Efficacy of Therapist Supported Interventions from the Neonatal Intensive Care Unit to Home: A Meta-Review of Systematic Reviews

Implementation of Nasogastric Tube Feedings at Discharge in a Large Quaternary NICU: A Literature Review, Proposed Algorithm, and Our Center Experience

The aim of this study is to provide an extensive review of the published literature regarding the use of nasogastric (NG) feeds at discharge in the neonatal population as well as our experience with the implementation of an NG feeds at discharge program in our level IV neonatal intensive care unit.We reviewed and compared the use of NG tubes at discharge and gastrostomy tubes in the neonatal population. We provide an extensive review of previous publications regarding programs of NG feeds at discharge in neonates across the United States and Europe including preterm neonates, neonates with chronic lung disease, and neurological injury. We also reviewed parents' perspectives on NG use at discharge in the neonatal population as well as the use of telehealth in remote monitoring of neonates discharged on NG feeds. We reviewed the economic benefits of such programs. We finally provide our center's algorithm and workflow as well as our center's experience.Twenty-five patients have been discharged so far from this program since its implementation in December 2020. Only 1 patient of the 25 patients discharged on NG tube feeds required gastrostomy tube placement.Discharge with NG tube feeds in a carefully selected population is safe, and feasible and can lead to increased parent satisfaction, besides offering a developmental advantage for the neonates when the only remaining inpatient need is achieving full oral feeds. · Discharge with NG tube feeds in a carefully selected neonatal population is safe and feasible.. · Nasogastric feeds at discharge can lead to increased parent satisfaction and a developmental advantage for the neonates when the only remaining inpatient need is achieving full oral feeds.. · Carefully structured education at discharge, as well as follow-up programs in place can ensure adequate parental support during this process.. · Telehealth can play a key role in implementation of such programs..

Neonatal therapy principles during transition from neonatal intensive care unit to home: A modified Delphi study

AIM

To establish expert consensus on key principles for therapist-supported interventions supporting infants born preterm and their families during the transition from neonatal intensive care unit (NICU) to home in the USA.

METHOD

A diverse, interdisciplinary panel of experts evaluated the use of key intervention principles. A modified Delphi technique was used to seek opinions from independent and relevant interdisciplinary experts on the clarity of terminology, efficacy, and feasibility of implementing these intervention principles during the NICU-to-home transition.

RESULTS

After our team consensus, one round of surveys was required to reach expert consensus. Twenty-four experts, representing a variety of disciplines, responded to the survey. Results showed strong consensus on four key therapist-supported interventions: building caregiver-child relationships; optimizing infant development; education and knowledge sharing; and enriched environments.

INTERPRETATION

This research provides valuable insights into key therapist-supported interventions that may be used during the NICU-to-home transition to address the needs of high-risk infants and the well-being of their families. Findings will inform the development of streamlined and effective interventions, improving child and family outcomes during this critical transition period.

Project Initiate: A Clinical Feasibility Trial of Equitable Access to Early Neurodevelopmental Therapy

Background/Objectives: Despite evidence of the effectiveness of early intervention (EI) programs, eligible infants often experience delays in initiation of services or fail to receive services entirely. Disparities have been documented, including lower enrollment rates for infants with public insurance. The objective of this pilot study was to evaluate the feasibility of initiating home physical therapy (PT) services promptly after neonatal or cardiac intensive care unit (NICU/CICU) discharge for infants with public insurance and to assess early motor outcomes for children who received study therapy compared with a standard of care group. Methods: Infants were recruited if discharged from a study NICU/CICU, had public insurance, and were eligible for Illinois EI services. Infants living in Chicago (n = 46) received weekly home-based PT from a study therapist until 3-4 months corrected age (CA). Infants living outside Chicago received standard of care services and served as a control group (n = 14). At discharge, infants were referred to EI and underwent the Test of Infant Motor Performance (TIMP). Outcomes at 3-4 months CA included initiation rates for study PT and EI and follow-up TIMP testing. Results: By 3-4 months CA, 78% of the intervention group had received ≥1 PT session. In contrast, just 13% of the entire cohort had received any EI therapy. Infants who had 8-10 PT sessions in the first 3-4 months after discharge were more likely to have a change in the TIMP Z-score of >0.5 SD. Conclusions: Prompt transition to home therapy was feasible for infants with public insurance in an urban setting who may benefit most due to the potential for neuroplastic change. Addressing barriers identified in this study may assist in improving access to EI for young infants.

Identifying Facilitators and Barriers to Neonatal Intensive Care Unit Visitation in Mothers of Low Socioeconomic Status: A Qualitative Investigation

BACKGROUND/OBJECTIVES

The experience of parenting in a highly medicalized, unnatural environment can result in impaired mother-infant bonding, but increased maternal presence at the infant's bedside has been associated with improved infant and maternal outcomes. The primary objective of this study was to explore barriers and facilitators during the NICU Experience in regard to maternal presence in an NICU.

METHODS

We interviewed 12 mothers (7 Black, 5 white) of low socioeconomic status (SES) whose preterm infants (average birth gestational age of 27 weeks) were currently hospitalized in an NICU. We engaged the NICU Family Advisory Board in all steps of the research process.

RESULTS

Barriers and facilitators to maternal presence spanned all levels of the Socioecological Model; however, barriers were mostly at the societal, community, and institutional levels, while facilitators varied based on interpersonal and individual-level factors. Assets that mothers accessed to facilitate visits, such as free housing and shuttle services, were not available to all mothers based on individual circumstances (e.g., caregiving responsibilities). While a few mothers identified negative interactions with health care practitioners, these encounters were not attributed to racism or described as barriers to visitation.

CONCLUSIONS

Hospitals can support families with infants in an NICU by providing free or inexpensive short-term sibling support, alleviating the burden of parking costs, and communicating early and frequently about available institutional resources during the hospital stay.

Identifying barriers and facilitators to care for infants with bronchopulmonary dysplasia after NICU discharge: a prospective study of parents and clinical stakeholders

OBJECTIVE

Understand barriers and facilitators to follow-up care for infants with bronchopulmonary dysplasia (BPD).

METHODS

Qualitative study of parents and clinical stakeholders caring for infants with BPD. The interview guide was developed by a mother of a former 23-week preterm infant, neonatologist, pulmonologist, nurse, and qualitative researcher. Purposive sampling obtained a heterogenous sociodemographic and professional cohort. Subjects discussed their experience with BPD, barriers to care, caregiver quality of life and health education. Interviews were audio-recorded, transcribed and coded. Thematic analysis was used.

RESULTS

Eighteen parents and 20 stakeholders completed interviews. Family-level themes included pragmatic barriers like transportation being multi-faceted; and caregiving demands straining mental health. System-level themes included caregiver education needing to balance immediate caregiving activities with future health outcomes; and integrating primary care, specialty, and community supports.

CONCLUSIONS

Individual and system barriers impact follow-up for infants with BPD. This conceptual framework can be used to measure and improve care.

Randomized Controlled Trial Protocol on the Effects of a Sensory Motor Intervention Associated with Kangaroo Skin-to-Skin Contact in Preterm Newborns

There is still very limited evidence on the effects of neonatal interventions on infant neurodevelopmental outcomes, including general movements (GMs). This research will primarily assess the effects of a sensory motor physical therapy intervention combined with kangaroo skin-to-skin contact on the GMs of hospitalized preterm newborns. Secondary outcomes include body weight, posture and muscle tone, behavioral state, length of hospital stay, and breastfeeding. This study protocol details a two-arm parallel clinical trial methodology, involving participants with a postmenstrual age of 34-35 weeks admitted to a Neonatal Intermediate Care Unit (NInCU) with poor repertoire GMs. Thirty-four participants will be randomly assigned to either the experimental group, receiving a 10-day sensory motor physical therapy associated with kangaroo skin-to-skin contact, or the control group, which will only receive kangaroo skin-to-skin contact. The study will measure GMs (primary outcome), and body weight, posture and muscle tone, behavioral state, length of hospital stay, and breastfeeding (secondary outcomes). Data collection occurs in the NInCU before and after the intervention, with follow-up measurements post discharge at 2-4 weeks and 12-15 weeks post-term. SPSS will be used for data analyses. The results will provide novel information on how sensory motor experiences may affect early neurodevelopment and clinical variables in preterm newborns.

Optimizing trajectories of social adaptive competencies after extreme prematurity during the first 1000 days

Over 75% of surviving extremely preterm infants do not have major neurodevelopmental disabilities; however, more than half face difficulties with communication, coordination, attention, learning, social, and executive function abilities. These "minor" challenges can have a negative impact on educational and social outcomes, resulting in physical, behavioral, and social health problems in adulthood. We will review assessment tools for social-emotional and adaptive functional skills in early childhood as these determine family and early childhood supports. We highlight bronchopulmonary dysplasia as an example of the critical intersections of parental wellbeing, medical and developmental adaptive trajectories in infancy and early childhood, and partnerships between child neurologists and community medical and developmental professionals. We examine studies of engaging parents to promote developmental trajectories, with a focus on supporting parent-child interactions that underlie communication, social-adaptive behaviors, and learning in the first 1000 days of life. Recommendations for neurodevelopmental surveillance and screening of extremely preterm infants can also be applied to infants with other risk factors for altered neurodevelopment.

Spanish Translation and Cultural Adaptations of Physical Therapy Parent Educational Materials for Use in Neonatal Intensive Care

Background

A paucity of Spanish language, culturally relevant parent education materials in the healthcare setting results in suboptimal care for Latinx families and further perpetuates health disparities. The purpose of this article is to describe the process for Spanish translation and cultural adaptations to parent education materials of a parent-centered physical therapy program designed to support maternal mental health and infant development during Neonatal Intensive Care (NICU).

Methods

Two bilingual physical therapy (PT) students translated educational materials from English to Spanish and were proofread by a professional translator. Next, we conducted a materials review with 5 members of the Latine Community Review Board (CRB), a "standing" advisory group of natively Spanish-speaking, Latine North Carolinians who contract with research teams under the coordination of the Inclusive Science Program (ISP) of the North Carolina Translational and Clinical Sciences Institute (NC TraCS). Review session recruitment, facilitation, and data analysis were conducted by bilingual NC TraCS project managers and the primary investigator for the main feasibility study. Readability analyses were performed at the final stage of translation and adaptation.

Results

Themes from CRB review sessions for improvement included to 1) use parent-friendly language, 2) use the plural masculine form of gendered language for caregivers to include all gender identities in this neonatal context, 3) address challenges with direct translation, and 4) use written education materials to supplement in-person, hands-on training with parents and their infants. All translated materials received a grade level of 5 on the Crawford grade-level index.

Conclusion

Based on CRB feedback and readability analysis, the translation and cultural-adaptation process resulted in comprehensible written parent education materials for Spanish-speaking families. Review meetings with the CRB reinforced the need for Spanish materials in the healthcare setting. Further assessment of these materials with Spanish-speaking families in the NICU setting is needed.

Postural Control Measurements to Predict Future Motor Impairment in Preterm Infants: A Systematic Review

Preterm infants are more likely to demonstrate developmental delays than fullterm infants. Postural measurement tools may be effective in measuring the center of pressure (COP) and asymmetry, as well as predicting future motor impairment. The objective of this systematic review was to evaluate existing evidence regarding use of pressure mats or force plates for measuring COP and asymmetry in preterm infants, to determine how measures differ between preterm and fullterm infants and if these tools appropriately predict future motor impairment. The consulted databases included PubMed, Embase, Scopus, and CINAHL. The quality of the literature and the risk of bias were assessed utilizing the ROB2: revised Cochrane risk-of bias tool. Nine manuscripts met the criteria for review. The postural control tools included were FSA UltraThin seat mat, Conformat Pressure-Sensitive mat, Play and Neuro-Developmental Assessment, and standard force plates. Studies demonstrated that all tools were capable of COP assessment in preterm infants and support the association between the observation of reduced postural complexity prior to the observation of midline head control as an indicator of future motor delay. Postural measurement tools provide quick and objective measures of postural control and asymmetry. Based on the degree of impairment, these tools may provide an alternative to standardized assessments that may be taxing to the preterm infant, inaccessible to therapists, or not sensitive enough to capture motor delays.

A Feasibility Study of a Physical and Occupational Therapy-Led and Parent-Administered Program to Improve Parent Mental Health and Infant Development

AIMS

Extremely premature birth puts infants at high risk for developmental delay and results in parent anxiety and depression. The primary objective of this study was to characterize feasibility and acceptability of a therapist-led, parent-administered therapy and massage program designed to support parent mental health and infant development.

METHODS

A single cohort of 25 dyads - parents (24 mothers, 1 father) and extremely preterm (<28 wk gestation) infants - participated in the intervention. During hospitalization, parents attended weekly hands-on education sessions with a primary therapist. Parents received bi-weekly developmental support emails for 12 months post-discharge and were scheduled for 2 outpatient follow up visits. We collected measures of parent anxiety, depression, and competence at baseline, hospital discharge, and <4 and 12 months post-discharge.

RESULTS

All feasibility targets were met or exceeded at baseline and discharge (≥70%). Dyads participated in an average of 11 therapy sessions (range, 5-20) during hospitalization. Lower rates of data collection adherence were observed over successive follow ups (range, 40-76%). Parent-rated feasibility and acceptability scores were high at all time points.

CONCLUSIONS

Results support parent-rated feasibility and acceptability of the TEMPO intervention for extremely preterm infants and their parents in the Neonatal Intensive Care Unit.

Identifying Barriers and Facilitators to Care for Infants with Bronchopulmonary Dysplasia After NICU Discharge: A Prospective Study of Parents and Clinical Stakeholders

Objective

Understand barriers and facilitators to follow-up care for infants with bronchopulmonary dysplasia (BPD).

Methods

Qualitative study of parents and clinical stakeholders caring for infants with BPD. The interview guide was developed by a mother of a former 23-week preterm infant, neonatologist, pulmonologist, nurse, and qualitative researcher. Purposive sampling obtained a heterogenous sociodemographic and professional cohort. Subjects discussed their experience with BPD, barriers to care, caregiver quality of life and health education. Interviews were audio-recorded, transcribed and coded. Thematic analysis was used.

Results

Eighteen parents and 20 stakeholders completed interviews. Family-level themes included pragmatic barriers like transportation being multi-faceted; and caregiving demands straining mental health. System-level themes included caregiver education needing to balance process needs with future trajectories; and integration of primary care, specialty care, and community supports.

Conclusions

Individual and system barriers impact follow-up for infants with BPD. This conceptual framework can be used to measure and improve care.