Randomized Controlled Trial to Improve Multisensory Neural Processing, Language & Motor Outcomes in Preterm Infants
Phase: NA
Conditions: Preterm Infant
Sponsor: Emory University

Study Protocol 
 
Title: Randomized Controlled Trial to Improve Multisensory Neural 
Processing, Language & Motor Outcomes in Preterm Infants 
 
NCT Number: NCT03232931 
 
Protocol date: December 19, 2022 

Protocol Title: Trial to Improve Multisensory Neural Processing, Language & Motor Outcomes 
in Preterm Infants
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PROTOCOL TITLE:   Trial to Improve Multisensory Neural Processing, Language & 
Motor Outcomes in Preterm Infants
NCT03232931
PRINCIPAL INVESTIGATOR:  Nathalie Maitre, MD, PhD
Department of Pediatrics/Division of Neonatology
Nathalie.linda.maitre@emory.edu 
VERSION: 3.0 Emory version
National Institutes of Health (NIH)
Eunice Kennedy Shriver National Institute of Child Health and Human Development (NICHD)

Protocol Title: Trial to Improve Multisensory Neural Processing, Language & Motor Outcomes 
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Table of Contents
1.     Study Summary                                                                                                                                     3
2.     Introduction                                                                                                                                           5
3.     Background and Rationale                                                                                                                  5
4.     Methods and Analysis                                                                                                                          7
5.     Study Design and Setting                                                                                                                     7
6.     Study Procedures                                                                                                                                  8
7.     Inclusion and Exclusion Criteria                                                                                                          8
8.      Randomization                                                                                                                                                   9
9.     Intervention                                                                                                                                         10
10.   Standard Care                                                                                                                                      10
11.   Multisensory Intervention                                                                                                                 11
12.    Assessment Methods                                                                                                                         14
13.    Primary Outcome Measures                                                                                                             14
14.    Secondary Outcome Measures                                                                                                        16
15.    Analysis Plan                                                                                                                                        17
16.   Power/Sample Size/Statistical Analysis                                                                                           17
17.   Data Management                                                                                                                              19
18.   Ethics and Dissemination                                                                                                                   20
19.   Discussion                                                                                                                                              20
20.   References                                                                                                                                            21

Protocol Title: Trial to Improve Multisensory Neural Processing, Language & Motor Outcomes 
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Study Summary
Project Title
Trial to Improve Multisensory Neural Processing, 
Language & Motor Outcomes in Preterm Infants
Project Design
Randomized Controlled Trial
Primary Objective
To demonstrate that preterm infants receiving a 
standardized, parent-supported, auditory-tactile 
intervention in addition to standard of care in the 
NICU will have more typical cortical multisensory 
processing at discharge to home and better sensory 
adaptation and motor and language outcomes than 
infants receiving only standard of care.
Secondary Objectives
To test the role of multisensory responses at 
discharge in mediating intervention effects on later 
sensory adaptation, and motor and language 
outcomes.  To explore the role of m responses in 
mediating intervention effects on later motor and 
language outcomes.
Research 
Interventions/Interactions
Listed in Table 1 on page 4
Study Population
Preterm infants 32-36 weeks postmenstrual age(PMA)
Sample Size
230
Study Duration for 
individual participants
 NICU intervention between 32-36 week PMA/Follow 
up at 3 months to 2 years of age
Study Specific 
Abbreviations/ Definitions 
Bayley III – Bayley Scales of Infant Development 3rd 
edition                                                                               
BCQ – Baby Care Questionnaire                                 
HNNE – Hammersmith Neonatal Neurological 
Examination  ITSP – Infant Toddler Sensory Profile  
MSP – Multisensory Procedures                                  
PLS5 – Preschool Language Scales 5th edition              

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PSDQ – Parenting Styles and Dimensions 
Questionnaire                                                                        
STS – Skin to Skin
Funding Source 
National Institute of Child Health and Development
Table 1
Construct
Procedure(s)
Timing
Variable derived
Variable type
Multisensory response
(Auditory-Tactile
processing)
ERP to simultaneous
puff + speech sound
Pre and post
intervention
(near discharge)
Pre-Post change in amplitude at frontal
scalplocations in 176-377 ms time window
IMP: Percentage of time spent in near-
typical neural activation
continuous
continuous
Sensory reactivity and
adaptation to
environment
ITSP
9-12 months
Behavioral neurological threshold score
(typical or atypical)
Raw score in sensory processing domain
nominal
continuous
Language
BayleyIII
22-26 months
Composite standard score
Scaledstandardscores for expressive and
receptive components
continuous
Motor
BayleyIII
Neurological Exam
22-26 months
9-12 months
22-26 months
Composite standard score
Scaledstandardscores for fine and gross
components
continuous
Tactile processing
Functional tactile
connectivity
ERP to calibratedair puff
ERP to calibratedair puff
Baseline/
After intervention
Baseline/
After intervention
Amplitude of response in 171-240 time
window at central and frontal scalp
locations
Absolute clustering coefficient of alpha
band coherence network
continuous
continuous
Speech Sound
differentiation
ERP to 6 speech sounds
Baseline/
After intervention
Difference in absolute amplitude between
/du/ and /gu/ infrontal scalplocations in
250-350 ms time window
continuous

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Introduction
Background and rationale
Every year, half a million infants are born prematurely in the United States and 15 million 
worldwide. The vast majority of preterm infants will have only moderate to mild impairments 
or delays in early childhood, with intellectual and behavioral consequences of prematurity only 
apparent at school age and beyond. These infants contribute most of the societal and economic 
burden of preterm birth, yet have often been overlooked in the face of other devastating and 
immediately visible consequences of extreme prematurity. Almost all preterm infants suffer 
from atypical brain maturation and its developmental consequences resulting from interactions 
between brain immaturity and premature extra-uterine sensory experience.
Brain development in the neonatal period is experience-dependent, yet the neonatal intensive 
care experience is largely comprised of atypical sensory stimuli. The critical importance of 
establishing functional sensory systems in infancy as the basis for all higher order processes 
(cognition, communication, behavioral adaptation) has been demonstrated in both animal 
models and humans. Preterm infants at discharge to home often have altered sensory reactivity 
and modulation in response to their environment, which are associated with negative 
neurodevelopmental outcomes in childhood. For the auditory system, preterm infants with 
deficient exposure to infant-directed speech sounds have poorer brain microstructure at 
discharge and worse neurodevelopmental outcomes at two years. For the tactile system, 
preterm infants with higher numbers of painful experiences have worse processing of light 
touch at discharge, decreased thalamic organization, decreased behavioral reactivity to tactile 
stimuli in the home environment, and less typical multisensory processing. Finally, brain 
responses to multisensory stimuli are supra-additive (greater than the sum of brain responses 
to unisensory stimuli).
Parents are critical in scaffolding early learning and development, especially with regards to 
early sensory exposures and responses. In particular, parental linguistic input is a key concept in 
learning language. Importantly, this input is more effective when it is contingent and immediate 
(i.e., language is presented immediately after infant action). This precept holds true even in 
early pre-linguistic phases, when infants differentiating among speech sounds, which is 
necessary for later development of higher-order language milestones. 

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Another type of scaffolding provided by parents is the multisensory support of skin-to-skin 
(STS), which helps maintain quiet and alert states in immature infants who have frequent 
autonomic instability. Unfortunately, providing STS is often challenging for parents who often 
have to travel long distances to see their infant, while balancing responsibilities of other 
children and jobs, in addition to potential unreliable transportation and/or lack of social 
support.
Multisensory processes (MSPs) are rarely studied in neonates, yet in children and adults MSPs 
are essential to building a coherent and unified perception of the world, a foundation for 
learning and social interactions.  In order to improve multisensory systems function of 
hospitalized preterm infants, further research is needed to design rigorous, standardized and 
mechanistically-based multisensory interventions using feasibly modifiable sensory exposures. 
There are currently no interventions that address rehabilitation of sensory function in the 
neonatal period, when brain-plasticity is at its greatest and when improvements can have an 
exponential downstream effect on later neurodevelopment.
The few associative studies, while critical, have not examined causal effects of interventions on 
neural processing changes to mediate neurodevelopmental outcomes. Fortunately, more 
infant-directed speech is associated with better language outcomes in the first 18 months and 
increased STS care with improved autonomic system stability and muscle tone in the hospital, 
and improved behavioral and motor outcomes in infancy. However, ours is the first study to use 
brain-based measures to test predictions regarding how the brain changes in response to 
multisensory treatment, which in turn affects functional outcomes. 
Our study is in direct response to the NIH announcement calling for applications that “elucidate 
the mechanisms and/or behavioral outcomes of multisensory processing, the integration or 
processing of at least two distinct types of sensory input” (PA-15-347). In addition, our study 
meets two of the top new research priorities of the National Center for Medical Rehabilitation 
Research, to “Explore multimodal approaches that promote plasticity and sensorimotor 
function” and to “Develop objective measures to monitor functional progress.”
To accomplish these goals, our team has leveraged expertise in high-density functional EEG in 
the NICU, showing that we can rapidly and non-invasively acquire large datasets of brain-based 
sensory measures and analyze them with innovative spatiotemporal computational tools. 
We have utilized these methodologies in pilot studies demonstrating that speech sound 
differentiation of preterm infants improves in response to a parent-supported standardized 

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language intervention and that preterm infants exposed to STS care have increased 
multisensory processing efficiency compared to those who do not. 
We have now designed a prospective, interventional RCT in preterm infants aimed at restoring 
more typical multisensory, rather than the unisensory, processing measures that were the 
outcomes of our pilot studies. 
Our multisensory intervention using parents’ voice and nurturing touch can be administered 
regularly in the NICU during sensitive periods of sensory development, even when parents 
cannot always be present. Our test of this multisensory intervention will involve 23 sessions of 
standardized, therapist-administered, auditory-tactile stimulation. This treatment will combine 
contingent presentation of recorded mother’s voice delivered using a suck-activated system 
during holding with supportive tactile containment against the therapist’s chest. This treatment 
will be tested in an internally-valid RCT. In addition to testing the efficacy of the treatment on 
gold-standard measures of language and motor functioning, we will also test whether the 
treatment effect is due to intermediate treatment effects on multisensory and unisensory 
processing. Understanding the mechanism by which the treatment works is important for laying 
the foundations of future improvements and potential recommendations for treatment that 
might be useful for wide-spread use even in lower resource settings with the ultimate goal of 
improving neurodevelopmental outcomes for these premature infants.
Methods and Analysis
Study aims
Our aims for this study are first, to demonstrate that preterm infants receiving a standardized, 
parent-supported, auditory-tactile intervention in addition to standard of care in the NICU will 
have more typical cortical multisensory processing at discharge to home and better sensory 
adaptation and motor and language outcomes than infants receiving only standard of care. 
Second, to test the role of multisensory responses at discharge in mediating intervention 
effects on later sensory adaptation, and motor and language outcomes. Finally, to explore the 
role of m responses in mediating intervention effects on later motor and language outcomes.
Study design and setting
In order to test these aims, we are conducting an RCT of a multisensory (MS) intervention with 
230 hospitalized preterm infants. Infants starting at 31 weeks will be randomized to either the 
control or intervention group. Both the control and intervention groups will receive standard 
care. Infants assigned to the MS group will also receive the MS intervention over two weeks, 

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starting at 32 0/7 weeks postmenstrual age (PMA). ERP testing will be performed prior to 
intervention and after intervention is complete., which occurs at 36 weeks PMA on average. 
ERP testing takes approximately 30 to 40 minutes. All infants will be seen at the NICU Follow-Up 
Program clinics at 3-4months PMA, 9-12 months PMA (Year 1) and 22-24 months PMA (Year 2), 
where neurodevelopmental outcomes will be assessed using standardized methods. If for any 
reason these standardized assessments are not able to be performed at the NICU Follow Up 
Clinic (e.g., parent request, infant not eligible to be seen in the NICU Follow Up Clinic), then the 
follow up visits will be conducted in the BBOP lab space with trained study personnel. Home 
visits may be provided on occasion, at the discretion of the Principal Investigator. If an in person 
visit is not able to be performed, we may do assessments virtually (e.g., zoom).   
Study procedures
For infants who meet inclusion criteria at 31 weeks, consent is obtained and parent’s voice is 
recorded and parent-scented T-shirt may be collected when possible. Study staff may approach 
parents of eligible infants about the study and obtain consent slightly before the infant is 31 
weeks, however, other study procedures will not start until the infant reaches 31 weeks. Infants 
are then randomized to the control or intervention group. If a patient is randomized to the 
control group, parents will be given the opportunity to consent to the secondary part of the 
study if they are interested. This part of the study is observational only and does not influence 
randomization. ERP testing is performed prior to the intervention. Infants assigned to the MS 
group receive the standardized MS intervention over 2 weeks, starting at 32 0/7 weeks PMA or 
at enrollment prior to 36 weeks. For both control and intervention groups, standard care 
includes skin-to-skin care on parent, when present, and playing of parents’ voice non-
contingent on infant suck. Parents may be asked to complete the Baby Care Questionnaire 
(BCQ) during infant’s stay in the NICU or as soon as possible after discharge. Prior to the infant’s 
discharge, a brief neurological examination (HNNE) and motor assessment (GMA) may be 
completed. ERP is repeated after intervention is completed, which occurs at 36 weeks PMA on 
average.
All infants are seen at the NICU Follow-Up Program clinics at 3-4, 9-12 (Year 1) and 22-26 
months (Year 2). At the 3-4 month visit, study staff may obtain the Baby Care Questionnaire 
(BCQ), a brief neurological exam (HINE), and a brief motor assessment (GMA). At the Year 1 
visit, study staff may obtain the BCQ, Infant Toddler Sensory Profile (ITSP), HINE, GMA, Bayley 
III, and the Parenting Styles and Dimensions Questionnaire (PSDQ). At Year 2, study staff may 
obtain the the Bayley III, HINE, BCQ, CBCL, PSDQ, and PLS-5. 

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If for any reason these standardized assessments are not able to be performed at the NICU 
Follow Up Clinic (e.g., parent request, infant not eligible to be seen in the NICU Follow Up 
Clinic), then the follow up visits will be conducted in the BBOP lab space with trained study 
personnel. Home visits may be provided on occasion, at the discretion of the Principal 
Investigator. If an in person visit is not able to be performed, we may do assessments virtually 
(e.g., zoom). Individual assessment results may be shared with the families at their request and 
after the scoring has been completed.  In addition, if a participant is seen outside of the NICU 
Follow Up clinic for their study follow up assessments, we may also share results with a 
participant’s primary care provider or the NICU Follow up Clinic (with the parent’s permission) 
with any concerns that were identified. 
Inclusion and Exclusion Criteria
The study population was originally comprised of 200 preterm infants. Due to Covid 19 losses to 
follow up, this number has been revised to 230 preterm infants. We anticipate the distribution 
to be 45% male and 55% female, as females have a small survival advantage after extreme 
prematurity. All races and ethnicities will be included, with an expected skew towards slightly 
more black children due to disproportionate effects of prematurity on race.
Inclusion criteria includes PMA 32 0/7 weeks gestation-36 0/7 weeks gestation. Exclusion 
criteria will be ventilation using an endotracheal tube, major congenital malformations, family 
history of genetic hearing loss, and use of sedatives or seizure medications. These medications 
may mask sensory processing as assessed by ERPs.
Randomization
Random assignment to groups will be carried out using unified reproducible methods (i.e. saved 
random number seeds) provided by our Biostatistics core. We will try to conceal allocation from 
all study personnel who could influence scores. Except for parent reports, examiners will be 
blind to treatment assignment. We will obtain recorded parent’s voice from both groups with 
the intent of masking parents to assignment. Although we cannot fully mask parents to group 
allocation, as bedside nurses communicate regularly with them, we will address the potential 
effect on the parent questionnaire at one-year by deemphasizing the sensory nature of the 
outcomes to both groups, and instead focusing on the proven positive links between parental 
involvement and improved intersubjectivity.

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In addition to randomization, we have addressed the problems of RCT design as follows: 
Adherence to treatment protocol: A highly manualized treatment for the MS treatment while 
monitored control treatments will be used by hospital staff during NICU hospitalization. These 
measures should help ensure uniform, high-quality implementation of the MS treatment. 
Sufficiently and randomly sampled fidelity of treatment (FOT) measures will be collected. Two 
of the first twelve MS sessions will be video recorded for study team review to ensure FOT. 
Treatment is provided in the NICU by experienced staff therapists. 
Total attrition: Total attrition is expected to be less than 10% We have experienced <5% data 
loss due to non-compliance with electrode placement in our prior studies. Should motion 
artifact occur, we will retest patients with insufficient data within 24 hours. For the Bayley, 
should children prove unable to complete follow-up testing during scheduled visits, they will be 
rescheduled within one week of the scheduled visit. Testers are trained to perform the Bayley 
III in the home environment, if necessary, The ITSP can be performed over the phone or 
through the mail if necessary and will be performed within one week of a missed visit. 
The BCQ and PSDQ may be completed by the parent in writing or via phone. Analysis will follow 
an intent-to-treat protocol. As such, all randomized participants will be analyzed and missing 
data will be handled using multiple imputation.
Differential attrition: Differential attrition is unlikely because children must be in the NICU 
during the treatment phase due to health concerns. There are no non-NICU treatments during 
the treatment phase. Thus, compensatory responses due to parental displeasure of group 
assignment is unlikely. 
Covariates: Biological variables are factored into our research design as potential covariates.  
Several pretreatment covariates will be statistically controlled if needed. These variables will be 
quantified at the pretreatment period, as past research or theory suggests they may be 
associated with neurodevelopmental outcomes or sensory processing. If preliminary tests of 
between-group differences of these pretreatment variables and the pretreatment variables 
showing between-group differences are associated with putative mediators or 
neurodevelopmental outcomes, these will be statistical controlled. Their statistical interaction 
with treatment group must be tested as part of the process of determining whether they 
should be statistically controlled. Thus, the possibility that treatment varies as a function of 
these biological variables will also be explored. These include: gestational age at birth, sex, 
presence of severe white neural injury on neuroimaging (intraventricular hemorrhage grade III 
or IV, periventricular leukomalacia, cerebellar hemorrhage, ischemic or thrombotic injury), 
presence of systemic inflammatory conditions (history of necrotizing enterocolitis Bells Stage 

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IIA or above, culture documented sepsis or meningitis, moderate or severe bronchopulmonary 
dysplasia per modified Shennan definition), cumulative caffeine exposure post intervention, 
total parental skin-to-skin time during the study period and pretreatment status on the General 
Movements Assessment (GMA).
Intervention
Standard Care
The standard care of infant currently follows two medical protocols, one for STS holding and 
one for exposure to parent’s voice. The protocols will be enhanced and monitored as follows:
Exposure to recorded parent’s voice: 
Preterm infants in the NICU currently receive noncontingent recorded parents’ voice during 
two 20 minute sessions per day. Recordings are standardized. Recordings are then played 
through a sterilizable device (DINO-egg). 
To enhance standard care, we will ensure that all parents have a voice recording before study 
start when possible so that the majority of infants are exposed to parent’s voice. A standard 
therapist recording may be used when it is not possible to obtain parent’s voice. Monitoring of 
standard care will be accomplished through bedside logs, designed to be filled out by nursing 
staff and family when DINO-egg is played.
Skin-to-skin holding: Per standard care, STS care will be carried out by parents in both groups. 
Parents in the NICU currently use either their hands or positioners to facilitate prolonged STS. 
Infants are placed in a prone position with head positioned over the sternum, allowing 
transmission of breath and heart sounds to the developing ear. Deeper pressure is applied to 
offer support and feedback to the child’s bottom. Session length is set to a minimum of 45 
minutes per unit protocols.  When primary caregivers are not comfortable with direct skin-to-
skin contact (e.g. are not a direct relation to the child, or parent or child skin problem), a thin 
single-use hospital gown that is not previously imprinted with the parent’s scent is used to 
facilitate the experience without hindering sound transmission. In order to ensure safety during 
STS holding, vital signs including heart rate, breathing patterns and rate, oxygen saturation and 
temperature are continuously and automatically monitored with preset alarms per unit 
protocol. If any negative deviation from the infant’s daily vital patterns occurs, the nurses 
examine the infant and decide whether to stop the STS.
To monitor STS, we will review the medical record for daily start time, duration and caregiver 
during STS. We may also leave a STS log at bedside for parents who provide frequent STS to 

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facilitate greater recording accuracy. We will also record any deviations from autonomic 
stability during STS (tachy/bradycardic events tachypnea or apnea).
Multisensory Intervention
Rational: Studies have shown that infant acquisition of early speech sound differentiation in 
term and preterm infants is essential to the construction of more complex cortical functions 
such as receptive language development. Furthermore, learning of language in infants is 
improved when language exposure is presented contingent on infant action and promptly after 
the action. Therefore, we will use preterm infants’ active non-nutritive sucking as the behavior 
that activates an audio recording of mother’s voice within a one second after the suck. The 
mother’s voice provides auditory input, which purportedly contributes to the infants’ 
representation of initial speech sound categories. 
The mother’s voice is a preferred stimulus and it’s frequency and patterns are distinguished 
early in life from other sounds. 
The infant must repeat the action every ten seconds to continue to receive the positive 
reinforcement of mother’s voice. This approach enables contingent linguistic input by the 
infant’s mother’s voice without parent having to be present. Because infant uptake of linguistic 
input may be enhanced during periods of calm attention to the auditory stimulus, the 
contingent linguistic input will be provided while the infant is in a state of autonomic stability. 
Thus, we will present the suck-contingent playing of parents’ voice while skin-to-skin (STS) 
holding occurs. STS holding is a form of MS stimulation combining tactile, vestibular, olfactory 
and auditory input that has been demonstrated to improve autonomic nervous system stability. 
Although STS can induce deep sleep, the contingent presentation of parent’s voice will be 
provided at the beginning of STS containment, when past work indicates that infants are still 
awake.
MS intervention protocol: The MS intervention will be carried out in addition to standard care 
and will include two components: holding and light pressure containment of the infant against 
the cotton T-shirt covered chest of the therapist for tactile and non-specific auditory 
stimulation simultaneous with playing of mother’s voice contingent on infant pacifier sucking 
for during a study session of no more than 15 minutes duration. No more than one study 
session will be completed per care period for each subject. Additionally, when possible, a 100% 
cotton T-shirt square scented with parent’s skin may be placed within 2 cm of infant’s face on 
the therapists’ chest, to provide olfactory stimulation without risk of suffocation. The 12-23 
intervention sessions will be dispersed across 2-3 weeks. 

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On the rare occasion that the parent is present, parental STS will always take precedence over 
the intervention and the intervention session will be separated from previous parental STS by a 
minimum of 1 nursing care interval (3 hours) in one 24-hour period. Infant autonomic stability 
during the MS intervention with the therapist will be recorded as above for parent STS   
         Contingent parent’s voice exposure: We will use the Pacifier Activated Lullaby® (PAL®) 
device, a 510k FDA approved digital music delivery system that integrates a sensor, a pacifier 
routinely used in the NICU, and a receiver). It delivers a predetermined 10 seconds of recorded 
parent’s voice singing lullabies upon detection of a suck that meets a preset pressure threshold. 
The original systems were modified for research use by decreasing the lower limit of activation 
thresholds for delivering the recording. Minimal effort is required to trigger the device. 
However, the settings ensure that regular attempts are needed to continue to receive 
continual presentation of the recording of mother’s voice by requiring another suck after 10 
seconds. 
The auditory stimulation with PAL will be provided when the infants are still awake (i.e., 
at the beginning of the session). 
STS holding: The therapist will wear a clean 100% cotton T-shirt with a clean hospital 
gown on top of the shirt (dependent on hospital guidelines) and wrap the “kangaroo” 
positioner securely over the gown. The positioner will allow containment with one-hand and 
PAL operations with the other. Should assistance be required, personnel will use the unit 
standard personal voice-activated call system to request a team member and minimize 
disruptions to the infant. The parent-scented T-shirt squares may be placed next to the infant’s 
nose will be obtained by having the parent wear the T-shirt for a minimum of one hour and 
storing it in a sealed bag when possible. Once collected, the shirt will be cut into squares, and 
when possible, the first square will be used within 3 hours of cutting for the multisensory 
intervention. After each session the cloth will be stored in its own sealed bag and a new square 
will be used every 3 days. Each square will be replaced if contaminated with infant’s bodily 
fluids. 
Relaxation training of the MS therapy team: Because effects of STS holding are thought 
to be partly mediated by the holder’s heart and respiratory rate, it is essential to maintain calm 
throughout the PAL administration in the way that parents would while holding their infant 
without additional activities. To promote this, therapists will be trained on mindfulness 
techniques and practice this prior to start of the intervention.  
Ensuring high intervention fidelity: 
The intervention will be implemented using a standardized training procedure implemented in 
the PI’s lab for fidelity of parent training in a previous clinical trial. A script for the therapy 
session detailing the essential steps and sequence of the procedure is produced in a video. All 

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study therapists and an independent observer in the laboratory study the videos prior to 
beginning implementation. During a common training phase, the observer scores the therapists 
on all aspects of the treatment, as indicated by the aforementioned script sequence. The 
therapists also score themselves on the fidelity rating scale in order to immediately compare 
their self-assessments with those of the observer. The training phase is concluded when there 
is 90% adherence to the protocol and concordance between therapists and observer scoring. 
This allows for development of a gold-standard non-therapist observer and back-up observers 
that will be used to monitor possible drift during the treatment phases.  
A random sample of 10% of all MS treatment sessions will be video recorded and assessed for 
fidelity with the fidelity rating scale by the trained observer. 
Twenty percent of the sessions coded for MS treatment fidelity will be randomly selected and 
independently recoded for fidelity by a second observer to estimate inter-observer reliability of 
the fidelity scores. 
Assessment Methods
Our outcomes (or constructs) of interest are listed in Table 1. These constructs are quantifiable 
using well validated tests and measures. Our primary outcome is multisensory response and 
our secondary outcome is neurodevelopmental outcomes, including sensory adaptation, motor, 
language, tactile processing, and speech sound differentiation.

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Table 1
                                                                                                                                                 
Primary Outcome Measures
Sensory processing measurement by ERP:
ERP Recording: A high-density array of 128 electrodes embedded in soft sponges (Hydrocel 
Sensor Net, EGI, Inc., Eugene, OR) will be used to record ERPs with a sampling rate of 1000 Hz, 
filters set to 0.1-400 Hz (Figure 2a). Recording of brainwaves will be controlled by Net Station 
(v. 4.3; EGI, Inc., Eugene, OR). E-Prime (v. 4.0, PST, Inc., Pittsburgh, PA) software will control 
stimulus delivery.
Stimulus-presentation paradigm: The ERP procedure involves blocks of trials from four 
conditions: multisensory (simultaneous speech sound-puff), puff alone, speech sound alone, 
and sham puff in a randomly generated sequence. To prevent habituation, no more than 
2 repetitions of a condition occur in a row, with inter-trial intervals varying randomly between 
2000-2500 ms. 
The “light touch” stimulus is an air puff emanating from a nozzle positioned above the skin of 
the palmar surface of the right hand secured in a mold holder (Figure 2b). Another mold holder 
connected to the second nozzle is placed 15 cm away at midline (sham condition). The pressure 
Construct
Procedure(s)
Timing
Variable derived
Variable type
Multisensory response
(Auditory-Tactile
processing)
ERP to simultaneous
puff + speech sound
Pre and post
intervention
(near discharge)
Pre-Post change in amplitude at frontal
scalplocations in 176-377 ms time window
IMP: Percentage of time spent in near-
typical neural activation
continuous
continuous
Sensory reactivity and
adaptation to
environment
ITSP
9-12 months
Behavioral neurological threshold score
(typical or atypical)
Raw score in sensory processing domain
nominal
continuous
Language
BayleyIII
22-26 months
Composite standard score
Scaledstandardscores for expressive and
receptive components
continuous
Motor
BayleyIII
Neurological Exam
22-26 months
9-12 months
22-26 months
Composite standard score
Scaledstandardscores for fine and gross
components
continuous
Tactile processing
Functional tactile
connectivity
ERP to calibratedair puff
ERP to calibratedair puff
Baseline/
After intervention
Baseline/
After intervention
Amplitude of response in 171-240 time
window at central and frontal scalp
locations
Absolute clustering coefficient of alpha
band coherence network
continuous
continuous
Speech Sound
differentiation
ERP to 6 speech sounds
Baseline/
After intervention
Difference in absolute amplitude between
/du/ and /gu/ infrontal scalplocations in
250-350 ms time window
continuous

Protocol Title: Trial to Improve Multisensory Neural Processing, Language & Motor Outcomes 
in Preterm Infants
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at the skin surface is 5 psi, or less than the pressure of the smallest microfilament used to test 
for neuropathies.55 The entire test session generates 60 trials per condition and lasts 8-10 
minutes. The speech sound condition is a computer-generated woman’s voicing of one of six 
syllables (i.e. /ba/, /da/, /ga/, /bu/, /du/, /gu/) delivered in a free field setting using a 
microphone placed at midline 15 cm. The speech stimuli are computer-synthesized consonant-
vowel syllables from the "transition-only" stimulus series. The five-formant syllables were 
synthesized on a Klatt (cascade) synthesizer, so that the amplitude of individual formants was 
modulated as a function of the respective formant frequencies. The central frequencies of the 
steady-state portion of the formants were kept constant across the different consonants and 
only varied as a function of the vowel sounds. The syllables are presented at 65 dB SPL(A).  
More than the 2 key stimuli (/bu/ and /gu/) are presented to prevent habituation. The stimulus 
presentation paradigm simultaneous allows collection of multi- and uni-sensory conditions and 
the replication of prior-identified time windows and scalp regions that quantify individual 
differences in multi- or uni-sensory processing. 
Preparation and analysis of ERP data: The recorded data will be filtered using a 0.3-40 Hz 
bandpass filter and segmented on stimulus onset to include a 200-ms prestimulus baseline and 
a 500-ms post-stimulus interval. Electrodes will be referred to Cz and re-referenced offline to 
an average reference. Resulting segments will be screened for motor/ocular artifacts using 
standard algorithms in NetStation, followed by a manual review. 
We will utilize the time windows and electrode clusters identified in our previously published 
and preliminary data (Section C1) to guide computation of the mean amplitude for each 
patient, condition and time point using NetStation statistical extraction tools. 
Index of multisensory processing (IMP): We have already identified template maps over the 
cumulative 500ms post-stimulus time window using a topographic cluster analysis (i.e., 
Topographic Atomize & Agglomerate Hierarchical Clustering approach) (see Preliminary Data 
section) for full-term (FT) and preterm (PT) infants, which accounted for 96.3% of the global 
explained variance in ERP response to the MS stimulus. Different pairs of template maps have 
been identified for the 3 time windows corresponding to previously-identified microstates 
during the multi-sensory condition (127-175ms,176-377ms, 378-599ms). Using a within-
participant spatial correlation process (i.e., cases are electrodes and the two variables are (a) 
participant’s ERP and (b) template map value), we can identify which template map (FT or PT) 
best fits each time sample’s observed topographical data for each participant. 
This fitting procedure will be carried out for each of the 3 time windows. From this procedure, 
we calculate the percentage of time the topographical pattern of the participant’s ERP to MS 
stimuli is most like the FT template map. We call this index the IMP. This index is expressed as a 
percentage from 100% (all time samples show nearly-typical activation) to 0% (no time samples 
show nearly-typical activation). 

Protocol Title: Trial to Improve Multisensory Neural Processing, Language & Motor Outcomes 
in Preterm Infants
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Secondary Outcome Measures
Baby Care Questionnaire (BCQ):
The BCQ is a parent questionnaire that assesses the degree of parental structure and parental 
attunement. The three sections include sleeping, feeding, and soothing. Parents are asked to 
indicate their feelings about each statement by circling strongly agree (SA), agree (A), disagree 
(D), or strongly disagree (SD). The tool is validated for parents expecting a baby through 24 
months of age. 
Hammersmith Neonatal/Infant Neurological Examination (HNNE/HINE):
The HNNE and HINE is a neonatal/infant neurological examination consisting of 34 items to 
assess tone, tone patterns, reflexes, movements, abnormal signs, and behavior.
Parenting Styles and Dimensions Questionnaire (PSDQ):
The PSDQ is a 32-item parent questionnaire that assesses parenting style based on a series of 
items scored by parents along a 5-point Likert-type scale.
Infant Toddler Sensory Profile (ITSP): 
The ITSP is the most validated test for the behavioral evaluation of sensory processing. This 
parent-rated questionnaire has 48 questions, addressing five sensory processing sections 
(Auditory, Visual, Tactile, Vestibular, and Oral Sensory Processing) and a General measure. One 
variable from this instrument is the infant’s neurological threshold (tendency to respond to 
sensory stimuli). ‘Low neurological threshold’ reflects situations when minimal sensory input 
causes a system to respond and ‘high neurological threshold’ reflects situations when a large 
amounts of stimulation is required before a response is registered. Typical, atypical high and 
atypical low ranges are provided for neurological threshold scores in the 7-12 month age band 
using published norms on 589 term-born American infants generating nominal variables.  
Raw individual section scores are also provided. The ITSP has been used in large studies of 
preterm infants.
Bayley Scales of Infant and Toddler Development (Bayley III) — 3rd Edition:
The Bayley III is the gold standard for the evaluation of former NICU graduates, especially 
preterm infants. We will use the language and motor composite standard scores for CA. The 
Bayley is currently administered in the Follow-Up Clinic by trained examiners who undergo 
yearly retraining by a Gold-standard examiner. 
Preschool Language Scales (PLS5) - 5th Edition

Protocol Title: Trial to Improve Multisensory Neural Processing, Language & Motor Outcomes 
in Preterm Infants
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The PLS-5 is a language assessment tool administered by a trained professional in which 
children point or verbally respond to pictures or objects. It assesses both receptive and 
expressive language skills in young children. 
Child Behavior Checklist (CBCL)
The CBCL is a 113-question standardized checklist used to detect social-emotional and 
behavioral concerns in young children. The form is filled out by parents and uses a 3-point 
Likert-type scale.
Analysis Plan
Power/Sample Size
A total sample size of 230 (115 in each group) will be recruited. Although attrition in past similar 
work has been much lower, we estimate power under an assumption of 10% attrition (i.e., 
180). Because pilot studies afford effect size estimates with wide confidence intervals due to 
small sample sizes, power analysis results were conducted for the effect size available from 
pilot data and lowest effect size that the after-attrition sample size affords. Feasibility of the 
expected effect size is then evaluated. Power analyses are based on primary variables (multi- 
and uni- sensory processing). If between-group differences occur on the putative covariates 
(i.e., pretreatment variables related to the outcomes) and they are associated with putative 
mediators or outcomes, the pretreatment variables will be statistically controlled after ensuring 
that the homogeneity of slopes assumption has been met. Pretreatment ERP variables will be 
statistically controlled regardless of the effect size of between-group differences to improve 
effect size estimates. Missing data will be handled using multiple imputation. 
Statistical Analysis
Our first aim is to demonstrate that preterm infants receiving a standardized, parent-supported, 
auditory-tactile intervention in addition to standard of care in the NICU will have more typical 
cortical multisensory processing at discharge to home and better sensory adaptation and motor 
and language outcomes than infants receiving only standard of care.
For Aim 1, the between-group differences will be tested on ERP-measured multisensory 
processing after completion of intervention, sensory reactivity and adaption at Year 1, and 
motor and language ability at Year 2. 

Protocol Title: Trial to Improve Multisensory Neural Processing, Language & Motor Outcomes 
in Preterm Infants
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When the dependent variable is continuous, we will use ANOVAs when controlling for 
pretreatment variables and independent sample t-tests when there is no need for a covariate. 
When testing the nominal form of the sensory reactivity and adaptation outcome, we will use 
logistic regression. 
Statistical power: Using PASS software, the estimated power using a 1-tailed test for an effect 
size based on the pilot data (Hedges g = .74) with a sample size of 180 is over 99%. Even if the 
actual effect size is g = .35, we will have over 80% power to detect the effect under the 
proposed conditions. Detecting the required minimum effect size is probably for a number of 
reasons. 
First, the expected effect size for the proposed treatment on multisensory processing should be 
larger than that derived from the pilot because the treatment used in the pilot
 (i.e., skin-to-skin contact without the suck-contingent presentation of parent’s voice) and 
theory strongly suggests the multisensory treatment will produce a larger effect than a 
unisensory treatment. Secondly, a medium main effect size of the proposed treatment on 
neurodevelopmental outcomes is expected because multisensory processing is moderately to 
strongly associated with later neurodevelopmental outcomes.
Our second aim is to test the role of multisensory responses at discharge in mediating 
intervention effects on later sensory adaptation, and motor and language outcomes.
Mediation models are presented in Figure 3. The indirect effect (the product of the a path 
coefficient * the b path coefficient) will be tested for significance using the bias-corrected 
bootstrap method. The a path is the main effect of treatment on the ERP measure of 
multisensory processing. The b path is the association of the ERP measure of multisensory 
processing with the outcome controlling for the treatment group.
Statistical power: Using simulation data, an indirect effect produced by paths each with at least 
the mid-point between small and medium effect sizes (0.26; i.e., at least 6.8% of the variance of 
the criterion variable accounted for in each path) will be detected with over 80% power when 
using a sample size of 180. For example, if paths a and b each have an effect size of 0.26, a 
significant indirect effect will be detected with 80% power with 148 participants, far fewer than 
the proposed sample size of 180. 
In the power analysis for Aim 1, we indicated that a medium effect of the treatment on 
multisensory processing is expected (i.e., the a path for Aim 2). We have no pilot data for the b 
path because it is the association of multisensory processing with neurodevelopmental 
outcome controlling for the treatment. The proposed study is the needed RCT to estimate the 
effect size of the b path. However, a zero-order correlation between multisensory processing 
and motor and language Bayley standard scores was 0.41 to 0.42, respectively, in the previous 
correlational study on preterm infants. These are considered between medium and large effect 

Protocol Title: Trial to Improve Multisensory Neural Processing, Language & Motor Outcomes 
in Preterm Infants
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sizes. Finally, multisensory processing was associated with more typical behavioral thresholds 
to sensory stimuli in the home as evaluated on the Infant Toddler Sensory Profile in a previous 
correlational study with preterm infants. Thus, the expectation for an indirect effect that is at 
least the mid-point between small and medium is quite realistic.
Figure 3
Our third aim is to explore the role of m responses in mediating intervention effects on later 
motor and language outcomes.
Plan: An analogous analysis procedure as was proposed for Aim 2 will be used to test Aim 3. 
The putative mediators are the two unisensory processing (i.e., speech processing or touch) 
variables. The putative mediator is speech processing for the language outcome and the 
putative mediator is touch processing for the motor outcome. 
Statistical power: The power analysis for Aim 2 applies to Aim 3. The expectation for an indirect 
effect that is at least the mid-point between small and medium is realistic. With regards to a 
path, the sample-size-adjusted standardized mean difference on speech processing effect size 
from the contingent parent-voice vs control (a treatment that is a subset of the proposed 
treatment) contrast was large (i.e., Hedges g = 1.06). The proposed treatment will provide more 
nurturing touch than infants in control group and nurturing touch has been associated with 
better touch perception experience in our preliminary studies.  The zero order correlation 
speech perception to later language was very large (R2 = .39) in the previous correlational study 
of preterm infants.
Data management
Data will be stored using Research Electronic Data Capture (REDCap), which is a secure, web-
based application designed to support data capture for research studies by building and 
managing online surveys and databases. Support for REDCap is available through Emory 
ERP
measure
of MS
processing
Assignment to MS
intervention or
standard of care
Behavioral sensory
threshold
Language and
motor outcomes
Pre-treatment Period
Discharge to home
Year 1 or Year 2
c’ path

Protocol Title: Trial to Improve Multisensory Neural Processing, Language & Motor Outcomes 
in Preterm Infants
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University.  In some cases, paper versions of assessments and forms may need to be used. If 
this happens, these completed forms will be kept in a locked cabinet within the lab space. 
Additionally, some participant data such as the parent recordings and the EEG data, will be kept 
in a password protected shared drive supported by Emory University (e.g., Lab-Specific 
Sharepoint/OneDrive/Amazon Web Service) that only designated study personnel (determined 
by the PI) have access to. Finally, each research participant will be assigned a code. All data 
collection procedures and all participant data storage will utilize this code. Only the PI and 
designated study personnel will have access to the code key.
Patient and public involvement
This study is based on our previous work and the NIH call for applications regarding 
multisensory processing and interventions. Neither patients nor public advisory boards were 
involved in the conception, design or implementation of this study. 
Ethics and dissemination
Informed consent will be obtained from the parent/guardian in accordance with the IRB 
protocol.
Data management: Data will be stored using Research Electronic Data Capture (REDCap), which 
is a secure, web-based application designed to support data capture for research studies by 
building and managing online surveys and databases. Support for REDCap is available through 
Emory University.  In some cases, paper versions of assessments and forms may need to be 
used. If this happens, these completed forms will be kept in a locked cabinet within the lab 
space. Additionally, some participant data such as the parent recordings and the EEG data, will 
be kept in a password protected shared drive supported by Emory University (e.g., Lab-Specific 
Sharepoint/OneDrive/Amazon Web Service) that only designated study personnel (determined 
by the PI) have access to. Finally, each research participant will be assigned a code. All data 
collection procedures and all participant data storage will utilize this code. Only the PI and 
designated study personnel will have access to the code key. In compliance with Emory’s record 
retention policy, data will be stored for at least six years from study completion and  consent 
forms will be stored for at least 25 years following study completion or in compliance with 
federal and Emory regulations.
Assuming acceptance, the results of this study will be disseminated via peer-reviewed 
publications and conference presentations. 
Discussion

Protocol Title: Trial to Improve Multisensory Neural Processing, Language & Motor Outcomes 
in Preterm Infants
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Previous studies prove that early sensory experiences shape brain development in former 
preterm infants. A few associative studies have demonstrated improved neurodevelopmental 
outcomes with supportive, targeted sensory input (ie STS or infant directed speech). 
To our knowledge, this is the first RCT study to design and test a MS intervention using brain-
based measurements in order to elucidate the causal effects of the MS intervention on neural 
processing changes to mediate neurodevelopmental outcomes. This study provides a critical 
link in further understanding interactions between brain development, plasticity, environment 
input, and subsequent neurodevelopment in this particularly vulnerable population of infants. 
References:
Listed in the published article: Nell et. al., BCM Pediatrics March 2019. Randomized Controlled 
Trial Protocol to Improve Multisensory Neural Processing, Language and Motor Outcomes in 
Preterm Infants.  https://bmcpediatr.biomedcentral.com/articles/10.1186/s12887-019-1455-
1#Sec36