Description and evidence on the supporting and enhancing neonatal intensive care unit sensory experiences (SENSE) program.

AIM: To describe the supporting and enhancing neonatal intensive care unit (NICU) sensory experiences (SENSE) program, associated research and opportunities for further study. METHODS: A review of current materials on SENSE program implementation, publications related to SENSE development, and research on program implementation and patient outcomes was conducted to describe the SENSE program and its associated research. RESULTS: The SENSE program combines structured, evidence-based, multisensory interventions with parent engagement in order to optimise outcomes in the complex NICU environment. Through a stepwise and scientific process, the SENSE program was developed to include specific doses and targeted timing (based on the infant's postmenstrual age, PMA) of evidence-based interventions such as massage, auditory exposure, rocking, holding and skin-to-skin care for parents to provide their infants each day of NICU hospitalisation. It is adapted in context of concurrent medical interventions, infant behavioural responses, as well as NICU culture. The program is feasible to implement, acceptable to staff, and related to infants receiving more developmentally appropriate sensory exposures. Adaptations related to NICU culture and parent involvement have been reported. Research has identified relationships of the SENSE program to improved parent confidence, neurobehaviour and feeding at term age as well as improved communication 1 year of age. CONCLUSION: The literature related to the SENSE program is promising, but more research on efficacy and implementation is needed.

Organizational Barriers to and Facilitators of the Successful Implementation and Sustainability of the Supporting and Enhancing NICU Sensory Experiences (SENSE) Program.

IMPORTANCE: The Supporting and Enhancing NICU Sensory Experiences (SENSE) program is an evidence-based intervention that promotes daily, positive sensory exposures for infants in the neonatal intensive care unit (NICU). Understanding program implementation across sites may aid in optimizing strategies for uptake of the program and subsequently improve outcomes for infants and families. OBJECTIVE: To investigate health care professionals' perceptions of implementing the SENSE program. DESIGN: The SENSE Program Implementation Survey was developed using Proctor et al.'s model and the BARRIERS scale to probe organizational practices across sites worldwide. SETTING: Survey distributed to 211 hospitals with a SENSE program license obtained before March 2020. PARTICIPANTS: One hundred fourteen NICU personnel (response rate = 54%). OUTCOMES AND MEASURES: The survey sought to understand barriers and facilitators, adaptations during implementation, and associated costs. RESULTS: Of the 53% (n = 57 of 107) of respondents who had implemented the SENSE program, many (n = 14; 31%) experienced quick timing (<1 mo) to use, including spread to nearly all infants in their NICU within 6 mo (n = 18; 35%). Most reported the program was used to educate families ≤3 days of birth (n = 20/59; 34%). Most of the sensory interventions in the program were performed by parents (n = 38; 67%) and therapists (n = 44; 77%). Barriers and facilitators at the organizational and individual levels were identified. No additional staff were hired to implement the program. CONCLUSIONS AND RELEVANCE: Given perceived successes and challenges, strategic enhancement of implementation can inform future administrations of the SENSE program. Plain-Language Summary: This study provides occupational therapists who are interested in implementing the SENSE program (Supporting and Enhancing NICU Sensory Experiences) with an understanding of common barriers, facilitators, costs, and adaptations, which can be used to advocate for program implementation in NICUs to improve outcomes for preterm infants worldwide.

Prevalence of Early Feeding Alterations Among Preterm Infants and Their Relationship to Early Neurobehavior.

IMPORTANCE: Feeding difficulties are common among preterm infants during neonatal intensive care unit (NICU) hospitalization. Although most preterm infants achieve full oral feeding by term-equivalent age, whether feeding difficulties persist despite the infant taking full volume and whether these difficulties may relate to other neurobehavioral challenges remain unclear. OBJECTIVE: To identify the prevalence of feeding problems among preterm infants and the relationships between infant feeding behaviors and neurobehavior at term-equivalent age. DESIGN: Cohort study. SETTING: Level 4 NICU with 85 beds. PARTICIPANTS: Thirty-nine very preterm infants born ≤32 wk gestation (range = 22-32 wk). Exclusion criteria were congenital anomalies, >32 wk gestation at birth, and lack of feeding or neurobehavioral assessment at term-equivalent age. OUTCOMES AND MEASURES: Standardized feeding assessments using the Neonatal Eating Outcome Assessment and standardized neurobehavioral evaluation using the NICU Network Neurobehavioral Scale. RESULTS: Thirty-nine infants (21 female) were included in the final analysis. The mean Neonatal Eating Outcome Assessment score was 66.6 (SD = 13.3). At term-equivalent age, 10 infants (26%) demonstrated feeding challenges, 21 (54%) demonstrated questionable feeding issues, and 8 (21%) demonstrated normal feeding performance. Lower Neonatal Eating Outcome Assessment scores (poorer feeding performance) at term-equivalent age were associated with more suboptimal reflexes (p = .04) and hypotonia (p < .01). CONCLUSIONS AND RELEVANCE: Feeding challenges and questionable feeding performance were prevalent among preterm infants at term-equivalent age and appeared in conjunction with suboptimal reflexes and hypotonia. Understanding this finding enables therapists to take a holistic approach to addressing feeding difficulties. What This Article Adds: Elucidating the relationships between feeding performance and neurobehavior during the neonatal period allows for a better understanding of potential contributors to early feeding challenges and identifies targets for intervention.

Neurodevelopmental Outcomes following Preterm Birth and the Association with Postmenstrual Age at Discharge.

OBJECTIVE: This study aimed to (1) define the prevalence of motor, cognitive, and language delays in preterm infants born <32 weeks estimated gestational age (EGA); and (2) identify the relationship between the timing of discharge from the neonatal intensive care unit (NICU) and neurodevelopmental outcome in early childhood. STUDY DESIGN: This retrospective study of 172 preterm infants born <32 weeks EGA and hospitalized in a level-IV NICU captured medical factors, including timing of discharge, from the NICU stay. Standardized developmental testing at 1 to 2 years corrected age was conducted in the newborn follow-up clinic. RESULTS: At 1 to 2 years corrected age, the sample had an average Bayley Scales of Infant and Toddler Development (Bayley-III) cognitive composite score of 91.5 ± 17.4, language composite score of 84.5 ± 17.3, and motor composite score of 88.9 ± 18.4. Lower EGA at birth, necrotizing enterocolitis, patent ductus arteriosus, and oxygen requirement for >28 days were independently associated with higher postmenstrual age (PMA) at NICU discharge. Higher PMA at discharge was associated with poorer cognitive outcome [p < 0.001, ß = -1.1 (-1.6, -0.7)], poorer language outcome [p = 0.049, ß = -0.5 (-0.9, -0.003)], and poorer motor outcome [p <0.001, ß = -1.0 (-1.5, -0.5)]. For every additional week of hospitalization, scores were an average of 1.1 points lower in cognitive, 1.0 point lower in motor, and 0.5 points lower in language domains of the Bayley-III assessment. CONCLUSION: Poorer cognitive, language, and motor outcomes were associated with longer hospitalization, even after controlling for medical risk factors known to be associated with poorer outcome. This provides further evidence for the potential role of the environment in impacting developmental outcomes of infants hospitalized in the NICU. KEY POINTS: · There are high rates of developmental impairment among preterm infants born <32 weeks at 1 year to 2 years.. · The longer the infant is exposed to the NICU environment, the higher the risk of neurodevelopmental challenges.. · These findings provide increased motivation for optimizing the early NICU environment..

Applying the RE-AIM framework to evaluate the implementation of the Supporting and Enhancing NICU Sensory Experiences (SENSE) program.

BACKGROUND: To maximize the benefit of parent-directed, positive sensory exposures in the NICU, a structured sensory-based program titled the Supporting and Enhancing NICU Sensory Experiences (SENSE) program was developed that includes specific doses and targeted timing of evidence-based sensory exposures. METHODS: The Reach, Effectiveness, Adoption, Implementation, Maintenance (RE-AIM) framework was used to systematically evaluate the SENSE program as an implementation strategy. One-hundred preterm infants ≤32 weeks gestation were studied (61 receiving the SENSE program and 39 standard-of-care). Parent education time and infant sensory exposures were tracked, and parents completed a questionnaire that probed their perceptions about the SENSE program. RESULTS: One-hundered thirty-one families were recruited, and 100 (76%) enrolled. The SENSE program was initiated at an average postmenstrual age of 29.8 (±2.4) weeks; 4.9 (±5.6) days after birth. The average number of education sessions with families was 4.8 (±3.7) amounting to 72.3 (±37.4) total minutes over hospitalization. The total time of logged tactile and auditory exposures among SENSE recipients over the length of hospitalization was a median (IQ range) of 9325 (5295-15,694) minutes over an average of 10.1 (±7.6) weeks of hospitalization. There were differences in the proportion of tactile and auditory exposure targets received by the infant among those receiving the SENSE program compared to standard-of-care (91% compared to 48%; p < 0.0001). Ninety-five percent of infants tolerated the SENSE program as defined, with 5% of infants requiring intermittent adaptations or the interventions being stopped for a period that typically lasted 1-2 weeks. Earlier parent education was related to more parent participation in SENSE program interventions (p = 0.04). Eighty-five percent of participants receiving the SENSE program had most of the sensory interventions completed by parents, as opposed to the medical or sensory support team. Seventy-two percent of infants had at least 100% of the auditory and tactile doses conducted over the length of stay. Parents reported acceptability. CONCLUSION: The SENSE program had good reach, was effective and acceptable with minimal cost, was adopted, and had good fidelity. Insights from implementation of the SENSE program (within a research study) informed future strategies to aid maintenance during dissemination.

Factors related to enrolment in early therapy services following neonatal intensive care unit discharge.

AIM: Early therapy can improve developmental outcomes for preterm infants. However, preterm infants who are referred have low enrolment in early therapy services following neonatal intensive care unit (NICU) discharge. This manuscript aims to investigate the relationship between infant medical and sociodemographic factors and enrolment in early therapy services post-NICU discharge, when system-related barriers to access are minimised. METHODS: This was a retrospective investigation of 89 families with infants born ≤32 weeks of gestation. Families were approached for enrolment into early therapy services following NICU discharge through Baby Bridge programming, which aims to improve access to therapy services following NICU discharge. RESULTS: Seventy-three (82%) families enrolled in early therapy services, and 16 (18%) families declined. Parents were more likely to enrol in early therapy if they had public insurance (P = 0.01), a maternal psychiatric diagnosis (P = 0.02) or additional children under 18 years in the home (P = 0.01). No infant medical factors were related to enrolment. CONCLUSION: Although enrolment rates were high, 18% of families refused therapy services, despite removing system-related barriers to access. Targeted interventions can be developed to increase enrolment in early therapy services among populations who are most likely to refuse therapy services after NICU discharge.

Neurobehaviour of very preterm infants at term equivalent age is related to early childhood outcomes.

AIM: To describe neurodevelopmental outcomes during early childhood among infants born very preterm and define the relationships between neurobehaviour of very preterm infants and neurodevelopmental outcomes at 4 years. METHODS: Forty-eight infants born ≤32 weeks gestation had neurobehaviour assessed at term equivalent age using the NICU Network Neurobehavioral Scale (NNNS). Outcomes at 4 years were assessed with the Ages and Stages Questionnaire (ASQ-3), the Sensory Profile-Short Form (SF) and the Behavior Rating Inventory of Executive Function-Preschool version (BRIEF-P). RESULTS: At 4 years, 23 (48%) children had at least one below average score on the ASQ-3, 15 (31%) had a below average total score on the Sensory Profile-SF, and 3 (6%) had an abnormal total score on the BRIEF-P. Children with lower fine motor scores at 4 years had poorer orientation (P = 0.03) and self-regulation (P =0.03), hypertonia (P = 0.01), and more sub-optimal reflexes (P = 0.02) as neonates. Children with lower gross motor scores at 4 years of age had more sub-optimal reflexes (P = 0.03) and lethargy (P = 0.046) as neonates. Children with tactile sensitivity at 4 years of age had poorer orientation (P = 0.01) and tolerance of handling (P = 0.03) as neonates. Children with decreased responsiveness at 4 years of age had low arousal (P = 0.02) as neonates, and those with poor auditory filtering at age 4 years had hypotonia (P = 0.03) as neonates. CONCLUSION: Early neurobehaviour is related to neurodevelopmental outcome in early childhood.

Neonatal Therapy Staffing in the United States and Relationships to Neonatal Intensive Care Unit Type and Location, Level of Acuity, and Population Factors.

OBJECTIVES: This study aimed to (1) estimate the total pool of neonatal therapists (occupational therapists, physical therapists, and speech-language pathologists who work in the neonatal intensive care unit [NICU]) and the average number represented in each U.S. based NICU, and (2) investigate the relationships between the number and type of neonatal therapy team members to NICU/hospital, population, and therapy factors. STUDY DESIGN: This study used several methods of data collection (surveys, phone calls, and web site searches) that were combined to establish a comprehensive list of factors across each NICU in the United States. RESULTS: We estimate that there are 2,333 full-time equivalent (FTE) positions designated to neonatal therapy coverage, with 4,232 neonatal therapists covering those FTEs. Among 564 NICUs with available neonatal therapy staffing data, 432 (76%) had a dedicated therapy team, 103 (18%) had pro re nata (as the circumstances arise; PRN) therapy coverage only, and 35 (6%) had no neonatal therapy team. Having a dedicated therapy team was more likely in level-IV (n = 112; 97%) and -III (n = 269; 83%) NICUs compared with level-II NICUs (n = 51; 42%; p < 0.001). Having a dedicated therapy team was related to having more NICU beds (p < 0.001), being part of a free-standing children's hospital or children's hospital within a hospital (p < 0.001), and being part of an academic medical center or community hospital (p < 0.001). Having a dedicated therapy team was more common in the Southeast, Midwest, Southwest, and West (p = 0.001) but was not related to the proportion of the community living in poverty or belonging to racial/ethnic minorities (p > 0.05). There was an average of 17 beds per neonatal therapy FTE, a good marker of therapy coverage based on NICU size. Three-hundred U.S. based NICUs (22%) had at least one Certified Neonatal Therapist (CNT) in early 2020, with CNT presence being more likely in higher acuity NICUs (59% of level-IV NICUs had at least one CNT). CONCLUSION: Understanding the composition of neonatal therapy teams at different hospitals across the U.S. can drive change to expand neonatal therapy services aimed at optimizing outcomes of high-risk infants and families. KEY POINTS: · We estimated that there are 4,232 neonatal therapists working in NICUs in the United States.. · Dedicated therapy teams for the NICU are more common in large, high acuity NICUs.. · An average of 17 beds per neonatal therapy FTE was observed.. · In 2020, 22% of NICUs had CNTs, and CNTs were more common in large and high acuity NICUs.. · Benchmarking neonatal therapy staffing can aid in expanding NICU therapy services where needed..

Auditory exposure of high-risk infants discharged from the NICU and the impact of social factors.

AIM: To (a) define the early home auditory environment of high-risk infants within one month of neonatal intensive care unit (NICU) discharge, (b) compare auditory exposures in the home environment to the NICU environment,  and (c) define relationships between maternal/infant factors and auditory exposures within the home. METHODS: Seventy-three high-risk infants (48 high-risk infants in the NICU at term-equivalent age and 25 high-risk infants in the home following NICU discharge) had auditory exposures measured. RESULTS: An average of 1.3 hours more noise (P ≤ .001) and 2 hours less silence (P = .01) were observed in the NICU compared with the home, but differences varied based on whether comparing to an open ward or private room. Infants with public insurance, lower household income and mothers without a college education were exposed to an average of 2.8, 3.0 and 2.3 hours more TV/electronic sounds respectively (P < .05). An average of 1744 fewer adult words (P = .03) were spoken in households with public insurance. There was an average of 3.1 hours less silence and 4.5 dB louder stimuli among households with lower income (P < .05). CONCLUSION: Elucidating differences across environments can lead to interventions to foster appropriate auditory exposures to improve language development of high-risk infants.

Maternal Milk and Relationships to Early Neurobehavioral Outcome in Preterm Infants.

The purpose of this study was to (1) define medical and sociodemographic factors related to maternal milk feedings and (2) explore relationships between maternal milk feeding and early neurobehavioral outcome. Ninety-two preterm infants born ≤ 32 weeks gestation had maternal milk feeding and breastfeeding tracked in this retrospective analysis. At 34 to 41 weeks postmenstrual age (PMA), neurobehavior was assessed with the NICU Network Neurobehavioral Scale. Maternal milk feeding was often delayed by the use of total parenteral nutrition, administered for a median of 11 (7-26) days, impacting the timing of gastric feeding initiation. Seventy-nine (86%) infants received some maternal milk during neonatal intensive care unit (NICU) hospitalization. Twenty-one (27%) infants continued to receive maternal milk at 34 to 41 weeks PMA, with 10 (48%) of those receiving maternal milk exclusively. Among mothers who initiated maternal milk feeds, 20 (25%) put their infants directly at the breast at least once during hospitalization. Mothers who were younger (P = .02), non-Caucasian (P < .001), or on public insurance (P < .001) were less likely to provide exclusive maternal milk feedings by 34 to 41 weeks PMA. Infants who received maternal milk at 34 to 41 weeks PMA demonstrated better orientation (P = .03), indicating they had better visual and auditory attention to people and objects in the environment. Our findings demonstrate a relationship between maternal milk feedings and better neurobehavior, which is evident before the infant is discharged home from the NICU.

Interrater Reliability and Concurrent Validity of the Neonatal Eating Outcome Assessment.

IMPORTANCE: Few neonatal feeding assessments are currently available, and the Neonatal Eating Outcome Assessment is the only one that identifies feeding impairment while considering the developmental changes that occur from preterm birth to term-equivalent age. OBJECTIVE: To determine the interrater reliability and concurrent validity of the Neonatal Eating Outcome Assessment. DESIGN: Prospective, observational study. SETTING: Level 4 neonatal intensive care unit. PARTICIPANTS: A convenience sample of 7 neonatal therapists participated in reliability testing. For concurrent validity, a prospective cohort of 52 preterm infants born ≤32 wk gestation had feeding assessed at term-equivalent age. OUTCOMES AND MEASURES: Intraclass correlations (ICCs) and Fleiss's κ statistics were used to define reliability across therapists, who independently scored five videos of preterm infants orally feeding using the Neonatal Eating Outcome Assessment. Concurrent validity was determined by evaluating relationships between the Neonatal Oral Motor Assessment Scale (NOMAS) and the Neonatal Eating Outcome Assessment using an independent-samples t test and χ² analysis. RESULTS: The ICC for the Neonatal Eating Outcome Assessment total score was 0.90 (confidence interval [CI] [0.70, 0.99]). Fleiss's κ scores for the 19 scorable items on the Neonatal Eating Outcome Assessment had predominately moderate, fair, and slight agreement, with 3 items having poor agreement. Dysfunctional NOMAS scores were related to lower Neonatal Eating Outcome Assessment scores (t[49.4] = 3.72, mean difference = 12.2, 95% CI [5.60, 18.75], p = .001). CONCLUSIONS AND RELEVANCE: The Neonatal Eating Outcome Assessment has excellent reliability. Concurrent validity was established. WHAT THIS ARTICLE ADDS: This article reports that the final version of the Neonatal Eating Outcome Assessment (Version 5.7) has excellent interrater and concurrent validity and is an important tool to assess the occupation of infant feeding in clinical practice.

Non-Nutritive Sucking in the Preterm Infant.

OBJECTIVE: To identify the progression of non-nutritive sucking (NNS) across postmenstrual age (PMA) and to investigate the relationship of NNS with medical and social factors and oral feeding. STUDY DESIGN: Fifty preterm infants born at ≤32 weeks gestation had NNS assessed weekly starting at 32 weeks PMA with the NTrainer System. Oral feeding was assessed at 38 weeks PMA. RESULTS: There were increases in NNS bursts per minute (p = 0.005), NNS per minute (p < 0.0001), NNS per burst (p < 0.001), and peak pressure (p = 0.0003) with advancing PMA. Level of immaturity and medical complications were related to NNS measures (p < 0.05). NNS measures were not related to Neonatal Oral Motor Assessment Scale scores. Smaller weekly change in NNS peak pressure (p = 0.03; ß = -1.4) was related to feeding success at 38 weeks PMA. CONCLUSION: Infants demonstrated NNS early in gestation. Variability in NNS scores could reflect medical complications and immaturity. More stable sucking pressure across time was related to feeding success at 38 weeks PMA.

Health Care Professionals' Perceptions about Sensory-Based Interventions in the NICU.

OBJECTIVE: The main objective of this article is to define perceptions of health care professionals regarding current use of sensory-based interventions in the neonatal intensive care unit (NICU). STUDY DESIGN: A multidisciplinary group of NICU health care professionals (n = 108) defined the types of sensory-based interventions used in their NICU, the postmenstrual age (PMA) sensory-based interventions are administered, conditions under which sensory-based interventions are used, and personnel who administer sensory-based interventions. RESULTS: The most commonly reported tactile intervention was infant holding (88% of respondents), the most common auditory intervention was recorded music/singing (69% of respondents), the most common kinesthetic intervention was occupational and physical therapy (85% of respondents), and the most common vestibular intervention was infant swings (86% of respondents). Tactile interventions were initiated most often at 24 to 26 weeks PMA (74% of respondents), auditory interventions at 30 to 32 weeks (60% of respondents), kinesthetic interventions at 30 to 32 weeks (76% of respondents), vestibular interventions at 33 to 34 weeks (86% of respondents), and visual interventions at 32 to 36 weeks (72% of respondents). Conditions under which sensory-based interventions were administered, and personnel who provided them, varied across settings. CONCLUSION: Varied use of sensory-based interventions in the NICU were reported. While this study was limited by biased sampling and the identification of health care professionals' perceptions but not real-world practice, this information can be used to build a comprehensive approach to positive sensory exposures in the NICU.

A Community Hospital NICU Developmental Care Partner Program: Feasibility and Association With Decreased Nurse Burnout Without Increased Infant Infection Rates.

BACKGROUND: Volunteers can provide staff-directed sensory inputs to infants hospitalized in the NICU, but research on volunteer programs is limited. PURPOSE: To evaluate the feasibility of a developmental care partner (DCP) program in a level III NICU and determine its relationship with provider burnout and infant infection rates. METHODS: DCPs were trained to provide sensory input to infants, based on the behavioral cues observed by the occupational therapists and nursing staff, in medically stable infants. Feasibility was assessed by documenting the process of training and utilizing volunteers, as well as tracking duration and frequency of DCP visits. Staff burnout measures were assessed using the Maslach Burnout Inventory Human Services Survey (MBI-HSS) before and after implementation. Infant infection rates before and after the introduction of volunteers were compared. RESULTS: Seventy-two volunteers were interested, and 25 (35%) completed the DCP competencies and provided sensory exposures to 54 neonates, who were visited an average of 8 times (range 1-15). Twelve (48%) DCPs did once-per-week visits, and 9 (36%) did at least 50 contact hours. MBI-HSS scores for staff emotional exhaustion (P < .001) and depersonalization (P < .006) were lower after DCP implementation. There were no differences in infant infection rates before and after DCP implementation (Fisher exact P = 1.000). IMPLICATIONS FOR PRACTICE: Volunteer-based DCP programs may be feasible to implement in community hospitals and could help reduce staff emotional exhaustion and depersonalization without increasing the incidence of infant infections. IMPLICATIONS FOR RESEARCH: Future research on NICU volunteer programs with larger sample sizes and different infant populations is warranted.

Pacifier use in newborns: related to socioeconomic status but not to early feeding performance.

AIM: Mothers are often advised not to use pacifiers until breastfeeding has been well-established. This study determined the infant and social factors that were related to pacifier use during the first few days of life and whether it led to alterations in feeding performance. METHODS: We enroled 51 full-term infants and their mothers at Barnes-Jewish Hospital in urban St. Louis, USA, in 2015. Before they were discharged the mothers completed a questionnaire, and infant feeding was assessed using a standardised assessment. RESULTS: There were 24 (47%) infants who used a pacifier during the first few days of life and seven (29%) of these were exclusively breastfed. Pacifier use was less common among mothers who exclusively breastfed (p = 0.04). Pacifier use was more common among mothers whose income was less than 25 000 US dollars (p = 0.02), who were single (p = 0.002) and who did not have a college education (p = 0.03). No associations between pacifier use and feeding performance were observed. CONCLUSION: While lower socioeconomic status was related to pacifier use, feeding performance in the first few days of life was no different between those infants who did and did not use pacifiers after a full-term birth.

Neonatal Eating Outcome Assessment: tool development and inter-rater reliability.

AIM: To define the process of tool development and revision for the Neonatal Eating Outcome (NEO) Assessment and to report preliminary inter-rater reliability. METHODS: Tool development consisted of a review of the literature and observations of feeding performance among 178 preterm infants born ≤32 weeks gestation. 11 neonatal therapy feeding experts provided structured feedback to establish content validity and define the scoring matrix. The tool was then used to evaluate feeding in 50 preterm infants born ≤32 weeks of gestation and 50 full-term infants. Multiple revisions occurred at each stage of development. Finally, six neonatal occupational therapists participated in reliability testing by independently scoring five videos of oral feeding of preterm infants using version 4 of the tool. RESULTS: The intraclass correlation for the 'prefeeding' score was 0.71 (0.37-0.96), and the intraclass correlation for the 'total' score was 0.83 (0.56-0.98). CONCLUSION: The 'total' score had good to excellent reliability. Fleiss' Kappa scores for all 18 scorable items ranged from slight agreement to moderate agreement. Items with the lowest Kappa scores were revised, and additional feedback from therapists engaged in reliability testing was incorporated, resulting in final version 5.

Auditory Exposure in the Neonatal Intensive Care Unit: Room Type and Other Predictors.

OBJECTIVE: To quantify early auditory exposures in the neonatal intensive care unit (NICU) and evaluate how these are related to medical and environmental factors. We hypothesized that there would be less auditory exposure in the NICU private room, compared with the open ward. STUDY DESIGN: Preterm infants born at ≤ 28 weeks gestation (33 in the open ward, 25 in private rooms) had auditory exposure quantified at birth, 30 and 34 weeks postmenstrual age (PMA), and term equivalent age using the Language Environmental Acquisition device. RESULTS: Meaningful language (P < .0001), the number of adult words (P < .0001), and electronic noise (P < .0001) increased across PMA. Silence increased (P = .0007) and noise decreased (P < .0001) across PMA. There was more silence in the private room (P = .02) than the open ward, with an average of 1.9 hours more silence in a 16-hour period. There was an interaction between PMA and room type for distant words (P = .01) and average decibels (P = .04), indicating that changes in auditory exposure across PMA were different for infants in private rooms compared with infants in the open ward. Medical interventions were related to more noise in the environment, although parent presence (P = .009) and engagement (P = .002) were related to greater language exposure. Average sound levels in the NICU were 58.9 ± 3.6 decibels, with an average peak level of 86.9 ± 1.4 decibels. CONCLUSIONS: Understanding the NICU auditory environment paves the way for interventions that reduce high levels of adverse sound and enhance positive forms of auditory exposure, such as language.

Early Therapy Services Following Neonatal Intensive Care Unit Discharge.

AIMS: To (1) characterize early therapy services for preterm infants in the first two years of life, and (2) define factors related to accessing early therapy services. METHODS: Therapy utilization after discharge from the neonatal intensive care unit (NICU) was tracked in 57 infants born ≤30 weeks gestation from 2007 to 2010. Participants returned for developmental testing at two years. Factors related to early therapy utilization were explored. RESULTS: Fifty-two (91%) infants received a referral for therapy at NICU discharge but only 44 (77%) received at least one type of therapy during the first two years of life. Infants who received early therapy services were more likely to have more days on ventilation (p =.005), have single mothers (p =.047), and exhibit abnormal neurobehavior at term equivalent age (p =.03). On average, infants first received occupational therapy at a mean age of 5.1 ± 4.6 months with a median of 2.6 (1.3-9.0), physical therapy at a mean age of 4.3 ± 4.1 months with a median of 3.7 (0.1-5.5), and speech-language pathology services at a mean age of 14.0 ± 6.1 months with a median of 15.0 (11.3-17.7) months corrected age. Of the 13 children who did not receive any therapy in the first two years after NICU discharge, seven (53%) had a developmental delay at an age of two years. CONCLUSIONS: In spite of high referral rates for therapy services, there is a delay in therapy activation following NICU discharge, and some infants who warrant services do not obtain them.

Head Lag in Infancy: What Is It Telling Us?

OBJECTIVE: To investigate changes in head lag across postmenstrual age and define associations between head lag and (1) perinatal exposures and (2) neurodevelopment. METHOD: Sixty-four infants born ≤ 30 wk gestation had head lag assessed before and at term-equivalent age. Neurobehavior was assessed at term age. At 2 yr, neurodevelopmental testing was conducted. RESULTS: Head lag decreased with advancing postmenstrual age, but 58% (n = 37) of infants continued to demonstrate head lag at term. Head lag was associated with longer stay in the neonatal intensive care unit (p = .009), inotrope use (p = .04), sepsis (p = .02), longer endotracheal intubation (p = .01), and cerebral injury (p = .006). Head lag was related to alterations in early neurobehavior (p < .03), but no associations with neurodevelopment were found at 2 yr. CONCLUSION: Head lag was related to medical factors and early neurobehavior, but it may not be a good predictor of outcome when used in isolation.

Neurodevelopmental Profile, Growth, and Psychosocial Environment of Preterm Infants with Difficult Feeding Behavior at Age 2 Years.

OBJECTIVE: To examine the association of difficult feeding behaviors in very preterm infants at age 2 years with growth and neurodevelopmental outcomes and family factors and functioning. STUDY DESIGN: Eighty children born ≤30 weeks gestation were studied from birth until age 2 years. Feeding difficulties were assessed using the Eating Subscale of the Infant-Toddler Social Emotional Assessment at age 2 years, along with growth measurement and developmental testing. Maternal mental health and family factors were assessed using standardized questionnaires. ANOVA and χ(2) analyses were performed to determine associations between feeding difficulties and growth, neurodevelopmental outcomes, and family characteristics. RESULTS: Twenty-one children (26%) were at risk for feeding difficulties, and an additional 18 (23%) had definite feeding difficulties at age 2 years. Those with feeding difficulties were more likely to be subject to a range of neurodevelopmental problems, including impaired cognition (P = .02), language (P = .04), motor (P = .01), and socioemotional (P < .007) skills. Compared with the parents of children with fewer feeding difficulties, parents of the children with feeding difficulties had higher parenting stress (P = .02) and reported more difficulty managing their child's behavior (P = .002) and more frequent parent-child interaction problems (P = .002). No associations were found between difficult feeding behaviors and growth, maternal mental health, or family factors. CONCLUSION: Difficult feeding behaviors in children born very preterm appear to be highly comorbid with other developmental and family challenges, including neurodevelopmental impairment and parent-child interaction difficulties. Focusing on improving feeding skills, in conjunction with supporting positive parent-child interactions, may be beneficial for improving outcomes.