The purpose of this study was to examine the effects of multi-modal stimulation (differing amounts of light and vocal stimulation) on preterm infants' behavioral and state organization. Specifically, we looked at the effects that supplemental vocal stimulation (taped female voice) had when varied in amount of exposure (three times a day versus once a day) and when provided in different lighting conditions ("typical illumination" versus "decreased illumination"). Forty infants were placed in one of four groups: Standard Illumination/High Voice (SIHV), Standard Illumination /Low Voice (SILV), Decreased Illumination/High Voice (DIHV) and Decreased Illumination/Low Voice (DILV). Infants receiving standard illumination were exposed to the vocal stimulus in standard NICU lighting conditions (approximately 20 lux), whereas infants in the "low" lighting conditions were exposed to the stimulus in darkened conditions (approximately 3 lux). Infants receiving high vocal stimulation listened to a taped female voice three times a day, whereas infants receiving low vocal stimulation were exposed to the voice only once a day. Each infant received 10 minutes of exposure per session over five consecutive days. Infants were videotaped in their incubator for 10 minutes before, during, and after the stimulus exposure (total of 30 minutes) for each day. The videotapes were then scored on the infant's frequency of stress related behaviors and self-regulatory behaviors before, during, and after the stimulus for each day. Results indicated that both lighting levels and vocal stimulation altered preterm infants' stress and self-regulatory behaviors, and that these effects were dependent on both the day and the stimulus condition the infant was in. In addition, the vocal stimulation and lighting levels had an effect on the states that infants exhibited during and after the presentation of stimulation. These results suggest that the occurrence of different types and amounts of stimulation have an effect on behavioral organization of the preterm infant, and these effects are highly dependent on both history and context in which this stimulation is presented / Ph. D.

Synchronous interaction between adolescent mothers with preterm infants in the Neonatal Intensive Care Unit was examined in this study. Understanding the characteristics of synchrony in adolescent mother and premature infant interactions during this early period in the development of the relationship provides direction for the development of nursing strategies to foster synchronous interaction in the neonatal intensive care unit (NICU) setting and, subsequently, positive developmental outcomes for preterm infants. The research design was a one-group, pretest-posttest, exploratory intervention assessing synchronous interaction using the Nursing Child Assessment Feeding Scale (NCAFS) among 27 adolescent mothers and their premature infants in the NICU. The study examined the differences in adolescent mother-premature infant interaction in the NICU environment prior to an intervention and within 48 hours after receiving the Preterm Infant Cues Intervention (PICI). Additional variables including stress, social support, age of the adolescent mother and preterm infant, ethnicity, length of stay in the NICU, and preterm infant weight were considered. Results showed a statistically significant difference between Time 1 and Time 2 synchronous interaction measurements indicating that the PICI may have resulted in the adolescent mother better understanding the preterm infant’s behavior. The Caregiver Total Scale score (t = -3.93, p < .001) and the Total Scale score (t = -3.96, p < .001) were the two main scales that the PICI could have affected. There were no correlations among the other independent variables and the dependant variable. Future research should focus on a large scale longitudinal study to measure synchronous interaction over multiple time points beginning in the NICU carrying through the first year of child development. Adding a qualitative component to future studies would provide further insight into experience of adolescent mothers with preterm infants. / text

Background and Aim: Preterm infants frequently receive blood transfusion (BT) during their stay in the neonatal unit. The aim of this study was to measure the effect of BT on cerebral and gut blood flow and oxygenation in preterm infants in relation to postnatal age. Another aim of the study was also to investigate the influence of measured pre-transfusion RCV on gut perfusion in preterm infants receiving first blood transfusion for clinical indication using NIRS and Doppler ultrasound scan. Methods: Preterm infants admitted to neonatal unit were recruited to three postnatal age groups: 1 to 7 days (group 1; n=20), 8 to 28 days (group 2; n=21) & ≥29 days of life (group 3; n=18). Pre and post-BT Anterior Cerebral artery (ACA) Time Averaged Mean Velocity (TAMV) and Superior Vena Cava (SVC) flow were measured to assess cerebral blood flow. Pre and post-BT Superior mesenteric artery (SMA) peak systolic velocity was measured to assess gut or splanchnic blood flow. Cerebral and gut Tissue Haemoglobin Index (THI), Oxygenation Index (TOI) were measured from 15-20 minutes before to 15-20 minutes post-BT using NIRS. Cerebral and gut fractional tissue oxygen extraction (FTOE) was calculated from the TOI and saturation of oxygen (SaO2). Vital parameters and blood pressure (BP) were also measured continuously from overhead monitors. Pretransfusion red cell volume (RCV) was measured by fetal haemoglobin (HbF) dilution method and compared with the cerebral and gut perfusion and oxygenation changes following blood transfusion. The cerebral and gut perfusion and oxygenation were also measured over a three hour period in 12 control infants not receiving blood transfusion. Results: There were 71 infants included in the study; of them 59 were study infants receiving blood transfusion and 12 were control infants. Amongst the vital parameters, mean BP increased significantly, and there was no significant change in heart rate (HR), respiratory rate (RR) or SaO2 following BT. Pre-transfusion ACA TAMV was higher in Group 2 and 3 compared to Group 1 (p < 0.001) which remained significant after multivariate analysis (p < 0.05). Pretransfusion ACA TAMV decreased significantly (p≤0.04) in all 3 postnatal age groups; pre-transfusion SVC flow decreased significantly in Group 1 (p=0.03) and Group 3 (p < 0.001) following transfusion. Pre-transfusion cTOI was significantly lower in Group 3 compared to Group 1 (p=0.02) which remained significant after multivariate analysis (p < 0.011). The cTHI (p < 0.001) and cTOI (p < 0.05) increased significantly post-transfusion in all three postnatal age groups. PDA had no effect on these measurements. Pre-transfusion SMA PSV increased with postnatal age (group 3 vs. group 1: p < 0.01; CI 0.6 to 0.1), proportion of feeds (> 50% feeds: 0.91±0.4 vs. < 50% feeds: 0.71±0.4 m/sec, p < 0.01); and decreased with presence of PDA (closed PDA: 0.94±0.4 vs. open PDA: 0.68±0.3 m/sec, p=0.006, CI 0.07 to 0.45); but remained unaltered following transfusion. The pre-transfusion sTOI varied with postnatal age (Group 2:44.6 vs. Group1: 36.7%; p=0.03, CI -0.6 to -15.2) on univariate analysis but was not significantly different on multivariate analysis; pre-transfusion sTOI was not influenced by feeds or presence of PDA. The sTHI and sTOI increased (p < 0.01) and sFTOE decreased (p < 0.01) significantly following transfusion in all postnatal age groups.

The central nervous system (CNS) develops in a temporally and spatially organised manner. Any adverse events happening during the critical periods of early brain formation may lead to arrest in the process or injury to specific developed structures. Infants born at less than 30 weeks of gestation and those with intra-partum asphyxia are at risk of motor delay. The cause of this delay may be related to injuries in the brain such as the motor cortex, basal ganglia and cerebellum, all of which are essential in controlling movements. According to the dynamical systems theory of motor development, other than the CNS, body systems within the infant such as the musculoskeletal system, and external to the infant such as environmental enrichment and supportive child-rearing practice also have a decisive role in motor development in infants. / Paediatric physiotherapists have been involved in the management of these infants since birth. A number of well-established assessment tools are used to assess these infants’ motor functions. Most of these tools typically do not describe the movement patterns of infants but emphasise the achievement of age-specific motor milestones. The Alberta Infant Motor Scale (AIMS) is one of the few tools that acknowledge the importance of movement quality. / The overall aim of the present research was to examine the impact of adverse events in early infancy, including birth prior to 30 weeks of gestation and intra-partum asphyxia, on motor development of infants during the first two years of (corrected) age. One hundred and twenty infants were recruited, including 58 preterm infants, 10 infants with post-asphyxia neonatal encephalopathy (NE) and 52 term born infants as the control group. All the infants were assessed using the AIMS at 4, 8, 12 and 18 months of (corrected) age. / The preterm group scored significantly lower on various sub-scores of the AIMS at all age levels than the control group. Uneven progression in the sit subscale from 4 to 8 months corrected age (CA) was found in the preterm infants, possibly due to a dominant extensor strength, inadequate tonus and postural control in the trunk. At 12 and 18 months CA, limited variations in movements were evident in some preterm infants in the crawling, sitting and standing positions. The ten infants with post-asphyxia NE showed scattered motor development, related mostly to the severity of their NE. The moderate NE group had the most varied motor outcomes ranging from normal to suspected mild cerebral palsy. / The AIMS was shown to be a valid assessment tool in the preterm population although limitations in its use were found at 4 months CA and when the infants walked or were close to independent ambulation. The present results show that motor performance of typically and non-typically developing infants should be investigated longitudinally as variations are the characteristic of early development. The dynamical systems theory provides a more satisfactory explanation of the motoric differences in infants in this study. All these findings have great implications for the clinical management of these at risk infants.

The aim of these studies was to increase knowledge about hospital feeding routines in high-risk neonates. A retrospective medical chart review procedure was used to study routines at the neonatal units of two Swedish hospitals. In Papers I and II, the sample (Uppsala n=21 and Umeå n=21) comprised of small for gestational age (SGA) infants, in Papers III (Uppsala n=64 and Umeå n=59) and IV (n=127), the samples comprised of appropriate for gestational age (AGA) infants. Paper I indicated large enteral/oral milk volumes rendered i.v. administration of glucose unnecessary, reduced weight loss and helped SGA infants regain birth weight earlier. More rapid postnatal growth did not remain up to 18 months with corrected age in any growth variable (Paper II). In Paper III, effects were compared whether the infants’ volume of breast milk intake in hospital was estimated by “clinical indices” or determined by test-weighing. Infants treated in hospitals where test-weighing was practised attained exclusive breastfeeding at an earlier postmenstrual age (PMA), and they were discharged at an earlier PMA. However, the two study units were similar regarding the proportion of infants attaining exclusive breastfeeding. Paper IV revealed preterm AGA infants with higher standard deviation scores (SDS) at birth had more negative changes from birth to discharge for all growth variables. Conclusions: Papers I and II indicated that early initiation of enteral/oral feeding with proactive increases in milk volume was beneficial short term. No evidence was found for a proactive nutrition regimen with initial large volumes of milk resulting in a different pattern of growth up to the corrected age of 18 months. Test-weighing before and after breastfeeding might help infants to attain exclusive breastfeeding at an earlier PMA (study III). Finally, preterm AGA infants with higher SDS at birth are at higher risk of inadequate growth during their hospital stay (study IV).

Maintaining adequate and stable blood oxygen level is important for preterm babies to avoid the risk of brain, lung and retinal injury such as retinopathy of prematurity (ROP). However, wide disparities in policies and practices of oxygenation in preterm babies exist among neonatal care providers as it is still unclear which best method of monitoring and what features of oxygen measurements are important to clinician’s interpretations for assessing preterm babies at risk of developing severe ROP or unstable health condition. This thesis consists of two projects: NZ-ROP that examines multiple factors of severe ROP including summary statistics (mean, standard deviation (SD), coefficient of variation (CV) and desaturation) for oxygen saturation (OS) features in very extreme preterm babies, and NZ-LP that investigates the efficacy of some of these statistics for health monitoring of late preterm babies. The OS data in NZ-ROP were recorded using modified oximeters that have offsets and inherent software artefact, both of which mask the actual saturation for certain OS ranges and may complicate the choice of methods in the analyses. Therefore, novel algorithms involving linear and quadratic interpolations are developed, implemented on the New Zealand data, and validated using the data of a UK preterm baby, as recorded from offsets and non-offsets oximeters. For all data sets, the algorithms produced saturation distributions that were very close to those obtained from the non-offset oximeter. The algorithms perform within the recommended standards of commercial oximeters currently used in the clinical practice. ROP is a multifactorial disease, with oxygenation fluctuations as one of the key contributors. The all-subsets logistic regression, robust and generalised additive statistical modelling, along with a model averaging approach, are applied in NZ-ROP to determine the relationship of variability and level of OS with severe ROP, and the extent of contribution of various clinical predictors to the severity of this eye disease. Desaturation, as a measure of OS variability, has the strongest association with severe ROP among all OS statistics, in particular, the risk of severe ROP is almost three times higher in babies that exhibit greater occurrences of desaturation episodes. Additionally, this study identifies longer periods of ventilation support, frequent desaturation events, extreme prematurity and low birth weight as the most important factors that substantially exacerbate the severity of ROP, and therefore signify babies’ underlying condition of being severely ill. Persistent cardiorespiratory instabilities prior to hospital discharge may expose preterm babies to a greater risk of neuro-developmental impairments. In NZ-LP, the statistical summaries of mean, SD and CV are computed from the OS measurements of healthy stable and unstable babies, and the performance of these statistics in detecting the unstable babies is evaluated using an extremeness index for outlying data and a hierarchical clustering technique. With SD and CV, the clinically unstable babies were very well separated from the group of stable babies, wherein, the separation was even more apparent with the use of CV. These suggest that measures of variability could be better than saturation level for highlighting babies’ underlying instability due to immature physiological systems, but the combination of variability and level through the CV are believed to be even better. Identification and summarisation of useful OS features quantitatively hold great promise for improved monitoring of oxygenation instability and diagnosis of severe ROP for preterm babies.

The central nervous system (CNS) develops in a temporally and spatially organised manner. Any adverse events happening during the critical periods of early brain formation may lead to arrest in the process or injury to specific developed structures. Infants born at less than 30 weeks of gestation and those with intra-partum asphyxia are at risk of motor delay. The cause of this delay may be related to injuries in the brain such as the motor cortex, basal ganglia and cerebellum, all of which are essential in controlling movements. According to the dynamical systems theory of motor development, other than the CNS, body systems within the infant such as the musculoskeletal system, and external to the infant such as environmental enrichment and supportive child-rearing practice also have a decisive role in motor development in infants. / Paediatric physiotherapists have been involved in the management of these infants since birth. A number of well-established assessment tools are used to assess these infants’ motor functions. Most of these tools typically do not describe the movement patterns of infants but emphasise the achievement of age-specific motor milestones. The Alberta Infant Motor Scale (AIMS) is one of the few tools that acknowledge the importance of movement quality. / The overall aim of the present research was to examine the impact of adverse events in early infancy, including birth prior to 30 weeks of gestation and intra-partum asphyxia, on motor development of infants during the first two years of (corrected) age. One hundred and twenty infants were recruited, including 58 preterm infants, 10 infants with post-asphyxia neonatal encephalopathy (NE) and 52 term born infants as the control group. All the infants were assessed using the AIMS at 4, 8, 12 and 18 months of (corrected) age. / The preterm group scored significantly lower on various sub-scores of the AIMS at all age levels than the control group. Uneven progression in the sit subscale from 4 to 8 months corrected age (CA) was found in the preterm infants, possibly due to a dominant extensor strength, inadequate tonus and postural control in the trunk. At 12 and 18 months CA, limited variations in movements were evident in some preterm infants in the crawling, sitting and standing positions. The ten infants with post-asphyxia NE showed scattered motor development, related mostly to the severity of their NE. The moderate NE group had the most varied motor outcomes ranging from normal to suspected mild cerebral palsy. / The AIMS was shown to be a valid assessment tool in the preterm population although limitations in its use were found at 4 months CA and when the infants walked or were close to independent ambulation. The present results show that motor performance of typically and non-typically developing infants should be investigated longitudinally as variations are the characteristic of early development. The dynamical systems theory provides a more satisfactory explanation of the motoric differences in infants in this study. All these findings have great implications for the clinical management of these at risk infants.

Purpose: To characterize the environment in both ground and aerial ambulances in an effort to identify and quantify the risk factors associated with intraventricular hemorrhage (IVH) in preterm infants, with the goal of developing a device to mitigate this problem. Methods: A small, stand-alone battery operated device was developed to characterize the environment inside neonatal transports. This device included an array of sensors to measure acceleration forces, sound levels, temperature, pressure, and light intensities. Two of the data acquisition devices were used to collect data inside and outside the transport incubator simultaneously for a period of thirty minutes during a test flight in a transport helicopter. Real-time digital signal processing was performed for the sound signals to reduce data. Furthermore batch digital signal processing was performed on an external computer to calculate the vibration spectrograms, occurrence of impulsive forces, and variations in ambient temperature, pressure and luminance. The results were compared between the two devices to determine whether the current transport incubator design is reducing or increasing the suspected risk factors. Results: The vibration levels registered in the transport incubator during flight were five times greater than in the crew cabin in the vertical direction. High vibration levels were registered in the horizontal direction in the transport incubator, which were not registered in the crew cabin. In contrast, vibration in lateral direction was nearly half of that registered in the crew cabin. Sound levels were on average 70 dBA in the transport incubator. Luminance levels reached values up to 6920 Lux. No major changes in temperature and pressure were registered. Conclusions: IVH is a serious consequence of transporting preterm infants from one health care facility to another and occurs in roughly one out of three infants. To address this problem, a transport monitoring device can help characterize the environment in these transports in an effort to design a new state of the art transport incubator to mitigate this problem. / Master of Science

In der Neonatologie ist die Verabreichung von Erythrozytenkonzentrat (EK) eine der häufigsten therapeutischen Maßnahmen. Ursachen dafür sind die Frühgeborenen-anämie und die iatrogen durch diagnostische Blutentnahmen hervorgerufene sekundäre Anämie. Obwohl ca. 80% der Frühgeborenen während des postnatalen stationären Aufenthaltes EK erhalten, gibt es noch immer keine einheitlichen Richtlinien zur Bluttransfusion bei Frühgeborenen. In der vorliegenden Studie sollte der Effekt einer EK-Gabe mit Hilfe der Messung der cerebralen und peripheren Gewebsoxygenierung (crSO2 und prSO2) erfasst werden. Und es wurde der Annahme nachgegangen, dass in der Neonatologie Subgruppen existieren, welche unterschiedlich von einer EK-Transfusion profitieren. Im Rahmen dieser Promotionsarbeit wurden Frühgeborene der neonatologischen Abteilung der Universitätsklinik und Poliklinik für Kinder- und Jugendmedizin Leipzig prospektiv analysiert. Es konnte gezeigt werden, dass bei allen untersuchten Patienten sowohl die cerebrale als auch die periphere Gewebsoxygenierung unter EK-Transfusion ansteigen und auch nach einem Intervall von 24 Stunden noch auf diesem gesteigerten Niveau konstant bleiben. Zudem konnte nachgewiesen werden, dass Kinder mit niedrigen crSO2-Ausgangswerten vor Transfusion mehr Sauerstoffsättigungsabfälle unter 80% (SaO2<80%) aufweisen. Nach Transfusion ist bei diesen Patienten zusätzlich ein stärkerer Rückgang der Anzahl der SaO2<80% zu beobachten. Somit ist die Gewebsoxygenierung möglicherweise ein sinnvoller Parameter für die Indikation zur EK-Transfusion, welcher bei der Erarbeitung neuer Transfusionsricht-linien in der Neonatologie mit einbezogen werden sollte.

Neonatal Intensive Care Units have experienced profound advances in technology and treatment modalities over the last two decades. Infants born at the edge of viability are now surviving despite prolonged hospitalizations. These infants born preterm are prone to a high degree of stress from life sustaining and routine interventions. Much focus has been directed toward addressing noxious environmental factors such as noise, light, and infectious disease; however, little has been done to examine the stress experienced by the professional caregiver who work in these environments. Environmental press theory, which focuses on the interplay between human beings and their surroundings, is explored as a way to provide insight into understanding and mitigating the stress experienced by health care providers working in the newborn intensive care. A proposal for a research study with a cross-over design was approved to study the effect of “four handed care” on infants’ physiologic responses (oxygenation, heart rate, and stress) and behavioral responses (state, stress and defense, self-regulatory and approach behaviors) to and recovery from endotracheal suctioning when compared to routine care. Results of this study demonstrated no significant differences were noted when heart rate (HR) or oxygen saturation (SpO2) taken at baseline were compared to HR and SpO2 obtained during and after suctioning while in the routine care condition. In the four-handed care condition, mean SpO2 increased from pre-observation 95.49 to during observation saturation 97.75 (p = 0.001). Salivary cortisol did not differ between groups at baseline or post-suctioning. There was no significant difference in behavior state between the two conditions at any time point. More stress and defense behaviors were seen post-suctioning when infants received routine care as opposed to four-handed care (p = .001) and more self-regulatory behaviors were exhibited by infants during (p = .019) and after suctioning (p = .016) when receiving four-handed care as opposed to routine care. There was no statistical difference in the number of monitor call-backs post-suctioning. In conclusion, four-handed care during suctioning was associated with a decrease in stress and defense behaviors and an increase in self-regulatory behaviors. These findings, while based on a small sample, provide modest evidence that the four-handed care intervention for suctioning should receive further testing. Interventions such as four-handed care that are theoretically developmentally supportive of the sick preterm infant, need further research attention before recommending widespread adoption.