Ushanalini Vasan

Effect of auditory, tactile, visual, and vestibular intervention on length of stay, alertness, and feeding progression in preterm infants

This study determined whether an auditory, tactile, visual, and vestibular intervention (ATVV) reduced the length of hospitalization of 37 preterm infants by increasing the proportion of alert behavioral states, thereby improving their feeding progression. Participants comprised 12 infants born between 23 and 26 weeks’gestation with normal head ultrasounds and 25 CNS‐injured infants born between 23 and 31 weeks’gestation. Infants were randomly assigned to the control group (11 males, five females) or study group (seven males, 14 females) at 32 weeks’postconceptional age. ATVV intervention was administered to the study group for 15 minutes, twice daily, 5 days per week, from 33 weeks of age until discharge. The study group demonstrated increased alertness during the first 5 minutes of intervention, which was significantly correlated to length of stay (p<0.05). The proportion of nippled (teat) intake increased significantly faster for the study group (p=0.0001). Infants in the study group were discharged at a mean of 36.54 weeks, 1.6 weeks earlier than control infants (p<0.05). ATVV intervention facilitated increased alertness, faster transition to complete nipple feeding, and decreased length of hospitalization.

Heart rate variability in preterm brain-injured and very-low-birth-weight infants.

Heart rate variability (HRV) reflects the complex interplay of the sympathetic and parasympathetic innervation of the heart. Developmental maturation of the fetus and newborn results in predictable alterations in the neural cardiac control of heart rate. Furthermore, patterns of HRV are closely correlated to clinical outcome in several pathologic situations. The first aim of this study was to characterize the maturational patterns of HRV in a group of developmentally at-risk newborns (those with severe hemorrhagic or ischemic brain injury and extremely immature, low-birth-weight infants). Secondly, we sought to determine whether a correlation exists between HRV and length of hospital stay, diagnosis of cerebral palsy, and neurodevelopmental test scores at 1-year corrected age. Time domain indices of HRV were computed longitudinally from 32 to 37 weeks of corrected gestational age in 19 very low birth weight, preterm infants. Among the 19 infants studied, 7 infants had no evidence of brain injury, 7 infants had periventricular leukomalacia (PVL), 3 infants had grade III/IV intraventricular hemorrhage (IVH), and 2 infants had both IVH and PVL. Neurologic injuries were documented using ultrasound and neurodevelopmental progress was followed through 1 year of corrected gestational age. A multivariate repeated measures analysis was performed to determine the relationship between the type of perinatal brain injury and neurodevelopmental status at 1 year of corrected gestational age. The type of perinatal brain injury was highly correlated to specific patterns of HRV with multivariate regression models producing adjusted r2 values ranging from 0.63 to 0.99. The type of perinatal brain injury was highly correlated to the developmental outcome measures (p < 0.0000) with PVL patients having the lowest neurodevelopmental scores, IVH patients having the highest scores, and noninjured infants having midrange, grossly normal values. Using ANOVA, HRV was correlated to outcome, but individual comparisons revealed statistical significance only for the noninjured group (p < 0.04). However, multivariate models, which characterized outcome within each brain injury group, were highly significant (adjusted r 2 ranged from 0.23 to 0.89). In summary, the type of perinatal brain injury determined the pattern of HRV and HRV was highly correlated to length of hospital stay and neurodevelopmental function assessed at 1 year of corrected gestational age.

Developmental intervention for preterm infants diagnosed with periventricular leukomalacia

Preterm infants with periventricular leukomalacia (PVL) were evaluated to determine whether multi-sensory stimulation is safe and to assess whether it improved neurobehavior and neurodevelopment. Thirty preterm infants with documented PVL were randomly assigned to control (n= 15) or experimental (Group E) (n= 15) groups at 33 weeks post-conceptional age. Group E infants received 15 minutes of auditory, tactile, visual, and vestibular (ATVV) intervention twice a day, five days a week, for four weeks during hospitalization. Repeated measures ANOVA demonstrated that Group E infants experienced significant increases in heart and respiratory rate and a 0.72% drop in hemoglobin saturation, coinciding with a significant behavioral state shift from sleep to alertness during intervention. No differences were identified in neurobehavioral function and neurodevelopment, indicating that Group E suffered no injury. Group E had an average hospital stay nine days shorter than that of controls, with the associated cost savings of

CRANIAL UL‐RASONOGRAPHY AND THE PREDICTION OF CEREBRAL PALSY IN INFANTS WEGHING ≤ 1200 GRAMS AT BIRTH

213,840. The earlier hospital discharge indicates that ATVV intervention promotes alertness without compromising physiologic status in vulnerable infants.

Developmental Intervention for Preterm Infants with Severe Intraventricular Hemorrhage and/or Periventricular Leukomalacia. † 1219

The rôle of serial cranial ultrasonography in the prediction of cerebral palsy was examined in 116 surviving infants with birthweights ≤ 1200g. All underwent serial real‐time sonographic examinations of the brain on days one, five and 21, then monthly, until term corrected age. Intraventricular hemorrhage (IVH) was diagnosed in 48 infants, and three had periventricular leukomalacia. Of the 116 infants, 31 had ultrasound abnormalities at term. At 12 to 18 months corrected age 12 infants had cerebral palsy and 38 were classified as suspect; the other 66 were normal. There was a clear association between risk group, based on sonographic findings at term, and outcome. Infants with IVH whose cranial ultrasounds failed to become normal by term corrected age were at higher risk for cerebral palsy than those with normal examinations at term, regardless of the severity of IVH. Thus an abnormal ultrasound at term corrected age was highly predictive of cerebral palsy, especially among survivors of IVH. It remained the best predictor of cerebral palsy, even when other perinatal and neonatal variables were considered. In contrast, duration of mechanical ventilation, rather than sonographic findings, was the best predictor of suspect neuromotor status.

1348 CAVITARY PERIVENTRICULAR LEUKOMALACIA (PVL): INCIDENCE AND SEQUELAE

Multisensory intervention in the NICU was implemented in a randomized study population of preterm infants ≤32 wk GA at birth with neurosonogram findings of grade 3-4 intraventricular hemorrhage &/or cavitary periventricular leukomalacia (CNS Injury). A stress-reduced environment was in place for all infants. The experimental group received a program of in-hospital Auditory, Tactile, Visual and Vestibular (ATVV) intervention sessions for 15 min. each, twice a day, 5 days/ week, for 3-6 weeks by trained nurses, beginning at 33 weeks postconceptional age after informed consent. Infants were polygraphically monitored for heart rate, respiratory rate, SpO2, temperature, color and behavioral state before, during, and after intervention. A matched group of infants with normal neurosonograms were compared, with and without ATVV. Infant groups were comparable with regard to Apgar scores (p>.78), GA at birth (p>.35), medical(Minde p>.70) and social factors (p>.05), except for fewer male intervention infants (p=02). Parents were trained regarding continuation of intervention at home. The infants were evaluated blindly in a multidisciplinary developmental follow-up program at 2, 4, 8, and 12 mo. corrected age: physical and neurological and motor assessment, Bayley mental and motor testing. A total of 39 infants were enrolled, 20 intervention, 19 control--22 infants have been evaluated thus far at 12 mo. Kruskal-Wallis analysis of percent CNS injured infants scoring < 50(moderate/severe delay) on the Bayley scales at 12 mo. revealed significantly fewer numbers in the intervention group (p<.05).Table

Intravenous Immune Globulin for the Prevention of Nosocomial Infection in Low-Birth-Weight Neonates

Recent real-time ultrasonographic studies have shown that the diagnosis of cavitary PVL can be made in vivo. From 1-31-82 to 6-30-84 all infants weighing ≤ 1200 g were screened for intracranial hemorrhage (ICH) using real-time ultrasonography at 1, 2, and 4 weeks postnatal age and at least monthly through term corrected age. PVL was diagnosed in 6/119 survivors. ICH was seen in 45/119 including 4 of 6 infants with PVL. Cavitary lesions of PVL were first diagnosed at 4-6 weeks postnatal age in all. Some lesions were undetectable by 10-12 weeks. Follow-up data is presented below.Poor visual attention at term was noted on the Brazelton Neonatal Assessment Scale in all patients.*Age corrected for prematurity in months.Conclusion: PVL is a marker for cerebral palsy and may occur in the absence of ICH. Careful longitudinal scanning, past the usual time of ICH is mandatory for diagnosis.