Polly Kellner MSOT, OTR/L

Objective. To characterize current infant massage practices in neonatal intensive care units (NICUs) and identify variability inapproaches among neonatal therapists.

Study Design. A cross-sectional survey was distributed to NICU-based occupational therapists, physical therapists, and speechlanguage pathologists. The survey inquired about massage use, training, protocols, techniques, and safety concerns. Descriptivestatistics were used for analysis.

Results. Among 101 respondents from 32 states, 90 (90%) used infant massage, with 64 (71%) considering it standard care. Infantmassage was most often administered by occupational therapists (77, 76%), physical therapists (70, 69%), and parents (46, 46%).Despite high training rates (87, 97%), only 48 (53%) followed a specific protocol. Techniques, frequency, and use of emollientsvaried widely. Safety concerns included infant stress and physiological instability, though adverse events were rare.

Conclusion. Despite widespread use of infant massage in NICUs, variability in findings underscores the need for standardizationto ensure safe, effective delivery of massage.

Keywords. Health Occupations, Rehabilitation

To determine the feasibility and acceptability of the Baby Bridge telehealth model, aimed at expediting the time to therapy activation after neonatal intensive care unit (NICU) discharge. High-risk infants needing therapy after NICU discharge had an in-person therapy visit in the NICU to consent and conduct standardized assessments, followed by weekly telehealth Baby Bridge services starting within 1 week of NICU discharge. Among eight families, the first Baby Bridge telehealth session occurred at an average of 6.0 ± 2.6 days following discharge. They received an average of 8.3 (±2.1) telehealth sessions over 9.2 (±3.5) weeks. All therapy sessions after NICU discharge were accomplished with telehealth rather than in-person sessions. Satisfaction surveys of the eight families indicated they were “very satisfied” with Baby Bridge telehealth services. Telehealth Baby Bridge services appear to be feasible and acceptable when implementing programming to improve early therapy access for high-risk infants.

Objective. Early alterations in function are evident in preterm infants during their neonatal intensive care unit (NICU) hospitalization. Therefore, it is common for preterm infants to be referred to early intervention (EI) as they transition from hospital to home. Access to EI is often assumed, but understanding gaps in service delivery is important. The aims of this project were to (1) determine rates of EI access at the first high-risk infant follow-up (HRIF) appointment (4–8 months corrected age) at a safety-net hospital in Los Angeles, and (2) identify relationships between infant, clinic, and EI factors with EI service uptake.

Study Design. Through a retrospective medical record review, EI utilization at the first HRIF appointment was documented among 189 NICU-graduate preterm infants born ≤32 weeks estimated gestational age who had their first HRIF visit (4–8 months corrected age) between January 2019 and November 2020.

Results. Ninety-two (49%) of the infants were receiving EI at their first HRIF appointment at 4 to 8 months corrected age. Extremely preterm infants were more likely to receive EI services than those born very preterm (p = 0.005). No other relationships between factors were identified.

Conclusion. Successful uptake of EI services cannot be assumed. Challenges with access to EI persist, even within systems designed to foster identification and access to therapy following NICU discharge. Future research is needed to identify the reasons for the lack of access to EI and to identify the impact of different types of programming to aid access to EI for high-risk populations.

Key Points

• EI access for a safety-net population is challenging.
• Only 49% of preterm infants received EI at 4 to 8 months corrected age.
• Extremely preterm infants were more likely to access EI.
• EI access was higher for infants hospitalized in the NICU associated with the HRIF.

Ethical Approval This study was approved by the USC IRB (approval no.: UP-20-01339). This study had a waiver of informed consent, which enabled data collection of factors related to EI access retrospectively. This research was approved by the Human Research Protection Office at the University of Southern California, Los Angeles, CA.

Keywords. healthcare service delivery, health equity, therapy, infant, preterm

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

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.

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

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 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

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. 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

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