Bobbi Pineda PhD, OTR/L, CNT (she/her/hers)

Background. One criterion for infant NICU discharge is the ability to meet all nutritional needs by mouth, therefore, it is important to understand interventions that can improve the trajectory to full oral feeding. While many oral motor and feeding interventions are used in clinical practice, it remains unclear which are supported by the literature.

Aim. The aim of this integrative review was to identify and understand what oral motor interventions are defined in the literature to support positive outcomes for preterm infants and their parents.

Methods. An integrative review of studies published from 2002 to 2022 focusing on applied oral motor interventions and their impact on feeding-related outcomes was completed. The systematic search used databases including PubMed, Cochrane, CINAHL, Scopus, and Google Scholar. Studies were included if they used a study population of preterm infants born

Results. Forty articles met inclusion criteria with four different interventions (or a combination of them) identified: nonnutritive sucking, oral motor stimulation [Fucile's protocol, Premature Infant Oral Motor Intervention (PIOMI)], NTrainer, and swallowing exercises.

Discussion. All interventions were associated with positive outcomes and began between 29- and 30-weeks PMA. Detailed information on adverse events (both physiologic and behavioral) in future research could allow for better risk-benefit analysis. The methodology and quality of the studies differed too much to allow for quantitative analysis; however, there does not appear to be compelling evidence that more stimulatory interventions are superior to less stimulatory interventions – a key consideration when working with preterm infants.

Background. The Neonatal Eating Outcome Assessment determines feeding performance based on the infant’s postmenstrual age (PMA).

Objective. To examine item-level measurement properties of this assessment’s rating scale.

Methodology. In this retrospective study, Rasch analysis was completed on clinical data from the Neonatal Eating Outcome Assessment for 100 infants (52 preterm and 48 full-term) using Winsteps version 3.93.1. Instead of PMA-based scores, ordered letters converted to numerical scores were analyzed.

Results. Analysis demonstrated that Section I (Pre-Feeding Skills) represents a separate construct from Sections II and III (Oral Feeding and End of Feeding, respectively). Sections II and III were adequately unidimensional to complete Rasch analysis. These sections fit the Rasch model overall, but rating scale category underuse was common, which may be attributed to sample characteristics.

Objectives. Investigate relationships between aEEG in the first 72 h in extremely preterm infants with 1) infant, medical, and environmental factors, and 2) infant feeding and neurobehavioral outcomes at term and school-age.

Methods.. Sixty-four preterm infants (≤28 weeks gestation) were enrolled within the first 24-hours of life and had two-channel aEEG until 72 h of life. Standardized neurobehavioral and feeding assessments were conducted at term, and parent-reported outcomes were documented at 5–7 years.

Results. Lower aEEG Burdjalov scores (adjusted for gestational age) were related to vaginal delivery (p = 0.04), cerebral injury (p = 0.01), Black race (p < 0.01) and having unmarried parents (p = 0.02). Lower Burdjalov scores related to less NICU Network Neurobehavioral Scale arousal (p = 0.002) at term and poorer BRIEF global executive function (p = 0.004), inhibition (p = 0.007), working memory (p = 0.02), material organization (p = 0.0008), metacognition (p = 0.01), and behavioral regulation (p = 0.02) at 5–7 years. We did not observe relationships of early aEEG to feeding outcomes or sensory processing measures.

Conclusion. Early aEEG within the first 72 h of life was related to medical and sociodemographic factors as well as cognitive outcome at 5–7 years.

Aim. To identify relationships between early medical factors and preterm infant feeding behaviors at term-equivalent age.

Methods. Forty-three very preterm infants born ≤32 weeks gestation had standardized feeding assessments using the Neonatal Eating Outcome Assessment at term-equivalent age (36–42 weeks postmenstrual age). Medical factors were collected and analyses were run to determine if associations between different medical factors and feeding performance exist.

Results. Lower Neonatal Eating Outcome Assessment scores at term-equivalent age were associated with lower estimated gestational age (p < .01), lower birthweight (p < .01), older postmenstrual age at discharge (p < .01), longer length of stay in the neonatal intensive care unit (p < .01), chronic lung disease (p = .03), as well as more days on total parenteral nutrition (p = .03), endotracheal intubation (p < .01), and noninvasive mechanical ventilation (p < .01).

Conclusion. More feeding problems are observed in infants born earlier, with longer hospital stays, and with complex medical courses. Knowledge of the association between these medical factors and feeding difficulties allows for identification of infants who may benefit from early, targeted interventions to optimize the feeding process.

Objective. This study aimed to (1) define the prevalence of motor, cognitive, and language delays in preterm infants born <32 weeks estimated gestational age (EGA); and (2) identify the relationship between the timing of discharge from the neonatal intensive care unit (NICU) and neurodevelopmental outcome in early childhood.

Study Design. This retrospective study of 172 preterm infants born <32 weeks EGA and hospitalized in a level-IV NICU captured medical factors, including timing of discharge, from the NICU stay. Standardized developmental testing at 1 to 2 years corrected age was conducted in the newborn follow-up clinic.

Results. At 1 to 2 years corrected age, the sample had an average Bayley Scales of Infant and Toddler Development (Bayley-III) cognitive composite score of 91.5 ± 17.4, language composite score of 84.5 ± 17.3, and motor composite score of 88.9 ± 18.4. Lower EGA at birth, necrotizing enterocolitis, patent ductus arteriosus, and oxygen requirement for >28 days were independently associated with higher postmenstrual age (PMA) at NICU discharge. Higher PMA at discharge was associated with poorer cognitive outcome [p < 0.001, β = −1.1 (−1.6, −0.7)], poorer language outcome [p = 0.049, β = −0.5 (−0.9, −0.003)], and poorer motor outcome [p <0.001, β = −1.0 (−1.5, −0.5)]. For every additional week of hospitalization, scores were an average of 1.1 points lower in cognitive, 1.0 point lower in motor, and 0.5 points lower in language domains of the Bayley-III assessment.

Conclusion. Poorer cognitive, language, and motor outcomes were associated with longer hospitalization, even after controlling for medical risk factors known to be associated with poorer outcome. This provides further evidence for the potential role of the environment in impacting developmental outcomes of infants hospitalized in the NICU.

Keywords. hospitalization; neonatal intensive care unit; length of stay; postmenstrual age; outcomes; child development; risk factors; environment

Objectives. To 1) estimate the total pool of neonatal therapists and the average number represented in each US-based NICU, and 2) investigate the relationships between the number and type of neonatal therapy team members to NICU/hospital, population, and therapy factors.

Study Design. This study used several methods of data collection (surveys, phone calls, website searches) that were combined to establish a comprehensive list of factors across each NICU in the US.

Results. We estimate 2333 neonatal therapy FTEs, with 4232 neonatal therapists covering those FTEs in the US. Among 564 NICUs, 432 (76%) had a dedicated therapy team, 103 (18%) had PRN therapy coverage only, and 35 (6%) had no neonatal therapy team. Having a dedicated therapy team was more likely in level IV (n=112; 97%) and III (n=269; 83%) NICUs compared to level II NICUs (n=51; 42%) (p<0.001). Having a dedicated therapy team was related to having more NICU beds (p<0.001), being part of a free-standing children’s hospital or children’s hospital within a hospital (p<0.001), and being part of an academic medical center or community hospital (p<0.001). Having a dedicated therapy team was more common in the Southeast, Midwest, Southwest, and West (p=0.001), but was not related to the proportion of the community living in poverty or belonging to racial/ethnic minorities (p>0.05). There was an average of 17 beds per neonatal therapy FTE, a good marker of therapy coverage based on NICU size. Three-hundred US-based NICUs (22%) had at least one Certified Neonatal Therapist (CNT) in early 2020, with CNT presence being more likely in higher acuity NICUs (59% of Level IV NICUs had at least one CNT).

Conclusions. Understanding the composition of neonatal therapy teams at different hospitals across the US can drive change to expand neonatal therapy aimed at optimizing outcomes of high-risk families.

Importance. The Supporting and Enhancing NICU Sensory Experiences (SENSE) program is an evidence-based intervention that promotes daily, positive sensory exposures for infants in the neonatal intensive care unit (NICU). Understanding program implementation across sites may aid in optimizing strategies for uptake of the program and subsequently improve outcomes for infants and families.

Objective. To investigate health care professionals’ perceptions of implementing the SENSE program.

Design. The SENSE Program Implementation Survey was developed using Proctor et al.’s model and the BARRIERS scale to probe organizational practices across sites worldwide.

Setting. Survey distributed to 211 hospitals with a SENSE program license obtained before March 2020.

Participants. One hundred fourteen NICU personnel (response rate = 54%).

Outcomes and Measures. The survey sought to understand barriers and facilitators, adaptations during implementation, and associated costs.

Results. Of the 53% (n = 57 of 107) of respondents who had implemented the SENSE program, many (n = 14; 31%) experienced quick timing (<1 mo) to use, including spread to nearly all infants in their NICU within 6 mo (n = 18; 35%). Most reported the program was used to educate families ≤3 days of birth (n = 20/59; 34%). Most of the sensory interventions in the program were performed by parents (n = 38; 67%) and therapists (n = 44; 77%). Barriers and facilitators at the organizational and individual levels were identified. No additional staff were hired to implement the program.

Conclusions and Relevance. Given perceived successes and challenges, strategic enhancement of implementation can inform future administrations of the SENSE program.

Neonatal intensive care unit (NICU) co-occupations may impact parent–infant outcomes. The main objective of this study was to explore relationships between parent and infant outcomes based on whether sensory-based interventions (co-occupations) occurred most often between parent–infant dyads or provider/volunteer–infant dyads. Thirty-five families received the Supporting and Enhancing NICU Sensory Experiences (SENSE) program, which includes education defining specific amounts of sensory exposures for infants to receive each day of NICU hospitalization (with a preference for parent delivery). Infant sensory experiences in the NICU were logged, and dyads were grouped based on who conducted most of the sensory interventions with the infant in the NICU into a Parent–Infant Co-occupation group or Other Administered group. The Parent–Infant Co-occupation group had infants with less lethargy on the NICU Network Neurobehavioral Scale (p = .04), and parents with lower scores on the Parental Stress Scale (p = .003) and State-Trait Anxiety Inventory-state (p = .047). Parent–infant engagement in co-occupations was related to parental mental health and infant neurobehavior.

Keywords. development; engagement; environment; family-centered care; intervention; parent mental health; parent–infant interaction; participation; sensory.

Introduction. Children born very preterm (VP) remain at risk for long-term neurodevelopmental impairment. Patterns of brain growth and injury, and how early neuropromotive therapies might mitigate developmental risk in VP infants remain insufficiently understood.

Methods. This is a prospective cohort study of VP infants born at/before 32 weeks gestation. The study will enroll n = 75 consecutively-born VP infants in a level-III NICU. Exposed infants will be categorized into two groups (group 1: low-risk, n = 25 or group 2: high-risk, n = 25) based on the degree of neurological injury on early brain magnetic resonance imaging (MRI) at enrollment. Infants in the low-risk group (i.e., without significant injury defined as intraventricular hemorrhage with dilation, moderate or severe white matter injury, or cerebellar hemorrhage) will receive neurodevelopmental support utilizing the Supporting and Enhancing NICU Sensory Experiences (SENSE) program, while infants in the high-risk group (with neurological injury) will receive more intensive neurorehabilitative support (SENSE-plus). Age-specific, tailored sensory experiences will be facilitated contingently, preferentially by the infant's family with coaching from NICU staff. VP infants in exposure groups will undergo a brain MRI approximately every 2 weeks from enrollment until term-equivalent to monitor brain growth and evolution of injury. Exposed infants will be compared with a reference group (group 3: n = 25), i.e. VP infants whose families decline initial enrollment in SENSE, and subsequently undergo a term-equivalent brain MRI for other purposes. The primary aim of this study is characterization of term-equivalent brain growth and development among VP infants receiving NICU-based neuropromotive interventions compared to VP infants receiving the standard of care. Secondary aims include defining the timing and factors associated with total and regional brain growth on serial brain MRI among VP infants, (Aim 2), and using early imaging to tailor developmental intervention in the NICU while exploring associations with outcomes in VP infants at discharge and at two years corrected age (Aim 3).

Discussion. This study will address gaps in understanding patterns of brain growth and injury drawing on serial MRI of hospitalized VP infants. These data will also explore the impact of intensive, tailored neuropromotive support delivered prior to term-equivalent on child and family outcomes.

Keywords. preterm, neurodevelopment, neurorehabilitation, multisensory experience, developmental care, NICU environment

The Supporting and Enhancing NICU Sensory Experiences (SENSE) program was developed in 2017 to guide parents in providing age-appropriate positive sensory exposures to their preterm infants each day of NICU hospitalization. The development of the guideline followed a systematic process with an integrative review to identify evidence-supported sensory exposures, interviews and focus groups with stakeholders, and a pilot study and a randomized controlled trial. Recently, another integrative review was conducted to identify newly published studies on sensory exposures in the NICU, and a SENSE advisory team was recruited to inform updates to the guideline to ensure that the latest evidence related to sensory exposures in the NICU was incorporated. Daily sensory activities that are supported by evidence are listed in the parent education booklet, allowing parents autonomy in selecting appropriate sensory activities to engage in with their infants as they grow and develop in the NICU, as well as enabling choices of activities to provide for infants with different levels of medical support. The healthcare team regularly monitors infant tolerance and development as described in the SENSE implementation manual. While implementation training is available, the program can be implemented by NICUs following a self-paced review of the implementation materials. The SENSE program implementation aims to optimize the NICU environment to improve infant brain development and parent confidence while facilitating their transition into their parental roles.

Keywords. high-risk infants, parenting, NICU, sensory stimulation, environmental modification, program, premature

Background. Parents report elevated stress during their infant's NICU hospitalization. Real-time measures may improve our understanding of parental stress in the NICU.

Aim. Examine the feasibility of wearable sensors to describe parental stress in the NICU.

Study design. In this prospective feasibility study of 12 parent-infant dyads, parents wore an Empatica E4 wristband to measure psychophysiological stress via electrodermal activity (EDA) during sensory interventions (holding, massage, reading, touch, etc.) with their babies. Baseline and intervention periods were delineated during which concurrent monitoring and clinical observations of infant behavior and environmental factors were recorded. Feasibility was assessed by investigating recruitment/enrollment, retention/adherence, acceptability, sensor usability, and changes in EDA waveforms based on potential stressors. For the latter, independent samples t-tests and ANOVA were used to examine differences in EDA from baseline to intervention, and the impact of environmental and infant factors on parent stress were visually analyzed against EDA waveforms.

Results. Wearable sensor use in the NICU appeared feasible as assessed by all methods. Preliminary data analysis indicated that overall parent EDA levels during parent-infant interactions were low, and engagement in sensory intervention(s) led to a non-significant increase in parental EDA, measured by both skin conductance levels and non-specific skin conductance responses. Three main patterns of EDA emerged: a temporary increase in EDA at the beginning of the intervention followed by a decrease and plateau, a plateau in EDA from baseline to intervention, and a gradual rise in EDA throughout intervention. Specific environmental and infant factors, such as infant stress and health care providers entering the room, appeared to impact parent stress levels.

Conclusion. Although these preliminary findings provide support for use of EDA in the NICU, future studies are needed.

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

The Baby Bridge program is an implementation strategy to improve access to in-person early therapy services following neonatal intensive care unit (NICU) discharge. The objective of this study was to evaluate acceptability of Baby Bridge telehealth services among health care providers. Interviews with health care providers were conducted, transcribed, and coded in NVivo. Deductive analysis was used to organize data into negative and positive comments, suggestions for optimization, and perceptions about the first visit. Next, a conventional approach was used to organize the data into themes. Telehealth was viewed as an acceptable, but not necessarily preferable, form of Baby Bridge delivery. Providers identified how telehealth may improve access to care, but with potential challenges in delivery. Suggestions for optimization of the Baby Bridge telehealth model were proposed. Identified themes included delivery model, family demographics, therapist and organizational characteristics, parent engagement, and therapy facilitation. These findings provide important insights to consider when transitioning from in-person therapy to telehealth.

Keywords. family-centered practice; neonate; pediatrics; qualitative research; services.

Objective. To 1) define the number and characteristics of NICUs in the United States (US) and 2) identify hospital and population characteristics related to US NICUs.

Study design. Cohort study of US NICUs.

Results. There were 1424 NICUs identified in the US. Higher number of NICU beds was positively associated with higher NICU level (p < 0.0001). Higher acuity level and number of NICU beds related to being in a children’s hospital (p < 0.0001;p < 0.0001), part of an academic center (p = 0.006;p = 0.001), and in a state with Certificate of Need legislation (p = 0.023;p = 0.046). Higher acuity level related to higher population density (p < 0.0001), and higher number of beds related to increasing proportions of minorities in the population up until 50% minorities. There was also significant variation in NICU level by region.

Conclusions. This study contributes new knowledge by describing an updated registry of NICUs in the US in 2021 that can be used for comparisons and benchmarking.

The Supporting and Enhancing NICU Sensory Experiences (SENSE) program promotes consistent, age-appropriate, responsive, and evidence-based positive sensory exposures for preterm infants each day of NICU hospitalization to optimize infant and parent outcomes. The initial development included an integrative review, stakeholder input (NICU parents and healthcare professionals), and feasibility focus groups. To keep the program updated and evidence-based, a review of the recent evidence and engagement with an advisory team will occur every 5 years to inform changes to the SENSE program. Prior to the launch of the 2nd edition of the SENSE program in 2022, information from a new integrative review of 57 articles, clinician feedback, and a survey identifying the barriers and facilitators to the SENSE program’s implementation in a real-world context were combined to inform initial changes. Subsequently, 27 stakeholders (neonatologists, nurse practitioners, clinical nurse specialists, bedside nurses, occupational therapists, physical therapists, speech-language pathologists, and parents) carefully considered the suggested changes, and refinements were made until near consensus was achieved. While the 2nd edition is largely the same as the original SENSE program, the refinements include the following: more inclusive language, clarification on recommended minimum doses, adaptations to allow for variability in how hospitals achieve different levels of light, the addition of visual tracking in the visual domain, and the addition of position changes in the kinesthetic domain.

Keywords. sensory-based interventions; sensory integration; sensation; exposure; environment; preterm; neonatal intensive care unit; NICU; tactile; auditory; multimodal; multisensory; vestibular; kinesthetic; visual; olfactory; gustatory; parenting; SENSE; review; program development

Importance. Feeding difficulties are common among preterm infants during neonatal intensive care unit (NICU) hospitalization. Although most preterm infants achieve full oral feeding by term-equivalent age, whether feeding difficulties persist despite the infant taking full volume and whether these difficulties may relate to other neurobehavioral challenges remain unclear.

Objective. To identify the prevalence of feeding problems among preterm infants and the relationships between infant feeding behaviors and neurobehavior at term-equivalent age.

Design. Cohort study.

Setting. Level 4 NICU with 85 beds.

Participants. Thirty-nine very preterm infants born ≤32 wk gestation (range = 22–32 wk). Exclusion criteria were congenital anomalies, >32 wk gestation at birth, and lack of feeding or neurobehavioral assessment at term-equivalent age.

Outcomes and Measures. Standardized feeding assessments using the Neonatal Eating Outcome Assessment and standardized neurobehavioral evaluation using the NICU Network Neurobehavioral Scale.

Results. Thirty-nine infants (21 female) were included in the final analysis. The mean Neonatal Eating Outcome Assessment score was 66.6 (SD = 13.3). At term-equivalent age, 10 infants (26%) demonstrated feeding challenges, 21 (54%) demonstrated questionable feeding issues, and 8 (21%) demonstrated normal feeding performance. Lower Neonatal Eating Outcome Assessment scores (poorer feeding performance) at term-equivalent age were associated with more suboptimal reflexes (p = .04) and hypotonia (p < .01).

Conclusions and Relevance. Feeding challenges and questionable feeding performance were prevalent among preterm infants at term-equivalent age and appeared in conjunction with suboptimal reflexes and hypotonia. Understanding this finding enables therapists to take a holistic approach to addressing feeding difficulties.

Objective. To describe differences in neurobehavior among very preterm infants with low medical risk at term equivalent age and full-term infants.

Study design. One-hundred eighty-six (136 infants born ≤32 weeks gestation with low medical risk at term equivalent age and 50 full-term infants within 4 days of birth) had standardized neurobehavioral assessments. Low medical risk was defined by ventilation <10 days and absence of significant brain injury, necrotizing enterocolitis, patent ductus arteriosus, and retinopathy of prematurity.

Results. Very preterm infants with low medical risk at term equivalent age demonstrated more sub-optimal reflexes (p < 0.001; ß = 1.53) and more stress (p < 0.001; ß = 0.08) on the NICU Network Neurobehavioral Scale compared to their full-term counterparts. Very preterm infants with low medical risk also performed worse on the Hammersmith Neonatal Neurological Examination (p = 0.005; ß = −3.4).

Conclusion. Very preterm infants at term equivalent age continue to demonstrate less optimal neurobehavior compared to full-term infants.

The neonatal intensive care unit (NICU) is a dynamic system with multiple stakeholders and contextual factors impacting the implementation of novel practices. This qualitative study aimed to (a) define health care professionals’ perceptions on the feasibility of implementing a sensory intervention to study its efficacy, and (b) elaborate on transactions occurring between NICU health care professionals and the proposed research. Eleven NICU professionals participated in one of three focus groups that were audio-recorded, transcribed, and analyzed thematically in NVivo first descriptively and then interpretively through a transactionalism lens. The health care professionals implied the intervention was feasible, but provided multiple suggestions to enhance implementation. The modification of familiar occupational practices, ingrained habits, and the potential impact on the collective occupational performance of NICU community members arose. Understanding occupations within the NICU as transactional allows for a broader view of occupational engagement and enhances knowledge of the nuances related to implementing clinical changes.

Keywords. qualitative research, neonate, occupational engagement, occupational science, occupational performance

Background. Parent-infant interaction is poorly understood among high-risk dyads in NICU settings. No parent-infant interaction measures are specifically designed for preterm infants within the NICU nor account for the education NICU parents receive to tailor their interactions based on the infant's cues.

Aim. To improve our understanding of a measure of parent-infant interaction in the NICU, we investigated relationships between parent-infant interaction scores on the Nursing Child Assessment Feeding Scale (NCAFS) and 1) socio-demographic and medical factors, 2) parent mental health and confidence, and 3) enhanced parental education (delivered as part of the Supporting and Enhancing NICU Sensory Experiences program) on tailoring interactions based on the infant's cues.

Method. Twenty-six preterm infants (born ≤32 weeks) had a video recorded oral feeding conducted by a parent in the NICU when the infant was 34–48 weeks postmenstrual age. A certified evaluator scored parent-infant interaction from the videos using the NCAFS.

Results. Seventeen (65 %) parent-infant dyads scored below the 10th percentile on the total NCAFS score. Despite it being well-understood that parent-infant interaction is related to sociodemographic factors and parental mental health, there were no relationships between these factors and NCAFS scores in this study. Dyads who received enhanced parent education (n = 15) had lower NCAFS scores than dyads receiving usual care (n = 11) (p = 0.01).

Conclusion. It remains unclear if the standard measure of parent-infant interaction, NCAFS, captured positive and negative interactions in context of assessment of a high-risk dyad within the NICU setting. The utility of the NCAFS with preterm infants in the NICU was not supported by this study.

Keywords. Premature infant; Human development; Parents; Interactions

Background. Mothers play an important role in providing positive sensory experiences to their infants during NICU hospitalization. However, little is known regarding maternal perceptions about sensory-based interventions in the NICU. Further, understanding maternal perceptions was an important part of the process during development of the Supporting and Enhancing NICU Sensory Experiences (SENSE) program.

Methods. Twenty mothers of very preterm infants were interviewed after NICU discharge and asked open-ended questions about sensory-based interventions they performed in the NICU and probed about their perceptions related to the development of a sensory-based guideline and the use of volunteers to provide sensory-based interventions when unable to be present in the NICU. Interviews were transcribed and uploaded into NVivoV.12 for content analysis.

Results. Mothers reported that kangaroo care was a common sensory intervention they performed in the NICU. Of the 18 mothers who commented on the development of a sensory-based guideline, 17 (94%) said they would be accepting of one. Among 19 mothers, 18 (95%) supported volunteers conducting sensory-based interventions in their absence. Identified themes included: 1) Perceptions about development of a sensory-based guideline, 2) Perceptions of interactions with healthcare providers, 3) Maternal participation in sensory interventions, 4) Maternal experience, and 5) Emotions from mothers.

Conclusion. Maternal perceptions regarding the development of a sensory-based guideline were favorable, and the SENSE program has since been finalized after incorporating important insights learned from stakeholders in this study. Mothers' perceptions were tied to their NICU experiences, which elicited strong emotions. These findings highlight important considerations when developing family-centered interventions.

Keywords. development, sensory, therapy, NICU (neonatal intensive care unit), qualitative study

Background. Early parent engagement in the neonatal intensive care unit (NICU) is important for both parent and infant mental health and for improving developmental outcomes. It remains unclear how different programs, such as the Supporting and Enhancing NICU Sensory Experiences (SENSE) program, may empower parents from various socio-demographic groups to engage in the NICU. An improved understanding could aid in individualizing interventions for those at the highest risk for health disparities.

Aims. This exploratory study, which was part of a larger study, sought to explore 1) socio-demographic factors related to parent presence and engagement in the NICU and 2) if the Supporting and Enhancing NICU Sensory Experiences (SENSE) program related to increased parent presence and engagement among different socio-demographic groups.

Methods. Seventy mother-infant dyads (≤ 32 weeks gestation) were randomized to SENSE programming (parent education and age-appropriate, positive sensory interventions for parents to conduct with their infants every day of hospitalization) or standard care after admission to the NICU. The amount of parent presence and participation in sensory activities was tracked using bedside logs, nursing records, and research team documentation.

Results. Being married (p=0.048; p=0.01), having private insurance (p<0.001; p=0.01), and having fewer children (p=0.004; p=0.03) related to more parent presence and engagement. Parents who were Black had less presence and engagement in the NICU (p=.04; p=0.02). Participation in the SENSE program was related to more parent presence and engagement among younger mothers (p=.002; p=<0.001) and among parents living farther distances from the hospital (p<0.001; p=0.004).

Conclusion. Programming, such as SENSE, can improve engagement among high-risk groups.

Objective. Evaluate the effect of a manualized multisensory program, applied across NICU hospitalization, on infant and parent outcomes.

Study design. Seventy parent-infant dyads (born ≤32 weeks gestation) in a Level IV NICU were randomized at birth to the multisensory program or standard-of-care. Parents in the multisensory group administered prespecified amounts of age-appropriate, evidence-based sensory interventions to their infants each day during NICU hospitalization according to the Supporting and Enhancing NICU Sensory Experiences (SENSE) program.

Results. Infants who received the SENSE program had more lethargy on the NICU Network Neurobehavioral Scale (NNNS) (p = 0.05), even after controlling for medical and social risk (p = 0.043), and had higher Communication scores on the Ages and Stages Questionnaire (p = 0.04) at 1-year corrected age, but this relationship failed to reach significance after controlling for medical and social risk (p = 0.12).

Conclusion. The SENSE program shows promise for improving outcomes, but more research with larger sample sizes is needed.

Aim. Early therapy can improve developmental outcomes for preterm infants. However, preterm infants who are referred have low enrollment in early therapy services following neonatal intensive care unit (NICU) discharge. This manuscript aims to investigate the relationship between infant medical and sociodemographic factors and enrollment in early therapy services post‐NICU discharge, when system‐related barriers to access are minimized.

Methods. This was a retrospective investigation of 89 families with infants born ≤ 32 weeks gestation. Families were approached for enrollment into early therapy services following NICU discharge through Baby Bridge programming, which aims to improve access to therapy services following NICU discharge.

Results. Seventy‐three (82%) families enrolled in early therapy services, and 16 (18%) families declined. Parents were more likely to enroll in early therapy if they had public insurance (p=0.01), a maternal psychiatric diagnosis (p=0.02), or additional children under 18 years in the home (p=0.01). No infant medical factors were related to enrollment.

Conclusion. Although enrollment rates were high, 18% of families refused therapy services, despite removing system‐related barriers to access. Targeted interventions can be developed to increase enrollment in early therapy services among populations who are most likely to refuse therapy services after NICU discharge.

Keywords. Baby Bridge program; birth to three; development; early intervention; preterm infant

Aim. To describe neurodevelopmental outcomes during early childhood among infants born very preterm and define the relationships between neurobehavior of very preterm infants and neurodevelopmental outcomes at 4 years.

Methods. Forty‐eight infants born ≤32 weeks gestation had neurobehavior assessed at term equivalent age using the NICU Network Neurobehavioral Scale (NNNS). Outcomes at 4 years were assessed with the Ages and Stages Questionnaire (ASQ‐3), the Sensory Profile – Short Form (SF), and the Behavior Rating Inventory of Executive Function – Preschool version (BRIEF‐P).

Results. At 4 years, 23 (48%) children had at least one below average score on the ASQ‐3, 15 (31%) had a below average total score on the Sensory Profile‐SF, and 3 (6%) had an abnormal total score on the BRIEF‐P. Children with lower fine motor scores at 4 years had poorer orientation (p=.03) and self‐regulation (p=.03), hypertonia (p=.01), and more sub‐optimal reflexes (p=.02) as neonates. Children with lower gross motor scores at 4 years of age had more sub-optimal reflexes (p=.03) and lethargy (p=.046) as neonates. Children with tactile sensitivity at 4 years of age had poorer orientation (p=.01) and tolerance of handling (p=.03) as neonates. Children with decreased responsiveness at 4 years of age had low arousal (p=.02) as neonates, and those with poor auditory filtering at age 4 years had hypotonia (p=.03) as neonates.

Conclusion. Early neurobehavior is related to neurodevelopmental outcome in early childhood.

Background. To maximize the benefit of parent-directed, positive sensory exposures in the NICU, a structured sensory-based program titled the Supporting and Enhancing NICU Sensory Experiences (SENSE) program was developed that includes specific doses and targeted timing of evidence-based sensory exposures.

Methods. The Reach, Effectiveness, Adoption, Implementation, Maintenance (RE-AIM) framework was used to systematically evaluate the SENSE program as an implementation strategy. One-hundred preterm infants ≤32 weeks gestation were studied (61 receiving the SENSE program and 39 standard-of-care). Parent education time and infant sensory exposures were tracked, and parents completed a questionnaire that probed their perceptions about the SENSE program.

Results. One-hundered thirty-one families were recruited, and 100 (76%) enrolled. The SENSE program was initiated at an average postmenstrual age of 29.8 (±2.4) weeks; 4.9 (±5.6) days after birth. The average number of education sessions with families was 4.8 (±3.7) amounting to 72.3 (±37.4) total minutes over hospitalization. The total time of logged tactile and auditory exposures among SENSE recipients over the length of hospitalization was a median (IQ range) of 9325 (5295-15,694) minutes over an average of 10.1 (±7.6) weeks of hospitalization. There were differences in the proportion of tactile and auditory exposure targets received by the infant among those receiving the SENSE program compared to standard-of-care (91% compared to 48%; p < 0.0001). Ninety-five percent of infants tolerated the SENSE program as defined, with 5% of infants requiring intermittent adaptations or the interventions being stopped for a period that typically lasted 1–2 weeks. Earlier parent education was related to more parent participation in SENSE program interventions (p = 0.04). Eighty-five percent of participants receiving the SENSE program had most of the sensory interventions completed by parents, as opposed to the medical or sensory support team. Seventy-two percent of infants had at least 100% of the auditory and tactile doses conducted over the length of stay. Parents reported acceptability.

Conclusion. The SENSE program had good reach, was effective and acceptable with minimal cost, was adopted, and had good fidelity. Insights from implementation of the SENSE program (within a research study) informed future strategies to aid maintenance during dissemination.

Aim. Define relationships of early feeding performance with feeding outcomes in childhood, while assessing the predictive validity of the Neonatal Eating Outcome Assessment.

Study design. Ninety-one infants (44 preterm infants born ≤32 weeks at term-equivalent age and 47 full-term infants within 4 days of life) had feeding evaluated using the Neonatal Eating Outcome Assessment and the Neonatal Oral Motor Assessment Scale (NOMAS). At 4 years of age, 39 of these infants (22 preterm infants and 17 full-term infants; 43% follow-up rate) had parent-report measures of feeding conducted using the Behavioral Pediatrics Feeding Assessment Scale (BPFAS) and Pediatric Eating Assessment Tool (PediEAT).

Results. Lower Neonatal Eating Outcome Assessment scores were related to higher PediEAT scores (p = 0.01; r = −0.44), but were not related to BPFAS scores (p = 0.17; r = −0.23). Relationships were not detected between the NOMAS and BPFAS (p = 0.35; r = 0.17), and relationships between the NOMAS and PediEAT failed to reach significance (p = 0.06; r = 0.34). There was a relationship between the BPFAS and PediEAT scores at 4 years (p < 0.001; r = 0.66). Preterm infants performed poorer than full-term infants on the Neonatal Eating Outcome Assessment (p < 0.001) and NOMAS (p < 0.001), but no differences were detected in preterm compared to full-term performance on the BPFAS (p = 0.87) and PediEAT scores (p = 0.27).

Discussion. Neonatal feeding performance is an important predictor of feeding outcomes at 4 years of age. The Neonatal Eating Outcome Assessment has predictive validity, and the Pediatric Eating Assessment Tool has concurrent validity with relationships to another childhood feeding tool.

Keywords. Oral motor, Neonatal intensive care unit, Development, Assessment, Neonatal Eating Outcome Assessment, Outcome

Aim. To (a) define the early home auditory environment of high‐risk infants within one month of neonatal intensive care unit (NICU) discharge, (b) compare auditory exposures in the home environment to the NICU environment, and (c) define relationships between maternal/infant factors and auditory exposures within the home.

Methods. Seventy‐three high‐risk infants (48 high‐risk infants in the NICU at term‐equivalent age and 25 high‐risk infants in the home following NICU discharge) had auditory exposures measured.

Results. An average of 1.3 hours more noise (P ≤ .001) and 2 hours less silence (P = .01) were observed in the NICU compared with the home, but differences varied based on whether comparing to an open ward or private room. Infants with public insurance, lower household income and mothers without a college education were exposed to an average of 2.8, 3.0 and 2.3 hours more TV/electronic sounds respectively (P < .05). An average of 1744 fewer adult words (P = .03) were spoken in households with public insurance. There was an average of 3.1 hours less silence and 4.5 dB louder stimuli among households with lower income (P < .05).

Conclusion. Elucidating differences across environments can lead to interventions to foster appropriate auditory exposures to improve language development of high‐risk infants.

The Baby Bridge program was developed to ensure timely and continuous therapy services following neonatal intensive care unit (NICU) discharge. A systematic process for development of the Baby Bridge program included a review of the evidence, integration of theory, and input from NICU health care professionals, early intervention leadership, and parents of preterm infants. Using the Consolidated Framework for Implementation Research, we aimed to (a) assess organizational readiness for the new programming; (b) determine adoptability, acceptability, and fidelity following implementation; and (c) evaluate the program. Following the development of Baby Bridge programming, readiness for implementation was observed at the study site. Baby Bridge programming was adopted by the team, acceptable to health care staff and parents, achieved the key features defined, and resulted in more infants born ≤30 weeks receiving early therapy services (n = 58/60, 97% compared with n = 44/57, 77%; p < .0001) an average of 85 days earlier, p < .0001, β = −84.7 (–70.2 to −99.2), than historical controls.

Keywords. Part C services, home visiting, neonates, transition, family collaboration and support, disabilities and developmental delays, preterm, NICU

Aims. To determine 1) the relationship between infant medical factors and early neurobehavior, and 2) the relationship between early neurobehavior at 30 weeks postmenstrual age (PMA) and neurobehavior at term equivalent age.

Study design. In this prospective longitudinal study, 88 very preterm infants born ≤30 weeks estimated gestational age (EGA) had neurobehavioral assessments at 30 weeks PMA using the Premie-Neuro and at term equivalent age using the NICU Network Neurobehavioral Scale (NNNS) and Hammersmith Neonatal Neurological Evaluation (HNNE).

Results. Lower Premie-Neuro scores at 30 weeks PMA were related to being more immature at birth (p = 0.01; β = 3.87); the presence of patent ductus arteriosus (PDA; p < 0.01; β = −16.50) and cerebral injury (p < 0.01; β = −20.46); and prolonged exposure to oxygen therapy (p < 0.01; β = −0.01), endotracheal intubation (p < 0.01; β = −0.23), and total parenteral nutrition (p < 0.01; β = −0.35). After controlling for EGA, PDA, and number of days of endotracheal intubation, lower Premie-Neuro scores at 30 weeks PMA were independently related to lower total HNNE scores at term (p < 0.01; β = 0.12) and worse outcome on the NNNS with poorer quality of movement (p < 0.01; β = 0.02) and more stress (p < 0.01; ß = −0.004), asymmetry (p = 0.01; β = −0.04), excitability (p < 0.01; β = −0.05) and suboptimal reflexes (p < 0.01; ß = −0.06).

Conclusion. Medical factors were associated with early neurobehavioral performance at 30 weeks PMA. Early neurobehavior at 30 weeks PMA was a good marker of adverse neurobehavior at NICU discharge.

Keywords. Preterm; Neurobehavior; Neonatal intensive care unit, outcome, development

Objective. The aim of this project was to determine revenues and costs over time to assess the sustainability of the Baby Bridge program.

Methods. The Baby Bridge program was developed to promote timely, consistent and high quality early therapy services for high-risk infants following neonatal intensive care unit (NICU) discharge. Key features of the Baby Bridge program were defined as: 1) having the therapist establish rapport with the family while in the NICU, 2) scheduling the first home visit within one week of discharge and continuing weekly visits until other services commence, 3) conducting comprehensive assessments to inform targeted interventions by a skilled, single provider, and 4) using a comprehensive therapeutic approach while collaborating with the NICU medical team and community therapy providers. The Baby Bridge program was implemented with infants hospitalized in an urban Level IV NICU from January 2016 to January 2018. The number of infants enrolled increased gradually over the first several months to reach the case-load capacity associated with one full-time therapist by mid-2017. Costs of the therapists delivering Baby Bridge services, travel, and equipment were tracked and compared with claim records of participants. The operational cost of Baby Bridge programming at capacity was estimated based on the completed and anticipated claims and reimbursement of therapy services as a means to inform possible scale-ups of the program.

Results. In 2016, the first year of programming, the Baby Bridge program experienced a loss of $26,460, with revenue to the program totaling $11,138 and expenses totaling $37,598. In 2017, the Baby Bridge program experienced a net positive income of $2,969, with revenues to the program totaling $53,989 and expenses totaling $51,020. By Spring 2017, 16 months after initiating Baby Bridge programming, program revenue began to exceed cost. It is projected that cumulative revenue would have exceeded cumulative costs by January 2019, 3 years following implementation. Net annual program income, once scaled up to capacity, would be approximately $16,308.

Discussion. There were initial losses during phase-in of Baby Bridge programming associated with operating far below capacity, yet the program achieved sustainability within 16 months of implementation. These costs related to implementation do not consider the potential cost reduction due to mitigated health burden for the community and families, particularly due to earlier receipt of therapy services, which is an important area for further inquiry.

Aim. To explore differences in maternal mental health and infant neurobehavioral outcome among infants who received and did not receive the Supporting and Enhancing NICU Sensory Experiences (SENSE) program.

Study design. Eighty preterm infants (50 receiving standard-of-care and 30 receiving the SENSE program) born ≤32 weeks gestation were enrolled within the first week of life in a prospective quasi-experimental design, using a historical control group for comparison. Standard-of-care consisted of tactile (skin-to-skin, touch, holding) and olfactory (scent cloth, close maternal contact) interventions as determined to be appropriate by health care professionals and parents. The SENSE group received specific doses of tactile (skin-to-skin care, holding, massage, touch), auditory (human speech, music), olfactory (scent cloth, close maternal contact), kinesthetic/vestibular (movement, rocking/transfers), and visual (dim or cycled light) exposures, based on the infant's postmenstrual age and tailored to medical status and infant cues according to the SENSE program. The SENSE program includes the intentional delivery of positive, age-appropriate sensory exposures by parents (or a sensory support team, when parents are unavailable) each day of NICU hospitalization. Infant neurobehavioral outcome, as well as maternal mental health and confidence, were assessed prior to NICU discharge, using standardized measures.

Results. Seventy-three infants were included in the final analysis. Mothers whose infants received the SENSE program demonstrated higher scores on the Maternal Confidence Questionnaire (p = 0.01). Infants who received the SENSE program demonstrated less asymmetry on the NICU Network Neurobehavioral Scale (p = 0.02; mean difference 0.9) and higher scores on the Hammersmith Neonatal Neurological Evaluation (p < 0.001; mean difference 4.8).

Discussion. Preliminary evidence demonstrates improvements in maternal confidence and infant neurobehavioral performance following SENSE implementation.

Objective. To identify differences in feeding skill performance among preterm infants at term equivalent age compared with full-term infants.

Study design. Ninety-two infants (44 preterm infants born ≤32 weeks gestation at term equivalent age and 48 full-term infants within 4 days of birth) had a standardized oral feeding assessment.

Result. Preterm infants at term equivalent age had lower Neonatal Eating Outcome Assessment scores (67.8 ± 13.6 compared with 82.2 ± 8.1; p < 0.001) and were more likely to have poor arousal (p = 0.04), poor tongue positioning (p = 0.04), suck–swallow–breathe discoordination (p < 0.001), inadequate sucking bursts (p = 0.01), tonal abnormalities (p < 0.001), discoordination of the jaw and tongue during sucking (p < 0.001), lack of positive engagement with the feeder and/or discomfort (p < 0.001), signs of aspiration (p < 0.001), difficulty regulating breathing (p < 0.001), and have an inability to maintain an appropriate state (p < 0.001), and complete the feeding (p < 0.001).

Conclusion. A broad range of feeding-related difficulties appear to remain evident in preterm infants at term equivalent age.

Importance. Few neonatal feeding assessments are currently available, and the Neonatal Eating Outcome Assessment is the only one that identifies feeding impairment while considering the developmental changes that occur from preterm birth to term-equivalent age.

Objective. To determine the interrater reliability and concurrent validity of the Neonatal Eating Outcome Assessment.

Design. Prospective, observational study.

Setting. Level 4 neonatal intensive care unit.

Participants. A convenience sample of 7 neonatal therapists participated in reliability testing. For concurrent validity, a prospective cohort of 52 preterm infants born ≤32 wk gestation had feeding assessed at term-equivalent age.

Outcomes and Measures. Intraclass correlations (ICCs) and Fleiss’s κ statistics were used to define reliability across therapists, who independently scored five videos of preterm infants orally feeding using the Neonatal Eating Outcome Assessment. Concurrent validity was determined by evaluating relationships between the Neonatal Oral Motor Assessment Scale (NOMAS) and the Neonatal Eating Outcome Assessment using an independent-samples t test and χ² analysis.

Results. The ICC for the Neonatal Eating Outcome Assessment total score was 0.90 (confidence interval [CI] [0.70, 0.99]). Fleiss’s κ scores for the 19 scorable items on the Neonatal Eating Outcome Assessment had predominately moderate, fair, and slight agreement, with 3 items having poor agreement. Dysfunctional NOMAS scores were related to lower Neonatal Eating Outcome Assessment scores (t[49.4] = 3.72, mean difference = 12.2, 95% CI [5.60, 18.75], p = .001).

Conclusions and Relevance. The Neonatal Eating Outcome Assessment has excellent reliability. Concurrent validity was established.

What This Article Adds. This article reports that the final version of the Neonatal Eating Outcome Assessment (Version 5.7) has excellent interrater and concurrent validity and is an important tool to assess the occupation of infant feeding in clinical practice.

The purpose of this study was to (1) define medical and sociodemographic factors related to maternal milk feedings and (2) explore relationships between maternal milk feeding and early neurobehavioral outcome. Ninety-two preterm infants born ≤ 32 weeks gestation had maternal milk feeding and breastfeeding tracked in this retrospective analysis. At 34 to 41 weeks postmenstrual age (PMA), neurobehavior was assessed with the NICU Network Neurobehavioral Scale. Maternal milk feeding was often delayed by the use of total parenteral nutrition, administered for a median of 11 (7-26) days, impacting the timing of gastric feeding initiation. Seventy-nine (86%) infants received some maternal milk during neonatal intensive care unit (NICU) hospitalization. Twenty-one (27%) infants continued to receive maternal milk at 34 to 41 weeks PMA, with 10 (48%) of those receiving maternal milk exclusively. Among mothers who initiated maternal milk feeds, 20 (25%) put their infants directly at the breast at least once during hospitalization. Mothers who were younger (P = .02), non-Caucasian (P < .001), or on public insurance (P < .001) were less likely to provide exclusive maternal milk feedings by 34 to 41 weeks PMA. Infants who received maternal milk at 34 to 41 weeks PMA demonstrated better orientation (P = .03), indicating they had better visual and auditory attention to people and objects in the environment. Our findings demonstrate a relationship between maternal milk feedings and better neurobehavior, which is evident before the infant is discharged home from the NICU.

Objective. The main objective of this article is to define perceptions of health care professionals regarding current use of sensory-based interventions in the neonatal intensive care unit (NICU).

Study Design. A multidisciplinary group of NICU health care professionals (n = 108) defined the types of sensory-based interventions used in their NICU, the postmenstrual age (PMA) sensory-based interventions are administered, conditions under which sensory-based interventions are used, and personnel who administer sensory-based interventions.

Results. The most commonly reported tactile intervention was infant holding (88% of respondents), the most common auditory intervention was recorded music/singing (69% of respondents), the most common kinesthetic intervention was occupational and physical therapy (85% of respondents), and the most common vestibular intervention was infant swings (86% of respondents). Tactile interventions were initiated most often at 24 to 26 weeks PMA (74% of respondents), auditory interventions at 30 to 32 weeks (60% of respondents), kinesthetic interventions at 30 to 32 weeks (76% of respondents), vestibular interventions at 33 to 34 weeks (86% of respondents), and visual interventions at 32 to 36 weeks (72% of respondents). Conditions under which sensory-based interventions were administered, and personnel who provided them, varied across settings.

Conclusion. Varied use of sensory-based interventions in the NICU were reported. While this study was limited by biased sampling and the identification of health care professionals' perceptions but not real-world practice, this information can be used to build a comprehensive approach to positive sensory exposures in the NICU.

Background. To date, no study has compared preterm and full term auditory environments.

Aim. To define differences in auditory exposure for preterm infants at term equivalent age in the neonatal intensive care unit (NICU) compared to auditory exposure in hospital rooms on a labor and delivery ward after full term birth.

Study design. Ninety-eight infants (48 preterm infants born 28 weeks gestation in the NICU at term equivalent age and 50 full term infants in a hospital room on the labor and delivery ward within 4 days of birth) had auditory exposure measured over a single 16-hour period using the Language Environment Acquisition (LENA) device.

Results. More language (p < 0.001) was observed on the labor and delivery ward than in the NICU, with an average of 3.3 h more language in a 16-hour period and an average of 14,110 more words spoken around infants in a 16-hour period on the labor and delivery ward (p < 0.001). More electronic sounds were observed in the NICU, with an average of 2.3 h more in the 16-hour period (p < 0.001). The average decibel level in the NICU was lower than in the hospital rooms on the labor and delivery ward (57.16 ± 2.30 dB, compared to 63.31 ± 2.22 dB; p < 0.001).

Conclusion. The NICU auditory environment for preterm infants is different than the auditory environment for full term infants, with less language, more electronic sounds, and quieter stimuli. This understanding can aid in developing appropriate interventions that enhance positive forms of auditory exposures.

Background. Volunteers can provide staff-directed sensory inputs to infants hospitalized in the NICU, but research on volunteer programs is limited.

Purpose. To evaluate the feasibility of a developmental care partner (DCP) program in a level III NICU and determine its relationship with provider burnout and infant infection rates.

Methods. DCPs were trained to provide sensory input to infants, based on the behavioral cues observed by the occupational therapists and nursing staff, in medically stable infants. Feasibility was assessed by documenting the process of training and utilizing volunteers, as well as tracking duration and frequency of DCP visits. Staff burnout measures were assessed using the Maslach Burnout Inventory Human Services Survey (MBI-HSS) before and after implementation. Infant infection rates before and after the introduction of volunteers were compared.

Results. Seventy-two volunteers were interested, and 25 (35%) completed the DCP competencies and provided sensory exposures to 54 neonates, who were visited an average of 8 times (range 1-15). Twelve (48%) DCPs did once-per-week visits, and 9 (36%) did at least 50 contact hours. MBI-HSS scores for staff emotional exhaustion (P < .001) and depersonalization (P < .006) were lower after DCP implementation. There were no differences in infant infection rates before and after DCP implementation (Fisher exact P = 1.000).

Implications for Practice. Volunteer-based DCP programs may be feasible to implement in community hospitals and could help reduce staff emotional exhaustion and depersonalization without increasing the incidence of infant infections.

Implications for Research. Future research on NICU volunteer programs with larger sample sizes and different infant populations is warranted.

Introduction. There is evidence to support the use of positive sensory exposures (music, touch, skin-to-skin) with preterm infants in the neonatal intensive care unit (NICU), but strategies to improve their consistent use are lacking. The Supporting and Enhancing NICU Sensory Experiences (SENSE) program was developed to promote consistent, age-appropriate, responsive, and evidence-based positive sensory exposures for the preterm infant every day of NICU hospitalization.

Methods. A systematic and rigorous process of development of the SENSE program included an integrative review of evidence on sensory exposures in the NICU, stakeholder feedback, expert opinion, and focus groups.

Results. SENSE implementation materials consist of parent education materials, tailored doses of sensory exposures for each postmenstrual age, an infant assessment of tolerance, bedside logs and implementation considerations for integrating the SENSE program into the NICU.

Discussion. Research is needed to evaluate the SENSE program as an implementation strategy and to assess its impact on parent and infant outcomes.

Objective. To identify the progression of non-nutritive sucking (NNS) across postmenstrual age (PMA) and to investigate the relationship of NNS with medical and social factors and oral feeding.

Study Design. Fifty preterm infants born at ≤32 weeks gestation had NNS assessed weekly starting at 32 weeks PMA with the NTrainer System. Oral feeding was assessed at 38 weeks PMA.

Results. There were increases in NNS bursts per minute (p = 0.005), NNS per minute (p < 0.0001), NNS per burst (p < 0.001), and peak pressure (p = 0.0003) with advancing PMA. Level of immaturity and medical complications were related to NNS measures (p < 0.05). NNS measures were not related to Neonatal Oral Motor Assessment Scale scores. Smaller weekly change in NNS peak pressure (p = 0.03; β = –1.4) was related to feeding success at 38 weeks PMA.

Conclusion. Infants demonstrated NNS early in gestation. Variability in NNS scores could reflect medical complications and immaturity. More stable sucking pressure across time was related to feeding success at 38 weeks PMA.

Keywords. non-nutritive sucking, preterm, medical factors, oral feeding

Background. Although considered an advanced area of practice, there has been insufficient standardization in clinical training and preparedness for occupational therapists (OTs), physical therapists (PTs), and speech-language pathologists (SLPs) practicing in the neonatal intensive care unit (NICU). The first step in developing a neonatal therapy certification process was to conduct a practice analysis.

Purpose. To describe: 1) the collection of OTs, PTs, and SLPs working in NICUs, 2) educational and professional preparation to practice in the NICU, and 3) interest in neonatal therapy national certification.

Methods. An online survey of 468 neonatal therapists was completed in 2015–2016.

Results. There were 208 (47%) participants who were OTs, 140 (32%) PTs, and 94 (21%) SLPs. Among respondents, 187 (50%) neonatal therapists had a clinical doctorate, and 143 (40%) therapists practiced for > 5 years prior to entering NICU practice. There were 299 (88%) therapists who believed oversight and accountability in the NICU are highly important, and 329 (98%) therapists were interested in a neonatal therapy certification program.

Conclusions. Advanced training and skills of neonatal therapists are vital to ensure safe, effective and evidence-based practice. Insufficient standardization in training and variable adherence to education and training guidelines provided credibility for the creation of a neonatal therapy national certification process, which has now been implemented.

Aim. Mothers are often advised not to use pacifiers until breastfeeding has been well‐established. This study determined the infant and social factors that were related to pacifier use during the first few days of life and whether it led to alterations in feeding performance.

Methods. We enroled 51 full‐term infants and their mothers at Barnes‐Jewish Hospital in urban St. Louis, USA, in 2015. Before they were discharged the mothers completed a questionnaire, and infant feeding was assessed using a standardised assessment.

Results. There were 24 (47%) infants who used a pacifier during the first few days of life and seven (29%) of these were exclusively breastfed. Pacifier use was less common among mothers who exclusively breastfed (p = 0.04). Pacifier use was more common among mothers whose income was less than 25 000 US dollars (p = 0.02), who were single (p = 0.002) and who did not have a college education (p = 0.03). No associations between pacifier use and feeding performance were observed.

Conclusion. While lower socioeconomic status was related to pacifier use, feeding performance in the first few days of life was no different between those infants who did and did not use pacifiers after a full‐term birth.

Purpose. To (1) examine the extent of a range of early mental health challenges in mothers with a very preterm infant hospitalized in the NICU and mothers of full-term infants, (2) identify family social background and infant medical factors associated with higher levels of maternal psychological distress, and (3) assess the relationship between maternal psychological distress and maternal perceptions of the parenting role, parenting confidence and NICU engagement.

Methods. At hospital discharge 37 mothers of very preterm infants (≤32 weeks gestation) and 47 mothers of full-term infants (≥37 weeks gestation) completed structured assessments of their psychological wellbeing and transition to parenting. Mothers of very preterm infants were also questioned about their NICU visitation and involvement in infant care.

Results. Sixty-four percent (n = 54) of mothers experienced psychological distress (n = 26, 70% of preterm; n = 28, 60% of full-term). Lower infant birthweight was associated with maternal psychological distress (p = .03). Mothers of very preterm infants had significantly more psychological distress related to having a Cesarean section delivery (p = .02). Higher levels of psychological distress were associated with lower levels of parenting confidence in mothers of both very preterm and full-term infants (p < .02).

Conclusion. Although parents of very preterm infants have higher rates of maternal mental health challenges, mothers of full-term infants at high social risk are also impacted.

Keywords. Postnatal; Parenting; Psychology; NICU; Preterm

Aim. To define the process of tool development and revision for the Neonatal Eating Outcome (NEO) Assessment and to report preliminary inter‐rater reliability.

Methods. Tool development consisted of a review of the literature and observations of feeding performance among 178 preterm infants born ≤32 weeks gestation. 11 neonatal therapy feeding experts provided structured feedback to establish content validity and define the scoring matrix. The tool was then used to evaluate feeding in 50 preterm infants born ≤32 weeks of gestation and 50 full‐term infants. Multiple revisions occurred at each stage of development. Finally, six neonatal occupational therapists participated in reliability testing by independently scoring five videos of oral feeding of preterm infants using version 4 of the tool.

Results. The intraclass correlation for the ‘prefeeding’ score was 0.71 (0.37–0.96), and the intraclass correlation for the ‘total’ score was 0.83 (0.56–0.98).

Conclusion. The ‘total’ score had good to excellent reliability. Fleiss’ Kappa scores for all 18 scorable items ranged from slight agreement to moderate agreement. Items with the lowest Kappa scores were revised, and additional feedback from therapists engaged in reliability testing was incorporated, resulting in final version 5.

Objective. To 1) define predictors of parent presence, any holding, holding in arms, and skin-to-skin care in the NICU and 2) investigate the relationships between parent participation and a) early neurobehavior and b) developmental outcomes at age 4 to 5 years among preterm infants.

Methods. Eighty-one preterm infants born ≤ 32 weeks estimated gestational age were prospectively enrolled within one week of life in a level III–IV NICU. Parent (maternal and paternal) presence and holding (including holding in arms and skin-to-skin care) were tracked throughout NICU hospitalization. Neurobehavior at term equivalent age and development at 4 to 5 years were determined using standardized assessments.

Results. The median number of days per week parents were documented to be present over NICU hospitalization was 4.0 (IQR = 2.4–5.8) days; days held per week 2.8 (IQR = 1.4–4.3) days [holding in arms days per week was 2.2 (IQR = 1.2–3.2) days and parent skin-to-skin care days per week was 0.2 (IQR = 0.0–0.7) days]. More parent presence was observed among mothers who were Caucasian, married, older, or employed and among those who had fewer children, familial support and provided breast milk (p < 0.05). More holding was observed in infants with fewer medical interventions (p < 0.05) and among those who were Caucasian, had a father who was employed, had fewer children and family support (p < 0.05). More parent holding in the NICU was related to better reflex development at term age (p = 0.02). More parent skin-to-skin care was related to better infant reflexes (p = 0.03) and less asymmetry (p = 0.04) at term and better gross motor development (p = 0.02) at 4–5 years.

Discussion. Social and medical factors appear to impact parent presence, holding, and skin-to-skin care in the NICU. Parent holding is related to better developmental outcomes, which highlights the importance of engaging families in the NICU.

Keywords. Neonatal intensive care unit; Preterm; Parent engagement; Participation; Development; Holding; Skin-to-skin care; Presence; Visitation; Outcomes; Environment; Attachment

Background. Preterm infants are exposed to a variety of sensory stimuli that they are not developmentally prepared to handle, which puts them at risk for developing a sensory processing disorder. However, the patterns and predictors of sensory processing disorder and their relationship to early behavior at term equivalent age are poorly understood.

Objectives. The aims of the study are to: 1) describe the incidence of sensory processing disorder in preterm infants at four to six years of age, 2) define medical and sociodemographic factors that relate to sensory processing disorder, and 3) explore relationships between early neurobehavior at term equivalent age and sensory processing disorder at age four to six years.

Methods. This study was a prospective longitudinal design. Thirty-two preterm infants born ≤ 30 weeks gestation were enrolled. Infants had standardized neurobehavioral testing at term equivalent age with the NICU Network Neurobehavioral Scale. At four to six years of age, participants were assessed with the Sensory Processing Assessment for Young Children (SPA).

Results. Sixteen children (50%) had at least one abnormal score on the SPA, indicating a sensory processing disorder. There were no identified relationships between medical and sociodemographic factors and sensory processing disorder. More sub-optimal reflexes (p = 0.04) and more signs of stress (p = 0.02) at term equivalent age were related to having a sensory processing disorder in early childhood.

Conclusion. Preterm infants are at an increased risk for developing a sensory processing disorder. Medical and sociodemographic factors related to sensory processing disorder could not be isolated in this study, however relationships between sensory processing disorder and early neurobehavior were identified.

Keywords. NICU; Sensory processing disorder; Neurobehavior; Prematurity

Objectives. 1) To describe the use of occupational therapy (OT), physical therapy (PT) and speech-language pathology (SLP) services in a level IV neonatal intensive care unit (NICU), 2) to describe predictors of early therapy usage, and 3) to test the hypothesis that more NICU-based therapy will relate to better neurobehavioral outcomes.

Methods. Seventy-nine infants born ≤32 weeks gestation had therapy interventions, as standard of care, tracked across NICU hospitalization. Infants received neurobehavioral testing prior to NICU discharge.

Results. All (100%) received OT and PT, and 41 (51%) received SLP. The average age at initiation of OT, PT, and SLP was 30.4 ± 1.4, 30.3 ± 1.4, and 35.9 ± 2.3 weeks postmenstrual age, respectively. Infants received therapy an average of 1.8 ± .4, 1.8 ± .4 and 1.1 ± .5 times per week for OT, PT and SLP, respectively. There were 56 different therapeutic interventions performed. There was overlap in the interventions provided by different NICU therapists; however, interventions unique to each discipline were identified. More therapy was not related to better neurobehavioral outcomes, but rather more frequent therapy could be attributed to more complex medical conditions (p < 0.05).

Conclusion. Early therapy services in the NICU can start early in gestation and continue routinely until NICU discharge in order to optimize outcomes. These findings can aid our understanding of how neonatal therapy services are implemented in a level IV NICU.

Keywords. Preterm birth; Development; Occupational therapy; Physical therapy; Speech-language pathology

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

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

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

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

Objective. To quantify early auditory exposures in the neonatal intensive care unit (NICU) and evaluate how these are related to medical and environmental factors. We hypothesized that there would be less auditory exposure in the NICU private room, compared with the open ward.

Study design. Preterm infants born at ≤ 28 weeks gestation (33 in the open ward, 25 in private rooms) had auditory exposure quantified at birth, 30 and 34 weeks postmenstrual age (PMA), and term equivalent age using the Language Environmental Acquisition device.

Results. Meaningful language (P < .0001), the number of adult words (P < .0001), and electronic noise (P < .0001) increased across PMA. Silence increased (P = .0007) and noise decreased (P < .0001) across PMA. There was more silence in the private room (P = .02) than the open ward, with an average of 1.9 hours more silence in a 16-hour period. There was an interaction between PMA and room type for distant words (P = .01) and average decibels (P = .04), indicating that changes in auditory exposure across PMA were different for infants in private rooms compared with infants in the open ward. Medical interventions were related to more noise in the environment, although parent presence (P = .009) and engagement (P = .002) were related to greater language exposure. Average sound levels in the NICU were 58.9 ± 3.6 decibels, with an average peak level of 86.9 ± 1.4 decibels.

Conclusions. Understanding the NICU auditory environment paves the way for interventions that reduce high levels of adverse sound and enhance positive forms of auditory exposure, such as language.

Keywords. preterm; senses; environment; language

Aims. To (1) characterize early therapy services for preterm infants in the first two years of life, and (2) define factors related to accessing early therapy services.

Methods. Therapy utilization after discharge from the neonatal intensive care unit (NICU) was tracked in 57 infants born ≤30 weeks gestation from 2007 to 2010. Participants returned for developmental testing at two years. Factors related to early therapy utilization were explored.

Results. Fifty-two (91%) infants received a referral for therapy at NICU discharge but only 44 (77%) received at least one type of therapy during the first two years of life. Infants who received early therapy services were more likely to have more days on ventilation (p = .005), have single mothers (p = .047), and exhibit abnormal neurobehavior at term equivalent age (p = .03). On average, infants first received occupational therapy at a mean age of 5.1 ± 4.6 months with a median of 2.6 (1.3–9.0), physical therapy at a mean age of 4.3 ± 4.1 months with a median of 3.7 (0.1–5.5), and speech-language pathology services at a mean age of 14.0 ± 6.1 months with a median of 15.0 (11.3–17.7) months corrected age. Of the 13 children who did not receive any therapy in the first two years after NICU discharge, seven (53%) had a developmental delay at an age of two years.

Conclusions. In spite of high referral rates for therapy services, there is a delay in therapy activation following NICU discharge, and some infants who warrant services do not obtain them.

Keywords. Developmental delay, early intervention, occupational therapy, physical therapy, prematurity, speech language pathology

Aim. To determine the relationship of head turn preference in the preterm infant to: 1) perinatal medical factors, 2) neonatal neurobehavior, and/or 3) infant neurodevelopmental outcomes.

Methods. Seventy preterm infants born ≤ 30 weeks gestation were enrolled at birth. Detailed information regarding neonatal intensive care unit (NICU) medical course was compiled for each infant. Neurobehavioral testing was performed during NICU hospitalization. Head turn preference was quantified at term equivalent age using a newly developed scale. Infants returned at age two years for standardized developmental testing.

Results. All infants demonstrated a head turning preference, with most preferring the right side (n = 51, 77%). Fifty-five infants (79%) had moderate to severe head turn preference. Head turn preference was associated with 1) medical severity (hours of inotrope use, p = 0.02; oxygen requirement at 36 weeks postmenstrual age, p = 0.03), 2) worse neurobehavioral performance (decreased self-regulation, p = 0.007; more sub-optimal reflexes p = 0.006), and 3) worse developmental outcome at age two years (poorer fine motor, p = 0.02).

Interpretation. Medical factors in the NICU appear to be associated with the development of a head turn preference. Increased severity of head turn preference may be a marker for poor developmental outcome. Early identification may inform therapeutic interventions designed to minimize symptoms and optimize neurodevelopmental outcome.

Keywords. Head turn preference; neonatal intensive care unit; infant; child development; infant positioning

Background. Fentanyl is commonly used in preterm infants. Relatively little is known regarding the neurodevelopmental outcomes of preterm infants exposed to fentanyl.

Objective. To investigate the association between cumulative fentanyl dose and brain injury and diameters in a cohort of preterm infants.

Methods. Data on demographics, perinatal course, and neonatal course, including total fentanyl exposure prior to term equivalent age, were retrospectively evaluated for 103 infants born at ≤30 weeks gestational age (mean gestational age 26.9 ± 1.8 weeks) who underwent magnetic resonance imaging at term equivalent age. Magnetic resonance images were evaluated for brain injury and regional brain diameters. Developmental testing was conducted at term equivalent and 2 years of age.

Results. Seventy-eight infants (76%) received fentanyl (median cumulative dose 3 µg/kg, interquartile range 1-441 µg/kg). Cumulative fentanyl dose in the first week of life correlated with the incidence of cerebellar hemorrhage after correction for covariates (odds ratio 2.1, 95% confidence interval 1.1-4.1). Cumulative fentanyl dose before term equivalent age correlated with reductions in transverse cerebellar diameter after correction for covariates, including the presence of cerebellar hemorrhage (r = 0.461, P = 0.002). No correlation was detected between cumulative fentanyl dose and development at 2 years of age.

Conclusions. Higher cumulative fentanyl dose in preterm infants correlated with a higher incidence of cerebellar injury and lower cerebellar diameter at term equivalent age. Our findings must be taken with caution, but emphasize the need for future prospective trials examining the risks and benefits of commonly used analgesic agents in preterm infants.

Objective. To investigate changes in head lag across postmenstrual age and define associations between head lag and (1) perinatal exposures and (2) neurodevelopment.

Method. Sixty-four infants born ≤30 wk gestation had head lag assessed before and at term-equivalent age. Neurobehavior was assessed at term age. At 2 yr, neurodevelopmental testing was conducted.

Results. Head lag decreased with advancing postmenstrual age, but 58% (n = 37) of infants continued to demonstrate head lag at term. Head lag was associated with longer stay in the neonatal intensive care unit (p = .009), inotrope use (p = .04), sepsis (p = .02), longer endotracheal intubation (p = .01), and cerebral injury (p = .006). Head lag was related to alterations in early neurobehavior (p < .03), but no associations with neurodevelopment were found at 2 yr.

Conclusion. Head lag was related to medical factors and early neurobehavior, but it may not be a good predictor of outcome when used in isolation.

Objective. To examine the association of difficult feeding behaviors in very preterm infants at age 2 years with growth and neurodevelopmental outcomes and family factors and functioning.

Study design. Eighty children born ≤30 weeks gestation were studied from birth until age 2 years. Feeding difficulties were assessed using the Eating Subscale of the Infant-Toddler Social Emotional Assessment at age 2 years, along with growth measurement and developmental testing. Maternal mental health and family factors were assessed using standardized questionnaires. ANOVA and χ² analyses were performed to determine associations between feeding difficulties and growth, neurodevelopmental outcomes, and family characteristics.

Results. Twenty-one children (26%) were at risk for feeding difficulties, and an additional 18 (23%) had definite feeding difficulties at age 2 years. Those with feeding difficulties were more likely to be subject to a range of neurodevelopmental problems, including impaired cognition (P = .02), language (P = .04), motor (P = .01), and socioemotional (P < .007) skills. Compared with the parents of children with fewer feeding difficulties, parents of the children with feeding difficulties had higher parenting stress (P = .02) and reported more difficulty managing their child's behavior (P = .002) and more frequent parent–child interaction problems (P = .002). No associations were found between difficult feeding behaviors and growth, maternal mental health, or family factors.

Conclusion. Difficult feeding behaviors in children born very preterm appear to be highly comorbid with other developmental and family challenges, including neurodevelopmental impairment and parent–child interaction difficulties. Focusing on improving feeding skills, in conjunction with supporting positive parent–child interactions, may be beneficial for improving outcomes.

Background. Standard-dose caffeine improves white matter microstructural development assessed by diffusion magnetic resonance imaging (MRI). We hypothesized that early high-dose caffeine would result in further improvement in white matter microstructural development.

Methods. Seventy-four preterm infants (≤30 wk gestational age) were randomly assigned to either a high (80 mg/kg i.v.) or standard (20 mg/kg i.v.) loading dose of caffeine citrate in the first 24 h of life. MRI and neurobehavioral testing were undertaken at term equivalent age. Infants returned at 2 y of age for developmental testing.

Results. Clinical characteristics were similar between groups, with the exception of higher maternal age in the high-dose caffeine group. There was an increased incidence of cerebellar hemorrhage in infants randomized to high-dose caffeine (36 vs. 10%, P = 0.03). Infants in the high-dose caffeine group also demonstrated more hypertonicity (P = 0.02) and more deviant neurologic signs (P = 0.04) at term equivalent age. Diffusion measures at term equivalent age and developmental outcomes at 2 y of age did not differ between groups.

Conclusion. Preterm infants randomized to early high-dose caffeine had a higher incidence of cerebellar injury with subsequent alterations in early motor performance. The results of this pilot trial discourage a larger randomized controlled trial.

Objective. To define neonatal social characteristics related to autism risk.

Method. Sixty-two preterm infants underwent neonatal neurobehavioral testing. At age 2 yr, participants were assessed with the Modified Checklist for Autism in Toddlers and Bayley Scales of Infant and Toddler Development, 3rd edition.

Results. Positive autism screening was associated with absence of gaze aversion, χ = 5.90, p =.01, odds ratio = 5.05, and absence of endpoint nystagmus, χ = 4.78, p = .02, odds ratio = 8.47. Demonstrating gaze aversion was related to better language outcomes, t(55) = −3.07, p ≤ .003. Displaying endpoint nystagmus was related to better language outcomes, t(61) = −3.06, p = .003, cognitive outcomes, t(63) = −5.04, p < .001, and motor outcomes, t(62) = −2.82, p = .006.

Conclusion. Atypical social interactions were not observed among infants who later screened positive for autism. Instead, the presence of gaze aversion and endpoint nystagmus was related to better developmental outcomes. Understanding early behaviors associated with autism may enable early identification and lead to timely therapy activation to improve function.

Objective. Thirty-five percent of women of child-bearing age are obese, and there is evidence that maternal obesity may increase the risk for adverse neurodevelopmental outcome. However, research regarding obesity and neurodevelopment among children born preterm is limited. This study aimed to determine associations between maternal obesity and neurodevelopment in very preterm children at age 2 years.

Study Design. Maternal/infant dyads (n=62) born ⩽30 weeks gestation were enrolled in a prospective cohort study at a level-III neonatal intensive care unit. Mothers were classified as obese or non-obese based on pre-pregnancy body mass index. Infants underwent magnetic resonance imaging at term equivalent and developmental testing at age 2. Maternal obesity was investigated for associations with neurodevelopment.

Result. Maternal obesity was associated with positive screen for autism (odds ratio=9.88, P=0.002) and lower composite language scores (β=−9.36, (confidence interval=−15.11, −3.61), P=0.002).

Conclusion. Maternal obesity was associated with adverse neurodevelopmental outcome at age 2 in this cohort of very preterm children. This study requires replication, but may support targeted surveillance of infants born to women with maternal obesity.

Aim. To determine the associations between perinatal exposures, cerebral maturation on amplitude‐integrated encephalography (aEEG) and outcome.

Methods. During this prospective cohort study, 136 infants ≤30 weeks estimated gestational age received 4 h of aEEG at four time points (between the first 2 weeks of life and term‐equivalent age) during hospitalisation. Perinatal factors were documented. Associations between perinatal exposures and Burdjalov‐scores were investigated. Neurodevelopmental outcome was assessed at the age of two.

Results. Immature cyclicity on the initial aEEG recording was associated with higher CRIB score (p = 0.01), vaginal delivery (p = 0.02), male gender (p < 0.01) and death (p = 0.01). Perinatal factors associated with lower Burdjalov‐scores included cerebral injury (p < 0.01), sepsis (p < 0.01), lower caffeine dose (p = 0.006), prolonged mechanical ventilation (p = 0.002) and death (p < 0.01). Burdjalov‐scores at 30 (β = 2.62, p < 0.01) and 34 weeks postmenstrual age (β = 2.89, p = 0.05) predicted motor scores.

Conclusion. aEEG measures of cyclicity and Burdjalov‐scores in the first 6 weeks of life, with an emphasis on 30 and 34 weeks postmenstrual age, demonstrated associations with perinatal factors known to predict adverse neurodevelopmental outcome.

There is a paucity of studies that have investigated the developmental benefits of positioning in the neonatal intensive care unit. The purpose of this study was to investigate the effects of a new, alternative positioning device compared to traditional positioning methods used with preterm infants. In this randomized, blinded clinical trial, one hundred preterm infants (born ≤32 weeks gestation) from a level III neonatal intensive care unit in the United States were enrolled at birth. Participants were randomized to be positioned in the alternative positioning device or to traditional positioning methods for their length of stay in the neonatal intensive care unit. Infants were assessed using the NICU Network Neurobehavioral Scale between 35-40 weeks postmenstrual age. Clinical and feeding outcomes were also captured. Linear and logistic regressions were used to investigate differences in neurobehavioral outcome, feeding performance, and medical outcomes. Infants in the alternative positioning arm of the study demonstrated less asymmetry of reflex and motor responses on the NICU Network Neurobehavioral Scale (p = 0.04; adjusted mean difference = 0.90, 95% CI 0.05–1.75) than those positioned using traditional positioning methods. No other significant differences were observed. Reduction in asymmetry among preterm infants is an important benefit of alternative positioning, as symmetrical movement and responses are crucial for early development. However, it will be important to follow this sample of preterm infants to determine the effects of early positioning on neurodevelopmental outcome in childhood.

Keywords. Development; Positioning; NICU; Preterm infants

Objective. To evaluate associations between neonatal intensive care unit (NICU) room type (open ward and private room) and medical outcomes; neurobehavior, electrophysiology, and brain structure at hospital discharge; and developmental outcomes at 2 years of age.

Study design. In this prospective longitudinal cohort study, we enrolled 136 preterm infants born <30 weeks gestation from an urban, 75-bed level III NICU from 2007-2010. Upon admission, each participant was assigned to a bedspace in an open ward or private room within the same hospital, based on space and staffing availability, where they remained for the duration of hospitalization. The primary outcome was developmental performance at 2 years of age (n = 86 infants returned for testing, which was 83% of survivors) measured using the Bayley Scales of Infant and Toddler Development, 3rd Edition. Secondary outcomes were: (1) medical factors throughout the hospitalization; (2) neurobehavior; and (3) cerebral injury and maturation (determined by magnetic resonance imaging and electroencephalography).

Results. At term equivalent age, infants in private rooms were characterized by a diminution of normal hemispheric asymmetry and a trend toward having lower amplitude integrated electroencephalography cerebral maturation scores (P = .02; β = −0.52 [CI −0.95, −0.10]). At age 2 years, infants from private rooms had lower language scores (P = .006; β = −8.3 [CI −14.2, −2.4]) and a trend toward lower motor scores (P = .02; β = −6.3 [CI −11.7, −0.99]), which persisted after adjustment for potential confounders.

Conclusion. These findings raise concerns that highlight the need for further research into the potential adverse effects of different amounts of sensory exposure in the NICU environment.

Aim. To investigate early medical and family factors associated with later feeding risk in preterm infants.

Methods. For this longitudinal study, 136 infants born ≤30 weeks gestation were enrolled. Medical and social background factors were assessed at term equivalent age. Infants underwent magnetic resonance imaging, neurobehavioral evaluation and feeding assessment. Parent involvement in the neonatal intensive care unit was tracked, and maternal mental health was assessed at neonatal intensive care unit discharge. At age 2 years, feeding outcome was assessed using the Eating Subscale of the Infant‐Toddler Social Emotional Assessment (n = 80). Associations between feeding problems at age 2 years and (i) early medical factors, (ii) neurobehavioral functioning and feeding at term equivalent age, (iii) cerebral structure and (iv) maternal mental health were investigated using regression.

Results. Eighteen (23%) children had feeding problems at age 2 years. Feeding problems were associated with early hypotonia (p = 0.03; β = 0.29) and lower socio‐economic status (p = 0.046; β = −0.22). No associations were observed between early medical factors, early feeding performance, cerebral structure alterations or maternal well‐being and feeding outcome.

Conclusion. Early hypotonia may disrupt the development of oral‐motor skills. Hypotonia and poor feeding also may share a common aetiology. Associations with lower socio‐economic status highlight the potential influence of family background factors in feeding problems in the preterm infant.

Aim. To establish the psychometrics of the Neonatal Oral Motor Assessment Scale (NOMAS).

Method. In this prospective cohort study of 75 preterm infants (39 females, 36 males) born at or before 30 weeks gestation (mean gestational age 26.56wks, SD 1.90, range 23–30wks; mean birthweight 967.33g, SD 288.54, range 480–2240), oral feeding was videotaped before discharge from the neonatal intensive care unit (NICU). The NOMAS was used to classify feeding as normal, disorganized, or dysfunctional. Neurobehavior was assessed at term equivalent, and infants underwent magnetic resonance imaging. Children returned for developmental testing at 2 years corrected age. Associations between NOMAS scores and (1) neurobehavior; (2) cerebral injury and metrics; and (3) developmental outcome were investigated using χ²‐analyses, t‐tests, and linear regression. For reliability, six certified NOMAS evaluators rated five randomly selected NOMAS recordings and re‐scored them 2 weeks later in a second randomized order. Reliability was calculated with Cohen's kappa statistics.

Results. Dysfunctional NOMAS scores were associated with lower Dubowitz scores [t=−2.14; mean difference −2.32 (95% confidence interval [CI] −0.157 to −4.49); p=0.036], higher stress on the NICU Network Neurobehavioral Scale (t=2.61; mean difference 0.073 [95% CI 0.017–0.129]; p=0.0110), and decreased transcerebellar diameter (t=−2.22; mean difference −2.04 [CI=−3.89 to −0.203]; p=0.03). No significant associations were found between NOMAS scores and 2‐year outcome.

Interpretation. Some concurrent validity was established with associations between NOMAS scores and measures of infant behavior and cerebral structure. The NOMAS did not show predictive validity in this study of preterm infants at high risk of developmental delay. Reliability was variable and suboptimal.

Objective. To investigate the effects of parental presence and infant holding in the neonatal intensive care unit (NICU) on neurobehavior at term equivalent.

Study Design. Prospective cohort enrolled 81 infants born ⩽30 weeks gestation. Nurses tracked parent visitation, holding and skin-to-skin care throughout the NICU hospitalization. At term, the NICU Network Neurobehavioral Scale was administered. Associations between visitation, holding and early neurobehavior were determined using linear and logistic regression.

Result. The mean hours per week of parent visitation was 21.33±20.88 (median=13.90; interquartile range 10.10 to 23.60). Infants were held an average of 2.29±1.47 days per week (median=2.00; interquartile range 1.20 to 3.10). Over the hospital stay, visitation hours decreased (P=0.01), while holding frequencies increased (P<0.001). More visitation was associated with better quality of movement (P=0.02), less arousal (P=0.01), less excitability (P=0.03), more lethargy (P=0.01) and more hypotonia (P<0.01). More holding was associated with improved quality of movement (P<0.01), less stress (P<0.01), less arousal (P=0.04) and less excitability (P<0.01).

Conclusion. Infants of caregivers who were visited and held more often in the NICU had differences in early neurobehavior by term equivalent, which supports the need for and importance of early parenting in the NICU.

The purpose of the study is to determine perceptions of clinical research in the NICU. This is a survey study. Nurses (n = 68) employed in a level III NICU in the Midwestern United States were included. The main outcome variable is the cross-sectional analysis of responses to a survey exploring perceptions of clinical research. Ninety-seven percent of nurses (n = 66) agree that clinical research is important for improving care, while 57% (n = 39) report that it affects their day positively. Thirty-seven percent reported excellent communication between clinical and research teams. In addition, 27% (n = 18) of nurses reported research presents complications for families, and 79% (n = 54) reported that it is acceptable to cease a research protocol for infant benefit. Years of practice and whether nurses read research affected various responses. Clinical research is imperative to inform best practice, and nurses are an integral part of care. Therefore, it is essential to better define strategies to bridge the gap between clinical and research teams.

Purpose. To determine factors associated with mother’s concern about infant development and intent to access therapy services following neonatal intensive care unit (NICU) discharge.

Methods. Infant medical factors, MRI results, neurobehavior at term, maternal factors, and maternal perceptions about developmental concern and intent to access therapy at NICU discharge were prospectively collected in 84 infants born premature (<30 weeks gestation). Regression was used to determine factors associated with developmental concern and intent to access therapy at NICU discharge.

Results. Decreased developmental concern was reported by mothers with more children (P=.007). Infant stress signs (P=.038), higher maternal education (P=.047), reading books (P=.030) and maternal depression (P=.018) had associations with increased developmental concern. More maternal education was associated with more intent to access services (P=.040).

Conclusion. Maternal factors, rather than infant factors, had important associations with caregiver concern. In contrast, abnormal term neurobehavior and/or the presence of cerebral injury were not associated with caregiver concern about development.

Keywords. adult, anxiety, child, disabled children/rehabilitation, early intervention, educational status, female, health services accessibility, infant, humans, income, male, neonatal intensive care, parents/psychology, premature infant, questionnaires, severity of illness, socioeconomic factors

Objective. To investigate differences in neurobehavior between preterm infants at term and full-term infants, changes in neurobehavior between 34 weeks postmenstrual age (PMA) and term equivalent in the preterm infant, and the relationship of neurobehavior to perinatal exposures.

Study design. In this prospective cohort study, 75 infants were tested at 34 weeks PMA and again at term using the Neonatal Intensive Care Unit Network Neurobehavioral Scale. Infants underwent magnetic resonance imaging at term equivalent. Regression was used to investigate differences in the scale's domains of function across time and in relation to perinatal exposures.

Results. At term equivalent, preterm infants exhibited altered behavior compared with full-term infants, with poorer orientation (P < .001), lower tolerance of handling (P < .001), lower self-regulation (P < .001), poorer reflexes (P < .001), more stress (P < .001), hypertonicity (P < .001), hypotonia (P < .001), and more excitability (P = .007). Preterm infants from 34 weeks PMA to term equivalent, demonstrated changes in motor functions with declining quality of movement (P = .006), increasing hypertonia (P < .001), decreasing hypotonia (P = .001), and changes in behavior with increasing arousal (P < .001), increasing excitability (P < .001), and decreasing lethargy (P < .001). Cerebral injury was associated with more excitability (P = .002). However, no associations were detected between any of the perinatal exposures and developmental change from 34 weeks PMA to term equivalent.

Conclusion. Preterm infants have altered neurobehavior in a broad number of domains at term equivalent. Cerebral injury alters neurobehavior but does not appear to impair early neurobehavioral changes. Important neurobehavioral changes occur before term, and this provides an opportunity for interventions in the neonatal intensive care unit.

Purpose. Determine perceptions about positioning for preterm infants in the neonatal intensive care unit (NICU).

Design. Twenty-item survey.

Sample. Neonatal nurses (n = 68) and speech, physical, and occupational therapists (n = 8).

Main outcome variable. Perceptions about positioning were obtained, and differences in perceptions between nurses and therapists were explored.

Results. Ninety-nine percent of respondents agreed that positioning is important for the well-being of the infant. Sixty-two percent of nurses and 86 percent of therapists identified the Dandle ROO as the ideal method of neonatal positioning. Forty-four percent of nurses and 57 percent of therapists reported that the Dandle ROO is the easiest positioning method to use in the NICU. Some perceptions differed: Therapists were more likely to report that the SleepSack does not hold the infant in good alignment. Nurses were more likely to report that the infant does not sleep well in traditional positioning.

Objective. To explore differences in maternal factors, including visitation and holding, among premature infants cared for in single-patient rooms (SPR) compared with open-bay in the neonatal intensive care unit (NICU).

Study Design. A total of 81 premature infants were assigned to a bed space in either the open-bay area or in a SPR upon NICU admission, based on bed space and staffing availability in each area. Parent visitation and holding were tracked through term equivalent, and parents completed a comprehensive questionnaire at discharge to describe maternal health. Additional maternal and medical factors were collected from the medical record. Differences in outcome variables were investigated using linear regression.

Result. No significant differences in gestational age at birth, initial medical severity, hours of intubation or other factors that could affect the outcome were observed across room type. Significantly more hours of visitation were observed in the first 2 weeks of life (P=0.02) and in weeks 3 and 4 (P=0.02) among infants in the SPR. More NICU stress was reported by mothers in the SPR after controlling for social support (P=0.04).

Conclusion. Increased parent visitation is an important benefit of the SPR, however, mothers with infants in the SPR reported more stress.

Objective. Although many perinatal factors have been linked to adverse neurodevelopmental outcomes in very premature infants, much of the variation in outcome remains unexplained. The impact on brain development of 1 potential factor, exposure to stressors in the neonatal intensive care unit, has not yet been studied in a systematic, prospective manner.

Methods. In this prospective cohort study of infants born at <30 weeks gestation, nurses were trained in recording procedures and cares. These recordings were used to derive Neonatal Infant Stressor Scale scores, which were employed to measure exposure to stressors. Magnetic resonance imaging (brain metrics, diffusion, and functional magnetic resonance imaging) and neurobehavioral examinations at term equivalent postmenstrual age were used to assess cerebral structure and function. Simple and partial correlations corrected for confounders, including immaturity and severity of illness, were used to explore these relations.

Results. Exposure to stressors was highly variable, both between infants and throughout a single infant's hospital course. Exposure to a greater number of stressors was associated with decreased frontal and parietal brain width, altered diffusion measures and functional connectivity in the temporal lobes, and abnormalities in motor behavior on neurobehavioral examination.

Interpretation. Exposure to stressors in the Neonatal Intensive Care Unit is associated with regional alterations in brain structure and function. Further research into interventions that may decrease or mitigate exposure to stressors in the neonatal intensive care unit is warranted.

Objective. Rates of breast milk feeding at hospital discharge are low in premature infants due to the many associated challenges. Although there are many benefits associated with breast milk, the effects of direct breast-feeding in the neonatal intensive care unit (NICU) have not been identified. The purpose of this study was to investigate the relationship between direct breast-feeding (infant sucking directly from the breast) and duration and success with breast milk feedings until discharge in premature infants.

Study Design. This retrospective cohort was conducted on 66 very-low birth weight infants whose mothers initiated breast milk feedings in the NICU. Chart review revealed documented type (breast milk with or without fortifiers or type of infant formula), volume and mode (nasogastric tube, breast or bottle) of all gastric feeds for each day of NICU hospitalization. From this documentation, whether the mother initiated breast milk feedings, the number of times the mother put the infant to breast, the gestational age of the first direct breast-feeding, whether the first oral feeding was at the breast, the duration of breast milk feedings and whether breast milk feedings continued until NICU discharge were determined. Associations between breast-feeding participatory factors and breast milk feeding outcomes were investigated using linear and logistic regression.

Result. Positive associations were found between breast milk feedings at discharge and mothers putting their infants directly to breast in the NICU (P=0.0005). The duration of breast milk feedings was associated with: mothers putting their infants directly to breast (P=0.0110), whether the first oral sucking feeding was at the breast (P=0.0108) and the gestational age of the first breast-feeding attempt (P<0.0001).

Conclusion. Breast milk feedings are encouraged in most NICU's, but direct breast-feeding is often overlooked as an important area of research in the tightly controlled environment of the NICU. This study demonstrates a link between direct breast-feeding behaviors in the NICU and success with provision of milk at discharge, as well as how early participation can be an important factor in the breast-feeding process for mothers of NICU infants. More research on the effects of direct breast-feeding is warranted.

Objective. This study investigated associations between maternal and infant factors and breastfeeding practices in infants born <30 weeks gestation in the neonatal intensive care unit (NICU).

Study Design. This study was a retrospective cohort. Mother and infant characteristics were investigated for associations with breastfeeding outcomes using multivariate logistic regression.

Results. Seventy-eight percent of infants initiated breastmilk feedings, 48% of those continued to have breastmilk at discharge, and 52% were breastfed in the hospital. The average duration of breastmilk feedings was 43 days. Mothers who were married and had a multiple-infant birth were more likely to initiate breastmilk feeds, African American mothers and younger mothers had less success with maintaining breastmilk feeds until hospital discharge, and African American mothers and mothers of lower socioeconomic status were less likely to participate in direct breastfeeding in the NICU.

Conclusions. Infant factors, such as birth weight and gestational age, were not associated with breastfeeding behaviors. Mothers can succeed with breastfeeding the premature infant. By understanding what maternal groups are at risk for breastfeeding failure, targeted interventions in the NICU can be implemented.

Purpose. To assess the effectiveness of an educational intervention aimed at staff and parents in changing breastfeeding practices in the NICU.

Design. The breastfeeding education initiative consisted of three parts: breastfeeding training for NICU staff, issuance of complementary breastfeeding materials to mothers of infants in the NICU, and addition of a breastfeeding pathway to the individualized care plan. Infants admitted before and after the initiative were compared to evaluate for changes in breastfeeding practices.

Sample. The study sample included very low birth weight (VLBW) infants hospitalized in the NICU for more than seven days and born weighing <1,500 g. Infants were grouped based on whether they were admitted before (pre-intervention) or after (post-intervention) implementation of the education initiative.

Main Outcome Variables. Health care professional (HCP) knowledge of breastfeeding interventions in the NICU was measured using a posttest following training. Breast milk feeding initiation rates, breastfeeding rates, and rates of breast milk feeding at discharge were measured via retrospective chart review among pre- and post-intervention infant groups.

Results. The post-intervention group demonstrated significant improvement in rates of breastfeeding (infants being put directly to the breast) in the NICU compared with the pre-intervention group. General positive trends in breast milk feeding initiation (up 11 percent) and breast milk feeding at discharge (up 5 percent) were observed, but these increases failed to reach significance.