IMPORTANCE:Oral motor interventions are used in the neonatal intensive care unit (NICU) to support the development of oral feeding skills in preterm infants. Literature regarding which oral motor interventions are used, when they are implemented, and how parents are involved is lacking. OBJECTIVE:To benchmark evidence of oral motor interventions in the literature against reported use in NICU practice, understand the type and timing of oral motor interventions used, and understand perspectives about implementation of oral motor interventions and family involvement in these interventions. DESIGN:Qualitative study. SETTING:Virtual, recorded focus groups and interviews on Zoom. PARTICIPANTS:Convenience sampling was used to recruit neonatal therapists with at least 2 yr experience in the NICU who were currently implementing oral motor interventions. OUTCOMES AND MEASURES:During semistructured focus groups and interviews, we specifically probed the type of oral motor interventions that clinicians use in the NICU to benchmark them against the interventions found in the literature. Recordings were transcribed and uploaded to NVivo for descriptive analysis. RESULTS:Twelve neonatal therapists participated in focus groups or interviews. Applied oral motor stimulation, nonnutritive sucking, NTrainer® intervention, swallowing exercises, and milk drops were reported to be used in practice and most often were started as early as 29 wk postmenstrual age. Parents were primarily involved in facilitating nonnutritive sucking and providing milk drops. CONCLUSIONS AND RELEVANCE:Oral motor interventions reported to be used in NICU clinical practice mirror those available in the evidence. This supports ongoing implementation of evidence-based practice for neonatal therapists. Plain-Language Summary: A recent integrative review was completed to understand oral motor interventions used to support the development of feeding skills in preterm infants. The interventions identified in the scientific literature were nonnutritive sucking, applied oral motor stimulation, swallowing exercises, and use of a pacifier that elicits a sensory pulse to stimulate sucking called the NTrainer. However, there was no published information regarding which (if any) of these interventions are actually used in clinical practice and how parents may be involved in their implementation at the neonatal intensive care unit bedside. Therefore, this qualitative study sought to understand oral motor interventions used in clinical practice. All of the interventions identified in the scientific literature were identified as being used in practice, although at varying rates. An additional intervention, milk drops, was also identified. Nonnutritive sucking and milk drops were most commonly used by the study participants and were most commonly taught to parents to implement with their infants. These findings support neonatal therapists' implementation of evidence-based practice in the clinical setting.

OBJECTIVE:To examine associations between parental holding during therapeutic hypothermia (TH) and neonatal intensive care unit (NICU) outcomes among infants with hypoxic-ischemic encephalopathy (HIE). STUDY DESIGN:Retrospective cohort of 379 infants with HIE at two level IV NICUs (2017-2024). Unadjusted and adjusted regression models evaluated associations between holding during TH and NICU outcomes. RESULT:Overall, 28% of infants were held during TH. Holding was less common among infants with greater clinical severity, public insurance, or those identified as Hispanic, Asian, or Black. After adjustment for clinical and sociodemographic factors, holding was associated with faster time to full oral feeding (HR = 1.4, p < 0.01), earlier age at full oral feeding (HR = 1.6, p < 0.01), shorter hospitalization (β = -7.5, p = 0.02), and higher odds of breastmilk feeding at discharge (OR = 3.2, p = 0.03). CONCLUSION:Parental holding during TH is associated with favorable short-term NICU outcomes, supporting its potential role as a family-centered care practice during neonatal neurocritical care.

Early alterations in function are evident in preterm infants during their neonatal intensive care unit (NICU) hospitalization. Therefore, it is common for preterm infants to be referred to early intervention (EI) as they transition from hospital to home. Access to EI is often assumed, but understanding gaps in service delivery is important. The aims of this project were to (1) determine rates of EI access at the first high-risk infant follow-up (HRIF) appointment (4-8 months corrected age) at a safety-net hospital in Los Angeles, and (2) identify relationships between infant, clinic, and EI factors with EI service uptake.Through a retrospective medical record review, EI utilization at the first HRIF appointment was documented among 189 NICU-graduate preterm infants born ≤32 weeks estimated gestational age who had their first HRIF visit (4-8 months corrected age) between January 2019 and November 2020.Ninety-two (49%) of the infants were receiving EI at their first HRIF appointment at 4 to 8 months corrected age. Extremely preterm infants were more likely to receive EI services than those born very preterm (p = 0.005). No other relationships between factors were identified.Successful uptake of EI services cannot be assumed. Challenges with access to EI persist, even within systems designed to foster identification and access to therapy following NICU discharge. Future research is needed to identify the reasons for the lack of access to EI and to identify the impact of different types of programming to aid access to EI for high-risk populations. · EI access for a safety-net population is challenging.. · Only 49% of preterm infants received EI at 4 to 8 months corrected age.. · Extremely preterm infants were more likely to access EI.. · EI access was higher for infants hospitalized in the NICU associated with the HRIF..

To determine the feasibility and acceptability of the Baby Bridge telehealth model, aimed at expediting the time to therapy activation after neonatal intensive care unit (NICU) discharge. High-risk infants needing therapy after NICU discharge had an in-person therapy visit in the NICU to consent and conduct standardized assessments, followed by weekly telehealth Baby Bridge services starting within 1 week of NICU discharge. Among eight families, the first Baby Bridge telehealth session occurred at an average of 6.0 ± 2.6 days following discharge. They received an average of 8.3 (±2.1) telehealth sessions over 9.2 (±3.5) weeks. All therapy sessions after NICU discharge were accomplished with telehealth rather than in-person sessions. Satisfaction surveys of the eight families indicated they were "very satisfied" with Baby Bridge telehealth services. Telehealth Baby Bridge services appear to be feasible and acceptable when implementing programming to improve early therapy access for high-risk infants.

Objective To characterize current infant massage practices in neonatal intensive care units (NICUs) and identify variability in approaches among neonatal therapists. Study design A cross-sectional survey was distributed to NICU-based occupational therapists, physical therapists, and speech language pathologists. The survey inquired about massage use, training, protocols, techniques, and safety concerns. Descriptive statistics were used for analysis. Results Among 101 respondents from 32 states, 90 (90%) used infant massage, with 64 (71%) considering it standard care. Infant massage was most often administered by occupational therapists (77, 76%), physical therapists (70, 69%), and parents (46, 46%). Despite high training rates (87, 97%), only 48 (53%) followed a specific protocol. Techniques, frequency, and use of emollients varied widely. Safety concerns included infant stress and physiological instability, though adverse events were rare. Conclusion Despite widespread use of infant massage in NICUs, variability in findings underscores the need for standardization to ensure safe, effective delivery of massage.

To describe the supporting and enhancing neonatal intensive care unit (NICU) sensory experiences (SENSE) program, associated research and opportunities for further study. A review of current materials on SENSE program implementation, publications related to SENSE development, and research on program implementation and patient outcomes was conducted to describe the SENSE program and its associated research. The SENSE program combines structured, evidence-based, multisensory interventions with parent engagement in order to optimise outcomes in the complex NICU environment. Through a stepwise and scientific process, the SENSE program was developed to include specific doses and targeted timing (based on the infant's postmenstrual age, PMA) of evidence-based interventions such as massage, auditory exposure, rocking, holding and skin-to-skin care for parents to provide their infants each day of NICU hospitalisation. It is adapted in context of concurrent medical interventions, infant behavioural responses, as well as NICU culture. The program is feasible to implement, acceptable to staff, and related to infants receiving more developmentally appropriate sensory exposures. Adaptations related to NICU culture and parent involvement have been reported. Research has identified relationships of the SENSE program to improved parent confidence, neurobehaviour and feeding at term age as well as improved communication 1 year of age. The literature related to the SENSE program is promising, but more research on efficacy and implementation is needed.

AIM:To examine the relationship between feeding therapy and the timing of independent oral feeding (IOF) in preterm infants in the neonatal intensive care unit (NICU). STUDY DESIGN:A retrospective analysis of 536 preterm infants (<37 wk gestation) admitted to a level IV NICU between January 2017 and December 2019 was conducted. Clinical and therapy data were extracted from the electronic health record to examine associations between feeding therapy utilization and feeding outcomes. RESULTS:Medically complex infants were more likely to receive a feeding therapy referral (p = .001), and infants who received feeding therapy achieved IOF an average of 1.5 wk later than those who did not (p < .001). Among infants receiving therapy, earlier initiation was beneficial as each additional week of delay in therapy initiation corresponded to a 0.02-week delay in achieving IOF after adjusting for medical factors (p = .023). No association was found between feeding therapy frequency and postmenstrual age at IOF. CONCLUSION:Early initiation of feeding therapy may help expedite IOF. Timely referrals can support oral motor development and improve feeding outcomes in preterm infants. The lack of association with frequency may reflect staffing limitations that impacted consistent therapy delivery rather than a true absence of benefit.

ObjectivesTo describe current practice and roles of the neonatal therapist.Study designA Neonatal Therapy Practice Analysis was distributed to neonatal therapists (physical therapists, occupational therapists, and speech-language pathologists) in 2019–2020 via social media, email, newsletters, and conference materials.ResultsThere were 1,313 respondents from 1,110 different hospitals. 41.7% (n = 277) were occupational therapists, 29.3% (n = 195) were physical therapists, and 29.0% (n = 193) were speech-language pathologists. 760 (59.1%) worked in level III NICUs, while 248 (19.3%) worked in level II NICUs and 273 (21.2%) in level IV NICUs. 166 (28.1%) of respondents were Certified Neonatal Therapists (CNTs), which was related to higher number of full-time equivalent (FTE) positions per bed (β = 1.066, SE = 0.478, p = 0.026) and higher percentage of infants served in the NICU (β = −3.2, SE = 0.589, p < 0.001). We observed a median of one therapy FTE per 17 NICU beds (range of 1 FTE per 10–200 beds). Higher acuity NICU levels (β = 2.23, SE = 0.197, p < 0.001) and NICUs with higher number of beds (β = 2.497, SE = 0.285, p < 0.001) had more neonatal therapy FTEs. Survey respondents reported working with a median of 76.0% of infants in their respective NICUs (IQR 65%–90%, range 1%–100%). There was a higher percentage of infants served in higher acuity NICUs (β = 4.358, SE = 1.517, p = 0.004), in NICUs with a higher number of beds (β = 0.058, SE = 0.029, p = 0.047), when there was a productivity standard (β=11.47, SE = 1.9, p < 0.001), and where there was a higher number of neonatal therapy FTEs (β = 1.0, SE = 0.239, p < 0.001). 294 (46%) of respondents reported having standing orders, which was related to a higher percentage of infants served in the NICU (β = −1.109, SE = 0.393, p < 0.001) and to having a productivity standard (β = −0.467, SE = 0.139, p < 0.001). 65.3% (n = 415) of respondents reported having productivity standards to meet each day, with a range between 50%–80%.ConclusionThis practice analysis provides insights into the changing landscape of neonatal therapy.

Introduction Innovative models are needed to improve access to early therapy for high-risk infants discharged from the NICU. This study aimed to 1) compare costs between in-person and telehealth early therapy, and 2) evaluate adoptability, feasibility, adaptations, and acceptability of each model. Methods and Materials Twenty high-risk NICU infants were enrolled before discharge and randomized to receive therapy via telehealth or in-person Baby Bridge programming until community-based services began. Weekly visits were scheduled, with flexibility for switching formats (telehealth or in-person) when agreed upon by the therapist and family. Cost, utilization, and adaptations were tracked. Parent satisfaction was assessed via a post-discharge questionnaire. Results One infant was withdrawn due to readmission prior to receiving Baby Bridge services. Completion rates were high (18/19, 95%). In-person sessions were significantly more expensive ($141.35 ± $51.10) than telehealth sessions ($46.29 ± $16.19; p<0.001). Telehealth sessions generated positive average net revenue ($61.45 ± $54.31), while in-person sessions incurred losses (-$44.96 ± $63.63; p<0.001). Medicaid-insured sessions incurred losses for both telehealth (-$10.36 ± 4.94) and in-person (-$85.56 ± 38.53), whereas privately insured sessions yielded positive net revenues for telehealth ($91.92 ± 32.35) and in-person ($5.78 ± 51.20) sessions. No group differences were found in time to first session or session frequency. Visit format adaptations occurred in both groups (17% of telehealth visits; 36% of in-person; p<0.03). Parent satisfaction was comparable across groups. Conclusion Telehealth therapy is significantly less costly and more financially sustainable than in-person therapy. Both delivery models were feasible, with high satisfaction reported by families. Flexibility in adapting visit format supports better access and uptake, especially within in-person models. Telehealth offers a promising alternative for early intervention in high-risk infants following NICU discharge. ### Competing Interest Statement The authors have declared no competing interest. ### Clinical Trial NCT0689300 ### Funding Statement Yes ### Author Declarations I confirm all relevant ethical guidelines have been followed, and any necessary IRB and/or ethics committee approvals have been obtained. Yes The details of the IRB/oversight body that provided approval or exemption for the research described are given below: This study was approved by the IRB at University of Southern California (UP-21-00362) and Children’s Hospital of Los Angeles (CHLA-21-00301). I confirm that all necessary patient/participant consent has been obtained and the appropriate institutional forms have been archived, and that any patient/participant/sample identifiers included were not known to anyone (e.g., hospital staff, patients or participants themselves) outside the research group so cannot be used to identify individuals. Yes I understand that all clinical trials and any other prospective interventional studies must be registered with an ICMJE-approved registry, such as ClinicalTrials.gov. I confirm that any such study reported in the manuscript has been registered and the trial registration ID is provided (note: if posting a prospective study registered retrospectively, please provide a statement in the trial ID field explaining why the study was not registered in advance). Yes I have followed all appropriate research reporting guidelines, such as any relevant EQUATOR Network research reporting checklist(s) and other pertinent material, if applicable. Yes The data supporting this study's findings are available upon request from the corresponding author.

BACKGROUND:One criterion for infant NICU discharge is the ability to meet all nutritional needs by mouth, therefore, it is important to understand interventions that can improve the trajectory to full oral feeding. While many oral motor and feeding interventions are used in clinical practice, it remains unclear which are supported by the literature. AIM:The aim of this integrative review was to identify and understand what oral motor interventions are defined in the literature to support positive outcomes for preterm infants and their parents. METHODS:An integrative review of studies published from 2002 to 2022 focusing on applied oral motor interventions and their impact on feeding-related outcomes was completed. The systematic search used databases including PubMed, Cochrane, CINAHL, Scopus, and Google Scholar. Studies were included if they used a study population of preterm infants born </= 32 weeks estimated gestational age (EGA) and imposed an oral motor intervention/exposure that commenced prior to 36 weeks postmenstrual age (PMA) while the infant was in the NICU, with outcomes of time to full oral feeding, length of stay (LOS), feeding performance measures, feeding efficiency, weight gain, infant physiology, and/or parental outcomes. Studies were excluded if they were observational, pilot, or feasibility designs; if they enrolled a purposefully healthy sample of infants; had non-relevant outcomes including apnea and incidence of retinopathy of prematurity; had a sample size <30 without a priori calculation of power or had a calculated sample size that was not attained. RESULTS:Forty articles met inclusion criteria with four different interventions (or a combination of them) identified: nonnutritive sucking, oral motor stimulation [Fucile's protocol, Premature Infant Oral Motor Intervention (PIOMI)], NTrainer, and swallowing exercises. DISCUSSION:All interventions were associated with positive outcomes and began between 29- and 30-weeks PMA. Detailed information on adverse events (both physiologic and behavioral) in future research could allow for better risk-benefit analysis. The methodology and quality of the studies differed too much to allow for quantitative analysis; however, there does not appear to be compelling evidence that more stimulatory interventions are superior to less stimulatory interventions - a key consideration when working with preterm infants.

AIM:To describe the supporting and enhancing neonatal intensive care unit (NICU) sensory experiences (SENSE) program, associated research and opportunities for further study. METHODS:A review of current materials on SENSE program implementation, publications related to SENSE development, and research on program implementation and patient outcomes was conducted to describe the SENSE program and its associated research. RESULTS:The SENSE program combines structured, evidence-based, multisensory interventions with parent engagement in order to optimise outcomes in the complex NICU environment. Through a stepwise and scientific process, the SENSE program was developed to include specific doses and targeted timing (based on the infant's postmenstrual age, PMA) of evidence-based interventions such as massage, auditory exposure, rocking, holding and skin-to-skin care for parents to provide their infants each day of NICU hospitalisation. It is adapted in context of concurrent medical interventions, infant behavioural responses, as well as NICU culture. The program is feasible to implement, acceptable to staff, and related to infants receiving more developmentally appropriate sensory exposures. Adaptations related to NICU culture and parent involvement have been reported. Research has identified relationships of the SENSE program to improved parent confidence, neurobehaviour and feeding at term age as well as improved communication 1 year of age. CONCLUSION:The literature related to the SENSE program is promising, but more research on efficacy and implementation is needed.

OBJECTIVE:To determine the scope of feeding therapy for preterm infants in the NICU and medical and sociodemographic factors related to feeding therapy referral and service provision. STUDY DESIGN:Retrospective study of infants born <37 weeks gestation in a level IV NICU between January 2017 and December 2019. RESULT:Among 547 infants, 27% of infants received a feeding therapy referral, and 74% of those referrals were problem-based referrals. Feeding therapy referrals were more likely among infants with lower gestational ages and birthweights (both p < 0.001). In addition, infants with greater medical complexity, who required oxygen at 36 weeks, who had a history of mechanical ventilation, and who had a higher postmenstrual age at discharge were more likely to be referred to feeding therapy (all p < 0.001). CONCLUSION:While medical factors relate to feeding therapy referrals, there are other complex person and system factors that determine feeding therapy referral and service provision.

BACKGROUND:The Neonatal Eating Outcome Assessment determines feeding performance based on the infant's postmenstrual age (PMA). OBJECTIVE:To examine item-level measurement properties of this assessment's rating scale. METHODOLOGY:In this retrospective study, Rasch analysis was completed on clinical data from the Neonatal Eating Outcome Assessment for 100 infants (52 preterm and 48 full-term) using Winsteps version 3.93.1. Instead of PMA-based scores, ordered letters converted to numerical scores were analyzed. RESULTS:Analysis demonstrated that Section I (Pre-Feeding Skills) represents a separate construct from Sections II and III (Oral Feeding and End of Feeding, respectively). Sections II and III were adequately unidimensional to complete Rasch analysis. These sections fit the Rasch model overall, but rating scale category underuse was common, which may be attributed to sample characteristics. IMPLICATIONS:This analysis supports using validated ordered letter scoring of Sections II and III to measure oral feeding performance in preterm and full-term newborns.

OBJECTIVES:Investigate relationships between aEEG in the first 72 h in extremely preterm infants with 1) infant, medical, and environmental factors, and 2) infant feeding and neurobehavioral outcomes at term and school-age. METHODS:Sixty-four preterm infants (≤28 weeks gestation) were enrolled within the first 24-hours of life and had two-channel aEEG until 72 h of life. Standardized neurobehavioral and feeding assessments were conducted at term, and parent-reported outcomes were documented at 5-7 years. RESULTS:Lower aEEG Burdjalov scores (adjusted for gestational age) were related to vaginal delivery (p = 0.04), cerebral injury (p = 0.01), Black race (p < 0.01) and having unmarried parents (p = 0.02). Lower Burdjalov scores related to less NICU Network Neurobehavioral Scale arousal (p = 0.002) at term and poorer BRIEF global executive function (p = 0.004), inhibition (p = 0.007), working memory (p = 0.02), material organization (p = 0.0008), metacognition (p = 0.01), and behavioral regulation (p = 0.02) at 5-7 years. We did not observe relationships of early aEEG to feeding outcomes or sensory processing measures. CONCLUSION:Early aEEG within the first 72 h of life was related to medical and sociodemographic factors as well as cognitive outcome at 5-7 years.

AIM:To identify relationships between early medical factors and preterm infant feeding behaviors at term-equivalent age. METHODS:Forty-three very preterm infants born ≤32 weeks gestation had standardized feeding assessments using the Neonatal Eating Outcome Assessment at term-equivalent age (36-42 weeks postmenstrual age). Medical factors were collected and analyses were run to determine if associations between different medical factors and feeding performance exist. RESULTS:Lower Neonatal Eating Outcome Assessment scores at term-equivalent age were associated with lower estimated gestational age (p < .01), lower birthweight (p < .01), older postmenstrual age at discharge (p < .01), longer length of stay in the neonatal intensive care unit (p < .01), chronic lung disease (p = .03), as well as more days on total parenteral nutrition (p = .03), endotracheal intubation (p < .01), and noninvasive mechanical ventilation (p < .01). CONCLUSION:More feeding problems are observed in infants born earlier, with longer hospital stays, and with complex medical courses. Knowledge of the association between these medical factors and feeding difficulties allows for identification of infants who may benefit from early, targeted interventions to optimize the feeding process.

Date Presented 03/22/24 Infants who received dysphagia therapy have higher medical complexities than those who did not receive therapy. Findings could lead to earlier identification of populations that are at higher risk for oral feeding delays to optimize therapy services. Primary Author and Speaker: Tiana Nguyen Contributing Authors: Audrey Kane, Stacey Reynolds, Roberta Pineda, Elizabeth E. Rogers

Abstract Date Presented 03/23/24 Parent mental health and infant neurobehaviour may relate to the amount of multisensory co-occupations that infants engage in with their parents as compared with co-occupational engagement between infants and health care team members in the neonatal intensive care unit (NICU). Primary Author and Speaker: Marinthea Richter Contributing Authors: Amber M. Angell, Polly Kellner, Roberta Pineda

Importance: The Supporting and Enhancing NICU Sensory Experiences (SENSE) program is an evidence -based intervention that promotes daily, positive sensory exposures for infants in the neonatal intensive care unit (NICU). Understanding program implementation across sites may aid in optimizing strategies for uptake of the program and subsequently improve outcomes for infants and families. Objective: To investigate health care professionals' perceptions of implementing the SENSE program. Design: The SENSE Program Implementation Survey was developed using Proctor et al.'s model and the BARRIERS scale to probe organizational practices across sites worldwide. Setting: Survey distributed to 211 hospitals with a SENSE program license obtained before March 2020. Participants: One hundred fourteen NICU personnel (response rate = 54%). Outcomes and Measures: The survey sought to understand barriers and facilitators, adaptations during implementation, and associated costs. Results: Of the 53% (n = 57 of 107) of respondents who had implemented the SENSE program, many (n = 14; 31%) experienced quick timing (<1 mo) to use, including spread to nearly all infants in their NICU within 6 mo (n = 18; 35%). Most reported the program was used to educate families <= 3 days of birth (n = 20/59; 34%). Most of the sensory interventions in the program were performed by parents (n = 38; 67%) and therapists (n = 44; 77%). Barriers and facilitators at the organizational and individual levels were identified. No additional staff were hired to implement the program. Conclusions and Relevance: Given perceived successes and challenges, strategic enhancement of implementation can inform future administrations of the SENSE program.

Objective To 1) define the number and characteristics of NICUs in the United States (US) and 2) identify hospital and population characteristics related to US NICUs. Study design Cohort study of US NICUs. Results There were 1424 NICUs identified in the US. Higher number of NICU beds was positively associated with higher NICU level ( p < 0.0001). Higher acuity level and number of NICU beds related to being in a children’s hospital ( p < 0.0001; p < 0.0001), part of an academic center ( p = 0.006; p = 0.001), and in a state with Certificate of Need legislation ( p = 0.023; p = 0.046). Higher acuity level related to higher population density ( p < 0.0001), and higher number of beds related to increasing proportions of minorities in the population up until 50% minorities. There was also significant variation in NICU level by region. Conclusions This study contributes new knowledge by describing an updated registry of NICUs in the US in 2021 that can be used for comparisons and benchmarking.