1 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 Changes in Maternal Competence, Responsiveness and Stress with Implementation of NICU-PLAY for Very Preterm Infants in the NICU

Why do we care? 23 weeks gestation 40 weeks gestation

Benefits of Touch and Massage 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 Touch First sense to develop Skin sends messages to the brain even when sleeping Release of hormones Infant Attachment Kinds of touch

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.

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

NICU- PLAY Parent-Participative Loving Gentle Massage Age Appropriate Your Cue-Based Assessment Short-term Infant Outcomes 1. Hospital Progression 2. Neuromotor Development 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 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 Primary Aim Exploratory Aim Secondary Aim Birth Transition to Home 46 wks PMA 6wks CA NICU-PLAY begins at 3 days of age through NICU discharge Figure 1. Conceptual Model: How NICU-PLAY affects Outcomes (Birth to 6 wks CA). Potential Biologic Mechanisms of Growth and Neurodevelopment 1. Cortisol 1. Cortisol 2. Insulin-like Growth Factors 2. Insulin-like Growth Factors

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 7

Sample Characteristics Very preterm infants between weeks gestation 19 enrolled 16 completed most aspects of protocol –1 infant passed away –1 infant withdrew for maternal complications 5 Caucasian11 African American 12 male4 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 scoresM = (SD = 14.99) Maternal AgeM= yrs. (SD = 5.9 yrs.) 8

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

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 weeks PMA Phase II – fingers, hands arms – weeks PMA Phase III – Abdomen, back – 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.

RESULTS Maternal Responsiveness measured with MIRI – mothers became more responsive over the course of the protocol Mean at enrollment 84.13, SD = 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 = Mean at discharge 75.91, SD = 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

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

RESULTS 14 Maternal Stress measured with PSS-NICU (Parent Stressor Scale) Phase 1 Phase 2 Phase 3 Phase 4 Discharge

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

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

Research is FUN!! QUESTIONS??