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Original Article The Influence of a Multisensory Intervention for Preterm Infants Provided by Parents, on Developmental Abilities and on Parental Stress Levels Journal of Child Neurology 2015, Vol. 30(7) 896-903 ª The Author(s) 2014 Reprints and permission: sagepub.com/journalsPermissions.nav DOI: 10.1177/0883073814549242 jcn.sagepub.com Lidia V. Gabis, MD1,2, Keren Hacham-Pilosof, OT, MSc1,2, Omer Bar Yosef, MD, PhD1,2, Gila Rabinovitz, OT, MSc2, Gili Leshem, MA1, Aya Shilon-Hadass, MD1,2, Yael Biran, MA1,2, Brian Reichman, MD1,2, Jacob Kuint, MD1,2, and Orit Bart, OT, PhD2 Abstract Evaluation of a multisensory intervention based on the developmental approach provided by parents, during neonatal intensive care unit hospitalization of their preterm infants. After guidance of parents and implementation of intervention program, children were followed up to 2 to 3 years using scales for evaluation of parental stress levels and child’s development. Our 2 to 3 years’ follow-up study included 41 infants (20 controls and 21 who received parental-guided intervention) as part of a group of 95 preterm infants who participated in a short-term study. The intervention group showed significantly higher scores in receptive language and fine-motor domains of the Bayley Scale of Infant and Toddler Development–3rd Edition. Boys showed superior improvements in language skills. No differences were found in the cognitive and adaptive domains. There were no differences in parental stress levels. A multisensory intervention program for preterm infants provided by trained and supervised parents may improve language and motor outcomes at 2 to 3 years. Keywords prematurity, parents, infants, development Received January 16, 2014. Received revised June 17, 2014. Accepted for publication August 02, 2014. Survival rates of preterm infants have risen over the past 2 decades as a result of improvements in obstetrics and neonatology.1,2 However, preterm infants are at increased risk of neurodevelopmental impairments3,4; that is, even near-term preterm infants tend to reach language milestones at a later age than comparable full-term infants.5 These deficiencies are often seen in light of biological factors, such as degree of prematurity, or central nervous system impairments due to disrupted brain development.6 The quality of early socioenvironmental factors, such as parent-infant interactions, influence child development.6-8 Parents of preterm infants often experience negative emotions because of a multitude of present and future concerns, including insecurity in interactions with their infants during hospitalization in the neonatal intensive care unit.9,10 Mothers of preterm infants were found to be less responsive to their infants than mothers of full-term infants. Poor maternal responsiveness was associated with deficits in early language acquisition.5 In the neonatal intensive care unit, preterm infants are repeatedly exposed to an overwhelming environment of noise, intense light, painful medical interventions, and lack of parental contact.11 These disturbances in the infant’s environment occur during a critical period for infant development of physiological immaturity and rapid brain development.12 It has been suggested that modification of infants’ physical and emotional environment in the neonatal intensive care unit may improve outcome, and various early intervention programs have been developed.11 1 Weinberg Child Development Center at Safra Children’s Hospital, Tel Hashomer, Ramat Gan, Israel 2 Tel Aviv University, Tel Aviv, Israel Corresponding Author: Lidia V. Gabis, MD, Weinberg Child Development Center, Sheba Tel-Hashomer, 5262000 Israel. Email: gabis@post.tau.ac.il Gabis et al In determining the effectiveness of these intervention programs, developmental differences between twins and singleton children, as well as gender, should also be considered.13-15 Implementation of a multisensory intervention program while the infants are hospitalized, performed by parents, may improve neurodevelopmental outcome, empower parents, and may conserve neonatal intensive care unit manpower resources. The objective of the current study was to assess the effects of the aforementioned early multisensory intervention and parents training applied in the neonatal intensive care unit, at short term and at 2 to 3 years postdischarge. We examined the same sample of preterm participants at 2 to 3 years of age in 5 different areas of development, that is, cognitive, language, motor, socialemotional, and adaptive behavior, using the Bayley developmental assessment battery. Because the intervention program emphasized these domains, we hypothesized that the intervention group will score higher on the Bayley subtests as toddlers, indicating a positive and long-term impact of the intervention program on several developmental areas. Additionally, we expected a differential long-term impact for the intervention program on prematurity level, gender, and twins/singletons. Methods Participants Ninety-five preterm infants hospitalized between the years of 2006 and 2008 in the neonatal intensive care unit of Chaim Sheba Medical Center were assigned to several integrated studies that were employed by the Weinberg Child Development Institute of Chaim Sheba Medical Center–Tel Hashomer. The control group included 48 infants born between July 2006 and May 2007. The intervention group included 47 infants born between July 2007 and June 2008. Inclusion criteria were infants born preterm at gestational age <36 weeks, with no congenital anomalies, who were stable without artificial respiration. The first study examined the preterm infants’ development in their first year of life. For major findings and conclusions, see Pilosof et al.13 At the 2-year follow-up, because of compliance, the assessments were performed in half the patients from each group, whereas the rest were interviewed by telephone to exclude possible bias and were not included in the current report. There were no significant differences between groups in the telephone-reported outcomes of excluded children. Therefore, our present study included 41 toddlers (63.4% boys, 48.8% twins). The control group included 20 toddlers who were part of the control group in the short-term study.13 Similarly, the intervention group included 21 toddlers from the previous study intervention group. Intervention A multisensory intervention and parental13 and staff training (bedside) was applied in the neonatal intensive care unit setting only during hospitalization. The parents performed the daily intervention under supervision of occupational therapists (authors KHP and GR) as far as the medical condition of the infants permitted. The intervention program was designed based on the ‘‘Developmental Care’’ approach.16 Parents from the intervention group were trained to support and enhance the infant’s self-regulatory competence and to adjust the environment 897 to their infant’s needs.14,7 They were guided to provide their infants with sensorimotor stimulations and trained to classify their infant’s behavior. In addition, they received instructions for daily intervention, including positioning, massage, and oral stimulation. Implementation was assessed and corrected daily during hospitalization. As expected, introduction of the Newborn Individualized Developmental Care and Assessment Program and developmental care in the neonatal intensive care unit influenced the care of all premature babies, including the ones who did not participated in the study. The nurses we instructed became more aware to noise, light, and handling of the infants, without knowledge of which babies were included in the study. Because those changes were expected, the controls were recruited upfront, before the study protocol was performed in order to better evaluate the effect of the intervention without influencing the controls. Assessments Perinatal. Gender, gestational age, singleton/multiple pregnancy, birth weight, birth head circumference, Apgar scores at 5 minutes, and length of parental feeding and hospitalization. The Test of Sensory Functions in Infants was conducted at 6 and 12 months (corrected age). The Test of Sensory Functions in Infants is a 24-item test developed to measure sensory processing and reactivity in infants 4 to 18 months of age with regulatory disorders, developmental delay, and risk for delayed learning and sensory processing disorders. In addition, head circumference and neurodevelopmental follow-up was assessed at 12 months.15 Two to 3 years. Developmental assessment was performed using the Bayley Scale of Infant and Toddler Development–3rd Edition, administered by a psychologist at the Weinberg Child Development Institute at the Chaim Sheba Medical Center–Tel Hashomer. Cognitive, Language, and Motor scales were administered, whereas parents completed the Social-Emotional and the Adaptive Behavior questionnaires from the Bayley Scale of Infant and Toddler Development–3rd Edition. On completion of the developmental assessment, parents received feedback on their child’s performance. Parental stress questionnaires. Parents completed the Parental Stressor Scale: Neonatal Intensive Care Unit and the Parenting Stress Index–Short Form16 at the 6-month follow-up visit. Statistical Analysis All statistical analyses were performed using SPSS 15.0. For group comparisons, t tests and chi-square were applied. The 5 Bayley Scale of Infant and Toddler Development–3rd Edition scales were converted to an age-standardized composite score with means of 100 and standard deviations of 15 points. There are subscale scores for expressive and receptive language and fine and gross motor development, each scaled to have a normative mean of 10 and a standard deviation of 3.17 In addition, t tests were performed to compare the results of the intervention and control groups for each domain of the Bayley Scale of Infant and Toddler Development–3rd Edition. Analyses of variance with post hoc Bonferroni tests were used to detect the presence of differences in Bayley Scale of Infant and Toddler Development–3rd Edition domains across gender, singletons/twins, and prematurity levels (gestational age in weeks: moderately preterm >32, very preterm 28 to 32, extremely preterm <28). P values less than .05 were considered statistically significant unless otherwise noted. 898 Journal of Child Neurology 30(7) Table 1. Distribution of Means and Standard Deviations of Independent Variables. Control group (n ¼ 48) Intervention group (n ¼ 47) Variable Mean Standard deviation Mean Standard deviation t P Gestational age (in wk) Birth weight Head circumference Apgar 2 Number of days of artificial respiration Number of days of oxygen reception in an incubator Infections 31.61 1.41 27.93 9.04 2.66 12.52 1.65 2.46 0.39 2.63 1.23 7.31 20.21 4.123 30.55 1.31 27.82 9.04 2.7 9.46 2.03 9.04 2.7 9.46 2.03 9.04 2.7 9.46 1.273 1.188 0.199 –0.003 –0.026 0.817 –0.416 .206 .238 .843 .998 .98 .416 .678 Ethics The study design was approved by the Ethics Committee for clinical research of Chaim Sheba Medical Center–Tel Hashomer. Written informed consent was obtained from one of the parents. Table 2. Distribution of Frequency of Demographic Variables of the Research Population (Intervention Group and Variable Group). Control group (n ¼ 48) Intervention group (n ¼ 47) Theoretical Basis of Intervention Variable n % n % ‘‘Developmental Care,’’ an early intervention that encompasses all care procedures in the neonatal intensive care unit, refers to a range of strategies designed to reduce accompanying stressors.18 It aims to support the individual needs of each infant and thereby supply an optimal environment for development.19 Because of the complex interplay of biological and environmental influences on preterm infant development,20 early interventions are utilized to improve aspects of early development, such as sensorimotor, cognitive, and behavioral development.2,21 In addition, various early intervention programs have been developed in order to improve short- and long-term neurodevelopmental outcomes.18,22 The Newborn Individualized Developmental Care and Assessment Program is a developmental care program that emphasizes family-centered developmentally supportive care.23 The major approach employed in the Newborn Individualized Developmental Care and Assessment Program involves sequential, formalized, naturalistic observations of the infant prior to, during, and after caregiving procedures (eg, feeding, diaper change, collection of blood samples, etc). An additional approach is the Infant Behavioral Assessment and Intervention Program, which was designed to support and enhance infants’ self-regulatory competence and various developmental functions in an integrative way, via responsive and positive parent-infant interactions.17 The Infant Behavioral Assessment and Intervention Program was created and developed based on the Newborn Individualized Developmental Care and Assessment Program principles, which were derived from the synactive model proposed by Als.14,22,23 Several studies have examined the effectiveness of early intervention programs on the neurodevelopment of preterm infants. Kleberg et al24 have shown that Newborn Individualized Developmental Care and Assessment Program–based care may positively impact the cognitive development of infants born very prematurely. Koldewijn et al25 reported that an Infant Behavioral Assessment and Intervention Program Gender (males) Twins 29 17 60.4 70.8 25 13 53.2 55.3 w2 P 0.505 .477 2.456 .117 postdischarge intervention improved the mental, motor, and behavioral outcomes of very low birth weight infants at 6 months corrected age. A longitudinal, follow-up study found a sustained motor improvement in very low birth weight infants until 2 years corrected age; however, the positive effect on mental and behavioral development that was found at 6 months was not observed at 24 months.26 The aforementioned data points to the possible crucial effect of parental intervention during neonatal intensive care unit hospitalization on infant development, parental well-being, and the utilization of developmental resources postdischarge. However, there are currently few theory-based, ‘‘parent-focused intervention’’ programs starting as early as during the neonatal intensive care unit stay. Therefore, a thorough evaluation of the influence of these programs is necessary. Results Group Differences No significant differences were found between the 2 subject groups on any of the descriptive parameters of the samples and the different demographic variables. The 2 groups did not differ in prematurity level, complications, and subsequent head circumference growth, t(39) ¼ –1.14, P ¼ .88 (as depicted in Tables 1 and 2). At 6 months, the intervention group showed significantly less sensory difficulties, particularly in vestibular and tactile responses. Influence of prematurity level, weight, and intraventricular hemorrhage presence were examined as possible confounding variables and were not found to significantly influence sensory regulation results. The most highly significant variable was group assignment (as depicted in Table 3). Gabis et al 899 Table 3. Differences in Sensory Regulation Capacities According to the Test of Sensory Functions in Infants Diagnosis at 6 Months Corrected Age. Mean rank Variable Reactivity to tactile deep pressure Adaptive motor functions Visual-tactile integration Reactivity to vestibular stimulation Total score Control group (n ¼ 19) Intervention group (n ¼ 40) Z P 23.53 25.47 28.37 24.67 22.79 30 32.15 30.78 31 30.33 –3.075 –1.757 –1.321 –3.026 –2.98 .002 .079 .186 .002 .003 Table 4. Differences in Sensory Regulation Capacities According to the Test of Sensory Functions in Infants Diagnosis at 1 Year Corrected Age. Mean rank Variable Reactivity to tactile deep pressure Adaptive motor functions Visual-tactile integration Reactivity to vestibular stimulation Total score Control group (n ¼ 19) Intervention group (n ¼ 40) Z P 37.22 31.73 35.91 36.31 33.93 35.86 41.86 38 37.63 38.8 –0.507 –2.326 –0.569 –0.519 –1.332 .612 .02 .57 .604 .183 Table 5. Comparison of Developmental Outcomes on the Bayley Scale of Infant and Toddler Development–3rd Edition Between the Intervention and Control Groups. Control (n ¼ 20) Cognitive (composite) Language (composite) Receptive (scale) Expressive (scale) Motor (composite) Fine (scale) Gross (scale) Social-emotional (composite) Adaptive behavior (composite) Intervention (n ¼ 21) Mean Standard deviation Mean Standard deviation Test scores P 102.25 98.32 10.11 9.32 93.95 9.26 8.68 99.58 100.8 8.96 7.7 1.1 1.86 10.13 1.94 2.38 12.7 13.12 105.48 105.95 11.86 10.1 100.84 10.74 9.43 108.93 101.14 11.72 9.8 2.31 1.61 12.02 2.83 1.96 17.87 15.25 –.99 –2.72 –3.11 –1.42 –1.91 –1.88 –1.08 1.51 –.99 .17 .005 .002 .08 .03 .03 .14 .07 .48 a Age-standardized, neurodevelopmental tests score from the Bayley Scale of Infant and Toddler Development–3rd Edition. Means composite scores 100 and standard deviation of 15 points. Means scale scores 10 and standard deviation of 3 points. At age 12 months (corrected age) the sensory differences from the age of 6 months diminished and were not significant. The only difference found was in adaptive motor function (as depicted in Table 4). At age 2 to 3 years, those in the intervention group exhibited significantly higher language skills t(38) ¼ –2.72, P < .01, compared to the control group on the Bayley Scale of Infant and Toddler Development–3rd Edition, language domain. Specifically, when divided into receptive and expressive subtests, the intervention group showed significantly higher scores on the receptive scale, t(38) ¼ –3.11, P < .01, compared to the control group, but this difference only approached significance on the expressive scale, t(38) ¼ –1.42, P ¼ .08. On the motor domain of the Bayley Scale of Infant and Toddler Development–3rd Edition, the intervention group presented significantly better motor abilities than the control group, t(36) ¼ –1.91, P < .05. On the fine motor subscale, the intervention group exhibited significantly higher skills, t(36) ¼ –1.88, P < .05 compared to the control group. However, although the intervention group scored higher on the gross motor scale, this difference did not yield significance, t(38) ¼ –1.08, P ¼ .14. Furthermore, group differences approached significance on the social-emotional domain, with toddlers in the intervention group showing higher levels of social-emotional skills than did control toddlers, t(24) ¼ –1.51, P ¼ .07. In addition, no significant differences were found between the intervention and the control groups in the cognitive domain, t(39) ¼ –0.99, P ¼ .17, or in the adaptive behavior domain, t(22) ¼ –0.99, P ¼ .48 (as depicted in Table 5). 900 Journal of Child Neurology 30(7) Gender Language Outcomes We found only 1 statistically significant interaction for the gender and group variables, on the Bayley Scale of Infant and Toddler Development–3rd Edition receptive language scale, F(3, 36) ¼ 4.21, P < .05. No other significant differences were found in the Bayley Scale of Infant and Toddler Development– 3rd Edition cognitive, language (expressive), motor (fine, gross), social-emotional, and adaptive behavior domains. Boys in the intervention group showed significantly better receptive language skills (mean ¼ 12.36, standard deviation ¼ 1.78) compared to both boys (mean ¼ 10.18, standard deviation ¼ 1.17, P ¼ .030) and girls (mean ¼ 10, standard deviation ¼ 1.07, P ¼ .034) from the control group. Our study showed a significant difference in language dev ...
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Tutor went the extra mile to help me with this essay. Citations were a bit shaky but I appreciated how well he handled APA styles and how ok he was to change them even though I didnt specify. Got a B+ which is believable and acceptable.

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