agreed that the infant's eye exam experience and the staff experience was "very much" improved by the CEEM.

Discussion

Despite variable findings in selected outcome measures, the CEEM was positively viewed by staff. Infants may benefit from the CEEM differently based on BGA and PMA.

Effect of tactile and/or kinesthetic stimulation therapy of preterm infants on their parents' anxiety and depressive symptoms: A systematic review

BACKGROUND

In the case of preterm birth, the idealized postnatal period is replaced by an anxious and even traumatic experience for parents. Higher prevalence of parental anxiety, postnatal depression, and posttraumatic stress disorder has been observed in mothers of preterm infants up to 18 months after childbirth. There is increasing evidence that proprioceptive stimulation has a beneficial effect on preterms' short-term outcomes. Could this care also have an impact on parental anxiety and depressive symptoms? We reviewed recent publications on the impact on parents' anxiety and depressive symptoms of delivering tactile and/or kinesthetic stimulation to their premature newborn.

METHODS

We conducted a systematic review by searching the PubMed, PsycInfo, Scopus, ScienceDirect and Google Scholar databases for English-language publications from the past 10 years. We focused on the mothers or fathers of infants born preterm (before 37 weeks of gestation) who provided tactile and/or kinesthetic stimulation to their premature newborn in the neonatal intensive care unit. Relevant outcomes were the parents' anxiety, stress, depressive symptoms, and symptoms of posttraumatic stress disorder, assessed with reliable standardized inventories.

RESULTS

Eleven articles were included in the systematic review. Results suggested a beneficial effect of parents' early tactile and kinesthetic stimulation of their preterm infants.

CONCLUSIONS

These interventions may act as protective factors against the occurrence of anxiety and depressive symptoms in parents and deserve to be studied further in this population.

Infant massage as a stress management technique for parents of hospitalized extremely preterm infants

Mothers of infants born extremely preterm requiring prolonged medical intervention in the Neonatal Intensive Care Unit (NICU) are at high risk of developing stress. Parent-administered infant massage is a well-established, safe intervention for preterm infants with many developmental benefits, but the published literature has mostly examined its impact on infants and parents through self-reported or observational measures of stress. The aim of this study was to measure salivary cortisol, a biomarker for stress, in extremely preterm infants and their mothers immediately pre and post parent-administered infant massage in order to detect potential changes in physiologic stress. Twenty-two mother-infant dyads completed massage education with a physical or occupational therapist. All dyads provided salivary cortisol samples via buccal swab immediately pre- and post-massage at the second session. Of mothers determined to be "cortisol responders" (15/22), salivary cortisol levels were lower after massage (pre-minus post-level: -26.47 ng/dL, [CI = -4.40, -48.53], p = .016, paired t-test). Our primary findings include a clinically significant decrease (as measured by percent change) in maternal cortisol levels immediately post parent-administered massage, indicating decreased physiological stress. Integration of infant massage into NICU clinical practice may support maternal mental health, but further powered studies are necessary to confirm findings.

Musical and vocal interventions to improve neurodevelopmental outcomes for preterm infants

BACKGROUND

Preterm birth interferes with brain maturation, and subsequent clinical events and interventions may have additional deleterious effects. Music as therapy is offered increasingly in neonatal intensive care units aiming to improve health outcomes and quality of life for both preterm infants and the well-being of their parents. Systematic reviews of mixed methodological quality have demonstrated ambiguous results for the efficacy of various types of auditory stimulation of preterm infants. A more comprehensive and rigorous systematic review is needed to address controversies arising from apparently conflicting studies and reviews.

OBJECTIVES

We assessed the overall efficacy of music and vocal interventions for physiological and neurodevelopmental outcomes in preterm infants (< 37 weeks' gestation) compared to standard care. In addition, we aimed to determine specific effects of various interventions for physiological, anthropometric, social-emotional, neurodevelopmental short- and long-term outcomes in the infants, parental well-being, and bonding.

SEARCH METHODS

We searched Cochrane Central Register of Controlled Trials (CENTRAL), MEDLINE, Embase, CINAHL, PsycINFO, Web of Science, RILM Abstracts, and ERIC in November 2021; and Proquest Dissertations in February 2019. We searched the reference lists of related systematic reviews, and of studies selected for inclusion and clinical trial registries.

SELECTION CRITERIA

We included parallel, and cluster-randomised controlled trials with preterm infants < 37 weeks` gestation during hospitalisation, and parents when they were involved in the intervention. Interventions were any music or vocal stimulation provided live or via a recording by a music therapist, a parent, or a healthcare professional compared to standard care. The intervention duration was greater than five minutes and needed to occur more than three times.

DATA COLLECTION AND ANALYSIS

Three review authors independently extracted data. We analysed the treatment effects of the individual trials using RevMan Web using a fixed-effects model to combine the data. Where possible, we presented results in meta-analyses using mean differences with 95% CI. We performed heterogeneity tests. When the I2 statistic was higher than 50%, we assessed the source of the heterogeneity by sensitivity and subgroup analyses. We used GRADE to assess the certainty of the evidence.

MAIN RESULTS

We included 25 trials recruiting 1532 infants and 691 parents (21 parallel-group RCTs, four cross-over RCTs). The infants gestational age at birth varied from 23 to 36 weeks, taking place in NICUs (level 1 to 3) around the world. Within the trials, the intervention varied widely in type, delivery, frequency, and duration. Music and voice were mainly characterised by calm, soft, musical parameters in lullaby style, often integrating the sung mother's voice live or recorded, defined as music therapy or music medicine. The general risk of bias in the included studies varied from low to high risk of bias. Music and vocal interventions compared to standard care Music/vocal interventions do not increase oxygen saturation in the infants during the intervention (mean difference (MD) 0.13, 95% CI -0.33 to 0.59; P = 0.59; 958 infants, 10 studies; high-certainty evidence). Music and voice probably do not increase oxygen saturation post-intervention either (MD 0.63, 95% CI -0.01 to 1.26; P = 0.05; 800 infants, 7 studies; moderate-certainty evidence). The intervention may not increase infant development (Bayley Scales of Infant and Toddler Development (BSID)) with the cognitive composition score (MD 0.35, 95% CI -4.85 to 5.55; P = 0.90; 69 infants, 2 studies; low-certainty evidence); the motor composition score (MD -0.17, 95% CI -5.45 to 5.11; P = 0.95; 69 infants, 2 studies; low-certainty evidence); and the language composition score (MD 0.38, 95% CI -5.45 to 6.21; P = 0.90; 69 infants, 2 studies; low-certainty evidence). Music therapy may not reduce parental state-trait anxiety (MD -1.12, 95% CI -3.20 to 0.96; P = 0.29; 97 parents, 4 studies; low-certainty evidence). The intervention probably does not reduce respiratory rate during the intervention (MD 0.42, 95% CI -1.05 to 1.90; P = 0.57; 750 infants; 7 studies; moderate-certainty evidence) and post-intervention (MD 0.51, 95% CI -1.57 to 2.58; P = 0.63; 636 infants, 5 studies; moderate-certainty evidence). However, music/vocal interventions probably reduce heart rates in preterm infants during the intervention (MD -1.38, 95% CI -2.63 to -0.12; P = 0.03; 1014 infants; 11 studies; moderate-certainty evidence). This beneficial effect was even stronger after the intervention. Music/vocal interventions reduce heart rate post-intervention (MD -3.80, 95% CI -5.05 to -2.55; P < 0.00001; 903 infants, 9 studies; high-certainty evidence) with wide CIs ranging from medium to large beneficial effects. Music therapy may not reduce postnatal depression (MD 0.50, 95% CI -1.80 to 2.81; P = 0.67; 67 participants; 2 studies; low-certainty evidence). The evidence is very uncertain about the effect of music therapy on parental state anxiety (MD -0.15, 95% CI -2.72 to 2.41; P = 0.91; 87 parents, 3 studies; very low-certainty evidence). We are uncertain about any further effects regarding all other secondary short- and long-term outcomes on the infants, parental well-being, and bonding/attachment. Two studies evaluated adverse effects as an explicit outcome of interest and reported no adverse effects from music and voice.

AUTHORS' CONCLUSIONS

Music/vocal interventions do not increase oxygen saturation during and probably not after the intervention compared to standard care. The evidence suggests that music and voice do not increase infant development (BSID) or reduce parental state-trait anxiety. The intervention probably does not reduce respiratory rate in preterm infants. However, music/vocal interventions probably reduce heart rates in preterm infants during the intervention, and this beneficial effect is even stronger after the intervention, demonstrating that music/vocal interventions reduce heart rates in preterm infants post-intervention. We found no reports of adverse effects from music and voice. Due to low-certainty evidence for all other outcomes, we could not draw any further conclusions regarding overall efficacy nor the possible impact of different intervention types, frequencies, or durations. Further research with more power, fewer risks of bias, and more sensitive and clinically relevant outcomes are needed.

NICU sensory experiences associated with positive outcomes: an integrative review of evidence from 2015-2020

To inform changes to the Supporting and Enhancing NICU Sensory Experiences (SENSE) program, studies investigating sensory-based interventions in the NICU with preterm infants born ≤32 weeks were identified. Studies published between October 2015 to December 2020, and with outcomes related to infant development or parent well-being, were included in this integrative review. The systematic search used databases including MEDLINE, Cumulative Index to Nursing and Allied Health Literature, the Cochrane Library, and Google Scholar. Fifty-seven articles (15 tactile, 9 auditory, 5 visual, 1 gustatory/olfactory, 5 kinesthetic, and 22 multimodal) were identified. The majority of the sensory interventions that were identified within the articles were reported in a previous integrative review (1995-2015) and already included in the SENSE program. New evidence has led to refinements of the SENSE program, notably the addition of position changes across postmenstrual age (PMA) and visual tracking starting at 34 weeks PMA.

The Role of Music Therapy with Infants with Perinatal Brain Injury

Perinatal brain injury occurs in 5.14/1000 live births in England. A significant proportion of these injuries result from hypoxic ischaemic encephalopathy (HIE) in term infants and intracranial haemorrhage (IVH) or periventricular leukomalacia (PVL) in preterm infants. Standardised care necessitates minimal handling from parents and professionals to reduce the progression of injury. This can potentially increase parental stress through the physical inability to bond with their baby. Recent research highlights the ability of music therapy (MT) to empower parental bonding without handling, through sharing culturally informed personal music with their infant. This review therefore aimed to systematically evaluate the use of MT with infants diagnosed with perinatal brain injury in a neonatal intensive care unit (NICU). Search terms were combined into three categories (audio stimulation (MT), population (neonates) and condition (brain injury), and eight electronic databases were used to identify relevant studies following PRISMA guidelines. Eleven studies using music or vocal stimulation with infants diagnosed with perinatal brain injury were identified and quality assessed using Cochrane ROB2, the ROBINSI Tool and the Newcastle Ottawa Scale. Studies used either voice as live (n = 6) or pre-recorded (n = 3) interventions or pre-recorded instrumental music (n = 2). Studies had two primary areas of focus: developmental outcomes and physiological effects. Results suggested the use of music interventions led to a reduction of infants' pain scores during procedures and cardiorespiratory events, improved feeding ability (increase oral feeding rate, volume intake and feeds per day) and resulted in larger amygdala volumes than control groups. Additionally, MT intervention on the unit supported long-term hospitalised infants in the acquisition of developmental milestones. Vocal soothing was perceived to be an accessible intervention for parents. However, infants with PVL showed signs of stress in complex interventions, which also potentially resulted in an increase in maternal anxiety in one study. MT with infants diagnosed with perinatal brain injury can have positive effects on infants' behavioural and neurological parameters and support parental involvement in their infants' developmental care. Further feasibility studies are required using MT to determine appropriate outcome measures for infants and the support required for parents to allow future comparison in large-scale randomised control trials.

Impact of diaper change frequency on preterm infants' vital sign stability and skin health: A RCT

BACKGROUND

Bundling nurse caregiving interventions are promoted to minimize infant stress.

PURPOSE

To evaluate impact of bundled nursing care and diaper change frequency on vital sign stability and skin health of preterm infants born ≤32 weeks gestation.

METHOD

Stable preterm infants on a 3-hour feeding schedule were randomly assigned to 3- vs. 6-hour diaper changes. Diapers were changed prior to 6 h if stool was present. Direct observation of bundled care events (BCE) identify caregiving activities during each BCE. Skin pH, transepidermal water loss (TEWL), and neonatal skin condition scores (NSCS) were obtained. Vital sign data (HR, RR, O₂ saturation) was downloaded from bedside monitors.

RESULTS

Forty-six infants contributed to 605 BCEs. BCEs lasted on average 28 min and included nine different activities (e.g., vital signs, feeding). Significant increases in heart rate during BCEs occurred in approximately half of the observations. Among observations with a diaper change increases in heart rate during diapering occurred in over 74% of observations Infants who were awake at the beginning of BCEs had 48% lower odds of having a change in heart rate than infants who were sleeping (p = .02). There were no group differences (3- vs. 6-hour diaper change) in skin health outcomes (TEWL, pH, NSCS).

CONCLUSION

Reducing diaper change frequency without stool present should be considered to minimize caregiving stress in preterm infants. Additional research should evaluate the intrusiveness and clusters of activities that significantly impact physiologic stability to better individualize the timing of routine yet intrusive activities. Clinicaltrials.gov registry # NCT03370757.

Purposeful Language Exposure by Neonatal Nurses and Caregivers in the NICU

BACKGROUND

Preterm infants are at significant risk of neurocognitive deficits including language delay. Extended hospitalization in the neonatal intensive care unit (NICU) causes missed opportunities for language exposure at critical developmental periods of neural pathways for language processing. Healthcare providers (HCPs), particularly nurses, may be instrumental in providing infant-directed speech to improve neurodevelopmental outcomes.

PURPOSE

To evaluate current evidence to determine what is known about the characteristics of HCP communication to infants in the NICU.

SEARCH/STRATEGY

Four databases and forward searching were used to respond to the clinical question: "What is known about the characteristics of HCP communication to infants in the NICU?" Empiric, primary research studies published in English without date restriction were included.

FINDINGS

Eight studies, primarily descriptive, were reviewed. Overall, infant-directed speech was rarely provided by HCPs. Language was more often directed to sicker infants, occurred in contexts of procedural pain, and was sometimes combined with touch. Perceptions of language by nurses, infants, and parents as well as inhibitors and benefits of infant-directed speech were reported.

IMPLICATIONS FOR PRACTICE

As frontline neonatal providers, nurses can serve as role models of infant-directed speech for parents, helping them gain comfort and understand the importance of speaking to their preterm infants. Nurses can also provide much-needed language nutrition to preterm infants when parents cannot be present.

IMPLICATIONS FOR RESEARCH

Methods to reduce barriers and support infant-directed speech in the NICU require testing. Predictive modeling using measures of language exposure in the NICU may support differences in neurodevelopmental outcomes.

Preterm infants with severe brain injury demonstrate unstable physiological responses during maternal singing with music therapy: a randomized controlled study

Preterm infants with severe brain injury are at high risk for poor outcomes and, therefore, may benefit from developmental care modalities such as music therapy (MT). In this prospective, randomized intervention, preterm infants with severe brain injury (grade 3 or 4 intraventricular hemorrhage or periventricular leukomalacia) who underwent skin-to-skin contact (SSC) with or without maternal singing during MT were evaluated for physiological responses, including autonomic nervous system stability (low frequency (LF)/high frequency (HF) power), heart rate, respiratory rate, oxygen saturation, and behavioral state. Maternal anxiety state and physiological data were also evaluated. A total of 35 preterm infants with severe brain injuries were included in the study analysis. Higher mean ± standard deviation (SD) LF/HF ratio (1.8 ± 0.7 vs. 1.1 ± 0.25, p = 0.01), higher mean ± SD heart rate (145 ± 15 vs. 132 ± 12 beats per minute, p = 0.04), higher median (interquartile range) infant behavioral state (NIDCAP manual for naturalistic observation and the Brazelton Neonatal Behavioral Assessment) score (3 (2-5) vs. 1 (1-3), p = 0.03), and higher mean ± SD maternal anxiety (state-trait anxiety inventory) score (39.1 ± 10.4 vs. 31.5 ± 7.3, p = 0.04) were documented in SSC combined with maternal singing during MT, as compared to SSC alone.Conclusion: Maternal singing during MT for preterm infants with severe brain injury induces physiological and behavioral instability and increases maternal anxiety during NICU hospitalization. A unique MT intervention should be designed for preterm infants with severe brain injury and their mothers. What is Known: • Preterm infants with severe brain injury are at high risk for poor outcomes. • Music therapy benefits brain development of preterm infants without severe brain injury, however it is unknown whether maternal singing during music therapy for preterm infants with severe brain injury is beneficial. What is New: • Maternal singing during music therapy for preterm infants with severe brain injury induces physiological and behavioral instability and increases maternal anxiety during NICU hospitalization. • A unique music therapy intervention should be designed for preterm infants with severe brain injury and their mothers.

The effects of early-stage neurodevelopmental treatment on the growth of premature infants in neonatal intensive care unit

The purpose of this study was to investigate the effects of early-stage neurodevelopmental treatment on the growth of premature infants in the neonatal intensive care unit. A total of 85 premature infants were included in this study. Infants with a birth weight of less than 2.5 kg and of 2.5 kg or higher were classified as premature infants with a high risk of growth delay and with a low risk of growth delay respectively. Of the 55 premature infants with a high risk of growth delay, 27 premature infants were placed in the intervention group and 28 were placed in the control group according to their hospitalization time. Thirty premature infants with a low risk of growth delay were included in the comparative group. The same general nursing care of the neonatal intensive care unit was provided to the intervention group, the control group, and the comparative group, but an additional neurodevelopmental treatment program was given only to the intervention group, for 15 min per session, 4 times a week, up to 40 weeks after conception. As growth indicators, the body weight and head circumference were measured before and 2 weeks after the intervention, and at 40 weeks after conception when the intervention was completed. The body weight and head circumference of the intervention group, which received the neurodevelopmental treatment, were significantly improved compared to the control group (P<0.05), but they were not significantly different from those of the comparative group. However, the body weight and head circumference of the control.

Sensory processing difficulties in school-age children born very preterm: An exploratory study

BACKGROUND

Very preterm birth has a detrimental impact on the developing brain, including widespread white matter brain abnormalities that threaten efficient sensory processing. Yet, sensory processing difficulties in very preterm children are scarcely studied, especially at school age.

AIMS

To investigate somatosensory registration, multisensory integration and sensory modulation.

PARTICIPANTS

57 very preterm school-age children (mean age=9.2years) were compared to 56 gender and age matched full-term children.

METHODS

Group differences on somatosensory registration tasks (Registration of Light Touch, Sensory Discrimination of Touch, Position Sense, Graphestesia), a computerized multisensory integration task, and the parent-reported Sensory Profile were investigated using t-tests and Mann-Whitney U tests.

RESULTS

In comparison to full-term children, very preterm children are less accurate on somatosensory registration tasks, including Registration of Light Touch (d=0.34), Position Sense (d=0.31) and Graphestesia (d=0.42) and show more sensory modulation difficulties (d=0.41), including both behavioral hyporesponsivity (d=0.52) and hyperresponsivity (d=0.56) to sensory stimuli. Tactile discrimination and multisensory integration efficiency were not affected in very preterm children. Aspects of sensory processing were only modestly related.

CONCLUSION

Very preterm children show sensory processing difficulties regarding somatosensory registration and sensory modulation, and preserved multisensory (audio-visual) integration. Follow-up care for very preterm children should involve screening of sensory processing difficulties at least up to school age.

Enhancing sensory experiences for very preterm infants in the NICU: an integrative review

OBJECTIVE

Very preterm infants hospitalized in the neonatal intensive care unit (NICU) experience alterations in sensory experiences. Defining types, timing and frequency of sensory-based interventions that optimize outcomes can inform environmental modifications. The objective of this study was to conduct an integrative review on sensory-based interventions used with very preterm infants in the NICU to improve infant and parent outcomes.

STUDY DESIGN

The data sources include MEDLINE, CINAHL, Cochrane Library and Google Scholar. Studies were identified that used sensory-based interventions in the NICU with preterm infants born ⩽32 weeks gestation, were published in a peer-reviewed journal between 1995 and 2015, and measured outcomes related to infant and parent outcomes. Studies were extracted from electronic databases and hand-searched from identified reference lists.

RESULTS

Eighty-eight articles were identified (31 tactile, 12 auditory, 3 visual, 2 kinesthetic, 2 gustatory/olfactory and 37 multimodal). There was evidence to support the use of kangaroo care, music and language exposure, and multimodal interventions starting at 25 to 28 weeks postmenstrual age. These interventions were related to better infant development and lower maternal stress, but not all findings were consistent. Limitations included lack of consistent outcome measures, study quality and gaps in the literature.

CONCLUSIONS

Most research identified interventions that were done for short periods of time. It is unclear what the potential is for improving outcomes if positive sensory exposures occur consistently throughout NICU hospitalization. Until more research defines appropriate sensory-based interventions to use with infants born very preterm in the NICU, information from this review can be combined with expert opinion and parent/family values to determine best practice.

Maternally administered interventions for preterm infants in the NICU: effects on maternal psychological distress and mother-infant relationship

Although studies have examined the effects of interventions focused on preterm infants, few studies have examined the effects on maternal distress (anxiety, depressive symptoms, post-traumatic stress symptoms, parenting stress) or parenting. This study examined the effects of the auditory-tactile-visual-vestibular (ATVV) intervention and kangaroo care (KC) on maternal distress and the mother-infant relationship compared to an attention control group. 240 mothers from four hospitals were randomly assigned to the three groups. Maternal characteristics in the three groups were similar: 64.1% of ATVV mothers, 64.2% of KC mothers, and 76.5% of control mothers were African American; maternal age averaged 26.3 years for ATVV mothers, 28.1 for KC mothers, and 26.6 for control mothers; and years of education averaged 13.6 for ATVV and KC mothers, and 13.1 for control mothers. Mothers only differed on parity: 68.4% of ATVV and 54.7% of KC mothers were first-time mothers as compared to 43.6% of control mothers. Their infants had a similar mean gestational ages (27.0 weeks for ATVV, 27.2 for KC, and 27.4 for control) and mean birthweights (993 g for ATVV, 1022 for KC, and 1023 for control). Mothers completed questionnaires during hospitalization, and at 2, 6 and 12 months corrected age on demographic characteristics, depressive symptoms, state anxiety, post-traumatic stress symptoms, parenting stress, worry about child health, and child vulnerability (only at 12 months). At 2 and 6 months, 45-min videotapes of mother-infant interactions were made, and the HOME Inventory was scored. Behaviors coded from the videotapes and a HOME subscale were combined into five interactive dimensions: maternal positive involvement and developmental stimulation and child social behaviors, developmental maturity, and irritability. Intervention effects were examined using general linear mixed models controlling for parity and recruitment site. The groups did not differ on any maternal distress variable. Kangaroo care mothers showed a more rapid decline in worry than the other mothers. The only interactive dimensions that differed between the groups were child social behaviors and developmental maturity, which were both higher for kangaroo care infants. Change over time in several individual infant behaviors was affected by the interventions. When mothers reported on the interventions they performed, regardless of group assignment, massage (any form including ATVV) was associated with a more rapid decline in depressive symptoms and higher HOME scores. Performing either intervention was associated with lower parenting stress. These findings suggest that as short-term interventions, KC and ATVV have important effects on mothers and their preterm infants, especially in the first half of the first year.

Maternal satisfaction with administering infant interventions in the neonatal intensive care unit

OBJECTIVE

To examine mothers' satisfaction with administering interventions for their preterm infants and with the helpfulness of the study nurse by comparing massage with auditory, tactile, visual, and vestibular stimulation (ATVV intervention), kangaroo care, and education about equipment needed at home and to explore whether mother and infant characteristics affected maternal satisfaction ratings.

DESIGN

Three-group experimental design.

SETTING

Four neonatal intensive care units (NICUs) (two in North Carolina, two in Illinois).

PARTICIPANTS

Two hundred and eight (208) preterm infants and their mothers.

METHODS

When the infant was no longer critically ill, mother/infant dyads were randomly assigned to ATVV, kangaroo care, or the education group all taught by study nurses. At discharge and 2 months corrected age, mothers completed questionnaires.

RESULTS

All groups were satisfied with the intervention and with nurse helpfulness, and the degree of satisfaction did not differ among them. Intervention satisfaction, but not nurse helpfulness, was related to recruitment site. Older, married, and minority mothers were less satisfied with the intervention but only at 2 months. Higher anxiety was related to lower intervention satisfaction at discharge and lower ratings of nurse helpfulness at discharge and 2 months. More depressive symptoms were related to lower nurse helpfulness ratings at 2 months.

CONCLUSIONS

Mothers were satisfied with interventions for their infants regardless of the intervention performed. Maternal satisfaction with the intervention was related to recruitment site, maternal demographic characteristics, and maternal psychological distress, especially at 2 months. Thus, nursing interventions that provide mothers with a role to play in the infant's care during hospitalization are particularly likely to be appreciated by mothers.

Endotracheal suctioning in preterm infants using four-handed versus routine care

OBJECTIVE

To evaluate the effect of four-handed care on preterm infants' physiologic and behavioral responses to and recovery from endotracheal suctioning versus routine endotracheal (ETT) suctioning.

DESIGN

Randomized crossover design with infants as their own controls.

SETTING

Single-family-room newborn intensive care unit in an academic health center.

PARTICIPANTS

Ten intubated infants on conventional ventilation with inline suctioning who were fewer than 37 weeks gestation at birth, and less than one week of age.

METHODS

Each infant was observed twice on a single day. One observation involved routine ETT suctioning and one involved four-handed care. Physiologic and behavioral response data were collected.

RESULTS

No differences were noted when comparing baseline heart rate (HR) or oxygen saturation (SpO(2)) data to those obtained during and after suctioning while in the routine care condition. In the four-handed care condition, mean SpO(2) increased from preobservation 95.49 to during observation saturation 97.75 (p = .001). Salivary cortisol levels did not differ between groups at baseline or postsuctioning. No significant difference in behavior state was observed between the two conditions. More stress and defense behaviors occurred postsuctioning when infants received routine care as opposed to four-handed care (p = .001) and more self-regulatory behaviors were exhibited by infants during (p = .019) and after suctioning (p = .016) when receiving four-handed care. No statistical difference was found in the number of monitor call-backs postsuctioning.

CONCLUSIONS

Four-handed care during suctioning was associated with a decrease in stress and defense behaviors and an increase in self-regulatory behaviors.

Effect of multisensory stimulation on neuromotor development in preterm infants

OBJECTIVE

To investigate the effect of Auditory, Tactile, Visual and Vestibular stimulus (ATVV) on neuromotor development in preterm infants.

METHODS

Fifty preterm infants born at 28-36 wk with a birth weight ranging from 1,000-2,000 g were recruited for the study. They were block randomized into a control group (n = 25) and study group (n = 25). New Ballard score was used for the baseline measurement of neuromaturity in both groups. In neonatal intensive care unit (NICU), the study group received multisensory stimulation for 12 min per session, 5 sessions per wk along with routine NICU care either from 33 wk corrected gestational age for infants born at 28-32 wk or from 48 h of birth for infants born at 33-36 wk until discharge from the hospital. The control group received the routine NICU care. At term age the preterm infants were assessed using Infant Neurological International Battery (INFANIB) and the groups were compared using independent t test.

RESULTS

The multisensory stimulated infants showed higher neuromotor score (p = 0.001) compared to the control group. The french angle components of INFANIB including heel to ear (p = 0.016) and popliteal angle (p = 0.001) were statistically significant between the groups.

CONCLUSIONS

Multisensory stimulation appears to have a beneficial effect on the tonal maturation in preterm infants. However, further studies are warranted to investigate the long-term effects of multisensory stimulation on neurodevelopmental outcome in preterm infants.

Teamwork in the neonatal intensive care unit

Medical and technological advances in neonatology have prompted the initiation and expansion of developmentally supportive services for newborns and have incorporated rehabilitation professionals into the neonatal intensive care unit (NICU) multidisciplinary team. Availability of therapists specialized in the care of neonates, the roles of rehabilitation professionals, and models of service delivery vary from hospital to hospital based on philosophy, resources, and other considerations. To provide quality care for infants and families, cohesive team dynamics are required including professional competence, mutual respect, accountability, effective communication, and collaboration. This article highlights the contribution of each member of the NICU team. The dynamics of team collaboration are presented with the goal of improving outcomes of infants and families.

Effectiveness of Environment-Based Interventions for People With Alzheimer’s Disease and Related Dementias

A systematic review of evidence for the efficacy of environment-based interventions on the affect, behavior, and performance of people with Alzheimer’s disease and related dementias was conducted as part of the American Occupational Therapy Association’s Evidence-Based Literature Review Project. Thirty-three reports met inclusion criteria. Results suggest that ambient music, aromatherapy, and Snoezelen® are modestly effective in reducing agitation but do not consistently have long-term effects. Visually complex environments that give the illusion of barriers deter people from wandering to unsafe places but do not reduce the urge to wander. Evidence that bright light therapy can aid in regulating mood and the sleep–wake cycle and thus help people remain awake during the day is preliminary. Montessori-based programming can be useful in matching activities to the person’s remaining skills. Further research is needed to evaluate the long-term effect, contraindications, and best dosages of these interventions.

Providing a Nurturing Environment for Infants in Adverse Situations: Multisensory Strategies for Newborn Care

Giving birth in dangerous settings, such as natural disasters and war, can have long-lasting consequences on infant growth and development. It is during birth and the neonatal period that mother and baby are particularly vulnerable to environmental stressors. This article explores the neurohormonal aspects of stress and social bonding and offers strategies aimed at reducing maternal and infant stress and improving the mother-infant relationship. Low-tech interventions, such as massage, Kangaroo Mother Care, and multisensory intervention (maternal voice, massage, eye-to-eye contact, and rocking) are described for their use in adverse environments.

A model of neurodevelopmental risk and protection for preterm infants

The purpose of this article is to introduce a model of neurodevelopmental risk and protection that may explain some of the relationships among biobehavioral risks, environmental risks, and caregiving behaviors that potentially contribute to neurobehavioral and cognitive outcomes. Infants born before 30 weeks of gestation have the poorest developmental prognosis of all infants. These infants have lengthy hospitalization periods in the neonatal intensive care unit (NICU,) an environment that is not always supportive of brain development and long-term developmental needs. The model supports the premise that interventions focused on neuroprotection during the neonatal period have the potential to positively affect long-term developmental outcomes for vulnerable very preterm infants. Finding ways to better understand the complex relationships among NICU-based interventions and long-term outcomes are important to guiding caregiving practices in the NICU.

Cuidado ao desenvolvimento: intervenções de proteção ao desenvolvimento inicial de recém-nascidos pré-termo

OBJETIVO: Revisar ensaios clínicos randomizados, publicados entre 2002 e 2009, sobre a eficácia de intervenções em Cuidado ao Desenvolvimento em recém-nascidos pré-termo em Unidade de Terapia Intensiva Neonatal. FONTES DE DADOS: Foram selecionados estudos randomizados dos bancos de dados Medline, PsycINFO, ISI Web of Science, LILACS e SciELO, usando-se as palavras-chave "developmental care" e "neonate". Realizou-se uma análise metodológica dos estudos, com base nos critérios: randomização, estimativa do tamanho amostral, perda amostral, critérios de inclusão e exclusão, controle de variáveis de confusão, validade dos instrumentos, condição "cega" do pesquisador, realização de seguimento, validades externa e ecológica e cuidados éticos. SÍNTESE DOS DADOS: As intervenções em Cuidado ao Desenvolvimento promoveram melhora em curto prazo nos resultados fisiológicos, comportamentais, neurológicos e clínicos dos recém-nascidos. Observou-se diminuição da reatividade à dor nos recém-nascidos durante procedimentos de pesagem e troca de fraldas. Os pais que receberam intervenções em Cuidado ao Desenvolvimento passaram a apresentar maior senso de competência para cuidar do recém-nascido. Os profissionais treinados em Cuidado ao Desenvolvimento demonstraram melhor desempenho na assistência ao recém-nascido e valorizaram mais os estímulos ambientais, físicos e sociais. CONCLUSÕES: Intervenções em Cuidado ao Desenvolvimento na Unidade de Terapia Intensiva Neonatal promoveram benefícios ao desenvolvimento e saúde dos recém-nascidos pré-termo no período neonatal e no primeiro ano de vida. Em estudos futuros, recomenda-se maior rigor metodológico no que se refere à condição de pesquisador "cego" em relação às intervenções e controle das variáveis de confusão. Estudos prospectivo-longitudinais são necessários para avaliar a eficácia das intervenções em médio e longo prazo no desenvolvimento

Neonatal physical therapy. Part II: Practice frameworks and evidence-based practice guidelines

PURPOSE

(1) To outline frameworks for neonatal physical therapy based on 3 theoretical models, (2) to describe emerging literature supporting neonatal physical therapy practice, and (3) to identify evidence-based practice recommendations.

KEY POINTS

Three models are presented as a framework for neonatal practice: (1) dynamic systems theory including synactive theory and the theory of neuronal group selection, (2) the International Classification of Functioning, Disability and Health, and (3) family-centered care. Literature is summarized to support neonatal physical therapists in the areas of examination, developmental care, intervention, and parent education. Practice recommendations are offered with levels of evidence identified.

CONCLUSIONS

Neonatal physical therapy practice has a theoretical and evidence-based structure, and evidence is emerging for selected clinical procedures. Continued research to expand the science of neonatal physical therapy is critical to elevate the evidence and support practice recommendations.

Salivary cortisol and behavioral state responses of healthy newborn infants to tactile-only and multisensory interventions

OBJECTIVE

To compare changes in stress reactivity (measured via the biomarker salivary cortisol) and behavioral state in healthy newborn infants immediately following 1 of 2 interventions: (1) tactile-only stimulation or (2) a multisensory, auditory, tactile, visual, and vestibular stimulation with a control group.

DESIGN

A randomized prospective design pilot study.

SETTING

Normal newborn nurseries of 2 midwestern perinatal centers.

PARTICIPANTS

Forty healthy newborn infants receiving standard nursing care.

METHODS

Infants were randomly assigned to receive 15 minutes of tactile-only, auditory, tactile, visual, and vestibular, or no stimulation 30 minutes before feeding. Saliva samples were collected before, immediately following, and 10 minutes postintervention. Behavioral state was judged every minute.

RESULTS

Tactile-only group infants had the largest increase in cortisol levels, followed by control group infants. In contrast, infants who received the multisensory intervention showed a significant steady decline in cortisol. Asleep was the predominant state for all 3 groups and cry was minimal.

CONCLUSIONS

Tactile-only stimulation may increase infant stress reactivity while the benefit of the multisensory auditory, tactile, visual, and vestibular intervention may be in the reduction of infant stress reactivity. Interventions appeared to have minimal effect on stress reactivity based on behavioral state.

Developmental care for promoting development and preventing morbidity in preterm infants

BACKGROUND

Preterm infants experience a range of morbidity related to the immaturity of their organ systems and to concurrent disease states. There is concern that an unfavourable environment in the neonatal intensive care unit (NICU) may compound this morbidity. Modification of the environment could minimize the iatrogenic effects. Developmental care is a broad category of interventions designed to minimize the stress of the NICU environment. These interventions may include elements such as control of external stimuli (vestibular, auditory, visual, tactile), clustering of nursery care activities, and positioning or swaddling of the preterm infant. Individual strategies have also been combined to form programs, such as the 'Newborn Individualized Developmental Care and Assessment Program' (NIDCAP) (Als 1986).

OBJECTIVES

In preterm infants, do developmental care interventions reduce neurodevelopmental delay, poor weight gain, length of hospital stay, length of mechanical ventilation, physiological stress and other clinically relevant adverse outcomes?

SEARCH STRATEGY

The Neonatal Review Group search strategy was utilized. Searches were made of MEDLINE from 1966 to June, 2005 and of CINAHL, The Cochrane Central Register of Controlled Trials (CENTRAL, The Cochrane Library, Issue 1, 2005), and conference and symposia proceedings in the English language from 1990 to June, 2005. A search of EMBASE was also made from 2003 to June 2005. A list of all relevant articles was sent to two experts in the field to identify any omissions or additional unpublished studies.

SELECTION CRITERIA

Randomized trials in which elements of developmental care are compared to routine nursery care for infants < 37 weeks gestation and that measured clinically relevant outcomes. Reports were in English or a language for which a translator was available. Computerized searches were conducted and all potentially relevant titles and abstracts were extracted. Retrieved articles were assessed for relevance independently by two reviewers, based on predetermined criteria. Articles that met all criteria for relevance were assessed for methodological quality based on predetermined criteria. Articles judged to have the appropriate quality by both reviewers were included in the analysis.

DATA COLLECTION AND ANALYSIS

Data were extracted independently by the two authors. Meta-analyses were conducted for each intervention where the same outcome measures and/or instruments were used within comparable time points.

MAIN RESULTS

This review detected 36 eligible randomized controlled trials involving four major groups of developmental care interventions, 19 sub-groups and multiple clinical outcomes. In addition, the long-term outcomes of a previously included trial were added to the review. The results of the review indicate that developmental care interventions demonstrate limited benefit to preterm infants with respect to: decreased moderate-severe chronic lung disease, decreased incidence of necrotizing enterocolitis and improved family outcome. Conversely, an increase in mild lung disease and an increase in the length of stay were demonstrated in infants receiving developmental care compared to controls. There is also very limited evidence of the long-term positive effect of NIDCAP on behavior and movement at 5 years corrected age but no effect on cognition. Other individualized developmental care interventions have also demonstrated some effect in enhancing neurodevelopmental outcome. Although a limited number of other benefits were demonstrated, those results were from single studies with small sample sizes. The lack of blinding of the assessors was a significant methodological flaw in half of the studies. The cost of the interventions and personnel was not considered in any of the studies.

AUTHORS' CONCLUSIONS

Because of the inclusion of multiple interventions in most studies, the determination of the effect of any single intervention is difficult. Although there is evidence of limited benefit of developmental care interventions overall, and no major harmful effects reported, there were a large number of outcomes for which no or conflicting effects were demonstrated. The single trials that did show a significant effect of an intervention on a major clinical outcome were based on small sample sizes, and the findings were often not supported in other small trials. Before a clear direction for practice can be supported, evidence demonstrating more consistent effects of developmental care interventions on important short- and long-term clinical outcomes is needed. The economic impact of the implementation and maintenance of developmental care practices should be considered by individual institutions.

Effectiveness of developmental intervention in the neonatal intensive care unit: implications for neonatal physical therapy

PURPOSE

Interdisciplinary team members interact with infants to facilitate progressive physiologic stability. The focus of the physical therapist's role is promotion of sensorimotor development in infants born preterm. The aim of this review was to examine evidence for physical therapist practice in the neonatal intensive care unit (NICU) as it relates to developmental intervention (DI) for infants born prematurely and to present the evidence of physical therapy techniques used in the NICU.

SUMMARY OF KEY POINTS

A literature review was performed resulting in identification of 26 articles that examined specific developmental intervention techniques. The articles were critiqued based on their design. Twelve articles were rated highly, indicating that sensory techniques implemented by physical therapists appear to be an appropriate and effective component of DI. The general consensus was that there is a lack of large, well-controlled, randomized studies in this area of pediatric outcome research.

CONCLUSIONS

Neonatal physical therapy falls under the umbrella of DI. There is substantial agreement about the benefits of DI, but the multimodal and interdisciplinary nature of the evidence limits the ability to identify the effectiveness of any one healthcare professional in the provision of DI in the NICU.