Director: Bobbi Pineda PhD, OTR/L, CNT
The NICU Therapy Lab, led by Dr. Bobbi Pineda, explores the impact of the environment, medical conditions, and therapeutic interventions on brain structure and functional outcomes of infants born prior to 32 weeks gestation who are hospitalized in the neonatal intensive care unit. The lab also conducts research centered around parental engagement, access to early intervention services, and development of assessment tools and new technologies and interventions. Recent developments from the NICU Therapy Lab include the Neonatal Eating Outcome Assessment, the Supporting and Enhancing NICU Sensory Experiences (SENSE) program, and the Baby Bridge program. Currently, the lab is focused on implementation of the SENSE program in hospitals throughout the US and abroad, adapting the Baby Bridge program to telehealth, and understanding early feeding performance and its implications on later outcomes.
Implementation of the Baby Bridge program via telehealth to enhance access to early intervention services in Los Angeles ⟩
The long-term goal of this project is to improve health and well-being of infants and families impacted by neonatal intensive care unit (NICU) hospitalization through early occupational therapy (OT). High-risk infants discharged from the NICU experience developmental challenges. Early OT: 1)…
Period: Sep 2021 – Apr 2024
Private Funding $100,000
Oral intake is an important indicator of weight gain and development for premature infants, especially as they approach discharge from the Neonatal Intensive Care Unit (NICU). However, the underlying skills for oral feeding such as coordinating suck-swallow-breathe, state regulation, and maintenance…
Period: May 2021 – Apr 2024
Federal Funding $1,730,866 (anticipated)
Multisensory Interventions to Improve Neurodevelopmental Outcomes of Preterm Infants Hospitalized in the Neonatal Intensive Care Unit ⟩
During hospitalization in the Neonatal Intensive Care Unit (NICU), premature infants repeatedly experience negative sensory experiences. Evidence suggests that combined with prematurity, experiences in the NICU environment are disruptive to neurodevelopment. The Supporting and Enhancing NICU Sensory…
Period: Mar 2022 – Mar 2027
Federal Funding $3,911,770 (anticipated)
Mulrenin, B., Pineda, R., Dodds, C., & Velozo, C. A. (2023). Item-level psychometrics of the Neonatal Eating Outcome Assessment in orally feeding infants. OTJR: Occupational Therapy Journal of Research. Advance online publication. https://doi.org/10.1177/15394492231212399 Show abstract
Background. The Neonatal Eating Outcome Assessment determines feeding performance based on the infant’s postmenstrual age (PMA).
Objective. To examine item-level measurement properties of this assessment’s rating scale.
Methodology. In this retrospective study, Rasch analysis was completed on clinical data from the Neonatal Eating Outcome Assessment for 100 infants (52 preterm and 48 full-term) using Winsteps version 3.93.1. Instead of PMA-based scores, ordered letters converted to numerical scores were analyzed.
Results. Analysis demonstrated that Section I (Pre-Feeding Skills) represents a separate construct from Sections II and III (Oral Feeding and End of Feeding, respectively). Sections II and III were adequately unidimensional to complete Rasch analysis. These sections fit the Rasch model overall, but rating scale category underuse was common, which may be attributed to sample characteristics.
Erdei, C., Cherkerzian, S., Pineda, R., & Inder, T. E. (2023). Serial neuroimaging of brain growth and development in very preterm infants receiving tailored neuropromotive support in the NICU. Protocol for a prospective cohort study. Frontiers in Pediatrics, 11, 1203579. https://doi.org/10.3389/fped.2023.1203579 Show abstract
Introduction. Children born very preterm (VP) remain at risk for long-term neurodevelopmental impairment. Patterns of brain growth and injury, and how early neuropromotive therapies might mitigate developmental risk in VP infants remain insufficiently understood.
Methods. This is a prospective cohort study of VP infants born at/before 32 weeks gestation. The study will enroll n = 75 consecutively-born VP infants in a level-III NICU. Exposed infants will be categorized into two groups (group 1: low-risk, n = 25 or group 2: high-risk, n = 25) based on the degree of neurological injury on early brain magnetic resonance imaging (MRI) at enrollment. Infants in the low-risk group (i.e., without significant injury defined as intraventricular hemorrhage with dilation, moderate or severe white matter injury, or cerebellar hemorrhage) will receive neurodevelopmental support utilizing the Supporting and Enhancing NICU Sensory Experiences (SENSE) program, while infants in the high-risk group (with neurological injury) will receive more intensive neurorehabilitative support (SENSE-plus). Age-specific, tailored sensory experiences will be facilitated contingently, preferentially by the infant's family with coaching from NICU staff. VP infants in exposure groups will undergo a brain MRI approximately every 2 weeks from enrollment until term-equivalent to monitor brain growth and evolution of injury. Exposed infants will be compared with a reference group (group 3: n = 25), i.e. VP infants whose families decline initial enrollment in SENSE, and subsequently undergo a term-equivalent brain MRI for other purposes. The primary aim of this study is characterization of term-equivalent brain growth and development among VP infants receiving NICU-based neuropromotive interventions compared to VP infants receiving the standard of care. Secondary aims include defining the timing and factors associated with total and regional brain growth on serial brain MRI among VP infants, (Aim 2), and using early imaging to tailor developmental intervention in the NICU while exploring associations with outcomes in VP infants at discharge and at two years corrected age (Aim 3).
Discussion. This study will address gaps in understanding patterns of brain growth and injury drawing on serial MRI of hospitalized VP infants. These data will also explore the impact of intensive, tailored neuropromotive support delivered prior to term-equivalent on child and family outcomes.
Keywords. preterm, neurodevelopment, neurorehabilitation, multisensory experience, developmental care, NICU environment
Richter, M., Kellner, P., & Pineda, R. (2023). Gravens by design: Supporting and Enhancing NICU Sensory Experiences (SENSE) program — an evidence-based guideline for daily parent-delivered positive multisensory exposures for infants in the NICU. Neonatology Today, 18(10), 66–71. Show abstract
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
Stein Duker, L. I., Kwon, J., Richter, M., & Pineda, R. (2023). Feasibility of wearable sensors in the NICU: Psychophysiological measures of parental stress. Early Human Development, 183, 105814. https://doi.org/10.1016/j.earlhumdev.2023.105814 Show abstract
Background. Parents report elevated stress during their infant's NICU hospitalization. Real-time measures may improve our understanding of parental stress in the NICU.
Aim. Examine the feasibility of wearable sensors to describe parental stress in the NICU.
Study design. In this prospective feasibility study of 12 parent-infant dyads, parents wore an Empatica E4 wristband to measure psychophysiological stress via electrodermal activity (EDA) during sensory interventions (holding, massage, reading, touch, etc.) with their babies. Baseline and intervention periods were delineated during which concurrent monitoring and clinical observations of infant behavior and environmental factors were recorded. Feasibility was assessed by investigating recruitment/enrollment, retention/adherence, acceptability, sensor usability, and changes in EDA waveforms based on potential stressors. For the latter, independent samples t-tests and ANOVA were used to examine differences in EDA from baseline to intervention, and the impact of environmental and infant factors on parent stress were visually analyzed against EDA waveforms.
Results. Wearable sensor use in the NICU appeared feasible as assessed by all methods. Preliminary data analysis indicated that overall parent EDA levels during parent-infant interactions were low, and engagement in sensory intervention(s) led to a non-significant increase in parental EDA, measured by both skin conductance levels and non-specific skin conductance responses. Three main patterns of EDA emerged: a temporary increase in EDA at the beginning of the intervention followed by a decrease and plateau, a plateau in EDA from baseline to intervention, and a gradual rise in EDA throughout intervention. Specific environmental and infant factors, such as infant stress and health care providers entering the room, appeared to impact parent stress levels.
Conclusion. Although these preliminary findings provide support for use of EDA in the NICU, future studies are needed.
Pineda, R., Kellner, P., Guth, R., Gronemeyer, A., & Smith, J. (2023). NICU sensory experiences associated with positive outcomes: An integrative review of evidence from 2015–2020. Journal of Perinatology, 43, 837–848. https://doi.org/10.1038/s41372-023-01655-y Show abstract
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.
Pineda, R., Knudsen, K., Breault, C. C., Rogers, E. E., Mack, W. J., & Fernandez-Fernandez , A. (2023). NICUs in the US: Levels of acuity, number of beds, and relationships to population factors. Journal of Perinatology, 43, 796–805. https://doi.org/10.1038/s41372-023-01693-6 Show abstract
Objective. To 1) define the number and characteristics of NICUs in the United States (US) and 2) identify hospital and population characteristics related to US NICUs.
Study design. Cohort study of US NICUs.
Results. There were 1424 NICUs identified in the US. Higher number of NICU beds was positively associated with higher NICU level (p < 0.0001). Higher acuity level and number of NICU beds related to being in a children’s hospital (p < 0.0001;p < 0.0001), part of an academic center (p = 0.006;p = 0.001), and in a state with Certificate of Need legislation (p = 0.023;p = 0.046). Higher acuity level related to higher population density (p < 0.0001), and higher number of beds related to increasing proportions of minorities in the population up until 50% minorities. There was also significant variation in NICU level by region.
Conclusions. This study contributes new knowledge by describing an updated registry of NICUs in the US in 2021 that can be used for comparisons and benchmarking.
Pineda, R., Kellner, P., Ibrahim, C., SENSE Advisory Team Working Group, & Smith, J. (2023). Supporting and Enhancing NICU Sensory Experiences (SENSE), 2nd edition: An update on developmentally appropriate interventions for preterm infants. Children, 10(6), 961. https://doi.org/10.3390/children10060961 Show abstract
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
Grabill, M., Smith, J., Ibrahim, C., & Pineda, R. (2023). Prevalence of early feeding alterations among preterm infants and their relationship to early neurobehavior. American Journal of Occupational Therapy, 77(3), 7703205170. https://doi.org/10.5014/ajot.2023.050123 Show abstract
Importance. Feeding difficulties are common among preterm infants during neonatal intensive care unit (NICU) hospitalization. Although most preterm infants achieve full oral feeding by term-equivalent age, whether feeding difficulties persist despite the infant taking full volume and whether these difficulties may relate to other neurobehavioral challenges remain unclear.
Objective. To identify the prevalence of feeding problems among preterm infants and the relationships between infant feeding behaviors and neurobehavior at term-equivalent age.
Design. Cohort study.
Setting. Level 4 NICU with 85 beds.
Participants. Thirty-nine very preterm infants born ≤32 wk gestation (range = 22–32 wk). Exclusion criteria were congenital anomalies, >32 wk gestation at birth, and lack of feeding or neurobehavioral assessment at term-equivalent age.
Outcomes and Measures. Standardized feeding assessments using the Neonatal Eating Outcome Assessment and standardized neurobehavioral evaluation using the NICU Network Neurobehavioral Scale.
Results. Thirty-nine infants (21 female) were included in the final analysis. The mean Neonatal Eating Outcome Assessment score was 66.6 (SD = 13.3). At term-equivalent age, 10 infants (26%) demonstrated feeding challenges, 21 (54%) demonstrated questionable feeding issues, and 8 (21%) demonstrated normal feeding performance. Lower Neonatal Eating Outcome Assessment scores (poorer feeding performance) at term-equivalent age were associated with more suboptimal reflexes (p = .04) and hypotonia (p < .01).
Conclusions and Relevance. Feeding challenges and questionable feeding performance were prevalent among preterm infants at term-equivalent age and appeared in conjunction with suboptimal reflexes and hypotonia. Understanding this finding enables therapists to take a holistic approach to addressing feeding difficulties.
Preterm Infant Feeding with Bobbi Pineda, Carolyn Ibrahim, & Molly Grabill ⟩
This session of AJOT Authors & Issues features guests Dr. Bobbi Pineda, Carolyn Ibrahim, & Molly Grabill. In this session we discuss their article entitled "The Prevalence of Early Feeding Alterations in Preterm Infants and their Relationship to Early Neurobehavior" published in the American Journal of Occupational Therapy Volume 77, Issue 3.
AJOT Authors & Issues, in YouTube | June 17, 2023