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Preterm Infants and Maternal Voice, Family Visitation, and Discharge Timing

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Title:
Preterm Infants and Maternal Voice, Family Visitation, and Discharge Timing
Series Title:
Journal of Undergraduate Research
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Cimino, Jillian
Krueger, Charlene ( Mentor )
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Gainesville, Fla.
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University of Florida
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English

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serial ( sobekcm )

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Abstract:
The purpose of this pilot study was to describe the combined effect of exposure to a recording of maternal voice and family visitation on discharge timing in preterm infants cared for within a neonatal intensive care unit (NICU) without an ongoing program of developmental care. Using a retrospective comparative design, a convenience sample of 67 preterm infants participated. Experimental infants participating in a larger ongoing study listened twice a day to a recording of their mother’s voice. Control infants received routine NICU care. The median number of family visits (3 per week) was used to differentiate between high (≥ 3) versus low (< 3) levels of visitation. A near significant reduction in the number of episodes of feeding intolerance (F = 3.16; p = .08) was noted between infants who heard the maternal voice recordings and whose families visited more often (experimental mean = 2.8; control mean = 5.5). A significant, yet counterintuitive finding, was noted in the number of days to discharge (i.e., the length of stay), independent of exposure to the maternal voice recordings (F = 8.42; p<.01). The number of days to discharge were fewer if family members visited less frequently (mean = 44.4 days) compared to those infants whose family visited more (mean = 61.3 days). Findings suggest that the combination of maternal voice and family visitation may have a positive effect on decreasing the number of days to discharge. Future research is needed to verify this combination's effect on discharge outcomes in preterm infants.

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Preterm Infants and Maternal Voice, Family Visitation, and

Discharge Timing


Jillian Cimino*


College of Nursing, University of Florida


The purpose of this pilot study was to describe the combined effect of exposure to a recording of maternal voice and family visitation
on discharge timing in preterm infants cared for within a neonatal intensive care unit (NICU) without an ongoing program of
developmental care. Using a retrospective comparative design, a convenience sample of 67 preterm infants participated. Experimental
infants participating in a larger ongoing study listened twice a day to a recording of their mother's voice. Control infants received
routine NICU care. The median number of family visits (3 per week) was used to differentiate between high e 3) versus low (< 3)
levels of visitation. A near significant reduction in the number of episodes of feeding intolerance (F = 3.16; p = .08) was noted
between infants who heard the maternal voice recordings and whose families visited more often (experimental mean = 2.8; control
mean = 5.5). A significant, yet counterintuitive finding, was noted in the number of days to discharge (i.e., the length of stay),
independent of exposure to the maternal voice recordings (F = 8.42; p<.01). The number of days to discharge were fewer if family
members visited less frequently (mean = 44.4 days) compared to those infants whose family visited more (mean = 61.3 days).
Findings suggest that the combination of maternal voice and family visitation may have a positive effect on decreasing the number of
days to discharge. Future research is needed to verify this combination's effect on discharge outcomes in preterm infants.


Introduction

Measurement of discharge timing (i.e., length of stay)
for preterm infants from neonatal intensive care units
(NICU) includes several milestones. These milestones
include respiratory stability and the ability to oral feed,
which may be improved by the inclusion of developmental
care, family visitation, and exposure to maternal voice.
Health milestones maintain importance because the longer
an infant remains hospitalized, the greater the risk of
contracting a nosocomial infection (Clark et al., 2004), the
more cost incurred (Clark et al., 2004; Committee on
Hospital Care, 2003), less time for interaction with the
family, and increased family stress (Cooper et al., 2007;
Petrou, 2003). The purpose of this pilot study was to
discern the effect of maternal voice and family visitation
on discharge timing in preterm infants.

Methods to Improve Discharge Timing

Methods to improve discharge timing include programs
that are centered on developmental care, which improves
ability to oral feed, and maternal visitation and voice,
which both decrease days to discharge.


*with Charlene Krueger, PhD, ARNP, and Leslie Parker, MSN,
APNP


Developmental Care. Programs of developmental care
which began in 1986 by Heidi Als and colleagues,
individualized care based on the maturity and health status
of each individual infant and focused on oral feeding and
other health milestones. Such emphasis is placed on the
ability to oral feed because most newborn preterm infants
are incapable of doing basic functions such as breathing,
sucking, and swallowing during feeding (Lau, Smith, &
Schanler, 2003) and to digest nutrients properly (Diehl-
Jones & Askin, 2004). This inability forces the infant to
stay within the hospital until standard function
achievement is complete, confirming the importance of this
health milestone. The program later was altered to
incorporate an emphasis on parent-infant interactions to
form a bonding relationship between the infant and mother
early on.
Infants participating in developmental care programs
have been shown to require significantly fewer days of
mechanical ventilation and supplemental oxygen support
(Als et al., 2003; Becker et al., 1991; Fleisher et al., 1995).
Research shows that the use of developmental care
programs has also been associated with decreased length of
hospital stay for preterm infants (Als et al., 2003; Becker et
al., 1991; Brown & Heermann 1997; Melnyk et al., 2006;
Zeskind & Iacino, 1984), diminished parental stress
(Melnyk et al., 2006), and quicker weight gain (Westrup et
al., 2000). With the findings from multiple studies showing


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JILLIAN CIMINO


numerous benefits for infants and parents resulting from
this program of care, the use of developmental care has
become more prevalent. Family visitation is one important
component of developmental care programs.
Family Visitation. While currently there is research
establishing the effect of maternal visitations on a preterm
infant's days to discharge, there is no information linking
whether or not visitations by other family members would
also improve discharging timing.
A study by Zeskind and lacino (1984) looked at
quantities of maternal visitation with a set of 2 groups (1
intervention, 1 control) composed of 32 mothers and their
infants ranging from 30-36 weeks of age. Both groups
experienced routine care offered by the NICU staff. The
intervention group, however, had the addition of help from
a project interventionist who provided advocacy, explained
the many actions of the NICU staff so the mothers might
better understand the processes, and made an appointment
each week for the mother to visit with her infant.
Comparisons of the 2 groups revealed that the intervention
group mothers independently (not including those set up
appointments to visit infant) visited their infants more than
twice as often as the mothers in the control group. Length
of hospitalization was looked at as well, and the
intervention infants stayed an average of 8 days fewer than
the control group. This established maternal visitation (in
conjunction with a program directed towards educating the
mother about her infant's health care) as a factor in
decreasing a preterm infant's days to discharge.
Family visitations, in addition to maternal visitations,
may be even more beneficial to the infant's discharge
timing than just solely by the one member. Perhaps any
increased exposure to family members is more advan-
tageous compared to the absence of any exposure.
Including other family members in family visitation may
assist in providing a nurturing environment for these
vulnerable babies by exposing them to a positive source of
sound. Preterm infants in the NICU are constantly exposed
to negative sources of sound through monitor alarms,
health care professional talk, and nearby infants crying.
Family visitation by multiple family members, especially
the mother, would provide more opportunities of positive
auditory stimulation for the preterm infant. While there is
general theoretical support indicating the significance of
exposure to maternal voice in the fetus and preterm infant
(Lickliter, 2000), research evaluating exposure to maternal
voice in preterm infants is equivocal.
Maternal Voice. In a study done by Chapman (1978)
and Malloy (1979), infants 26-33 weeks post-menstrual age
were split into 3 groups (Group 1, Group 2, and control),


with all receiving standard NICU care. Group 1 was
exposed daily to a recording of maternal voice while Group
2 was exposed daily to an orchestra playing a lullaby.
Chapman reported that the infants exposed to their
mothers' voice demonstrated the gross motor pattern of
laterality (preference for use of one side) more often than
those infants listening to the lullaby and those in the
control group. In Malloy's following study with these same
infants, the weight gain and developmental outcomes were
evaluated at 1 day following discharge and at 9 months of
age using components of Rosenblith's Behavioral
Examination of the Neonate and Bayley Scales of Infant
Development (Bayley, 1969; Malloy, 1979: Rosenblith,
n.d.). There were no statistical between-group differences
noted; however, infants exposed to maternal voice gained
more weight.
More recently, Krueger (in press) reviewed all studies
addressing exposure to maternal voice in preterm infants
and found that all used unsafe sound levels. All studies
used decibel levels ranging between 75-80 decibels, which
is much more than what is recommended. Sound levels are
important in preterm infant exposure, because depending
on the gestational age, the infant is undergoing neuro-
behavioral advances that can be negatively affected. Out of
the 7 studies viewed, the true significance of the findings
are difficult to evaluate because of these high sound levels.
Taken together, the above studies suggest that both the
frequency of maternal visitation and exposure to maternal
voice positively impact the number of days to discharge.
We therefore sought to describe whether this combination
(using safe sound levels) could potentially be an effective
and efficient way of decreasing length of hospitalization
for preterm infants.


Study Design and Methods

A retrospective comparative design was used with a
convenience sample of 67 preterm infants. Thirty-two
infants within this group took part in an experimental
component; 35 infants were retrospectively selected to
create a control group comparison. All infants were cared
for within the same time period within a level 3 NICU at an
academic teaching institution in the southeastern United
States. During this time period there was no ongoing
program of developmental or family-centered care
occurring within the NICU.
Following Institutional Review Board approval, criteria
selected for inclusion were: 1) birth between 27 and 28
weeks post-menstrual age, and 2) English as a native


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DISCHARGE TIMING IN PRETERM INFANTS


language. Exclusion criteria consisted of: 1) prenatally
transmitted viral/bacterial infections, 2) abnormal head
ultrasound, 3) sensorineural hearing loss, 4) cardiac
abnormalities, or 5) abdominal disorders. Ethnicity was
obtained for 66 infants (one subject's chart was not
available to obtain demographic information). Among
these infants, 60.6% were Caucasian 36.4% were African
American, and 3% were Hispanic.
Additional demographic information obtained was the
infant's gestational age at birth, Apgar score, and
neurobehavioral risk score (NBRS). An Apgar score is
calculated at both 1 minute and 5 minutes post birth. The
infant is rated on a scale of 0-4 (0 being bad and 4 being
well) on 5 categories related to the infant's health. The
higher the score, the better the infant's health. The average
is between 7 and 10. The NBRS score is the status of the
preterm infant while hospitalized to differentiate between
high risk and low risk infants.
Participants in the experimental component of this study
were part of a larger quasi-experimental study entitled,
Heart Rate Variability and Learning in the 28-34 Week
Old Preterm (NIH/NINR P20 NR07791; NIH/NCRR M01
RR00082; Southern Nursing Research Society) in which
32 experimental infants listened to a CD recording of a
nursery rhyme recited by their mothers twice a day for 2-6
weeks. These infants were cared for within the NICU
during the same time period as the experimental infants but
received standard NICU care and no exposure to maternal
voice recordings.


Variables

Nursery Rhyme. A CD recording of the mother reciting
a nursery rhyme was used in the experimental component
of the study. The untitled rhyme (Simon & Schuster, 1985)
was 9 lines long, took approximately 15 seconds to recite,
and was not a common verse (making it unlikely that
infants would be unexpectedly exposed to it). Recordings
lasted approximately 45 seconds and were played twice a
day over a 12.5-cm speaker positioned 20 cm from the
infant's ear. Sound levels were measured using an A-scale
of a Bruel-Kjaer (220SLM) sound level meter. Overall
stimulus intensity was 50-55 dB (M=53.9; SD=2.35), with
background NICU sound levels just prior to initiation of
recordings ranging between 48.6 to 69.2 dB (M=57.90;
SD=4.01). Fifty to 55 decibels was chosen in order to
maintain the decibel level just below the normal level of
human speech (58-60 dB) (Gerhardt, 1989) and to remain
within recommended sound levels for the preterm infant
(Graven, 2000).


Family visitation was defined as the average number of
days in a week (0-7 days) for a total of 6 weeks that a
family member visited the infant's bedside. Multiple
family visits per day were counted as 1 visit (due to
inability to quantify the length of time spent at the infant's
bedside). Family members included mothers, fathers,
grandparents and/or guardians. The median # of visits (3
per week) was used to differentiate between hig) (
versus low (<3) levels of visitation.
Number of days to discharge was defined by the
number of days from birth to the infant's discharge home
or transfer to another facility.
Average daily weight gain was obtained by dividing the
infant's total weight gained in grams (from birth) by the
number of days cared for within the NICU.
Days to full enteral feedings was defined as the number
of days from birth to the day the infant tolerated
120ml/kg/day of either breast milk or formula feedings.
Days to full oral feeding was defined as the number of
days from birth to the day the infant ingested all feedings
via breast or bottle for 24 hours.
Number episodes of feeding intolerance was defined as
the number of times the infant had gastric residuals equal
to or greater than 3 ml/kg or was placed in NPO (receiving
nothing by mouth) status due to events other than routine
preparation for a procedure or intervention. Gastric
residuals of less than 3 ml/kg have been shown to be safe
in previous research concerning VLBW infants (Mihatsch
et al., 2002).
Percent days on respiratory support was defined as the
percentage of hospital days on respiratory support (nasal,
CPAP, ventilator) provided.
Days of NPO status was defined as the number of days
the infant was placed on NPO status for over 50% of a 24-
hour period.

Procedure

A retrospective chart review for infants participating in
both the experimental and control component was
conducted in order to determine the quantity of family
visitation and nutritional and respiratory outcomes. Data
retrieval was initiated at >95% inter-rater reliability and
maintained at the same by evaluating 10% of the charts
once data retrieval was completed. The frequency of family
visitation was extracted by 2 research assistants whose
inter-rater reliability was maintained at >95% agreement.
All variables related to achievement of oral feeding and
respiratory support were similarly extracted by one
Advanced Practice registered nurse and maintained at
>95% inter-rater agreement.


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JILLIAN CIMINO


Table 1: Demographic Information and Outcome Variables of Preterm Infants

Demographic Information Outcome Variables

NBRS
Age min min Weight Days to Weight Feed PO Feed Feed O Resp.
(gm) Score DC Gain days days Intol. Outcome

All Infants (Experimental and Control) N 67

Visit Status:
24.8 5.4 7.6 1145.4 2.3 9.8 44.4 14.9 28.4 51.0 3.6 7.5 57.0%
Low


High 25.4 5.4 7.0 1012.2 3.5 21.5 61.3 19.9 31.5 59.3 4.1 9.8 61.8%

Experimental Infants n 32

Visit Status:
26.8 5.6 7.9 1107.6 1.4 8.1 41.0 16.4 26.0 48.0 3.4 6.0 51.7%
Low


High 24.9 5.9 7.1 1069.7 3.3 27.1 61.8 21.0 27.4 56.7 2.8 9.6 58.4%


Control Infants n 35

Visit Status:
23.4 5.3 7.5 1170.5 2.8 10.9 46.6 13.8 30.5 52.3 3.4 8.4 60.7%
Low


High 25.9 4.9 6.9 949.1 3.9 15.5 60.8 18.2 36.5 61.8 5.3 10.0 65.4%



NBRS = Neurobehavioral Risk Score; DC = discharge; PO by mouth; Intol. = intolerance; NPO= nothing by mouth; Resp. =respiratory


Statistical Analyses. Data were analyzed using SAS (v8,
Cary, NC). Descriptive statistics were determined to
characterize the sample. A two-way ANOVA was used to
compare outcomes between groups. A level of significance
of P < 0.05 was used.


Results

Using a two-way ANOVA, variables related to
discharge timing were compared (Table 1). A near
significant finding was noted for episodes of feeding
intolerance. The number of episodes of feeding intolerance
was less for infants whose families visited more often, as
well as heard the maternal voice recordings. A near
significant difference was noted in between the high
visitation Experimental (or maternal voice group) and the
high visitation Control group (F = 3.16; p = .08;
Experimental mean = 2.8, Control mean = 5.5). Further, a
counterintuitive finding was noted. Infants in the both the
Experimental and Control groups whose family members
visited less were discharged earlier (F = 8.42; p<.01;


combined Experimental and Control low visitation mean =
44.4, combined Experimental and Control high visitation
mean = 61.3).

Discussion

Findings suggest that the combined effects of family
visitation and exposure to maternal voice recordings
(within a NICU without an organized program of
developmental care) does not significantly affect discharge
timing. A near significant difference (F = 3.16; p = .08),
however, was noted for the Experimental infants between
the Low versus High visitation groups in episodes of
feeding intolerance.
The finding related to episodes of feeding intolerance
may be explained by a variation in feeding type between
the Low versus High visitation status groups. The effect
may be due to the fact that the high visitation infants
experienced more days of breast milk feeds (F = 4.77;
p<.05; high visitation mean = 21.5 days, low visitation
mean =9.8 days). Breast milk could have influenced this
finding because it is known to decrease episodes of feeding


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DISCHARGE TIMING IN PRETERM INFANTS


intolerance (Boyd, 2007). This suggests that further studies
are needed to confirm whether our combination of family
visitation and exposure to maternal voice is effective. The
differences in number of days breastfed however could not
have been known beforehand.
Additional limitations to this study are related to the
accuracy and reliability of medically charted variables. A
retrospective review of medical records allowed for a bias
of accurate interpretations because no precise protocol was
followed by the nurses for documentation of the visitations.
There was a lack of identifying which family member
visited, the duration of visit, and what type of interaction
(whether the infant was held, spoken to, etc.) occurred.
Due to this limitation, we chose to opt for the most
accurate option and simply measure the absence or
presence of a family member at the bedside each day.
Further, infant feeding treatment and decisions on when to
progress feeding are largely subjective and vary between
clinicians, thus reducing the reliability of the findings.
Future studies using a prospective design are needed to
increase confidence in the findings. Further, the use of
quota sampling is recommended in order to balance risk
status and feed type between groups in this study. In order
to overcome limitations related to the reliability of taking
the frequency of family visitations from the medical
records, family members could be asked to record their
visitations on a log. The use of a log would also allow
future researchers to obtain the length of time families
stayed by the bedside.
If it is true that episodes of feeding intolerance are
affected by a combination of these simple interventions
(exposure to maternal voice and frequent visitation by
family members), additional research is needed to
investigate other areas that may be impacted by exposure
to maternal voice. For example, studies investigating
whether mother-infant/family-infant interactions are
affected by providing a combination of exposure to
maternal voice and frequent visits by the family. Future
investigations such as these could show immense reasoning
for the importance of maternal voice and high frequencies
of family visitation in the health and wellbeing of preterm
infants.

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