Supporting and Enhancing NICU Sensory Experiences (SENSE)

Premature Birth of Newborn Clinical Trial

— SENSE  

Official title:

Supporting and Enhancing NICU Sensory Experiences to Optimize Developmental Outcomes in Preterm Infants

Clinical Trial Details — Status: Completed

Administrative data

• NCT number: NCT03316547
• Other study ID #: 201601057
• Status: Completed
• Phase: N/A
• Start date: August 16, 2017
• Est. completion date: November 1, 2019

Study information

• Verified date: June 2021
• Source: Washington University School of Medicine
• Contact: n/a
• Is FDA regulated: No
• Study type: Interventional

Clinical Trial Summary

Seventy preterm infants born less than or equal to 32 weeks gestation were put into either the sensory-based intervention (experiment) group or traditional care (control) group. Consecutive admissions at St. Louis Children's Hospital (SLCH) who were hospitalized in a private NICU room were recruited. The parents of infants in the sensory-based intervention group were educated and supported by trained therapists to give different positive sensory experiences to their infants while hospitalized. The traditional care group received normal, standard care while hospitalized. For both care groups, infant neurobehavior, sensory processing, and parent mental health were measured at term age prior to hospital discharge. Child development, sensory processing, and parent mental health were measured again at age one year (corrected). Differences between the two groups were explored.

Description:

Approximately 12%, or 500,000 infants, are born preterm each year in the United States alone. Although survival rates of preterm infants have increased with advances in medical care, the risk of developmental delay and disability has remained constant. Very preterm infants (<32 weeks gestation) necessitate care in the neonatal intensive care unit (NICU) for an average of three months after birth, which is a significant period of time coinciding with a critical window of brain development. While medical factors, such as brain injury, can heighten the risk of adverse neurodevelopmental outcome, the NICU environment may also have deleterious effects on early brain structure and function.

The Influence of Early Environment: Maternal deprivation and isolation from positive sensory experiences are prominent features of orphan studies. Consequences of language and human deprivation include emotional disturbances, delayed cognitive and language skills, and abnormalities evident on magnetic resonance imaging (MRI). Although the preterm infant differs from a child who has been institutionalized or deprived of caregiving attention after full term birth, there are similarities, such as the altered temporal lobe structures, and the pattern of developmental impairments. There is growing evidence supporting the importance of parents in the NICU. Low frequency visits between parents and their hospitalized preterm infants have been associated with suboptimal outcomes, like child abuse and abandonment and adverse emotional functioning. NICU's in Sweden have been successful with engaging parents in care from admission to discharge and have reported shorter hospitalizations. There is also a growing body of evidence supporting positive sensory exposures for preterm infants, including maternal voice recordings, massage, skin-to-skin holding, and vestibular and kinesthetic interventions. In addition, my team has made important research findings pointing to the potential need for developmentally-appropriate sensory exposures in the NICU.

Outcomes Associated with Preterm Birth: While advances in medical technologies have improved the rates of survival among preterm infants, the risk of long-term morbidities remains high, with 50-70% of very preterm infants exhibiting developmental problems. In addition to motor problems, language and communication problems are common in former preterm infants when studied at school age, and recent evidence suggests that language deficits persist through childhood. Language difficulties have also been shown to affect a broad range of factors important for social prowess and academic achievement. In addition, preterm infants have a heightened risk of attachment disorders and other social-emotional problems.

Outcomes Associated with Parenting a Preterm Infant: Many negative psychological sequelae are associated with parenting a preterm infant, including depression, anxiety, and post-traumatic stress. Such negative parental mental health outcomes proceed to influence the parent-child relationship, leading to a parent's inability to recognize infant cues as well as increased negativity and intrusiveness. Negative maternal-child interactions continue into the first several months of life if stress remains high. Forming such a foundation may then lead to negative child outcomes associated with social-emotional development, including attachment insecurity, and mental health issues.

Sensory Stimuli and Current Practice in the NICU: High-risk infants who receive care in the NICU are exposed to significant stressors that include painful procedures, disruption of normal sensory experiences, and stress related to parent-infant separation. In addition to the loss of parental nurturing, there is growing concern that stress during a period of extensive brain development may result in permanent and deleterious developmental outcomes.

Developmental care, which includes sensory minimization, has been the predominant model of care in the NICU since the 1980s, because the bright and noisy environment, which exceeds sensory standards set by the American Academy of Pediatrics, is understood to adversely affect growth and development of the preterm infant. In support of developmental care principles, NICU staff makes efforts to reduce modifiable stimuli to the high-risk infant in the NICU. However, there is emerging research on the positive effects of sensory stimulation for preterm infants in the NICU.

Positive sensory exposures in the NICU are critical, as they can have life-long implications on learning, memory, emotions, and developmental progression. In an environment where stimuli are primarily negative, it is especially important to define and implement positive sensory exposures in the NICU. Further, it is well understood that multi-dimensional sensory exposures are present in utero in the final months and weeks of pregnancy, but the preterm infant misses potentially important, timed exposures that may be absent or altered in the NICU environment. Positive forms of sensory exposure during periods of infant readiness may be important to facilitate appropriate neural pathways and enable positive experiences.

Results from a rigorous systematic review, benchmarking, and expert opinion were used to develop a clinical practice guideline for sensory-based interventions for hospitalized, very preterm infants using the Appraisal of Guidelines for Research and Evaluation II instrument. The manualized intervention (from the integrative review and development of the implementation plan) includes evidenced-based interventions that can be conducted by parents with their preterm infants across postmenstrual age while hospitalized. The sensory-based intervention includes the provision of specific amounts of auditory, tactile, vestibular, kinesthetic, olfactory, and visual exposure to be conducted daily through hospitalization. The intervention plan is intended to be implemented by parents (when available) and by surrogates when the parents are unable to be present in the hospital. Surveys, focus groups of a multidisciplinary team of health care professionals and parents of preterm infants in the NICU, and a pilot/feasibility study were conducted to assess acceptability, appropriateness and feasibility of the sensory-based intervention plan. The investigators enrolled 30 very preterm infants within the first week of life and implemented the sensory-based program. Logging sheets were placed at the infant's bedside to document the execution of sensory-based interventions, who conducted the intervention (parent, member of research team or other caregiver), and infant responses and consequences of the intervention. Physiological (such as heart rate and oxygen saturation fluctuations), state (levels of arousal) and behavioral (such as crying, changes in motoric tone) responses were recorded by caregivers during interventions on the bedside logs. Negative sequelae of the intervention resulted in stopping the intervention and modifying the criteria for sensory-based interventions accordingly. A licensed therapist provided guidance as to when infants can and cannot tolerate sensory exposures. From clinical documentation and bedside logging, implementation factors were assessed. Adaptations to the sensory-based program were made until it was deemed appropriate by the investigative team. This occurred after the model for an enhanced sensory environment could be documented 75% of the time on at least 3 consecutive participants.

The aim of this randomized clinical trial was to assess the effect of a sensory-based intervention in the NICU on outcomes of preterm infants and their families.

After obtaining informed consent, 70 preterm infants were randomized to 2 levels of sensory exposure: the sensory-based intervention or traditional care group. The parents of infants in the sensory-based intervention group were educated and supported to conduct sensory interventions with their infants using the systematized protocol. The traditional care group had therapists and nurses provide and educate parents about sensory exposures as standard of care. For both care groups, infant neurobehavior, sensory processing, mother-infant interaction, and parent mental health were assessed at term age prior to hospital discharge. Child development, sensory processing, and parent mental health were measured again at age one year corrected using standardized measures. Differences between groups were explored.

Recruitment information / eligibility

• Status: Completed
• Enrollment: 70
• Est. completion date: November 1, 2019
• Est. primary completion date: November 1, 2019
• Accepts healthy volunteers: Accepts Healthy Volunteers
• Gender: All
• Age group: N/A to 32 Weeks

Eligibility

Inclusion Criteria:

Preterm Infants:

• A prospective cohort very preterm infants (VPT) born less than or equal to 32 weeks gestation at the St. Louis Children's Hospital in St. Louis, Missouri.

• Infant is less than or equal to 7 days old when approached about the study.

Parents:

-Parents (including emancipated minors age 12-17) of very preterm infants (VPT) born less than or equal to 32 weeks gestation at the St. Louis Children's Hospital in St. Louis, Missouri.

Exclusion Criteria:

Preterm Infants:

• Known or suspected congenital anomaly, congenital infection (e.g., syphilis, HIV, TORCH), or known prenatal brain lesions (e.g., cysts or infarctions)

• Infants that are wards of the state, or become wards of the state after enrolling in the study. Any data collected beginning at the time the state obtains custody onward will not be used in the research study.

• Infants who are in the open ward area/bed spaces of the SLCH NICU (due to the significant variation in sensory exposure among those infants, and also to provide consistency during the hospital's impending transition to strictly private rooms in the very near future).

Parents:

-Parents with limited or no understanding of the English Language

Related Conditions & MeSH terms

• Premature Birth
• Premature Birth of Newborn

Intervention

Other:
• SENSE Program
Specific amounts of auditory, tactile, vestibular, kinesthetic, and visual exposure conducted daily through hospitalization. This includes specifically timed and set amounts of reading/talking/singing, cycled lighting, skin-to-skin (kangaroo) care or gentle human touch, rocking, and therapeutic exercises [passive range of motion (PROM), gentle stretching]. The intervention plan is intended to be implemented by parents when available, and by surrogates when the parents are unable to be present in the hospital. Specific amounts and timing of interventions will be tailored to the current medical status and age of each infant.

Locations

Country	Name	City	State
United States	St. Louis Children's Hospital	Saint Louis	Missouri

Sponsors (2)

Lead Sponsor	Collaborator
Washington University School of Medicine	University of Southern California

Country where clinical trial is conducted

United States, 

References & Publications (89)

Abidin, R.R., Parenting stress index professional manual. 3 ed. 1995, Odessa, FL: Psychological Assessment Resources, Inc.

Aeby A, Van Bogaert P, David P, Balériaux D, Vermeylen D, Metens T, De Tiège X. Nonlinear microstructural changes in the right superior temporal sulcus and lateral occipitotemporal gyrus between 35 and 43 weeks in the preterm brain. Neuroimage. 2012 Oct 15;63(1):104-10. doi: 10.1016/j.neuroimage.2012.06.013. Epub 2012 Jun 17. — View Citation

Anderson P, Doyle LW; Victorian Infant Collaborative Study Group. Neurobehavioral outcomes of school-age children born extremely low birth weight or very preterm in the 1990s. JAMA. 2003 Jun 25;289(24):3264-72. — View Citation

Anderson PJ, Doyle LW. Cognitive and educational deficits in children born extremely preterm. Semin Perinatol. 2008 Feb;32(1):51-8. doi: 10.1053/j.semperi.2007.12.009. Review. — View Citation

Barre N, Morgan A, Doyle LW, Anderson PJ. Language abilities in children who were very preterm and/or very low birth weight: a meta-analysis. J Pediatr. 2011 May;158(5):766-774.e1. doi: 10.1016/j.jpeds.2010.10.032. Epub 2010 Dec 10. Review. — View Citation

Beck, A.T., R.A. Steer, and G.K. Brown, Manual for the beck depression inventory-II. 1996, San Antonio, TX: Psychological Corporation.

Berument SK, Sönmez D, Eyüpoglu H. Supporting language and cognitive development of infants and young children living in children's homes in Turkey. Child Care Health Dev. 2012 Sep;38(5):743-52. doi: 10.1111/j.1365-2214.2011.01314.x. Epub 2011 Sep 27. — View Citation

Botting, N., Z. Simkin, and G. Conti-Ramsden, Associated reading skills in children with a history of Specific Language Impairment (SLI). Read Writ, 2006. 19: p. 77-98.

Bouet KM, Claudio N, Ramirez V, García-Fragoso L. Loss of parental role as a cause of stress in the neonatal intensive care unit. Bol Asoc Med P R. 2012 Jan-Mar;104(1):8-11. — View Citation

Brandon DH, Holditch-Davis D, Belyea M. Preterm infants born at less than 31 weeks' gestation have improved growth in cycled light compared with continuous near darkness. J Pediatr. 2002 Feb;140(2):192-9. — View Citation

BRODBECK AJ, IRWIN OC. The speech behaviour of infants without families. Child Dev. 1946 Sep;17(3):145-56. — View Citation

Brouwers MC, Kho ME, Browman GP, Burgers JS, Cluzeau F, Feder G, Fervers B, Graham ID, Grimshaw J, Hanna SE, Littlejohns P, Makarski J, Zitzelsberger L; AGREE Next Steps Consortium. AGREE II: advancing guideline development, reporting and evaluation in health care. J Clin Epidemiol. 2010 Dec;63(12):1308-11. doi: 10.1016/j.jclinepi.2010.07.001. Epub 2010 Jul 24. — View Citation

Burns CM, Rutherford MA, Boardman JP, Cowan FM. Patterns of cerebral injury and neurodevelopmental outcomes after symptomatic neonatal hypoglycemia. Pediatrics. 2008 Jul;122(1):65-74. doi: 10.1542/peds.2007-2822. — View Citation

Byers JF. Components of developmental care and the evidence for their use in the NICU. MCN Am J Matern Child Nurs. 2003 May-Jun;28(3):174-80; quiz 181-2. Review. — View Citation

Bystron I, Blakemore C, Rakic P. Development of the human cerebral cortex: Boulder Committee revisited. Nat Rev Neurosci. 2008 Feb;9(2):110-22. doi: 10.1038/nrn2252. Review. — View Citation

Caskey, M., Tucker, R., Vohr. Language environment in a single familly room NICU. in Pediatric Academic Societies. 2012. Boston, MA.

Cox JL, Holden JM, Sagovsky R. Detection of postnatal depression. Development of the 10-item Edinburgh Postnatal Depression Scale. Br J Psychiatry. 1987 Jun;150:782-6. — View Citation

Daunhauer LA, Coster WJ, Tickle-Degnen L, Cermak SA. Effects of caregiver-child interactions on play occupations among young children institutionalized in Eastern Europe. Am J Occup Ther. 2007 Jul-Aug;61(4):429-40. — View Citation

Daunhauer LA, Coster WJ, Tickle-Degnen L, Cermak SA. Play and cognition among young children reared in an institution. Phys Occup Ther Pediatr. 2010 May;30(2):83-97. doi: 10.3109/01942630903543682. — View Citation

Diego MA, Field T, Hernandez-Reif M. Preterm infant weight gain is increased by massage therapy and exercise via different underlying mechanisms. Early Hum Dev. 2014 Mar;90(3):137-40. doi: 10.1016/j.earlhumdev.2014.01.009. Epub 2014 Jan 27. — View Citation

Douret, L., M. Robin, and M. Le Normandy, The history of care of premature infants: from neonate intensive care to special care baby unit. Early Child Dev Care, 1994. 182: p. 21-29.

Dunn, W., Infant/Toddler Sensory Profile 2. 2014, San Antonio: Pearson Education, Inc.

Durkin K, Conti-Ramsden G. Language, social behavior, and the quality of friendships in adolescents with and without a history of specific language impairment. Child Dev. 2007 Sep-Oct;78(5):1441-57. — View Citation

Ellis BH, Fisher PA, Zaharie S. Predictors of disruptive behavior, developmental delays, anxiety, and affective symptomatology among institutionally reared romanian children. J Am Acad Child Adolesc Psychiatry. 2004 Oct;43(10):1283-92. — View Citation

Endler, N., Coping Inventory for Stressful Situations (CISS): Manual. 1990, Toronto: Multi-Health Systems.

Fanaroff AA, Kennell JH, Klaus MH. Follow-up of low birth weight infants--the predictive value of maternal visiting patterns. Pediatrics. 1972 Feb;49(2):287-90. — View Citation

Feldman R, Rosenthal Z, Eidelman AI. Maternal-preterm skin-to-skin contact enhances child physiologic organization and cognitive control across the first 10 years of life. Biol Psychiatry. 2014 Jan 1;75(1):56-64. doi: 10.1016/j.biopsych.2013.08.012. Epub 2013 Oct 4. — View Citation

Field T. Alleviating stress in newborn infants in the intensive care unit. Clin Perinatol. 1990 Mar;17(1):1-9. Review. — View Citation

Govindan RM, Behen ME, Helder E, Makki MI, Chugani HT. Altered water diffusivity in cortical association tracts in children with early deprivation identified with Tract-Based Spatial Statistics (TBSS). Cereb Cortex. 2010 Mar;20(3):561-9. doi: 10.1093/cercor/bhp122. Epub 2009 Jun 22. — View Citation

Goyen TA, Lui K, Woods R. Visual-motor, visual-perceptual, and fine motor outcomes in very-low-birthweight children at 5 years. Dev Med Child Neurol. 1998 Feb;40(2):76-81. — View Citation

Graven SN, Bowen FW Jr, Brooten D, Eaton A, Graven MN, Hack M, Hall LA, Hansen N, Hurt H, Kavalhuna R, et al. The high-risk infant environment. Part 1. The role of the neonatal intensive care unit in the outcome of high-risk infants. J Perinatol. 1992 Jun;12(2):164-72. — View Citation

Gray RF, Indurkhya A, McCormick MC. Prevalence, stability, and predictors of clinically significant behavior problems in low birth weight children at 3, 5, and 8 years of age. Pediatrics. 2004 Sep;114(3):736-43. — View Citation

Heinemann AB, Hellström-Westas L, Hedberg Nyqvist K. Factors affecting parents' presence with their extremely preterm infants in a neonatal intensive care room. Acta Paediatr. 2013 Jul;102(7):695-702. doi: 10.1111/apa.12267. Epub 2013 May 8. — View Citation

Hepper PG, Shahidullah BS. Development of fetal hearing. Arch Dis Child Fetal Neonatal Ed. 1994 Sep;71(2):F81-7. — View Citation

Hernandez-Reif M, Diego M, Field T. Preterm infants show reduced stress behaviors and activity after 5 days of massage therapy. Infant Behav Dev. 2007 Dec;30(4):557-61. Epub 2007 Jun 4. — View Citation

Holditch-Davis D, Bartlett TR, Blickman AL, Miles MS. Posttraumatic stress symptoms in mothers of premature infants. J Obstet Gynecol Neonatal Nurs. 2003 Mar-Apr;32(2):161-71. — View Citation

Holsti L, Grunau RV, Whitfield MF. Developmental coordination disorder in extremely low birth weight children at nine years. J Dev Behav Pediatr. 2002 Feb;23(1):9-15. — View Citation

Howe TH, Sheu CF, Wang TN, Hsu YW. Parenting stress in families with very low birth weight preterm infants in early infancy. Res Dev Disabil. 2014 Jul;35(7):1748-56. doi: 10.1016/j.ridd.2014.02.015. Epub 2014 Mar 19. — View Citation

Khlif MS, Colditz PB, Boashash B. Effective implementation of time-frequency matched filter with adapted pre and postprocessing for data-dependent detection of newborn seizures. Med Eng Phys. 2013 Dec;35(12):1762-9. doi: 10.1016/j.medengphy.2013.07.005. Epub 2013 Aug 21. — View Citation

Krueger C, Parker L, Chiu SH, Theriaque D. Maternal voice and short-term outcomes in preterm infants. Dev Psychobiol. 2010 Mar;52(2):205-12. doi: 10.1002/dev.20426. — View Citation

Lasky RE, Williams AL. Noise and light exposures for extremely low birth weight newborns during their stay in the neonatal intensive care unit. Pediatrics. 2009 Feb;123(2):540-6. doi: 10.1542/peds.2007-3418. — View Citation

Latva R, Lehtonen L, Salmelin RK, Tamminen T. Visiting less than every day: a marker for later behavioral problems in Finnish preterm infants. Arch Pediatr Adolesc Med. 2004 Dec;158(12):1153-7. — View Citation

Lickliter R. The integrated development of sensory organization. Clin Perinatol. 2011 Dec;38(4):591-603. doi: 10.1016/j.clp.2011.08.007. Epub 2011 Oct 13. Review. — View Citation

Liu WF. Comparing sound measurements in the single-family room with open-unit design neonatal intensive care unit: the impact of equipment noise. J Perinatol. 2012 May;32(5):368-73. doi: 10.1038/jp.2011.103. Epub 2011 Aug 18. — View Citation

Lobb R, Colditz GA. Implementation science and its application to population health. Annu Rev Public Health. 2013;34:235-51. doi: 10.1146/annurev-publhealth-031912-114444. Epub 2013 Jan 7. Review. — View Citation

Maguire CM, Walther FJ, van Zwieten PH, Le Cessie S, Wit JM, Veen S. Follow-up outcomes at 1 and 2 years of infants born less than 32 weeks after Newborn Individualized Developmental Care and Assessment Program. Pediatrics. 2009 Apr;123(4):1081-7. doi: 10.1542/peds.2008-1950. — View Citation

Mendes EW, Procianoy RS. Massage therapy reduces hospital stay and occurrence of late-onset sepsis in very preterm neonates. J Perinatol. 2008 Dec;28(12):815-20. doi: 10.1038/jp.2008.108. Epub 2008 Jul 17. — View Citation

Miles MS, Holditch-Davis D, Schwartz TA, Scher M. Depressive symptoms in mothers of prematurely born infants. J Dev Behav Pediatr. 2007 Feb;28(1):36-44. — View Citation

Mulder H, Pitchford NJ, Hagger MS, Marlow N. Development of executive function and attention in preterm children: a systematic review. Dev Neuropsychol. 2009;34(4):393-421. doi: 10.1080/87565640902964524. — View Citation

Noise: a hazard for the fetus and newborn. American Academy of Pediatrics. Committee on Environmental Health. Pediatrics. 1997 Oct;100(4):724-7. — View Citation

Nomura Y, Wickramaratne PJ, Warner V, Mufson L, Weissman MM. Family discord, parental depression, and psychopathology in offspring: ten-year follow-up. J Am Acad Child Adolesc Psychiatry. 2002 Apr;41(4):402-9. — View Citation

O'Hara MW, McCabe JE. Postpartum depression: current status and future directions. Annu Rev Clin Psychol. 2013;9:379-407. doi: 10.1146/annurev-clinpsy-050212-185612. Epub 2013 Feb 1. Review. — View Citation

Ortenstrand A, Westrup B, Broström EB, Sarman I, Akerström S, Brune T, Lindberg L, Waldenström U. The Stockholm Neonatal Family Centered Care Study: effects on length of stay and infant morbidity. Pediatrics. 2010 Feb;125(2):e278-85. doi: 10.1542/peds.2009-1511. Epub 2010 Jan 25. — View Citation

Pedespan L. [Attachment and prematurity]. Gynecol Obstet Fertil. 2004 Sep;32(9):716-20. Review. French. — View Citation

Pineda JA, Leonard JR, Mazotas IG, Noetzel M, Limbrick DD, Keller MS, Gill J, Doctor A. Effect of implementation of a paediatric neurocritical care programme on outcomes after severe traumatic brain injury: a retrospective cohort study. Lancet Neurol. 2013 Jan;12(1):45-52. doi: 10.1016/S1474-4422(12)70269-7. Epub 2012 Nov 28. — View Citation

Pineda RG, Neil J, Dierker D, Smyser CD, Wallendorf M, Kidokoro H, Reynolds LC, Walker S, Rogers C, Mathur AM, Van Essen DC, Inder T. Alterations in brain structure and neurodevelopmental outcome in preterm infants hospitalized in different neonatal inten — View Citation

Pineda RG, Stransky KE, Rogers C, Duncan MH, Smith GC, Neil J, Inder T. The single-patient room in the NICU: maternal and family effects. J Perinatol. 2012 Jul;32(7):545-51. doi: 10.1038/jp.2011.144. Epub 2011 Oct 27. — View Citation

Pineda RG, Tjoeng TH, Vavasseur C, Kidokoro H, Neil JJ, Inder T. Patterns of altered neurobehavior in preterm infants within the neonatal intensive care unit. J Pediatr. 2013 Mar;162(3):470-476.e1. doi: 10.1016/j.jpeds.2012.08.011. Epub 2012 Oct 1. — View Citation

Pineda, R., Neil, J., Dierker, D., Smyser, C., Kidokora, H., Reynolds, L., Walker, S., Rogers, C., Mathur, A., VanEssen, D., Inder, T., The Impact of Different Neonatal Intensive Care Environments on Brain Development and Function in Preterm Infants, 2012, Washington University School of Medicine.

Proctor E, Silmere H, Raghavan R, Hovmand P, Aarons G, Bunger A, Griffey R, Hensley M. Outcomes for implementation research: conceptual distinctions, measurement challenges, and research agenda. Adm Policy Ment Health. 2011 Mar;38(2):65-76. doi: 10.1007/s10488-010-0319-7. — View Citation

Proctor E. Implementation science and child maltreatment: methodological advances. Child Maltreat. 2012 Feb;17(1):107-12. doi: 10.1177/1077559512437034. Epub 2012 Feb 15. — View Citation

Proctor EK, Landsverk J, Aarons G, Chambers D, Glisson C, Mittman B. Implementation research in mental health services: an emerging science with conceptual, methodological, and training challenges. Adm Policy Ment Health. 2009 Jan;36(1):24-34. doi: 10.1007/s10488-008-0197-4. Epub 2008 Dec 23. — View Citation

Proctor EK, Powell BJ, Baumann AA, Hamilton AM, Santens RL. Writing implementation research grant proposals: ten key ingredients. Implement Sci. 2012 Oct 12;7:96. doi: 10.1186/1748-5908-7-96. — View Citation

Proctor EK, Rosen A. From Knowledge Production to Implementation: Research Challenges and Imperatives. Res Soc Work Pract. 2008 Jul 1;18(4):285-291. — View Citation

Quesada AA, Tristão RM, Pratesi R, Wolf OT. Hyper-responsiveness to acute stress, emotional problems and poorer memory in former preterm children. Stress. 2014 Sep;17(5):389-99. doi: 10.3109/10253890.2014.949667. — View Citation

Reproductive Health, Preterm Birth. March 23, 2012; Available from: http://www.cdc.gov/reproductivehealth/maternalinfanthealth/PretermBirth.htm.

Reynolds LC, Duncan MM, Smith GC, Mathur A, Neil J, Inder T, Pineda RG. Parental presence and holding in the neonatal intensive care unit and associations with early neurobehavior. J Perinatol. 2013 Aug;33(8):636-41. doi: 10.1038/jp.2013.4. Epub 2013 Feb 14. — View Citation

Scher MS, Ludington-Hoe S, Kaffashi F, Johnson MW, Holditch-Davis D, Loparo KA. Neurophysiologic assessment of brain maturation after an 8-week trial of skin-to-skin contact on preterm infants. Clin Neurophysiol. 2009 Oct;120(10):1812-8. doi: 10.1016/j.clinph.2009.08.004. Epub 2009 Sep 17. — View Citation

Seay B, Harlow HF. Maternal separation in the rhesus monkey. J Nerv Ment Dis. 1965 Jun;140(6):434-41. — View Citation

Shah PE, Clements M, Poehlmann J. Maternal resolution of grief after preterm birth: implications for infant attachment security. Pediatrics. 2011 Feb;127(2):284-92. doi: 10.1542/peds.2010-1080. Epub 2011 Jan 17. — View Citation

Singer LT, Fulton S, Kirchner HL, Eisengart S, Lewis B, Short E, Min MO, Satayathum S, Kercsmar C, Baley JE. Longitudinal predictors of maternal stress and coping after very low-birth-weight birth. Arch Pediatr Adolesc Med. 2010 Jun;164(6):518-24. doi: 10 — View Citation

Smith GC, Gutovich J, Smyser C, Pineda R, Newnham C, Tjoeng TH, Vavasseur C, Wallendorf M, Neil J, Inder T. Neonatal intensive care unit stress is associated with brain development in preterm infants. Ann Neurol. 2011 Oct;70(4):541-9. doi: 10.1002/ana.22545. Epub 2011 Oct 4. — View Citation

Snaith, R.P. and A.S. Zigmond, The hospital anxiety and depression scale manual. 1994, Windsor, Ontario: NFER-Nelson.

Speilberger, C., State-Trait Anxiety Inventory for Adults. 2005-2008, Menlo Park, CA: Mind Garden.

Spinelli M, Poehlmann J, Bolt D. Predictors of parenting stress trajectories in premature infant-mother dyads. J Fam Psychol. 2013 Dec;27(6):873-83. doi: 10.1037/a0034652. Epub 2013 Nov 4. — View Citation

Squires, J., et al., Ages and Stages Questionnaires - 3. 2009, Baltimore, MD: Paul H. Brookes Publishing Co.

Tottenham N, Hare TA, Quinn BT, McCarry TW, Nurse M, Gilhooly T, Millner A, Galvan A, Davidson MC, Eigsti IM, Thomas KM, Freed PJ, Booma ES, Gunnar MR, Altemus M, Aronson J, Casey BJ. Prolonged institutional rearing is associated with atypically large amygdala volume and difficulties in emotion regulation. Dev Sci. 2010 Jan 1;13(1):46-61. doi: 10.1111/j.1467-7687.2009.00852.x. — View Citation

Tottenham N, Sheridan MA. A review of adversity, the amygdala and the hippocampus: a consideration of developmental timing. Front Hum Neurosci. 2010 Jan 8;3:68. doi: 10.3389/neuro.09.068.2009. eCollection 2009. — View Citation

Tronick E, Lester BM. Grandchild of the NBAS: the NICU network neurobehavioral scale (NNNS): a review of the research using the NNNS. J Child Adolesc Psychiatr Nurs. 2013 Aug;26(3):193-203. doi: 10.1111/jcap.12042. Review. — View Citation

Vignochi CM, Silveira RC, Miura E, Canani LH, Procianoy RS. Physical therapy reduces bone resorption and increases bone formation in preterm infants. Am J Perinatol. 2012 Sep;29(8):573-8. doi: 10.1055/s-0032-1310520. Epub 2012 Jul 6. — View Citation

Volpe, J., Neurology of the Newborn 2008, Saunders: Philadelphia.

White-Traut RC, Nelson MN, Silvestri JM, Vasan U, Littau S, Meleedy-Rey P, Gu G, Patel M. Effect of auditory, tactile, visual, and vestibular intervention on length of stay, alertness, and feeding progression in preterm infants. Dev Med Child Neurol. 2002 Feb;44(2):91-7. — View Citation

Williams J, Lee KJ, Anderson PJ. Prevalence of motor-skill impairment in preterm children who do not develop cerebral palsy: a systematic review. Dev Med Child Neurol. 2010 Mar;52(3):232-7. doi: 10.1111/j.1469-8749.2009.03544.x. Epub 2010 Feb 4. Review. — View Citation

Wolin KY, Colditz GA, Proctor EK. Maximizing benefits for effective cancer survivorship programming: defining a dissemination and implementation plan. Oncologist. 2011;16(8):1189-96. doi: 10.1634/theoncologist.2011-0054. Epub 2011 Jul 17. — View Citation

Woodward LJ, Bora S, Clark CA, Montgomery-Hönger A, Pritchard VE, Spencer C, Austin NC. Very preterm birth: maternal experiences of the neonatal intensive care environment. J Perinatol. 2014 Jul;34(7):555-61. doi: 10.1038/jp.2014.43. Epub 2014 Mar 20. — View Citation

Wraight CL, McCoy J, Meadow W. Beyond stress: describing the experiences of families during neonatal intensive care. Acta Paediatr. 2015 Oct;104(10):1012-7. doi: 10.1111/apa.13071. Epub 2015 Jun 26. — View Citation

Yu YT, Hsieh WS, Hsu CH, Chen LC, Lee WT, Chiu NC, Wu YC, Jeng SF. A psychometric study of the Bayley Scales of Infant and Toddler Development - 3rd Edition for term and preterm Taiwanese infants. Res Dev Disabil. 2013 Nov;34(11):3875-83. doi: 10.1016/j.ridd.2013.07.006. Epub 2013 Sep 9. — View Citation

Zelkowitz P, Na S, Wang T, Bardin C, Papageorgiou A. Early maternal anxiety predicts cognitive and behavioural outcomes of VLBW children at 24 months corrected age. Acta Paediatr. 2011 May;100(5):700-4. doi: 10.1111/j.1651-2227.2010.02128.x. Epub 2011 Jan 11. — View Citation

Zigmond AS, Snaith RP. The hospital anxiety and depression scale. Acta Psychiatr Scand. 1983 Jun;67(6):361-70. — View Citation

* Note: There are 89 references in all — Click here to view all references

Outcome

Type	Measure	Description	Time frame	Safety issue
Primary	Ages and Stages Questionnaire (ASQ) - Communication at 1 Year	Parents completed the parent-report measure of child development, the Ages and Stages Questionnaire (ASQ), at 1 year corrected age. The ASQ The Communication subscore is the primary variable of interest, which looks at the child's language and communication skills at time of assessment. Higher scores on the ASQ Communication subsection indicate more positive outcomes. A child can score a minimum of 0 points and a maximum of 60 points on the Communication subscale.	One year corrected age
Primary	Neonatal Intensive Care Unit (NICU) Network Neurobehavioral Scale (NNNS) Excitability Score at Term Equivalent Age	Infants were assessed using the NICU Network Neurobehavioral Scale (NNNS) by a blinded evaluator. The Excitability subscore, which measures state-related level of arousal over the course of the whole examination, is the primary variable of interest, and ranges from 1-8. An average response falls in the moderate, midpoint range (4-5), and describes an infant who could be brought to respond to stimuli in spite of a high degree of upset or excitement, but then can return to moderate state. Thus, a midpoint range score (4-5) would indicate a better outcome on the Excitability sub scale, whereas a lower (<4) or higher (>5) score would indicate a worse outcome.	At term equivalent age (35-41 weeks PMA)
Secondary	Language Environmental Acquisition Device (LENA)	Audio recordings of a single 16 hour period to capture language and sound exposure occurred at 34 weeks using the Language Environmental Acquisition Device (LENA). The LENA device is a digital language processor that captures environmental sound for up to 16 hours and quantifies: % of the recording with meaningful word exposure, % of the recording with electronic noise, % of the recording with noise, % of the recording with silence, and % of the recording with distant word exposure.	Single 16 hour period to capture language and sound exposure will occur at 34 weeks to assess treatment fidelity/differentiation.
Secondary	Sensory Exposures Provided During Hospitalization	During each day of hospitalization (from day of consent, often within 1 week of birth, to day of discharge, often near term-equivalent age; an average of about 2 months), parents, health care professionals and the sensory support team documented the type and amount of tactile and auditory exposures conducted. The proportion of the SENSE program doses, whether parents conducted the majority of the sensory exposures and whether the doses were met were defined after hospital discharge was complete.	Sensory exposures were documented every day of hospitalization (from birth to term-equivalent age; an average of about 2 months).
Secondary	Dubowitz/Hammersmith Neonatal Neurological Evaluation	At the NICU bedside, infant neurobehavior was assessed by a blinded evaluator using the Dubowitz/Hammersmith Neonatal Neurological Evaluation (HNNE). The HNNE is an assessment of neonatal neurological status. The total score is used as an outcome variable and ranges from 0-78. A higher score indicates a better outcome, whereas a lower score indicates a worse outcome.	At term equivalent age (between 35-41 weeks post menstrual age), just prior to discharge from the hospital.
Secondary	General Movement Assessment (GMA)	A video recording was conducted to enable scoring of general movements and infant neurological/motor status using the General Movements Assessment. However, video quality was deemed insufficient for analysis.	At term equivalent age (between 35-41 weeks post menstrual age), just prior to discharge from the hospital.
Secondary	Discharge Questionnaire	Prior to discharge from the hospital, the infant's mother completed a questionnaire. Measures included the Sensory Profile-2 (SP-2), the State Trait Anxiety Inventory (STAI), the Edinburgh Postnatal Depression Scale (EPDS), the Parent Stress Index (PSI), The Parental Stress Scale: NICU (PSS), the Maternal Confidence Questionnaire, and the Infant Care Questionnaire (ICQ). The SP-2 assesses infant sensory processing skills with summary scores for tactile, auditory, visual, movement, oral, and general processing. The STAI measures maternal anxiety separated into state-related and trait-related anxiety. The PSI includes subscales to measure defensive responding, parental distress, parent-child dysfunctional interaction, & difficult child behaviors. The ICQ measures maternal connection, emotionality, and responsiveness. Possible score ranges and directions of scores listed with each variable below.	Just prior to discharge from the hospital (between 35-41 weeks post menstrual age).
Secondary	1 Year Follow-Up Questionnaire	The infant's mother completed a questionnaire with the following measures: the ASQ, SP-2, STAI, Beck Depression Inventory (BDI), PSI, Maternal Confidence Questionnaire (MCQ), ICQ, Pediatric Eating Assessment Tool (Pedi-eat), and Behavioral Pediatrics Feeding Assessment Scale (BPFAS). ASQ, SP-2, STAI, PSI, MCQ, and ICQ are previously described in discharge questionnaire outcome data. The BDI was used to measure maternal depression at time of follow-up. The Pedi-eat and BPFAS were used to assess infant feeding skills. Possible score ranges and directions of scores are reported below under each individual variable.	One year corrected age.
Secondary	Mother-Infant Interaction (at 1 Year Follow-up)	At one year follow-up, mother-infant interaction will be assessed through the interaction subscale of the Parental Stress Index (PSI). A score in this subscale can range from 12-60, with higher scores indicating a greater degree of dysfunction.	One year corrected age.
Secondary	Parent Engagement During Hospitalization	On each day of hospitalization (from birth to discharge, which often occurred close to term equivalent age; for an average of about 2 months), parents, health care professionals and the sensory support team documented the frequency of parent visitation, holding, and skin-to-skin care.	Every day of hospitalization (from birth through discharge, often close to term equivalent age; on average about 2 months).
Secondary	Language Environmental Acquisition Device (LENA) Adult Word Count	Audio recordings of a single 16 hour period to capture language and sound exposure occurred at 34 weeks using the Language Environmental Acquisition Device (LENA). The LENA device is a digital language processor that captures environmental sound for up to 16 hours and can quantify the number of adult words spoken during the 16 hour recording.	Single 16 hour period to capture language and sound exposure will occur at 34 weeks to assess treatment fidelity/differentiation.
Secondary	Percentage of Sensory Interventions Received	Throughout hospitalization, parents, health care professionals and the sensory support team documented the type and amount of tactile and auditory exposures conducted. The percentage of recommended sensory doses that were received were documented.	Sensory exposures were documented every day of hospitalization (birth through discharge, often close to term) equivalent age).