The Newborn Individualized Developmental Care and Assessment Program (NIDCAP) with Kangaroo Mother Care (KMC): Comprehensive Care for Preterm Infants

Barriers and Facilitators in Lactation Support for the Preterm Mother-Infant Dyad: An Integrated Approach

Breastfeeding offers significant health benefits for both mothers and infants, particularly preterm infants, where it serves as a therapeutic strategy to reduce mortality and morbidities. However, breastfeeding practices are threatened globally by societal norms and systemic barriers at both micro and macro levels. This paper explores the complex interplay of these barriers and facilitators, focusing on the Neonatal Intensive Care Unit (NICU) setting. Preterm infants face specific feeding challenges due to immature physiological functions, yet evidence supports that strategies like cue-based feeding and individualized care can enhance feeding success and health outcomes. For mothers, initiating and maintaining lactation after preterm birth is critical but challenging, with early lactation support and achieving sufficient milk volume being key predictors of success. Partner support significantly influences lactation outcomes, although more inclusive research is needed for diverse family structures. In the NICU, a multidisciplinary approach to lactation care is vital, emphasizing the need for experienced staff and family-centered practices. NICU design, policies promoting parental presence, and adherence to Baby-friendly Hospital Initiative guidelines further support breastfeeding. This paper aims to provide directives for local breastfeeding policies through an integrated approach, considering societal attitudes and healthcare practices. The findings advocate for improved lactation support in NICUs, inclusive language and policies, and further research into diverse familial and gender roles in breastfeeding.

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.

Olfactory stimulation for promoting development and preventing morbidity in preterm infants

OBJECTIVES

This is a protocol for a Cochrane Review (intervention). The objectives are as follows: To evaluate the benefits and harms of olfactory stimulation with different odorants in the NICU for promoting development and preventing morbidity in preterm infants.

Instructional guidelines and group discussion effects on new nurses' competency regarding nursing care of preterm infants

Background

Premature birth was once one of the leading causes of infant mortality. Premature infants require improved medical and nursing skills from a highly competent nursing team.

Purpose

This investigation aimed to assess the effects of instructional guidelines and group discussion on new nurses' competency in preterm infants caring at the Neonatal Intensive Care Unit (NICU).

Methods

A single-anonymized, two-group pre-test and post-test study design was accompanied in 2022. The study was accompanied for 50 newly graduated nurses concerned with competence in nursing management of preterm infants at the Neonatal Intensive Care Unit (NICU) in two hospitals: Al-Namas General Hospital, KSA, and the Pediatric Hospital of Assiut University, Egypt. Two groups were randomly selected from among the nurses to be trained on preterm infant nursing care competence either through an instructional guideline or group discussion. Nursing attitudes and practices were measured before and after training using questionnaires and checklists.

Results

There was no significant difference between the instructional guideline group and the group discussion in the mean total score of attitudes (11.72 and 14.65, P = 0.455) and practices (14.36 and 14.80, P = 0.494) towards caring for preterm infants before intervention. While mean nurses' attitude and practice scores increased significantly in both groups after the intervention, in the discussion group, nurses' practice scores increased significantly (p = 0.001). Still, there were no significant changes in the instructional guideline group (P = 0.202).

Conclusion

Both methods were effective on the newly graduated nurses' attitude; however, the instructional guidelines did not affect their practice regard nursing care of preterm infants. However, group discussion training techniques can effectively improve the nurses' attitude and practice toward nursing care of preterm infants.

Relevance to clinical practice

The group discussion training method should be the approved and proven method for hospitals to train new nurses to increase clinical practices, especially during nursing care for premature infants, because this method has proven its worth in increasing the skill of nurses. It enables a group to talk about a specific subject and exchange personal stories. This approach involves a group leader facilitating communication and interaction between participants.

Neuroprotective Infant and Family-Centered Developmental Care for the Tiniest Babies: Perspectives from Key Members of the Neonatal Intensive Care Unit Small Baby Team

Caring for extremely preterm infants in the neonatal intensive care unit (NICU) is a multidisciplinary team effort. A clear understanding of roles for each member of the delivery team, anticipation of challenges, and standardized checklists support improved outcomes for this population. Physicians and nursing leaders are responsible for being role models and holding staff accountable for creating a unit culture of Neuroprotective Infant and Family-Centered Developmental Care. It is essential for parents to be included as part of the care team and babies to be acknowledged for their efforts in coping with the developmentally unexpected NICU environment.

Developmental care education in Australian surgical neonatal intensive care units: A cross-sectional study of nurses' perceptions

Background

Nurse perceptions of developmental care practices have been researched globally for almost 30 years. Yet, there is a lack of research exploring this subject in the specialised setting of the surgical neonatal intensive care unit (sNICU). This research explores the effect of developmental care education programs on sNICU nurses' perceptions of developmental care.

Objective

To determine perceptions and attitudes towards developmental care in a specialty neonatal setting.

Design

Cross-sectional study.

Settings

Two surgical neonatal intensive care units in Australia.

Participants

Registered nurses permanently employed at the study sites between May 2021 to April 2022.

Methods

A modified electronic survey explored sNICU nurse perceptions of developmental care organised around three themes: effects of developmental care on parents and infants, application of developmental care, and unit practices. Associations between site, nurse characteristics, developmental care education and nurses' perceptions were explored using logistic regression [odds ratios (OR) and 95 % confidence intervals (CI)].

Results

Of 295 sNICU nurses, 117 (40 %) participated in the survey. Seventy-five percent of respondents had attended a formal developmental care education program. High levels of agreement (>90 %) were reported regarding the benefits of developmental care for parents and infants. Exposure to developmental care education influenced perceptions of its application. Nurses without formal developmental care education were more likely to agree that it was consistently applied [OR:3.3, 95%CI:1.3-8.6], developmental care skills are valued [OR:2.7, 95%CI:1.1-6.8], and that their nursing peers offered support in its application ([OR:2.5, 95%CI:1.1-6.2].

Conclusions

The results from our research suggest sNICU nurses have a high level of awareness of developmental care and its positive impacts. Despite differences between the surveyed units' developmental care education programs, the value of developmental care in reducing stress for infants and supporting families was collectively recognised. Future research in this setting should focus on evaluating the application of developmental care in this setting.

Effects of the use of a cocoon on the autonomic, motor, and regulatory systems in preterm newborns: Randomized clinical trial

INTRODUCTION

The wrapping of the newborn in an orthopedic tubular mesh, simulating a cocoon, can allow the infant to regain the feeling of security and stability experienced in the uterus given that the movement of one of the parts of the body exerts tactile and pressure variation in others.

OBJECTIVE

We aimed to evaluate the influence of an orthopedic tubular mesh, simulating a cocoon, in therapeutic positioning, on the variables of the autonomous, motor, and regulatory systems of preterm newborns.

METHODS

A controlled and randomized clinical trial was conducted with preterm newborns positioned in dorsal decubitus and divided into two groups: (a) cocoon - newborns covered with an orthopedic tubular mesh, and (b) control - newborns positioned according to the sector's routine and without the use of an orthopedic mesh. During the follow-up, each newborn was placed in the position for 30 min and was recorded for a total of 2 min, once at the beginning and again at the end of the observation period. Variables related to the autonomous system (heart rate, respiratory rate, and peripheral oxygen saturation), motor system (general movements), and regulatory system (Neonatal Infant Pain Scale) were evaluated before and after the intervention. The videos were evaluated by a researcher blind to the purpose of the study, and the resulting data were analyzed using SPSS.

RESULTS

Of the 40 preterm newborns evaluated (32.5 ± 1.83 weeks), 21 were female, and 20 were allocated to the cocoon group. The variables related to the autonomous, motor, and regulatory systems remained unchanged following the positioning in the cocoon, as compared to the typical positioning employed in the neonatal unit.

CONCLUSION

The simulation of a cocoon, utilizing an orthopedic tubular mesh, when applied to preterm newborns admitted to a neonatal intensive care unit can contribute to maintaining low levels of stress, without altering variables of the autonomous, motor, and regulatory systems.

'Baby Liberation' - Developing and implementing an individualised, developmentally-supportive care bundle to critically unwell infants in an Australian Paediatric Intensive Care Unit

BACKGROUND

Infants requiring high acuity care within a Paediatric Intensive Care Unit are at multifactorial risk of neurological injury to the immature brain, resulting in long-term developmental difficulties. In 2020, Queensland Children's Hospital implemented an individualised family-centred developmental care program, 'Baby Liberation', to address an identified service gap for critically unwell infants, aimed at optimising early neuroprotective strategies and minimising risk of suboptimal developmental outcomes.

AIM

To implement Baby Liberation for infants admitted to a quaternary paediatric intensive care referral centre. Secondary aims were to describe environmental changes, enablers and limitations related to implementation.

STUDY DESIGN

A single-centre, prospective implementation pilot study investigated the feasibility of implementing Baby Liberation. Subjects included infants less than six months of age admitted to Queensland Children's Hospital Paediatric Intensive Care Unit.

OUTCOME MEASURES

Primary measures comprised data collected during the implementation period, including number of eligible patients and number of developmental care plans provided. Environmental audit data were collected pre and post implementation to inform secondary outcomes.

RESULTS

Baby Liberation was feasibly implemented into the Queensland Children's Hospital Paediatric Intensive Care Unit. During implementation, 181 individualised care plans were provided to 313 eligible infants (57.8 %). Environmental audits showed improvements in all areas of developmental care, with greatest improvements noted in pain and stress management (+95 %) and staff support and development (+83.3 %).

CONCLUSION

Implementation of Baby Liberation was feasible within a large quaternary paediatric intensive care unit and has potential to be expanded into other clinical areas providing acute infant care.

Neurodevelopment in the Congenital Heart Disease Population as Framed by the Life Course Health Development Framework

BACKGROUND

Adverse neurodevelopment is a common comorbidity associated with congenital heart disease (CHD). The consequences of adverse neurodevelopment are seen across the life course. The cause of adverse neurodevelopment is multifactorial, and use of a life course perspective can assist with understanding and enhancing neurodevelopment in individuals with CHD.

PURPOSE

The purposes of this article are to (1) apply the Life Course Health Development framework to neurodevelopment in the population with CHD and (2) discuss how exposure to the pediatric cardiac intensive care unit (PCICU) environment during infancy is a point of intervention for improving neurodevelopmental outcomes.

CONCLUSION

Individuals with CHD are at an increased risk for adverse neurodevelopment across the life course. The PCICU environment is a point of intervention for improving neurodevelopmental outcomes. Stress can lead to changes in brain structure and function that are associated with negative outcomes in terms of outward behavioral and functional capacity, and the PCICU environment is a source of stressful stimuli. Infancy is a period of rapid brain growth, and the brain is more susceptible to stress during this period of the life course, putting infants receiving care in the PCICU at an increased risk of adverse neurodevelopment.

CLINICAL IMPLICATIONS

Interventions to support optimal neurodevelopment should focus on the PCICU environment during infancy. Developmentally supportive care models should be explored as a means of modifying the PCICU environment. In addition, more research is needed on the relationship between the PCICU and neurodevelopment. The conceptual model introduced can serve as a starting point for this research.

Follow-up care and support to parents of premature children: Multidisciplinary versus regular follow-up care

BACKGROUND

Preterm care involves clinical measures almost exclusively aimed at keeping the preterm alive and ready for discharge from hospital. Children are then enrolled in clinical follow-up care after this stressful period, but mental or specialised care for parents and child is often not embedded in the routine of a neonatal hospital ward and the family is then dependent on institutions for mental health or child health clinics, that is, regular care that is regionally scattered. This study aimed to investigate experiences of parents with regular care and compare them with parents visiting a fixed, specialised, multidisciplinary institute, outside the hospital walls, for preterm follow-up care.

METHODS

A survey was conducted among 56 parents (regular follow-up care N = 26; multidisciplinary follow-up care N = 30) of children born prematurely. The survey consisted out of items like parents' experiences with follow-up care, like the organisation of care, supportive care, environmental support and experienced stress.

RESULTS

Parents receiving multidisciplinary follow-up care reported higher levels of satisfaction with organisation of care (F = 5.45; p = 0.023) and supportive care (F = 11.69; p = 0.001) than parents receiving regular follow-up care. Also, it was found that the extent of support from the social environment alleviated stress but only in parents receiving regular follow-up care (ß = -0.47; p = 0.016).

CONCLUSIONS

The current study findings indicate that experience with follow-up care is valued higher when receiving multidisciplinary care than regular care, and the degree in environmental support alleviates stress in parents receiving regular care.

Trends in neonatal morbidity and mortality for very low birthweight infants: a 20-year single-center experience

OBJECTIVE

To describe trends in mortality and morbidity rates of very low birth weight infants as well as their pre-, peri- and postnatal characteristics over a period of 20 years' time.

METHODS

Retrospective study in all very low birth weight infants admitted to the neonatal intensive care unit of the University Hospitals Ghent from 1 January 2000, to 31 December 2020. Mortality was the primary outcome variable with major morbidities being co-primary outcome variables. Pre-, peri- and postnatal characteristics are secondary outcome variables. We compared pre-, peri- and postnatal characteristics, as well as major morbidities between different groups with comparable rates of mortality.

RESULTS

We included a total of 2037 very low birth weight infants and divided them in 3 epochs based on stepwise reductions in mortality in 2008 and 2013: 2000-2007 (n = 718), 2008-2012 (n = 506) and 2013-2020 (n = 813). Mortality decreased significantly over the years in all gestational ages, but predominantly in those with the youngest gestational age. Changes in obstetric and neonatal care were observed over time. Most significant changes were the increased use of antenatal corticosteroids, magnesium sulfate and surfactant. Intraventricular hemorrhage grade III/IV decreased significantly in all gestational ages. Significant increase in retinopathy of prematurity was observed. Bronchopulmonary dysplasia at 36 weeks and discharge home with oxygen is increasing in the total group. In those born below 26 weeks a slight increase in all major morbidities was observed especially of patent ductus arteriosus and retinopathy of prematurity. Increase of all other major morbidities seems to stabilize in epoch 3. The number of infants surviving without any major morbidity increases to almost 1/2 in all very low birth weight infants and to 1/10 in those born 24-25 weeks gestation.

CONCLUSION

Analysis of the real-life experience showed that survival in very low birth weight infants significantly increased over time. Evolution of major morbidities will have to be carefully watched in the future.

[Formula: see text] Optimizing neurodevelopmental outcomes following fetal diagnosis of congenital heart disease: a call for primary prevention neuropsychology

Critical congenital heart disease (CHD) presents a lasting threat to quality of life through its adverse impact on neurodevelopmental and psychosocial outcomes. As recognition of this threat has increased, so too has an appreciation for the role of pediatric neuropsychologists in supporting families affected by CHD. But there is more to offer these families than traditional neuropsychological services, which tend to focus on secondary/tertiary forms of prevention. Now that many children with CHD are diagnosed prenatally, it may be possible to begin mitigating CHD-related risks and promoting positive outcomes earlier than ever before. Through primary prevention-oriented fetal neuropsychological consultation, as well as close collaboration with allied specialists, pediatric neuropsychology has an opportunity to re-envision its typical borders and more familiar practice models; to forge early and enduring partnerships with families; and to help promote the best possible neurodevelopmental trajectories, beginning before children are even born. In this conceptual review, we survey and integrate evidence from developmental science, developmental origins of health and disease, maternal-fetal medicine, and cardiac neurodevelopmental literatures, along with current practice norms, arriving ultimately at two central conclusions: 1) there is an important role to fill on multidisciplinary teams for the pediatric neuropsychologist in fetal cardiac care and 2) role expansion (e.g., through valuing broader-based training, flexing more generalist skills) can likely improve neuropsychological outcomes earlier than has been standard for pediatric neuropsychologists. Such a reimagining of our practice may be considered primary prevention neuropsychology. Implications for care in various settings and pragmatic barriers to implementation are discussed.

A Pilot Study of Family-Integrated Care (FICare) in Critically Ill Preterm and Term Infants in the NICU: FICare Plus

Family-integrated care (FICare) is associated with improved developmental outcomes and decreased parental mental health risks in stable preterm infants. However, less is known about its application in critically ill infants who are at greater risk for adverse outcomes. The objective of this study was to assess the safety and feasibility of implementation of an augmented FICare program, FICare Plus, in critically ill infants in the first few weeks of life. Resources were specifically developed for staff and parents to support earlier parental engagement in infant care. Infant health outcomes and standardized measures of parental stress, anxiety and parenting self-efficacy were also collected using standardized questionnaires: State -Trait Anxiety Inventory (STAI), Parental Stressor Scale: NICU (PSS: NICU), Perceived Parenting Self-Efficacy Tool and Family Centered Care Survey. The t-test or Wilcoxon rank-sum test were used to compare continuous variables, while the Chi-square or Fisher exact test were used for categorical variables, respectively. In this prospective cohort study, 41 critically ill infants were enrolled: 17 in standard care (SC) and 24 in the FICare Plus group. The tools and procedures developed for FICare Plus successfully supported greater engagement in the care of their infants with no increase in adverse events and no increase in parental stress. Parents in the FICare Plus cohort felt confident to participate in their infant's care. The staff also found this model of care acceptable and well adopted. Preliminary measures of infant efficacy were similar in both groups. Total anxiety scores were high among all parents at enrollment (87 (67-94) vs. 70.5 (66-86); p-value 0.22). However, the scores prior to discharge were lower in FICare Plus group (78 (71-90) vs. 63 (52-74.5); p-value 0.02). This pilot study showed that it is feasible and safe to implement family-integrated care in critically ill infants.

Preterm infant cues during breastfeeding and its measurement: A scoping review

Background

Preterm infants display certain behaviors to communicate their needs, known as preterm infant cues. However, the existing research on preterm infant cues primarily draws from studies conducted on bottle-fed infants rather than breastfed infants.

Objective

This study aimed to investigate the concept of preterm infant cues during breastfeeding and its appropriate instruments.

Design

A scoping review.

Data Sources

The articles published up to January 2022 were searched from multiple sources from EBSCOhost Web, namely CINAHL Plus with Full Text, MEDLINE, ERIC, and E-Journals.

Review Methods

The articles retrieved for this review were screened using PICO (Population, Intervention, Comparison, and Outcomes) format. Preferred Reporting Items for Systematic Reviews (PRISMA) checklist was used in selecting the articles, and Joanna Briggs Institute Critical Appraisal was utilized by two independent authors to assess the articles' quality. A descriptive method was used to analyze the data.

Results

The initial review stage found 183 potential articles, but only four satisfied the criteria. The notion of preterm infant cues during breastfeeding is centered on the actions of preterm infants while positioned on their mother's chest. These feeding cues are identifiable before, during, and after breastfeeding and include cues for hunger, self-regulation, stress, satiation, approach, avoidance, and sucking quality. To effectively recognize these cues, tools such as the Preterm Infants Cues Coding System (PFCCS), Infant Driven Scale (IDS), Newborn Individualized Developmental Care and Assessment Program (NIDCAP), and Preterm Breastfeeding Behavior Scale (PIBBS) can be utilized.

Conclusion

The study findings highlight the importance of recognizing preterm infant cues during breastfeeding to facilitate proper feeding and developmental care. Observational studies have proven to be an effective means of observing these cues during breastfeeding. By leveraging the cues identified in this review alongside tools such as PFCCS, IDS, NIDCAP, and PIBBS, nurses can accurately interpret preterm infants' breastfeeding cues in neonatal care settings of all levels. This, in turn, can aid in developing care plans that promote better feeding ability outcomes.

Knowledge gaps in optimal umbilical cord management at birth

In 2014 the World Health Organisation recommended providing placental blood to all newborn infants by waiting for at least one minute before clamping the umbilical cord. Mounting evidence supports providing a placental transfusion at the time of birth for all infants. The optimal time before clamping and cutting the umbilical cord is still not yet known, and debate exists around other cord management issues. The newborn's transition phase from intra- to extra-uterine life and the effects of blood volume on the many necessary adaptations are understudied. How best to support these adaptations guides our suggested research questions. Parents' perceptions of enrolling their unborn infant into a study play important parts in the conduct of such trials. This article aims to address these topics and suggest research questions for further studies.

Neonatal Care Unit Interventions on Preterm Development

Prematurity is becoming a real public health issue as more and more children are being born prematurely, alongside a higher prevalence of neurodevelopmental disorders. Early intervention programs in Neonatal Intensive Care Units (NICUs) correspond to these uni- or multi-sensorial solicitations aiming to prevent and detect complications in order to support the development of preterm infants. This article aims to distinguish sensory intervention programs according to the gradient of the type of solicitations, uni- or multi-modal, and according to the function of the person who performs these interventions. Uni-sensorial interventions are essentially based on proprioceptive, gustatory, or odorant solicitations. They allow, in particular, a reduction of apneas that support the vegetative states of the preterm infant. On the other hand, the benefits of multi-sensory interventions seem to have a longer-term impact. Most of them allow the support of the transition from passive to active feeding, an increase in weight, and the improvement of sleep-wake cycles. These solicitations are often practiced by caregivers, but the intervention of parents appears optimal since they are the main co-regulators of their preterm child's needs. Thus, it is necessary to co-construct and train the parents in this neonatal care.

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

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

Feasibility of automated early postnatal sleep staging in extremely and very preterm neonates using dual-channel EEG

OBJECTIVE

To investigate the feasibility of automated sleep staging based on quantitative analysis of dual-channel electroencephalography (EEG) for extremely and very preterm infants during their first postnatal days.

METHODS

We enrolled 17 preterm neonates born between 25 and 30 weeks of gestational age. Three-hour behavioral sleep observations and simultaneous dual-channel EEG monitoring were conducted for each infant within their first 72 hours after birth. Four kinds of representative and complementary quantitative EEG (qEEG) metrics (i.e., bursting, synchrony, spectral power, and complexity) were calculated and compared between active sleep, quiet sleep, and wakefulness. All analyses were performed in offline mode.

RESULTS

In separate comparison analyses, significant differences between sleep-wake states were found for bursting, spectral power and complexity features. The automated sleep-wake state classifier based on the combination of all qEEG features achieved a macro-averaged area under the curve of receiver operating characteristic of 74.8%. The complexity features contributed the most to sleep-wake state classification.

CONCLUSIONS

It is feasible to distinguish between sleep-wake states within the first 72 postnatal hours for extremely and very preterm infants using qEEG metrics.

SIGNIFICANCE

Our findings offer the possibility of starting personalized care dependent on preterm infants' sleep-wake states directly after birth, potentially yielding long-run benefits for their developmental outcomes.

Reading Aloud with Infants in the Neonatal Intensive Care Unit: A Unit-Based Program to Enhance Language Enrichment and Support Early Foundational Relationships

OBJECTIVE

Early meaningful auditory experiences in the neonatal intensive care unit (NICU) enhance language outcomes and promote cognitive and social-emotional development.

METHODS

This is a descriptive report sharing our level III NICU experience of building a reading-aloud enrichment program with the goals of enhancing infant neurodevelopment and strengthening early parent-infant relationships.

RESULTS

We propose a roadmap for program development, outline challenges and possible ways to mitigate them, and highlight opportunities for further research in this area.

KEY POINTS

· Early auditory experiences enhance language, cognitive, and social-emotional development.. · High-risk infants experience an atypical neurosensory environment while receiving care in the NICU.. · Reading aloud in the NICU enhances language enrichment and supports early foundational relationships.. · We describe our center's experience with building a reading-aloud enrichment program in the NICU..

Protocol for a prospective multicenter longitudinal randomized controlled trial (CALIN) of sensory-tonic stimulation to foster parent child interactions and social cognition in very premature infants

Introduction

Premature birth is associated with long-term somatic and neurological disorders, including cognitive, social and behavioral impairments. Moreover, the mothers of infants born preterm exhibit a higher prevalence of anxiety and depressive symptoms after birth. Early rehabilitation, developmental care, and parenting support have already been shown to have a positive impact on neurological outcome. However, no randomized controlled study has so far assessed the effects on parenting and long-term neurological outcomes of proprioceptive stimulation to trigger positive brain plasticity in very preterm babies. The CALIN project will therefore investigate the impact of sensory-tonic stimulation (STS) of extremely preterm infants by their parents on child parent interactions, infants' morphological and functional brain development and subsequent cognition (including social cognition), and parents' anxiety and depressive symptoms in the postpartum period.

Methods and analysis

Infants born between 25 and 32 weeks of gestation will be randomly assigned to the "STS + Kangaroo care" or "Kangaroo care" group. The primary endpoint, child and parent interactions, will be rated at 12 months corrected age using the Coding Interactive Behavior system. Secondary endpoints include: 1/functional and anatomical brain maturation sequentially assessed during neonatal hospitalization using electroencephalogram (EEG), amplitude-integrated EEG (aEEG), cranial ultrasound and MRI performed at term-corrected age, 2/social and cognitive outcomes assessed at 15 months, 2, 4 and 6 years, and 3/parents' anxiety and depressive symptoms assessed at 7 ± 1 weeks after birth, using dedicated questionnaires.

Ethics and dissemination

This study was approved by the French Ethics Committee for the Protection of Persons on 18 October 2021. It is registered with the French National Agency for the Safety of Medicines and Health Products (ANSM; no. 2020-A00382-37). The registry number on ClinicalTrials.gov is NCT04380051.

Perceptions and expectations of parents regarding their position in a French NICU: quantitative and qualitative approaches

OBJECTIVES

To assess perceptions, expectations, and concerns of parents of preterm infants regarding their position during hospital admission in the neonatal intensive care unit.

DESIGN

Data were analysed from two studies, using complementary methods (quantitative and qualitative). Study I surveyed parents via a questionnaire, and study II was a reanalysis of interviews with fathers, collected in a previous study.

SETTING

Neonatology department in a French tertiary care university hospital that promotes the Newborn Individualised Care and Assessment Program (NIDCAP).

PARTICIPANTS

In both studies, participants had a premature child admitted for any level of care in the neonatal intensive care unit.

RESULTS

For study I, about half (33) of eligible families participated in the questionnaire survey, and for study II, we reanalysed interviews with 20 fathers. In both analyses, parents were satisfied overall with their involvement in the care of their child. In both studies, however, they expressed that they had expected to be better informed about their child's condition and more involved in medical decision-making. Parents also reported relational issues with some healthcare practitioners who made them feel judged, unheard or not competent to discuss their child's case. These concerns were not reported for NIDCAP staff. Respondents in both studies also described insufficient contact with physicians and an inability to obtain rest in the room with their child.

CONCLUSION

Provision of training to healthcare practitioners regarding information that parents request and doing so respectfully might be keys to fulfilling parent-reported needs. Such improvements could facilitate parental empowerment and involvement.

The Influence of Parent Education on the Neurobehavior and Sucking Reflexes of Very Preterm Infants

The diagnosis of neurobehavioral problems in very preterm neonates helps with planning and applying proper and direct therapeutic interventions. (1) Background: The aim of this study was to determine the direct impact of neurobehavior on the sucking reflex and eating abilities of neonates. (2) Methods: We assessed 18 preterm neonates twice hospitalized at the Gynecology and Obstetrics Clinical Hospital through the use of the Neonatal Behavioral Assessment Scale (NBAS). (3) Results: We found that that a neonate’s sucking ability positively correlated with the activity level item from the motor system cluster of the NBAS. (4) Conclusions: Neurobehavior should be closely assessed in very preterm neonates. Firstly, because assessments can detect fundamental problems and help a practitioner plan for early intervention. Secondly, the education of parents regarding the neurobehavior of their child can help in the facilitation of feeding skills and the planning of early rehabilitation.

The Sleep Well Baby project: an automated real-time sleep–wake state prediction algorithm in preterm infants

Study Objectives

Sleep is an important driver of early brain development. However, sleep is often disturbed in preterm infants admitted to the neonatal intensive care unit (NICU). We aimed to develop an automated algorithm based on routinely measured vital parameters to classify sleep–wake states of preterm infants in real-time at the bedside.

Methods

In this study, sleep–wake state observations were obtained in 1-minute epochs using a behavioral scale developed in-house while vital signs were recorded simultaneously. Three types of vital parameter data, namely, heart rate, respiratory rate, and oxygen saturation, were collected at a low-frequency sampling rate of 0.4 Hz. A supervised machine learning workflow was used to train a classifier to predict sleep–wake states. Independent training (n = 37) and validation datasets were validation n = 9) datasets were used. Finally, a setup was designed for real-time implementation at the bedside.

Results

The macro-averaged area-under-the-receiver-operator-characteristic (AUROC) of the automated sleep staging algorithm ranged between 0.69 and 0.82 for the training data, and 0.61 and 0.78 for the validation data. The algorithm provided the most accurate prediction for wake states (AUROC = 0.80). These findings were well validated on an independent sample (AUROC = 0.77).

Conclusions

With this study, to the best of our knowledge, a reliable, nonobtrusive, and real-time sleep staging algorithm was developed for the first time for preterm infants. Deploying this algorithm in the NICU environment may assist and adapt bedside clinical work based on infants’ sleep–wake states, potentially promoting the early brain development and well-being of preterm infants.

Assessing virtual education on nurses' perception and knowledge of developmental care of preterm infants: a quasi-experimental study

Background

To implement developmental care accurately, neonatal intensive care unit nurses should have a proper understanding and sufficient knowledge in this field. Applying new approaches in education such as offline and online education help nurses improve their skills and knowledge. This study aimed to investigate the effect of virtual education on the perception and knowledge of neonatal developmental care in nurses working in neonatal intensive care units.

Methods

This quasi-experimental study was conducted using a pretest-posttest design with two groups. The participants were 60 nurses working in neonatal intensive care units who were selected using convenience sampling (30 persons in each group). The data were collected before and 1 month after the intervention. The participants in the intervention group received developmental care training using an electronic file uploaded to Navid Learning Management System, while the members of the control group received no intervention. The instruments used to collect the data were the Demographic Information Questionnaire, the Developmental Care Knowledge Scale, and the Developmental Care Perception Scale. The collected data were analyzed using SPSS V25 software. All statistical tests were performed at the significance level of 0.05.

Results

The Developmental Care perception scores before the intervention in the control and intervention groups were 83.40 ± 11.36 and 84.53 ± 9.48, respectively, showing no statistically significant difference (P = 0.67). Also, Developmental Care perception scores after the intervention in the control and intervention groups were 83.16 ± 13.73, and 94.70 ± 6.89, respectively, showing a statistically significant difference (P < 0.001). The results of paired t-test showed that the mean knowledge score in the control group before and after the intervention was not statistically significant (P < 0.903), while in the intervention group there was a statistically significant difference between the mean knowledge score before and after the intervention (P < 0.001).

The Developmental Care Knowledge scores before the intervention in the control and intervention groups were 52.66 ± 18.08 and 77.16 ± 17.20, respectively, showing a statistically significant difference (P = 0.001). Also, Developmental Care Knowledge scores after the intervention in the control and intervention groups were 53.66 ± 26.55and 90.33 ± 13.82, respectively, showing a statistically significant difference (P < 0.001). The results of paired t-test showed that the mean knowledge score in the control group before and after the intervention was not statistically significant, while in the intervention group there was a statistically significant difference between the mean knowledge score before and after the intervention.

Conclusion

The results of this study showed that virtual education for the developmental care of premature infants plays an effective role in the perception and knowledge of nurses working in the neonatal intensive care unit. Therefore, the development of e-learning packages for developmental care and their availability for nurses can be a step to improve the quality of nursing care for infants admitted to the NICU.

Advantages of side-lying position. A comparative study of positioning during bottle-feeding in preterm infants (≤34 weeks GA)

BACKGROUND

The quality and safety of bottle-feeding in premature infants can be improved by optimal positioning. This study analysed the advantages of side-lying position (SLP) and semielevated position (SEP) during bottle-feeding in premature infants.

MATERIAL AND METHODS

A total of 42 neonates (n=42) born ≤34 weeks of gestational age were included in the study. Four feeding sessions-two in SLP and two in SEP- were analysed for each newborn. The level of saturation (SpO₂) and heart rate, which are the parameters assessing the physiological stability, were measured in the studied newborns. The other factors that were examined to determine the quality of feeding included the total time of decline of SpO₂ to ≤85%, level of the newborn's alertness measured using the Neonatal Behavioral Assessment Scale, and the frequency of choking episodes. The proportion of milk consumed (volume of milk consumed relative to the volume expected) and the feeding duration as well as the total time of feeding session were recorded.

RESULTS

SLP was safer in terms of the frequency of choking episodes. Choking episodes were more frequently observed with feeding in SEP (p<0.001). Moreover, the proportion of milk consumed by infants was statistically significantly higher in SLP (p<0.046) compared to SEP. No significant differences in the other tested parameters were noted in infants fed in SLP and infants fed in SEP.

CONCLUSIONS

This study demonstrated that SLP is effective in reducing the number of choking episodes during feeding. The proportion of milk consumed was better when the neonates were fed in SLP.

Disparities in Kangaroo Care for Premature Infants in the Neonatal Intensive Care Unit

OBJECTIVE

The aim of this study was to investigate whether preterm infants whose families have lower socioeconomic status (SES) or communicate with clinical staff in a language other than English experience differences in the rate, frequency, and duration of kangaroo care (KC) in the neonatal intensive care unit (NICU) compared with preterm infants of higher SES or primarily English-speaking families.

METHODS

Participants were infants born <32 weeks' gestational age (GA), N = 116. We defined SES by the infants' health insurance (private/higher vs public/lower) and language by the language mothers used to communicate with clinical staff (English vs Other language). SES or language groups were compared on (1) rate of KC infants experienced during hospitalization per visitation days, (2) frequency of KC per visitation days, and (3) duration of KC events per day.

RESULTS

Infants in the lower SES and Other language groups experienced KC in reduced amounts, lower frequencies, and shorter durations than infants in either the higher SES or English language groups. SES and language group differences remained significant after controlling for family visitation and GA at birth. After controlling for SES, language group differences in KC duration remained significant.

CONCLUSION

Our findings revealed disparities in the rate, frequency, and duration of KC experienced in the NICU as a function of both SES and language. Such disparities reduced infants' access to this developmental care practice shown to stabilize clinical status and promote neurodevelopment. We recommend that hospital nurseries implement policies that minimize these disparities.

Neuroscience meets nurture: challenges of prematurity and the critical role of family-centred and developmental care as a key part of the neuroprotection care bundle

Advances in neonatal-perinatal medicine have resulted in increased survival at lower gestations. Although the incidence of germinal matrix haemorrhage-intraventricular haemorrhage and cystic periventricular leucomalacia is reducing, a new phenotype of preterm brain injury has emerged consisting of a combination of destructive and dysmaturational effects. Consequently, severe neurological disability is reported at a lower rate than previously, but the overall morbidity associated with premature birth continues to present a large global burden and contributes significantly to increased financial costs to health systems and families. In this review, we examine the developmental milestones of fetal brain development and how preterm birth can disrupt this trajectory. We review common morbidities associated with premature birth today. Although drug-based and cell-based neuroprotective therapies for the preterm brain are under intense study, we outline basic, sustainable and effective non-medical, family-centred and developmental care strategies which have the potential to improve neurodevelopmental outcomes for this population and need to be considered part of the future neuroprotection care bundle.

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

OBJECTIVE

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

DATA SOURCE

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

DATA SYNTHESIS

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

CONCLUSIONS

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

Missing out on precious time: Extending paid parental leave for parents of babies admitted to neonatal intensive or special care units for prolonged periods

In Australia, approximately 18% of newborn babies are admitted to a neonatal intensive or special care nursery. While most babies admitted to a neonatal intensive or special care nursery are discharged home within a few weeks, around 6% of babies spend more than 2 weeks in hospital. For the parents of these babies, much of their leave entitlements (Australian Government Paid Parental Leave Scheme is up to18 weeks for the primary care giver and up to 2 weeks for partners) are used before their baby comes home from hospital. The time babies and parents spend together in the early developmental period, during the hospitalisation and when the baby is discharged home, is crucial for optimal child development and bonding. Yet care givers who have a baby admitted to neonatal intensive or special care for extended periods are not currently entitled to any extra parental leave payments in Australia. We recommend the Australian Paid Parental Leave Act is changed to allow primary carers access to 1 week of extra parental leave pay for every week in hospital (for babies admitted to hospital for more than 2 weeks), up to a maximum of 14 weeks. For fathers and partners of these babies, we recommend an additional 2 weeks of extra Dad and Partner Pay. The net cost, taking into account likely productivity benefits, would be less than 1.5% of the current cost of the scheme and would improve health and socio-economic outcomes for the baby, family and society.

[Course of a child born with a transfusion-transfusion syndrome from prenatal to college]

The literature concerning the neurocognitive evolution of children with transfusion-transfusion syndrome (TTS) is poor beyond the first year of life. It is therefore of particular interest to trace the developmental and management pathway, from the age of 18 months to 11 years, of a boy who presented with TTS in utero. This example illustrates the benefit of early multidisciplinary support and the diagnostic issues raised with the development of the child.

A feasibility randomized controlled trial of a NICU rehabilitation program for very low birth weight infants

Motor disability is common in children born preterm. Interventions focusing on environmental enrichment and emotional connection can positively impact outcomes. The NICU-based rehabilitation (NeoRehab) program consists of evidence-based interventions provided by a parent in addition to usual care. The program combines positive sensory experiences (vocal soothing, scent exchange, comforting touch, skin-to-skin care) as well as motor training (massage and physical therapy) in a gestational age (GA) appropriate fashion. To investigate the acceptability, feasibility and fidelity of the NeoRehab program in very low birthweight (VLBW) infants. All interventions were provided by parents in addition to usual care. Infants (≤ 32 weeks' GA and/or ≤ 1500 g birthweight) were enrolled in a randomized controlled trial comparing NeoRehab to usual care (03/2019-10/2020). The a priori dosing goal was for interventions to be performed 5 days/week. The primary outcomes were the acceptability, feasibility and fidelity of the NeoRehab program. 36 participants were randomized to the intervention group and 34 allocated to usual care. The recruitment rate was 71% and retention rate 98%. None of the interventions met the 5 days per week pre-established goal. 97% of participants documented performing a combination of interventions at least 3 times per week. The NeoRehab program was well received and acceptable to parents of VLBW infants. Programs that place a high demand on parents (5 days per week) are not feasible and goals of intervention at least 3 times per week appear to be feasible in the context of the United States. Parent-provided motor interventions were most challenging to parents and alternative strategies should be considered in future studies. Further studies are needed to evaluate the relationship between intervention dosing on long term motor outcomes.

Extreme prematurity: Risk and resiliency

Individuals born extremely preterm (before 28 weeks of gestation) comprise only about 0.7% of births in the United States and an even lower proportion in other high resource countries. However, these individuals account for a disproportionate number of children with cerebral palsy, intellectual deficit, autism spectrum disorder, attention deficit hyperactivity disorder, and epilepsy. This review describes two large multiple center cohorts comprised of individuals born extremely preterm: the EPICURE cohort, recruited 1995 in the United Kingdom and the Republic of Ireland, and the Extremely Low Gestational Age Newborn (ELGAN), recruited 2002-2004 in five states in the United States. The primary focus of these studies has been neurodevelopmental disorders, but also of interest are growth, respiratory illness, and parent- and self-reported global health and well-being. Both of these studies indicate that among individuals born extremely preterm the risks of most neurodevelopmental disorders are increased. Early life factors that contribute to this risk include perinatal brain damage, some of which can be identified using neonatal head ultrasound, bronchopulmonary dysplasia, and neonatal systemic inflammation. Prenatal factors, particularly the family's socioeconomic position, also appear to contribute to risk. For most adverse outcomes, the risk is higher in males. Young adults born extremely preterm who have neurodevelopmental impairment, as compared to those without such impairment, rate their quality of life lower. However, young adults born extremely preterm who do not have neurodevelopmental impairments rate their quality of life as being similar to that of young adults born at term. Finally, we summarize the current state of interventions designed to improve the life course of extremely premature infants, with particular focus on efforts to prevent premature birth and on postnatal efforts to prevent adverse neurodevelopmental outcomes.

Electroencephalographic studies in growth-restricted and small-for-gestational-age neonates

Foetal growth restriction (FGR) and being born small for gestational age (SGA) are associated with neurodevelopmental delay. Early diagnosis of neurological damage is difficult in FGR and SGA neonates. Electroencephalography (EEG) has the potential as a tool for the assessment of brain development in FGR/SGA neonates. In this review, we analyse the evidence base on the use of EEG for the assessment of neonates with FGR or SGA. We found consistent findings that FGR/SGA is associated with measurable changes in the EEG that present immediately after birth and persist into childhood. Early manifestations of FGR/SGA in the EEG include changes in spectral power, symmetry/synchrony, sleep-wake cycling, and the continuity of EEG amplitude. Later manifestations of FGR/SGA into infancy and early childhood include changes in spectral power, sleep architecture, and EEG amplitude. FGR/SGA infants had poorer neurodevelopmental outcomes than appropriate for gestational age controls. The EEG has the potential to identify FGR/SGA infants and assess the functional correlates of neurological damage. IMPACT: FGR/SGA neonates have significantly different EEG activity compared to AGA neonates. EEG differences persist into childhood and are associated with adverse neurodevelopmental outcomes. EEG has the potential for early identification of brain impairment in FGR/SGA neonates.

Evaluation of the social skills of low birthweight infants using the Interaction Rating Scale

[Purpose] This study aimed to examine, using the Interaction Rating Scale, the effect of social skills at 18 months of life on the subsequent development of low birthweight infants. [Participants and Methods] The study participants were made up of a total of 23 infants who were admitted to the neonatal intensive care unit of Hospital A and whose developmental indexes were followed up at the outpatient clinic for up to 3 years of age. The survey was conducted twice in each infant, at a corrected age of 18 months and at 36 full months of age. Social skills and developmental indexes were assessed at the corrected age of 18 months, meanwhile only developmental indexes were assessed at 36 full months, to examine associations. The Interaction Rating Scale was used to assess social skills. This scale measures various aspects of social development by observing caregiver-child interactions in situations wherein children are engaged in tasks more difficult for their age. [Results] The results demonstrated that social skills at 18 months were associated with the developmental indexes at 18 and 36 months, whereas more items were associated with the developmental index at 36 months. [Conclusion] The results indicate the need for early prediction of developmental delay and timely intervention, by assessing social skills in low birthweight infants.

Newborns' clinical conditions are correlated with the neonatal assessment manual scorE (NAME)

OBJECTIVE

To investigate the relationship between the Neonatal Assessment Manual scorE (NAME) and newborns' clinical condition on a large number of infants. The NAME model was developed as an instrument to assess the infant's general conditions, especially in NICUs, by evaluating how the infant's body responds to an external stressor such as static touch. Previous studies, employing experienced assessors, showed good validity indices as well as high inter-rater reliability.

STUDY DESIGN

Newborns were recruited at the "Vittore Buzzi" Pediatric Hospital NICU ward in Milan and their clinical conditions were collected through a standardized form-the complexity index. Two manual practitioners assessed all eligible newborns using the NAME scores. Data was analyzed using Kendall's τ correlation and odds ratio (OR) to assess the relationship between the NAME scores and the complexity index.

RESULTS

Two hundred two newborns (46% female; 34.1 w ± 4.3; birth weight of 2,093.4 gr ± 879.8) entered the study. The Kendall's correlation between the clinical conditions (complexity index) and the NAME score was -0.206 [95% CI: (-0.292, -0.116), p-value < 0.001], corresponding to an OR of 0.838 [95% CI: (0.757, 0.924), p-value < 0.001]. Further exploratory analyses showed significant correlation between gestational age, birth weight and NAME scores.

CONCLUSION

The present paper adds evidence to the NAME model validity by demonstrating its applicability in the clinical neonatological context.

Cue-based versus scheduled feeding for preterm infants transitioning from tube to oral feeding: the Cubs mixed-methods feasibility study

BACKGROUND

There is a lack of evidence of the effect of cue-based feeding compared with scheduled feeding on important outcomes for preterm infants.

OBJECTIVES

The objectives were as follows: (1) to describe the characteristics, components, theoretical basis and outcomes of approaches to feeding preterm infants transitioning from tube to oral feeding; (2) to identify operational policies, barriers and facilitators, and staff and parents' educational needs in neonatal units implementing cue-based feeding; (3) to co-produce an intervention for feeding preterm infants in response to feeding cues; (4) to appraise the willingness of parents and staff to implement and sustain the intervention; (5) to assess associated costs of implementing cue-based feeding; (6) to determine the feasibility and acceptability of a future trial; (7) to scope existing data-recording systems and potential outcome measures; and (8) to determine stakeholders' views of whether or not a randomised controlled trial of this approach is feasible.

DESIGN

This was a mixed-methods intervention development and feasibility study comprising (1) a systematic review, case studies, qualitative research and stakeholder consensus; (2) the co-production of the intervention; (3) a mixed-methods feasibility study; and (4) an assessment of stakeholder preferences for a future evaluation.

SETTING

Three neonatal units in the UK (two level 3 units and one level 2 unit).

PARTICIPANTS

Developmentally normal, clinically stable preterm infants receiving enteral feeds (n = 50), parents (n = 15 pre intervention development; n = 14 in the feasibility study) and health-care practitioners (n = 54 pre intervention development; n = 16 in the feasibility study).

INTERVENTION

An evidence-informed multicomponent intervention comprising training, a feeding protocol, feeding assessment tools, supplementary training materials [including posters, a film and a narrated PowerPoint (Microsoft Corporation, Redmond, WA, USA) presentation] and the 'Our Feeding Journey' document.

MAIN OUTCOME MEASURES

The main outcome measures were recruitment and screening rates, infant weight gain, duration of the intervention, feeding outcomes, implementation outcomes (contextual facilitators and barriers, acceptability, adoption, appropriateness and fidelity) and stakeholder preferences for a future evaluation.

RESULTS

The systematic review of 25 studies concluded that evidence in favour of cue-based feeding should be treated cautiously. The case studies and qualitative research highlighted contextual barriers to and facilitators of the implementation of cue-based feeding. The telephone survey found that many neonatal units are considering implementing cue-based feeding. We recruited 37% of eligible infants, and there was good retention in the study until discharge but a high loss to follow-up at 2 weeks post discharge. The mean number of days from intervention to transition to full oral feeding was 10.8, and the mean daily change in weight gain was 25 g. The intervention was acceptable to parents and staff, although there was dissatisfaction with the study documentation. Intervention training did not reach all staff. A cluster-randomised design with a composite outcome was suggested by stakeholders for a future study.

LIMITATIONS

The intervention was available only in English. Intervention training did not reach all staff. There was low recruitment to qualitative interviews and observations. Only a small number of medical staff engaged in either the training or the interviews.

CONCLUSIONS

It is feasible to implement a cue-based feeding intervention with improved training and documentation. Further work is needed to assess the feasibility of a future trial, noting evidence of existing lack of equipoise.

FUTURE WORK

The next steps are to digitalise the intervention and conduct a survey of all neonatal units in the UK.

STUDY REGISTRATION

This study is registered as PROSPERO CRD42018097317 and ISRCTN13414304.

FUNDING

This project was funded by the National Institute for Health Research (NIHR) Health Technology Assessment programme and will be published in full in Health Technology Assessment; Vol. 25, No. 74. See the NIHR Journals Library website for further project information.

[Optimization of neonatal hospital care for very preterm babies while supporting early parent-child relationships]

Research shows that not only medical but also psychological factors such as parents' emotional state, their parenting skills, quality of very early relationships with the infant influence child's physical and mental health and development. The support of good infant-mother relationships is an essential part of early family-centered help to premature babies. The article reviews existing evidence-based programs of neonatal care and support of early mother-child relationships for preterm babies at the hospital. It covers three main directions: discussing with parents prognosis of a child's health and development; supporting natural conditions of child development, and including parents into child early care and observation. Data presented in the article shows that if using each of the mentioned above directions that are important for quality early care and interaction, positive dynamics is seen both on parents' and preterm infant's side. Designated programs can be widely implemented in neonatal intensive care units for children born before term, including those with extremely low body weight when they achieve clinical stabilization. The material presented in the article may be used as the scientific base for implementing in Russian Federation early care system both at the hospital level and, later, in the family environment. It also constitutes new directions for research of preterm babies and their parents.

Surveying family access: kangaroo mother care and breastfeeding policies across NICUs in Italy

BACKGROUND

Studies on the application of developmental care initiatives in Italian NICUs are rather scarce. We aimed to assess parental access to the NICUs and facilities offered to the family members and to test "the state of art" regarding kangaroo mother care (KMC) and breastfeeding policies in level III Italian NICUs.

METHODS

A questionnaire both in paper and in electronic format was sent to all 106 Italian level III NICUs; 86 NICUs (i.e., 80% of NICUs) were completed and returned. The collected data were analysed. In addition, a comparison between the 2017 survey results and those of two previous surveys conducted from 2001 to 2006 was performed.

RESULTS

In total, 53 NICUs (62%) reported 24-h open access for both parents (vs. 35% in 2001 and 32% in 2006). Parents were requested to temporarily leave the unit during shift changes, emergencies and medical rounds in 55 NICUs (64%). Some parental amenities, such as an armchair next to the crib (81 units (94%)), a room for pumping milk and a waiting room, were common, but others, such as family rooms (19 units (22%)) and adjoining accommodation (30 units (35%)), were not. KMC was practised in 81 (94%) units, but in 72 (62%), i.e., the majority of units, KMC was limited to specific times. In 11 (13%) NICUs, KMC was not offered to the father. The average duration of a KMC session, based on unit staff estimation, was longer in 24-h access NICUs than in limited-access NICUs. KMC documentation in medical records was reported in only 59% of questionnaires. Breastfeeding was successful in a small proportion of preterm infants staying in the NICU.

CONCLUSION

The number of 24-h access NICUs doubled over a period of 13 years. Some basic family facilities, such as a dedicated kitchen, rooms with dedicated beds and showers for the parents, remain uncommon. KMC and breastfeeding have become routine practices; however, the frequency and duration of KMC sessions reported by NICU professionals still do not meet the WHO recommendations.

Perception of Stress and Styles of Coping with It in Parents Giving Kangaroo Mother Care to Their Children during Hospitalization in NICU

The experience of hospitalization of a newborn in the Neonatal Intensive Care Unit (NICU) may become distressing both for the baby and parent. The study aimed to assess the degree of parental stress and coping strategies in parents giving KMC to their babies hospitalized in NICU compared to the control group parents not giving KMC. The prospective observational study enrolled a cohort of 337 parents of premature babies hospitalized in NICU in 2016 in Eastern Poland. The Parental Stressor Scale: Neonatal Intensive Care Unit, Coping Inventory for Stressful Situations were used. The level of stress in parents giving KMC was defined as low or moderate. Analysis confirmed its greater presence in the group of parents initiating KMC late (2–3 weeks) compared to those starting this initiative in week 1 of a child’s life. An additional predictor of a higher level of stress in parents initiating KMC “late” was the hospital environment of a premature baby. Task oriented coping was the most common coping strategy in the study group. KMC and direct skin-to-skin contact of the parent with the baby was associated with a higher level of parental stress only initially and decreased with time and KMC frequency.

Parental Book-Reading to Preterm Born Infants in NICU: The Effects on Language Development in the First Two Years

Background: After preterm birth, infants are at high risk for delays in language development. A promising intervention to reduce this risk is represented by the exposure to parental voices through book-reading in Neonatal Intensive Care Units (NICU). This study investigated the possible advantages of book-reading to preterm neonates during their NICU stay on their subsequent language development. Methods: 100 families of preterm infants were recruited. The parents of 55 preterm infants (Reading Group) received a colored picture-book on NICU admission and were supported to read to their neonate as often as possible and to continue after hospital discharge. Forty-five infants (Control Group) were recruited before the beginning of the intervention. Infant language development was assessed with the Hearing and Language quotients of the Griffith Mental Development Scale at the corrected ages of 3, 6, 9, 12, 18 and 24 months. Results: Regardless of group membership, Hearing and Language mean quotients decreased between 9 and 18 months; nevertheless, this decrease was considerably reduced in the Reading group, compared to the Control Group. Conclusions: Reading in NICUs represents a suitable intervention that could positively influence language development and parent-infant relationships in preterm children. The study findings support its implementation as a preventive measure.

Neuropsychomotor development in children born preterm at 6 and 12 months of corrected gestational age

OBJECTIVE

To assess the incidence of neuropsychomotor developmental delay at 6 and 12 months of corrected gestational age in children born at 32 gestational weeks or less.

METHODS

A descriptive and prospective study was carried out at two public maternity hospitals. Between April 2017 and January 2019, we assessed 133 children without any known risk factors for neuropsychomotor developmental delay. The Bayley III scale was used to evaluate cognitive and motor development. The p value of the numerical variables was calculated using the Mann-Whitney test, whereas proportions of categorical variables were compared using the Z-test.

RESULTS

The mean maternal age was 26±6.9 years,78.8% were from middle and lower economic classes, and 57.1% of the analyzed children were female. Children presented with a higher incidence of delay at 12 months than at 6 months (10.3 and 2.3% at 12 and 6 months, respectively, for the cognitive score; 22.7 and 12% at 12 and 6 months, respectively, for the composite motor score; and 24.7 and 8.4% at 12 and 6 months, respectively, for the fine motor score).

CONCLUSIONS

Cognitive and motor developmental delays were significant, with the highest incidence at 12 months. The results of this study encourage further research on this topic, since the exclusion criteria were comprehensive and the delays in neuropsychomotor development were significant.

NICU music therapy effects on maternal mental health and preterm infant's emotional arousal

In recent decades, music therapy in the Neonatal Intensive Care Unit (NICU) has been shown to regulate preterm infant's physiological responses and improve maternal mental health. This study investigated the effects of the music therapy intervention for the mother-preterm infant dyad (MUSIP) for maternal anxiety, postnatal depression, and stress, and preterm infants' weight gain, length of hospitalization, heart rate (HR), and oxygen saturation (So₂ ). A pre-experimental design was used with 33 mother-preterm infant dyads in a Brazilian NICU: 16 dyads in the Music Therapy Group (MTG) and 17 dyads in the Control Group (CG). The MTG took part in the MUSIP, aimed at supporting maternal singing with the preterm baby. Infants' HR and So₂ were recorded at each minute from 10 min before to 10 min after sessions 1, 3, and 6. Before infants' discharge, maternal anxiety and depression scores were lower in the MTG compared to the CG. Anxiety, depression, and stress levels decreased significantly after the intervention in the MTG. With regard to infants, HR and So₂ ranges were higher during music therapy, compared to before and after sessions. MUSIP improved maternal mental health and affected preterm infants' emotional arousal, with positive trends in decreasing HR, stabilizing So₂ , and reducing length of hospitalization.

Supportive Interventions to Reduce Pain and Stress During Ophthalmic Examinations for Retinopathy of Prematurity in Premature Infants

BACKGROUND

Ophthalmic examinations are a frequent source of pain and stress in premature infants. There is evidence for the use of supportive interventions during infant ophthalmic examinations to reduce pain and stress, but there are no standard recommendations for their implementation.

PURPOSE

The purpose of this quality improvement project was to implement evidence-based, supportive interventions during ophthalmic examinations in premature infants and evaluate the impact on pain, oxygen saturation, heart rate, bradycardic events, and neonatal stress cues.

METHODS

A preintervention and intervention group design was used. Primary outcomes were pain and oxygen saturation. Secondary outcomes were heart rate, number of bradycardic events, and number of neonatal stress cues. Independent-sample t tests were used to compare means of the measures in the preintervention and intervention groups.

RESULTS

Supportive interventions during ophthalmic examinations significantly reduced infant pain (during and after the examination), number of bradycardic events (during and after the examination), and number of neonatal stress cues (before, during, and after the examination). There was also a trend for supportive interventions to decrease pain before the examination.

IMPLICATIONS FOR PRACTICE

Supportive interventions during ophthalmic examinations are effective in reducing pain, bradycardic events, and neonatal stress cues in premature infants and can be successfully implemented as part of a unit-based protocol.

IMPLICATIONS FOR RESEARCH

Future research is needed to determine the long-term outcomes associated with supportive interventions during ophthalmic examinations in premature infants.

Parent-Administered Oral Stimulation in Preterm Infants: A Randomized, Controlled, Open-Label Pilot Study

OBJECTIVE

 The study aimed to assess whether there was any difference in the transition time to full oral feedings between parent-administered and professional-administered premature infant oral motor intervention (PIOMI). The study also evaluated parental satisfaction with performing the intervention through an open-ended questionnaire.

STUDY DESIGN

 A single-center, randomized, controlled, open-label pilot study was carried on between March 2017 and May 2019. A total of 39 infants born ≤32 weeks' gestation were randomly assigned to either parent-performed or professionally performed oral stimulation. The oral stimulation was performed once a day for seven consecutive days between 31 and 32 weeks' postmenstrual age.

RESULTS

 There was no statistically significant difference in transition time, weight gain, or length of hospital stay between the two groups. No adverse events were observed. Parents' satisfaction was high, and their active involvement enhanced their perception of adequacy to care for their infant.

CONCLUSION

 Following adequate training, a parent-administered PIOMI may be considered in preterm infants to reduce the transition time to full oral feeding and enhance the direct involvement of parents in neonatal care.

KEY POINTS

· No difference in transition time between parent-performed and professional-performed PIOMI.. · PIOMI may be delivered by parents following appropriate training.. · Active involvement of parents may improve the parent-infant bonding..

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.

Encouraging Parental Reading for High-Risk Neonatal Intensive Care Unit Infants

OBJECTIVE

To assess whether a citywide structured book-sharing program (NICU Bookworms) designed to promote reading to infants while admitted in the neonatal intensive care unit (NICU) would increase parental reading behaviors (≥3-4 days/week) in the NICU and after discharge home, including high-risk parents who do not themselves enjoy reading.

STUDY DESIGN

The NICU Bookworms program comprised staff training, parent education, and building a literacy-rich environment. In this quasi-experimental intervention study, parents of medically high-risk NICU graduates <6 months of age were administered a questionnaire at their first NICU follow-up clinic visit. The survey incorporated questions from the StimQ-I READ subscale to assess home reading environment and shared reading practices.

RESULTS

A total of 317 infants were enrolled, 187 in an unexposed comparison group and 130 in the intervention group. Parents exposed to Bookworms were significantly more likely to read ≥3-4 days per week while in the NICU (34.5% vs 51.5%; P = .002; aOR, 2.2; 95% CI, 1.2-4.0), but reading at home did not differ (67.9% vs 73.1%; P = .28; aOR, 0.99; 95% CI, 0.5-1.8). However, among parents who did not themselves enjoy reading, frequency was significantly higher both in the NICU (18.4% vs 46.1%; P = .009; aOR, 5.0; 95% CI, 1.2-21.5) and at home (36.9% vs 70%; P = .003; aOR, 3.7; 95% CI, 1.1-12.9). A qualitative thematic analysis found that Bookworms decreased parental stress, enhanced bonding, and supported positive parent-infant interactions.

CONCLUSIONS

A book-sharing intervention in the NICU increased parent-reported reading aloud during hospitalization and among parents disinclined to read for pleasure, both in the NICU and following discharge. This change may have been mediated by enhancement of parent-infant interactions.

The effect of kangaroo mother care on aEEG activity and neurobehavior in preterm infants: a randomized controlled trial

OBJECTIVE

To evaluate the effect of kangaroo mother care (KMC) versus traditional care (TC) on aEEG activity and neurobehavior in preterm infants.

METHODS

A prospective randomized control single-blinded trial conducted in a tertiary level neonatal intensive care unit between October 2019 and October 2020. Preterm infants with gestational age of 31-33 weeks were randomly divided into either a KMC group or a TC group. Outcomes were compared between the groups including aEEG scores, the percentage of mature sleep-wake cycling (SWC) and background activity continuity, narrowband upper and lower bound amplitude, narrowband bandwidth, and neonatal behavioral neurological assessment (NBNA) scores on day 1, day 7, and day 14 after randomization.

RESULTS

A total of 65 infants (32 in KMC group and 33 in TC group) completed protocol. No significant differences were observed in outcomes on day 1. aEEG scores (p = .027 and p = .007, respectively) and the percentage of mature SWC (p = .034 and p = .039, respectively) were significantly higher in KMC group on day 7 and day 14. Compared to the TC group, KMC group had a narrower bandwidth on day 7 (p = .003) and day 14 (p = .016) and higher lower bound amplitude on day 14 (p = .002). Upper bound amplitude and the percentage of continuity were comparable between the groups on day 7 and day 14. The NBNA scores in the KMC group were significantly higher than that of the TC group on day 7 (p < .001) and day 14 (p < .001).

CONCLUSIONS

Preterm infants submitted to the KMC, compared to those non-submitted, have more mature aEEG activity and better neurobehavior performance on day 7 and day 14 after random.

TRIAL REGISTRATION

Chinese Clinical Trial Registry: ChiCTR1900026363.

Sleep in the Hospitalized Child: A Contemporary Review

Acute illness and hospitalization introduce several risk factors for sleep disruption in children that can negatively affect recovery and healing and potentially compromise long-term cognition and executive function. The hospital setting is not optimized for pediatric sleep promotion, and many of the pharmacologic interventions intended to promote sleep in the hospital actually may have deleterious effects on sleep quality and quantity. To date, evidence to support pharmacologic sleep promotion in the pediatric inpatient setting is sparse. Therefore, nonpharmacologic interventions to optimize sleep-wake patterns are of highest yield in a vulnerable population of patients undergoing active neurocognitive development. In this review, we briefly examine what is known about healthy sleep in children and describe risk factors for sleep disturbances, available sleep measurement tools, and potential interventions for sleep promotion in the pediatric inpatient setting.