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Improving Outcomes for Preterm Infants and Families

Changes in Maternal Competence, Responsiveness and Stress with Implementation of NICU-PLAY for Very Preterm Infants in the NICU. Improving Outcomes for Preterm Infants and Families. Jacqueline M. McGrath, PhD, RN, FNAP, FAAN RK Elswick, PhD, Heidi Fidler, BS, RN,

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Improving Outcomes for Preterm Infants and Families

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  1. Changes in Maternal Competence, Responsiveness and Stress with Implementation of NICU-PLAY for Very Preterm Infants in the NICU Improving Outcomes for Preterm Infants and Families • Jacqueline M. McGrath, PhD, RN, FNAP, FAAN • RK Elswick, PhD, Heidi Fidler, BS, RN, • Susan Vollum, BS, RN, Sara Wagner, BS, RN • Ashlee Noorthoek, MS, BS, RN, • funded by a Presidential Award from Virginia Commonwealth University • in conjunction with the School of Nursing, Richmond, VA

  2. Why do we care? 23 weeks gestation 40 weeks gestation

  3. Benefits of Touch and Massage Touch • First sense to develop • Skin sends messages to the brain even when sleeping • Release of hormones • Infant Attachment • Kinds of touch • Improved weight gain • Enhanced neurological development • Decreased length of stay • Improved feeding/digestion • Increased active sleep and less REM sleep • Improved glucose metabolism • Parental social interaction

  4. Touch and Massage Infant Massage • Flows from head to toes • Involves soft and non-mechanical touch Preterm Infant Massage • Begins with gentle stroking • Begins with one extremity, fingers or toes and progresses to more body involvement as tolerated • Field, Diego & Hernandez • White-Traut et al.

  5. Maternal Participation in Massage Parent-Participative Loving Gentle Infant Massage Age Appropriate Touch Your Cue-Based Assessment Synactive Theory of Development Cue-Based Protocol Driven Intervention EMPOWER Education Program NICU-PLAY Loving Touch and Massage

  6. Short-term Infant Outcomes 1. Hospital Progression 2. Neuromotor Development Pre-Existing Risk Factors Infant Characteristics Gestational Age, Gender, Ethnicity, Birth Weight, Acuity of Illness, Stress, Neurodevelopment ----------------------------- Maternal Characteristics Maternal Age, Ethnicity, Acuity of Illness, Socio-Economic Status, Depression, Anxiety, Stress NICU- PLAY Parent-Participative Loving Gentle Massage Age Appropriate Your Cue-Based Assessment Primary Aim Maternal Preterm Competence 1. Recognition/sensitivity to infant behavioral cues 2. Competence in preterm infant care 3. Infant temperament, vulnerability and overprotection 4. Mother Infant Interaction Potential Biologic Mechanisms of Growth and Neurodevelopment 1. Cortisol 2. Insulin-like Growth Factors Exploratory Aim Secondary Aim 46 wks PMA 6wks CA NICU-PLAY begins at 3 days of age through NICU discharge Transition to Home Birth Figure 1. Conceptual Model: How NICU-PLAY affects Outcomes (Birth to 6 wks CA).

  7. PURPOSE & STUDY DESIGN • Determine the feasibility of the experimental protocol. • Examine maternal stress during implementation of a mother-participative massage intervention for very preterm infants beginning in the first week of life and continued until infant discharge. • A prospective single-arm design

  8. Sample Characteristics • Very preterm infants between 25-30 weeks gestation • 19 enrolled 16 completed most aspects of protocol • 1 infant passed away • 1 infant withdrew for maternal complications • 5 Caucasian 11 African American • 12 male 4 female • Birth Weight M = 1205 gms. (SD = 313 gms.) • Gestational Age M = 28 wks. 5 days (SD = 12 days) • APGARS 1 minute M = 4.67 (SD = 2.50) • APGARS 5 minute M = 6.83 (SD = 1.47) • SNAPPE – II scores M = 20.79 (SD = 14.99) • Maternal Age M= 25.47 yrs. (SD = 5.9 yrs.)

  9. Measurement of Maternal Outcomes • Competence • Wellbeing • Stress • Satisfaction • Depression • Skill • Maternal-Child Interaction

  10. INTERVENTION PROTOCOL: • Infants received PLAY protocol minimum of three times each week beginning by 7 days of age (preferably by 3 days of age), all delivered by mothers • Dose --- Age specific & Physiologic & Behavioral Cue-Based -- A decision-tree for monitoring the infants’ responses that has been tested in other research was used for implementation decisions related to administration of the intervention. • Phase I – toes, feet, legs -- 26-27 weeks PMA • Phase II – fingers, hands arms – 28-29 weeks PMA • Phase III – Abdomen, back – 30-31 weeks PMA • Phase IV – Face 32+ weeks PMA • Infants do not progress beyond the phase appropriate for their gestational age and if older will progress only one phase each day they are on the PLAY protocol.

  11. RESULTS • Maternal Responsiveness measured with MIRI – mothers became more responsive over the course of the protocol Mean at enrollment 84.13, SD = 13.33 Mean at discharge 93.92, SD = 9.51 Mean at follow-up 99.71, SD = 8.88 • Mothers were more confident in care of the infant ICQ scores increased over course of intervention Mean at enrollment 71.80, SD = 13.79 Mean at discharge 75.91, SD = 11.39 Mean at follow-up 85.14, SD = 4.45 • Parent Sense of Competence (PSOC) also increased over the course of the intervention (not as meaning full change) Mean at enrollment 3.65, SD = 0.44 Mean at discharge 3.66, SD = 0.50 Mean at follow-up 3.70, SD = 0.40

  12. RESULTS • Infant cues recognition also increased as measured with the RIBBS Engagement tool (White-Traut et al.) Mean at enrollment 7.73, SD = 1.28 Mean at discharge 7.83, SD = 1.12 Mean at follow-up 8.17, SD = 1.33 • Mother’s sense of child’s vulnerability decreased over the course of the protocol. Mean at discharge 38.69, SD = 5.15 Mean at follow-up 36.91, SD = 5.94 • Mother’s sense of the infant’s temperament did not change over time. Mean at discharge 1.96, SD = 0.30 Mean at follow-up 2.01, SD = 0.31

  13. RESULTS Maternal Stress measured with PSS-NICU (Parent Stressor Scale) Phase 1 Phase 2 Phase 3 Phase 4 Discharge

  14. RESULTS • Maternal stress WAS decreased significantly over the course of study as compared to results from other studies where PSS-NICU has been used. • Although it would seem the result would decrease over time as the infant becomes more stable; participation decreased stress right from the start. • Our participants also became increasingly involved in caregiving and were able to provide care and NICU-PLAY with less assistance as comfort with their infants increased. • They also visited more than other mothers and were more likely to be actively involved with caregiving.

  15. CONCLUSIONS • No significant negative responses to the PLAY protocol • Mothers found the intervention helpful and fun for them • Connecting mothers to the program is easy to do but further refinement is needed. • Physiologic parameters remained within normal limits through-out the protocol

  16. IMPLICATIONS for further Research • PLAY Protocol was well received by parents and staff in the NICU • Finding of this study support further research on developmentally appropriate multi-sensory massage in preterm infants

  17. Research is FUN!!QUESTIONS??

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