Implementation of Listening Visits with Parents of Preterm Infants in an Italian Neonatal Intensive Care Unit.

PURPOSE: To assess the feasibility of implementing Listening Visits (LV) in an Italian neonatal intensive care unit (NICU). STUDY DESIGN AND METHODS: This feasibility implementation of LV included empathic listening and problem-solving sessions provided by a psychologist to 26 parents of hospitalized preterm newborns. Using the RE-AIM implementation framework, three facets of feasibility were assessed: reach, adoption, and implementation. RESULTS: It is feasible to integrate LV into the NICU: 76% of families were willing to try LV (reach). Listening Visits recipients reported high satisfaction. Twelve of the 16 families (75%) received six or more LV sessions (adoption), with mothers attending more sessions. Implementation fidelity, defined here as the percentage of LV recipients that received at least four sessions, was 94% among mothers and 30% among fathers. CLINICAL IMPLICATIONS: The LV intervention for parental support during the NICU stay is feasible and deemed helpful by parents. Parents were motivated to participate even though their levels of depression, stress, and anxiety were not high. In addition to the use of standardized screening questionnaires, parental requests and clinical team indications should be included in the decision-making for the provision of parental support services.

Early Intervention for Children Aged 0 to 2 Years With or at High Risk of Cerebral Palsy: International Clinical Practice Guideline Based on Systematic Reviews.

Importance: Cerebral palsy (CP) is the most common childhood physical disability. Early intervention for children younger than 2 years with or at risk of CP is critical. Now that an evidence-based guideline for early accurate diagnosis of CP exists, there is a need to summarize effective, CP-specific early intervention and conduct new trials that harness plasticity to improve function and increase participation. Our recommendations apply primarily to children at high risk of CP or with a diagnosis of CP, aged 0 to 2 years. Objective: To systematically review the best available evidence about CP-specific early interventions across 9 domains promoting motor function, cognitive skills, communication, eating and drinking, vision, sleep, managing muscle tone, musculoskeletal health, and parental support. Evidence Review: The literature was systematically searched for the best available evidence for intervention for children aged 0 to 2 years at high risk of or with CP. Databases included CINAHL, Cochrane, Embase, MEDLINE, PsycInfo, and Scopus. Systematic reviews and randomized clinical trials (RCTs) were appraised by A Measurement Tool to Assess Systematic Reviews (AMSTAR) or Cochrane Risk of Bias tools. Recommendations were formed using the Grading of Recommendations Assessment, Development, and Evaluation (GRADE) framework and reported according to the Appraisal of Guidelines, Research, and Evaluation (AGREE) II instrument. Findings: Sixteen systematic reviews and 27 RCTs met inclusion criteria. Quality varied. Three best-practice principles were supported for the 9 domains: (1) immediate referral for intervention after a diagnosis of high risk of CP, (2) building parental capacity for attachment, and (3) parental goal-setting at the commencement of intervention. Twenty-eight recommendations (24 for and 4 against) specific to the 9 domains are supported with key evidence: motor function (4 recommendations), cognitive skills (2), communication (7), eating and drinking (2), vision (4), sleep (7), tone (1), musculoskeletal health (2), and parent support (5). Conclusions and Relevance: When a child meets the criteria of high risk of CP, intervention should start as soon as possible. Parents want an early diagnosis and treatment and support implementation as soon as possible. Early intervention builds on a critical developmental time for plasticity of developing systems. Referrals for intervention across the 9 domains should be specific as per recommendations in this guideline.

Principles of early intervention.

The great majority of children with neurodevelopmental challenges do not get specific intervention until after their second birthday. This worsens their outcomes, because a great part of the entire neuroplastic window for learning is misspent. There is emerging evidence that the impact on outcomes of early goal-directed training involving the parents in infants with neurodevelopmental disabilities is significantly superior to the results achieved in older children and adults, especially if intervention commences in the first months of life. This chapter outlines the common elements of neurodevelopment and early intervention. It includes an outline of some of the primary early intervention practices and the scientific evidence driving them.

Relationship between brain structure and Cerebral Visual Impairment in children with Cerebral Palsy: A systematic review.

BACKGROUND: Cerebral Visual Impairment (CVI) is very common yet often unrecognised visual dysfunction in children with Cerebral Palsy (CP). Magnetic Resonance Imaging (MRI) is the diagnostic tool in the investigation of brain lesions in children with CP and CVI. AIM: The aim of this systematic review is to evaluate the relationship between brain structure and CVI, as determined by MRI in children with CP. METHODS AND PROCEDURES: A comprehensive search of 5 database (PubMed, EMBASE, SCOPUS, CINAHL and Cochrane Database) was undertaken up until June 2019. The PRISMA checklist was then utilised to report on the process of selecting eligible papers. A total of 30 observational studies met the full inclusion criteria. Further, STROBE checklist was employed to report on the observational studies. OUTCOMES AND RESULTS: Periventricular leucomalacia on MRI was found to have a strong association with CVI in all 30 studies. Only 13 (43 %) studies described dorsal and/ ventral stream dysfunction. There was ambiguity in the definition of CVI. CONCLUSIONS AND IMPLICATIONS: The overall level of evidence correlating different patterns of CVI and CP (based on GMFCS, motor type and distribution) and MRI was low. Further studies utilising advances in MRI are needed to understand brain reorganisation and patterns of CVI and suggest rehabilitation therapy inclusive of vision.

EPISIOTOMY INFECTIONS IN THE PUERPERIUM AND ANTIMICROBIAL RESISTANCE OF RESPONSIBLE PATHOGENS IN UKRAINE.

OBJECTIVE: The aim: To obtain the first estimates of the current prevalence rate of episiotomy infections in the puerperium and antimicrobial resistance of responsible pathogens in Ukraine. PATIENTS AND METHODS: Materials and methods: We performed a retrospective multicenter cohort study was based on surveillance data. The study population consisted of all women who had a vaginal delivery in 7 Regional Women's Hospitals of Ukraine. Definitions of episiotomy infections were used from the Centers for Disease Control and Prevention's National Healthcare Safety Network (CDC/NHSN). RESULTS: Results: Total 35.6% women after vaginal delivery had episiotomy done. The prevalence rate of episiotomy infections was 17.7%. The predominant pathogens were: Escherichia coli (49.2%), Enterobacter spp. (11.1%), Streptococcus spp. (9.1%), Enterococcus faecalis (6.5%), Klebsiella spp. (8.1%), followed by Pseudomonas aeruginosa (4.7%), Staphylococcus aureus (4.2%), Proteus spp.(2.9%) and Staphylococcus epidermidis (2.8%). The overall proportion of methicillin-resistance was observed in 17.3% of Staphylococcus aureus (MRSA). Vancomycin resistance was observed in 6.8% of isolated enterococci. Carbapenem resistance was identified in 8% of P.aeruginosa isolates. Resistance to third-generation cephalosporins was observed in 15.2% Klebsiella spp. and E.coli 16.4% isolates. The overall proportion of extended spectrum beta-lactamases (ESBL) production among Enterobacteriaceae was 26.4%. The prevalence of ESBL production among E. coli isolates was significantly higher than in K. pneumoniae (31.4%, vs 12.5%). CONCLUSION: Conclusions:Episiotomy infections in the puerperium are common in Ukraine and most of these infections caused by antibiotic-resistant bacteria. Optimizing the management and empirical antimicrobial therapy may reduce the burden of episiotomy infections, but prevention is the key element.

The Pooled Diagnostic Accuracy of Neuroimaging, General Movements, and Neurological Examination for Diagnosing Cerebral Palsy Early in High-Risk Infants: A Case Control Study.

INTRODUCTION: Clinical guidelines recommend using neuroimaging, Prechtls' General Movements Assessment (GMA), and Hammersmith Infant Neurological Examination (HINE) to diagnose cerebral palsy (CP) in infancy. Previous studies provided excellent sensitivity and specificity for each test in isolation, but no study has examined the pooled predictive power for early diagnosis. METHODS: We performed a retrospective case-control study of 441 high-risk infants born between 2003 and 2014, from three Italian hospitals. Infants with either a normal outcome, mild disability, or CP at two years, were matched for birth year, gender, and gestational age. Three-month HINE, GMA, and neuroimaging were retrieved from medical records. Logistic regression was conducted with log-likelihood and used to determine the model fit and Area Under the Curve (AUC) for accuracy. RESULTS: Sensitivity and specificity for detecting CP were 88% and 62% for three-month HINE, 95% and 97% for absent fidgety GMs, and 79% and 99% for neuroimaging. The combined predictive power of all three assessments gave sensitivity and specificity values of 97.86% and 99.22% (PPV 98.56%, NPV 98.84%). CONCLUSION: CP can be accurately detected in high-risk infants when these test findings triangulate. Clinical implementation of these tools is likely to reduce the average age when CP is diagnosed, and intervention is started.

Cerebral Palsy: Early Markers of Clinical Phenotype and Functional Outcome.

The Prechtl General Movement Assessment (GMA) has become a cornerstone assessment in early identification of cerebral palsy (CP), particularly during the fidgety movement period at 3-5 months of age. Additionally, assessment of motor repertoire, such as antigravity movements and postural patterns, which form the Motor Optimality Score (MOS), may provide insight into an infant's later motor function. This study aimed to identify early specific markers for ambulation, gross motor function (using the Gross Motor Function Classification System, GMFCS), topography (unilateral, bilateral), and type (spastic, dyskinetic, ataxic, and hypotonic) of CP in a large worldwide cohort of 468 infants. We found that 95% of children with CP did not have fidgety movements, with 100% having non-optimal MOS. GMFCS level was strongly correlated to MOS. An MOS > 14 was most likely associated with GMFCS outcomes I or II, whereas GMFCS outcomes IV or V were hardly ever associated with an MOS > 8. A number of different movement patterns were associated with more severe functional impairment (GMFCS III-V), including atypical arching and persistent cramped-synchronized movements. Asymmetrical segmental movements were strongly associated with unilateral CP. Circular arm movements were associated with dyskinetic CP. This study demonstrated that use of the MOS contributes to understanding later CP prognosis, including early markers for type and severity.

Surgical Site Infections and Antimicrobial Resistance in Kyiv City Hospitals, Ukraine.

OBJECTIVE: Introduction: Surgical site infections (SSIs) are associated with increased morbidity and mortality. Scant information is available on the SSI in Ukrainian hospitals. The aim: to determine the incidence of SSIs and estimates antimicrobial resistance of the major responsible pathogens in Kyiv city hospitals. PATIENTS AND METHODS: Materials and methods:This study was conducted from January 2011 to December 2013 in 3 hospitals. Definitions of SSIs were adapted from the CDC/NHSN. The identification and antimicrobial susceptibility of cultures were determined, using automated microbiology analyzer. Some antimicrobial susceptibility test used Kirby - Bauer antibiotic testing. RESULTS: Results: Among 9,162 patients, 1,912 (20.9%) SSIs were observed. The high SSI case in appendectomy (29.8 %), gastric, small and large bowel surgeries (28.4 %), cholelithiasis (25.7%), and orthopedic procedures (22.9 %). Low infection rate in excision of dermoid cysts, lipoma (5.3%) and lower segment caesarean structure (6.5%). Staphylococcus aureus were most commonly reported, accounting for 27,8% of all organisms, followed by Escherichia coli (18.4 %), Pseudomonas aeruginosa (11.9 %) and Enterococcus faecalis (11.6 %). The antimicrobial resistance in the isolates associated with SSIs showed, among the Gram-positive bacteria, that 43.8% and 4.7% of CoNS isolates were ß-lactam (oxacillin) - and glycopeptide (teicoplanin) - resistant, respectively. Meticillin resistance was reported in 35.7 % of S. aureus isolates. CONCLUSION: Conclusions: SSIs and antimicrobial resistance of the responsible pathogens is an actually problem. One essential step in the prevention of SSIs is to implement a nationalsystem for their surveillance.

Standardized music therapy with and without acclimatization, to improve EEG data acquisition in young children with and without disability.

INTRODUCTION: In young children, EEG data acquisition during stimulation tasks is difficult due to anxiety, movement and behaviorally-related interruptions, especially in those with disabilities. NEW METHOD: We used standardized music therapy (MT) protocols with and without acclimatization, during and prior to time-locked EEG with a published tactile testing protocol. Our prospective study leveraged a larger trial in children with/without cerebral palsy aged 7-27 months. Group1 received no preparation, Group2 received 15-minute MT prior to the EEG session, Group3 received the same as Group2 plus a rubber cap for home practice. All groups received MT procedural support during the EEG session. Sessions were stopped/started to acquire a full dataset. Trials were reviewed using a two-step artifact detection strategy by specialists masked to group allocation. RESULTS: 64 patients were included, 20 each in Groups 2 and 3, and 24 in Group1. Average age was 16.08 ± 6.33 months. All (100%) of children had data of sufficient quality and quantity for outcomes measurement without a second testing visit. There were no differences in useable trials by procedural group, disability status, age or stimulus condition. EEG recording time was shorter in Group3 vs. 1 (p = 0.02) and more patients in Group1 required repeat trials compared to Groups2 and 3 (p = 0.04 for both). COMPARISON WITH OLD METHOD: Our new methods resulted in no attrition from data loss, an improvement compared to published similar studies with data loss 30-55%. Acclimatization had minimal effects. CONCLUSION: In children under 3, MT protocols result in high rates of EEG data acquisition, decrease behaviorally-related interruptions and session acquisition time. This method is successful for typically developing children and those with cerebral palsy.

Early Intervention to Improve Sucking in Preterm Newborns: A Systematic Review of Quantitative Studies.

BACKGROUND: Premature birth is associated with feeding difficulties due to inadequate coordination of sucking, swallowing, and breathing. Nonnutritive sucking (NNS) and oral stimulation interventions may be effective for oral feeding promotion, but the mechanisms of the intervention effects need further clarifications. PURPOSE: We reviewed preterm infant intervention studies with quantitative outcomes of sucking performance to summarize the evidence of the effect of interventions on specific components of sucking. METHODS: PubMed, CINAHL, MEDLINE, EMBASE, and PSYCOLIST databases were searched for English language publications through August 2017. Studies were selected if they involved preterm infants, tested experimental interventions to improve sucking or oral feeding skills, and included outcome as an objective measure of sucking performance. Specific Medical Subject Headings (MeSH) terms were utilized. RESULTS: Nineteen studies were included in this review: 15 randomized, 1 quasi-randomized, and 3 crossover randomized controlled trials. Intervention types were grouped into 6 categories (i) NNS, (ii) NNS with auditory reinforcement, (iii) sensorimotor stimulation, (iv) oral support, (v) combined training, and (vi) nutritive sucking. Efficiency parameters were positively influenced by most types of interventions, though appear to be less affected by trainings based on NNS alone. IMPLICATIONS FOR PRACTICE: These findings may be useful in the clinical care of infants requiring support to achieve efficient sucking skills through NNS and oral stimulation interventions. IMPLICATIONS FOR RESEARCH: Further studies including quantitative measures of sucking performance outcome measures are needed in order to best understand the needs and provide more tailored interventions to preterm infants.

A randomised controlled trial of protocolised music therapy demonstrates developmental milestone acquisition in hospitalised infants.

AIM: To compare the effectiveness of an intensive-intermittent vs. standard spaced protocolised music therapy intervention on supporting developmental milestone acquisition of infants >44 weeks postmenstrual age (PMA) hospitalised in a Neonatal Intensive Care Unit (NICU). METHOD: This was a comparative effectiveness study of infants 44-66 weeks PMA with a projected NICU stay of at least one month from recruitment. Infants were randomised to one of two treatment groups: traditional therapy (2x/week) and intermittent-intensive (4x/week, off, 4x/week, off). Both groups received the same number of sessions over a 4-week period. Sessions at the start and end of the treatment period were video recorded. Two masked researchers reviewed and coded videos. Milestones used for video recording were adapted from the Developmental Assessment of Young Children. RESULTS: Twenty-four infants participated, with groups matched for birth age, PMA at start of study, race, IVH severity, and respiratory support. Total and motor composite scores were higher post-intervention (Cohen's d = 0.71 and 0.97, both p < 0.01), with the same degree of skill acquisition found for both intervention groups. CONCLUSION: A developmental music therapy protocol supports developmental skills acquisition of post-term infants in a NICU. Similar outcomes for both groups provide therapists with varying treatment dosing options to best support their patients.

Hammersmith Infant Neurological Examination Asymmetry Score Distinguishes Hemiplegic Cerebral Palsy From Typical Development.

BACKGROUND: The Hammersmith Infant Neurological Examination is one of several useful tools for early identification of cerebral palsy; however, cut-off scores for cerebral palsy do not consistently distinguish infants with hemiplegia from those typically developing. We hypothesized that use of an asymmetry score, in addition to the assessment's standard total cutoff score, could remedy this problem in a clinical setting. METHODS: This retrospective study of a neonatal intensive care follow-up program with consistent clinical use of the Hammersmith Infant Neurological Examination matched infants with a diagnosis of cerebral palsy to infants without motor delays or evidence of neurodevelopmental impairments. Groups had same corrected and gestational ages at Hammersmith Infant Neurological Examination assessment. Asymmetry presence was recorded. RESULTS: Of 74 infants with cerebral palsy, 28 had quadriplegia, 11 had diplegia, and 35 had hemiplegia. Median total Hammersmith Infant Neurological Examination and asymmetry scores for hemiplegia were 57.5 and 10 versus 76 and 0 for those without cerebral palsy. Sensitivity and specificity to distinguish hemiplegia from typical development by combining a total Hammersmith Infant Neurological Examination score less than 63 and an asymmetry score greater than 5 were 91.8% and 100%, respectively. CONCLUSIONS: In a clinical setting, combining total Hammersmith Infant Neurological Examination and asymmetry scores can help providers differentiate infants with hemiplegia from those typically developing.

Feasibility of event-related potential (ERP) biomarker use to study effects of mother's voice exposure on speech sound differentiation of preterm infants.

Atypical maturation of auditory neural processing contributes to preterm-born infants' language delays. Event-related potential (ERP) measurement of speech-sound differentiation might fill a gap in treatment-response biomarkers to auditory interventions. We evaluated whether these markers could measure treatment effects in a quasi-randomized prospective study. Hospitalized preterm infants in passive or active, suck-contingent mother's voice exposure groups were not different at baseline. Post-intervention, the active group had greater increases in/du/-/gu/differentiation in left frontal and temporal regions. Infants with brain injury had lower baseline/ba/-/ga/and/du/-/gu/differentiation than those without. ERP provides valid discriminative, responsive, and predictive biomarkers of infant speech-sound differentiation.

Pulmonary sequelae and functional limitations in children and adults with bronchopulmonary dysplasia.

Preterm infants with bronchopulmonary dysplasia (BPD) often suffer from life-long pulmonary impairments in pulmonary physical function. This review summarizes our current understanding of the chronic pulmonary impairments and physical functional limitations associated with BPD from preterm birth to adulthood. It also identifies opportunities for intervention in children and adults living with chronic lung disease (CLD) after preterm birth.

Vision Assessments and Interventions for Infants 0-2 Years at High Risk for Cerebral Palsy: A Systematic Review.

We performed a systematic review and evaluated the level of evidence of vision interventions and assessments for infants at high risk for or with a diagnosis of cerebral palsy from zero to two years of age. Articles were evaluated based on the level of methodologic quality, evidence, and clinical utilization. Thirty publications with vision assessments and five with vision interventions met criteria for inclusion. Assessments included standard care neuroimaging, electrophysiology, and neuro-ophthalmologic examination techniques that are utilized clinically with any preverbal or nonverbal pediatric patient. The overall level of evidence of interventions was strong for neuroprotective interventions such as caffeine and hypothermia but weak for surgery, visual training, or developmental programs. There are few evidence-based interventions and assessments that address cerebral/cortical visual impairment-related needs of infants and toddlers at high risk for or with cerebral palsy. Recommendation guidelines include the use of three types of standard care methodologies and two types of protective interventions.

Cry presence and amplitude do not reflect cortical processing of painful stimuli in newborns with distinct responses to touch or cold.

OBJECTIVE: Newborns requiring hospitalisation frequently undergo painful procedures. Prevention of pain in infants is of prime concern because of adverse associations with physiological and neurological development. However, pain mitigation is currently guided by behavioural observation assessments that have not been validated against direct evidence of pain processing in the brain. The aim of this study was to determine whether cry presence or amplitude is a valid indicator of pain processing in newborns. DESIGN: Prospective observational cohort. SETTING: Newborn nursery. PATIENTS: Healthy infants born at >37 weeks and <42 weeks gestation. INTERVENTIONS: We prospectively studied newborn cortical responses to light touch, cold and heel stick, and the amplitude of associated infant vocalisations using our previously published paradigms of time-locked electroencephalogram (EEG) with simultaneous audio recordings. RESULTS: Latencies of cortical peak responses to each of the three stimuli type were significantly different from each other. Of 54 infants, 13 (24%), 19 (35%) and 35 (65%) had cries in response to light touch, cold and heel stick, respectively. Cry in response to non-painful stimuli did not predict cry in response to heel stick. All infants with EEG data had measurable pain responses to heel stick, whether they cried or not. There was no association between presence or amplitude of cries and cortical nociceptive amplitudes. CONCLUSIONS: In newborns with distinct brain responses to light touch, cold and pain, cry presence or amplitude characteristics do not provide adequate behavioural markers of pain signalling in the brain. New bedside assessments of newborn pain may need to be developed using brain-based methodologies as benchmarks in order to provide optimal pain mitigation.

The Dual Nature of Early-Life Experience on Somatosensory Processing in the Human Infant Brain.

Every year, 15 million preterm infants are born, and most spend their first weeks in neonatal intensive care units (NICUs) [1]. Although essential for the support and survival of these infants, NICU sensory environments are dramatically different from those in which full-term infants mature and thus likely impact the development of functional brain organization [2]. Yet the integrity of sensory systems determines effective perception and behavior [3, 4]. In neonates, touch is a cornerstone of interpersonal interactions and sensory-cognitive development [5-7]. NICU treatments used to improve neurodevelopmental outcomes rely heavily on touch [8]. However, we understand little of how brain maturation at birth (i.e., prematurity) and quality of early-life experiences (e.g., supportive versus painful touch) interact to shape the development of the somatosensory system [9]. Here, we identified the spatial, temporal, and amplitude characteristics of cortical responses to light touch that differentiate them from sham stimuli in full-term infants. We then utilized this data-driven analytical framework to show that the degree of prematurity at birth determines the extent to which brain responses to light touch (but not sham) are attenuated at the time of discharge from the hospital. Building on these results, we showed that, when controlling for prematurity and analgesics, supportive experiences (e.g., breastfeeding, skin-to-skin care) are associated with stronger brain responses, whereas painful experiences (e.g., skin punctures, tube insertions) are associated with reduced brain responses to the same touch stimuli. Our results shed crucial insights into the mechanisms through which common early perinatal experiences may shape the somatosensory scaffolding of later perceptual, cognitive, and social development.

Speech and language interventions for infants aged 0 to 2 years at high risk for cerebral palsy: a systematic review.

AIM: We evaluated the level of evidence of speech, language, and communication interventions for infants at high-risk for, or with a diagnosis of, cerebral palsy (CP) from 0 to 2 years old. METHOD: We performed a systematic review of relevant terms. Articles were evaluated based on the level of methodological quality and evidence according to A Measurement Tool to Assess Systematic Reviews (AMSTAR) and Grading of Recommendations Assessment, Development and Evaluation (GRADE) guidelines. RESULTS: The search terms provided 17 publications consisting of speech or language interventions. There were no interventions in the high level of evidence category. The overall level of evidence was very low. Promising interventions included Responsivity and Prelinguistic Milieu Teaching and other parent-infant transaction frameworks. INTERPRETATION: There are few evidence-based interventions addressing speech, language, and communication needs of infants and toddlers at high risk for CP, and none for infants diagnosed with CP. Recommendation guidelines include parent-infant transaction programs.

Implementation of the Hammersmith Infant Neurological Examination in a High-Risk Infant Follow-Up Program.

BACKGROUND: High-risk infant follow-up programs provide early identification and referral for treatment of neurodevelopmental delays and impairments. In these programs, a standardized neurological examination is a critical component of evaluation for clinical and research purposes. METHODS: To address primary challenges of provider educational diversity and standardized documentation, we designed an approach to training and implementation of the Hammersmith Infant Neurological Examination with precourse materials, a workshop model, and adaptation of the electronic medical record. CONCLUSIONS: Provider completion and documentation of a neurological examination were evaluated before and after Hammersmith Infant Neurological Examination training. Standardized training and implementation of the Hammersmith Infant Neurological Examination in a large high-risk infant follow-up is feasible and effective and allows for quantitative evaluation of neurological findings and developmental trajectories.