Bobbi Pineda PhD, OTR/L, CNT
Room: CHP 222R
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Dr. Pineda served in pediatric clinical roles at Tampa General Rehabilitation, All Children’s Hospital, Duke University Medical Center and University of Florida Shands Hospital from 1992 through 2006, where she gained expertise with outpatient and inpatient pediatric therapy, including services to fragile infants in the neonatal intensive care unit. The premature birth of her first child in addition to her ongoing interest in learning, led her to pursue her doctorate to conduct research with premature infants. Her dissertation investigated an educational intervention to promote breastfeeding in very low birth weight infants. Upon graduation with her doctorate in 2006, she began working at Washington University, where she spent 12 years exploring factors that can improve the lives of infants born prematurely.
She is a member of the American Occupational Therapy Association and the National Association of Neonatal Therapists. She is the co-chair of the Neonatal Therapy National Certification Board, which aims to validate the experience and knowledge of those practicing in this advanced area of occupational therapy. She joined USC’s faculty in early 2020, and plans to continue her research that can impact the lives of high-risk infants and families, and continue mentoring and advising occupational therapy students.
Dr. Pineda’s research interests include investigating factors associated with cerebral alterations and adverse neurodevelopmental outcome in high risk newborn infants, specifically infants born prematurely. Early factors that can impede function and are being investigated include the environment (low stimulation environments as well as higher stimulation environments), stress, pain, medical complications and interventions, parenting, brain injury and prenatal exposures. Dr. Pineda has investigated the differences in language and sound exposure across different NICU room types (open ward compared to NICU private room) and investigated associations with brain structure and outcome. Dr. Pineda has also developed a sensory-based intervention, the Supporting and Enhancing NICU Sensory Experiences (SENSE) program, which is supported by current evidence and aims to engage parents in providing age-appropriate, positive sensory exposures to their infants each day of NICU hospitalization. Dr. Pineda has also developed the Neonatal Eating Outcome Assessment tool, which assesses the most important clinically and research-derived factors associated with feeding skills in preterm infants and can be used to improve the understanding of age appropriate feeding skills, improve early identification of feeding difficulties, and enable targeted interventions to preterm infants with eating problems. Other research interests include neurobehavioral assessment of preterm infants and early identification of developmental challenges, neonatal feeding, neurodevelopmental outcomes, empowering parents and early intervention services.
Patricia Buehler Legacy Award for Clinical Innovation | 2018
University of Southern California
A. Jean Ayres Award | 2018
American Occupational Therapy Foundation
Award for Research Excellence | 2017
National Association of Neonatal Therapists
Doctor of Philosophy (PhD)
in Rehabilitation Science
2006 | University of Florida
Master of Health Science (MHS)
in Occupational Therapy
1994 | University of Florida
Bachelor of Health Science (BHS)
in Occupational Therapy
1992 | Florida Agricultural and Mechanical University
Pineda, R., Wallendorf, M., & Smith, J. (2020). A pilot study demonstrating the impact of the supporting and enhancing NICU sensory experiences (SENSE) program on the mother and infant. Early Human Development, 144, 105000. https://doi.org/10.1016/j.earlhumdev.2020.105000 Show abstract
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.
Pineda, R., Prince, D., Reynolds, J., Grabill, M., & Smith, J. (2020). Preterm infant feeding performance at term equivalent age differs from that of full-term infants. Journal of Perinatology, 40, 646–654. https://doi.org/10.1038/s41372-020-0616-2 Show abstract
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.
Liszka, L., Heiny, E., Smith, J., Schlaggar, B. L., Mathur, A., & Pineda, R. (2020). Auditory exposure of high‐risk infants discharged from the NICU and the impact of social factors. Acta Paediatrica. Advance online publication. https://doi.org/10.1111/apa.15209 Show abstract
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.
Pineda, R., Heiny, E., Roussin, J., Nellis, P., Bogan, K., & Smith, J. (2020). Implementation of the Baby Bridge program reduces timing between NICU discharge and therapy activation. Journal of Early Intervention. Advance online publication. https://doi.org/10.1177/1053815119900241 Show abstract
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
Pineda, R., Liszka, L., Kwon, J., & Wallendorf, M. (2020). Interrater reliability and concurrent validity of the Neonatal Eating Outcome Assessment. American Journal of Occupational Therapy, 74(2), 7402205050. https://doi.org/10.5014/ajot.2020.039578 Show abstract
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.
Pineda, R., Muñoz, R., Chrzastowski, H., Dunsirn-Baillie, S., Wallendorf, M., & Smith, J. (2020). Maternal milk and relationships to early neurobehavioral outcome in preterm infants. Journal of Perinatal & Neonatal Nursing, 34(1), 72-79. https://doi.org/10.1097/JPN.0000000000000460 Show abstract
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.
Smith, J. R., Raney, M. R., & Pineda, R. (2019). Developmental care. In L. Jain & G. K. Suresh (Eds.), Clinical guidelines in neonatology (pp. 577-586). New York, NY: McGraw-Hill Education.
Pineda, R., DeGaetano, S., Kindra, M., Hand, T., Craig, J., Fernandez-Fernandez, A., & Collette, D. (2019). Neonatal therapy: A survey of current practice. Journal of Pediatric Rehabilitation Medicine, 12(3), 285-294. https://doi.org/10.3233/PRM-180565 Show abstract
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.
Pineda, R., Roussin, J., Heiny, E., & Smith, J. (2019). Health care professionals' perceptions about sensory-based interventions in the NICU. American Journal of Perinatology, 36(12), 1229-1236. https://doi.org/10.1055/s-0038-1676536 Show abstract
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.
Liszka, L., Smith, J., Mathur, A., Schlaggar, B. L., Colditz, G., & Pineda, R. (2019). Differences in early auditory exposure across neonatal environments. Early Human Development, 136, 27-32. https://doi.org/10.1016/j.earlhumdev.2019.07.001 Show abstract
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.
Clubbs, B., Barnette, A., Gray, N., Weiner, L., Bond, A., Harden, J., & Pineda, R. (2019). A community hospital NICU developmental care partner program: Feasibility and association with decreased nurse burnout without increased infant infection rates. Advances in Neonatal Care, 19(4), 311-320. https://doi.org/10.1097/ANC.0000000000000600 Show abstract
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.
Pineda, R., Dewey, K., Jacobsen, A., & Smith, J. (2019). Non-nutritive sucking in the preterm infant. American Journal of Perinatology, 36(3), 268-276. https://doi.org/10.1055/s-0038-1667289 Show abstract
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
Pineda, R., Raney, M., & Smith, J. (2019). Supporting and enhancing NICU sensory experiences (SENSE): Defining developmentally-appropriate sensory exposures for high-risk infants. Early Human Development, 133, 29-35. https://doi.org/10.1016/j.earlhumdev.2019.04.012 Show abstract
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.
Harris, R., Gibbs, D., Mangin-Heimos, K., & Pineda, R. (2018). Maternal mental health during the neonatal period: Relationships to the occupation of parenting. Early Human Development, 120, 31-39. https://doi.org/10.1016/j.earlhumdev.2018.03.009 Show abstract
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
Pineda, R., Luong, A., Ryckman, J., & Smith, J. (2018). Pacifier use in newborns: related to socioeconomic status but not to early feeding performance. Acta Paediatrica, 107(5), 806-810. https://doi.org/10.1111/apa.14253 Show abstract
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.
Pineda, R., Harris, R., Foci, F., Roussin, J., & Wallendorf, M. (2018). Neonatal Eating Outcome Assessment: tool development and inter‐rater reliability. Acta Paediatrica, 107(3), 414-424. https://doi.org/10.1111/apa.14128 Show abstract
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.
Pineda, R., Bender, J., Hall, B., Shabosky, L., Annecca, A., & Smith, J. (2018). Parent participation in the neonatal intensive care unit: Predictors and relationships to neurobehavior and developmental outcomes. Early Human Development, 117, 32-38. https://doi.org/10.1016/j.earlhumdev.2017.12.008 Show abstract
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
Ryckman, J., Hilton, C., Rogers, C., & Pineda, R. (2017). Sensory processing disorder in preterm infants during early childhood and relationships to early neurobehavior. Early Human Development, 113, 18-22. https://doi.org/10.1016/j.earlhumdev.2017.07.012 Show abstract
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
Ross, K., Heiny, E., Conner, S., Spener, P., & Pineda, R. (2017). Occupational therapy, physical therapy and speech-language pathology in the neonatal intensive care unit: Patterns of therapy usage in a level IV NICU. Research in Developmental Disabilities, 64, 108-117. https://doi.org/10.1016/j.ridd.2017.03.009 Show abstract
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
Pineda, R., Durant, P., Mathur, A., Inder, T., Wallendorf, M., & Schlaggar, B. L. (2017). Auditory exposure in the neonatal intensive care unit: Room type and other predictors. The Journal of Pediatrics, 183, 56-66.e3. https://doi.org/10.1016/j.jpeds.2016.12.072 Show abstract
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
Nwabara, O., Rogers, C., Inder, T., & Pineda, R. (2017). Early therapy services following neonatal intensive care unit discharge. Physical & Occupational Therapy In Pediatrics, 37(4), 414-424. https://doi.org/10.1080/01942638.2016.1247937 Show abstract
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
Pineda, R., Guth, R., Herring, A., Reynolds, L., Oberle, S., & Smith, J. (2017). Enhancing sensory experiences for very preterm infants in the NICU: an integrative review. Journal of Perinatology, 37, 323–332. https://doi.org/10.1038/jp.2016.179 Show abstract
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.
Pineda, R. G. (2016). Feeding: an important, complex skill that impacts nutritional, social, motor and sensory experiences [short commentary]. Acta Paediatrica, 105(10), e458-e458. https://doi.org/10.1111/apa.13535
Smith, J. R., & Pineda, R. G. (2016). Determining appropriate sensory exposures in the NICU: Too much, too little, or just right? [Editorial]. Neonatal Network, 35(2), 63-65. https://doi.org/10.1891/0730-08188.8.131.52
Dunsirn, S., Smyser, C., Liao, S., Inder, T., & Pineda, R. (2016). Defining the nature and implications of head turn preference in the preterm infant. Early Human Development, 96, 53-60. https://doi.org/10.1016/j.earlhumdev.2016.02.002 Show abstract
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
Crapnell, T. L., Woodward, L. J., Rogers, C. E., Inder, T. E., & Pineda, R. G. (2015). Neurodevelopmental profile, growth, and psychosocial environment of preterm infants with difficult feeding behavior at age 2 years. The Journal of Pediatrics, 167(6), 1347-1353. https://doi.org/10.1016/j.jpeds.2015.09.022 Show abstract
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.
Pineda, R. G., Reynolds, L. C., Seefeldt, K., Hilton, C. L., Rogers, C. E., & Inder, T. E. (2015). Head lag in infancy: What is it telling us? American Journal of Occupational Therapy, 70(1), 7001220010. https://doi.org/10.5014/ajot.2016.017558 Show abstract
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.
McPherson, C., Haslam, M., Pineda, R., Rogers, C., Neil, J. J., & Inder, T. E. (2015). Brain injury and development in preterm infants exposed to fentanyl. Annals of Pharmacotherapy, 49(12), 1291–1297. https://doi.org/10.1177/1060028015606732 Show abstract
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.
McPherson, C., Neil, J. J., Tjoeng, T. H., Pineda, R., & Inder, T. E. (2015). A pilot randomized trial of high-dose caffeine therapy in preterm infants. Pediatric Research, 78, 198–204. https://doi.org/10.1038/pr.2015.72 Show abstract
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.
Pineda, R., Melchior, K., Oberle, S., Inder, T., & Rogers, C. (2015). Assessment of autism symptoms during the neonatal period: Is there early evidence of autism risk? American Journal of Occupational Therapy, 69(4), 6904220010. https://doi.org/10.5014/ajot.2015.015925 Show abstract
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.
Reynolds, L. C., Inder, T. E., Neil, J. J., Pineda, R. G., & Rogers, C. E. (2014). Maternal obesity and increased risk for autism and developmental delay among very preterm infants. Journal of Perinatology, 34, 688–692. https://doi.org/10.1038/jp.2014.80 Show abstract
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.
Reynolds, L. C., Pineda, R. G., Mathur, A., Vavasseur, C., Shah, D. K., Liao, S., & Inder, T. (2014). Cerebral maturation on amplitude‐integrated electroencephalography and perinatal exposures in preterm infants. Acta Paediatrica, 103(3), e96-e100. https://doi.org/10.1111/apa.12485 Show abstract
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.
Madlinger-Lewis, L., Reynolds, L., Zarem, C., Crapnell, T., Inder, T., & Pineda, R. (2014). The effects of alternative positioning on preterm infants in the neonatal intensive care unit: A randomized clinical trial. Research in Developmental Disabilities, 35(2), 490-497. https://doi.org/10.1016/j.ridd.2013.11.019 Show abstract
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
Pineda, R. G., Neil, J., Dierker, D., Smyser, C. D., Wallendorf, M., Kidokoro, H., Reynolds, L. C., Walker, S., Rogers, C., Mathur, A. M., Van Essen, D. C., & Inder, T. (2014). Alterations in brain structure and neurodevelopmental outcome in preterm infants hospitalized in different neonatal intensive care unit environments. The Journal of Pediatrics, 164(1), 52-60.e2. https://doi.org/10.1016/j.jpeds.2013.08.047 Show abstract
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.
Zarem, C., Kidokoro, H., Neil, J., Wallendorf, M., Inder, T., & Pineda, R. (2013). Psychometrics of the Neonatal Oral Motor Assessment Scale. Developmental Medicine & Child Neurology, 55(12), 1115-1120. https://doi.org/10.1111/dmcn.12202 Show abstract
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.
Crapnell, T. L., Rogers, C. E., Neil, J. J., Inder, T. E., Woodward, L. J., & Pineda, R. G. (2013). Factors associated with feeding difficulties in the very preterm infant. Acta Paediatrica, 102(12), e539-e545. https://doi.org/10.1111/apa.12393 Show abstract
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.
Reynolds, L. C., Duncan, M. M., Smith, G. C., Mathur, A., Neil, J., Inder, T., & Pineda, R. G. (2013). Parental presence and holding in the neonatal intensive care unit and associations with early neurobehavior. Journal of Perinatology, 33, 636–641. https://doi.org/10.1038/jp.2013.4 Show abstract
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.
Pineda, R. G., Tjoeng, T. H., Vavasseur, C., Kidokoro, H., Neil, J. J., & Inder, T. (2013). Patterns of altered neurobehavior in preterm infants within the neonatal intensive care unit. The Journal of Pediatrics, 162(3), 470-476.e1. https://doi.org/10.1016/j.jpeds.2012.08.011 Show abstract
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.
Zarem, C., Crapnell, T., Tiltges, L., Madlinger, L., Reynolds, L., Lukas, K., & Pineda, R. (2013). Neonatal nurses’ and therapists’ perceptions of positioning for preterm infants in the neonatal intensive care unit. Neonatal Network, 32(2), 110-116. https://doi.org/10.1891/0730-08184.108.40.206 Show abstract
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.
Reynolds, L. C., Crapnell, T., Zarem, C., Madlinger, L., Tiltges, L., Lukas, K., & Pineda, R. G. (2013). Nursing perceptions of clinical research in the neonatal intensive care unit. Newborn and Infant Nursing Reviews, 13(2), 62-66. https://doi.org/10.1053/j.nainr.2013.04.002 Show abstract
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.
Pineda, R., Castellano, A., Rogers, C., Neil, J., & Inder, T. (2013). Factors associated with developmental concern and intent to access therapy following discharge from the NICU. Pediatric Physical Therapy, 25(1), 62–69. https://doi.org/10.1097/PEP.0b013e31827a822c Show abstract
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
Pineda, R. G., Stransky, K. E., Rogers, C., Duncan, M. H., Smith, G. C., Neil, J., & Inder, T. (2012). The single-patient room in the NICU: maternal and family effects. Journal of Perinatology, 32, 545–551. https://doi.org/10.1038/jp.2011.144 Show abstract
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.
Smith, G. C., Gutovich, J., Smyser, C., Pineda, R., Newnham, C., Tjoeng, T. H., Vavasseur, C., Wallendorf, M., Neil, J., & Inder, T. (2011). Neonatal intensive care unit stress is associated with brain development in preterm infants. Annals of Neurology, 70(4), 541-549. https://doi.org/10.1002/ana.22545 Show abstract
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.
Pineda, R., Foss, J., Richards, L., & Pane, C. (2009). Breastfeeding changes for VLBW infants in the NICU following staff education. Neonatal Network, 28(5), 311-319. https://doi.org/10.1891/0730-08220.127.116.111 Show abstract
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.