Preterm infants’ orally directed behaviors and behavioral state responses to the integrated H-HOPE intervention

Abstract

Preterm infants are challenged by immature infant behavioral organization which may negatively influence their ability to oral feed. The purpose of this study was to determine whether the integrated H-HOPE (Hospital to Home: Optimizing the Infant’s Environment) intervention would improve infant behavioral organization by increasing the frequency of orally directed behaviors and the proportion of time spent in an alert behavioral state when offered prior to oral feeding. Mother–infant dyads (n = 198) were randomly assigned to the H-HOPE intervention or the Attention Control groups. Infants were born at 29 to 34 weeks gestation and were clinically stable. Mothers had at least two social environmental risk factors such as minority status or less than high school education. H-HOPE is an integrated intervention that included (1) twice-daily infant directed stimulation using the ATVV intervention (auditory, tactile, visual, and vestibular stimuli) and (2) maternal participatory guidance sessions by a nurse-community advocate team. Orally directed behaviors and behavioral states were assessed weekly prior to feeding during hospitalization when infants were able to feed orally. There were no differences between the groups at baseline (Day 0, prior to the initiation of the integrated H-HOPE intervention). We observed a pattern of increased frequency of orally directed behaviors in the H-HOPE intervention group when compared to the Attention Control group, however, the proportion of time spent in an alert behavioral state remained stable in both groups over the course of the study. On Day 7, the H-HOPE intervention group exhibited a significantly higher mean frequency of orally directed behaviors than the Attention Control group (12.6 vs. 7.1 pre-intervention, 51.8 vs. 33.2 during intervention, 4.3 vs. 3.2 immediately after intervention, and 8.9 vs. 5.3 immediately prior to feeding). On Day 7, the H-HOPE intervention group exhibited a significantly higher proportion of time spent in an alert behavioral state only during intervention (0.26 vs. 0.11) and immediately after intervention (0.28 vs. 0.06). These findings are suggestive that the integrated H-HOPE intervention facilitated infant behavioral organization for clinically stable infants born between 29 and 34 weeks gestation. The orally directed behaviors appear to be an important indicator of the infant’s preparation for feeding, and when used in conjunction with assessment of behavioral states, are especially valuable to the clinician. Use of this combined assessment approach in practice would strengthen clinician assessment for initiation of (beginning the first oral feeding) and daily preparation for oral feeding in preterm infants.

Enhancing sensory experiences for very preterm infants in the NICU: an integrative review

“…18,85–120 Eight articles were on the Auditory, Tactile, Vestibular, Visual (ATVV) intervention originally described by Rosemary White-Traut, two on the Family Nurture intervention, 99,113 three on the Hospital to Home: Optimizing the Premature Infant's Environment (H-HOPE) intervention, 114,115,120 one on massage with aromatic oil, 112 three on use of kangaroo care coupled with auditory stimuli 87,108,111 and 20 described a massage intervention that was coupled with a kinesthetic component. 85,86,89–98,100,102–107,109 …”

The Relationship Between Behavioral States and Oral Feeding Efficiency in Preterm Infants

“…The interventions include but are not limited to oral sensory stimulation, 52 non-nutritive sucking, 38,53–55 and multisensory intervention. 42,43,56 While these interventions have been shown to improve alert states, little research has identified sleep states or crying in response to these interventions. The findings from this research confirm the influence of behavioral states immediately prior to feeding on oral feeding efficiency, and thus may be instrumental in future designing and testing of interventions that facilitate optimal behavioral states for oral feeding in preterm infants.…”

“…self-identified as Black or Latina, less than high school education, less than 18 years old, history of current mental illness, family income less than 150% of poverty, more than one child under 24 months, four or more children under four in the household, or residing in a disadvantage neighborhood. 41,42 Infants were excluded if they had congenital anomalies, necrotizing enterocolitis, positive finding on head ultrasound (e.g. cystic PVL or grade III or IV IVH), receiving assisted ventilation at the time of enrollment, chronic lung disease, and/or prenatal drug exposure.…”

“…Interventions that have been shown to increase alertness include but not limited to oral sensory stimulation, 52 non-nutritive sucking, 38,53–55 and multisensory intervention. 42,43,56 Offering oral feeding only when infants are alert will support high oral feeding efficiency and oral feeding success.…”

Do orally-directed behaviors mediate the relationship between behavioral state and nutritive sucking in preterm infants?

“…They include mouthing, tonguing, rooting, hand-to-mouth, and sucking-on-hand [6, 17, 26, 28]. In full term infants, orally-directed behaviors emerge in the first hour following birth.…”