Improvement of short- and long-term outcomes for very low birth weight infants: Edmonton NIDCAP trial

Asymptomatic Maternal Diseases Presenting with Symptomatic Neonatal Manifestations: A Short Case Series

It is documented that maternal diseases or treatments influence a newborn's clinical status at birth. If a prenatal medical history is not available, or if signs or symptoms of a mother's disease are revealed for the first time during pregnancy or postpartum, their effects on the newborn may be misattributed.

OBJECTIVE

The objective of this study is to emphasize the paramount importance of prenatal care, for both mothers and newborns, as a lack of maternal signs and symptoms during pregnancy does not exclude a potential severe neonatal condition.

MATERIALS AND METHODS

We present a series of three cases of pregnant women who gave birth to very sick preterm newborns that required admission to the Neonatal Intensive Care Unit (NICU). The mothers were asymptomatic during pregnancy and unaware of their subclinical disease. The newborns' complications, considered initially as consequences of prematurity or infection, subsequently revealed transient autoimmune disease in two of the cases (myasthenia gravis and hyperthyroidism) and a severe form of thrombophilia in the third case.

RESULTS

The newborns' diagnosis preceded maternal diagnosis and contributed to the identification of the maternal pathology; adequate treatment was prescribed, with favorable short- and long-term outcomes.

CONCLUSIONS

Prenatal exams and investigations throughout pregnancy are a good opportunity to detect subclinical diseases or predispositions. As newborns usually develop non-specific signs, one should have experience and pay attention to differentiating among etiologies. Our paper takes a reversed approach to the usual medical diagnosis pathway: from infant to mother instead of from mother to infant, proving that inter-specialty collaboration can work bi-directionally.

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.

Evaluation of a new tool - "Step by step with my baby" - to support parental involvement in the care of preterm infants

BACKGROUND AND AIMS

Parental guidance is essential for supporting parental involvement, maintaining the quality and safety of infant care, and limiting parental stress. The efficiency of a new tool to support parental empowerment - "Step by step with my baby" - was evaluated. The perception of this tool by parents and nurses was studied.

METHODS

This was a prospective, observational study conducted from September 2019 to December 2020 at a level-3 neonatal center. A total of 79 newborns (<33 weeks of gestational age or small for gestational age), 84 parents, and 94 nurses were included. The new tool that was evaluated is in the form of a drawing of flowers to be colored according to the parents' ability to care for their newborn. Six domains were explored and given a score (total of 35 points) according to the parents' ability to care for each item: behavior, skin-to-skin contact, carrying, oral and tube feeding, and routine care. The use and relevance of this tool were evaluated by parents and caregivers.

RESULTS

At a mean of 19 days of life, parents required caregiver support regardless of the skill domain (6/35). After 26 days, the mean score increased to 19.4 (p < 0.05). Parents felt autonomous in changing diapers and monitoring temperature but always required help for skin-to-skin contact, carrying, and feeding with or without a tube. The progression was not affected by the presence of siblings, the distance from home, and staying in the parental hospital room. For 67 % of the parents, the tool gave them a better understanding of their newborn and helped them be more confident (69 %) without feeling judged (81 %). These feelings were upheld by nurses.

CONCLUSIONS

This tool was efficient for evaluating parents' autonomy and helped them take ownership of the care provided.

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.

Diagnostic performance of synthetic relaxometry for predicting neurodevelopmental outcomes in premature infants: a feasibility study

OBJECTIVES

To investigate the predictability of synthetic relaxometry for neurodevelopmental outcomes in premature infants and to evaluate whether a combination of relaxation times with clinical variables or qualitative MRI abnormalities improves the predictive performance.

METHODS

This retrospective study included 33 premature infants scanned with synthetic MRI near or at term equivalent age. Based on neurodevelopmental assessments at 18-24 months of corrected age, infants were classified into two groups (no/mild disability [n = 23] vs. moderate/severe disability [n = 10]). Clinical and MRI characteristics associated with moderate/severe disability were explored, and combined models incorporating independent predictors were established. Ultimately, the predictability of relaxation times, clinical variables, MRI findings, and a combination of the two were evaluated and compared. The models were internally validated using bootstrap resampling.

RESULTS

Prolonged T1-frontal/parietal and T2-parietal periventricular white matter (PVWM), moderate-to-severe white matter abnormality, and bronchopulmonary dysplasia were significantly associated with moderate/severe disability. The overall predictive performance of each T1-frontal/-parietal PVWM model was comparable to that of individual MRI finding and clinical models (AUC = 0.71 and 0.76 vs. 0.73 vs. 0.83, respectively; p > 0.27). The combination of clinical variables and T1-parietal PVWM achieved an AUC of 0.94, sensitivity of 90%, and specificity of 91.3%, outperforming the clinical model alone (p = 0.049). The combination of MRI finding and T1-frontal PVWM yielded AUC of 0.86, marginally outperforming the MRI finding model (p = 0.09). Bootstrap resampling showed that the models were valid.

CONCLUSIONS

It is feasible to predict adverse outcomes in premature infants by using early synthetic relaxometry. Combining relaxation time with clinical variables or MRI finding improved prediction.

CLINICAL RELEVANCE STATEMENT

Synthetic relaxometry performed during the neonatal period may serve as a biomarker for predicting adverse neurodevelopmental outcomes in premature infants.

KEY POINTS

• Synthetic relaxometry based on T1 relaxation time of parietal periventricular white matter showed acceptable performance in predicting adverse outcome with an AUC of 0.76 and an accuracy of 78.8%. • The combination of relaxation time with clinical variables and/or structural MRI abnormalities improved predictive performance of adverse outcomes. • Synthetic relaxometry performed during the neonatal period helps predict adverse neurodevelopmental outcome in premature infants.

Development of the Individualised Developmental Care Knowledge and Attitude Scale

BACKGROUND

There is a need for a valid and reliable scale to determine the individualised developmental care levels of nurses who provide care for preterm newborns.

AIMS

To develop the Individualised Developmental Care Knowledge and Attitude Scale for nurses who provide care to preterm newborns and to evaluate its validity and reliability.

METHODS

This methodological study was performed with 260 nurses who provide care for preterm newborns in neonatal intensive care units. The content validity of the research was evaluated under the guidance of professionals working in the pediatric field. Collected data were analysed using values, percentage, mean, standard deviation, correlation analysis, Cronbach's alpha reliability coefficient and factor analysis methods.

RESULTS

The total Content Validity Index for all items was found to be 0.930. The result of Bartlett's test of sphericity (x² = 4691.061, p = 0.000) was significant, and the KMO (Kaiser-Meyer-Olkin) measure of sampling adequacy was 0.906. The fit indices for confirmatory factor analysis were x²/SD = 4.35, GFI = 0.97, AGFI = 0.97, CFI = 0.97, RMSEA = 0.057 and SRMR = 0.062. All of the related fit indices were in the accepted range. The Individualised Developmental Care Knowledge and Attitude Scale was developed at the end of the study, and 34 items and four dimensions were identified. The Cronbach's alpha of the full scale was 0.937.

CONCLUSIONS

From the results, it can be concluded that the Individualised Developmental Care Knowledge and Attitude Scale is both a reliable and valid measurement tool for determining individualised developmental levels.

All Care is Brain Care: Neuro-Focused Quality Improvement in the Neonatal Intensive Care Unit

Neonates requiring intensive care are in a critical period of brain development that coincides with the neonatal intensive care unit (NICU) hospitalization, placing these infants at high risk of brain injury and long-term neurodevelopmental impairment. Care in the NICU has the potential to be both harmful and protective to the developing brain. Neuro-focused quality improvement efforts address 3 main pillars of neuroprotective care: prevention of acquired injury, protection of normal maturation, and promotion of a positive environment. Despite challenges in measurement, many centers have shown success with consistent implementation of best and potentially better practices that may improve markers of brain health and neurodevelopment.

Cognitive and motor development in preterm children from 6 to 36 months of age: Trajectories, risk factors and predictability

BACKGROUND

Although numerous studies have examined the development of preterm children born very low birth weight (VLBW, birth body weight < 1500 g), variations of developmental progress within individuals have rarely been explored. The aim of this research was to examine the cognitive and motor trajectories in preterm children born VLBW at early ages and to assess the risk factors and predictability of these trajectories.

METHOD

Five hundred and eighty preterm infants born VLBW from three cohort studies (2003 to 2014) were prospectively assessed their mental and motor development using the Bayley Scales at 6, 12, 24, and 36 months, and cognitive, motor and behavioral outcomes using the Movement Assessment Battery for Children and the Child Behavior Checklist for Ages 1.5-5 at 4 years of age.

RESULTS

Preterm children born VLBW manifested three cognitive patterns (stably normal [64.0 %], deteriorating [31.4 %], and persistently delayed [4.6 %]) and four motor patterns (above average [6.3 %], stably normal [60.0 %], deteriorating [28.5 %], and persistently delayed [5.2 %]) during 6-36 months. Low birth body weight, stage III-IV retinopathy of prematurity and low parental socio-economic status were associated with the deteriorating patterns; prolonged hospitalization and major brain damage were additionally associated with the persistently delayed patterns. Furthermore, the cognitive and motor deteriorating pattern was each predictive of cognitive and motor impairment at 4 years of age; whereas, the persistently delayed patterns were predictive of multiple impairments.

CONCLUSION AND IMPLICATIONS

Preterm children born VLBW display heterogeneous trajectories in early cognitive and motor development that predict subsequent developmental and behavioral outcomes.

Protecting the brain of the micropreemie

Advances in perinatal care have seen substantial improvements in survival without disability for extremely preterm infants. Protecting the developing brain and reducing neurodevelopmental sequelae of extremely preterm birth are strategic priorities for both research and clinical care. A number of evidence-based interventions exist for neuroprotection in micropreemies, inclusive of prevention of preterm birth and multiple births with implantation of only one embryo during in vitro fertilisation, as well as antenatal care to optimize fetal wellbeing, strategies for supporting neonatal transition, and neuroprotective developmental care. Avoidance of complications that trigger ischemia and inflammation is vital for minimizing brain dysmaturation and injury, particularly of the white matter. Neurodevelopmental surveillance, early diagnosis of cerebral palsy and early intervention are essential for optimizing long-term outcomes and quality of life. Research priorities include further evaluation of putative neuroprotective agents, and investigation of common neonatal interventions in trials adequately powered to assess neurodevelopmental outcome.

Evaluation of the Effectiveness of Digital Game-Based Learning Given to Nursing Students for the Developmental Care of Infants in Neonatal Intensive Care Unit

Although simulation laboratories are widely used in today's nursing education programs, it is becoming more and more difficult to find adequate physical space, equipment, and instructors for laboratory practices in schools. With increasing access to quality technology, schools prefer Web-based education or virtual games as another way of learning through simulation laboratories. This study was carried out to evaluate the effect of digital game-supported teaching activity given to nursing students for the developmental care of infants in neonatal ICU on learning. This study is a quasi-experimental study with a control group. Within the scope of the study, the researchers, together with the technical team, developed a digital game in accordance with the purpose of the study. The study was conducted in a health sciences faculty, nursing department, between September 2019 and March 2020. Sixty-two students were included in the study, which were divided into two groups, with 31 students in the experimental group and 31 students in the control group. The study data were collected using a personal information tool and a developmental care information tool. Whereas the digital game learning method was used for the students in the experimental group, the traditional teaching method was used for the students in the control group. No significant difference has been found between the pretest knowledge scores of the students in the experimental and control groups (P > .05). A statistically significant difference has been found in the rates of giving correct answers between the groups in the posttest and retention test (P < .05). The students in the experimental group gave more correct answers in the posttest and retention test than the students in the control group. In line with these results, the learning method with digital games is effective in increasing the knowledge level of nursing undergraduate students. Therefore, it is recommended to integrate digital games into education.

Developmental Care Practice and Documentation Variability in the Cardiac ICU

OBJECTIVES

Describe variability in developmental care practices, as documented in the electronic health record, for infants undergoing congenital heart surgery.

DESIGN

Multicenter, retrospective, cohort study.

SETTING

Six pediatric cardiac centers.

PATIENTS

One hundred eighty-two infants undergoing one of three index operations: Norwood palliation, aortic arch reconstruction with ventricular septal defect closure, or arterial switch.

INTERVENTIONS

None.

MEASUREMENTS AND MAIN RESULTS

Core domains of developmental care encompassing pain assessment, feeding, infant holding, caregiver involvement, therapy, and psychosocial services were reviewed. Practices varied across individuals, institutions, and the hospital stay. At five of six sites, greater than 90% of individuals had physical or occupational therapy services as part of their care, but the day of first evaluation ranged from day of admission to postoperative day 28. Similar patterns were seen in feeding team and social work involvement. Consistent documentation of developmental care was dependent on the domain and site. Of the total days reviewed (n = 1,192), pain scores were documented in 95%. In those same days, documentation of whether or not a patient was out of the crib to be held varied by site from 11% to 93%. Type of oral feeding, breast versus bottle, was documented on the day prior to discharge 48% of the time.

CONCLUSIONS

There are significant, quantifiable variations in documented developmental care practices at both the individual and site level. More reliable documentation of developmental care practices is required to associate these variables with later outcomes and investigate disparities in individualized developmental care practices.

Multi-level hypothalamic neuromodulation of self-regulation and cognition in preterm infants: Towards a control systems model

Preterm infants, age-corrected for prematurity, score on average, 10 points lower on IQ tests than full-term infants tested at comparable ages. This review focuses on the potential contribution of the hypothalamus to cognitive neuro-regulatory development in preterm infants through its bidirectional neural connections with the prefrontal cortex and its neuroendocrine activity. It aims to clarify the central role of the hypothalamus in preterm high stress situations and in influencing cognitive development via its connectivity to the cerebral cortex. The review further evaluates epigenomic sensitivity to environmental inputs. Recent results suggest that an optimal range of DNA methylations (via a continuous process of decreasing levels of receptor methylations that are too high, and increasing levels that are too low) appears necessary in order to reach an adaptive level of receptor availability. Several studies have demonstrated amelioration of preterm infants' stress while in the Newborn Intensive Care Unit (NICUs) and following discharge. The authors postulate that feedback mechanisms and correction signals are the basis for a hypothalamic homeostatic modulating function, a "hypothalamic resistance response", which may account for the stress reduction brought about by in- and post-NICU early interventions and their results of promoting self-regulation and cognition.

Dissemination of newborn behavior observation skills after Newborn Individualized Developmental Care and Assessment Program (NIDCAP) implementation

Aim

To assess nurses’ ability to observe newborn behaviour after in situ training provided by caregivers with advanced practice certification in the Newborn Individualized Developmental Care and Assessment Program (NIDCAP).

Design

Prospective observational study.

Methods

Twelve nurses viewed 20‐min films showing the behaviour of 10 premature newborns before, during and after the usual caregiving. The behaviour was rated on an observation sheet with 88 items distributed into six systems. The responses were compared to the reference ratings established by two professionals certified for this programme.

Results

Despite less accurate observations during care and for some components, the nurses generally showed a satisfactory ability to observe newborn behaviour after training by NIDCAP expert professionals. The dissemination of observation skills among caregivers may result in an improved quality of patient care and better communication among professionals in a department of neonatology.

Protocol for assessing if behavioural functioning of infants born <29 weeks' gestation is improved by omega-3 long-chain polyunsaturated fatty acids: follow-up of a randomised controlled trial

INTRODUCTION

During the last trimester of pregnancy, the fetal brain undergoes a rapid growth spurt and accumulates essential nutrients including docosahexaenoic acid (DHA). This takes place ex-utero for infants born <29 weeks' gestation, without the in-utero provisions of DHA. Infants born <29 weeks' are more likely to experience behavioural and emotional difficulties than their term-born counterparts. It has been hypothesised that supplementing preterm infants with dietary DHA may alleviate insufficiency and subsequently prevent or minimise behavioural problems. This protocol describes a follow-up of infants born <29 weeks gestation who were enrolled in a randomised controlled trial (RCT) of DHA supplementation. We aim to determine whether DHA supplementation improves the behaviour, and general health of these infants.

METHODS AND ANALYSIS

Infants born <29 weeks' gestation were enrolled in a multicentre blinded RCT of enteral DHA supplementation. Infants were randomised to receive an enteral emulsion that provided 60 mg/kg/day of DHA or a control emulsion commenced within the first 3 days of enteral feeding, until 36 weeks' postmenstrual age or discharge home, whichever occurred first. Families of surviving children (excluding those who withdrew from the study) from the Australian sites (up to 955) will be invited to complete a survey. The survey will include questions regarding child behavioural and emotional functioning, executive functioning, respiratory health and general health. We hypothesise that the DHA intervention will have a benefit on the primary outcome, parent-rated behaviour and emotional status as measured using the Total Difficulties score of the Strengths and Difficulties Questionnaire. Detecting a 2-point difference between groups (small effect size of 0.25 SD) with 90% power will require follow-up of 676 participants.

ETHICS AND DISSEMINATION

The Women's and Children Health Network Human Research Ethics Committee reviewed and approved the study (HREC/16/WCHN/184). Results will be disseminated in peer-reviewed publications and conference presentations.

TRIAL REGISTRATION NUMBER

ACTRN12612000503820.

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.

Promoting attachment between parents and neonates despite the COVID-19 pandemic

Social distancing is the only option available during the COVID‐19 pandemic until a vaccine is developed. However, this is having a major impact on human relationships and bonding between parents and neonates is a major concern. Separation during this health emergency could have lifelong consequences for offspring, and there are even greater concerns if newborn infants are sick or vulnerable and need intensive care. We look at how bonding can be safely supported and maintained without risking infecting neonates, by comparing the international guidelines and proposing safe actions within those frameworks.

French neonatal society position paper stresses the importance of an early family-centred approach to discharging preterm infants from hospital

AIM

The families of hospitalised preterm infants risk depression and post-traumatic stress and the preterm infants risk re-hospitalisation. The French neonatal society's aim was to review the literature on how the transition from hospital to home could limit these risks and to produce a position paper.

METHODS

A systematic literature review was performed covering 1 January 2000 to 1 January 2018, and multidisciplinary experts examined the scientific evidence.

RESULTS

We identified 939 English and French papers and 169 are quoted in the position paper. Most studies stressed the importance of early, personalised and progressive involvement of the family. Healthcare staff and families should assess discharge preparations jointly. This evaluation should assess the capacities of the newborn infant, with regard to its physiological maturity. It should also assess the family's ability to supply the medical, psychological and social assistance required before and after discharge. There should be a structured follow-up process that includes effective communication, various tools, interventions, networks, health and social professionals.

CONCLUSION

Discharge preparations may improve the transition from hospital to home and the outcomes for the parents and newborn preterm infant. This early family-centred approach should be structured, coordinated and based on individual needs and circumstances.

The role of weighing-bathing sequence and postmenstrual age in eliciting adaptive/maladaptive responses in very low birth weight preterm infants

PURPOSE

In the neonatal intensive care unit, preterm infants are exposed to several stressful stimuli. Inappropriate stimulation led to high risk for short- and long-term neurocognitive disabilities. This study aimed to evaluate whether the sequence of execution of weighing/bathing nursing procedures and postmenstrual age (PMA) have any effect on preterm infants' stress responses.

DESIGN AND METHODS

Prospective cross-sectional study on a sample of 21 preterm infants. Responses to the procedures were assessed using an observational sheet based on Als's Synactive Theory of Development. Autonomic and motor responses were scored according to five-point Likert scales. The order of execution of weighing/bathing nursing procedures and PMA were documented. Effects of weighing/bathing execution sequence and PMA on autonomic and motor response scores were analyzed by linear multiple regression analysis.

RESULTS

The sequence of execution had a significant effect on the autonomic score during weighing (p = .035), evidencing more stress when weighing was executed first. A higher level of stress response on the autonomic score during both weighing (p = .015) and bathing (p = .018) procedure was independently associated with a lower infant PMA.

CONCLUSIONS AND PRACTICE IMPLICATIONS

The real-time recognition of adaptive/maladaptive responses allows nurses to personalize their approach to preterm infants, taking into account PMA and adjusting the appropriate sequence of execution of weighing/bathing nursing procedures.

Do NICU developmental care improve cognitive and motor outcomes for preterm infants? A systematic review and meta-analysis

Background

The aim of this study was to review the effects of developmental care in neonatal intensive care unit (NICU) setting on mental and motor development of preterm infants.

Method

We searched PubMed, EMBASE, CINAHL, Scopus, Web of Science and Cochrane library until October 8th 2017, and included randomized controlled trials that assessed effects of developmental care in NICU on mental and motor development of preterm infants at 12 and 24 months of age, using the Bayley scale of infant development in this systematic review. In addition, data were pooled by random effects model and Standardized Mean Difference (SMD) with 95% confidence intervals (CI), calculated for meta-analysis.

Results

Twenty one studies were eligible to be included in this systematic review; however, only thirteen studies had data suitable for meta-analysis. According to statistical analysis, developmental care in NICU improved mental developmental index (MDI) (standardized mean difference [SMD] 0.55, 95% confidence interval [CI] 0.23–0.87; p < 0.05), and psychomotor developmental index (PDI) (SMD 0.33, [CI] 95% CI 0.08–0.57; p < 0.05) of BSID at 12 months of age and PDI at 24 months of age (SMD 0.15, 95% CI -0.02–0.32; p < 0.1) of preterm infants. However, the benefit was not detected at 24 months of age on MDI (SMD 0.15, 95% CI -0.05–0.35; p = 0.15).

Conclusion

Current evidence suggests that developmental care in only NICU setting could have significant effect on mental and motor development of preterm infants, especially at 12 months of age. However, because of clinical heterogeneity, more studies are needed to evaluate the effects of developmental NICU care in the development of preterm infants.

Effects of early interventions focused on the family in the development of children born preterm and/or at social risk: a meta-analysis

OBJECTIVE

To verify whether early intervention focused on the family improves the cognitive, motor, and language development of children born preterm and/or at social risk in the first 3 years of life.

SOURCE OF DATA

Meta-analysis of clinical trials published between 2008 and 2018, in the following databases: CINAHL, MEDLINE - PubMed, MEDLINE - BVS, LILACS - BVS, IBECS - BVS, PEDro and Cochrane Reviews. Experimental studies on early interventions focused on the family, whose target groups were children born preterm and/or at social risk, with assessment of cognitive and/or motor and/or language development up to 3 years were included. The studies were rated using the PEDro Scale.

DATA SYNTHESIS

Twelve studies were included from a total of 3378 articles. Early intervention focused on the family contributed to the development of the cognitive (Standardized Mean Difference - SMD=0.48, 95% CI: 0.34-0.61) and motor (SMD=0.76, 95% CI: 0.55-0.96) domains of preterm infants. Regarding cognitive development, performance improvement was observed at 12, 24 and 36 months, while in the motor domain, the effect was observed only at 12 months in preterm infants. There was no benefit of the intervention in the cognitive, motor, and language outcomes of children with the social risk factor associated to biological risk.

CONCLUSION

Early intervention focused on the family has a positive effect on the cognition of preterm infants. The effect on motor development was lower, possibly due to the emphasis on interventions in family-child interaction. The effect of interventions on the development of children at social risk and on the language domain was inconclusive, due to the scarcity of studies in the area.

Guidelines for the Institutional Implementation of Developmental Neuroprotective Care in the Neonatal Intensive Care Unit. Part A: Background and Rationale. A Joint Position Statement From the CANN, CAPWHN, NANN, and COINN

The use of age-appropriate care as an organized framework for care delivery in the neonatal intensive care unit is founded on the work of Heidelise Als, PhD, and her synactive theory of development. This theoretical construct has recently been advanced by the work of Gibbins and colleagues with the "universe of developmental care" conceptual model and developmental care core measures which were endorsed by the National Association of Neonatal Nurses in their age-appropriate care of premature infant guidelines as best-practice standards for the provision of high-quality care in the neonatal intensive care unit. These guidelines were recently revised and expanded. In alignment with the Joint Commission's requirement for health-care professionals to provide age-specific care across the lifespan, the core measures for developmental care suggest the necessary competencies for those caring for the premature and critically ill hospitalized infant. Further supported by the Primer Standards of Accreditation and Health Canada, the institutional implementation of theses core measures requires a strong framework for institutional operationalization, presented in these guidelines. Part A of this article will present the background and rationale behind the present guidelines and their condensed table of recommendations.

Guidelines for the Institutional Implementation of Developmental Neuroprotective Care in the NICU. Part B: Recommendations and Justification. A Joint Position Statement From the CANN, CAPWHN, NANN, and COINN

The use of age-appropriate care as an organized framework for care delivery in the NICU is founded on the work of Heidelise Als, PhD, and her synactive theory of development. This theoretical construct has recently been advanced by the work of Gibbins and colleagues with the "universe of developmental care" conceptual model and developmental care core measures which were endorsed by the National Association of Neonatal Nurses in their age-appropriate care of premature infant guidelines as best-practice standards for the provision of high-quality care in the NICU. These guidelines were recently revised and expanded. In alignment with the Joint Commission's requirement for healthcare professionals to provide age-specific care across the lifespan, the core measures for developmental care suggest the necessary competencies for those caring for the premature and critically ill hospitalized infant. Further supported by the Primer Standards of Accreditation and Health Canada, the institutional implementation of these core measures require a strong framework for institutional operationalization presented in these guidelines. Part B will present the recommendations and justification of each steps behind the present guidelines to facilitate their implementation.

Neonatal Intensive Care Unit Nurses' Perceptions and Knowledge of Newborn Individualized Developmental Care and Assessment Program: A Multicenter Study

Background

The newborn individualized developmental care and assessment program (NIDCAP) is a new multifaceted approach, which is developmentally and functionally supportive of health especially in premature newborns at the neonatal intensive care unit (NICU). This study is designed for assessing the knowledge and perception of nurses as the most important members of the multidisciplinary team of NIDCAP about this program.

Materials and Methods

This cross-sectional study was conducted on 120 nurses working in the NICUs of Alzahra, Taleghani, and Children hospitals affiliated to the educational and treatment centers of Tabriz University of Medical Sciences as well as 29 Bahman Hospital affiliated to Tabriz Social Security Organization in 2016 using census sampling method. Three questionnaires were employed to collect demographic data and to explore the nurses' perceptions and knowledge of the NIDCAP program.

Results

Findings of the study indicated that the mean (SD) nurses' knowledge and perception scores for NIDCAP were 71.83 (1.64) and 76.80 (0.79), respectively. In the terms of knowledge, significant differences were found with regard to being married (t = -2.39, p < 0.019), having an MSc degree (t = -2.14, p = 0.034), and employment experience (t = -3.38, p = 0.001). However, there was no significant relationship between perception and demographic variables (p > 0.05), nor was there any significant relationship between perception and knowledge (p = 0.275).

Conclusions

The results of this study showed that the majority of nurses participating in the study had high knowledge about NIDCAP.

The biological embedding of neonatal stress exposure: A conceptual model describing the mechanisms of stress-induced neurodevelopmental impairment in preterm infants

The biological embedding of early life stress exposure may result in life-long neurodevelopmental impairment in preterm infants. Infants hospitalized in the neonatal intensive care unit are exposed to significant experiential, environmental, and physiologic stressors over the course of their extended hospitalization. Stress exposure during the sensitive period of brain development may alter biological processes, including functioning of the immune system, the autonomic nervous system, and the hypothalamic-pituitary-adrenal axis as well as gene expression. These alterations may subsequently affect brain structure and function. Changes to these processes may mediate the relationship between neonatal stress exposure and neurodevelopment in preterm infants and represent potential therapeutic targets to improve long-term outcomes. The purpose of this paper is to introduce a conceptual model, based on published research, that describes the mechanisms mediating stress exposure and neurodevelopment impairment in preterm infants and to provide the theoretical foundation on which to base future descriptive research, intervention studies, and clinical care.

Parental experiences of family-centred care from admission to discharge in the neonatal intensive care unit

AIM

It has been increasingly recognised that family-centred care (FCC) is associated with enhanced well-being for both parents and infants in paediatric settings, including the neonatal intensive care unit (NICU). Over the past 4 years, our NICU has increasingly adopted a collaborative philosophy of care. The purpose of the study was to examine parental experiences of FCC during both the admission and discharge time points in order to examine differences in parents' experiences and identify areas for improvement.

METHODS

We conducted interviews at two time points (admission and discharge) with 83 parents (mothers and fathers) of premature and medically fragile infants and analysed the data using thematic analysis.

RESULTS

Three key themes (and sub-themes) were identified: disempowerment, hierarchy between parents and staff and the father's peripheral role. The themes were equally prevalent across admission and discharge.

CONCLUSIONS

The challenges relating to FCC reported by parents at both admission and discharge represent some of the key barriers that parents still face in terms of being truly involved in the care of their infant in the NICU. Similar themes at both time points suggest that parents need equal amounts of support during their stay in NICU, irrespective of the level of care the infant is receiving and whether they are approaching discharge. Implications for improving FCC more generally are discussed.

A gradient relationship between low birth weight and IQ: A meta-analysis

Multiple studies have reported that individuals with low birth weights (LBW, <2500 g) have a lower intelligence quotient (IQ) than those with normal birth weights (NBW, ≥2500 g). Based on 57 eligible individual studies including 12,137 participants, we performed a meta-analysis to estimate the association between low birth weight and individuals' IQ scores (IQs). The pooled weight mean difference (WMD) in IQs between NBW and LBW individuals was 10 (95% CI 9.26-11.68). The WMD was stable regardless of age. No publication bias was detected. The mean IQs of the extremely low birth weight (ELBW, <1000 g), very low birth weight (VLBW, 1000-1499 g), moderately low birth weight (MLBW, 1500-2499 g) and NBW individuals were 91, 94, 99 and 104, respectively. Additionally, the WMD in IQs with NBW were 14, 10 and 7 for ELBW, VLBW, and MLBW individuals, respectively. Two studies permitted estimates of the influence of social determinants of health to the discrepancy in IQs, which was 13%. Since IQ is inherited and influenced by environmental factors, parental IQs and other factors contribute to residual confounding of the results. As the conclusion was based on population studies, it may not be applicable to a single individual.

Family-centered Care Improved Neonatal Medical and Neurobehavioral Outcomes in Preterm Infants: Randomized Controlled Trial

BACKGROUND

Family-centered care for preterm infants in Western societies has yielded short- to medium-term benefits. However, the intervention effects have rarely been validated in Eastern societies.

OBJECTIVE

The aim of this study was to examine whether a family-centered intervention program (FCIP) could improve the short-term medical and neurobehavioral outcomes in preterm infants with very low birth weight (VLBW; a birth weight of <1,500 g) in Taiwan over the outcomes seen with a usual care program (UCP).

DESIGN

This was a multicenter, single-blind, randomized controlled trial study.

SETTING

Three medical centers in northern and southern Taiwan were the locations for the study.

PARTICIPANTS

The participants were 251 VLBW preterm infants without severe perinatal complications.

INTERVENTION

The infants were randomly assigned to receive the FCIP or the UCP during hospitalization.

MEASUREMENTS

Infant morbidities, feeding, growth, and neurobehavioral performance were evaluated during the neonatal period. Parental adherence to interventions was measured in the FCIP group.

RESULTS

The FCIP promoted earlier full enteral feeding (β = -1.1 weeks; 95% CI = -1.9 to -0.2 weeks) and hospital discharge (β = -0.6 week; 95% CI = -1.1 to -0.1 weeks), greater weight gain (β = 3.3 g/d; 95% CI = 0.1 to 6.6 g/d), and better neurobehavioral performance than the UCP (β = 1.2 points; 95% CI = 0.2 to 2.3 points). Furthermore, a higher degree of parental motivation in interventions, goal attainment, and comprehensiveness of home activities was significantly associated with greater effects in infants' neurobehavioral performance and weight gain (r = .20-.31; all Ps < .05).

LIMITATIONS

The findings may not be generalized to preterm infants with severe perinatal diseases and parents with a low level of interest in interventions.

CONCLUSIONS

Family-centered care facilitated short-term medical and neurobehavioral outcomes in VLBW preterm infants in Taiwan; the effects were likely achieved through parental adherence to interventions. The designated strategies may be considered in a future launch of family-centered care in Taiwan.

The NICU Environment: Infusing Single-Family Room Benefits into the Open-Bay Setting

Two distinct architectural designs are found in today's NICUs-the open-bay (OPBY) and the single-family room (SFR) designs. When neonatology was recognized as a medical subspecialty in the 1970s, the OPBY design was the only platform offered to neonates and families. The OPBY design facilitated communication between staff, collegiality, and interprofessional collaboration among members of the neonatal team. Over time, pitfalls to the design were recognized, including increased transmission of sound and light. As a result, the SFR design emerged offering a family-centered, customizable environment. Through recognition and adoption of best practices, the neurodevelopmental benefits to SFRs can be infused within the OPBY unit. This article aims to identify best practices to infuse the benefits of SFR design (such as low light, low sound, and less overstimulation) into the OPBY NICU to reduce negative stimulation and optimize developmental outcomes for vulnerable neonates.

Developmentally Supportive Care in Congenital Heart Disease: A Concept Analysis

THEORETICAL PRINCIPLES

Improved survival of infants and children with congenital heart disease experience has led to recognition that up to half of congenital heart disease survivors also experience developmental delay. Developmentally supportive care is a care model shown in Neonatal Intensive Care Units to be associated with improved outcomes, but developmentally supportive practices with premature infants may not be equally effective in the cardiac population that includes all ages.

PHENOMENA ADDRESSED

The purpose of this paper is to present a concept analysis using the Walker and Avant method in order to identify and define characteristics of developmentally supportive care as it may be applied to the population of neonates, infants, and children with congenital heart disease. A theoretical definition of developmentally supportive care is presented.

RESEARCH LINKAGES

This concept analysis will provide nurses and allied health professionals with a theoretical basis to implement high quality, family-centered care that meets individual developmental needs in a population at high risk for developmental sequelae. Nursing implications for developmentally supportive care as it applies to infants and children with heart disease are discussed.

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.

Breaking down barriers: enabling care-by-parent in neonatal intensive care units in China

BACKGROUND

Denying parents access to their infant in the Neonatal Intensive Care Unit (NICU) is a standard practice in most hospitals across China. Visitation is not usually permitted or may be strictly limited, and NICU care for most neonates is provided by health-care professionals with little participation of the parents. An exception to this rule is the level 2 "Room-In" ward in Qilu Children's Hospital, Shandong University, where parents have 24-hour access to their infants and participate in providing care.

METHODS

This retrospective cohort study compared the outcomes of infants who were admitted to the NICU and remained there throughout their stay (NICU-NICU group, n=428), admitted to the NICU and then transferred to the Room-In ward (NICU-RIn group, n=1018), or admitted straight to the Room-In ward (RIn only group, n=629).

RESULTS

There were no significant differences in the rates of nosocomial infection, bronchopulmonary dysplasia, intraventricular hemorrhage, and retinopathy of prematurity between the NICU-NICU and NICU-RIn groups. The rate of necrotizing enterocolitis was significantly lower in the NICU-RIn group (P=0.04), while weight gain and duration of hospital stay were significantly higher (both P<0.001). Rates of adverse outcomes were lower in RIn-only infants due to their low severity of illness on admission.

CONCLUSIONS

Allowing parents access to their infant in the NICU is feasible and safe in China, and may result in improvements in infant outcomes. Further studies are required to generate stronger evidence that can inform changes to neonatal care in China.

Longitudinal Responses to Weighing and Bathing Procedures in Preterm Infants

Knowledge of the effects of nursing-induced stress on short-term outcomes in preterm infants is limited. Effects of 2 standard nursing procedures-weighing and bathing-on autonomic and motor stability of preterm infants were studied during their hospitalization. Outcomes were evaluated during and after the procedures. Eleven preterm infants were observed between 32 and 35 weeks' postmenstrual age (PMA) (postnatal days range: 4-63). Neonatal responses were assessed according to the Synactive Theory of Development and nursing was performed taking into account Newborn Individualized Developmental Care and Assessment Program (NIDCAP) principles. Effects of the studied nursing procedures on infants' stability during and after their execution were evaluated by nonparametric statistics. During monitored procedures, stress responses in autonomic and motor systems were observed at all PMAs. However, after 32 weeks' PMA, preterm infants also showed an autonomic and motor stability recovery 5 minutes after procedure completion. Contrary to our hypothesis, preterm infants showed to be stressed by weighing and bathing procedures up to 35 weeks' PMA. However, if facilitated and supported after nursing conclusion by interventions such as swaddling and nesting, according to NIDCAP principles, they recovered autonomic and motor stability by 5 minutes after ending procedures.

Creating a Holding Environment for Caregivers

The quality of care that families and infants receive during their time on the neonatal unit will be influenced by the well-being of the people who care for them. The emotional work of caring for infants and families in this demanding setting often goes unrecognized and can result in stress, burnout, and compassion fatigue, which in turn are a threat to the quality of care. Resilience and well-being can be fostered by encouraging self-maintenance, supportive systems organization, providing a healthy working environment, education, and opportunities for reflection.

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).

The use of short message services (SMS) to provide medical updating to parents in the NICU

OBJECTIVE

Premature delivery and prolonged hospitalization of infants in the neonatal intensive care unit (NICU) are very stressful for parents. As technology has advanced, short message services (SMS) have been used increasingly in the medical disciplines. To date, the use of SMS for updating patients and families regarding medical information has not been reported. We implemented the SMS technique to daily update the parents regarding the health status of their preterm infant. The objective of this study was to evaluate the use of SMS technology and to assess its impact on the parents and the nursing staff.

STUDY DESIGN

Parents and nurses completed questionnaires at two time periods: pre-SMS implementation (pre-SMSi) and post-SMS implementation (post-SMSi). The parent questionnaires included statements about medical information delivery, communication and trust between parents and medical staff, parental anxiety and overall satisfaction. The nurse questionnaires included statements about the expected and actual impact on their workload.

RESULTS

Comparison of the parents' responses at the two time periods indicated that in the post-SMSi time period, they felt that the physician was more available when needed (P=0.002), they were more comfortable about approaching the physician (P=0.001) and more satisfied with the medical information provided by the staff (P=0.03). In the post-SMSi period, 78.1% of the nurses noted that the SMS communication is a convenient and user-friendly method.

CONCLUSIONS

SMS updating is an easy and user-friendly technology that enriches the modalities of information delivery to parents of hospitalized preterm infants. It is a complementary and useful tool for encouraging and improving personal communication between parents and medical staff and should be considered part of quality improvement in health care.

Impact of a Developmental Care Training Course on the Knowledge and Satisfaction of Health Care Professionals in Neonatal Units: A Multicenter Study

BACKGROUND

The impact of health-related continuing education courses on knowledge acquisition and clinical practice is infrequently evaluated, despite higher numbers of people enrolling in them. The majority of health care professionals working in neonatal intensive care units (NICUs) have received no training in developmental care (DC). The purpose of this study was to determine whether participation in a theoretical-practical course on DC had an effect on the degree of knowledge possessed by professionals in general terms and with respect to neonatal intensive care. The relationship between course satisfaction and knowledge acquisition was also studied.

METHODS

This was an observational multicenter study conducted in 20 neonatal units in Madrid. A pre- and post-course questionnaire evaluated both knowledge and satisfaction levels regarding the course on DC and the Newborn Individualized Developmental Care and Assessment Program (NIDCAP). We carried out a multivariate linear regression analysis to determine whether there was a correlation between knowledge gained and satisfaction level.

RESULTS

A total of 566 professionals participated, with a 99% pre-course and a 90% post-course response rate. The mean rate of correct pre-course answers was 65%, while the mean rate of post-course correct answers was 81% (p < 0.001). Results were similar at all levels of neonatal care (Level I: 64% vs 80%; Level II: 64% vs. 83%; and

LEVEL III

65% vs. 81%). Scores on a scale of satisfaction from 1 to 5 were high (averages of above 4 for all lectures and workshops). Pre-course knowledge scores, but not satisfaction, significantly influenced post-course knowledge (β 0.499; p < 0.01).

CONCLUSION

Previous DC knowledge among Madrid health care professionals was similar, regardless of the level of neonatal care. Course attendance significantly improved the rate of correct answers. Although course satisfaction was high, there did not seem to be a correlation between knowledge gained and satisfaction.

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.

Family-centered developmentally supportive care: the Swedish example

The prematurely born infant is probably the most vulnerable patient in our hospitals due to the immaturity of all organ systems including the brain. Over recent years, the importance of neurodevelopmentally supportive care has been clarified. In addition, to provide the best possible treatment and environmental conditions for the vital functions of the infant to properly develop, we also must support the psychological processes of bonding and attachment between parents and their newborn infant, which is so crucial for long-term health and development. By integrating scientific findings from natural and behavioral science in multidisciplinary developmentally supportive intervention programs, recommendations for redesigning nurseries and integrating families have developed to meet these challenges. It not only is "baby- and family-friendly" but also has economic benefits and improves the long-term development of the child. The basis of family-centered developmentally supportive care interventions is the recognition that the newborn infant is a human being in his or her own right, and letting the caregivers be guided by the current needs of the individual infant and family. In this context, the Newborn Individualized Developmental Care and Assessment Program (NIDCAP) is unique since it is the only program designed to be implemented from the moment the infant is born. Different strategies can be used to support the nursing and medical teams to help the family become the primary caregivers of their own infants. Sweden has a long tradition of engaging parents in the actual care and of around-the-clock visiting hours. Nurseries have, or are remodeling to have, the facilities enabling parents to live in the units throughout the entire hospital stay. Skin-to-skin contact is widely implemented. In order to ensure that these strategies are in tune with the individual needs of the infant and the families, all major nurseries have trained NIDCAP professionals. Care and intervention based on the infant's own behavior makes good biological sense and is also ethically attractive.

What is the role of the physiotherapist in paediatric intensive care units? A systematic review of the evidence for respiratory and rehabilitation interventions for mechanically ventilated patients

BACKGROUND

Physiotherapy in intensive care units (ICU) has traditionally focussed on the respiratory management of mechanically ventilated patients. Gradually, focus has shifted to include rehabilitation in adult ICUs, though evidence of a similar shift in the paediatric ICU (PICU) is limited.

OBJECTIVES

Review the evidence to determine the role of physiotherapists in the management of mechanically ventilated patients in PICU.

DATA SOURCES

A search was conducted of: PEDro, CINAHL, Medline, PubMed and the Cochrane Library.

ELIGIBILITY CRITERIA

Studies involving PICU patients who received physiotherapy while invasively ventilated were included in this review. Those involving neonatal or adult ICU patients, or patients on non-invasive or long-term ventilation, were not included in the study.

STUDY APPRAISAL

All articles were critically appraised by two reviewers and results were analysed descriptively.

RESULTS

Six studies on chest physiotherapy (CPT) met the selection criteria. Results support the use of the expiratory flow increase technique and CPT, especially manual hyperinflation and vibrations, for secretion clearance. Evidence does not support the routine use of either CPT or suction alone. No studies investigating rehabilitation in PICU met selection criteria.

LIMITATIONS

A lack of high level evidence was available to inform this review.

CONCLUSION

Evidence indicates that CPT is still the focus of physiotherapy intervention in PICU for mechanically ventilated patients, and supports its use for secretion clearance in this setting. PROSPERO register for systematic reviews (registration no. CRD42014009582).

A comparison of the direct cost of care in an open-bay and single-family room NICU

OBJECTIVE

This research examined the proposition that the direct costs of care were no different in an open-bay (OPBY) as compared with a single-family room (SFR) neonatal intensive care (NICU) environment.

STUDY DESIGN

This was a sequential cohort study.

RESULT

General linear models were implemented using clinical and cost data for all neonates admitted to the two cohorts studied. Costs were adjusted to year 2007 U.S. dollars. Models were constructed for the unadjusted regression and subsequently by adding demographic variables, treatment variables, length of respiratory support and length of stay. With the exception of the last, none were found to achieve significance. The full model had R(2)=0.799 with P=0.0095 and predicted direct costs of care less in the SFR NICU.

CONCLUSION

For the time, location and administrative practices in place, this study demonstrates that care can be provided in the SFR NICU at no additional cost as compared with OPBY NICU.

Factors Influencing Implementation of Developmental Care Among NICU Nurses in China

The main aim of this article is to describe current developmental care nursing practices among registered nurses (RNs) working in neonatal intensive care units (NICUs) in China and to explore selected personal and unit characteristics related to developmental care implementation. A convenience sample of 207 RNs participated in this descriptive, cross-sectional exploratory study. A tool of Practice Standards for Individualized, Family-Centered Developmental Care was used to collect the data. The findings indicate that Chinese NICU nurses are not implementing developmental care consistently. Higher patient caseloads, fewer work hours per day, higher level of education, and fewer years worked in NICUs are the significant predictors for lower implementation of developmental care. NICU nurses in China currently carry out developmental care based mainly on their accumulated clinical experience rather than their educational experience. More systematic developmental care training for NICU nurses and more support at both unit and hospital levels are necessary in China.

[Variables determining the amount of care for very preterm neonates: the concept of medical stance]

OBJECTIVE

To compare the amount of medical interventions on very preterm neonates (24-31 weeks of gestation) in two French university tertiary care centers, one of which is involved in a Neonatal Developmental Care program. A secondary objective is to assess whether this difference in medical interventions can be linked to a difference in mortality and morbidity rates.

METHODS

We prospectively included all very preterm neonates free from lethal malformation born live in these two centers between 2006 and 2010. These inclusion criteria were met by 1286 patients, for whom we compared the rate of five selected medical interventions: birth by caesarean section, chest intubation in the delivery room, surfactant therapy, pharmacological treatment of patent ductus arteriosus, and red blood cell transfusion.

RESULTS

The rates of the five medical interventions were systematically lower in the center that is involved in Neonatal Developmental Care. There was no significant difference in survival at discharge with no severe cerebral ultrasound scan abnormalities between the two centers. There were, however, significantly higher rates of bronchopulmonary dysplasia and nosocomial sepsis and longer hospital stays when the patients were not involved in a Neonatal Developmental Care program.

DISCUSSION

This benchmarking study shows that in France, in the first decade of the 21st century, there are as many ways to handle very preterm neonates as there are centers in which they are born. This brings to light the concept of medical stance, which is the general care approach prior to the treatment itself. This medical stance creates the overall framework for the staff's decision-making regarding neonate care. The different parameters structuring medical stance are discussed. Moreover, this study raises the problematic issue of the aftermath of benchmarking studies when the conclusion is an increase of morbidity in cases where procedure leads to more interventions.

A psychometric study of the Bayley Scales of Infant and Toddler Development - 3rd Edition for term and preterm Taiwanese infants

The Bayley Scales of Infant and Toddler Development - 3rd Edition (Bayley-III) was updated to enhance its usefulness for contemporary child developmental assessment. However, recent data in Western countries have implicated the overestimation of child development by the new instrument. This study aimed to investigate the psychometric features of the Bayley-III for term and preterm infants in Taiwan. Forty-seven term infants and 167 preterm infants were prospectively examined with the Bayley Scales of Infant Development - 2nd Edition (BSID-II) and the Bayley-III at 6, 12, 18, and 24 months of age (corrected for prematurity). The psychometric properties examined included reliability, construct validity, and known-group validity. The intra- and inter-rater reliabilities of the Bayley-III were good to excellent. The correlations between the BSID-II and Bayley-III raw scores were good to excellent for the cognitive and motor items and low to excellent for the language items. Term infants achieved higher composite scores than preterm infants on all of the Bayley-III scales (p<0.05). However, their rates of developmental delay were lower than the previously established prevalence estimates. The Bayley-III cut-off composite score was adjusted 10-20, 1-13, and 12-24 points higher than 70 for optimal prediction of cognitive, language, and motor delay, respectively, as defined by the BSID-II index score<70. The Bayley-III is a reliable instrument that extends its previous edition, especially in early language assessment. However, the upward adjustment of its cut-off score is recommended for the accurate identification of developmental delay in term and preterm Taiwanese infants.