An examination of the effectiveness of multiple summary scoring procedures of the BNBAS in detecting group differences

The Brazelton Neonatal Behavioral Assessment Scale is the most widely used and accepted tool in the study of the behavior of the human newborn; yet there remains some controversy over the most appropriate way to score the results. The present research compares three a priori methods of scoring. The sample consisted of 43 infants: (a) 11 preterms, (b) 10 fullterms in intensive care, (c) 7 fullterms with sick mothers, and (d) 15 healthy fullterms. BNBAS exams administered to these four groups of infants were scored using the Als (1978), Lester, Als, and Brazelton (1982), and Jacobsen, Fein, Jacobsen, and Schwartz (1984) clusters. The data from these three methods were analyzed by means of one-way ANOVAs for group differences. In addition, a factor analysis on the BNBAS scores was also completed. These three approaches all detected differences between medically at-risk and healthy infants on those items assessing motor maturity and orientation. These results suggest that at this time no one scoring system can capture the richness of behavior of the newborn and address the question by researchers, clinicians, and parents.     

Immediate Effect of Training at the Onset of Reaching in Preterm Infants: Randomized Clinical Trial

The authors' aim was to investigate the immediate effect of a single specific training session (serial varied practice), of short duration on the kinematic parameters of reaching, in the period of the emergence of the skill in preterm and low birth weight infants. The study included 16 infants of both sexes, born at a mean gestational age of 32.13 (±1.36) weeks and mean birth weight of 1720.94 (±358.46) g. The infants were randomly divided into 2 groups: experimental and control. The experimental group was given a 5-min training session in reaching, while the control group received no training. The results showed significant differences in peak velocity in the intra (Z = –2.10, p = .036) and intergroup (U = 9.00, p = .016) evaluations, which decreased in the experimental group after training. Cohen's d test for clinical relevance suggested that the specific, short duration training proved effective in promoting slower reaches, with greater adjustment and lower number of units of movement. These results are positive for preterm infants given that these parameters more closely resemble the typical development of mature reaching behaviors in term infants, which suggests that this protocol of reaching training (serial varied practice) could be used as an evidence-based intervention strategy.     

Visual‐motor and executive functions in children born preterm: The Bender Visual Motor Gestalt Test revisited

Böhm, B., Lundequist, A. & Smedler, A.‐C. (2010). Visual‐motor and executive functions in children born preterm: The Bender Visual Motor Gestalt Test revisited. Scandinavian Journal of Psychology, 51, 376–384. Visual‐motor development and executive functions were investigated with the Bender Test at age 5½ years in 175 children born preterm and 125 full‐term controls, within the longitudinal Stockholm Neonatal Project. Assessment also included WPPSI‐R and NEPSY neuropsychological battery for ages 4–7 ( Korkman, 1990 ). Bender protocols were scored according to Brannigan & Decker (2003) , Koppitz (1963) and a complementary neuropsychological scoring system (ABC), aimed at executive functions and developed for this study. Bender results by all three scoring systems were strongly related to overall cognitive level (Performance IQ), in both groups. The preterm group displayed inferior visual‐motor skills compared to controls also when controlling for IQ. The largest group differences were found on the ABC scoring, which shared unique variance with NEPSY tests of executive function. Multiple regression analyses showed that hyperactive behavior and inattention increased the risk for visual‐motor deficits in children born preterm, whereas no added risk was seen among hyperactive term children. Gender differences favoring girls were strongest within the preterm group, presumably reflecting the specific vulnerability of preterm boys. The results indicate that preterm children develop a different neurobehavioral organization from children born at term, and that the Bender test with a neuropsychological scoring is a useful tool in developmental screening around school start.     

The impact of childbirth settings and maternal medication on infant behaviors

The Brazelton Neonatal Behavioral Assessment Scale (BNBAS) was administered to 61 full-term, healthy newborns between 7–10 days of age. Three groups of newborns made up the sample: 23 babies were born at planned home births to nonmedicated mothers, 22 were born in the hospital to nonmedicated mothers, and 16 neonates were born in the hospital to mothers who received obsteric medication. Analysis of variance indicated a significant F ratio on the BNBAS cluster for orienting behaviors; comparison of the BNBAS scores of the three groups revealed a significant difference on the BNBAS cluster for orienting behavior between the home-born babies and infants born in the hospital to mothers who received obsteric medication. There was no significant difference between groups for medication or birth setting alone, suggesting these perinatal factors have a complex, perhaps synergistic effect on newborn behavior.     

Preterm infants show reduced stress behaviors and activity after 5 days of massage therapy

Preterm infants residing in an NICU were randomly assigned to a massage therapy or to a control group. The preterm infants in the massage therapy group received three 15-min massages each day for 5 consecutive days, with the massages consisting of moderate pressure stroking to the head, shoulders, back, arms and legs and kinesthetic exercises consisting of flexion and extension of the limbs. Infant stress behaviors and activity were recorded on the first and last day of the study. Preterm infants receiving massage therapy showed fewer stress behaviors and less activity from the first to the last day of the study. The findings suggest that massage has pacifying or stress reducing effects on preterm infants, which is noteworthy given that they experience numerous stressors during their hospitalization.     

Affective expression among preterm infants of varying levels of biological risk

This investigation examines the association between risk status and the quality of emotional arousal and regulation among preterm infants in the second year of life. The behavior of 55 preterm infants stratified into three risk groups by severity and chronicity of respiratory illness was recorded during the procedures of the Strange Situation. Measures of emotional responsiveness included temporal and intensity features of facial and vocal expressions as well as concurrent activity with toys. Significant relationships between neonatal risk status and these expressive and regulatory features were observed. Infants in the High-Risk group (N = 16) differed from healthy Low-Risk infants (N = 23) and from those in the Moderate-Risk group (N = 16). The High-Risk infants showed a greater sensitivity to distress arousal at low levels of stress and less ability to modulate distress once aroused. High-Risk infants also demonstrated significantly less adaptive play with toys than the other preterm infants. In short, this study suggests that, when placed under stress, High-Risk preterm infants in their second year of life become more distressed and demonstrate less ability to recover from this distress and effectively re-engage their environment than preterm infants born at lower risk.     

Emotional interaction in a group of preterm infants at 3 and 6 months of corrected age

Twenty preterm infants (birthweight<1500 g) and 20 healthy fullterm infants were compared with respect to emotional interaction with their mothers in a face‐to‐face situation at 3 months of age and in a feeding situation at 6 months of age (ages corrected for preterm birth). The assessed outcome was analysed with respect to infant variables (group, gender, gestational age, birthweight and neonatal risk factors) and maternal variables (age, education and parity). The outcomes at 3 and 6 months of age were also compared with findings of Griffiths’ testing at 10 months of age. At 3 months of age, the findings reveal no significant difference between the two groups with respect to emotional interaction. Maternal variables are more important for this interaction than are infant variables. The mother's level of formal education has a significant impact in both groups. In the group of fullterm infants, significantly lower scores for interaction are obtained by first‐time mothers in comparison with multi‐parae mothers. At 6 months of age, the difference between fullterm and preterm infants is significant. The preterm infants and their mothers now relate to one another more poorly than is the case for the fullterm dyads. These findings suggest that the difficulties encountered by the preterm infant emerge with time. Emotional interaction at this age and the results of Griffiths’ testing 4 months later are significantly correlated. Copyright © 1999 John Wiley & Sons, Ltd.     

Comparison of Maternal Perceptions of Preterm and Fullterm Infants

We compared maternal attitudes and feelings in two groups of mother–infant dyads: 25 mothers with preterm newborns (M=30.9 weeks of gestational age) and 25 mothers with fullterm newborns (M=39.7 weeks of gestational age). Both groups were matched for infant sex, age (corrected in preterms) and birth order as well as for maternal age and education. Semi-structured interviews were used to collect data on maternal attitudes and feelings about pregnancy and the first contacts with the newborn. Mothers completed rating scales to indicate the specific behavioural problems they perceived in their infants at 6 weeks and 3 months of (corrected) age. Observations of infant responses to visual and/or auditory stimuli were made at 6 weeks and 3 months in a laboratory setting. At 3 months, each infant was administered the Bayley Scale of Mental Development. There were no differences in maternal attitudes and feelings between the two groups of mothers prior to the birth. However, significant differences appeared after birth and indicated increased anxiety in mothers of preterm infants. Significantly more 6-week-old preterm infants were perceived by their mothers as irritable and to cry more than fullterm infants. At the age of 3 months, both groups of infants differed only in terms of irritability. Differences between the two groups of mother–infant dyads, age-related changes in these differences and relationships between maternal evaluations and the laboratory-based assessments are discussed in the context of contrasts in the stability of behavioural regulation in preterm and fullterm infants.     

Consistency of maternal cognitions and principles across the first five months following preterm and term deliveries

The aims of this study were to examine and compare the development of parenting cognitions and principles in mothers following preterm and term deliveries. Parenting cognitions about child development, including thinking that is restricted to single causes and single outcomes (categorical thinking) and thinking that takes into account multiple perspectives (perspectivist thinking), have been shown to relate to child outcomes. Parenting principles about using routines (structure) or infant cues (attunement) to guide daily caregiving have been shown to relate to caregiving practices. We investigated the continuity and stability of parenting cognitions and principles in the days following birth to 5 months postpartum for mothers of infants born term and preterm. All parenting cognitions were stable across time. Categorical thinking increased at a group level across time in mothers of preterm, but not term, infants. Perspectivist thinking increased at a group level for first-time mothers (regardless of birth status) and tended to be lower in mothers of preterm infants. Structure at birth did not predict later structure (and so was unstable) in mothers of preterm, but not term, infants and neither group changed in mean level across time. Attunement was consistent across time in both groups of mothers. These results indicate that prematurity has multiple, diverse effects on parenting beliefs, which may in turn influence maternal behavior and child outcomes.     

The development of reaching behavior in low-risk preterm infants

This longitudinal study investigated the development of reaching behavior in the seated position in preterm infants at the ages of 5–7 months by analyzing kinematic variables (straightness and adjustment indexes, movement unit, mean and final velocities). The correlation between kinematic variables and grasping was verified. The participants were nine low-risk preterm infants with no cerebral lesions. Ten fullterm infants served as control. In both groups, kinematic variables remained unchanged over age, except for the adjustment index, which was higher at 6 months in the preterm group. Successful grasping increased in both groups over age and it was shown to be negatively correlated with mean velocity in the preterm infants. At the ages of 6 and 7 months, preterms showed lower mean and final velocities and higher adjustment index when compared with fullterms. The relative constancy in the kinematic variables suggests that, after having explored the action possibilities during the acquisition phase, the infants selected an adaptative pattern to perform the reaching movements. Slower movements and greater adjustments may be functional strategies of preterms to achieve successful grasps.     

Effects of nonnutritive sucking on state and activity: Term-preterm comparisons

The effects of ad libitum access to a pacifier on the behavioral state and motor activity of preterm infants have been compared with those observed in full-term neonates. Regardless of maturity, nonnutritive sucking (NNS) decreases the amount of time spent in active states and increases that spent in quiescent states, lengthens the longest state bout, and decreases the frequency of state transitions. NNS also reduces overall motor activity as well as that during Active Sleep. Provided such ad libitum sucking opportunity, preterm infants thus appear to derive no less benefit from NNS than do term neonates. This result contrasts with an earlier finding that preterms are less soothed by NNA than are term infants.     

The association between maternal interaction and infant cortisol stress reactivity among preterm and full term infants at 4 months adjusted age

The purpose of this study was to assess the association between maternal interactive behavior and infant cortisol stress reactivity in response to the Still Face paradigm (SF) in a cohort of four-month old infants (adjusted age) born preterm (<32 weeks gestation, N = 22) compared with infants born full term (>37 weeks gestation, N = 28). Infant cortisol reactivity was calculated as area under the curve (AUC) from baseline to the third cortisol sample (30 min post-SF) using the trapezoidal rule, while the percent of time mothers spent using a contingent interaction style was measured (0–100%) during episodes 1 (Play; baseline), 3 (Reunion#1), and 5 (Reunion#2) while mother-infant dyads participated in the SF paradigm. We hypothesized that because infants born preterm are at increased risk for dysregulation, they would show, compared to full-term infants, a blunted stress response, involving under-responsiveness. We found blunted cortisol stress reactivity among the preterm infants. We also found that mothers of preterm infants demonstrated less contingent maternal interaction during Renion#1 of the SF; and that contingent maternal interaction at Reunion#2 of the SF was protective against cortisol stress reactivity in response to the SF. However, we did not find that the influence of maternal interaction on cortisol reactivity was moderated by gestational age group (full term vs preterm): the association between contingent maternal interaction and stress reactivity was similar for both gestational groups across episodes. In order to improve self-regulation and longer term social and cognitive developmental outcomes in medically at-risk infants, future research is warranted to determine how these findings relate to infants’ stress reactions in naturalistic settings, and the directionality and temporal relationship between cortisol stress responses and maternal interactive behavior.     

Visual and auditory orienting responses in preterm infants: a comparison of three cohorts over time.

Visual and auditory orienting responses were compared in three cohorts of preterm infants (N = 351) born between 1977 and 1987. The infants were divided into one group born between 25 and 34 weeks gestational age (n = 140) and one group born between 35 and 37 weeks gestational age (n = 211). Ratings were made of the infants' best orienting responses to a bull's-eye, rattle, bell, voice, and face plus voice combined. Analyses of covariance were computed to adjust for changes in perinatal variables between 1977 and 1987. For both groups, there were significant differences between cohorts on orienting to the bull's-eye, with a trend for the 25- to 34-week group on orienting to the rattle. Behavioral outcome for preterm infants has improved with changes in neonatal intensive care.     

The effect of mother-infant skin-to-skin contact on plasma cortisol and β-endorphin concentrations in preterm newborns

The aim of this study was to assess the effect of mother-infant skin-to-skin contact on plasma β- endorphin and cortisol concentrations in stable, preterm infants on a newborn intensive care unit. Blood samples were obtained before and at the end of a 20-min period of skin-to-skin contact. Similarly paired samples, obtained at the same times and after the same interval, without skin-to- skin contact, were obtained on another day and served as controls. Both cortisol and β-endorphin concentrations fell significantly after the skin-to-skin session (cortisol: geometric mean change 66%, p=0.008; β-endorphin: geometric mean change 74%, p=0.002). There was also a significant fall in cortisol levels during the control session (geometric mean change 78%, p=0.02), in contrast to β-endorphin levels, in which there was no significant change. Analysis of variance showed that the fall in β-endorphin, but not the fall in cortisol, during the skin-to-skin session was significant when compared with the control session. These results emphasize the hormonal responsiveness of the preterm newborn to relatively minor interventions. We conclude that maternal skin-to-skin contact results in a significant reduction in circulating β-endorphin in the newborn; there was no evidence of any adverse effect.     

Vocal responsiveness of preterm infants to maternal infant-directed speaking and singing during skin-to-skin contact (Kangaroo Care) in the NICU

Vocalizations of full-term newborns occur in a short latency time during the neonatal period. Contingent response time of preterm babies is still unknown. An increase of preterm babies’ vocalizations following exposure to parental speech was also observed. Mothers and babies co-modulate their vocalizations in preterm dyads. Purpose: To observe temporal features of maternal and infants’ vocalizations in speaking and singing conditions in preterm dyads. Methods: In a NICU mothers (N = 36) were invited to speak and to sing to their preterm infants during Kangaroo Care. Microanalysis of temporal units were performed with ELAN Software. Results and conclusions: Preterm infants vocalize less often while their mothers speak and sing than during baseline and their vocalizations tend to be more alternating in the speaking condition and more overlapping in the singing condition. It is also concluded that preterm infants take more time to respond to maternal speaking than to maternal singing.     

Hormonal sensitivity of preterm versus full-term infants to the effects of maternal depression

Comparisons were made of differences in the hormonal sensitivity of preterm versus full-term infants to maternal depression, as reflected in children's cortisol levels. In Study 1 (N=25), a comparison was made between preterm versus healthy full-term children. In Study 2 (N=80), a comparison was made between preterm infants and full-term infants with mild or moderate medical problems. Preterm infants were found to be highly reactive to maternal depression (as measured by the Beck Depression Inventory). That is, they demonstrated higher cortisol levels when paired with depressed mothers and lower cortisol levels when paired with non-depressed mothers. No equivalent effects were found for children who were full-term, even when they had experienced other medical problems at birth. It was concluded that premature infants are exceptionally sensitive to the "emotional climate" in their home environment. As a result, they may manifest very different hormonal outcomes--with implications for their later development.     

Influence of Additional Ankle Weights on Kinematic Variables of Late Preterm Infants Aged 3–4 Months

The authors analyzed and compared the effect of additional weight on the spatiotemporal parameters of the kicking movement of late preterm and full-term infants. The experiment was divided into 4 conditions: training, baseline, weight, and postweight. In the W condition, a weight of one third the lower limb mass was added to the infant's ankle. During the baseline and postweight conditions, the ankle weight was removed. Late preterm infants do not differ from full-term infants in relation to spatiotemporal variables at 3 and 4 months. However, during the weight condition, the straightness index and the hip-ankle and knee-ankle correlations decreased in the preterm infants at both ages. In contrast, the straightness index increased in the postweight condition compared to the baseline values at both ages.     

Differential effects of massage and heelstick procedures on transcutaneous oxygen tension in preterm neonates

The present study investigated the differential effects of heelsticks and tactile-kinesthetic massage on transcutaneous oxygen tension (TcPO₂) in preterm infants. The sample was comprised of 37 stabilized preterm neonates from the Neonatal Intensive Care Unit. During the heelstick procedure, TcPO₂ significantly declined an average of 14 mmHg. When compared to the tactile-kinesthetic massage, TcPO₂ levels during the heelstick (M = 39.8) were significantly lower than during the stimulation (M = 72.8). Mean TcPO₂ levels remained clinically safe during the four massage sessions evaluated. The TcPO₂ levels during kinesthetic stimulation were somewhat more varied, and movement and pressurization of the TcPO₂ electrode were investigated as possible artifactual explanations for this phenomenon. Overall, the findings indicate that social forms of touch such as tactile-kinesthetic massage do not appear to have a medically compromising effect on TcPO₂ in the preterm neonate. These findings are evaluated in relation to the “minimal touch” policy, and implications for future handling of the stabilized preterm neonate are discussed.     

The effect of a short course of moderate pressure sunflower oil massage on the weight gain velocity and length of NICU stay in preterm infants

ObjectiveThe aim of this study was to evaluate the efficacy of five-day course of sunflower oil massage with moderate pressure on the weight gain and length of NICU stay in preterm infants.MethodsForty-four healthy preterm infants with a corrected gestational age of 30–36 weeks at the time of the study, were randomly assigned to the study group receiving body massage with sunflower oil and the control group receiving only routine NICU care. The massage was performed three times per day, each session including three consecutive five-minute stages, for five days. The primary outcome was to evaluate the efficacy of a short course of moderate pressure sunflower oil massage on the weight gain velocity. The secondary outcome was to compare the length of NICU stay between the two groups.ResultsDuring the study period, the increase in the average daily and fifth-day weight gain was significant in the intervention group. The length of NICU stay was shorter in the intervention group significantly.ConclusionOur findings suggest that even a short course of body massage with sunflower oil for only five days increases preterm infants’ weight gain and decreases their duration of NICU stay significantly.     

Positive effects of low intensity recorded maternal voice on physiologic reactions in premature infants

ObjectiveTo evaluate the effect of low intensity recorded maternal voice on the physiologic reactions of healthy premature infants in the neonatal intensive care unit (NICU).MethodsPhysiologic responses of 20 healthy preterm infants in the NICU of Shariati Hospital, Tehran, were obtained during a 15 min intervention including three 5 min periods (no-sound control, audio recorded playback of mother’s voice, no-sound post-voice). The intervention was presented three times a day for three consecutive days. During each intervention, oxygen saturation (%, OSPR), heart rate (HR), and respiratory rate (RR) were recorded at 1 min intervals over the 15 min and then averaged over each 5 min period, resulting in 3 averages for each variable for each intervention.ResultsRepeated Measures Analysis of Variance were employed to examine each variable separately. Over the three days, comparison of oxygen saturation over each of the three periods (before, during voice, after) revealed an increase in oxygen saturation during the voice period, compared to the pre-voice period, which persisted over the post-voice period; there were no differences between the voice and post-voice periods. Analyses of the HR and RR data showed a decrease in both variables during the voice period compared to the pre-voice period which persisted over the post-voice period. Again, there were no differences between the voice and post-voice periods.ConclusionExposure to low intensity recorded maternal voice has positive effects on the preterm infants ‘physiologic responses.