Infant handling in the NICU: does developmental care make a difference? An evaluative review of the literature

Acoustic Cry Characteristics of Infants as a Marker of Neurological Dysfunction: A Systematic Review and Meta-Analysis

BACKGROUND

Atypical cries have been identified in infants with neurological dysfunction. The aim of this study was to conduct a systematic review and meta-analysis to appraise existing evidence for associations between acoustic cry characteristics and neurological dysfunction in infants aged 18 months or less.

METHODS

PubMed/MEDLINE, PsycINFO, CINAHL, and Embase were searched for original, peer-reviewed studies published in English reporting cry variables in infants aged 18 months or less with or at risk of neurological dysfunction. Studies without a nonneurologically impaired control sample were excluded. Pooled effect sizes were estimated using standardized mean difference (SMD) and odds ratio (OR). I² indicated study heterogeneity, and the risk of bias was assessed using the Newcastle-Ottawa Scale.

RESULTS

From March 2018 to February 2019, 28,294 studies were retrieved. Eight were meta-analyzed. Infants with or at risk of neurological dysfunction exhibited higher mean (SMD = 0.11 [95% confidence interval, 0.00 to 0.23]) and minimum (SMD = 0.93 [0.64 to 1.23]) fundamental frequency; higher odds of hyperphonation (OR = 13.17 [1.05 to 165.87]), biphonation (OR = 10.62 [1.53 to 73.59]), rise-fall-rise melodies (OR = 4.66 [1.16 to 18.66]), and flat melodies (OR = 4.47 [1.27 to 15.68]); and lower odds of fall-rise-fall melodies (OR = 0.21 [0.05 to 0.83]).

CONCLUSIONS

Infants with underlying neuropathology have unique cries characterized by higher fundamental frequency, dysphonation, and atypical melodies, although study heterogeneity and imprecision of effect size estimates limited our interpretation. Assessment of acoustic cry characteristics offers the potential for noninvasive, rapid, point-of-care screening for neurologically high-risk infants.

Translation and study of the measurement properties of the Early Feeding Skills Assessment tool in premature newborn

INTRODUCTION

With the aim of improving the care of the premature newborn during their hospital stay, and their well-being in the transition from enteral to independent feeding, it is proposed to incorporate an assessment system within a Spanish Neonatal Unit. The translation of the Early Feeding Skills Assessment (EFSA) tool is presented, along with a study of its measurement properties.

PATIENTS AND METHOD

A total of 104 assessments were made on premature babies of less than 34 + 6 weeks of gestational age, admitted to the neonatal unit with total or partial feeding, including a normal neurological examination for their age and with physiological stability.

RESULTS

The EFSA 2010 tool achieved an acceptable value (0.76) as regards its internal consistency. The EFSA 2018 tool maintained an acceptable internal consistency value (0.751). As regards the reliability between two observers, the results showed a satisfactory and excellent reliability in 57.69% of the items in the EFSA 2010 tool, a property that improved in the EFSA 2018 tool (73.68%).

CONCLUSIONS

The Spanish version of the EFSA tool is consistent and reliable for use as a tool for the assessment of oral abilities for feeding premature babies admitted into a Spanish Neonatal Unit.

Amplitude-integrated electroencephalography signals in preterm infants with cerebral hemorrhage

OBJECTIVE

To evaluate whether preterm infants with cerebral hemorrhage show alterations of aEEG signals in the first four weeks of life.

STUDY DESIGN

Preterm infants (n = 536) born before 32 completed weeks of pregnancy at Innsbruck Medical University Hospital were included in the study. AEEG recordings were evaluated for the Burdjalov score and cerebral hemorrhage was diagnosed by cerebral ultrasound.

RESULTS

Eighty preterm infants with cerebral hemorrhage (median gestational age 28.9 weeks, median birth weight 1157 g) and 456 preterm infants without cerebral hemorrhage (median gestational age 30.0 weeks, median birth weight 1300 g) were investigated. Burdjalov total scores were significantly lower in infants with cerebral hemorrhage. Infants with mild cerebral hemorrhage showed higher Burdjalov total scores compared to infants with severe cerebral hemorrhage in the first days of life. A Burdjalov total score of seven or more was predictive for no development of a cerebral hemorrhage, with a highest area under the curve (0.613) at postnatal day three.

CONCLUSION

Preterm infants with cerebral hemorrhage show alterations in aEEG signals in the newborn period. In future aEEG could be used as a supplemental method to monitor preterm infants at risk for cerebral hemorrhage. The use of aEEG in early life could reduce the number of ultrasound examinations and limit cumulative stress and discomfort in preterm infants.

Longitudinal Responses to Weighing and Bathing Procedures in Preterm Infants

Knowledge of the effects of nursing-induced stress on short-term outcomes in preterm infants is limited. Effects of 2 standard nursing procedures-weighing and bathing-on autonomic and motor stability of preterm infants were studied during their hospitalization. Outcomes were evaluated during and after the procedures. Eleven preterm infants were observed between 32 and 35 weeks' postmenstrual age (PMA) (postnatal days range: 4-63). Neonatal responses were assessed according to the Synactive Theory of Development and nursing was performed taking into account Newborn Individualized Developmental Care and Assessment Program (NIDCAP) principles. Effects of the studied nursing procedures on infants' stability during and after their execution were evaluated by nonparametric statistics. During monitored procedures, stress responses in autonomic and motor systems were observed at all PMAs. However, after 32 weeks' PMA, preterm infants also showed an autonomic and motor stability recovery 5 minutes after procedure completion. Contrary to our hypothesis, preterm infants showed to be stressed by weighing and bathing procedures up to 35 weeks' PMA. However, if facilitated and supported after nursing conclusion by interventions such as swaddling and nesting, according to NIDCAP principles, they recovered autonomic and motor stability by 5 minutes after ending procedures.

Comparing the effects of minimal handling protocols on the physiological parameters of preterm infants receiving exogenous surfactant therapy

BACKGROUND

The practice of minimal handling is recommended for preterm infants (PTIs). However, few studies have investigated the effects of this practice among these infants or the time needed to ensure greater physiological stability, especially after exogenous surfactant treatments.

OBJECTIVE

The current study compared the effects of two protocols of minimal handling on the physiological variables of PTIs after surfactant therapy.

METHOD

An exploratory prospective observational study was performed with 40 PTIs weighing less than 1,500 g. The infants were divided into two groups and monitored for 72 hours. One group received the standard minimal handling procedure during the first 12 hours after surfactant therapy; the other group (i.e., the modified group) received minimal handling within 72 hours after surfactant therapy. Infant heart rate (HR), oxygen saturation, body temperature, and the adverse events associated with changes to these variables were monitored every 10 minutes.

RESULTS

Significant between-group differences were not found with regard to the occurrence of the adverse events associated with physiological changes (p>0.05).

CONCLUSION

The practice of minimal handling among very low birth weight infants did not alter their physiological stability when performed either 12 or 72 hours after surfactant therapy.

[Handling of preterm infants in a neonatal intensive care unit]

While hospitalized in neonatal units, preterm infants undergo various manipulations and procedures that have negative health consequences. The aim of this study was to describe the manipulations that preterm infants are subjected to over a 24-hour period in a neonatal intensive care unit (NICU). An observational, descriptive, exploratory study was conducted with 20 preterm infants who were filmed continuously in a NICU over a 24-hour period from September 2008 to March 2009. Preterm infants were subjected to an average of 768 manipulations and 1341 procedures. The average duration of the manipulations over the 24-hour period was 2 hours and 26 minutes. Each manipulation included an average of 2.2 procedures, most occurring during the morning shift. Individual manipulations accounted for 65.6% of all manipulations, and most manipulations lasted less than a minute. The results of this study show that preterm infants in the NICU underwent an excessive number of manipulations over the 24-hour period evaluated.

Sleep-wake cycling in a neonate admitted to the NICU: a video-EEG case study during hypothermia treatment

This retrospective case study describes the sleep-wake cycles of an infant in the neonatal intensive care unit. We analyzed video-electroencephalographic recording of the term infant monitored during treatment with therapeutic hypothermia for hypoxic-ischemic encephalopathy. The continuous video-electroencephalographic recording over a 4-day period also allowed us to describe the following dimensions of daily care in relation to the infant's sleep-wake states: (1) handling by professional and parent caregivers and (2) stress, pain, and analgesia. Physical contact constituted 17% to 36% of each 24-hour period. The infant's care was fragmented, with a mean of 3 to 4 physical contacts per hour. As a result, the structure of infant sleep was altered by the increased amount of awake and quiet sleep. The number of painful procedures ranged from 5 to 24 per day. Nurses were the main care providers. Parents had more contact after the infant was rewarmed. This case study suggests that neonatal intensive care unit infants are exposed to frequent handling and stress as well as altered sleep. The cumulative negative impact of frequent handling and sleep fragmentation may go unnoticed by caregivers focused on episodes of care. Continuous video-electroencephalographic monitoring is a useful tool for longitudinal evaluation of infant sleep and responses to caregiving in the neonatal intensive care unit.

Closeness and separation in neonatal intensive care

In this paper, we highlight the need for acknowledging the importance and impact of both physical and emotional closeness between the preterm infant and parent in the neonatal intensive care unit. Physical closeness refers to being spatially close and emotional closeness to parental feelings of being emotionally connected to the infant (experiencing feelings of love, warmth and affection). Through consideration of the literature in this area, we outline some of the reasons why physical closeness and emotional closeness are crucial to the physical, emotional and social well-being of both the infant and the parent. These include positive effects on infant brain development, parent psychological well-being and on the parent–infant relationship. The influence of the neonatal unit environment and culture on physical and emotional closeness is also discussed.

Cautionary tales from the neonatal intensive care unit: diapers may mislead urinary output estimation in extremely low birthweight infants

OBJECTIVE

To examine the validity of the weighing of modern polyacrylate diapers to determine urine output in the extremely low birth weight infant nursed in a humidified incubator.

DESIGN

Observational study with repeated measures using high-absorbency cellulose/polyacrylate diapers and a humidified incubator in a modeled clinical scenario.

SETTING

A tertiary referral neonatal intensive care unit.

INTERVENTIONS

Six dry diapers were placed into eight levels of humidity, between 55% and 90% inclusive, in an incubator set at 37 degrees C. Hourly weight increments were recorded. The study was repeated with 5 mL of normal saline added to the diaper to mimic prior urine output. Results were compared by Kruskal-Wallis nonparametric analysis of variance.

MEASUREMENTS AND MAIN RESULTS

Dry diapers increased in weight for each humidity level after 1 hr (p < .05). This was significantly greater at higher humidity. The maximum increase was a median of 3.06 g (range, 2.47-3.31 g) at 85% humidity after 6 hrs. When 5 mL of 0.9% saline had been added, the diaper weight changes depended on environmental relative humidity. At > or = 80% humidity, the diapers continued to gain weight; at 70% or 75% humidity, they did not change weight; and at < or = 65% humidity, the diapers lost weight. Maximal evaporative loss was median 1.11 g (range, 0.8-1.24 g) at 6 hrs in 55% relative humidity.

CONCLUSIONS

The use of diaper weighing in high-humidity infant environments may not be an accurate measure of actual urine output in the extremely low birth weight infant. This study demonstrates the need for caution when interpreting this measure, and we discuss some possible clinical approaches to ameliorate this difficulty.

Application of Neurobiologic Risk Score in a tertiary care hospital in Pakistan

Many health-care institutions are equipped to provide high-quality care to high-risk neonates. Purpose of this study was to assess validity of a tool using Neurobiologic Risk Score in our setting. This tool is applicable in our setting, although further studies should be initiated to determine development delay.

Effects of handling procedures on pain responses of very low birth weight infants

PURPOSE

The purpose of this study was to investigate the effects of handling on pain responses of infants with very low birth weight (VLBW) and the frequency, duration, and type of handling procedures used during a 24-hour period for infants with VLBW.

METHODS

Eighteen infants with VLBW were observed for two-hour periods. Infants' pain responses were recorded using the Neonatal Inventory Pain Scale before and after each handling episode. Twelve infants were observed once, six were observed twice. Variables relating to each handling episode observed were documented.

RESULTS

Pain scores were significantly greater after handling. During a 24-hour period, infants were handled an average of 53 times for an average of 2.7 hours. Ten handling episodes included social touch.

CONCLUSIONS

Handling infants with VLBW significantly alters their pain responses. In some infants with VLBW are handled frequently in the neonatal intensive care unit. The results have implications for the training of neonatal caregivers.

Origins of tactile vulnerability in high-risk infants

PURPOSE

This study examined the degree to which birthweight, gestational age, fetal drug exposure, hazardous postnatal medical events, and a mother's predisposition toward touch predicted the likelihood of an infant's tactile vulnerability during nursing care.

SUBJECTS

The convenience sample included 99 hospitalized infants in their second week of life and their mothers.

DESIGN

The design was correlational.

METHODS

A standardized observational assessment was used to code the infant's physiological and behavioral responses to touch during 4 different episodes of nursing care. Chart review was performed to collect information regarding fetal drug exposure, birthweight, gestational age, and postnatal medical events. Mothers completed a questionnaire regarding their own comfort with using touch and being touched.

MEASURES

The Tactile Vulnerability Assessment measured infant reactivity to and tolerance for touch during nursing care. The Postnatal Complications Scale identified hazardous medical conditions and treatments experienced by the infant during the first 2 weeks of life, and the Physical Contact Assessment evaluated a mother's predisposition toward touch.

RESULTS

The number of hazardous postnatal medical events experienced by an infant was the primary predictor of tactile vulnerability, accounting for 28% of the variance in the infant's likelihood of developing hyperarousal and distress from touch during care. Illicit fetal drug exposure and maternal predisposition toward touch were also significant predictors.

CONCLUSIONS

The significant relationship of postnatal medical events to tactile vulnerability suggests that it may be associated with the presence of infant pain or injury to the infant's central nervous system. Symptoms of drug withdrawal and the impact of teratogens on arousal regulation may also be implicated in greater distress from touch by infants. In addition, findings suggest the potential for inherited transmission of a vulnerability to touch. Assessment of infant vulnerability, including discussion with parents about their views of the infant's needs regarding touch, may enhance problem identification and early intervention to reduce infant distress and further medical problems.

Evaluation of a developmental care training programme for neonatal nurses

Although the impact of developmental care on premature infants has been investigated at length, often the issue of professional development and training related to this type of care has not been examined. The aim of the present study was to evaluate the impact of a developmental care training programme on nurses' behaviours and cognitive attributes with regard to the prevention of overstimulation of premature infants. The Theory of Reasoned Action (TRA) was the framework underlying the study. This programme evaluation used a quasi-experimental one group pre-test/post-test design. Participants were nurses working in a neonatal intensive care unit. Data were collected by self-administered questionnaires. Significantly higher post-test scores were observed for knowledge and for a variety of theoretical constructs. The results of this study showed the potential of such training programmes to help nurses implement developmental care.

Prior pain induces heightened motor responses during clustered care in preterm infants in the NICU

BACKGROUND

Acute pain is a significant stressor for preterm infants in neonatal intensive care units (NICU); however, little is known about the effects of acute pain on subsequent motor responses during clusters of tactile handling.

AIMS

(1) To compare facial, body and heart rate reactivity in preterm infants at 32 weeks gestational age (GA) during routine care-giving tasks following a rest period (RCC: diapering, measuring abdominal girth and axillary temperature, mouth care) with their responses to Clustered Care following blood collection (PCC). (2) To examine how GA at birth affects patterns of stress and self-regulatory behaviors during RCC and PCC.

STUDY DESIGN

Within-group crossover design (random order).

SUBJECTS

Preterm infants, N=54 (mean GA at birth 29.3 +/- 2.2 weeks; mean birth weight 1257 +/- 423 g) were assessed at 32 weeks GA in the NICU.

OUTCOME MEASURES

The Newborn Developmental Care and Assessment Program (NIDCAP) and Neonatal Facial Coding System (NFCS) were coded from continuous bedside video recordings. Changes in mean heart rate (HR) were computed using custom physiologic software.

RESULTS

All infants had heightened facial, body and HR responses when CC followed a painful procedure compared to when they had not been handled prior to CC. Infants born at earlier GA (<30 weeks) had equal numbers of stress cues during RCC and PCC, but dampened self-regulatory behaviors during PCC.

CONCLUSION

Prior pain induces heightened biobehavioral reactivity in preterm infants during subsequent tactile procedures. In addition, clustering care is particularly stressful for infants born at earlier GA.

Effects of facilitated tucking during routine care of infants born preterm

PURPOSE

The purpose of this study was to compare stress responses of infants born preterm during routine nursing assessments performed under two conditions. One condition incorporated a second caregiver supporting the infant in a facilitated tucked position, whereas the second condition did not.

METHODS

A convenience sample of 12 infants born preterm, ages 25 to 34 weeks postconceptual age on the day of testing (mean = 30.9 weeks), were evaluated using the Premature Infant Pain Profile (PIPP), during the two caregiving conditions. For each trial, the infant received a PIPP score. The level of significance was set at p = 0.05.

RESULTS

A significant difference (p = 0.013) existed between the two testing positions as measured by the PIPP. Nine of the 12 infants received a lower PIPP score with facilitated tucking during routine care assessments.

CONCLUSIONS

By incorporating facilitated tucking during routine care events, the stress level of the infants born preterm may be reduced. When the infants' stress levels are reduced, they may be better able to maintain stability in their autonomic, motor, and state systems.

The relationship between physiological and behavioral measures of stress in preterm infants

OBJECTIVE AND DESIGN

The purpose of this exploratory descriptive analysis was to explore relationships among physiological stress, behavioral stress, and motor activity cues in preterm infants when they were not being handled or disturbed, and to determine whether there were differences between younger and older preterm infants in these variables or relationships.

SETTING AND PARTICIPANTS

The convenience sample included 42 preterm infants who had been 27 to 33 weeks gestational age at birth and were from 6 to 19 days old at the time of data collection in the neonatal intensive-care unit.

MEASURES

In each 10-minute observation, heart rate (HR) and oxygen saturation (O2 sat) levels were recorded every 5 seconds, and observational measures of behavioral distress and motor activity were recorded twice a minute. The physiological data were coded to reflect the percentage of each 10-minute period during which HR levels were less than 100 bpm or more than 200 bpm or O2 sat levels were abnormally low (less than 90 mg%). Data were analyzed with correlational and general linear mixed models procedures.

RESULTS

Stress cues and motor activity were more often related to low levels of O2 sat than to low or high HR. Physiological status was more often related to motor activity than to stress cues. Few differences in the relationships were observed between younger and older preterm infants.

CONCLUSION

Although these results are preliminary, they suggest that neonatal nurses should monitor preterm infants' behavioral stress and motor activity cues in response to caregiving and minimize stimuli that evoke stress responses linked to physiological instability.

Determination of positional skin-surface pressures in premature infants

PURPOSE

To describe the skin-surface pressure distributions and points of maximal pressure that are generated by healthy premature infants in the supine, prone, and right side-lying positions.

DESIGN

A descriptive, repeated-measures design.

SAMPLE

Four medically stable premature infants of 34 weeks postconceptional age. The mean weight was 2,180 gm, and the mean age was 24.5 days.

RESULTS

Similar regions of increased skin-surface pressures were identified for the four infants. Within areas of peak pressure, some sensor cells reached 28-32 millimeters of mercury, which is considered to be the critical compressive pressure for obstruction of nutritive flow to the underlying body tissues. These descriptive results may be a starting point for development of research studies to determine positioning strategies to optimize the skin integrity of premature infants while minimizing unnecessary handling.

Developmentally supportive care in the newborn intensive care unit: early intervention in the community

The traditional focus of hospital nurses on the medical concerns of infants and toddlers is expanding to encompass the more global view that integrates the developmental level of each infant/toddler into the nursing care plan. Research on early brain development has supported the focus on developmentally supportive care in the NICU. Nursing support of the early relationship between infant and parent that will influence the infant's future development is part of this process. The integration of developmental care concepts including family-centered care that begins on admission to the NICU may continue into the process of discharge and transition to home. The nurse is in an excellent position to support the family in naming their concerns, their strengths, and the hopes and dreams they have for their infant. Nurses in the NICU, home care, community, and public health increasingly focus on a developmental perspective in their work but will be continually challenged to increase their knowledge and understanding of developmental milestones, neurodevelopmental assessment, and their role in collaborating with the wider world of early intervention. This collaboration includes the health care system, the educational system, and the social service system as equal players. For some nurses, this will be a new experience whereby the responsibility for the child is shared among members of an interdisciplinary team that includes the parents. Nurses are key to providing developmentally supportive care and working collaboratively on behalf of the infants and toddlers and their families.

Assessment of neonatal nurses' behaviors that prevent overstimulation in preterm infants

This study assessed the adoption by neonatal nurses of behaviors that prevent visual, auditory, and tactile overstimulations in preterm infants, as well as the intentions, attitudes, and subjective norms related to the adoption of these behaviors. The convenience sample consisted of 54 neonatal nurses working in three Montreal region teaching hospitals. A multiple-choice questionnaire, composed on the basis of a review of the literature and the Theory of Reasoned Action, was used for data collection. The results revealed that the nurses often adopted behaviors that prevented tactile overstimulation, and that their intentions, attitudes, and subjective norms all favored the adoption of such behaviors. However, more than the half of the nurses did not frequently adopt behaviors that prevent visual and auditory overstimulations, nor did their intentions, attitudes, and subjective norms favor the adoption of these behaviors. Findings suggest that neonatal nurses lack specific knowledge in this area and that they would benefit from the completion of an evidence-based educational program on the prevention of overstimulation of preterm infants prior to their employment in a Neonatal Intensive Care Unit (NICU).

Care of children and families in the CICU: A focus on their developmental, psychosocial, and spiritual needs

The staff of Patient and Family Support Services oversees the developmental, psychosocial, and spiritual care of the child in the cardiac intensive care unit. Staff collaborate with medical team members, as well as the patient's family, to promote holistic care. This article describes the roles and responsibilities of the child life specialist, the social worker, and the chaplain and identifies discipline-specific assessment techniques and interventions. The article highlights identified needs of children and their families, offering tools and interventions health care clinicians can use in the cardiac intensive care unit.

Effects of sponge bathing on vagal tone and behavioural responses in premature infants

The purpose of this study was to evaluate the effects of sponge bathing on physiological (vagal tone, heart rate, heart period, oxygen saturation) and behavioural responses in newly born premature infants in the intensive care unit of a university hospital in South Korea. A convenience sample was taken of 40 infants who were between 27 and 36 weeks gestational age at birth and free of congenital defects. The infants' physiological parameters were recorded 10 min before, during and after bathing. To determine behavioural status, tools were modified from the instruments used in a previous study by Scafidi et al. (1990). Analysis of the results showed that the premature infants reacted to sponge bathing with decreases in vagal tone and heart period and increases in heart rate. Oxygen saturation did not demonstrate any remarkable alteration during bathing. Also, there were no significant differences in behavioural signs, motor activity and behavioural distress. Results of this study indicated that nurses in a neonatal intensive care unit should decide according to a premature infant's physiological state whether or not to give a sponge bath.