The Neonatal Behavioral Assessment Scale (NBAS) and Newborn Behavioral Observations (NBO) system for supporting caregivers and improving outcomes in caregivers and their infants

The value of Pediatric Early Warning Score combined with SBAR in neonatal pneumonia nursing: A retrospective cohort study

To observe the effect of the Pediatric Early Warning System (PEWS) score combined with the situation-background-assessment-recommendation (SBAR) shift communication system in neonates with severe pneumonia in the pediatric intensive care unit. A total of 230 neonates admitted to the pediatric intensive care unit of our hospital from January 2018 to January 2021 were enrolled in this study. Participants were divided into an experimental group (110 patients, PEWS score combined with SBAR shift communication system) and a control group (120 patients, routine diagnosis and treatment and shift change). The early recognition rate, incidence of handover problems, and prognosis of critically ill children in the 2 groups were analyzed. Compared to the control group, the correct recognition rate of disease observation and early recognition rate of critically ill children in the experimental group were significantly higher, and the incidence of handover problems was significantly lower (P < .05). There was no significant difference in the incidence of asphyxia, heart failure, and toxic encephalopathy between both groups. The application of the PEWS score combined with the SBAR shift communication system can facilitate timely identification of deterioration of the condition of children with severe pneumonia, reduce handover problems, and help to implement interventions or rescue according to the changes in a patient's condition, which may be beneficial in improving the patient's prognosis.

Bedside tracking of functional autonomic age in preterm infants

BACKGROUND

Preterm birth predisposes infants to adverse outcomes that, without early intervention, impacts their long-term health. To assist bedside monitoring, we developed a tool to track the autonomic maturation of the preterm by assessing heart rate variability (HRV) changes during intensive care.

METHODS

Electrocardiogram (ECG) recordings were longitudinally recorded in 67 infants (26-38 weeks postmenstrual age (PMA)). Supervised machine learning was used to generate a functional autonomic age (FAA), by combining 50 computed HRV features from successive 5-minute ECG epochs (median of 23 epochs per infant). Performance of the FAA was assessed by correlation to PMA, clinical outcomes and the infant's functional brain age (FBA), an index of maturation derived from the electroencephalogram.

RESULTS

The FAA was strongly correlated to PMA (r = 0.86, 95% CI: 0.83-0.93) with a mean absolute error (MAE) of 1.66 weeks and also accurately estimated FBA (MAE = 1.58 weeks, n = 54 infants). The relationship between PMA and FAA was not confounded by neurodevelopmental outcome (p = 0.18, n = 45), sex (p = 0.88, n = 56), patent ductus arteriosus (p = 0.08, n = 56), IVH (p = 0.63, n = 56) or body weight at birth (p = 0.95, n = 56).

CONCLUSIONS

The FAA, an index derived from the ubiquitous ECG signal, offers direct avenues towards estimating autonomic maturation at the bedside during intensive care monitoring.

IMPACT

The development of a tool to track functional autonomic age in preterm infants based on heart rate variability features in the electrocardiogram provides a rapid and specialized view of autonomic maturation at the bedside. Functional autonomic age is linked closely to postmenstrual age and central nervous system function response, as determined by its relationship to functional brain age from the electroencephalogram. Tracking functional autonomic age during neonatal intensive care unit monitoring offers a unique insight into cardiovascular health in infants born extremely preterm and their maturational trajectories to term age.

Parent-infant interaction in the NICU: Challenges in measurement

BACKGROUND

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

AIM

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

METHOD

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

RESULTS

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

CONCLUSION

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

Conceptual Framework Behind the Development of a Level of Confidence Tool: The Pediatric Videofluoroscopic Swallow Study Value Scale

PURPOSE

The videofluoroscopic swallow study (VFSS) is the most commonly used instrumental procedure for evaluating swallowing in pediatric populations suspected of having dysphagia. Assessment and interpretation of a VFSS in pediatric populations is frequently challenged by testing-specific factors that can raise concerns regarding the representativeness of swallow events observed during testing compared to daily feeding/swallowing physiology. When VFSS findings do not represent typical swallowing patterns, treatment recommendations can result in suboptimal outcomes. To address this current challenge to pediatric VFSS interpretation and associated treatment recommendations, the pediatric VFSS Value Scale (pVFSS Value Scale) was developed within a tertiary regional pediatric medical center. This clinical focus article summarizes the initial scale development phases and resulting conceptual framework for rating clinical testing factors that influence a clinician's level of confidence regarding pediatric VFSS findings. Future goals for scientific evaluation and clinical utilization of this new rating scale are also reported.

CONCLUSIONS

The pVFSS Value Scale was developed to assist clinicians with interpretation of pediatric VFSS assessment outcomes and to efficiently communicate factors influencing impressions and treatment recommendations with team members and caregivers. This clinical concept article summarizes potential uses of this tool to inform treatment planning as well as future clinical research to evaluate its psychometrics and clinical utility.

The immediate and long-term effects of prenatal opioid exposure

The opioid epidemic has adversely affected neonates and children, yet the mechanisms by which it impacts this population are not well understood. Not only does prenatal opioid exposure result in short-term consequences shortly after birth, it also creates long-term sequelae that may predispose these children to physical, emotional, psychiatric, cognitive, and socioeconomic problems in the future. This article provides a scoping overview of the long-term effects of antenatal opioid exposure on neonates and children as well as quality improvement and research efforts to understand and mitigate this major public health concern.

Supporting Premature Infants’ Oral Feeding in the NICU—A Qualitative Study of Nurses’ Perspectives

One major task in the neonatal intensive care unit (NICU) involves ensuring adequate nutrition and supporting the provision of human milk. The aim of this study was to explore nurses’ experiences of the oral feeding process in the NICU when the infant is born extremely or very preterm. We used a qualitative inductive approach. Nine nurses from three family-centered NICUs were interviewed face-to-face. The interviews were transcribed verbatim and analyzed using content analysis. Five sub-categories and two generic categories formed the main category: ‘A complex and long-lasting collaboration.’ The nurses wished to contribute to the parents’ understanding of the feeding process and their own role as parents in this process. The nurses’ intention was to guide and support parents to be autonomous in this process. They saw the family as a team in which the preterm infant was the leader whose needs and development directed the feeding and the parents’ actions in this process. Written and verbal communication, seeing all family members as important members of a team and early identification of the most vulnerable families to direct the emotional and practical feeding support accordingly can strengthen the feeding process in the NICU.

Application of the Neonatal Behavioral Assessment Scale to Evaluate the Neurobehavior of Preterm Neonates

Background: The neonatal behavioral assessment scale (NBAS) was primarily developed to aid in the assessment of full-term neonates. The aim of this study was to detect if the NBAS was also valuable in the assessment of preterm neonates. Materials and Methods: We assessed 112 infants at a neonatal unit using the NBAS, 4th edition. The inclusion criteria included an oxygen saturation level between 88–95% and a heartrate of 100–205 beats per minute. Infant neurobehavior was assessed using the NBAS. Results: For full-term and preterm neonates, we observed that the NBAS enabled us to assess both groups of infants and gave relevant information pertaining to them. We found a significant correlation between the average week of gestation and response to touch, sensory input, peak of excitement, cost of attention, hand-to-mouth, and quality of alertness. Conclusions: The NBAS is a valuable scale for evaluating the neurobehavior of preterm neonates. The week of gestation at birth affects certain aspects of neurobehavior, such as response to sensory input, putting hand to mouth, peak of excitement, and cost of attention. The NBAS as an individually structured assessment may help in planning for early rehabilitation and intervention for this vulnerable population.

An Early Collaborative Intervention Focusing on Parent-Infant Interaction in the Neonatal Period. A Descriptive Study of the Developmental Framework

Moderate to late preterm infants are at risk of developing problems later in life. To support attachment and infants’ development, high quality parent-infant interaction is important. Parent-infant interaction is known to improve through intervention programs but since no such intervention program is addressed directly to moderate to late preterm infants, a tailor-made intervention was developed. The aim was to describe the rationale, development, framework and practical provision of a new early collaborative intervention program. This study has a descriptive design and the intervention is described using the Template for Intervention Description and Replication. During an intervention-session, the preterm infant’s cues are made visible to the parents as they perform an everyday care-taking procedure. Instant feedback is delivered to give the parents the opportunity to notice, interpret and respond to cues immediately. The infant’s response to the parent’s action is discussed in a dialogue to instantly guide parents´ awareness of the preterm infant’s subtle cues. This study describes a new early collaborative intervention, developed to support interaction between parents and their moderate to late preterm infants starting in the neonatal intensive care unit. Clinical studies evaluating parental experiences as well as the effects of the early intervention are ongoing, ClinicalTrials.gov NCT02034617.

Relationship between thoracoabdominal mobility and hours of life in infants: A cross-sectional study

Assessing the relationship between thoracoabdominal mobility (TAM) in newborns (NBs) is relevant for a greater understanding of pulmonary kinematics. This study aimed to assess the association between TAM, hours of life and respiratory rate (RR) in term NBs. Healthy NBs were included in the sample. They were filmed for 2 min, with markers in the lateral region of the trunk, delimiting the thoracic and abdominal areas. TAM and RR were assessed using a MATLAB® routine. For kinematic analysis, an algorithm created graphs presenting thoracoabdominal mobility. A total of 26 NBs were evaluated. TAM was the only variable that exhibited a statistically significant intergroup difference, showing that the fewer the hours of life, the greater the mobility. Simple linear regression analysis showed that RR can explain 31% of the variation in abdominal mobility (p = 0.002). Thus, the fewer the hours of life, the greater the TAM of NBs, with a predominance of abdominal compartment mobility.

What are the effects of supporting early parenting by newborn behavioral observations (NBO)? A cluster randomised trial

BACKGROUND

Professional support to enhance the early parent-infant relationship in the first months after birth is recommended, but little is known about the effect of universal interventions. The objective was to investigate the effect of health visitors' use of the Newborn Behavioral Observations system in new families.

METHODS

A cluster-randomised study was conducted in four Danish municipalities. Health visitors' geographical districts constituted the units for randomisation (n = 17). In the intervention group, 1332 families received NBO from 3 weeks after birth; in the comparison group, 1234 received usual care. Self-administered questionnaires were collected at baseline one to two weeks after birth, and at follow-up three and nine months postpartum. The outcomes were change over time measured by The Karitane Parenting Confidence Scale (KPCS), The Major Depression Inventory (MDI), The Ages and Stages Questionnaire: social-emotional (ASQ:SE) and The Mother and Baby Interaction Scale (MABIC). Data were analysed with mixed-effects linear regression using the intention-to-treat approach.

RESULTS

At baseline, no significant differences between the two groups were seen regarding maternal and infant factors. At follow-up three and nine months after birth, the change in maternal confidence and mood, infant's socio-emotional behaviour, and early parent-infant relationship moved in a slightly more positive direction in the intervention group than in the comparison group, though not statistically significant. The only significant effect was that the intervention mothers reported higher level of knowledge about infant's communication skills, response to cues, and how to sooth and establish a relation with the infant, compared to the comparison group.

CONCLUSIONS

We found no effect of the NBO system delivered in a universal context to all families in a community setting. The only significant difference between groups was a higher maternal degree of knowledge regarding early parenting in the intervention group.

TRIAL REGISTRATION

ClinicalTrials.gov ID: NCT03070652 . Registrated February 22, 2017.

Effect of early childhood development interventions implemented by primary care providers commencing in the neonatal period to improve cognitive outcomes in children aged 0-23 months: protocol for a systematic review and meta-analysis

BACKGROUND

Impacts of early childhood development (ECD) interventions (such as fostering attachment and responsiveness through communication, play and stimulation) are well known. Globally, there is increasing recognition of the importance of the 'golden' minutes, hours and days after birth for infant health and development. However, only one systematic review has examined ECD interventions implemented in the neonatal period (0-27 days), and this review only assessed interventions implemented by specialised providers. Primary care providers have many potential contacts with mothers and infants throughout the neonatal period. However, it is unclear how many research studies or programmes have examined the effectiveness of ECD interventions commencing in the neonatal period and which methods were used. To date, there has been no systematic review of the effect of ECD interventions delivered by primary care providers commencing in the neonatal period.

METHODS

Our overall aim is to conduct a systematic review of the effect of ECD interventions implemented by primary care providers in the neonatal period. We will assess effects by timing and number ('dose') of contacts with primary care providers. Subgroup assessment will include effects in disadvantaged infants such as those born with low birth weight and to mothers with mental health disorders. We will also assess effects in low- and high-income countries and by type of care provider. The primary outcome is cognitive status in children aged 0-23 months as measured using standardised scales. Secondary outcomes include other child neurodevelopment domains (speech, language, fine motor, gross motor, social, emotional, behaviour, executive functioning, adaptive functioning) in children aged 0-23 months. Effects on maternal mental health will also be assessed between 0-23 months postpartum. Databases such as MEDLINE (OVID), PsycINFO (OVID), EMBASE (OVID), CINAHL, Cochrane Library, WHO databases and reference lists of papers will be searched for relevant articles. Only randomised controlled trials will be included. A narrative synthesis for all outcomes will be reported. Meta-analyses will be performed where exposures and outcomes are sufficiently homogeneous. Guidelines for PRISMA-P (Preferred Reporting Items for Systematic Reviews and Meta-Analyses Protocols) will be followed.

DISCUSSION

This review appears to be the first to be conducted in this area. The findings will be an important resource for policymakers, primary care providers and researchers who work with young infants in primary care settings.

SYSTEMATIC REVIEW REGISTRATION

PROSPERO CRD42019122021.

Swallowing behaviours and feeding environment in relation to communication development from early infancy to 6 years of age: a scoping review protocol

INTRODUCTION

Understanding the influences of early swallowing function and feeding environment on the development of communication will enhance prevention and intervention initiatives for young children. This scoping review will help elucidate key elements affecting the developmental trajectory of communicative systems, typically robust and well-developed by formal school entry. We aim to (1) map the current state of the literature in a growing field of interest that has the potential to advance knowledge translation, (2) identify existing gaps and (3) provide research direction for future investigations surrounding feeding-swallowing functions and environment that support or forestall communication development in young children.

METHODS AND ANALYSIS

We are proposing a scoping review to identify the breadth and depth of the existing literature regarding swallowing-feeding functions and environment relative to the onset and progression of communicative behaviours from infancy to 6 (<6;0) years of age. Our protocol delineates rigorous methods according to Arskey and O'Malley's framework and includes elaborations by Levac and colleagues. We will search the literature based on 10 databases, 17 peer-reviewed journals, 4 conference proceedings and 6 grey literature sources. Two authors will independently screen abstracts and review full articles, remaining blind to each other's results. A third author will contribute to resolving any discrepant results from both the abstract and article review. Subsequently, we will extract data and chart information from accepted articles using a pre-established data collection form. We will stratify results according to healthy versus impaired swallowing-feeding functions and communication development.

ETHICS AND DISSEMINATION

Our scoping review does not require ethical approval. We will disseminate our final study results through international and national conference presentations, publication in a peer-reviewed journal and knowledge translation activities with stakeholders.

What are the effects of supporting early parenting by enhancing parents' understanding of the infant? Study protocol for a cluster-randomized community-based trial of the Newborn Behavioral Observation (NBO) method

Background

Support to strengthen the early parent-infant relationship is recommended to ensure the infant’s future health and development. Little is known about the universal approaches taken by health visitor to support this early relationship. The aim of this study is to investigate the effects of health visitors’ use of the Newborn Behavioral Observation (NBO) method among new parents.

Methods

This is a cluster-randomised community-based study implemented in four Danish municipalities. Health visitors will conduct the trial, and the geographical districts they work in will constitute the clusters as units of randomisation. The participants will be approximately 2800 new families, randomised into an intervention or a comparison group according to their health visitor. The families are recruited at the first postpartum home visit. Parents in both groups receive care as usual: parents in the intervention group also receive the standardised NBO method in home visits performed from 3 weeks to 3 months postpartum. Data consist of self-reported parent questionnaires and video recordings of a selected group of vulnerable first-time mothers recorded 4 months postpartum. The self-reported data are obtained: at baseline 1 week postpartum and then at follow-up 3, 9 and 18 months postpartum. Data will be analysed using the intention-to-treat method and the analyses will include comparison of change in the primary variables across time supplemented by multiple regression analysis. The primary study outcomes are measured by the following factors: parental confidence, infants’ socio-emotional development and mother-infant relationship. Other measures include parental mood and stress, breastfeeding duration and utility of the health visitor services. Data collection among the health visitors in both groups will serve to monitor any change in practice regarding the work with early parent-infant interactions.

Discussion

This protocol describes an evaluation of the NBO method used universally in health visiting practice. The intervention seeks to support early parenting by increasing parents’ understanding of their infants’ cues. The NBO is currently implemented in Denmark even though an evaluation of the NBO has yet to be made in a community setting in Denmark and internationally. The study may contribute to building an increasingly evidence-based practice for health visitors.

Trial registration

ClinicalTrials.gov ID: NCT03070652. Registered February 22, 2017.

The Neonatal Behavioral Assessment Scale (NBAS) and Newborn Behavioral Observations (NBO) system for supporting caregivers and improving outcomes in caregivers and their infants

BACKGROUND

The first three years of a child's life are a key period of physical, physiological, cognitive and social development, and the caregiver-infant relationship in early infancy plays an important role in influencing these aspects of development. Specifically, caregiver attunement facilitates the move from coregulation to self-regulation; a parent's ability to understand their infant's behaviour as communication is a key part of this process. Early, brief interventions such as the Neonatal Behavioral Assessment Scale (NBAS) or Neonatal Behavioral Observation (NBO) system are potential methods of improving outcomes for both infant and caregiver.

OBJECTIVES

To assess the effects of the NBAS and NBO system for improving caregiver-infant interaction and related outcomes in caregivers and newborn babies. Secondary objectives were to determine whether the NBAS and NBO are more effective for particular groups of infants or parents, and to identify the factors associated with increased effectiveness (e.g. timing, duration, etc.).

SEARCH METHODS

In September 2017 we searched CENTRAL, MEDLINE, Embase, PsycINFO, 12 other databases and four trials registers. We also handsearched reference lists of included studies and relevant systematic reviews, and we contacted the Brazelton Institute and searched its websites to identify any ongoing and unpublished studies.

SELECTION CRITERIA

We included randomised controlled trials (RCTs) and quasi-RCTs that had used at least one standardised measure to assess the effects of the NBAS or NBO versus inactive control for improving outcomes for caregivers and their infants.

DATA COLLECTION AND ANALYSIS

Two reviewer authors independently assessed the records retrieved from the search. One reviewer extracted data, and a second checked them for accuracy. We presented the results for each outcome in each study as standardised mean differences (SMDs) or as risk ratios (RR) with 95% confidence intervals (CIs). When appropriate, we combined the results in a meta-analysis using standard methodological procedures expected by Cochrane. We used the GRADE approach to assess the overall quality of the body of evidence for each outcome.

MAIN RESULTS

We identified and included 16 RCTs in this review: 13 assessing the NBAS and 3 the NBO for improving outcomes in 851 randomised participants, including parents and their premature or newborn (aged 4 to 12 weeks) infants. All studies took place in the USA, and we judged all of them to be at high risk of bias.Seven studies involving 304 participants contributed data to one meta-analysis of the impact of the NBAS or NBO for caregiver-infant interaction, and the results suggest a significant, medium-sized difference between intervention and control groups (SMD -0.53, 95% CI -0.90 to -0.17; very low-quality evidence), with moderate heterogeneity (I² = 51%). Subgroup analysis comparing the two types of programmes (i.e. NBAS and NBO) found a medium but non-significant effect for the NBAS (-0.49, 95% CI -0.99 to 0.00, 5 studies), with high levels of heterogeneity (I² = 61%), compared with a significant, large effect size for the NBO (-0.69, 95% CI -1.18 to -0.20, 2 studies), with no heterogeneity (I² = 0.0%). A test for subgroup differences between the two models, however, was not significant. One study found a significant impact on the secondary outcome of caregiver knowledge (SMD -1.30, 95% CI -2.16 to -0.44; very low-quality evidence). There was no evidence of an impact on maternal depression. We did not identify any adverse effects.

AUTHORS' CONCLUSIONS

There is currently only very low-quality evidence for the effectiveness of the NBAS and NBO in terms of improving parent-infant interaction for mostly low-risk, first-time caregivers and their infants. Further research is underway regarding the effectiveness of the NBO and is necessary to corroborate these results.

Assessment: The Newborn

Neonatal neurobehavioral assessment has become a standardized component of clinical care provided to newborn infants, guiding neonatal clinical care and subsequent access to early interventions and services. Links between neonatal assessment and neurosensory and motor impairments in high-risk infants have been relatively well established. In contrast, the extent to which newborn neurobehavioral assessment might also facilitate the early identification of infants susceptible to socioemotional impairments in early childhood is less well documented. This review examines longitudinal links between the neonatal neurobehavioral assessment, temperament, and socioemotional outcomes in early childhood.