Symposium
Chair: Elvidina N. Adamson-Macedo
Discussant: Christina DelúPriore
Notwithstanding more than three decades of work on early or very-early intervention studies with preterm infants, published reports are mainly concerned with specific outcomes. Particular lacunae are lack of systematic comparison of different programmes which have been used in the same locale, failure to compare past practices with results of routines originating and borrowed from elsewhere, and absence of investigation of maternal self-efficacy during the neonatal period, i.e., the first 28 days of postnatal life. Moreover, routines of Neonatal Care continue to differ widely between different countries and cultures; some Units, for example, presently adopt programmes of early sensory stimulation or individualised care of preterm populations without investigating the responses of staff, whilst others conduct scientific investigations prior to adoption of programmes or therapy as part of routine care. Around the world, policies vary regarding parental access; there are still many Units which admit parents for only minimal periods, thereby limiting opportunities for learning appropriate programmes which would increase maternal self-efficacy. Garcia, Nicolau, Toma, Guares, Leone and Adamson-Macedo report on preliminary results of work in progress which compares the immediate effects on oxygen saturation and State of preterm neonates of a unimodal (tactile-light stroking only) therapy known as TAC-TIC (Touching And Caressing; Tender In Caring) with a multimodal (tactile-kinaesthetic and vestibular) therapy. Constantinou, Thomas, Korner and Fleisher, examined the impact of a Neonatal Individualized Developmental Care and Assessment Programme (NIDCAP¨) devised to teach parents to read the behavioural cues of their very low birthweight preterms, and so implement the programme when visiting within the context of a family centered study. Comparison was made with a control group of their neurobehavioural development at 36 weeks postconceptional age (PCA), using the Neurobehavioral Assessment of the Preterm Infant (NAPI). Although there are studies which investigate changes in attitudes of parents after watching professionals assessing the behavioural competence of preterm neonates, there are no reports of systematic studies into the behavioural changes of staff of Neonatal Units before and after the training period of the TAC-TIC therapy; this subject is explored by Toma, Guares, Nicolau, Garcia, Adamson-Macedo and Leone with data derived from work in progress. Several investigations have been conducted into the mediating role of maternal self-efficacy on behavioural competence of mothers of infants. Hitherto such studies have not been extended to the self-efficacy of mothers of preterm babies during their neonatal period, and preliminary results and analysis of such a study are reported by Barnes and Adamson-Macedo. These show that a new questionnaire has internal validity, and will consequently be used for our on-going studies which seek to determine whether, or not, the self-efficacy of mothers will be enhanced by teaching them appropriate sensory nurturing programmes to be applied during the neonatal period.
Details of individual items:
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We examined the impact of developmental care on the preterm neonate within the context of a family centered study. Seventy seven preterm infants with birthweight <1250 grams were assigned to one of two groups by Efron's adaptive randomization method. Intervention infants (N 39) received a Neonatal Individualized Developmental Care and Assessment Program (NIDCAP¨) devised by a developmental specialist as a component of a program to teach parents to read their infants' behavioral cues and implement the program when visiting their infant. One of the recommendations was that intervention subjects be in a contained environment such as a nest (Children's Medical Ventures), a bunting (Tarry Manufacturing, Inc.), or wrapped in a blanket from the first week of life until discharge. There were no group differences in birth weight, gestational age, severity of illness, incidence of brain injury, and time on the ventilator. The mean length of stay was 92 and 90 days for intervention and controls respectively. Control infants (N 38) received usual nursery care which included wrapping at the care givers discretion. Infants were examined at 36 weeks postconceptional age (PCA) using the Neurobehavioral Assessment of the Preterm Infant (NAPI). Results showed no differences between intervention and control groups or the normative values for this age in the motor development cluster, the alertness and orientation cluster or the percent asleep ratings. No significant differences were found in the popliteal angle between intervention and control but both groups differed significantly from the normative values which were established prior to the advent of infant containment in our nurseries. Significant differences were found in the scarf sign between intervention and control groups and between both groups and the normative values. The intervention infants had a significantly tighter scarf sign and were also significantly more irritable (extent of cry) with a more robust cry quality. Results are presented as a mean+/-S.D. percentage where 0 represents the least mature and 100 the most mature response.NAPI at 36 wks PCA InterventionN 39 ControlN 38 P value NormativeValuesN 161Motor Development 67.45±13.59 65.16±14.20 0.50 63.0±14.5Alert & Orient 47.36±19.29 53.74±17.61 0.16 54.0±19.4% Asleep Rating 19.74±19.81 14.75±12.05 0.22 29.2±28.8Popliteal Angle 82.38±20.19 74.48±21.99 0.13 41.7±27.8Scarf Sign 87.04±17.86 72.41±18.74 0.002 55.9±17.8Irritability 54.65±20.93 43.84±24.38 0.05 41.5±20.4Cry Quality 57.86±35.75 37.07±35.12 0.02 63.4±24.2These results may reflect the extent of containment experienced by preterm infants. Infants removed from this consistent environment for assessment were more irritable and had a more robust cry. This may be a situational response to release from containment. These findings raise the question as to whether the effects on development are transitory or have a sustained impact. The relation between specific interventions such as containement and neurodevelopmental outcome needs further investigation in a randomized control trial with specific attention to the degree of containment as well as the duration of the effect.
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Controversy remains regarding the appropriateness of sensory stimulation programmes for preterm neonates. In a contribution to clarify the issues involved, the effects on oxygen saturation and State of preterms have been investigated whereby a unimodal therapy (TAC-TIC) has been compared with a multimodal (tactile-kinaesthetic and vestibular ) therapy which is used as routine care at the Neonatal Unit of the Hospital das Cl’nicas of the University of S‹o Paulo, Brazil. The hypothesis was that neither TAC-TIC nor the multimodal therapies would significantly provoke a sharp fall in oxygen saturation of non-ventilated preterm neonates. With Ethics Committee approval and parental informed consent, thirty preterm neonates were recruited [Gestational age (GA) < 34 weeks and birthweight (BW) > 750 g], and admitted to the Neonatal Intensive Care Unit. The exclusion criteria were :- congenital infections and/or malformations, perinatal asphyxia ( Apgar Score at 5 minutes of < 6), intracranial haemorrhage, air leaks, twins, and use of sedatives or analgesics. The selected neonates were divided into two groups. Group I (Control, n16) were born on an even-numbered day, and received multimodal stimulation (539 sessions) beginning from day-1 but not later than day-6 of postnatal life, as permitted by the clinical conditions. Group II (Experimental, n14) were born on an odd-numbered day, and received TAC-TIC therapy (752 sessions), beginning between 24 and 48 hours of postnatal life. Both therapies were applied twice daily until forty weeks post-conceptional age (PCA); each session lasted from 4-8 minutes and was always carried out by the same investigators (2 nurses and 2 physiotherapists) both of whom were qualified to use both therapies. Using an OHMEDA Biox 3.700 - Pulse Oxymeter, the saturation of oxygen was measured 3 times, before, immediately after, and 5 minutes after each therapy. State before and immediately after was recorded following categories established using the Neurobehavioral Assessment of the Preterm Infant (NAPI). Birthweight, gestational age, gender, Apgar Score at 1st and 5th minutes of life were recorded. Results show that the groups were significantly different (Fisher's p < 0. 001) on BW, GA, and Apgar at 1 and 5 minutes with the experimental group being smaller, younger and with lower Apgars. A Repeated Measures Analysis of Variance (ANOVA) have shown an effect of intervention with O2 saturation significantly decreasing immediately after, and significantly increasing five minutes after both therapies [F (1, 1289) 35.93, p < 0.001], although neither of these changes can be considered to be sharp. It is noteworthy that although both groups were initially between States 4 and 5 (alert inactive; waking activity), immediately after TAC-TIC they occupied State 5 but were in State 6 immediately after multimodal therapy; this may indicate that TAC-TIC has a more calming, relaxing and comforting effect on these babies. The initial falls in O2 saturation were small and within medical tolerance; 5 minutes later after both therapies, the O2 saturation significantly increased, a result which implied that positive or beneficial coactions were occurring between the baby's physiological, neurobehavioural and sensory systems (tactile-kinaesthetic and vestibular).These results have been interpreted using the Equilibrium Model (ThEM), proposed by Adamson-Macedo and based on the concepts of Gottlieb's theory of Experiential Canalization.
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The Neonatal Unit (BAM-HC) of the Clinic's Hospital of the University of S‹o Paulo Medical School is a Unit of risk with a rate of prematurity (gestational age < 37 weeks) of 22.9%. Under the coordination of one Neonatologist and one Psychologist, a multidisciplinary team (2 nurses and 2 physiotherapists) applied TAC-TIC (Touching And Caressing - Tender In Caring) therapy to preterm neonates. The original method of TAC-TIC was used in this study consists of a systematic sequence of 22 light stroking movements from head to toe, and are guided by the four principles of gentleness, rhythm, equilibrium and continuity. The aim of this qualitative study was to investigate possible behavioural changes of 3 groups, as each group handled the neonates :- * the TAC-TIC team, the members of which had been trained to use the method, * the other members of staff, * the parents. Two questionnaires were developed; the one applied to the TAC-TIC team had 10 questions referring to their training period, 7 questions in relation to time when they were applying TAC-TIC. and 8 questions focusing on the period after the application of TAC-TIC. The other questionnaire comprised 14 questions and was applied to nurses (n5) and assistant nurses (n5). Results indicate that all staff involved reported that they had changed their behaviour of appreciating that a programme of sensory stimulation had been of value to the babies; they also reported that they started to read the behavioural cues of the babies with more care and attention, and were more gentle during necessary handling and positioning of the baby. As a consequence of their training and subsequent application of the method at the Unit, the TAC-TIC group reported that they had developed more gentle ways of touching and handling the babies. Overall, the staff (TAC-TIC team 4/4; others 8/10) reported observing that the babies were calmer and slept longer after TAC-TIC. TAC-TIC team observed that parents seemed more confident in handling their babies; moreover, after being show how to conduct the touching, the frequency of handling increased. This small qualitative and exploratory study thus detected changes in behaviour of different professionals and parents in relation to how they touched and handled the babies in their care, and promoted greater tranquility in the babies. The authors concluded that TAC-TIC therapy is safe, and is a type of stimulation of preterm neonates which has positive results not only to the neonate, but also to those who are the caregivers.
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In the many investigations of the mediating role of perceived self-efficacy beliefs in influencing behaviour, several studies have shown the mediating role of maternal self-efficacy on behavioural competence amongst mothers of very young infants. However there has hitherto been no study which investigates the level of perceived self-efficacy of mothersof preterm neonates during their first 28 days in hospital and its correlates. Moreover, mothers of preterm neonates may have the knowledge of how to care, comfort or console her distressed hospitalised baby, but may not feel competent to do so because of self-doubt. The aim of this study was to adapt a questionnaire based on Teti and Gelfand (1991), but which had only measured the self-efficacy of parents of toddlers. The hypothesis was tested that the levels of perceived self-efficacy of mothers of preterm neonates during their neonatal period in hospital were significantly correlated with their babies birthweight (BW), Gestational age (GA) and post-conceptional age (PCA). A correlational design was used and forty babies were recruited, with Ethics Committee approval and parental written informed consent, in 2 Hospitals [one in the West Midlands (Royal New Cross) and the other in Shropshire (Royal Shrewsbury)]. The Questionnaire consisted of 37 questions using a 4-point Likert-type scale ranging from 'strongly disagree to strongly agree'. Twenty four babies were in their cots and 16 in their incubators on the day of applying the questionnaire. The range of maternal age was between 18-42 years with a mean age of 27 years. First phase of analysis has shown that the questionnaire has internal validity. Self-efficacy scores for parents whose babies were in cots were higher (76) than the scores for parents (65) whose babies were in incubators. Significant correlations were also found between Birthweight (rho 0.36; p < 0. 02), Gestation age (rho 0.36; p < 0. 03) and Conceptional age (rho 0.34; p < 0. 04) . This would seem to suggest that if the baby was of increased weight, older in Gestation age and/or Conceptional age thenSelf-efficacy was greater for these mothers. No significant correlations were found with maternal age, parity, type of feeding or type of delivery. The stressors that affect maternal ability in this study were birthweight, gestational age and conceptional age. A factorial Analysis of Variance using location (baby in incubator or in cot) has shown that mothers whose babies were in their incubators had lower scores (NS), thereby suggesting that they may indeed have self-doubts regarding their competence in caring, consoling and comforting their babies, particularly if they are in their incubators. Second phase of this study involves refining the questionnaire, and investigating the mediating role of appropriate tactile interventions and/or individualised care in increasing maternal self-efficacy.