Feasibility of a caregiver-assisted exercise program for preterm infants.

Mounting evidence shows that low-birth-weight and prematurity are related to serious health problems in adulthood, including increased body fat, decreased fitness, poor bone mineralization, pulmonary problems, and cardiovascular disease. There are data to suggest that increasing physical activity in preterm infants will have effects on short-term muscle mass and fat mass, but we also hypothesized that increasing physical activity early in life can lead to improved health outcomes in adulthood. Because few studies have addressed the augmentation of physical activity in premature babies, the objective of this study was to evaluate the feasibility of whether caregivers (mostly mothers) can learn from nurses and other healthcare providers to implement a program of assisted infant exercise following discharge. Ten caregivers of preterm infants were taught by nurses, along with occupational therapists and other healthcare providers, to perform assisted infant exercise and instructed to conduct the exercises daily for approximately 3 weeks. The researchers made home visits and conducted qualitative interviews to understand the caregivers' experiences with this exercise protocol. Quantitative data included a caregiver's daily log of the exercises completed to measure adherence as well as videotaped caregiver sessions, which were used to record errors as a measure of proficiency in the exercise technique. On average, the caregivers completed a daily log on 92% of the days enrolled in the study and reported performing the exercises on 93% of the days recorded. Caregivers made an average of 1.8 errors on 2 tests (with a maximum of 23 or 35 items on each, respectively) when demonstrating proficiency in the exercise techniques. All caregivers described the exercises as beneficial for their infants, and many reported that these interventions fostered increased bonding with their babies. Nearly all reported feeling "scared" of hurting their babies during the first few days of home exercise but stated that fears were alleviated by practice in the home and further teaching and learning. Caregivers were willing and able to do the exercises correctly, and they expressed a belief that the intervention had positive effects on their babies and on caregiver-infant interactions. These findings have important implications for nursing practice because nurses are in key positions to teach and encourage caregivers to practice these exercises with their newborn babies.

The Societal Importance of Embracing Counterintuitive Thought in Science: Assisted Exercise in Preterm Infants for Long-term Health Outcomes.

For research to lead to progressive change, scientists and society must embrace what may seem counterintuitive. While there is often resistance to changing views of what we presume to already understand, we must be open to evolving knowledge and evidence. Our research is examining the effect of a novel intervention designed to increase physical activity of premature babies in their first year of life on: (1) body composition, (2) associated biochemical and cellular mechanisms of growth and inflammation, and (3) quality of maternal care. This study is novel because it is counterintuitive to prevailing knowledge of the care and treatment of infants born prematurely. Traditionally, we swaddle infants and restrict their movement in order to minimize energy expenditure. We are proposing the opposite: to increase energy expenditure in a systematic, controlled way in order to increase muscle mass and bone density, with the ultimate goal of preventing diseases associated with lack of muscle mass or bone density. Our research actively engages the mothers in the study by learning about their perceptions and their experiences of doing the exercise with their infants because the mothers, too, are aware of the prevailing views that are counter to what they are being asked to do. The mothers have taught us, however, that they are willing to participate in this exercise study, while paradoxically also viewing their infants as "fragile" and are fearful of hurting their infants. Our thesis in this research-based paper is that science and society must work in tandem to be effective.

Enhancing the Construct and Content Validity of Rating Scales for Clinical Research: Using Qualitative Methods to Develop a Rating Scale to Assess Parental Perceptions of Their Role in Promoting Infant Exercise.

With a focus on the early stages of developing new assessment tools, we present an example of how researchers can apply qualitative data to the development of conceptual domains and specific items representing those domains for quantitative instruments. Specifically, our previous research examining mothers' perceptions and experiences of engaging in assisted exercise with their infants provided the foundation for the development of the Perceptions of Pediatric Activity Scale (PPAS). We describe the process we used to develop the PPAS as an exemplar for the process of incorporating qualitative data in instrument development. In addition, we address instrument development for diverse populations, and we provide examples illustrating how we extracted concepts using a concept-indicator model to construct the items in the PPAS. We conclude by noting that we are currently in the process of pilot-testing the PPAS to evaluate its utility and reliability.

Body composition and its components in preterm and term newborns: A cross-sectional, multimodal investigation.

A prospective, cross-sectional, observational study in preterm and term infants was performed to compare multimodal measurements of body composition, namely, limb ultrasound, bone quantitative ultrasound, and dual X-ray absorptiometry (DXA). One hundred and two preterm and term infants appropriate for gestational age were enrolled from the newborn nursery and neonatal intensive care unit. Infants were included when they were medically stable, in an open crib, on full enteral feeds and within 1 week of anticipated discharge. Correlations among the various measurements of body composition were performed using standard techniques. A comparison between preterm infant (born at 28-32 weeks) reaching term to term-born infants was performed. Limb ultrasound estimates of cross-sectional areas of lean and fat tissue in a region of tissue (i.e., the leg) were remarkably correlated with regional and whole-body estimates of fat-free mass and fat obtained from DXA suggesting the potential usefulness of muscle ultrasound as an investigative tool for studying aspects of body composition in this fragile population. There was a weak but significant correlation between quantitative ultrasound measurements of bone strength and DXA-derived bone mineral density (BMD). Preterm infants reaching term had significantly lower body weight, length, head circumference, muscle and fat cross-sectional area, bone speed of sound, whole-body and regional lean body mass, fat mass, and BMD compared to term-born infants. Current postnatal care and nutritional support in preterm infants is still unable to match the in-utero environment for optimal growth and bone development. The use of relatively simple bedside, noninvasive body composition measurements may assist in understanding how changes in different components of body composition early in life affect later growth and development.

Maternal perceptions of infant exercise in the neonatal intensive care unit.

OBJECTIVE: To identify important factors that influence mothers' perceptions of engaging in exercise with their preterm infants. DESIGN: Qualitative, semistructured individual interviews. SETTING: Neonatal Intensive Care Unit. PARTICIPANTS: Thirteen mothers of preterm infants who were in the Neonatal Intensive Care Unit. METHODS: Two researchers conducted interviews with mothers in English or Spanish. Interviews were recorded, transcribed, and analyzed. RESULTS: Mothers tended to view infant exercise as beneficial but feared for the safety of their infants. They perceived nurses as experts who could safely exercise their infants but feared that they themselves might harm their infants. Factors that influenced their beliefs included previous experiences with infant exercise and views regarding the fragility or the strength of their own infants. Mothers identified nurses, doctors, family members, and research studies as trusted sources of information on exercise efficacy and safety. CONCLUSION: Understanding and addressing mothers' perceptions is a crucial component of a nursing intervention that teaches parents to do assisted exercises at home with their preterm infants.