On first listen, a pacifier that plays music to your baby sounds like just another product to put in the “useless baby stuff” file along with the Diaper Genie, the Wipe Warmer, hard–soled shoes, and infant hairbrushes. But for some babies, the Pacifier-Activated-Lullaby or PAL apparently has real value.

Some babies, especially those born prematurely, have great difficulty sucking and swallowing, making feeding at the breast or bottle difficult or impossible. Traditionally, these babies have been said to have a “weak suck”; however, in most cases, it has little to do with strength. The problem is a co-ordination issue: until premature babies reach 34 weeks gestational age, their brains have not developed the ability to coordinate sucking and swallowing.

Other babies, especially those on a respirator, develop an “oral aversion” and resist having things put in their mouths. It is not difficult to imagine that being intubated, which involves having a plastic tube inserted in the mouth and down the windpipe allowing air into the lungs, might make babies weary of having things in their mouths.

When these infants are ready to start breast feeding, it can often take a while for them to get over their aversion or develop the coordination to suck and swallow properly. Since a baby’s weight gain, and therefore general health, is dependent on feeding, good breast or bottle skills are very important. Moreover, until a baby learns to breast or bottle feed, they must stay in the hospital getting their nutrition through a feeding tube.
Pacifier-Activated-Lullaby

“I wondered if babies could be taught to feed properly with the right reinforcement,” says Dr Jayne Standley, a music therapist working at Florida’s Children’s Hospital in Orlando. Dr. Standley spent ten years developing the musical pacifier and conducting studies on its ability to teach babies how to coordinate their suck and swallow skills. “Turns out they will suck in return for the music.” Standley says premature babies at 34 weeks gestational age, who would normally spend another six weeks developing in the womb, respond and learn from the device in minutes.

PAL works like this: a specially-wired pacifier is connected to a small computer that contains a CD of female-voiced lullabies. When sensors in the pacifier detect the baby sucking properly, it instantly activates the CD player rewarding the infant with music. If the baby stops sucking, the music shuts off after ten seconds. When the baby starts sucking again, the music comes back on. In this way, the babies learn to suck, a lesson that is retained when bottles and breasts are given between the PAL sessions.

So far, two studies have shown PAL’s effectiveness at improving feeding and the device was recently approved by the US Food and Drug Administration for use with newborns.

“The main study showed that most babies with PAL training were feeding at twice the rate they were before, and better than babies who did not use PAL,” says Amy Cermak, a music therapist working at Florida Hospital’s Neonatal Intensive Care Unit (NICU) in Orlando. “Even after the first treatment you can see a big change in the feeding ability.” Another study showed the PAL trained infants gained weight more quickly and were released from the NICU sooner than babies not using PAL.

“If it works on improving sucking, swallowing, and breathing skills, I could see [PAL] could have value for premature babies who have yet to develop that coordination,” says Debbie Stone, RN and lactation specialist at Toronto’s SickKids Hospital, adding that this was a “unique group of patients”. Stone says in utero, many babies often swallow amniotic fluid and suck on their own thumbs and have mastered these skills on their own at birth. “Under normal circumstances, soothers should not be used until breast feeding has been well established.”

Cermak notes that since the device can be easily programmed, it can help with several different types of feeding problems. “Some babies can suck well but have endurance problems. For these cases, we gradually decrease the sensitivity of the device.” In other words, over time the baby has to suck a little longer for the music to begin which builds up their strength. “Once you know what the goal for the baby is, you set the function keys. It’s not that hard to learn to use [PAL],” Cermak says.

Perhaps not surprisingly, PAL has also been used to help relieve pain in newborns. Music therapy has long been under study as means for relieving pain. Moreover, what clinicians call “non-nutritive sucking” has been shown to reduce signs of pain in newborns. “We have used it to decrease pain after surgery,” says Cermak. “These babies don’t have to suck so hard to trigger the music and the music plays for longer than for a feeding. They become more calm and more pacified.”

Other studies validating PAL are under review and should be published later this year. In the meantime, several other hospitals are beginning to implement PAL programs.

Article from aboutkidshealth

Highly enriched formula milk is better for the development of premature babies’ brains than breast or standard formula milk, according to research.

British researchers found that premature babies’ diet had a clear influence on brain development and IQ.

The doctors from Great Ormond Street Hospital for Children and the UCL Institute of Child Health looked at 76 premature babies born in the 1980s who were fed standard formula milk, banked breast milk (donated by other mothers) or an enriched formula with high protein and fat levels.

They found that the babies, now teenagers, fed the enriched nutrient formula had significantly higher verbal IQ and the area in the brain associated with IQ was larger.

Lead researcher Elizabeth Isaacs said scientists had previously thought that this area of the brain, called the caudate nucleus, might be influenced by nutrition in infancy when the brain had its chief growth spurt.

“The fact that early nutrition may program the development of specific brain structures is of fundamental biological importance,” Dr Isaacs said. “Although studies are beginning to appear that link aspects of current diet to brain function the data presented here are among the first to show that the structure of the human brain can be influenced by early nutrition.”

The formula contained extra calcium, phosphorus, iron, zinc and copper but it was not clear whether one or a combination was responsible for increased brain growth.

King Edward Memorial Hospital’s Perron Rotary Express Milk Bank manager Ben Hartmann said feeding programs had improved since the study was done in the 1980s.

He said it was ideal for premature babies to be breastfed by their mothers. If this was not possible, donor milk was next best but if a mother was not comfortable with this, formula milk was used. In all cases, if a baby was not reaching growth targets, nutrients were added to the milk.

DEBBIE GUEST

Article from thewest.com.au 

My little battlers are coming home

Tiny twins Ben and Jordan Alexander came into the world more than 15 weeks early, weighing less than 1.5kgs between them.

Their early arrival was a real shock for first time mother-to-be Karen Banks, who was having a trouble-free pregnancy. The 39-year-old was 24 weeks weeks and five days into her gestation when her waters broke in the middle of the night while she was home along in Dingley Valley.

Her partner, Mark Alexander, was on his way to Queensland. Within an hour she was having an emergency caesarean at Monash Medical Centre. “I rang my sister, who rang an ambulance that took me straight to the hospital,” Mrs Banks said.

“When i got there i was fully dilated”.

“I don’t know what happened”.

“All of a sudden it felt like something wasn’t right”.

“It was very frightening. It has taken me a long time to come to terms with it”.

Maternity experts at Monash’s Newborn Services Unit stabilised the fragile babies.

“Mark was just near Parkes with his son, Jackson, and they turned around and drove straight to the hospital, “Karen said.

“He got there at 9.30 that night, but at least it was still the same day as the babies were born”.

Baby girl Jordan was strong of the two premature babies. She weighed 687g and was 31.5cm long when she came into the world on September 2005.

“Just a bit bigger than a tub of butter,” her mother said.

Meanwhile her twin brother Ben (700g and 32cm long) was facing an uphill battle.

“Like many very premature babies their lings were too immature for them to be able to breathe without help”, Monash Medical Centre Newborn Services director Dr Andrew Ramsden said.

“For a time, they were both needed full intensive care support with a mechanical ventilator,” he said.

“When Ben was about one month old he developed a condition called necrotising enterocolitis in which the bowel becomes inflammed and in severe cases can cause the bowel to perforate. “Ben needed emergency surgery, which was performed in the intensive care nursery, as he was too unwell to be moved to the operating theatre.

“The affected region of the bowel was re-moved and the ends were brought out on to the skin.

“On Valentine’s Day Ben had further surgery to reconnect his bowel and he and his sister are now well on their way to recovery and should be home before long with Mum, Dad and big brother, Jackson”.

Ms Banks was proud to reveal the twins were growing well.

“Ben is now 4078g and Jordan is 4510g”. she said.

“I can’t believe we will have them home in just a few weeks”.

Story by Suellen Hinde – Medical Reporter the Sun Herald.

Premature babies who receive morphine may grow up to be more sensitive to pain, a study on rats suggests.

US researchers found rodents given the drug just after birth later needed higher doses of morphine to kill pain than counterparts in a placebo group.

Morphine is a standard part of care for premature babies, who may need hundreds of painful treatments and tests.

The study reported in New Scientist, raises questions, if not answers, about the practice, experts say.

Researchers at the University of South Carolina treated newborn rats with morphine injections for the first nine days of life and tested their pain responses a few weeks later.

Rats are born so immature that their early development is comparable with that of a premature baby.

After nearly six weeks, broadly equivalent to a human becoming a teenager, the morphine rat appeared to be more sensitive to be pain than the rat given the placebo.

For instance it withdrew it paws more readily when these were heated with a lamp, and when pain was induced appeared to need more morphine to quell it.

‘Least harm’
About 3% of babies in the US and UK are born so prematurely they need treatments which in turn are believed to require pain relief.

The mortality rate is higher for unsedated babies, not to mention the fact that it would be totally unacceptable to wilfully expose newborn infants to severe pain.

Their pain is judged on their physical response, and the drug is administered accordingly. Premature babies may require many painful procedures. This research does raise questions about that practice, but other studies have produced contradictory findings about children and pain.

For instance, a Canadian study found that infants who were circumcised without anaesthetic appeared more sensitive to pain when given their immunisation injections later on that children who had not been circumcised.

“Of course if there are adverse affects of giving morphine to infants then we need to look into them, and this is a very interesting – and indeed plausible – study,” says Malcolm Levene, professor of paediatrics at Leeds School of Medicine.

“But ultimately we are interested in the option which causes the least amount of harm. The mortality rate is higher for unsedated babies, not to mention the fact that it would be totally unacceptable to wilfully expose newborn infants to severe pain.”

Article and photo from BBC News

New techniques mean tailored treatments for premature babies, writes Denise Cullen

ANDREA Krieger’s son Angus faced tough odds when he was was born 15 weeks early five years ago. Sophisticated medical interventions over the past two decades have dramatically increased survival rates for very premature babies.
Health

But the flipside of these advances is that babies born pre-term, particularly if, like, Angus they are born before 26 weeks’ gestation, are likely to be dogged by a host of neurodevelopmental difficulties, many of which persist into adult life.

“When Angus was born at 25 weeks, he was given less than a 50 per cent chance of survival,” Krieger recalls. “We were told that the babies like him that do survive will have brain injury, or delayed development, along with other health issues.

“It was a very difficult time, but for me, having all the cards laid out on the table, and knowing all the possibilities was important, because with knowledge, there’s power, and your choices can be more informed.”

While the balance of the risk of health problems had been thought to be still on the baby’s side in the case of a pre-term birth, in population terms the dangers are relatively high. One study, published in the journal Brain (2007;130:667-677), revealed that 10-15 per cent of very pre-term infants developed cerebral palsy, while up to half had other significant problems such as lowered IQ, attention deficit hyperactivity disorder (ADHD), anxiety disorders and learning disabilities.

To make matters worse, trying to predict which pre-term babies will experience these outcomes using standard clinical indicators — gestational age, birth weight, and complications during the neonatal period — has proven problematic. Some children considered to be at high risk for developmental dysfunction seem to do just fine; others who are predicted to do well do not.

But a novel study in Melbourne is using high-tech magnetic resonance imaging (MRI) to uncover vital clues as to how premature babies will develop, by identifying specific abnormalities in their brains.

Doctor Peter Anderson, a psychologist and senior research fellow at the University of Melbourne and Murdoch Childrens Research Institute (MCRI), says the long-term study will follow 230 children recruited as premature babies from 2001-2003, throughout childhood and hopefully into adulthood.

In doing so, it will focus on the consequences of brain abnormalities revealed in the neonatal period on subsequent brain development and neurobehavioural outcome in this high-risk population.

“Cranial ultrasound is the standard technique for assessing brain injury in premature infants, and while this technique is good at picking up significant abnormalities, it is not as sensitive when it comes to picking up more common and subtle brain abnormalities,” Anderson says.

“We have also demonstrated that brain MRI scans are more predictive of early developmental delay than cranial ultrasound.”

Krieger’s son was recruited into the MCRI study and underwent an MRI scan on his due date.

“It showed that his brain was immature in general, but that was always going to be the case because he was a premature baby,” his mother says.

“The researchers then linked the information in the scan to the types of physical, motor and intellectual problems Angus may be at risk for, and the challenges he could face in the future.”

As a result of that information, the family engaged in early intervention services including speech therapy, physiotherapy and occupational therapy through Victoria’s Broad Insight Group.

“He reached all his milestones, like learning to crawl — he just reached them later,” Krieger said.

Anderson points out that MRI studies, such as the one conducted in Melbourne, have revealed a far higher incidence of brain abnormalities in premature babies than was believed to exist, with about 70 per cent later having pathology ranging from mild to severe.

For fraught parents already struggling to deal with the health and other issues that typically confront their premature infants, such figures sound anything but comforting.

Yet through delving into the reasons why particular patterns of difficulty occur, researchers hope to devise intervention and remediation strategies to bridge the babies’ developmental gaps.

“Our ability to identify children at risk for different types of developmental delay is critical for selecting the most appropriate early intervention program for each child,” says Anderson.

While no one can explain exactly why early intervention works, most people agree it does. It’s generally believed young, malleable brains can be “rewired”, at least to some degree, through speech therapy, occupational therapy, physiotherapy and other interventions.

MRI scans have shown that babies born prematurely not only tend to have smaller brains overall, but that certain parts of the brain — in particular the white matter, the cabling that facilitates communication within the brain — are at risk of injury.

“Research tends to suggest that prematurity has a selective effect on specific regions of the brain, or that there are regions of specific vulnerability,” says Anderson.

One of these regions is the corpus callosum, which links the right and left hemispheres of the brain, and plays an important role in establishing which sides of the brain become specialised for performing particular tasks.

According to a previous paper in Brain (2004;127:2080-2089), research conducted on adolescents aged 14-15 years revealed that thinning of the corpus callosum was often observed in those born very pre-term.

This was strongly correlated with their deficits in verbal intelligence and verbal fluency, and is believed to be the case because the corpus callosum is integral to high-order cognitive processes, such as language, which require complicated information transfer between both hemispheres of the brain.

The cerebellum, located at the base of the brain and playing a crucial role in motor co-ordination, muscle tone and different types of cognitive functioning, including planning ability, also seems susceptible to the effects of early birth.

The hippocampus is further implicated in the learning difficulties, particularly memory impairments, that children born prematurely may demonstrate upon reaching school age.

Yet the reasons why prematurity causes these changes in the brain remains something of a mystery.

What is known is that during the third trimester, the brain is maturing at a rapid rate and the developmental events that are occurring during this period are likely to explain why some parts are more vulnerable than others to alteration by pre-term birth.

Fever, infections, breathing difficulties and hypoxic episodes (during which the babies’ brains receive insufficient oxygen) are also suspected to play a part.

Even the medical interventions designed to save their lives and the environment of the neonatal intensive care unit — typically involving bright lights, loud noises and painful medical procedures — might expose fragile bodies and brains to damaging stimuli.

“Their sensory systems are immature and just aren’t ready for all of that input,” Anderson says. “What impact it all has on the brain is not known but it is likely to be negative.”

“But there’s no simple or single thing that’s causing these abnormalities in pre-term babies’ brains … It’s clear that there are a number of factors that are involved, and many of these are inter-related.”

While MRI has been in use for many years, it is still not used routinely with very premature infants, despite the high rates of brain abnormalities and neurodevelopmental problems. This is partly because it is difficult to scan very sick infants.

“Before Angus went for a repeat scan at two years old, we recorded all the screeches and grinds and other awful sounds from the machine and played that to him at bed-time, so he was more comfortable,” says Krieger.

But she says it was worth all the trouble: “There was huge development in his brain right up to the skull… he’s perhaps still behind his peers, but I could see the difference.”

Now aged 5, and looking forward to kindergarten, Angus’ life is not without its challenges. His muscle tone remains low — which means, for instance, that producing the sounds required for speech is difficult for him, and as a result he continues to have speech therapy and physiotherapy. But as children like Angus start to be scheduled for the scans due when they turn seven, and the associated neuropsychological assessments, Anderson is hopeful of gaining insight into some of the factors that facilitate brain development in this vulnerable group of children.

“The group that we’re following up is the largest group of children anywhere in the world to undergo neonatal scans and follow-up,” says Anderson. “While most infants with severe brain injury develop marked disabilities, others have reasonable outcomes, (and so) identifying the processes associated with such recovery is of major importance.”

Article & photo from The Australian

Folic acid supplements taken for a year before pregnancy can cut the risk of premature births by 70% and save thousands of lives, researchers have found.

One in three babies born under 28 weeks die, and many others face lifelong disability. Experts say the research, based on a study of nearly 40,000 women, adds weight to calls for flour and bread to be fortified with folic acid.

Doctors have long recommended that women planning a family take folic acid supplements to reduce the risk of neural tube defects, including spina bifida, which can cause profound disabilities. But the latest study shows it has other benefits.

The Royal College of Obstetricians and Gynaecologists described the study as “extremely exciting”. Tim Draycott, a consultant obstetrician and gynaecologist, said: “[Premature births] are a tremendous burden on the children, the families and society … Anything that is potentially beneficial and particularly something as safe as folic acid – we would welcome as an intervention.”

Reducing the number of premature births would also ease the burden on the NHS. Cots in premature baby units cost between £43,672 and £256,248 a year, according to the National Audit Office, depending on the level of care they provide.

More than 60,000 babies are admitted to such units each year and the total cost to the NHS in England is £420m.

In the US, it has been compulsory for manufacturers to enrich cereal-based products with 140 micrograms of folic acid per 100 grams since 1998.

The RCOG recommends that flour should be boosted with 240mcg of folic acid per 100g grams to prevent brain and spinal cord defects. Draycott said fortifying foods was more likely to be successful than asking all women of child-bearing age to take the vitamin as a supplement. According to the college only about a third of women take folic acid supplements before becoming pregnant.

The latest study looked at the effect of taking folic acid – the synthetic form of vitamin B9 – before conception. The team used information from a National Institutes of Health study about the pregnancies of 38,033 women.

By comparing groups of women who had taken folic acid for different lengths of time, the researchers found the supplement could cut the risk of premature delivery by 70% for very early premature births – 20 to 28 weeks of pregnancy – and by 50% in births after 28 to 32 weeks.

The study will be presented at the annual meeting of the US Society for Maternal-Fetal Medicine today.

In 2005-06, the latest year for which figures are available, 4,150 babies were born between 20 and 28 weeks of pregnancy. Babies born this early run a high risk of developing disabling conditions such as cerebral palsy, learning difficulties, blindness and chronic lung disease.

According to Radek Bukowski, an assistant professor of obstetrics and gynaecology at the University of Texas, who led the research, the study was prompted by previous research which showed that women who gave birth early had lower levels of folic acid in their blood.

Professor Gordon Smith, an expert in obstetrics and gynaecology at Cambridge University, said: “What you can now say is that folic acid has more general effects in pregnancy, which bolsters the case for fortifying flour. A lot of pregnancies aren’t planned, so most women don’t take folic acid supplements because they won’t be thinking about pregnancy.”

Until the research is confirmed though, Draycott said the findings should be treated with caution. Large epidemiological studies of this kind are prone to throwing up spurious results if the true factor causing health benefits is linked to whether women take folic acid or not. “The difficulty is that folic acid could be a marker of other good behaviours,” he said, for example the people who take folic acid might also be well off and attend antenatal classes.

In May last year the Food Standards Agency said ministers should order the mandatory fortification of food with folic acid. But the FSA has not decided whether to add the vitamin to bread or flour because of concerns that people from ethnic minorities do not eat processed bread. There is also some evidence that folic acid has adverse effects on older people with a deficiency in vitamin B12.

“This is another piece of positive research showing fortifying is a good thing,” the FSA said.

Bliss, the premature baby charity, said: “This … could signal a positive new approach for reducing the number of premature births.

“We look forward to seeing further work done in this area – anything that improves outcomes for babies and increases their chance of having the best start to life is a very welcome development.”

Article from The Guardian