References for:

D. Protecting the Vulnerable Newborn-Parent Bond

1A. Select a birthing environment that clearly supports the infant-parent attachment process.

Caregivers in an environment supporting this process will:

  1. Protect the infant from bright lights, loud noises, separation from mother, or circumcision.

References:

  1. Stevens, B., Johnston, C., & Grunan, R., (1995). Issues of assessment of pain and discomfort in neonates. Journal of Obstetric, Gynecologic and Neonatal Nursing, 24(9), 849-855. (abstract)
  2. Vickers, C., Ohlsson, A., Lacy J. B., & Horsley, A. (2000). Massage for promoting growth and development of preterm and/or low birth-weight infants. The Cochrane Library, 13-19. (abstract)
  3. Als, H., Lawhon, G., Duffy, F. H., McAnulty, G. B., Gibes-Grossman, R., & Blickman, J. (1994). Individualized developmental care for the very low-birth-weight preterm infant: Medical and neurofunctional effects. Journal of the American Medical Association, 272(11), 853-858. (abstract)
  4. Mouradian, L., & Als, H. (1994). The influence of neonatal intensive care unit caregiving practices on motor functioning of preterm infants. The American Journal of Occupational Therapy, 48(6), 527-533. (abstract)
  5. Porter, F., Wolf, C., & Miller, J. P. (1999). Procedural pain in newborn infants: The influence of intensity and development. Pediatrics, 104(1), e13. (abstract)
  6. Lawrence, J., Alock, D., McGrath, P., Kay, J., MacMurray, S., & Dulberg, C. (1993). The development of a tool to assess neonatal pain. Neonatal Network, 12(6), 59-66. (abstract)
  7. To, T., Agha, P., Dick, P., & Feldman, W. (1999). Cohort study on circumcision of newborn boys and subsequent risk of urinary-tract infection. Journal of Urology, 162(4), 1562. (abstract)
  8. Additional articles that support non-circumcision.

Abstract 1:

Stevens, B., Johnston, C., & Grunan, R., (1995). Issues of assessment of pain and discomfort in neonates. Journal of Obstetric, Gynecologic and Neonatal Nursing, 24(9), 849-855.

Premise: Infant pain is important to understand.

Research Hypothesis: Pain in the infant is not assessed adequately or accurately.

Background: One longstanding misconception about infant pain is that it is not remembered and therefore not significant.

Subjects:Infants from various studies were included in this article.

Review Topics:This is a review article on infant pain. The article summarizes research on infant response by physiologic/autonomic indicators such as heart rate, respiration rate, vagal tone, oxygen saturation, blood pressure, palmar sweating, transcutaneous saturation levels, PO2 levels, intracranial pressure, and cortisol levels. The article also discusses behavioral indicators such as facial expressions, crying, and body movements. The article explores pain transmission mechanisms and the infant’s ability for memory of pain.

Findings: After reviewing 54 studies, the article’s findings were that:

The article concluded that pain assessment is difficult for caregivers and parents. Good assessment of infant pain is a step in maintaining infants in a comfortable, pain-free environment. The frequency of painful procedures should be carefully ordered and delivered in order to better manage infant pain.

Research reviewed by Kay Liska, RN, while a student at Virginia Commonwealth University, School of Nursing, in Richmond, VA.

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Abstract 2:

Vickers, C., Ohlsson, A., Lacy J. B., & Horsley, A. (2000). Massage for promoting growth and development of preterm and/or low birth-weight infants. The Cochrane Library, 13-19.

Premise: Infants born preterm and cared for within the newborn intensive care unit setting are thought to be subjected to excessive amounts of noise and light and not enough tactile stimuli. The ideal environment for infants born preterm is theorized to resemble as closely as possible the uterine environment from which these infants emerged early–that is: warm, dim with muffled sound, and the provision of constant support for flexion of the infant’s extremities and trunk.

Research Hypotheses: Are tactile stimuli beneficial for preterm infants?

Background: A massage or other gentle tactile stimuli might be more rewarding or therapeutic for infants born preterm; if so, one would expect to see some evidence of such benefit, such as an increase in weight or improved behavioral state organization.

Subjects: The study included infants <37 weeks or with a weight at birth of <2500 g.

Study Design: Infants were placed in the prone position and stroked for a one-minute periods (12 strokes at approximately 5 seconds per stroking motion) over different parts of the body: a) from the infant’s head and face and neck, b) from the neck across the shoulders, c) from the back to the waist, and d) from the thigh to the foot to the thigh on both legs and from the shoulder to the hand to the shoulder on both arms. This was used with other form of stimuli.

Findings: Massage therapy provision was related to improved weight gain. Massage also resulted in a reduced length of stay by an average of 4.6 days. The massage intervention also had a slight, positive effect on the incidence of postnatal complications and weight at 4 to 6 months of corrected age.

Research reviewed Annette Stevenson, RN, while a student at Virginia Commonwealth University, School of Nursing, in Richmond, VA.

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Abstract 3:

Als, H., Lawhon, G., Duffy, F. H., McAnulty, G. B., Gibes-Grossman, R., & Blickman, J. (1994). Individualized developmental care for the very low-birth-weight preterm infant: Medical and neurofunctional effects. Journal of the American Medical Association, 272(11), 853-858.

Premise: Newborn Intensive Care Units (NICU) environment changes that reduce stress for the very low-birth-weight infants impact positively on outcomes for those who need mechanical ventilation and are at increased risk for bronchopulmonary dysplasia (BPD), intraventricular hemorrhage (IVH), and retinopathy of prematurity (ROP). Individualized developmentally focused intensive care is geared toward infants using their own ability to regulate their functioning.

Research Question: Does individualized developmental care in the NICU for low-birth-weight infants improve medical status and neurodevelopment?

Background: Premature infants with low birth weight and on mechanical ventilation are at increased risk for BPD, IVH, ROP. Consequently, long-term conditions such as pulmonary, neurological, cognitive, behavioral, and emotional compromise can result in increase costs for medical treatment. NICUs are typically noisy, very well lit, and busy with multiple procedures performed on each infant on an ongoing basis. This activity level appears to have adverse effects on preterm infants’ maturing brains. Specifically, it may inhibit developing neuronal pathways. The environment and care practices in the NICU also appear to contribute to the development of chronic lung disease in preterm infants.

Subjects: Thirty-eight preterm infants who met the following criteria were included in this study. They were inborn, had a birth weight less than 1250 g., had no known congenital abnormalities, were born before 30 weeks gestation, and were placed on a mechanical ventilator within 3 hours of birth for a duration greater than 24 hours. After inclusion in the study, each infant was randomly assigned to the control or experimental group.

Study Design: This study employed a prospective randomized clinical trial design. The NICU was staffed with specially educated nurses in the administration of individualized developmental care. The control group received the traditional protocol-based primary nursing care. Medical and demographic background variables were assessed. The infants were monitored for two minutes on 91 behaviors. Assessment of medical factors was done with double-blind review of chest roentgenograms, IVH by double-blind review of cranial ultrasound scans, and retinopathy of prematurity by the NICU pediatric ophthalmologist. Medical and developmental assessments were made at two weeks and nine months post the EDC. Developmental factors were assessed using the Assessment of Preterm Infants’ Behavior (APIB). At nine months, the Bayley Scales of Infant Development, the Kangaroo Box Paradigm, and a 15-minute video documenting infant behavior were used as outcome measures.

Findings: Eight of the 12 medical outcome variables revealed significant differences between groups. IVH was found to be more common in the control group. The experimental group had a reduction in lung and brain morbidity. Infants from the experimental group, when assessed at two weeks after estimated date of confinement (EDC) using the ABIP scale, demonstrated increased autonomic and motor system functioning compared to control group infants. At nine months post EDC, the experimental group displayed a higher Mental Development Index, and Psychomotor Development Index than the control infants. These initially ill, premature infants demonstrated improved medical and behavioral outcomes as a result of the individualized developmental framework instituted in their care.

Research reviewed by Brenda Friend, RN, while a student at Virginia Commonwealth University, School of Nursing, in Richmond, VA.

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Abstract 4:

Mouradian, L., & Als, H. (1994). The influence of neonatal intensive care unit caregiving practices on motor functioning of preterm infants. The American Journal of Occupational Therapy, 48(6), 527-533.

Premise: Studies show that low-birth-weight, preterm infants are positively influenced when the individualized developmental care approach is adopted as the standard of care in the Newborn Intensive Care Unit (NICU).

Research Question: What is the relationship between infants cared for in the NICU before the intervention of developmental care approach and those cared for after its inception? Can infants in the NICU and not involved in the study realize increased motor functioning from the changes in nursing practice?

Background: Healthy, low-birth-weight preterm infants’ motor system functioning is heightened to that of a full-term infant under the conceptual model of specific individualized care in the NICU. The approach of care given was adopted from the synactive theory of development and is responsible for the improved motor functioning.

Subjects: Forty preterm infants, all healthy and less than 34 weeks gestational age at birth.

Study Design: Part of this study was taken from a retrospective, descriptive analysis of data from 20 preterm infants, identified as Cohort I, being cared for in the NICU before the developmental approach was set in place as the standard. The other 20 preterm infants, identified as Cohort II, were cared for under the adaptation of developmental care. Their Assessment of Preterm Infants’ Behavior (ABIP) scores were compared at approximately two weeks after the expected due date. All staff members were trained formally in the concepts of individualized developmental care for the preterm infants. The parents were included within 24 hours of birth in the care of their infant.

Findings: Individualized developmental care in the NICU is adapted to meet infants’ behavioral strengths and their endeavor at reducing stress from overstimulation of the critical care environment. After assessment using the APIB tests and after adjustment for covariables, specific categories from the data analyzed revealed that the infants in Cohort II had better motor functioning scores than those from the Cohort I group on eight of the 23 summary variables. They also had improved scores on seven of the 17 specific motor variables on the APIB tests. Cohort II infants demonstrated more competent behavioral systems organization and increased autonomic and motor stability. These infants were well regulated and stable, had a decrease in their extensor overflow, and more effective flexor maintenance comparable to that of a full-term infant. Infants in the NICU who were not involved in the individualized developmental care approach study demonstrated APIB scores as high as those included in the study. The findings suggest the possibility that preterm infant function, especially motor function, can easily be influenced by modification in caregiving approach.

Research reviewed by Brenda Friend, RN, while a student at Virginia Commonwealth University, School of Nursing, in Richmond, VA.

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Abstract 5:

Porter, F., Wolf, C., & Miller, J. P. (1999). Procedural pain in newborn infants: The influence of intensity and development. Pediatrics, 104(1), e13.

Premise: Even at very early prematurity, infants respond to pain and can differentiate between stimulus intensity.

Research Question: Does infant response to painful stimuli differ as a function of the intensity or invasiveness of the procedure and does it differ by gestational age at birth? How do clinicians rate the pain for various procedures?

Background:Infant pain is often poorly managed and dismissed.

Subjects:The study included 152 infants; 135 of these infants were studied at least two times (ranges 2-27). Both premature infants <28 weeks gestation and term infants within the first postnatal week of life were studied.

Study Design: Informed consent was obtained from the mothers of the eligible infants based on the set criteria. The infants were grouped by gestational age and did not have major congenital anomalies or cardiac defects. The population included premature infants, full-term infants, and healthy and sick infants. The infants were studied during their hospitalization and during medical/nursing procedures. The procedures were documented as mildly, moderately, or highly invasive. Procedures were also categorized by duration, site of procedure, and depth and extent of tissue damage. To measure the outcome before the procedure, three electrodes were placed on the chest, along with a pulse oximeter and blood pressure cuff. Input was collected at the bedside by a documenting computer. Information was collected during four stages: a) the baseline period, b) the preparatory period, c) during the procedure, and d) during the recovery period. Current medications were also documented. Procedures included gavage tube insertion, physical examinations, nose cultures, umbilical arterial catheter insertion (mild), venous punctures and heel sticks (moderate), lumbar puncture, circumcision, and eye exams for retinopathy (highly invasive).

Findings: Both full-term and preterm infants demonstrated increased magnitude responses to increasingly invasive procedures. Thus, infants not only respond to noxious stimuli, but also differentiate their intensity.

Research reviewed by Kay Liska, RN, while a student at Virginia Commonwealth University, School of Nursing, in Richmond, VA.

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Abstract 6:

Lawrence, J., Alock, D., McGrath, P., Kay, J., MacMurray, S., & Dulberg, C. (1993). The development of a tool to assess neonatal pain. Neonatal Network, 12(6), 59-66.

Premise: It is important to be able to accurately assess neonatal pain because not all pain can be avoided.

Research Question: What is the reliability and validity of a tool to examine the reliability and validity of a tool to measure neonatal pain?

Background: Health professionals are acknowledging infant pain and taking an active role in managing infants’ pain.

Subjects: The Neonatal Infant Pain Scale (NIPS) was used to evaluate pain in 38 neonates during 90 procedures. No single infant was used for more than three procedures. Infants that received analgesics within three hours were excluded.

Study Design:The procedures were videotaped using ambient lighting. The infant was taped for two minutes prior to the needle stick and three minutes after the completion of the procedure. The infant’s response was rated on the NIPS (0-7) based on facial expression, crying, breathing patterns, flexion of arms and legs, and state of arousal.

Findings: The NIPS had a high internal consistency with Alphas of .95, .87, and .88 before, during, and after the procedure. Inner rater-reliability was .92 to .97. Concurrent validity within a visual analog scale was .53 to .84. The NIPS was judged to be an objective reliable tool to assess infant pain.

Research reviewed by Kay Liska, RN, while a student at Virginia Commonwealth University, School of Nursing, in Richmond, VA.

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Abstract 7:

To, T., Agha, P., Dick, P., & Feldman, W. (1999). Cohort study on circumcision of newborn boys and subsequent risk of urinary-tract infection. Journal of Urology, 162(4), 1562.

Premise: Only a minimally reduced risk of urinary infection exists in circumcised infants.

Research Question: Does a greater incidence of urinary tract infection (UTI) occur in uncircumcised males?

Variables: Incidence of UTI in newborn males born between 1993 and 1994 at one year follow up.

Subjects: A total of 69,100 male neonates born in Ontario, Canada, between April 1993 and March 1994.

Data Collection: Hospital discharge data used in a population-based cohort study.

Findings: Of 69,100 eligible boys, 30,105 (43.6%) were circumcised and 38,995 (56.4%) were uncircumcised. Admissions for UTI were 1.88 per 1,000 (247 cases at the end of follow-up). Findings support the notion that circumcision may protect boys from UTI. At one year, hospital admissions for circumcised infants were 83 and uncircumcised infants were 247. The researchers concluded that 195 infants would need to be circumcised to prevent one hospital admission. This rate is similar to Australia and lower than previous figures in the United States. Realization that the actual number are lower than previously thought led the American Academy of Pediatrics to conclude that the difference is not great enough to advocate routine circumcision for male infants.

Research reviewed by Luella Bell, RN, while a student at Virginia Commonwealth University, School of Nursing, in Richmond, VA.

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Additional articles that support non-circumcision:

Goldman R. The psychological impact of circumcision. BJU International 1999;83 Suppl. 1:93-103. (cirp.org/library/psych/goldman1/)

Rhinehart J. Neonatal circumcision reconsidered. Transactional Analysis Journal 1999; 29(3):215-221. (cirp.org/library/psych/rhinehart1/)

Williams N, Kapila L. Complications of Circumcision. Brit J Surg 1993; 80:1231-1236. (cirp.org/library/complications/williams-kapila/)

Boyle G.J., Goldman R., Svoboda, J. & Fernandez, E. (2002) Male Circumcision: Pain, Trauma, and Psychosexual Sequelae. J Health Psychology 2002;7(3):329-43.(cirp.org/library/psych/boyle6/)

An earlier article by two of the same authors is:

Boyle G.J., Goldman R., Svoboda, J., Price, C.P., & Turner, J. N. (2000). Circumcision of Healthy Boys: Criminal Assault? Journal of Law and Medicine 7 February, 301-310 (http://www.cirp.org/library/legal/boyle1/)

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