Behavioral state organization of very low birth weight infants: Effects of developmental handling during caregiving

Human interaction in the NICU and its association with outcomes on the Brief Infant-Toddler Social and Emotional Assessment (BITSEA)

BACKGROUND

Extremely preterm infants represent one of the highest risk categories for impairments in social competence. Few studies have explored the impact of the neonatal intensive care unit (NICU) environment on social development. However, none have specifically analyzed the effects of the care structure the infant receives during hospitalization on later social competence indicators.

OBJECTIVE

To identify associations between the care structures received by extremely preterm infants in the NICU and scores on the Brief Infant-Toddler Social and Emotional Assessment (BITSEA) post-discharge.

PARTICIPANTS

50 extremely preterm infants (mean gestational age: 25 weeks during hospitalization; mean chronological age during follow-up assessment: 2 years, 4 months).

METHODS

A secondary analysis of BITSEA data was performed exploring its relation to care structure data we extracted from electronic medical records (i.e., how much time infants were engaged in human interaction during their first thirty days of hospitalization and what types of interaction they were exposed to).

RESULTS

Extremely preterm infants spend a considerable amount of time alone during hospitalization (80%) with nursing care comprising the majority of human interaction. Infants who experienced greater human interaction scored significantly higher on the Social Competence (p = 0.01) and lower on the Dysregulation (p = 0.03) BITSEA subscales.

CONCLUSION

Human interaction and isolation in the NICU is associated with social competence and dysregulation outcomes in extremely preterm infants. Further research is needed to understand how various NICU care structures including centralized nursing teams, parental skin-to-skin care, and early therapy may synergistically play a positive role in developing social competence.

An evidence-based guideline for introducing oral feeding to healthy preterm infants

The ability of a preterm infant to make the transition from gavage to oral nipple feeding depends on the infant's neurodevelopment in relation to behavioral organization, to a rhythmic suck-swallow-breathe pattern, and to cardiorespiratory regulation. Research-based knowledge about infant neurodevelopment in these three areas has led to the creation of a semidemand feeding method to aid in this transition. The method combines the use of nonnutritive sucking to promote awake behavior for feeding, use of behavioral assessment to identify readiness for feeding, and systematic observation of and response to infant behavior cues to regulate frequency, length, and volume of oral feedings. Semidemand feeding may be individualized for healthy preterm infants. This article discusses both the relevant knowledge about neurodevelopment and the semidemand feeding method itself.

Patterns of premature newborns' sleep-wake states before and after nursing interventions on the night shift

OBJECTIVE

To examine patterns of behavioral states of premature newborns before and after nursing interventions.

DESIGN

Secondary analysis of videotaped data, using a repeated measures design.

SETTING

1 8-bed neonatal intensive- and intermediate-care unit in a 400-bed suburban teaching hospital.

PARTICIPANTS

Forty medically stable premature newborns with an average postconceptional age of 32.79 weeks at the time of testing.

MAIN OUTCOME MEASURE

Behavioral states measured by observations of videotape recordings.

RESULTS

Five-hour observations of behavioral states revealed that newborns showed more quiet sleep, F (2, 38) = 5.65, p = .023, and fewer waking episodes, F (2, 38) = 14.4, p = .001, in the 30 minutes after nursing interventions than in the 30 minutes before. This repeated measures ANOVA analysis accounted for effects of caffeine or theophylline. Neither the frequency nor the duration of nursing interventions predicted duration or frequency of behavioral states before or after interventions. Some newborns experience waking outside the context of nursing interventions.

CONCLUSIONS

For medically stable newborns, nursing interventions are generally followed by sleep, possibly indicating satiety after feeding or significant energy expenditure. The findings also may suggest that some newborns show anticipation of feeding by waking, although 50% of the newborns did not experience any waking prior to interventions. Further research is needed to examine associations between specific types of nursing interventions and newborn behavioral responses, as well as the relationship of behavioral state patterns and newborn development.

A feeding protocol for healthy preterm infants that shortens time to oral feeding

OBJECTIVE

To test the hypothesis that healthy preterm infants randomly assigned to a semi-demand feeding protocol would require fewer days to attain oral feeding and have a satisfactory weight gain compared with control infants receiving standard care.

STUDY DESIGN

In 2 neonatal intensive care nurseries, 81 infants 32 to < or = 34 weeks' postconceptional age were randomly assigned to the control (n = 41) or experimental (n = 40) protocol for transition from gavage to oral feedings. The control protocol followed the standard practice of gradually increasing scheduled oral feedings, whereas the experimental protocol used a semi-demand feeding method contingent on infant behavior. Analysis of variance techniques were used to compare the study groups for number of days to attain oral feeding and weight gain.

RESULTS

The semi-demand method shortened the time for infants to achieve oral feeding by 5 days (P < .001). There were no differences in weight gain between the study groups, and both groups had satisfactory weight gain.

CONCLUSION

The semi-demand method for the transition from gavage to oral feeding in healthy, preterm infants 32 to < or = 34 weeks postconceptional age promotes faster attainment of oral feeding and does not compromise their weight gain.

Contextual dynamics of ethical decision making in the NICU

The manner in which the contextual dynamics of the neonatal intensive care unit (NICU) culture influence decisions around withholding and withdrawing treatment for very low birth weight infants is examined based on sociological studies of the NICU culture. The influence of these dynamics on nurse and parent participation in treatment decisions is discussed. Steps toward increasing nurses' role in decision making and ability to empower the participation of parents include (a) using an understanding of the dynamics of the individual NICU to establish a collaborative team culture, and (b) demonstrating that data obtained through relationship with the infant make an important and valid contribution to ethical decision making.

Nurses' experiences working with families in an NICU during implementation of family-focused developmental care

PURPOSE

To explore and describe nurses' experiences while working with parents and infants receiving family-focused developmental care (FFDC), to gain insight into the process of changing from a traditional model of care to FFDC.

DESIGN

The qualitative design was based on Spradley's method.

SAMPLE

Data were collected by interviewing ten nurses who worked in an NICU during a pilot study of FFDC. Transcripts were analyzed using Spradley's domain analysis.

FINDINGS

Four themes describe aspects of the transition from traditional care to FFDC: (1) negative experiences of FFDC, (2) transitions central to partnering with parents, (3) positive experiences of parental participation, and (4) organizational transitions necessary for the move to a family-centered model of care.

CONCLUSION

Learning to share responsibility with families will require change in the NICU culture as well as in nurses' role identity.

Preterm infant behavioral and heart rate responses to antenatal phenobarbital

The effects of antenatal phenobarbital on behavioral state and heart rate (HR) were examined in a randomized sample of 49 preterm infants > 24 and < 34 weeks postconceptional age. Behavioral state and HR observations were made during a routine care giving procedure on Days 1, 2, and 3 of life. There were no differences in behavioral state and HR responses between control and experimental subjects, suggesting that antenatal phenobarbital did not have a sedative effect on experimental subjects. Infants in both study groups responded to caregiving with changes to fussy/cry behavior and increases in HR. Older infants and nonventilated infants were more often in fussy/cry states during care giving than younger infants and ventilated infants. The HR increases were not clinically important, but the behavioral changes were, suggesting that behavioral response may be a more sensitive sign of distress than HR in very young preterm infants.