Pilot Study: Effects of CCP Intervention on NICU Environment and Preterm Infants Development

The quantity of adult speech is recorded and analyzed. The quantity of adult speech includes the duration (minutes per hour), number of words (per hour), syllables (per hour), and phonemes (per hour). The recording is done with a commercial recording device. The microphone is placed in the incubator or infant cot. The data analyses are performed using ALICE, an open-source tool to count words, syllables, and phonemes.

The sound level includes sound pressure (dB) and its variation. The main focus of this measurement is to detect a sudden change in the sound pressure caused by alarms and other activities which are a common source of stress in a NICU environment. The recording is done with a sound level detector, a different device from that for speech recording. The microphone is placed in the incubator or infant cot. The data analyses are performed using a one-minute resolution of the recording regarding the average, maximum and minimum and 5 and 95 percentiles of the sound level.

The artificial intelligence-based algorithm tool to analyze infant behavior with a camera captured image will be used to classify infant state into six categories: Non-REM (rapid eye movement) sleep, REM (rapid eye movement) sleep, drowsy, quiet awake, active awake, and crying. In addition, caretaking and procedures will be recorded and scored. The diary data is used to get information of the times the infants is not under the camera image like during skin-to-skin contact. The camera is custom-designed with the connection to a local computer. The night-vision camera works well also in a dimmed light environment. The module can be used for both infants in an incubator and in an open bed.

Parents' presence is defined as their presence beside their infant or at least in the same room with the infant. Parent-infant skin-to-skin contact is defined as the infant being held by the parent on the bare chest, with only a diaper and a cap if necessary.

The duration of parents' presence and parent-infant skin-to-skin contact will be recorded using a modified Parent-Infant Closeness Diary. Parents or staff indicate the specific items by drawing a line. The caretaking includes hands-on care and holding, breastfeeding and bottle feeding of the infant. The start and the end times should be put in 5-minute increments.

The amount of enteral feeding divided into 4 categories, fresh breast milk, refrigerated/frozen breast milk, donated breast milk, and formula milk will be collected per day. Both the absolute amount of milk and its proportion of the total enteral nutrition will be calculated. We hypothesize that the infants will receive more fresh maternal milk after the intervention.

The body weight of the participated infant, and its percentile/Z-score based on the standardized growth curve (Fenton 2025 and National growth curve) will be collected.

The frequency (times per day) and proportion (% of total feeding number per day) of breastfeeding will be recorded between 36+0 and 36+6 weeks of postmenstrual age and between 7 and 1 day before the day of NICU discharge. Then the average frequency and proportion of breastfeeding at 36 weeks of postmenstrual age and at NICU discharge will be calculated.

The questionnaire consists of 26 questions about the parenting self-efficacy. Each question is rated by parents using a Likert scale from 1 (fully disagree) to 6 (fully agree).

The hospitalization duration and the postmenstrual age (PMA) at NICU discharge will be collected from the medical records.

The brain MRI will be taken at the term age, between 37+0 and 41+6 weeks of postmenstrual age or shortly before the NICU discharge. The brain MRI image will be evaluated using a standardized scoring system, that consists of six items for white matter injury and seven for gray matter injury. The total score is 17 for white matter and 22 for gray matter and cerebellum. A higher score indicates better brain development. The severity of the injury is defined using the total score for white and gray matter, respectively.

The measurements will be done during a structured test situation. The mother or father and the child are positioned face-to-face at a table and engaged with a standardized set of toys for 10 minutes. The parent will wear glasses with an eye tracker and a camera. The child will not wear such devices due to the high rates of data attrition for child-held devices. Infant face-looking will be analyzed using a deep neural network based on the video data recorded by the parent's glasses. Parent's face-looking behavior will also be extracted from the eye tracking and video data recorded by the parent's glasses. Parent reactions to child face-looking (facial and vocal) will be obtained from a separate video and audio recording, using automatic tools.

The duration of the infants crying at home will be recorded using the Cry Diary. The parents record baby's state to 6 categories (sleeping, awake & happy, awake & fussy, awake & crying, feeding, not sure) and parents' action to 3 categories (holding the baby, transport, baby care) with 5-minute accuracy using the Cry Diary for 3 consecutive days, shortly before the 6 months corrected age follow-up visit.

The IBQ-R has 191 items in which parents rate their infant's behavior over the past one to two weeks on a 7-point Likert scale (1 = never, 7 = always) based on the frequency of the observed behavior. If a behavior was not observed, parents mark it as "not applicable". The items form three broad temperament dimensions with subscales: Surgency/Extraversion (Approach, Vocal Reactivity, High Intensity Pleasure, Smiling and Laughter, Activity Level), Negative Affectivity (Perceptual Sensitivity, Sadness, Distress to Limitations, Fear, Falling Reactivity), Orienting/Regulatory Capacity (Low Intensity Pleasure, Cuddliness, Duration of Orienting, Soothability). The IBQ-R has shown predictive validity for later child temperament and behavioral outcomes.

The ECBQ consists of 201 items and has the same 7-point scale as the IBQ-R. It measures three broad dimensions of temperament, each with multiple subscales: Surgency/Extraversion (Activity Level, High-Intensity Pleasure, Sociability, Impulsivity, Approach, Shyness), Negative Affectivity (Fear, Frustration, Discomfort, Sadness, Soothability), Effortful Control (Attention Focusing, Cuddliness, Inhibitory Control, Low-Intensity Pleasure, Perceptual Sensitivity. The ECBQ has shown predictive validity for children's later emotional and behavioral regulation.

Bayley scale scores for each development areas (cognitive, language, motor) score range : 0-200 above average (1 to -2 standard deviation, score 116-130) average (1 to -1 standard deviation, score 85-115) below average (1 to -2 standard deviation, score 84-70) well below average (<-2 standard deviation, scores < 70).

The ITSEA is a screening method for infants between 12 and 36 months of age to predict their future social and emotional problems. It has 170 items, each rated from 0 (not true/rarely) to 2 (very true/often).