The Growth and Development Unit. A proposed approach for enhancing infant neurodevelopment and family-centered care in the Neonatal Intensive Care Unit

The Science of Neurohabilitation and Neurodevelopmental Care for Infants with High Risk Neonatal Illnesses

Infants born preterm and infants born at term with neurological injury continue to be identified as "high-risk" for adverse neurodevelopmental outcomes. To mitigate neurodevelopmental risk, these infants may receive a wide range of habilitative and early intervention strategies ranging from minimal support to intensive therapies in the neonatal intensive care unit and early childhood. There is a growing body of science regarding the opportunity for targeted individualized strategies, related to the nature and timing of injury, to improve neurodevelopmental outcomes in high-risk infant populations. This report aims to briefly review the current state of understanding of neurobiological injury in high-risk infant populations, discuss strategies for early detection along with critical periods for intervention, and offer suggestions for development of tailored neurodevelopmental or neurohabilitative care approaches to optimize outcomes in hospitalized infants.

Needs of Parents and Neonates in the Intensive Care Unit: A Literature Review

The admission of a neonate to the neonatal intensive care unit (NICU) presents unique and complex needs for both the infant and their parents. This literature review aims to synthesize existing research to comprehensively understand these needs, focusing on parental psychosocial well-being, practical requirements, and the neonate's developmental necessities. Understanding these needs is crucial for optimizing clinical outcomes and fostering healthy parent-infant relationships. A nonsystematic literature review was conducted using PubMed, Google Scholar, and PsycINFO databases. Search criteria focused on "neonatal intensive care" and "parental needs." Articles published in English between 2011 and 2022 were included. The review analyzed 123 articles, primarily focusing on research conducted in Western countries. Parental needs were categorized into seven areas: mental health/psychosocial well-being, practical needs (physical, safety, monetary), parental involvement, relationships (infant, staff, peers), information, spiritual needs, and help with other responsibilities. Neonatal needs included parental involvement, skin-to-skin contact, breastfeeding, and reduced length of stay. Key findings highlighted the prevalence of parental anxiety and depression, the importance of practical support, and the critical role of parental involvement in both parent and infant well-being. This review underscores the interconnectedness of parental and neonatal needs within the NICU environment. Parental involvement is essential for both groups, and factors such as hospital policies, community resources, and socioeconomic status significantly influence fulfilling these needs. The limitation of the review indicates the need for more diverse global research. Future studies should address these limitations and explore effective interventions to meet the identified needs, improving outcomes for NICU families. · The review identifies seven key parental needs in the NICU and four neonatal needs.. · It is important to provide support for the well-being of both parents and infants.. · Hospital policies, community resources, and socioeconomic status impact the ability to meet these..

Brain care bundles applied over each and successive generations

Worldwide polycrises continue to challenge the World Health Organization's proposed 2030 sustainable development goals. Continuity of brain care bundles helps attain these goals by sustaining brain health over successive generations. Factors representing social drivers of health must incorporate transdisciplinary care into equitable intervention choices. Drivers are more effectively addressed by combining maternal and pediatric assessments to address morbidity and mortality across each lifespan. Care bundles comprise at least three evidenced-based interventions collectively implemented during a clinical experience to achieve a desired outcome. Synergy among stakeholders prioritize communication, responsibility, compliance and trust when choosing bundles in response to changing clinical conditions. A prenatal transdisciplinary model continues after birth with infant and family-centered developmental care practices through discharge to supplement essential skin-to-skin contact. Fetal-neonatal neurology training encourages participation in this model of brain health care to more effectively choose neurodiagnostic and neuroprotective options. Shared clinical decisions evaluate interventions from conception through the first 1000 days. At least eighty percent of brain connectivity will have been completed during this first critical/sensitive period of neuroplasticity. The developmental origins of health and disease concept offers neurology subspecialists a life-course perspective when choosing brain health strategies. Toxic stressor interplay from reproductive and pregnancy diseases and adversities potentially impairs embryonic, fetal and neonatal brain development. Continued exposures throughout maturation and aging worsen outcome risks, particularly during adolescence and reproductive senescence. Intragenerational and transgenerational use of care bundles will guide neuromonitoring and neuroprotection choices that strengthen preventive neurology strategies.

Music Therapy in the Neonatal Intensive Care Unit: A Center's Experience with Program Development, Implementation, and Preliminary Outcomes

BACKGROUND

The role of music in the NICU continues to evolve, with recent studies documenting the positive impact of music therapy for hospitalized infants and families. With many potential benefits and no substantial adverse effects reported to date in medically stable infants, we aimed to create a clinical guideline to integrate this therapy into the NICU operations.

METHODS

we launched and implemented a pilot music therapy clinical program within a subunit of a level-III NICU, building upon available evidence.

RESULTS

In this report, we describe our experience with initial program development and early outcomes in terms of population served, frequency of music therapy, and therapeutic modalities employed to implement service delivery.

CONCLUSION

we highlight the importance of establishing practices that are aligned with currently available data and recommendations, in order to facilitate delivery of a safe, evidence-based, meaningful therapeutic experience with monitoring of preliminary effects of the therapy on all those involved in the experience.

Neuroprotective therapies in the NICU in preterm infants: present and future (Neonatal Neurocritical Care Series)

The survival of preterm infants has steadily improved thanks to advances in perinatal and neonatal intensive clinical care. The focus is now on finding ways to improve morbidities, especially neurological outcomes. Although antenatal steroids and magnesium for preterm infants have become routine therapies, studies have mainly demonstrated short-term benefits for antenatal steroid therapy but limited evidence for impact on long-term neurodevelopmental outcomes. Further advances in neuroprotective and neurorestorative therapies, improved neuromonitoring modalities to optimize recruitment in trials, and improved biomarkers to assess the response to treatment are essential. Among the most promising agents, multipotential stem cells, immunomodulation, and anti-inflammatory therapies can improve neural outcomes in preclinical studies and are the subject of considerable ongoing research. In the meantime, bundles of care protecting and nurturing the brain in the neonatal intensive care unit and beyond should be widely implemented in an effort to limit injury and promote neuroplasticity. IMPACT: With improved survival of preterm infants due to improved antenatal and neonatal care, our focus must now be to improve long-term neurological and neurodevelopmental outcomes. This review details the multifactorial pathogenesis of preterm brain injury and neuroprotective strategies in use at present, including antenatal care, seizure management and non-pharmacological NICU care. We discuss treatment strategies that are being evaluated as potential interventions to improve the neurodevelopmental outcomes of infants born prematurely.

'Baby Liberation' - Developing and implementing an individualised, developmentally-supportive care bundle to critically unwell infants in an Australian Paediatric Intensive Care Unit

BACKGROUND

Infants requiring high acuity care within a Paediatric Intensive Care Unit are at multifactorial risk of neurological injury to the immature brain, resulting in long-term developmental difficulties. In 2020, Queensland Children's Hospital implemented an individualised family-centred developmental care program, 'Baby Liberation', to address an identified service gap for critically unwell infants, aimed at optimising early neuroprotective strategies and minimising risk of suboptimal developmental outcomes.

AIM

To implement Baby Liberation for infants admitted to a quaternary paediatric intensive care referral centre. Secondary aims were to describe environmental changes, enablers and limitations related to implementation.

STUDY DESIGN

A single-centre, prospective implementation pilot study investigated the feasibility of implementing Baby Liberation. Subjects included infants less than six months of age admitted to Queensland Children's Hospital Paediatric Intensive Care Unit.

OUTCOME MEASURES

Primary measures comprised data collected during the implementation period, including number of eligible patients and number of developmental care plans provided. Environmental audit data were collected pre and post implementation to inform secondary outcomes.

RESULTS

Baby Liberation was feasibly implemented into the Queensland Children's Hospital Paediatric Intensive Care Unit. During implementation, 181 individualised care plans were provided to 313 eligible infants (57.8 %). Environmental audits showed improvements in all areas of developmental care, with greatest improvements noted in pain and stress management (+95 %) and staff support and development (+83.3 %).

CONCLUSION

Implementation of Baby Liberation was feasible within a large quaternary paediatric intensive care unit and has potential to be expanded into other clinical areas providing acute infant care.

A unit's experience with hybrid NICU design: description of care model and implications for patients, families, and professionals

As the first extra-uterine setting for hospitalized infants, the neonatal intensive care unit (NICU) environment can make a lasting impact on their long-term neurodevelopment. This impact is likely mediated through both specific characteristics of the physical design of the care environment, as well as the experiences that occur within this environment. Recent studies document many established benefits of single-family rooms (SFRs). However, there is concern that infants who spend a prolonged time in SFRs without their parents being intimately involved in their care have reduced opportunities for meaningful experiences, with possible adverse consequences. The purpose of this report is to share an example of an application of the family-centered developmental care model through a hybrid NICU design, inclusive of both SFRs and semi-private bays. In this paper, we empirically describe the physical and operational considerations of a hybrid model, outline the strengths and challenges of this approach, and discuss implications for patients, families, and professionals.

Parental Perceptions of the Impact of NICU Visitation Policies and Restrictions Due to the COVID-19 Pandemic: A Qualitative Study

BACKGROUND

The COVID-19 pandemic has impacted parents' ability to participate in their infants' care during the neonatal intensive care unit (NICU) stay in unprecedented ways.

PURPOSE

The purpose of this study was to explore the lived experience of parents whose infants was in the NICU during the COVID-19 pandemic.

METHODS

A qualitative telephone interview survey was conducted. Participants included parents of preterm infants who were born less than 34 weeks' gestation during the first wave of the COVID-19 pandemic (March 2020-August 2020). Telephone surveys were conducted through open-ended questions. A thematic content analysis identifying themes was performed after interviews were completed and transcribed.

RESULTS

A total of 8 mothers completed the telephone survey. Key themes from this study include parents experiencing increased stress due to the restricted visitation policies, limited opportunities to care for their infant, lack of support, and inconsistent communication regarding their infant status and COVID-19 protocols.

IMPLICATIONS FOR PRACTICE

Suggestions provided to enhance NICU services during the pandemic include increasing parental engagement opportunities to care for their infant in the NICU, enhanced empathy and compassion from the neonatal team, and open and transparent communication.

IMPLICATIONS FOR RESEARCH

Further research investigating cultural impact on parents' perspectives, perspectives of fathers, long-term impact of how parents coped after discharge from the NICU, and emotional impact on NICU staff members may be beneficial to aid improvements in NICU service delivery during the ongoing and future pandemic.

Oxytocin Levels Increase and Anxiety Decreases in Mothers Who Sing and Talk to Their Premature Infants during a Painful Procedure

(1) Background: Preterm infants spend their first weeks of life in the hospital partially separated from their parents and subjected to frequent potentially painful clinical procedures. Previous research has found that early vocal contact reduces infant pain perception while simultaneously increasing oxytocin (OXT) levels. The current study aims to assess the effect of maternal singing and speaking on mothers. (2) Methods: During a painful procedure over two days, twenty preterm infants were randomly exposed to their mother's live voice (speaking or singing). Maternal OXT levels were measured twice: before and after singing, as well as before and after speaking. The anxiety and resilience responses of mothers were studied before and after the two-day interventions, regardless of the speaking/singing condition. OXT levels in mothers increased in response to both singing and speech. Concurrently, anxiety levels decreased, but no significant effects on maternal resilience were found. (3) Conclusions: OXT could be identified as a key mechanism for anxiety regulation in parents, even in sensitive care situations, such as when their infant is in pain. Active involvement of parents in the care of their preterm infants can have a positive effect on their anxiety as well as potential benefits to their sensitivity and care abilities through OXT.

Reading Aloud with Infants in the Neonatal Intensive Care Unit: A Unit-Based Program to Enhance Language Enrichment and Support Early Foundational Relationships

OBJECTIVE

Early meaningful auditory experiences in the neonatal intensive care unit (NICU) enhance language outcomes and promote cognitive and social-emotional development.

METHODS

This is a descriptive report sharing our level III NICU experience of building a reading-aloud enrichment program with the goals of enhancing infant neurodevelopment and strengthening early parent-infant relationships.

RESULTS

We propose a roadmap for program development, outline challenges and possible ways to mitigate them, and highlight opportunities for further research in this area.

KEY POINTS

· Early auditory experiences enhance language, cognitive, and social-emotional development.. · High-risk infants experience an atypical neurosensory environment while receiving care in the NICU.. · Reading aloud in the NICU enhances language enrichment and supports early foundational relationships.. · We describe our center's experience with building a reading-aloud enrichment program in the NICU..

How parents and health professionals experience prematurity in an Italian neonatal intensive care: A grounded theory study

PURPOSE

The aim of this study was to explore prematurity as a psycho-social process from the point of view of both parents and healthcare professionals.

DESIGN AND METHODS

We conducted a Grounded Theory study through semi-structured interviews. Participants were from an Italian Neonatal Intensive Care Unit, including parents of premature children, and health professionals. Interviews were analyzed according to Grounded Theory coding strategies, to hypothesize a theoretical model.

RESULTS

On one side, behaviors, emotions, and feelings of parental couples; on the other one, the activities and reactions of professionals have been interpreted in a four-phase negotiated process: 1) the initial breakup; 2) the floating family; 3) the event processing; 4) the reconstruction of a new family.

CONCLUSIONS

Managing prematurity is a negotiated process which could be better managed through a family-centered approach as fundamental in neonatal and pediatric services. Being open in listening, coherent in the given answers, and knowing the entire process and story of being suddenly parents of a premature child can make the difference in the future definition of a new family.

PRACTICE IMPLICATIONS

Perinatal care would benefit from the following suggested practical implications: i) reducing feelings of separation and solitude by integrating diverse professionals around the family systems; ii) expediting prematurity-related changes through peer-support during hospitalization and attention to rooms' organization; iii) enhancing information exchange between all professionals involved in the care of dyads/parents and new-borns, starting since the pregnancy and continuing after the child's birth by implementing multidisciplinary meetings or appropriate care pathways.

Music Therapy and Family-Integrated Care in the NICU: Using Heartbeat-Music Interventions to Promote Mother-Infant Bonding

BACKGROUND

Family-integrated care in the neonatal intensive care unit (NICU) is the criterion standard. Parent-infant bonding may be an indicator of successful family involvement. Music therapy (MT) is a growing service in the NICU, with interventions to support meaningful family involvement and improve bonding.

PURPOSE

To study the effects of heartbeat-music interventions to support mother-infant bonding in the NICU and explore experiences of mothers participating in MT.

METHODS

Parallel-group randomized trial (MT vs standard care) to compare Mother-to-Infant Bonding Scale (MIBS) scores from baseline to 1 week postenrollment. MT included 2 heartbeat-music interventions (recorded maternal lullaby and heartbeat for infants, and recorded infant heartbeat and preferred music for mothers). Five mothers were randomly asked to complete a survey regarding their experiences with MT services.

RESULTS

One hundred mothers enrolled. In total, 44.3% completed the MIBS follow-up. Covarying out baseline MIBS, one-way analysis of covariance found no statistical difference between groups for MIBS 1-week follow-up (MT: mean = 0.64, SD = 1.6; standard care: mean = 0.57, SD = 1.5; P = .60) but underpowered in post hoc. Comforting, family cohesion, and personal growth and development themes emerged in qualitative analysis of survey responses.

IMPLICATIONS FOR PRACTICE

MT remains a viable service for purposefully including parents in the care of their NICU infants. Nurses and music therapists must work closely to successfully implement meaningful interventions such as heartbeat-music.

IMPLICATIONS FOR RESEARCH

Heartbeat-music interventions should be further studied for diverse applications, including family integration, family coping, and bereavement.

Perinatal and early childhood biomarkers of psychosocial stress and adverse experiences

The human brain develops through a complex interplay of genetic and environmental influences. During critical periods of development, experiences shape brain architecture, often with long-lasting effects. If experiences are adverse, the effects may include the risk of mental and physical disease, whereas positive environments may increase the likelihood of healthy outcomes. Understanding how psychosocial stress and adverse experiences are embedded in biological systems and how we can identify markers of risk may lead to discovering new approaches to improve patient care and outcomes. Biomarkers can be used to identify specific intervention targets and at-risk children early when physiological system malleability increases the likelihood of intervention success. However, identifying reliable biomarkers has been challenging, particularly in the perinatal period and the first years of life, including in preterm infants. This review explores the landscape of psychosocial stress and adverse experience biomarkers. We highlight potential benefits and challenges of identifying risk clinically and different sub-signatures of stress, and in their ability to inform targeted interventions. Finally, we propose that the combination of preterm birth and adversity amplifies the risk for abnormal development and calls for a focus on this group of infants within the field of psychosocial stress and adverse experience biomarkers. IMPACT: Reviews the landscape of biomarkers of psychosocial stress and adverse experiences in the perinatal period and early childhood and highlights the potential benefits and challenges of their clinical utility in identifying risk status in children, and in developing targeted interventions. Explores associations between psychosocial stress and adverse experiences in childhood with prematurity and identifies potential areas of assessment and intervention to improve outcomes in this at-risk group.

Perspectives on developing and sustaining a small baby program

The Small Baby Program at Nationwide Children's Hospital was launched in 2004 in response to a need for better care for infants born extremely preterm. Standardization of care, decreased variability, multidisciplinary support, and robust research and quality improvement have allowed us to greatly improve our outcomes. In addition to the numerous medical and technological advances during this time, a strong commitment to kangaroo care and family-centered care have been integral to the growth and success of our program. The following review of the program aims to highlight the above areas while detailing the specific processes that have contributed to its ongoing success. Key areas of focus have been on respiratory management, neurodevelopmental care, and nutritional optimization. The implementation and continued refinement of the Small Baby Program has allowed us to improve the survival of extremely preterm infants, decrease certain morbidities, and improve long-term neurodevelopmental outcomes.

Do small baby units improve extremely premature infant outcomes?

Increasing numbers of neonatal intensive care units have formed small baby units or small baby teams with the intention to optimize care of extremely premature infants. Considerable time, energy, and resources are required to develop and sustain complex quality improvement constructs, so legitimate questions about effectiveness, unintended consequences, and lost opportunity costs warrant scrutiny. The small baby unit literature is diminutive. Errors of chance, bias, and confounding secondary to insufficient definitions of process and outcome metrics, overlapping quality improvement projects, and limited cost analyses restrict firm conclusions. Well-established quality improvement methodologies such as evidence-based guidelines, standardized variability reduction using measurement-and-adjust techniques, family-integrated focus, and developmentally sensitive care, reliably improve outcomes for all-sized premature infants. There is not compelling published evidence that adding specialized small baby units or designated teams for extremely premature infants further enhances short- or long-term health if robust quality improvement fundamentals are already imbedded within local culture.

Development of a small baby unit to improve outcomes for the extremely premature infant

Survival and outcomes for extremely premature (EP) infants have improved and even infants born at 23 and 24 weeks that were previously considered non-viable are now routinely surviving. This review describes our particular institution's basis for and process of creating and sustaining a small baby program for a quaternary, referral-based neonatal intensive care unit. Through multi-disciplinary collaboration, small baby guidelines were developed that established uniform care and optimized evidence-based practice for the care of this unique patient population. A focus on parent-centered care while removing noxious stimuli for the patient has improved neurodevelopmental outcomes. Data collection, quality improvement, and ongoing research are incorporated in the small baby program to establish and sustain best practices and outcomes for the EP patient. Through the establishment of a small baby unit, we have improved survival, decreased short-term morbidities, and improved neurodevelopmental outcomes for the EP infant in our region.

Effect of guided reciprocal peer questioning strategy on pediatric nursing students' self-esteem and metacognitive awareness: Current approach and future directions

BACKGROUND

Guided Reciprocal Peer Questioning Strategy (GRPQS) restructures the classroom context from a passive into an engaging environment, where the students are empowered to actively participating in their learning process.

OBJECTIVE

To investigate the impact of GRPQS on the pediatric nursing students' self-esteem and metacognitive awareness.

DESIGN

A Quasi-experimental, pre-posttest, two groups research was carried out at University of Bahrain. A sample of 89 out of 112 pediatric nursing-students were divided into two groups.

METHOD

Through GRPQS, the students mutually generated and responded to questions, activated their critical thinking, elicited ideas, and shared learning experiences within the team and the teachers act as facilitators.

RESULTS

It is revealed that 75% of the students in the study group developed high self-esteem after their engagement in the GRPQS compared to only 48.8% among those in the control one. Students who practiced GRPQS showed an improvement in their knowledge about cognition. As the mean score of students in the study group is increased from 2.16 ± 0.45 to 2.89 + 0.35 for the procedural knowledge, from 2.33 ± 0.56 to 2.86 ± 0.41 for declarative and from 2.18 + 0.53 to 3.09 ± 0.29 for the conditional knowledge (p < 0.001 for each). Concerning the regulation of cognition, the mean score of the planning dimension was improved from2.21 ± 0.46 to 3.10 ± 0.31 among the students in the study group. Moreover, it is clear that applying GRPQS in the lectures helped in improving the students' information management strategies, comprehension monitoring, debugging strategies and evaluation (p < 0.001 for each) compared to the control group p = 0.169, p = 0.009, p = 0.117 and 0.887 respectively).

CONCLUSION

The application of GRPQS provided an interactive and engaging learning experience that helped the students to develop the habit of organizing, judging, and summarizing information as well as focusing on the significant portions of the learning materials. Moreover, exchanging questions between the nursing students was effective in enhancing their self-esteem and metacognitive awareness. Hence, incorporating this innovative pedogeological approach in the nursing curricula is recommended.

Implementation of Cue-Based Feeding to Improve Preterm Infant Feeding Outcomes and Promote Parents' Involvement

OBJECTIVE

To implement cue-based feeding for preterm infants and to assess its effects on time to achieve full oral feedings, length of stay, and parents' involvement in the feeding process.

DESIGN

A quality improvement project with a pre-post evidence-based practice implementation design.

SETTING

Level III NICU in a quaternary hospital in the U.S. Northeast.

PARTICIPANTS

Medical records of preterm infants from 23 0/7 weeks to 31 6/7 weeks gestational age who were eligible for initiation of oral feeding.

INTERVENTION/MEASUREMENTS

We implemented cue-based feeding through staff education and training. We completed a retrospective review of the medical records of 82 preterm infants before implementation and 167 preterm infants after implementation for the outcomes of time to achieve full oral feedings, length of stay, and parents' involvement in the feeding process.

RESULTS

For infants 23 0/7 weeks to 27 6/7 weeks gestation, time to achieve full oral feedings decreased by 7 days, length of stay decreased by 4.4 days, and parents' involvement in the feeding process increased by 80% from before to after implementation. For infants 28 0/7 weeks to 31 6/7 weeks, time to achieve full oral feedings decreased by 6.6 days, length of stay decreased by 2.7 days, and parents' involvement in the feeding process increased by 49% from before to after implementation. The organization saved $103,950 per year by decreasing length of stay.

CONCLUSIONS

Cue-based feeding decreased time to achieve full oral feedings, decreased length of stay, increased parents' involvement in the feeding process, and resulted in cost savings for the institution.

Capabilities that experienced nurses expect of new nurses in pediatric wards: A research study using Q methodology

BACKGROUND

To meet the expected levels of nursing care in pediatric wards, it is necessary to identify and strengthen the skills, job satisfaction levels, and personality characteristics required of nurses.

OBJECTIVES

This study aimed to identify the types of capabilities experienced nurses expect of new nurses in order to perform professional nursing in pediatric wards.

DESIGN

Q methodology was used to explore the subjective perceptions of experienced nurses regarding new nurses.

SETTING

The research was conducted in the pediatric wards of university hospitals.

PARTICIPANTS

A convenience sample of 31 experienced nurses was recruited for the P-set from the pediatric wards of university hospitals.

METHODS

Data were collected from the 31 participants from August to December 2019.

RESULTS

Based on the study results, the abilities experienced nurses expect new nurses to possess were grouped into three categories: 1) "honesty and effort type," 2) "problem-solving type," and 3) "relationship-oriented type."

CONCLUSIONS

This study provides basic data for constructing a program that is advantageous for clinical practice and for the education of pediatric nurses. The results also suggest that increasing the effectiveness of collaboration, understanding, and communication between newly graduated and experienced nurses may improve the level of professional care provided in pediatric wards.

Establishing a Foundation for Optimal Feeding Outcomes in the NICU

Many infants in the NICU experience difficulties with oral feeding, which contribute to prolonged length of stay. Oral feeding is a complex task involving sensorimotor functioning of the face, mouth, and larynx, as well as coordination of sucking, swallowing, and breathing. The care provided in the NICU starting at birth sets the stage for future oral feeding. The purpose of this article is to describe strategies that will establish a positive foundation to support optimal oral feeding. Nurses can use these strategies to protect newborns from noxious stimuli and promote positive auditory, tactile, gustatory, and olfactory experiences to optimize neurodevelopment for the complex task of feeding.