معیار هسته نوروپروتکتیو ۲: اثرات یک دستگاه وزن دار شبیه ساز والدینی دارای رایحه مادری روی نوزادان نارس در مراقبت های ویژه نوزادان Neuroprotective Core Measure 2: Partnering with Families – Effects of a Weighted Maternally-Scented Parental Simulation Device on Premature Infants in Neonatal Intensive Care

Infants born prematurely (b37 of 40 completed weeks of gestation) are a significant perinatal health concern, contributing to substantial economic, social, and medical costs across the globe. In the United States alone, the estimated costs are $26.2 billion with one in eight infants born prematurely each year.1,2 Premature infants are at greater risk for cognitive, health, developmental, and behavioral disabilities than term infants (39–۴۰ weeks completed gestation).3 Although the majority of premature infants are free of major morbidities, major morbidities account for 17–۲۹% of the impairments found in this population.4 Major morbidities include impairments with vision, hearing, and cognition including cerebral palsy. Most infants born LBW (b2500 grams) or very LBW (b1500 grams) exhibit minor morbidities (50–۷۰%) that include motor delays, executive dysfunction (EDF), attention deficit disorder (ADD), attention deficit hyperactivity disorder (ADHD), language deficits, learning disabilities, auditory dyssynchrony, visual motor difficulties, and social emotional dysregulation.5–۸ These morbidities impact daily living and educational attainment and have been well established in the literature since early 2000.6,9–۱۳ Morbidities rates are also higher in early term infants (37–۳۸weeks completed gestation) as compared to term infants.14,15 Short-term outcomes of early term infants include increased NICU stays (N7 days), sepsis, hyperbilirubinemia, respiratory distress, and feeding difficulty.14 To minimize the risks of these morbidities, healthcare professionals caring for infants in the neonatal intensive care unit (NICU) require an understanding of neuroprotective care. Rapid brain growth occurs between 28 and 38 weeks gestation during the sensitive time of neural pathway formation and is susceptible to environmental influences.11,16,17 These environmental influences may also alter gene expression or cellular phenotype in a process referred to as epigenetics.18 Environmentally induced epigenetic changes are documented in the literature in animal models and can persist across the adult lifespan.19,20 The early developmental experiences of premature infants may have epigenetic effects on their developing brain leading to phenotypical changes.21 According to the Synactive Model of Newborn Behavioral Organization and Development,16 premature infants respond to stimuli in their environment with unique cues such as hiccups, or variations in alertness and tone, which may be categorized as stressful or self-regulating behaviors. The ability for premature infants to self-regulate is essential to their neurodevelopment. Providing care based on understanding family involvement and the infant’s cues is an emerging field of study. Care aimed at neuroprotective care has been shown to positively affect neurobehavioral outcomes such as self-regulation and early brain development.22–۲۵ Neuroprotective care, protection of sleep, and support of evolving selfregulatory skills should be incorporated into the care of premature and early term infants to facilitate optimal brain development.11 Furthermore, the evaluation and promotion of neuroprotective care are essential in minimizing the consequences of the altered and distorted brain development in the premature brain.26 Clinical research which evaluates neuroprotective care is needed to better understand the impact of care within the environment of the NICU. The primary practice model in most NICUs is a model that supports the physical separation of the mother and infant, which heightens the traumatic event sequelae. The infant is transported to the NICU while the mother recovers on another unit. Subsequently, it may be hours after delivery before the mother is able to visit her infant. This disruption of the parental–infant relationship has molecular, physiologic, and behavioral consequences for the infant and mother.27 Maternal stress, grief, and depression are intensified by the preterm birth and traumatic separation impacting maternal interactions, confi- dence, and attachment.28,29 Research supports minimizing the effects of this physical separation with the use of skin-to-skin contact and family-centered care.30,31 In the mother’s absence, sensory stimulation such as the mother’s voice and scent has been shown to have positive effects on premature infants. Infants in the NICU are exposed to many negative olfactory experiences. One study revealed that during their hospital stay, premature infants were exposed several thousand times on average to negative nosocomial odors (skin preps, alcohol pads, and adhesive remover).32 Detection and discrimination of odors develop between 28 and 29 weeks gestation with evidence to support infant familiarization and preferences for odors such as their amniotic fluid, their mother’s breast milk, and their mother’s scent.33,34 Research supports that infants respond to sensory stimulation with both positive and negative behaviors. Positive benefits from exposure to these preferred odors include self-regulation, pain reduction, and reduction in occurrences of apnea.35–۳۷ In a sample of 49 premature infants, researchers found that infants who received an intervention with a multimodal approach using sensori-tonico-motor touch with oils had increased weight gain, shorter hospital stays, and better neurological/psychomotor scores compared to the control group.38 Healthcare professionals providing care in the NICU need to minimize noxious stimuli and promote care that incorporates positive sensory stimulation. Evidence-based nursing interventions that support the fragile premature infant and mother are challenging in the current health care system. Interventions aimed at neuroprotective support and positive sensory modalities such as the mother’s scent may improve the infant’s stability. Interventions using scent and neuroprotective care have been explored in other studies, but no research has combined these methods with use of a parental simulation device. The purpose of this pilot study was to explore the effects of 24 to 38 week gestation infants in a level III NICU receiving neuroprotective care using a maternally-scented parental simulation device. The intervention for this study included use of a weighted maternally-scented parental simulation device that mimics holding. Infants who received the intervention were compared with infants receiving nursing care without the simulation device. The weighted maternally-scented parental simulation device used in this study is called The Zaky®, a human hand mimetic and pediatric bolster support device with patent pending from Nurtured by Design, Incorporated (Fig. 3). The Zaky® is ergonomically designed to provide familycentered developmental care to infants by conserving the scent of the parent and simulating the shape, touch, weight (500 grams), and warmth of the parents’ hands and forearms that stay with the infant when not being held in skin-to-skin contact.