Running Head: CHANGING PATTERNS OF RESPIRATION IN PREMATURE INFANTS 1 Changing Patterns of Respiration in Premature Infants Samantha Berberich University of Florida College of Nursing
CHANGING PATTERNS OF RESPIRATION IN PREMATURE INFANTS 2 Abstract The benefi cial effects of the maternal voice in infant development ha ve been demonstrated in numerous body systems. Due to underdeveloped respiratory system s p remature infants are at an increased risk for health problems. The purpose of this pilot study was to describe respiration patterns in premature infants in response to daily controlled exposure to a maternal voice recording. Twenty three infants born at 27 th to 28 th weeks post menstrual age ( PMA ) were recruited from a Level III neonatal intensive care unit located at UF Health, a teaching hospital in the southeastern United States. Two experimental groups were exposed to maternal voice recordings; group 1 from 28 34 weeks PMA a nd group 2 from 32 34 weeks PMA. The control group was not exposed to a recording and was observed for respiratory pattern changes from 28 34 weeks PMA Comparisons of the experimental groups to the control revealed that maternal voice recordings appear to reduce observed episodes of irregular deep breathing in premature infants ( g roup 1 = 60%, group 2 = 70%, control group = 90%). The percentage of deep respirations also differ ed between male (40%) and female (62 %) infants This pilot study suggests that exposure to maternal voice recordings may affect breathing patterns in premature infants.
CHANGING PATTERNS OF RESPIRATION IN PREMATURE INFANTS 3 I. Introduction Premature birth occurring before the completion of the 37 th gestation week is one of the most significant causes of infant morbidity and mortality. Often, t hese infants are considered v ery low birth weight (VLBW) weighing l ess than 1500 grams ( U CSF Chil 2004) Furthermore, underdevelopment of the lungs contributes to several health complications within this population. Lung development is still ongoing at term birth, with the maturation of the surfactant system and appearance of complete alveoli extending slightly past 40 weeks gestation. Premature infants born before the 37 th week of gestation, are still in the saccula r period of lung development and do not have the capabilities of mature respiration ( Glass et. al., 2015). Due to the immaturity of their lungs respiratory complications continue to threaten premature infant survival and long term clinical success. In a review of her current research, Christine Moon addresse d the role of auditory development on fetal and infant attachment and communication. For example, Moon (2011) found that sound can stimulate fetal movement as early as twenty seven weeks gestation ind icating the development of the sensory system Additionally, she demonstrated auditory discrimination as early as twenty eight weeks gestational age as the fetal cochlea was still developing. These findings suggest that the fetus can and does become accustomed to certain sounds while still in likely the most familiar sound to the fetus as it is the most accessible sound to them in the womb in intensity, clarity and total exposure to the fetus, but is transferred as the diaphragm produces movement against the fetus while the mother vocalizes Given that has this multi modal effect it likely act s auditory and attachment development.
CHANGING PATTERNS OF RESPIRATION IN PREMATURE INFANTS 4 Several studies have examined maternal voice recordings as therapeutic interventions that assist in the development of various body systems (i.e. cardiac system, Segall 1972; neuromuscular system, Chapman,1978; gastroin testinal system, Kruger et. al 2010), including the respiratory system (Standley and Moore, 2010). When exposed to the maternal voice, infants had lower heart rates (Segall, 1972), demonstrated laterality or the preference to one side of the body (Chapman 1978), and fewer episodes of feeding intolerance (Kruger et al. 2010). Finally, has been found to have outcomes such as oxygen saturation ( Standley & Moore, 2010) However, music exposure has led to better oxygen saturation outcomes compared to maternal voice recordings ( Standley & Moore, 2010) Despite these findings, the effects of the maternal voice on respiratory patterns have not been described; this is the aim of the current pilot study. Describing which patterns are seen in these infants will inform future research on the health implications of the respiratory patterns that are seen here. Overall, these studies highlight the potential of maternal voice recordings as therapeut ic options treating respiratory problems in premature infant. II. Project narrative The current project is a pilot s tu dy conducted as part of a larger study, Maternal Voice as a Regulator of Neurobehavioral Development, conducted by Dr. Charlene Krueger, PhD, RN (Appendix A). The study was performed in a L evel III neonatal intensive care unit (NICU) at UF Health Shands Hospital. Participants in the project included Dr. Charlene Krueger, PhD, RN of the University of Flori da College of Nursing along with her research team of graduate and undergraduate students. Shands Hospital NICU staff nurses were informed about the testing procedures and actively assisted with the planning of test sessions. Stakeholders in the study are
CHANGING PATTERNS OF RESPIRATION IN PREMATURE INFANTS 5 identified as Shands Hospital, NICU physicians and nurses and the premature infants themselves, as well as their families and the research team. Positive outcomes of the study would potentially inform future NICU practices imperative to nurse and physicia n planning. The positive impact on the growth and success of infants would not only benefit the infants but also their caregivers and the hospital in terms of overall increases in positive patient outcomes and cost of care. Before members of the research team were allowed access to the study, IRB approval was achieved. Mothers of premature infants were approached by Dr. Krueger and a trained graduate student 24 hours post delivery to describe the study and obtain both consent and a voice recording of the mother reciting a nursery rhyme A t wenty four hour waiting period between birth and enrollment was implemented to allow mothers to feel more comfortable, relaxed, and open to participation. Infants had to meet the following inclusion criteria : (1) birth a t twenty seven or twenty eight weeks post menstrual age ( PMA ) (2) English as the native household language, and (3) no major infant health complications. In total 2 3 infants ten males and thirteen females, were enrolled in this pilot study. Subjects were randomly divided into two experimental groups and a control group. Experimental groups were exposed to maternal voice during two developmental periods. Group 1 comprised of six patients, listened to a playback recording of their mothers reci ting a nursery rhyme twice daily for 45 seconds from weeks 28 34 PMA Group 2 was comprised of seven patients who were exposed to the maternal voice recording also twice daily for 45 seconds but only from weeks 32 34 PMA. This delay in time before exp osing the infants to the recording was used to evaluate whether developmental differences affect the response to the voice recordings Lastly, t he control group of ten infants were not exposed to any particular sound
CHANGING PATTERNS OF RESPIRATION IN PREMATURE INFANTS 6 stimuli, and were observed once per wee k in their resting state from 28 34 weeks PMA. Beginning at week 28 PMA, infants were observed in weekly test sessions. Breathing patterns, eye movement, and body movement were noted during test session s to assess that the patient was in a quiet resting state, i.e. without large limb movement, with minimal eye movement, and respirations within normal limits (see Appendix C) For the control group, test sessions included two defined 45 second periods of obs ervation without any maternal voice recording playback For group 1, each test session consisted of recorded observation both prior to and during a 45 second long playback of the maternal voice recording. For group 2, test sessions from week 28 31 were ide ntical to those of the control group and from week 32 34, they were identical to those of group 1. Interrater reliability was maintained by using two research team members to observe respirations with greater than 95% agreement. To blind parents and healt h care team members from the treatments, blank playback devices were placed in the NICU incubators of the control group. Research team members were not blinded to the treatment groups. Test sessions were planned to occur between infant feedings, visits fr om their mothers and procedures Additionally, test sessions were performed when the infant was in a stable, quiet resting condition. Test sessions followed a strict procedure using t est session logs that included a pre procedure checklist with the materi als needed for testing and number to confirm the infant w as stable and recently fe d before test sessions began ( Appendix B) The checklist also included a detailed step by step procedure for setting up the equipment at the and preparing the infant for testing. To control for variation s in maternal behavior (Appendix D) The maternal log rated time spe nt on a scale 0 5, with 0 being
CHANGING PATTERNS OF RESPIRATION IN PREMATURE INFANTS 7 mothers to specify if they talked to or touched the infant. Potential barriers to the study included first and foremost the unpredictable nature of patient enrollment and high risk infant care as a whole. NICU premature infants are considered high risk, and enrollment in the study was contingent on general health o f the infant. Test session and participant unpredictability both factored into our pilot study S ome infants dropped out due to health issues and compromised health status es Additionally, a number of test sessions were cancelled due to emergency, unplanned procedures or infant irritability (i.e. excessive crying, fussiness) that carried potential to influence results from the session. The acceptable time frame for rescheduling test sessions was identified as 30 minutes at bedside; if the test sessi on could not Descriptive statistics were used to examine the data obtained Specifically, comparisons were made between the total number of deep breaths obser ved in male versus female infants across time, the proportion of infants experiencing deep breathing by test session and the total proportion of infants experiencing deep breathing episodes by experimental and control groups III. Results and D iscussion We found that infants who were not exposed to the maternal voice recordings experienced more deep breathing episodes compared to those who did, regardless of the developmental timing of exposure to the recording Deep breathing w as observed in 90% of the infa nts that were not exposed to maternal voice recordings whereas only 60% of the infants in group 1 and 70% of infants in group 2 exhibited these deep respirations across all test sessions (Figure 1)
CHANGING PATTERNS OF RESPIRATION IN PREMATURE INFANTS 8 The sex ratio of each group varied from 33% male in group 1 to 50% male in the control group. Interestingly, the data collected showed a difference in the amount of deep respirations seen in male i nfants versus female infants regardless of group assignment Four out of ten male infants (40%) experienced deep respirations at least once across all test sessions, compared to eight of the thirteen total female infants (62%). Additionally, in terms of total deep breathing demonstrated deep breathing in eighteen individual test sessions, while male infants sh owed only five total episodes These differences were most notable in the first few test sessions; female infants were the only infants who demonstrated deep respirations in the firs t second, and fifth test session s and were the predominant exhibitors of deep respirations until the final test session (TS7). By the final session, two male infants and five female infants exhibited deep respirations While this difference could be attributable to low sample size, it may also indicate a difference between the sexes in respiratory development and stability. The findings of this pilot study suggest that the maternal voice might play a role in stabilizing premature infant respirations specifically in reducing the amount of deep respirations experienced by the infants If the deep respirations are interpreted as a startle response, then the maternal voice may serve as a calming stimulus. 60 70 90 0 25 50 75 100 6 WEEK EXPOSURE 2 WEEK EXPOSURE CONTROL (NO EXPOSURE) Percentage of Infants with Deep Respirations Groups Percentage of Deep Respirations by Group
CHANGING PATTERNS OF RESPIRATION IN PREMATURE INFANTS 9 Figure 1: Percentage of infants exhibiting deep respirations by group. Group 1 represents the 6 week exposure experimental group, Group 2 represents the 2 week exposure group, and Group 3 represents the control. Figure 2: Total number of infants showing deep respiration episodes across gender and time IV. Summary and C onclusions The goal of this project was to evaluate the effects of the maternal voice on premature infant respiratory patterns. The results of our study suggest that the maternal voice may be a 0 0 1 1 0 1 2 2 2 4 1 1 3 5 TEST SESSION 1 TS 2 TS 3 TS 4 TS 5 TS 6 TS7 Total Deep Respiratory Episodes by Gender Male Female
CHANGING PATTERNS OF RESPIRATION IN PREMATURE INFANTS 10 beneficial stimulus for these premature infants. If the maternal voice serves as a calming stimulus in premature infants, it should be considered a s an intervention for stabilizing respirati on patterns and improving respiratory maturation for NICU admitted premature infants The maternal voice is not only a simple tool but a very accessible one as well Despite the evidence favoring its use maternal voice recordings have not implemented as a true method for improvement of NICU infant development. Here, we argue that maternal voice recordings may improve patient o utcomes in premature infants. With further research, i t may be recommended that NICU s attempt to provide recordings for premature infants when feasible. For patients and their families, these recordings may lead to more positive health outcomes and shorter hospitalization time due to enhanced respiratory stability and potential respiratory system maturation. Lastly, maternal voice recordings promote the advancement of nursing by providing a simple yet effective way for nurses to improve the health of their patients. Additionally, these recordings can involve the mother in the care of their infants during a time when they feel they m ay be unable to, which could promote maternal satisfaction and overall bonding between mother and child Our pilot study was limited by a small sample size participant attrition and multiple missing data points Future studies should increase the sampl e size, stratify the groups by gender, and increase retention rates across the study, and examine the long term consequences of maternal voice recordings. These future studies should connect the relevance of deep breathing respirations with long term healt h outcomes. Furthermore, these studies should involve quantitative methods to identify significant differences between the groups. For example, identifying a quantifiable method to measure the respiratory deep breaths of these premature infants possibly w ith the use of Fast Fourier graph s (Appendix E ) to evaluate the interactions
CHANGING PATTERNS OF RESPIRATION IN PREMATURE INFANTS 11 between heart rate and respiration patterns c ould strengthen the decision whether or not to use maternal voice recordings in premature infant care In terms of my own learning and professional development, this project has taught me the importance of nursing research in multiple dimensions. Research in nursing puts the majority of its focus and purpose into finding the most effective improvements in p atient care; in the improvements that are safe, easy, and effective without unnecessary procedures or medications. With research like this, the benefits of the maternal voice have been strengthened and expanded I have been able to see how nursing research can develop new practices that can be put into place to change patient care. Additionally, working on my project has taught me the practical developmental and analytic components of research. After working on this project I now understand the time, energy, and effort that is necessary to develop a successful research project It is incredibly motivating to see the results of the study and the effects it can have on patient care, and inspires me to continue with clinical research in the future.
CHANGING PATTERNS OF RESPIRATION IN PREMATURE INFANTS 12 References Chapman JS. The relationship between auditory stimulation and gross motor activity of short gestation infants. Res Nurs Health. 1978;1(1):29 36. Glass, H. C., Costarino, A. T., Stayer, S. A., Brett, C. M., Cladis, F., & Davis, P. J. (2015). Outcomes for Extremely Premature Infants. Anesthesia & Analgesia,120 (6), 1337 1351. doi:10.1213/ane.0000000000000705 Krueger, C. (2010). Exposure to Maternal Voice in Preterm Infants: A Review. Advances in Neonatal Care, 10(1). Krueger, C., Parker, L., Chiu, S., & Theriaque, D. (2010). Maternal Voice and Short Term Outcomes in Preterm Infants. Developmental Psychobiology doi:10.1002/dev.20426 Moon, C. (2011). The Role of Early Auditory Development in Attachment and Communication. Clinics in Perinatology, 38 (4). doi:10.1016/j.clp.2011.08.009 Segall M. Cardiac R esponsivity to A uditory S timulation in P remature I nfants. Nurs Res. 1972;21(2):15 19. Standley, J. M. preterm infants. Pediatric Nursing, 21 (6):509 512, 574. U (2004). Very Low and Extremely Low Birthweight Infants. Re trieved December 15, 2017, from https://www.ucsfbenioffchildrens.org/pdf/manuals/20_VLBW_ELBW.pdf
CHANGING PATTERNS OF RESPIRATION IN PREMATURE INFANTS 13 Appendix A Maternal Voice as a Regulator of Neurobehavioral Development in Premature Infants Charlene Krueger PhD, RN findings in the fetus and premature infant in order to establish the reproducibility of our previous empirical progress in regulatory implications for ma ternal voice recordings on neurobehavioral development in very low birth weight (VLBW) preterm infants. Preterm infants experience major disruptions in maternal nurturing due to limits imposed during their hospitalization within the Neonatal Intensive Car e Unit (NICU). In nonhumans exposed to similar disruptions (e.g., loud sounds, limited maternal touch and voice), short and long term alterations in the brain, behavior patterns and hormone levels have been demonstrated. Our central hypothesis is that prov iding a low times during the day will beneficially regulate early neurobehavioral and that these benefits will vary depending upon the developmental timing at which exposure was begun. Our hypothesis has b een formulated on our own previous work in which controlled exposure to maternal voice recordings potentially improved weight gain, significantly reduced the number of days to achieve enteral feeds and, more recently, resulted in earlier learning and matur ation of the parasympathetic nervous system. Forty five stable premature infants born between 27 and 28 weeks postmenstrual age (PMA) and their forty five mothers will be randomized to listen to a recording of their mothers reciting a passage during two d ifferent developmental time periods (28 34 weeks PMA or 31 34 weeks PMA) or to no recording (sham control group). Maternal recordings will be played twice daily for 45 seconds, 7 days/week for each developmental time period. Neurobehavioral development wil enteral feeding and days to oral feeding) and weekly assessments for determining when infants ate variability as a measure of autonomic nervous system development (using a spectral analysis). Results are expected to contribute to the development of interventions to improve a variety of health outcomes for preterm infants who are at high risk for co mplications related to neurobehavioral development.
CHANGING PATTERNS OF RESPIRATION IN PREMATURE INFANTS 14 Appendix B
CHANGING PATTERNS OF RESPIRATION IN PREMATURE INFANTS 15 Appendix C Test Session Log Sample
CHANGING PATTERNS OF RESPIRATION IN PREMATURE INFANTS 16 Appendix D Maternal Log Sample
CHANGING PATTERNS OF RESPIRATION IN PREMATURE INFANTS 17 Appendix E Fast Fourier Graph sample from data.