To explore relationships between physiological stress signals and stress behaviors in preterm infants during periods of exposure to environmental stress in the hospital

Pathogenesis of Necrotizing Enterocolitis in Preterm Infants: An Adaptation of Neuman's Systems Theory

Preterm infants have increased morbidity and mortality due to immature physiology and neonatal complications. Necrotizing enterocolitis (NEC) is a devastating gastrointestinal complication that affects morbidity and mortality in preterm infants. The authors present an adaptation of Neuman's systems model called the NEC systems model to explore intrinsic and extrinsic factors leading to NEC in preterm infants. The literature was searched for theoretical models to guide exploration of neonatal disease influenced by the environment. Neuman's Systems Model provides a holistic approach to care of the system, offering a foundation to develop frameworks to examine preterm infants in their environment with associated stressors.

Feasibility Case Series of Environment and Sleep in Infants With Congenital Heart Disease

BACKGROUND

Developmental delay is a significant concern for infants born with complex congenital heart disease (CCHD). Environmental exposures (e.g., excessive light and sound exposure, sleep disruption) in neonatal intensive care are associated with poor developmental outcomes. However, the environmental experience of newborn infants in cardiac care is unknown.

OBJECTIVES

The aim of the study was to examine the feasibility of continuous environmental data collection (i.e., light and sound exposure, sleep pattern) in pediatric cardiac care units and describe the environmental experience of three hospitalized infants with CCHD.

METHODS

A case series of three infants undergoing cardiac surgery for CCHD within the first month of life was performed. Measures of light, sound, and sleep were collected in 24-hour periods on three to four separate hospital days. For each day, light and sound meters were attached to the hospital bed, and an actigraphy band was placed on the infant's lower leg to measure sleep/wake states. Feasibility of continuous environmental data collection was assessed through acceptability of data collection for families and clinical staff, usability of data collection equipment for research staff, and study protocol adherence. Descriptive statistics were used to calculate the count and duration of episodes of excessive light and sound exposure, hourly levels of light and sound exposure, total sleep time, duration of individual sleep episodes, and number of arousals from sleep.

RESULTS

Although continuous environmental data collection was generally acceptable to families and clinical staff, multiple usability issues were identified by research staff, and study protocol adherence was variable. Missing data were a major limitation. User error during equipment setup was a main contributor to missing data. Infants experienced frequent episodes of sound exposure above recommended maximum levels, whereas light exposure generally remained below recommended maximum levels. Infant sleep patterns were highly fragmented, with frequent arousals and short duration of individual sleep episodes.

DISCUSSION

Lessons learned during preliminary data collection with the infants in this case series will inform methods and prevent missing data in future, large-scale studies of this vulnerable, hard-to-recruit population. Data reflect a cardiac care environment characterized by excessive sound exposure and highly disrupted sleep. These environmental stressors may affect developmental outcomes in infants with CCHD.

The lived experiences of critically ill infants hospitalised in neonatal intensive care: A scoping review

BACKGROUND

Neonatal intensive care saves lives, but the environment in which this occurs is complex and has been shown to negatively disrupt some aspects of an infant's early development. Identifying these negative effects has relied on measuring physiological and behavioural responses. Little research has sought to understand and learn from what an individual infant can communicate about their lived experience.

AIM

To examine what is known of the lived experiences of infants hospitalised in neonatal intensive care.

STUDY DESIGN

A scoping review using the revised Arksey and O'Malley framework was undertaken. Relevant studies, exploring an infant's experience of hospitalisation were identified through a comprehensive, systematic literature search.

RESULTS

4955 articles were retrieved, 88 full texts reviewed, and 23 studies included. We identified no studies that assessed the experience from the infant's perspective. The infant experience was explored using quantitative methodology, characterising, and describing the experience in measurable physiological, behavioural, and neurodevelopmental terms or through the lens of medical outcomes. The environment is described as too loud and too bright and infants are exposed to high levels of medical handling, impacting on physiology, behaviour, sleep, feeding, and both short- and longer-term outcomes.

CONCLUSION

The studies captured in this review focused on quantitative, measurable outcomes as a proxy for the experience as it might be felt, interpreted, and processed by an infant. Medical focus has been crucial to advance the field of neonatology, but the review highlights an important gap; the need to explore and better understand the infant's experience through their eyes.

Individualized Family-Centered Developmental Care: An Essential Model to Address the Unique Needs of Infants With Congenital Heart Disease

BACKGROUND

Infants born with critical congenital heart disease (cCHD) who require surgical intervention in the newborn period are often hospitalized in a cardiac intensive care unit (CICU). Cardiac surgery and the CICU environment are traumatic to infants and their families. Infants are exposed to overwhelming stress, which can result in increased pain, physiologic instability, behavioral disorganization, disrupted attachment, and altered brain development. Individualized Family-centered Developmental Care (IFDC) is a model that can address the unique needs and developmental challenges of infants with cCHD.

PURPOSE

The purpose of this article is to (1) clearly describe the uniqueness of the infant with cCHD, including the medical, neurological, and parental challenges, and (2) propose methods to apply IFDC to support recovery of infants with cCHD in the CICU.

CONCLUSIONS

The experiences in the CICU shape the developing brain and alter recovery and healing, thus adversely impacting development. Individualized Family-centered Developmental Care is a promising model of care that nurses can integrate into the CICU to promote neuroprotection and development. Nurses can effectively integrate IFDC into the CICU by understanding the unique characteristics of infants with cCHD and applying IFDC interventions that include both maturity and recovery perspectives.

CLINICAL IMPLICATIONS

The incorporation of IFDC interventions is essential for the infant with cCHD and should be a standard of care. Applying IFDC with a recovery perspective in all aspects of caregiving will provide opportunities for individualization of care and parent engagement, allowing infants in the CICU to recover from surgery while supporting both short- and long-term neurodevelopment.

The Effect of Earmuffs on Physiological Parameters in Preterm Infants: A Systematic Review

Noise may cause stress responses such as apnea, hypoxemia, changes in oxygen saturation and augmented oxygen consumption secondary to elevated heart and respiratory rates. Moreover, stress results in increased intracranial pressure, abnormal sleep patterns, hearing impairment, and bronchopulmonary dysplasia, retinopathy of prematurity, intraventricular hemorrhage, periventricular leukomalacia, retardate development and alterations in the neuroendocrine system. Herein, this study aimed to discuss the effects of earmuffs on physiological parameters in preterm infants. The relevant and available peer-reviewed publications from 2012 to 2018 from various databases were analyzed. For the assessment of the studies, the full-text accessible studies were included for analysis. The retrieved documents were analyzed using VOSviewer regarding the geographical distributions of the documents with their numbers and citations, keywords proposed by the researchers. All records with the term "earmuffs OR earmuff" in the "article title, abstract, keywords" were retrieved from different databases. Accordingly, 396 documents containing the word "earmuffs OR earmuff" were recorded. The search was then restricted for publications that contain the words "noise AND nursing AND preterm" in the title and abstracts (TITLE-ABS-KEY (earmuffs OR earmuff)) AND (noise AND nursing AND preterm) (Scopus=390; Web of Science=1, Medline=2; Cochrane=1; Embase=1= Pubmed=1=n=396). After inclusion and exclusion criteria, 7 documents were recorded and then evaluated for the present study. As a conclusion, the effects of earmuffs on physiological parameters of preterm infants have not been clearly understood and reported yet. Along with the present documents, it is not clear that the use of earmuffs reduces stress and provides physiological stability in preterm infants born between approximately 28-32 weeks. The studies with a larger sample size are needed for validation of information reported in the articles analyzed herein.

Filling a significant gap in the cardiac ICU: implementation of individualised developmental care

Mortality rates among children with CHD have significantly declined, although the incidence of neurological abnormalities and neurodevelopmental impairment has increased. Research has focussed on outcomes, with limited attention on prevention and intervention. Although some developmental differences and challenges seen in children with CHD are explained by the cumulative effect of medical complications associated with CHD, many sequelae are not easily explained by medical complications alone. Although cardiac intensive care is lifesaving, it creates high levels of environmental and tactile stimulation, which potentially contribute to adverse neurodevelopmental outcomes. The therapeutic method of individualised developmental care, such as the Newborn Individualized Developmental Care and Assessment Program, provides early support and preventive intervention based on each child's behavioural signals of stress, comfort, and strength. Implementing developmental care practices in a cardiac ICU requires a thoughtful and well-planned approach to ensure successful adoption of practice changes. This paper reviews how developmental care was introduced in a paediatric inpatient cardiac service through multidisciplinary collaborative staff education, clinician support, child neurodevelopment assessment, parent support, and research initiatives. Given the known risk for children with CHD, cardiac medical professionals must shift their focus to not only assuring the child's survival but also optimising development through individualised developmental care in the cardiac ICU.

Physiological stress responses in infants at 29-32 weeks' postmenstrual age during clustered nursing cares and standardised neurobehavioural assessments

OBJECTIVE

To compare the physiological stress responses of infants born <30 weeks' gestational age when undergoing clustered nursing cares with standardised neurobehavioural assessments in neonatal nurseries.

DESIGN/METHODS

Thirty-four infants born <30 weeks' gestation were recruited from a tertiary neonatal intensive care unit. Heart rate (HR) and oxygen saturation were recorded during clustered nursing cares and during standardised neurobehavioural assessments (including the General Movements Assessment, Hammersmith Neonatal Neurological Examination and Premie-Neuro Assessment). Two assessors extracted HR and oxygen saturations at 5 s intervals, with HR instability defined either as tachycardia (HR >180 beats per minute (bpm)) or bradycardia (HR <100 bpm). Oxygen desaturations were defined as SpO₂<90%. Physiological stability was compared between nursing cares and neurobehavioural assessments using linear (for continuous outcomes) and logistic (HR instability and oxygen desaturation) regression.

RESULTS

Compared with clustered nursing cares HR was lower (mean difference -5.9 bpm; 95% CI -6.5 to 5.3; P<0.001) and oxygen saturation higher (mean difference 2.4%; 95% CI 2.1% to 2.6%; P<0.001) during standardised neurobehavioural assessments. Compared with clustered nursing cares neurobehavioural assessments were also associated with reduced odds of tachycardia (OR 0.44, 95% CI 0.22 to 0.86), HR instability (OR 0.43, 95% CI 0.22 to 0.85) and oxygen desaturation (OR 0.43, 95% CI 0.26 to 0.70).

CONCLUSIONS

Standardised neurobehavioural assessments are associated with less physiological stress than clustered nursing cares in infants aged 29-32 weeks' postmenstrual age, and are therefore possible without causing undue physiological disturbance in medically stable infants.

Relationship between energy expenditure and stress behaviors of preterm infants in the neonatal intensive care unit

PURPOSE

This research evaluated the relationship between behaviors and energy expenditure in preterm infants receiving nursing interventions.

DESIGN AND METHODS

This study was an explorative secondary data analysis from a previous study. The current study investigated energy expenditure calculated using heart rate-based energy expenditure-estimate across 500 repeated measures for 37 infants.

RESULTS

Research results indicate that preterm infants expend more energy when they show the following seven behaviors: grimace, sucking, diffusion squirm, fist, gape face, salute, and sneezing.

PRACTICE IMPLICATIONS

The interventions for preterm infants should be flexible, according to the infant's stress behaviors and conditions of energy expenditure.

Maternal behavior and infant physiology during feeding in premature and term infants over the first year of life

Little is known about the relationship between maternal behavior and the stability of premature infants' physiologic responses during feeding. In a secondary data analysis, we examined relationships between quality of maternal behavior and cardiorespiratory physiology during feeding in 61 premature and 53 term infants at four times over the first year of life. Measures included heart rate (HR), respiratory rate (RR), and oxygen saturation; Child Feeding Skills Checklist; and Parent-Child Early Relational Assessment. Birthweight, gestational age, and neurodevelopmental risk were covariates. Quality of maternal behavior did not predict infants' physiologic response to feeding. However, birthweight was related to infant feeding physiology among all infants over the first year of life. Stress during fetal life, which may lead to impaired intrauterine growth and low birthweight, may have longitudinal effects on cardiorespiratory functioning of premature infants. Research is needed to further investigate the biological pathways by which maternal-infant interaction supports behavioral and physiologic feeding outcomes of premature infants.

Neonatal physiological and behavioral stress during neurological assessment

Physiological and behavioral effects of evaluative handling procedures were studied in 72 newborn infants: 36 preterm (30-35 weeks of gestation) and 36 full-term neonates (39-41 weeks of gestation). While the neurological assessment was physiologically and behaviorally destabilizing to both age groups, preterm subjects had higher heart rate (P < .001), greater increase in blood pressure (P < .01); decreased peripheral oxygenation inferred from mottled skin color (P < .001); and higher frequencies of finger splay (P < .001), arm salute (P < .01), hiccoughs (P < .001), and yawns (P < .001) than full-term subjects. Both groups demonstrated greater stress during the neuromotor phase of testing. Neonatal care professionals must scrutinize the diagnostic benefit, reliability, safety, and timing of neurological assessment given expected physiological and behavioral changes in stable preterm neonates.

A randomized placebo-controlled trial of massage therapy on the immune system of preterm infants

OBJECTIVES

The aim of this study was to investigate the effects of massage therapy (MT) on the immune system of preterm infants. The primary hypothesis was that MT compared with sham therapy (control) will enhance the immune system of stable premature infants by increasing the proportion of their natural killer (NK) cell numbers.

METHODS

A randomized placebo-controlled trial of MT versus sham therapy (control) was conducted among stable premature infants in the NICU. Study intervention was provided 5 days per week until hospital discharge for a maximum of 4 weeks. Immunologic evaluations (absolute NK cells, T and B cells, T cell subsets, and NK cytotoxicity), weight, number of infections, and length of hospital stay were also evaluated.

RESULTS

The study enrolled 120 infants (58 massage; 62 control). At the end of the study, absolute NK cells were not different between the 2 groups; however, NK cytotoxicity was higher in the massage group, particularly among those who received ≥5 consecutive days of study intervention compared with control (13.79 vs 10 lytic units, respectively; P = .04). Infants in the massage group were heavier at end of study and had greater daily weight gain compared with those in the control group; other immunologic parameters, number of infections, and length of stay were not different between the 2 groups.

CONCLUSIONS

In this study, MT administered to stable preterm infants was associated with higher NK cytotoxicity and more daily weight gain. MT may improve the overall outcome of these infants. Larger studies are needed.