Impact of Parental Presence and Holding in the NICU
This investigation was a prospective longitudinal cohort study of naturally occurring parental practices. Study participants were infants born ≤30 weeks gestation. Infants were enrolled within the first 3 days of life. Infants with known congenital anomalies and those expected to expire within the first days of life were excluded. This study was approved by the Human Research Protection Office at the study site. The study included serial neuro imaging and serial neurobehavioral testing during hospitalization.
The study NICU is a 76-bed Level III unit, contained within a 275-bed free-standing children’s hospital. The NICU consists of 38 open-bay beds and 36 single-patient rooms, which are assigned by bed and nursing availability. Policies allow for parent visitation 24h per day. Visitors are restricted to two at the infant bedside. Nurses are available to teach parents basic care tasks, and parents are also provided information about how to interact with their infant in a responsive and developmentally appropriate way. Parents are encouraged to hold their infants when the infant is able to tolerate it, without physiological compromise. This includes holding while intubated, but often does not include time when the infant has physiological fluctuations, is on oscillatory ventilation or has chest tubes in place. Siblings older than 2 years of age are permitted to visit in the NICU.
Recording sheets were delivered to the bedside upon enrollment. A modified version of the Neonatal Infant Stressor Scale was used for all infants admitted to the study. Space was available for nurses to denote who visited and for how long. Holding factors added for documentation included 'Infant Received Cuddle' (traditional holding) and 'Infant Received Kangaroo Care' (skin-to-skin holding). Nurses recorded visitation and holding factors during each shift from the infant's birth until term equivalent. The completed daily logs were supplemented by documentation in the medical record. When discrepancies occurred, the largest amount of visitation and holding documented in either place was recorded for a given shift.
In order to investigate trends over the hospitalization, data were grouped in accordance with specific timeframes. The average number of hours visited per week over the first two weeks of life, the third and fourth weeks of life and the fifth weeks of life through term equivalent (37 weeks estimated gestational age) were calculated. In addition, a summary score representing the average number of hours visited per week from birth through term equivalent was calculated. The average number of days per week that the infant received either traditional holding or skin-to-skin care were calculated over the same timeframes.
The NICU Network Neurobehavioral Assessment Scale (NNNS) was administered and scored by an occupational therapist certified in its use to provide an assessment of neurological integrity, behavioral functioning and response to stressors. Thirteen summary scores are derived from the NNNS, including habituation, tolerance of handling, quality of movement, self-regulation skills, nonoptimal reflexes, stress signs, arousal, hypertonia, hypotonia, asymmetry, excitability, lethargy and orientation. Each is a continuous variable on its own scale, and higher scores indicate 'more' of the respective construct being present. Each of the summary scores were used as a dependent variable.
Several factors affecting developmental outcome were collected and analyzed for potential relationships with neurobehavior. Initial perinatal medical severity score, called the Critical Risk Index for Babies Score, was taken from the infant’s medical record. Estimated gestational age at birth, gender and race were collected, as well as in-utero drug exposure based on maternal toxicology screening at delivery. Additionally, maternal age, marital status and insurance status (to reflect socioeconomic status) were collected from a questionnaire filled out upon the infant’s discharge. The following additional variables were collected at discharge as other medical or social factors, which might have been related to early neurobehavior: number of days the infant was ventilated, number of days on continuous positive airway pressure, whether the infant had sepsis, presence of necrotizing enterocolitis or patent ductus arteriosis and use of postnatal steroids. Finally infants underwent routine cranial ultrasound at 1 week and 1 month of life in addition to magnetic resonance imaging at term equivalent age. Results were interpreted by a single, trained neuroradiologist. Cerebral injury was dichotomized into no significant injury or moderate to severe brain injury, which was defined as any cerebellar hemorrhage, grades 3 to 4 intraventricular hemorrhage or cystic periventricular leukomalacia. All perinatal and demographic variables were investigated for associations with the independent and dependent variables. To best isolate the effects of parent visitaiton and holding, those that reached significance (P<0.05) were further investigated for colinearity and controlled for in the statistical model. Other variables known to predict function were also included in the model.
Analyses were conducted using Predictive Analytic SoftWare 18.0 (SPSS, Chicago, IL, USA). Nonparametrics, via a Wilcoxon Signed Rank test, were used to investigate the association between visitation and holding. Univariate regression analyses were used to investigate the associations between parent visitation and holding on neurobehavioral outcome measures. Multivariate regression analyses were conducted to isolate the effect of parent presence and holding, while controlling for race, cerebral injury, postnatal steroid use and days of ventilation.
Methods
This investigation was a prospective longitudinal cohort study of naturally occurring parental practices. Study participants were infants born ≤30 weeks gestation. Infants were enrolled within the first 3 days of life. Infants with known congenital anomalies and those expected to expire within the first days of life were excluded. This study was approved by the Human Research Protection Office at the study site. The study included serial neuro imaging and serial neurobehavioral testing during hospitalization.
The study NICU is a 76-bed Level III unit, contained within a 275-bed free-standing children’s hospital. The NICU consists of 38 open-bay beds and 36 single-patient rooms, which are assigned by bed and nursing availability. Policies allow for parent visitation 24h per day. Visitors are restricted to two at the infant bedside. Nurses are available to teach parents basic care tasks, and parents are also provided information about how to interact with their infant in a responsive and developmentally appropriate way. Parents are encouraged to hold their infants when the infant is able to tolerate it, without physiological compromise. This includes holding while intubated, but often does not include time when the infant has physiological fluctuations, is on oscillatory ventilation or has chest tubes in place. Siblings older than 2 years of age are permitted to visit in the NICU.
Visitation and Holding
Recording sheets were delivered to the bedside upon enrollment. A modified version of the Neonatal Infant Stressor Scale was used for all infants admitted to the study. Space was available for nurses to denote who visited and for how long. Holding factors added for documentation included 'Infant Received Cuddle' (traditional holding) and 'Infant Received Kangaroo Care' (skin-to-skin holding). Nurses recorded visitation and holding factors during each shift from the infant's birth until term equivalent. The completed daily logs were supplemented by documentation in the medical record. When discrepancies occurred, the largest amount of visitation and holding documented in either place was recorded for a given shift.
In order to investigate trends over the hospitalization, data were grouped in accordance with specific timeframes. The average number of hours visited per week over the first two weeks of life, the third and fourth weeks of life and the fifth weeks of life through term equivalent (37 weeks estimated gestational age) were calculated. In addition, a summary score representing the average number of hours visited per week from birth through term equivalent was calculated. The average number of days per week that the infant received either traditional holding or skin-to-skin care were calculated over the same timeframes.
Neurobehavioral Assessment
The NICU Network Neurobehavioral Assessment Scale (NNNS) was administered and scored by an occupational therapist certified in its use to provide an assessment of neurological integrity, behavioral functioning and response to stressors. Thirteen summary scores are derived from the NNNS, including habituation, tolerance of handling, quality of movement, self-regulation skills, nonoptimal reflexes, stress signs, arousal, hypertonia, hypotonia, asymmetry, excitability, lethargy and orientation. Each is a continuous variable on its own scale, and higher scores indicate 'more' of the respective construct being present. Each of the summary scores were used as a dependent variable.
Potential Confounders
Several factors affecting developmental outcome were collected and analyzed for potential relationships with neurobehavior. Initial perinatal medical severity score, called the Critical Risk Index for Babies Score, was taken from the infant’s medical record. Estimated gestational age at birth, gender and race were collected, as well as in-utero drug exposure based on maternal toxicology screening at delivery. Additionally, maternal age, marital status and insurance status (to reflect socioeconomic status) were collected from a questionnaire filled out upon the infant’s discharge. The following additional variables were collected at discharge as other medical or social factors, which might have been related to early neurobehavior: number of days the infant was ventilated, number of days on continuous positive airway pressure, whether the infant had sepsis, presence of necrotizing enterocolitis or patent ductus arteriosis and use of postnatal steroids. Finally infants underwent routine cranial ultrasound at 1 week and 1 month of life in addition to magnetic resonance imaging at term equivalent age. Results were interpreted by a single, trained neuroradiologist. Cerebral injury was dichotomized into no significant injury or moderate to severe brain injury, which was defined as any cerebellar hemorrhage, grades 3 to 4 intraventricular hemorrhage or cystic periventricular leukomalacia. All perinatal and demographic variables were investigated for associations with the independent and dependent variables. To best isolate the effects of parent visitaiton and holding, those that reached significance (P<0.05) were further investigated for colinearity and controlled for in the statistical model. Other variables known to predict function were also included in the model.
Statistical Analysis
Analyses were conducted using Predictive Analytic SoftWare 18.0 (SPSS, Chicago, IL, USA). Nonparametrics, via a Wilcoxon Signed Rank test, were used to investigate the association between visitation and holding. Univariate regression analyses were used to investigate the associations between parent visitation and holding on neurobehavioral outcome measures. Multivariate regression analyses were conducted to isolate the effect of parent presence and holding, while controlling for race, cerebral injury, postnatal steroid use and days of ventilation.
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