Soothability and Growth in Preterm Neonates

This proposal seeks to understand the relationship between soothability, weight gain and length of hospital stay in premature infants when the infants receive a simple, non-invasive treatment to help them cope with the noxious environment of the special care nursery. Thousands of premature infants are born every year in the United States, and the numbers are increasing. Prematurity is the leading cause of mortality in infants. Despite numerous technological and medical advances in treatment and care, premature infants still have difficulty adapting to life outside the uterus as a result of immature nervous systems and significant differences in the pre and post delivery environments. Developmental Care and Family Centered Care have made significant improvements in the lives of hospitalized premature infants. However, care continues to be costly and complex, encouraging health care providers to continue to search for simpler and less expensive methods to care for these tiny patients. This paper describes the effect of a flax seed pillow, placed on the back of premature infants in a prone position on their ability to sooth themselves, moderate their activity, gain weight and the length of hospital stay. Each infant will receive two 15 minute treatments, twice a day, over the course of five consecutive days. Measurements will be obtained on various physiologic parameters including temperature, heart rate, respiratory rate, and pain scores and activity. The design is a randomized control study, with infants stratified for birth weight. Infants in the treatment group had decreases in heart rate, respiratory rate and pain scores significantly greater than infants in the control group. Infants in the treatment group also gained more weight in the first three weeks of life, however this difference was lost by time of discharge. Hospital length of stay did not vary between the two groups. The treatment of the flax seed pillow is a new method to assist premature infants to cope with the stressful environment of the nursery. The pillow is simple, easy to use and was not associated with any adverse events. Further research is recommended to explore the efficacy of this intervention in other populations

Neonatal developmental care makes SENSE: implementation of an evidence-based guideline for developmentally appropriate multi-modal positive sensory exposures.

Background: There is increasing awareness of the contribution of the neonatal intensive care (NICU) environment and the importance of developmental care (DC) interventions to long-term outcomes in high-risk infants. Care at the project site reflected that given at many hospitals, where positive sensory experiences and negative sensory mitigation are done but inconsistently. There was not a guideline in place for DC interventions. Setting: The project site housed a newly renovated single-family room (SFR) NICU with 12 licensed Level II beds and ability to flex to 19 beds. Neonates at gestational ages ≥28 weeks, requiring critical care for a variety of reasons make up the patient population. Purpose: This project assessed the implementation of the Supporting and Enhancing NICU Sensory Experiences (SENSE©) Program in a Level II NICU in a suburban setting in the southeast United States as a way to increase the consistent application of positive sensory experiences in routine caregiving. Procedures: Staff were educated on neurodevelopment and neurosupportive care and oriented to SENSE©. Program-provided materials were supplied in the unit. Families were oriented to SENSE© via a program-provided educational website, and interventions were supplied per evidence-based sensory guidelines for gestational age (GA). Measures: Nurses’ integration of developmentally supportive practices in routine care were assessed before education/implementation and then again after 14 weeks of program implementation. Data was collected from bedside SENSE© medical log sheets and analyzed to assess the use of DC interventions as prescribed by SENSE©

Social emotional assessment of infants at-risk using the Ages and stages questionnaire social emotional (ASQ:SE)

Purpose: The purpose of the current study is to examine relationships between parent completed scores of full term and preterm infants on two standardized questionnaires: 1) Ages and Stages Questionnaire (ASQ) measuring all areas of development and 2) Ages and Stages Questionnaire Social Emotional (ASQ-SE) measuring social-emotional development. Methods: Participants included parents of 25 preterm infants who were referred to UNMH Special Baby Clinic and 25 term infants. Parents filled out the ASQ and the ASQ:SE as well as a Social History Questionnaire. Results: No significant correlations were found between individual ASQ domains with the ASQ:SE for separate groups of infants. When groups were combined, scores for ASQ Gross Motor (r = -.30: p = .03), Personal Social (r = -.28: p = .05), and Total (r = -.32: p = .02) reached significance. Between group analyses yielded significant differences on the ASQ:SE (p = .01) as well ASQ Personal Social domain (p = .05). Trends towards significance were: ASQ Total Scores compared to ASQ:SE scores in the at-risk infants (r = -0.36: p = 0.08), and the ASQ Communication domain with both groups combined (r = -0.24: p = 0.09). Conclusions: Significant differences between groups on the ASQ:SE were found, however the at-risk group was not above the cut off for developmental concerns. Significant but weak correlations were revealed with combined groups on the ASQ Gross Motor, Personal Social and Total scores, indicating that the ASQ:SE and the ASQ have preliminary construct validity in these areas. Additional research with a larger sample size may establish construct validity between the ASQ and the ASQ:SE

Early Kangaroo mother care for mild-moderately unstable neonates <2000g in The Gambia

Complications of prematurity are the largest cause of childhood deaths globally, with >1 million deaths and high risk of long-term neurodevelopmental impairment. The first day after birth is the period of greatest risk and greatest potential for improving outcomes, especially with hospital-based small and sick newborn care (SSNC). Kangaroo mother care (KMC) involves continuous skin-to-skin contact and is recommended by WHO for all stable neonates ≤2000g. At PhD onset a priority evidence gap existed for initiation of early KMC before stability, which may contribute towards reducing the Sustainable Development Goal (SDG) for neonatal mortality, especially in low-resource, high-mortality contexts. My PhD aimed to investigate early KMC (< 24h of admission) in unstable neonates <2000g in one Gambian level 2/2+ neonatal unit. There were four objectives: (1) To prepare the research site with mitigation of barriers to trial implementation; (2) To investigate the effect of early KMC on survival and other clinical outcomes and safety (eKMC trial); (3) To explore pathways to preterm mortality and the effect of early KMC on physiological factors; (4) To determine the programmatic/policy and research implications of the PhD findings. The first PhD section provides the rationale for studying this topic and description of the local study site context at PhD onset. Substantial site preparations were required for trial implementation, including establishment of KMC as standard care and development/implementation of SSNC guidelines to minimise bias. Local data informed trial protocol development along with a conceptual framework to guide implementation process data collection. Unavailability of the mother during the first 24h of admission was a key recruitment barrier, mitigated by involving female relatives, and informed by a qualitative study to understand their perceptions towards SSNC and KMC. The second section focuses on the eKMC randomised controlled trial primary and secondary outcome findings. Despite adequate power at trial onset, no evidence of 28-day mortality effect was identified, with possible reasons including (1) Insufficient sample size to detect a between-arm difference due to large reductions in control arm mortality compared to pre-trial mortality (2) Low fidelity of the intervention delivered. However, important insights were gained for secondary outcomes, and feasibility of delivering prolonged KMC contact to unstable neonates, along with safety considerations. The final section presents a conceptual framework to describe pathways to mortality for neonates <2000g and potential amelioration by early KMC. Exploratory analyses of eKMC trial data identified substantial survival gains during the trial period, with 24% relative mortality reduction for all neonates <2000g and 29% relative risk reduction associated with trial participation. Weight <1200g, factors. This PhD provides valuable insights into SSNC in a West African context, underlining the importance of improving quality of SSNC overall as well as the potential for KMC as an entry point for family centred care. Female relatives are key stakeholders for family integrated SSNC and KMC in this socio-cultural context. The eKMC trial findings alone do not support a change to KMC policy, but a recent WHO multi-centre trial is influencing a shift towards immediate KMC. These findings provide rich data and insights into implementation and impact of SSNC, operationalisation of KMC for stable neonates, and novel data regarding the impact, feasibility, and realities of providing early KMC to unstable newborns in a typical African hospital neonatal unit

Indirect approaches: A systematic review of paediatric dysphagia interventions

Background and purpose: Dysphagia can be described as difficulty within the oral, pharyngeal and/or oesophageal phases of deglutition and occurs in approximately 80% of children with developmental disabilities, according to the American Speech and Hearing Association (2015). It occurs when there is impairment to the motor and/or sensory aspects of swallowing, due to a range of disorders affecting the voluntary and reflexive components of deglutition. The ability to swallow safely is essential in preventing medical complications, sustaining life and maintaining social participation. Paediatric interventions can be categorized into three broad approaches; direct, indirect and mixed. At present, two systematic reviews have examined the efficacy of direct interventions. Despite a large body of evidence supporting the efficacy and safety of indirect paediatric dysphagia interventions, no studies have systematically grouped and compared the relative effectiveness of indirect interventions, across all paediatric ages and conditions. Methods and procedure: Following a comprehensive search of 19 databases by two independent searches and using an identical search strategy, a systematic review appraised 13 randomized and non-randomized control studies relating to indirect paediatric dysphagia interventions. Based on retrieved results, indirect interventions included modified equipment, environmental changes and altered rate of food and liquid presentation. Articles included in the analysis were rated for quality on two separate appraisal scales; The Cochrane Risk of Bias Tool and the Pedro Scale. Additionally, effect size calculations and forest plots were derived to standardize and compare the effects of individual intervention types. Outcomes and results: The review demonstrated that whilst a lack of high quality evidence exists in the field of paediatric dysphagia, the available RCTs are of high methodological quality. Overall, effect size calculations demonstrate a positive trend towards improved feeding, anthropometric measures and length of hospital stay outcomes for interventions involving modified equipment, environmental changes and altered rate of presentation. Conclusions: The available RCT evidence involving indirect interventions are of high methodological quality. As effects of these interventions demonstrate positive outcomes, Speech Pathologists should continue to implement these interventions within everyday practice. To further validate the effects of indirect management approaches, additional high quality research is required

EARLY INTERVENTION IN PRETERM INFANTS: EFFECTS ON NUTRITION AND NEURODEVELOPMENT

Background: Preterm infants are at high risk for neurodevelopmental disorders, even in the absence of overt brain lesions. NICU stressful environment, inadequate nutritional support and paucity of parental contact seem to negatively impact early brain development. In this context, mother milk feeding, could play a beneficial role although it is known to be challenging. Recent studies have shown how early interventions can reduce stress exposure with a positive effect on mother-infant relationship and subsequent neurodevelopment in preterm infants. Aims: To determine the effectiveness, in preterm infants, of an Early Intervention program on: i) visual function at term equivalent age (TEA) as an early emerging cognitive function; ii) infant\u2019s feeding behavior and in particular on mother milk assumption at discharge; iii) epigenetic changes in DNA methylation status at TEA; iv) brain growth and maturation assessed by advanced Magnetic Resonance Imaging (MRI) at TEA. Methods: We conducted a parallel-group, randomized controlled trial (Trial Registration Number: NCT02983513). We included preterm infants born between 25+0 and 29+6 weeks of gestational age (GA) without severe morbidities and their families. Infants were recruited and randomized to either receiving Early intervention (EI) or Standard Care (SC). EI program included PremieStart, based on parental involvement, together with a multisensory stimulation (both tactile \u2013 through infant massage - and visual stimulation). SC, delivered according to NICU protocols, included Kangaroo Mother Care and minimal handling. Infants with major neonatal morbidities (i.e. surgical NEC; severe brain injuries as GMH-IVH>2\ub0, cPVL) were excluded. The following evaluation were performed: i) Visual ability were assessed at TEA according to the protocol developed by Ricci et al. ii) Infants\u2019 human milk intake at discharge was calculated from the infants\u2019 computerized medical chart, as well as time of acquisition of full-oral feeding iii) As a proxy of DNA methylation we explored LINE-1 methylation status. The analyses were conducted using two blood samples: a cord blood sample, collected at birth, and a peripheral blood sample, harvested at TEA. iv) To calculate brain growth automated segmentation was conducted on each neonatal Axial T2 2 mm scan, in conjunction with the T1 scan. Volumetric measures of the structures were extracted from each segmentation. Results: Seventy preterm (EI n=34, SC n=36) infants were enrolled. According to the protocol 3 infants allocated to EI did not receive treatment. All babies in the SC group received allocated treatment as part of routine clinical practice. Main results include: i) Visual abilities: in total, 59% of infants in the EI group achieved the highest score possible in all 9 items of the visual assessment compared to 17% in the SC group (p=0.001). All infants in both groups showed complete maturation in four items, but EI infants showed more mature findings also in the other 5 items (ocular motility both spontaneous and with target, tracking arc, visual acuity and attention at distance). ii) Infant\u2019s feeding behavior: a significantly higher rate of infants fed with any human milk was observed in the EI group (75.9%) compared to SC group (32.1%) (p=0.001) and EI infants were four times more likely to be fed exclusively with human milk at NICU discharge. Full oral feeding was achieved almost one week before in EI infants (mean postmenstrual age 36.8\ub11.6 vs 37.9\ub12.4 weeks in EI vs SC, p=0.04). iii) Epigenetic changes: LINE-1 methylation status increased from preterm birth to TEA for both group but was more pronounced in the EI group (p=0.0077) especially when looking at single CpG sites. iv) Brain growth: no differences were observed between the two groups in terms of regional brain volumes for the 48 areas analyzed. Conclusions: The present work provides further insights in the field of EI. Combining parental involvement and multisensory stimulation, our EI strategy showed an overall beneficial effect for preterm infants. This study, despite far to be conclusive, concur with recent evidence that the quality of early experiences influences neurodevelopment in preterm infants

Informing the design of a trial of kangaroo mother care initiated before stabilisation amongst small and sick newborns in a sub-Saharan African context using mixed methods

An estimated 2.5 million neonates die every year, with preterm birth being the leading cause. Sub-Saharan Africa and southern Asia account for 78% of neonatal deaths. The WHO recommends kangaroo mother care (KMC) for stabilised newborns ≤2000g; however, most deaths occur before stabilisation. An evidence gap exists regarding KMC for this population. The overall aim of this PhD was to inform the design of a trial of KMC initiated before stabilisation in a sub-Saharan African context. The first part focused on assessing facility readiness and quantifying neonatal mortality risk. Cascade models were developed and used to assess 23 East African facilities. A logistic model was derived and validated using data from 187 UK hospitals and one Gambian hospital. The final model, including three parameters, demonstrated very good performance. The score requires further validation in low-resource contexts, but has potential to improve neonatal resource allocation. The second part of this PhD focused on evaluating the feasibility of initiating KMC before stabilisation and designing the trial. This study showed it was feasible to monitor and provide care in the KMC position, and found the intervention was acceptable to parents and providers. Launched in 2020, the OMWaNA trial will determine the mortality impact of this intervention within 7 days relative to standard care at four Ugandan hospitals. Process and economic evaluations will explore causal pathways for clinical effects, estimate incremental cost and costeffectiveness, and examine barriers and facilitators to inform uptake and sustainability. This PhD has developed a cascade model to assess facility readiness, validated a score to assess individual risk, and demonstrated the feasibility of initiating KMC before stabilisation. These studies have informed the design of a trial evaluating the mortality impact of this intervention in Uganda. The findings are expected to have broad applicability to low-resource hospitals and important policy implications

Shaping the Lives of Little Ones Developmental Equipment Project

Premature infants in the Neonatal Intensive Care Unit (NICU) may experience extensive hospitalizations due to prematurity and medical complications requiring interventions to sustain life and support physiological development. NICU staff are often focused on immediate medical concerns for these infants and may not consider the development and play needs for these long term hospitalized infants. Occupational therapists are aware of the importance of play and supporting the parental role and co-occupations between the infant and parents. This capstone paper discusses the Shaping the Lives of Little Ones Developmental Equipment Project for infants, nurses, and parents designed to provide opportunities for sensory-motor experiences and play for older infants by increasing access to essential equipment and toys for infants’ development. Details of the project, methodology, implementation, results and future implications for practice and research are presented

Reducing stress in the neonatal intensive care unit:an occupational therapy approach to preterm infant massage

Thesis (Ph.D.)--Boston UniversityPreterm infants and their parents in the neonatal intensive care unit (NICU) are a growing client population for occupational therapists. The NICU environment of care can be over stimulating and cause high amounts of stress for preterm infants and their parents. Evidence-based literature supports preterm infant massage to decrease stress for preterm infants and improve overall neurobehavioral development. Evidenced-based literature also supports decreased stress for parents that perform preterm infant massage with their child as well as improved confidence of parental skills and infant-parent attachment. Despite these benefits, infant massage is practiced in less than half of the NICUs in the United States (Field, Diego & Hernandez-Reif, 2010). This may be related to the underlying mechanisms not being well understood and/or cost effectiveness considerations. This doctoral project (1) identifies evidenced-based literature to support the benefits of preterm infant massage for both the infant and the parent, (2) investigates evidence and best practice in designing a preterm infant massage parent education program in the NICU that supports the infant-parent dyad, (3) provides an overview of best practice for implementing a preterm infant massage parent education program in the NlCU, (4) describes a detailed evaluation plan and dissemination of the results including estimated budgets for implementation and dissemination. This project's target audiences are medical directors, directors of occupational therapy departments, neonatal occupational therapists, neonatologists, other health care staff in the NICU, and parents of preterm infants in the NICU. This project will be presented to the medical director of a Level IV NlCU and the director of occupational therapy at University of Rochester Medical Center-Golisano Children's Hospital for consideration of implementation. This project contributes to three areas of occupational therapy: (1) addressing best practice for implementing a preterm infant massage program in the NlCU to reduce stress levels for infants and parents, (2) providing more evidenced-based practice with a growing occupational therapy population of preterm infants and their parents, and (3) building a more diverse occupational therapy profession

Translating Evidence of Skin-to-Skin and Rooming-in to Practice

The old practice of separating the mother-baby-dyad was without measurable benefits to mothers or their infants. Evidence has shown that skin-to-skin care (SSC) prevents hypothermia and hypoglycemia, decreases crying during painful procedures in newborns, and reduces maternal anxiety, stress, and postpartum depression. Rooming-in care (RIC) has been linked to an increase in the rate of breastfeeding and mother-infant interaction, as well as a decrease in the infant morbidity rate. This project assessed the effect of an educational intervention to increase rates of SSC and RIC in an obstetric unit, in addition to measuring nurses\u27 attitudes and barriers in relation to SSC and RIC. The obstetric nurses received educational content related to SSC and RIC based on Kotter\u27s model of change. A pre and postintervention evaluation showed a significant increase in the rates of SSC and RIC from pretest of 10%, to posttest of 96%; and RIC from pretest of 10% to posttest of 92%. Using a Wilcoxon test, a significant difference was found from pretest to posttest for every subscale score of the Mother-Newborn Skin-to-Skin Contact Questionnaire and Nurse Attitudes and Barriers to nonseparation Scale (p \u3c 0.001), with the exception of belief about obstacles for SSC, which yielded a nonsignificant change (p = 0.57). This DNP project led to changes in the organization\u27s culture, including the closure of the well-baby nursery. This project promoted social change across the organization, in that the team health care providers delivered evidence-based, standardized, unbiased, and family-centered care to the mother-baby dyad