NICU Therapy

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

Study design. Cohort study of US NICUs.

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

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

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

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

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

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

Design. Cohort study.

Setting. Level 4 NICU with 85 beds.

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

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

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

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