Dissertation submitted in fulfilment of the requirements for the Degree of Master of Technology: Emergency Medical Care, Durban University of Technology, 2012. / Introduction The safe transfer of neonates from one healthcare facility to another is an integral component in the process of neonatal care. Neonates, a term applying specifically to infants during the first 28 days of life, are transferred from medical healthcare facilities which do not have specialist care or intensive care management to more specialised facilities in order to improve their clinical outcome and chance of survival. The transfer system is thus an important aspect of the overall care provided to neonates. The transfer process, however, poses a threat of aggravating the clinical condition of the neonate. Inter-healthcare facility transfer of a neonate requires careful planning, skilled personnel and specialised equipment to maintain the continuum of care, as this directly impacts on the morbidity and mortality of the neonate. Purpose of the study The purpose of the study was to undertake a descriptive analysis of the current neonatal inter-healthcare facility transfer system in the eThekwini Health District of KwaZulu-Natal (KZN). This service is provided by the public sector ambulance service known as the Emergency Medical Rescue Service (EMRS). The study, based on 120 consecutive transfers, assessed the clinical demographics of the neonates, the time taken to complete the transfers, including time sub-intervals, the equipment that was necessary for the transfers and the qualifications and procedures performed by the transfer team. The study also identified any adverse events that were encountered during the transfers. Methodology The study was conducted from 19 December 2011 to 30 January 2012. It used quantitative methodology and a non-experimental prospective design to undertake a descriptive analysis of 120 inter-healthcare facility transfers of neonates within the eThekwini Health District of KwaZulu-Natal. Data collection relied upon two types of questionnaires. A descriptive survey method incorporated logistic and deductive reasoning to evaluate the objectives of this study. Frequency distributions were generated to describe data categories. Bivariate analysis was conducted using chi- square. Results During the study period there were a total of 120 neonatal inter-healthcare facility transfers. All referrals were undertaken by road ambulances. Eighty-three (62.2%), transfers were undertaken by the operational ambulance units, 35 (29.2%) by the obstetric unit and 2 (1.7%) by the planned patient transport units. Thirty one (28.5%) transfers were on Fridays, followed by 24 (20.8%) on Mondays and 20 (16.6%) on weekends. Ninety seven (80.8%) were during the hours of dayshift (07h00-19h00) and 23 (19.2%) were during nightshift (19h00-07h00). Of the 120 neonatal transfers, 29 (24.2%) were specialised transfers, of which 22 (75.9%) were ventilated. With reference to the gestational ages of the neonates being transferred 90 (76.7%), were pre-term, 26 (21.7%) were term and 2 (1.7%) were post-term. There were 11 (9.2%) newborns (from birth to 4 hours), 56 (46.7%) early neonates (from 4 hours to 7 days) and 53 (44.2%) late neonates (from 7 days to 28 days). Of the 120 neonatal transfers, 90 (75.0%) were pre-term having associated co-morbidities and 49 (40.8%) had respiratory problems. The mean time ± standard deviation (SD), taken by EMRS eThekwini to complete an inter-healthcare facility transfer was 3h 49min ± 1h 57min. The minimum time to complete a transfer was 55min and the maximum time was 10h 34min. The mean time ± SD from requests to dispatch was 1h 20min ± 1h 36min. The delays in dispatch were associated with no ambulances being available 70 (58.3%), no ALS personnel available 48 (40.0%), no equipment available 23 (19.2%) and no ILS personnel available 7 (5.8%) to undertake the transfers. Junior or inexperienced personnel in the communication centre also contributed to the time delays by dispatching ALS personnel for non-specialised transfers and requesting neonatal equipment when it had not been requested by the referring personnel for the transfer. The mean time ± SD from the referring hospital to the time mobile to the receiving hospital was 43min ± 26min. Six (5.0%) neonates were clinically unstable at the referring facility for transfer. For 15 (12.5%) transfers, neonates had been inappropriately packaged for transport by the hospital staff, which added to the delays, p. value = 0.018. The necessary equipment was unavailable for 37 (30.8%) of the transfers. The lack of equipment was due to problems such as poor resource allocation, and malfunctioning, inappropriate, insufficient and unsterile equipment. The pre- departure checklist had not been completed in 50 (41.67%) of the transfers. The study identified 10 (8.3%) adverse events related to the physiological state of the neonate and included 1 (0.8%) mortality. Nine (7.5%) neonates suffered serious life threating complications during transportation, 8 (6.7%) of which were due to desaturation, 6 (5.0%) due to respiratory deterioration, 3 (2.5%) due to cardiac deterioration and 1 (0.8%) due to temperature related problems. Eighteen (15.0%) of 120 transfers experienced equipment related adverse events of which 9 (7.5%) were associated with ventilators, 9 (7.5%) with incubators, 3 (2.5%) with the ambulance, 2 (1.7%) with the oxygen supply and 1 (0.8%) with arterial cannulation. Five (33.3%) of the 15 equipment related adverse events contributed directly to life threatening physiologically related adverse events, p. value = 0.007. Conclusion and recommendation The Emergency Medical Rescue Service (EMRS) is involved in the transportation of a significant number of neonates between various healthcare facilities in the eThekwini Health District, some requiring intensive care and some not. This descriptive, prospective study has identified numerous shortfalls in the service provided by the EMRS in the eThekwini District. Inter-healthcare facility transfer of neonates can be safely performed by the transport services if the operations are well co-ordinated and there are dedicated, specialised and trained transport teams armed with appropriate equipment and medication, together with the guidance of policies and quality assurance. Transport teams must be trained to provide this specialised care in various environments, including ground and air ambulances and understand the multiphase neonatal transfer processes. There must be good communication and co-ordination by all role players, which is underpinned by good team work to improve the standards of neonatal care and monitoring. Only then can clinical excellence be achieved when transporting neonates between healthcare facilities.

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Smooth tracking and efficient reaching for moving objects require the ability to predict the velocity and trajectory of the object. This skill is important to be able to perceive human action and object motion in the world. This thesis explores early visual motor development in full term and preterm infants. Study I showed that horizontal eye tracking develops ahead of vertical (full term infants at 5, 7 and 9 months of age). The vertical component is also more affected when a second dimension is added during circular pursuit. It is concluded that different mechanisms appear to underlie vertical and horizontal eye movements Study II-IV compared the development of the ability to visually track and reach for moving objects in very preterm infants born <32 gestational weeks to healthy infants born at term. The development of horizontal smooth pursuit at 2 and 4 months of corrected age was delayed for the preterm group (Study II). Some infants were catching up whereas others were not improving at all. A question raised by the results was whether the delay was caused by specific injuries as a result of the prematurity. However, the delays persisted when all infants with known neonatal complications and infants born small for gestational age were excluded (Study III), indicating that they were caused by prematurity per se. At 8 months corrected age preterm and full term infants were equally good at aiming reaches and successfully catching a moving object. Nevertheless, the preterm group used a bimanual strategy more often and had a more jerky and circuitous path than the full term group (Study IV). In summary, preterm infants showed a delayed visual motor development compared to infants born at term. The results of these studies suggest that there is additional diffuse damage to the visual motor system that is not related to neonatal complications as diagnosed today. Measuring smooth pursuit could potentially be a new method for early non-invasive diagnosis of impaired visual function.

The life of a preterm infant admitted to a neonatal intensive care unit may be stressful from the moment of birth. Ever since Hans Selye’s initial characterisation of the biological stress response, cortisol has been frequently measured as an indicator of stress responsivity. However, research of the stress response and cortisol in infants, especially those who are preterm and/or ill, has been scarce basically because of methodological issues. The first aim with this thesis was to investigate the acute stress response, as measured by salivary cortisol and behaviour, for preterm infants, healthy infants, and infants at high psychosocial risk in response to certain defined handling procedures. The second aim was to investigate the stress response, as measured by salivary cortisol and psychometric measures, for parents present during the handling procedure of their infants. The intention was to perform all investigations in an as naturally occurring situation as possible, which means that the studied procedures would have been performed irrespectively of the research. The present thesis includes six original articles. The results of the first study demonstrate that it is feasible to collect sufficient amounts of saliva and to analyse salivary cortisol in neonates using the presented method of collection and analysis. The second study shows that preterm infants, usually cared for in incubators, show no signs of discomfort and have variable cortisol responses during skin-to-skin care with their mothers. The mothers, however, experience stress and low control before their first skin-to-skin care with their preterm infant and do not relax completely until after the session. In the third study we found that preterm infants have higher baseline salivary cortisol as compared to healthy full-term infants. Moreover, preterm infants have higher and sustained pain response during a nappy change as compared to healthy full-term infants. The results of the fourth study shows that infants younger than three months, living in psychosocial high-risk families, have increased cortisol responses during a nappy change, performed by the mother. However, support with the aim of improving mother-infant interaction, dampens the stress response. The results of the fifth study show that oral sweet-tasting solution in combination with a pacifier dampen the levels of the stress hormone cortisol in three months old infants during routine immunisation. Moreover, parents experience more self-rated emotional stress before immunisation if it is their first child who is being immunised. The sixth paper shows that the material used for saliva collection (cotton buds with wooden or plastic sticks) is of importance when saliva is collected but for practical reasons not centrifuged within 24 hours prior to cortisol analyse. The present thesis shows that it is practically feasible to collect saliva and to analyse the stress hormone cortisol in infants. The interpretation of infants’ and parents’ salivary cortisol responses to different handling procedures are discussed in relation to shortand long-term consequences, neonatal intensive care, preterm birth, attachment, mood, and pain.

We aimed to determine the short- and long-term effects on growth, body composition, metabolic and inflammatory markers following supplementation with the probiotic Lactobacillus paracasei ssp. paracasei F19 (LF19) during weaning. Methods: One-hundred and seventy-nine healthy, infants in Umeå city, Västerbotten County were randomised to daily intake of cereals with (n=89) or without (n=90) LF19 108 colony-forming units from 4 to 13 months of age. Weight, length, head circumference and body composition, assessed by skinfold thickness, were examined at 4, 5.5, 6.5, 9, 12 and 13 months of age. Venous blood was drawn at 5.5 and 13 months. In all, 171 infants completed the intervention and were invited to a follow-up at 8-9 years of age between 2009 and 2011, 120 children participated. Weight, height, sagittal abdominal diameter and body composition (using Dual Energy X-ray Absorptiometry-scan) were measured. Data on weight and height at 4 years were collected from medical records. The families filled out a 4-day food record and a food frequency questionnaire, physical activity was assessed using a pedometer for 7 days. At 5.5, 13 months and 8-9 years of age we analysed the serum blood lipid profile. At 8-9 years fasting glucose, insulin, aspartate and alanine transaminases were analysed in serum. Homeostatic Model Assessment index was calculated. At follow-up serum adiponectin, high-sensitivity C-reactive protein and plasma C-peptide, ghrelin, gastric inhibitory polypeptide, glucagon-like peptide 1, glucagon, insulin, leptin, plasminogen activator inhibitor-1, resistin and visfatin were analysed. For characterisation of the plasma metabolome, a subgroup (n=40) was analysed at 5.5 and 13 months of age by gas chromatography time-of-flight mass spectrometry (GC-TOF/MS) analysis and in all (n=112) children at the follow-up using untargeted GC-GC/MS. Results: There were no differences between the LF19 and placebo group regarding body weight, length/height at any assessment from 4 months to 8-9 years of age; nor were there any differences between the groups in body composition. In the LF19 group 19 % were overweight/obese, the corresponding number was 21 % in the placebo group (p=0.78). Analysed metabolic and inflammatory markers, both during the intervention and the follow-up did not differ between the two groups. At 13 months of age lower levels of palmitic acid and palmitoleic acid (both p<0.04) and higher levels of putrescine (p<0.01) were seen in the LF19 compared to the placebo group. These differences did not persist at 8-9 years of age. At that age, we found statistically stronger models when comparing overweight/obese and normal weight children as well as in relation to sex. Conclusion: Early intervention with the probiotic LF19 at the time of weaning exerted transient effects on the metabolome. In a long-term perspective, we found neither benefit nor harm on growth, body composition, metabolic or inflammatory markers following supplementation with LF19 during weaning.

Thesis (MEng) -- Stellenbosch University, 2014. / ENGLISH ABSTRACT: The thermal regulation response of a neonate has to maintain temperature homeostasis, thus resisting the changes to core temperature caused by the unstable external environment. In this thesis a theoretical thermal regulation response model for human infants subject to a well-defined environment is presented. This model will aid in understanding the influences of environmental effects on core and skin temperature. The respiratory system was also included in the thermal regulation response model. A literature study was undertaken emphasising thermal regulation of neonates. The blood circulation system, skin tissue physiology and the respiratory system physiology were reviewed and helped to provide a better understanding of the thermal regulation mechanisms and how heat transfer theory can be used to analyse heat loss in neonates. The thermal heat transfer properties of skin tissue was specified and used in the development of the theoretical simulation model. The bioheat equation developed by Pennes was reviewed as well as a mathematical model developed by Fiala et al. The theoretical model was developed by applying the conservation of energy and the applicable properties to one dimensional layers to generate a set of time dependent differential equations. The set of equations was solved using an explicit numerical finite difference method, given the initial conditions. The mathematical model included heat loss through the skin, heat loss through the respiratory system, as well as the effect of environments (in incubator or in a bassinette) with different temperatures, relative humidity’s and air velocities. Clothing was also incorporated. A clinical trial was conducted to facilitate a better understanding of thermal stability in neonates. The data acquired during the clinical trial was also used to verify/validate the theoretical simulation model. The results from the simulation temperatures were compared with the average outer skin layer temperature measured during the clinical trial and an average deviation of only 0.22 °C was found, thereby proving that the simulation model gives realistic results. An experimental respiratory model was designed to simulate the respiratory system and illustrate the functioning thereof with regards to heat transfer. This was done by designing an experimental mechanical lung apparatus. The apparatus was tested and successfully imitated the respiratory system with regards to heat transfer. The results obtained from this experiment indicated that the trachea must be moistened continuously in order to condition inhaled air. The outcome of this project identified two possible applications. For the first application it can be used as a test tool for quickly evaluating the influence of different environmental conditions in the transient temperature distribution of neonates. The second application would be to enable medical professionals to monitor the influence of the thermal environment, including the temperature, relative humidity and air velocity, on the neonate’s temperature change to allow for a speedier thermal intervention strategy. / AFRIKKANSE OPSOMMING: Die hitte regulering reaksie van 'n pasgebore baba moet temperatuur homeostase handhaaf, en sodoende die veranderinge aan die kern temperatuur weerstaan wat veroorsaak word deur ‘n onstabiele eksterne omgewing. In hierdie tesis word 'n teoretiese hitte regulerings reaksie model vir menslike babas, onderhewig aan 'n goed-gedefinieerde omgewing, aangebied. Hierdie model sal help met die verstaan van die invloed wat omgewings effekte het op die kern en vel temperatuur. Die respiratoriese sisteem is ook ingesluit in die hitte regulering reaksie model. 'n Literatuurstudie is onderneem met die klem op hitte regulering van pasgebore babas. Die bloed sirkulasie sisteem, vel weefsel fisiologie en die respiratoriese sisteem fisiologie is hersien en help met beter begrip van die hitte regulering meganismes en hoe hitteoordrag teorie kan gebruik word om hitte verlies in pasgebore babas te analiseer. Die hitte-oordrag eienskappe van vel weefsel is gespesifiseer en word gebruik in die ontwikkeling van die teoretiese simulasie model. Die ‘bioheat’ vergelyking ontwikkel deur Pennes is hersien asook 'n wiskundige model wat ontwikkel is deur Fiala et al. Die teoretiese model is ontwikkel deur die toepassing van die behoud van energie tesame met die gebruik van toepaslike eienskappe en een dimensionele lae om 'n stel tyd afhanklike differensiaalvergelykings op te wek. Die stel vergelykings is opgelos met behulp van 'n eksplisiete numeriese eindige verskil metode, gegewe die aanvanklike toestande. Die wiskundige model sluit in die hitte verlies deur die vel, hitte verlies deur die respiratoriese stelsel, sowel as die effek van die omgewing (broeikas of in 'n bassinette) met verskillende temperature, relatiewe humiditeit en lug snelhede. Klere is ook in ag geneem. 'n Kliniese proef is gedoen om 'n beter begrip van termiese stabiliteit in pasgebore babas te fasiliteer. Die data wat tydens die kliniese proef verhaal is, is ook gebruik om die die teoretiese simulasie model te verifieer. Die resultate van die simulasie temperature is vergelyk met die gemiddelde buitenste vel laag temperatuur gemeet tydens die kliniese proef en 'n gemiddelde afwyking van slegs 0.22 °C is gevind, wat dus bewys dat die simulasie model realistiese resultate gee. 'n Eksperimentele respiratoriese model is ontwerp om die respiratoriese stelsel te simuleer en die funksionering daarvan te illustreer met betrekking tot hitte-oordrag. Dit is gedoen deur die ontwerp van 'n eksperimentele meganiese long apparaat. Die apparaat is getoets en slaag daarin om die respiratoriese stelsel suksesvol na te boots met betrekking tot hitteoordrag. Die resultate verkry uit hierdie eksperiment het aangedui dat die tragea kostant klam gemaak moet word om ingeasemde lug te kondisioneer. Die uitkoms van hierdie projek het twee moontlike toepassings geïdentifiseer. Die eerste is dat dit as 'n toets instrument vir die vinnige evaluering van die invloed van verskillende omgewingsfaktore in die temperatuur verspreiding van pasgebore babas gebruik kan word. Die tweede toepassing sal wees om medici in staat te stel om die invloed van die termiese omgewing te monitor, insluitend die temperatuur, relatiewe humiditeit en lug snelheid, om die neonaat se temperatuur verandering te monitor en voorsiening te maak vir 'n vinniger verwarmings intervensiestrategie.

The UK currently has the highest number of premature births (babies born before 37 weeks gestation age and below 2.5kg) in Europe affecting around 70,000 babies and their caregivers each year. Consequently many interventions have been created to support the development of the preterm newborn and minimise the complications of prematurity. Many of the interventions developed have been predominantly tactile and have almost exclusively focused upon their effect upon the baby and not, for example considered the effect that this type of intervention might have upon the parents; specifically the mother, when they are the ones who perform the therapy. In fact there is a severe lack of systematic studies investigating the latter. Hence, the aim of this thesis was to search for research-based evidence on the benefits of environmental support to both babies (e.g. increased weight gain or awake periods) and their mothers (e.g. higher perceptions of themselves as a mother) during hospital confinement and within the context of Neonatal Health Psychology (NNHP). For this reason, the main hypothesis investigated whether mothers’ cognitions and emotions; specifically Maternal Self-Efficacy, Self-Esteem and Attachment, would be affected by environmental mediators in the form of structured or non-structured tactile sensory nurturing interventions. The empirical work reported in this thesis is divided into 3 distinct phases. Firstly, as their was no appropriate measure of maternal Self-Efficacy for mothers of hospitalised preterm neonates the main aim of Phase-1 was to develop and validate an appropriate measure. Using a prospective survey method and a mixed design (between/within and correlational) a total of 160 mother-preterm dyads (pooled from 2 cohorts; cohort 1, N=100; cohort 2, N=60) were recruited. The results demonstrated that the Perceived Maternal Parenting Self-Efficacy (PMPS-E) tool had good initial psychometric properties (including internal/external reliability and construct validity) for its use with mothers of relatively healthy hospitalised preterm neonates. Secondly, in order to investigate mothers’ perceived maternal parenting self-efficacy beliefs further Phase-2 examined whether the type of feeding a mother chose to give to her baby mediated her self-efficacy beliefs. The results suggested that breastfeeding a preterm neonate during hospital confinement may adversely affect mothers’ perceptions of their efficacy in all aspects of parenting. Finally, using an experimental method Phase-3 tested the main hypothesis of this thesis and used a randomised cluster control trial (RCCT) design to allocate 60 mothers and their preterms equally to one of three cluster groups; consisting of either structured (e.g. TAC-TIC therapy or Using a Toy) or non-structured (Placebo/Control) tactile sensory nurturing interventions. The main findings illustrate that tactile sensory nurturing interventions do mediate maternal cognitions and emotions, preterm weight gain and behavioural state. In particular, mothers who performed TAC-TIC demonstrated significantly higher self-reported perceptions in their self-efficacy, self-esteem and attachment, which was attributed to the fact that these babies spent increased amounts of time in an alert and responsive behavioural state, and gained more weight throughout the study period. Thus, the work presented throughout this thesis has implications for Neonatal Health Psychologists and other Health Care professionals’ practice within neonatal units, the use of Neonatal Health Psychology as a framework to study the preterm neonate and their family, and also the way in which both mothers and their hospitalised preterm neonates are supported during hospital confinement.

published_or_final_version / Social Work / Master / Master of Social Work

published_or_final_version / Speech and Hearing Sciences / Doctoral / Doctor of Philosophy

It has been shown that infants build representations of their visual world by forming relations among its parts. However little is known about how they select the parts to relate. One possibility is that while constructing their visual world part by part they are also decomposing it, using finer and finer parts. One way to test this theory is to simply control the parts infants see. This easiest way to do this is to filter real life objects of their high and low spatial frequencies. High spatial frequencies provide information about the smaller parts where as low spatial frequencies provide information about the larger ones. By removing high or low spatial frequency we can control the coarseness of their representation and ultimately determine the level at which they function best. The present study examined infants’ ability to use high and low spatial frequencies to discriminate between objects. Infants were habituated and tested using a combination of high and low spatial frequency images. Only infants experiencing a consistent spatial frequency across habituation and test were able to discriminate between objects. Infants were also better at discriminating between objects containing high spatial frequencies. In a second study designed to be more true to life, infants were habituated to broadband images and tested using high or low spatial frequencies. This time infants did not discriminate between objects but they did look longer at low spatial frequency information than at the high. From these findings we can conclude that infants use both high and low spatial frequency information when discriminating objects, and that in certain cases one frequency may become more important than the other. The spatial frequency they use may be dependent on the context of the task. Numerous studies have shown that adults prioritize high and low spatial frequency information depending on how fast they want to process the object, the amount of detail they require, and whether they used high or low spatial frequency information during previous experiences. Infants may be similar. At times they may emphasize low spatial frequency information and the big picture. At other times they may emphasize high spatial frequency information and the detail. More studies examining how infants select information for processing are necessary and spatial frequency will likely to be an important tool in the investigation. / text