published_or_final_version / abstract / toc / Paediatrics and Adolescent Medicine / Master / Master of Philosophy

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Purpose/Objective: The purpose of this practice inquiry was to propose the development and evaluation of Information for Parents of Premature Infants (IPPI). The IPPI is an educational handout that increases parent knowledge by discussing the growth and developmental expectations of a premature infant at a particular adjusted age. The IPPI includes: growth patterns; motor development; nutritional requirements; provider contact information; and useful informational resources. Specifically, this tool encourages the PCP to appropriately assess the premature infant's development based on adjusted age, preventing misdiagnosis or needless referrals. The development of the IPPI was guided by the four principles of Levine's model of conservation, and a plan for implementation and evaluation of the IPPI has been drafted utilizing the five components of the RE-AIM framework. Introduction: Each year one-in-nine babies are born prematurely in the United States. Over the last 25 years the rate of premature birth has increased by 36%. Compared to parenting a term infant, parents of premature infants face a significant number of challenges and stress. The cause of such stress is due to a lack of knowledge regarding the unique physical and developmental care needs of a premature infant and the lack of available educational resources that are designed to address this deficit. Rationale: The increased incidence of premature births has placed an enormous burden on primary care providers (PCP) to meet the exceptional health and developmental needs of this vulnerable population. The neurodevelopmental expectations for premature infants vary significantly when compared to those of full-term infants and in addition to the risk for neurodevelopment disabilities there is a significant amount of stress faced by parents. In order to manage the care and physical needs of a preterm infant and have the confidence to bond with their fragile infants, parents need a great deal of support and education regarding the unique physical and developmental needs of their premature infant. Furthermore, parents must rely on the baby's PCP to have the ability to recognize the sequelae that is associated with premature birth and provide appropriate education, anticipatory guidance, resources, and reassurance.

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Iron-deficiency anaemia (IDA) is considered to be the most common nutritional deficiency among infants and children worldwide. The consequences of IDA on the developing central nervous system may be irreversible; these may include delayed mental and motor development, and reduced school performance. Infants are particularly prone to develop IDA if given foods low in iron content or foods that contain iron of low bioavailability. Infants from low socioeconomic background and Asian, Black or Hispanic infants, are believed to be at higher risk for IDA than White infants. There are no published studies on iron status in relation to feeding history from British Columbia or other parts of Canada. The purpose of this study was to determine the prevalence of IDA and low iron status in 9 month old infants in Vancouver, British Columbia, and to determine which infants are at highest risk for IDA and low iron status based on their feeding history, economic and ethnic background. Infants who could participate in the study were identified from birth and death lists provided by the Vancouver Public Health Department. Eligibility criteria were that the infant was full term (gestational age a: 37-<42 weeks) with a birth weight of 2500-4500g and born between January 1st, and March 2nd, 1993, or between June 4th and August 7th, 1993 to parents resident in Vancouver, with an address to enable contact. Initial contact with parents of all eligible infants (n = 1813) was made through a letter. A subsequent telephone call was made to the parents to describe the study protocol and to arrange an appointment for parents interested in participating with their infant. All the appointments were made to coincide with the time when the infant would be 39 ± 1 weeks old. At the clinic appointment, blood samples were collected from the infants, parents completed questionnaires regarding their family background and their infant's nutritional history from birth to 9 months of age, and a visual recognition memory test (Fagan Test of Infant Intelligence) was administered to the infant. Because many tests used to diagnose iron-deficiency anaemia lack specificity, several tests were used in combination. IDA was classified as a Hgb ^101 g/L or Hgb <110 g/L with 2 or 3 abnormal biochemical tests from serum ferritin :S 10 //g/L, total iron binding capacity > 60 //mol/L, and zinc protoporphyrin >70 //mol ZPP/mol heme. Low iron status was classified as a serum ferritin ^10 //g/L without iron-deficiency anaemia. Four hundred and thirty four (434) 9 month old infants and their parents participated in the study, representing 23.9% of all the eligible infants. The prevalence of IDA and low iron status was 6.9% and 24.4%, respectively. A statistically significant association (p<0.0001) was found between the infants' iron status and the duration of breast-feeding. IDA and low iron status was found in 15.2% and 30.4%, respectively, in infants who had received breastmilk as their main source of milk for more than 8 months. In contrast, the prevalence of IDA and low iron status was 1.5% and 10.3%, respectively, among the group of infants who were never breast-fed. Feeding low iron milk (cows' milk, low iron infant formula or goat's milk) also showed a statistically significant (p < 0.05) association with the iron status of the infants. No statistically significant association was found between iron status and the age of introduction of specific solid foods (iron-fortified infant cereals, fruits, vegetables, legumes, egg yolk, tofu, meat, chicken, or fish), or fruit juice. No statistically significant association was found between the annual family income and iron status of the infants, when considering either the entire group of infants, or the infants from two parent households. However, a statistically significant association (p< 0.05) was found between iron status and family income for the group of infants (n = 30) from one parent families. Of note, only 7 of these infants were from families with an annual income of > $20,000. The low number of infants in this group limits the ability to predict the true prevalence of IDA and low iron status, or the association with income in the single parent families. No statistically significant association was found between the infants' iron status and the mothers' level of education. A higher prevalence of iron-deficiency anaemia and low iron status was found in infants of mothers born in Canada compared to infants of mothers not born in Canada. The difference was statistically significant (p<0.05) suggesting a higher risk for iron-deficiency anaemia and low iron status among infants' whose mother had been born in Canada. No statistically significant association was found between the infants' iron status and the number of years an immigrant mother had resided in Canada. Ethnic background as reported by the mother was significantly associated (p<0.05) with the iron status of the infants. Specifically, the prevalence of IDA was higher among infants of European and Canadian parentage than among infants of East Indian and Chinese parentage. No statistically significant differences were found between the scores on the visual recognition memory test of the infants with iron-deficiency anaemia, low iron status or normal iron status. In conclusion, the prevalence of iron-deficiency anaemia (6.9%) and low iron status (24.4%) among otherwise healthy 9 month old infants who participated in this study suggests the need to develop strategies for the prevention of iron-deficiency anaemia, or for early detection and treatment. The results of this study show that the infants at highest risk for iron-deficiency anaemia and low iron status in Vancouver, when defined by feeding history, are infants with a history of breast-feeding as the main source of milk for more than 8 months, and infants bottle-fed low iron milk (cows' milk, goat's milk or low iron infant formula). When defined by economic and ethnic background the infants at highest risk for iron-deficiency anaemia are infants of Caucasian mothers (European or Canadian).

Recognizing and learning one’s native language requires knowledge of the phonetic and rhythmical characteristics of the language. Few studies address the rich source of language information available in a speaker’s face. Solely visual speech permits language discrimination in adults (Soto-Faraco et al., 2007). This thesis tested infants and adults on their ability to use only information available in a speaker’s face to discriminate rhythmically dissimilar languages. Monolingual English infants discriminated French and English using only visual speech at 4 and 6 months old, but failed this task at 8 months old. To test the role of language experience, bilingual (English/French) 6 and 8-month-old infants were tested and successfully discriminated the languages. An optimal period for sensitivity to visual language information necessary for discriminating languages may exist in early life. To confirm an optimal period, adults who had acquired English as a second language were tested. If English was learned before age 6 years, adults discriminated English and French, but if English was learned after age 6, adults performed at chance. Experience with visual speech information in early childhood influences adult performance. To better understand the developmental trajectory of visual language discrimination, visual correlates of phonetic segments and rhythmical information were examined. When clips were manipulated to remove rhythmical information, infants used segmental visual phonetic cues to discriminate languages at 4, but not 8 months old. This suggests that a decline in non-native visual phonetic discrimination (similar to the decline seen for non-native auditory phonetic information; Werker & Tees, 1984), may be impairing language discrimination at 8 months. Infants as young as newborn use rhythmical auditory information to discriminate languages presented forward, but not backward (Mehler et al., 1988). This thesis showed that both 4 and 8-month-old infants could discriminate French from English when shown reversed language clips. Unlike auditory speech, reversed visual speech must conserve cues that permit language discrimination. Infants’ abilities to distinguish languages using visual speech parallel auditory speech findings, but also diverge to highlight unique characteristics of visual speech. Together, these studies further enrich our understanding of how infants come to recognize and learn their native language(s).

Previous research indicates that for adults and children the perception of speech can be significantly influenced by watching a speaker's mouth movements. For example, hearing the syllable /bi/ while watching a speaker mouth the syllable /vi/ results in reports of a 'heard' /vi/. Some evidence suggests young infants also may be able to integrate heard and seen speech. One theory suggests that an innate link between perception and production (Liberman & Mattingly, 1985) accounts for this phenomenon while another theory suggests that experience (e.g., producing speech sounds) may be necessary into order to develop fully the underlying representation of visible speech (Desjardins, Rogers & Werker, in press; Meltzoff & Kuhl, 1994). My dissertation addresses the above controversy by examining whether the integration of heard and seen speech is obligatory for young infants as it is for adults. In Experiment 1, 4-month-old female infants habituated to audiovisual /bi/ showed renewed visual interest to an auditory /bi/-visual NM suggesting that they may have perceived the auditory /bi/-visual /vi/ as /vi/, as do adults. In Experiment 2, neither male nor female infants showed renewed visual interest to a dishabituation stimulus which represents only a change in mouth movements. In Experiment 3, male infants looked longer to an audiovisual /bi/ than to an audiovisual /vi/ following habituation to an audio /bi/-visual /vi/, while female infants tended to look only slightly longer to an audiovisual /vi/ than to an audiovisual /bi/. Taken together these experiments suggest that at least some infants are able to integrate heard and seen speech, but that they do not do so consistently. Although an innate mechanism may be responsible for integration, a role for experience is suggested as integration does not appear to be obligatory for young infants as it is for adults.

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