A Study of Neurophysiologically Based Occupational Therapy Intervention (NBOTI) for Feeding in the NCCU.
Condition: Cerebral Palsy; Sensorimotor Deficits; Sensory Processing Disorder; Feeding Problems; Developmental Coordination Disorder; Picky Eaters; NICU
MeSH terms: Cerebral Palsy; Motor Skills Disorders
Study type: Interventional

Summary: 
      Many critically ill newborns in the neonatal intensive care (NICU) or critical care unit
      (NCCU) environment develop feeding and movement problems. The purpose of this study was to
      determine the extent to which neurophysiologically based occupational therapy intervention
      (NBOTI) for NCCU infants would affect the intervention group's oral feeding and other
      covariates, such as heart rate variability (HRV) during feeding. The biopsychosocial model
      provided the study's conceptual framework. The key research question explored whether NBOTI
      in the NCCU promoted healthy infant development through feeding, movement organization, and
      parent self-efficacy. This exploratory study with 10 NCCU infants and 10 historical matched
      controls utilized a mixed method design of qualitatively coded video analysis and inferential
      statistics such as the t test, the binomial test, hierarchal linear modeling (HLM), and
      multivariate analysis. Significant differences were obtained between the intervention and
      comparison groups in the number of days from all tube to all oral feeding before discharge
      and speed at which the infants gained weight. Longitudinal analyses of the intervention group
      data were employed to reveal significant trends and pre/post differences in the HRV data
      along with how quickly the infants ate, parent perceptions of self efficacy and decreased
      stress in the NCCU. Finally, qualitative findings obtained from videotape analysis provide
      further evidence that NBOTI was effective in facilitating feeding and promoting development.
      The recommendations are to replicate this study to validate and expand the findings of the
      current study. The model for infant care suggested by the findings could contribute to
      positive social change by fostering positive physical and emotional child development and
      healthy child-parent and family-caregiver relationships.
    

Detailed description: 
      Cerebral palsy (CP) is the most common physical disability in childhood (Surveillance of
      Cerebral Palsy in Europe [SCPE], 2000, 2002; Winter, Autry, Boyle, & Yeargin-Allsopp,
      2002),and epidemiological studies of industrialized countries indicate that CP occurs in 2.0
      to 2.5 per 1000 live births (Hagberg, Hagberg, Beckung, & Uvebrant, 2001; Paneth & Kiely,
      1984; Parkes, Dolk, Hill, & Pattenden, 2001). CP is defined as a movement impairment ranging
      from mild to severe (Bax et al., 2005; Bobath, 1954; Nelson, 2001); and occurs through
      social, physical and environmental causal pathways that result in a brain lesion sometime
      during the ante, peri or post natal period of birth (Stanley, Blair, & Alberman, 2000).

      Preterm birth accounts for 40% of all cases of cerebral palsy (Stanley et al., 2000). An
      infant is born preterm if the birth occurs between 17-36 weeks from their date of conception.
      Per 1,000 births in the United States between 1989 and 1996, the rate of preterm births
      increased by 4%, with African American preterm births nearly twice that of whites (Morbidity
      and Mortality Weekly Report [MMWR], 1999). The rate of preterm birth in the United States is
      about 10% of all births. Early born preterm infants need organ support in neonatal intensive
      care unit (NICU) nurseries. Problems encountered by this population due to their undeveloped
      systems consist of respiratory, cardiac, central nervous system (CNS) vulnerability for
      damage, feeding and gastrointestinal, and kidney problems (Goldenring, 2004). Very and
      extremely preterm infants (less than 32 weeks) have the highest rate of developmental
      disability. Norm referenced cognitive, social, and neuro-developmental test scores at 6 years
      of age indicated that 80% of extremely preterm infants exhibited mild, moderate, and severe
      sensorimotor (perceptual-cognitive-motor) disability; with 12% of these infants diagnosed
      with disabling CP (Marlow, Wolke, Bracewell, & Samara, 2005). Rose, Feldman, & Jankowski,
      (2002) found that very preterm children needed 30% more time to process visual and
      somatosensory perceptual information needed for intellectual tasks at 5, 7, and 12 months of
      age. These discrepancies in efficient processing of sensorimotor stimulation continue into
      childhood (DeMaio-Feldman, 1994; Feder, et al. 2005) as measured from a child's cognitive
      responses to their environment (Barlow & Lewandowski, 2000), and internally from mechanisms
      that provide a foundation for equilibrium and perception such as information generated from
      within joints, muscles, and skin as tactile-kinesthetic information (Bracewell & Marlow,2002;
      de Groot, van Hoek, Hopkins, & Touwen, 1993), and as auditory, vestibular, and visual
      postural-spatial processing (de Graaf, Samsom, Pettersen, Schaaf, van Schie, & de Groot,
      2004; De Vries, & De Groot, 2002). In addition to factors such as low birth weight that
      predispose infants to central nervous system insult (40%), the remaining 60% of infants who
      are diagnosed with CP suffer from acute insult to the CNS (hemorrhage, increased intracranial
      pressure, or hypoxic ischemic injury) for other reasons, such as respiratory disease, sepsis,
      and necrotizing enterocolitis in neonates (NEC). Many different factors, endogenous mediators
      and mechanisms, and mechanical, can alter vascular pressure. One respiratory condition in
      pre, near, and at term age infants that results in a composite of neuro-developmental and
      audiologic impairment (motor, cognitive, perceptual, and behavioral), ranging from between
      15-50%, is persistent pulmonary hypertension in the newborn (PPHN) (Lipkin, Davidson, Rhines,
      & Chang, 2002; Lipkin, Davidson, Rhines, & Chang, 2002). As a respiratory disease process,
      PPHN can result from pulmonary hypoplasia associated with diaphragmatic, and to a lesser
      degree abdominal wall hernias, or from vasoconstriction associated with bacterial sepsis, in
      addition to other pathophysiology (Hagedorn, Gardner, Dickey, & Abman, 2006). This
      exploratory within group study focuses upon pre, near, and term age infants with differing
      diagnoses and varying degrees of risk for a diagnoses of CP, developmental coordination
      disorder, or sensory processing difficulties. Feeding problems are usually prevalent in
      infants who sustain neurological insult in addition to near term or term age infants with
      serious developmental disruptions. The investigators measured the intervention effects of
      neurophysiologically based occupational therapy upon adaptive CNS maturation using several
      outcome measures. Since infants in the intervention group exhibited a large treatment effect
      in relationship to their feeding abilities and other covariates, this study should be
      replicated with infants with similar diagnoses with the same longitudinal outcome measures to
      learn more about and to further validate the efficacy of neurophysiologically based
      occupational therapy upon feeding, infant sensorimotor development, and parent efficacy in
      the NICU.

      The following collaborators assisted on this research project:

      Walden University: Minneapolis, Minnesota - Ray Thron, PhD, Lela Llorens, Ph.D, OTR, FAOTA,
      Chester Jones, Ph.D, and Aqueil Ahmad, Ph.D

      Primary Children's Medical Center: Salt Lake City, Utah - Mr. Ramsey Worman, Department of
      Bioengineering, David Bradley, MD and Ms. Barbara Wright, Department of Cardiology, and Mr.
      Doug Wolfe, Systems Administrator

      Mesa State College: Grand Junction, Colorado - Richard Ott, Ph.D, Computer Science,
      Mathematics, & Statistics

      Politecnico di Milano: P.zza Leonardo da Vinci, 32, 20133 Milano, Italy - Manuela Farrario,
      Ph.D, and Sergio Cerutti, Ph.D. Department of Bioingeneering
    

Intervention name(s): The intervention group: Neurophysiologically Based Occupational Therapy Intervention (NBOTI)
Intervention type(s): Other
Intervention description(s): This study included a pre-feeding, feeding, and postural-respiratory protocol, given per the attending physician's order. The interventions were given daily when possible, and the infants FiO2 and heart rate, along with stress behaviors, were monitored prior to, during, and after the NBOTI. The intervention included parent education for feeding, handling, and interaction with their infant, along with nursing training during the feeding session. The occupational therapy investigator partnered with the parents and when the parents were not available, she partnered with the nursing staff.
Allocation: Non-Randomized
Intervention model: Single Group Assignment
Masking: None (Open Label)
Primary purpose: Treatment
Keywords: Neurophysiologically Based Occupational Therapy Intervention (NBOTI); NBOTI; NICU; NCCU; Developmental Biology; Critical Period; Brain Development; Sensory Integration; Neurodevelopment; Sensitive Period