DOI: https://doi.org/10.21203/rs.3.rs-1702015/v1
Background: Prevalence of NICU admission is 44% in India. NICU stay is a precursor of various complications faced later in life. Language developmental delay is one of the complications of NICU stay with a prevalence ranging from 2.3% to 19% in Indian population. Elevated prevalence of linguistic delay in youngsters emphasizes the necessity to focus on language development in initial years to minimize the possibility of ill-effects and thus give optimal the chance for improvement.
Aim: To evaluate effectiveness of Reach Out and Read intervention on language development for infants in NICU.
Method: Single group pre-post assessment was carried out with 18 infants recruited from NICU. Reach Out and Read program was taught to parents of the recruited participants. Parents were given one book every follow up till the infant was 5months of age. At recruitment and CA 3 months GMA was recorded. At CA 5 months BSID III language subtest was noted.
Results: GMA at recruitment and 5th month comparison shows significant improvement p=0.0277, GMA at 3rd month compared to 5th month shows significant improvement p=0.0431.
Conclusion: Reach Out and Read literacy program improves GMs of infants from birth to CA 5 months of age. It looks to be a viable and promising new language intervention. A RCT needed to evaluate and generalize if ROR can help these infant’s language development.
Language delay has been discovered to be common in a wide range of age groups and populations. According to studies, prevalence rates among children under the age of five range from 2.3 percent to 19 percent.[1] The risk of language development delay is higher in infants because of admission in NICU, prematurity, low birth weight. Along with this, offspring's of mothers with gestational diabetes, pregnancy induced hypertension, low socioeconomic status, poor education are at a higher risk of language delay.[2]
This NICU exposure in early years of life due to several complications has been shown to have negative consequences on numerous aspects of a child’s life when compared to other children. As a result, these circumstances have an immediate or later impact on the normal developmental trajectory of the child.[3] Prematurely born infants (32 weeks gestation) and with a LBW (< 1500 g) are more likely to suffer intellectual and linguistic impairments before reaching schooling, according to research.[3]
Hence, intervening at the earliest will aid to beneficial results among infants with numerous risks. Increased prevalence of language delay in youngsters underlines the urge to target language development in early years to minimize the possibility of negative end results and thus provide optimum chance for improvement.
Reach out and Read is a research-based intervention for language development and home literacy.[4] The most essential source of early linguistic input for children is their parents, who are also the key source of variety in that input.[5] Human speech exposure during the neonatal period, particularly the voice of the mother, adds linguistic significance that can be critical for the brain's early wiring for language acquisition.[6]
Although linguistic delay has a high prevalence, there a paucity of literature on early interventions that can be provided to have positive effect on the same. Hence the need to assess the effectiveness of Reach out and Read literacy program on infants in Neonatal Intensive Care Unit.
Ethical clearance was obtained and a signed form for willingness to participate was attained from the parents of recruited subjects. Eighteen infants admitted in NICU of a tertiary tier hospital were recruited for this pre-post experimental study. Inclusion criteria include; infants admitted to the NICU of a tertiary care hospital, infants admitted in NICU for equal to or more than 7 days,[6] mothers should be able to read and parents willing to participate. Infants having APGAR score < 6 at 10th minute, diagnosed with congenital and or visual loss by physician and infants referred for any surgeries were excluded from the study. Parents were informed about the study’s purpose and procedure and explained the Reach Out and Read program. At recruitment, they were given a take-home book in their mother’s preferred language to read to their child. Mothers were demonstrated the intervention and were asked to perform from the day of recruitment in NICU. All queries regarding the procedure of performing the intervention at home were answered. Emphasis on conducting regular intervention at home was done through weekly phone calls and during a monthly visit to the hospital. During monthly visits, each time a new book to take home was given to the mother until corrected age 5 months.
Reach Out and Read had three components [6]
Literacy room: Efforts were made to make the NICU atmosphere more conducive to reading. A waiting area with a high level of literacy was created with posters raising awareness about the importance of reading to infants and books like tale books, books with illustrations of animals/birds, letters, colours, shapes, books with vibrant colours and larger illustrations, kinesthetic books were made accessible.
Anticipatory guidance: One-on-one anticipatory guidance was delivered during the first engagement with the family providing instructions on how to read to a new-born, what to anticipate in terms of response and the significance of reading aloud.
A book to take home: Parents were given one book to take home with them when they were discharged to read to their infant. Throughout the monthly follow-up, one book was provided to the infant to take home until he or she became five months old.
Prechtl’s General Movement Assessment (GMA) [7, 8, 9]
GMA is a qualitative instrument to evaluate the spontaneous motor repertoire in infants from preterm up to the post-term age. It is an easily performable non-invasive method with the benefit of being cost-effective.
Bayley Scales of Infant Development III [10, 11]
The Bayley Scales of Infant and Toddler Development III is an individually conducted tool that intends to evaluate the age appropriate functioning of infants, toddlers and young children aged between 1 to 42 months. Using BSID kit, expressive communication and receptive communication were analyzed for this study.
GMA assessment was done at baseline (in NICU), at 3rd month and at corrected age 5 months 0 days to 6 months 30 days along with BSID III assessment.
The result analysis was done using statistical software R version 4.0.2 with the assistance of a qualified medical statistician. For this, the data was recorded into an excel sheet, tabulated and statistically analysed. Continuous variables were represented by Mean ± SD/Median and categorical variables were represented by frequency and percentage. To check the association between categorical variables test was used. Comparison of GMA at three different times is done by Wilcoxon matched pairs test. Comparison of GMA and BSID III scaled scores is done by Mann Whitney U test. Level of significance was considered 5% (p < 0.05).
Demographic characteristics: Number and percentage of distribution of participants based on age, birth weight, NICU stay, gender, complications, type of delivery, SES, mother’s education is explained in Table 1.
| Number (percentage) | Mean ± SD | |
|---|---|---|
| Gestational Age | 35.89 ± 2.97 | |
| < 36 weeks | 10 (55.56) | |
| > 36 weeks | 08 (44.44) | |
| Birth weight | 1.17 ± 0.70 | |
| < 1.5 kilograms | 7(38.89) | |
| 1.5–2.5 kilograms | 8 (44.44) | |
| > 2.5 kilograms | 3(16.67) | |
| Length of NICU stay (days) | 19.67 ± 12.62 | |
| < 15days | 7(38.89) | |
| > 15days | 11(61.11) | |
| Birth Complication | - | |
| Birth Asphyxia | 3(16.67) | |
| Birth Asphyxia with Jaundice | 1(5.56) | |
| Intrauterine Growth Retardation | 1(5.56) | |
| Jaundice | 1(5.56) | |
| Low Birth Weight | 10(55.56) | |
| Low Birth Weight with Birth Asphyxia | 1(5.56) | |
| Pulmonary Arterial Hypertension | 1(5.56) | |
| Gender | - | |
| Male | 12(66.67) | |
| Female | 6(33.33) | |
| Mother Education | - | |
| Secondary School Certificate | 2(11.11) | |
| Higher Secondary Certificate | 7(38.89) | |
| Degree+ | 9 (50.00) | |
| Type of Delivery | - | |
| Lower Segment Caesarian Section | 17(94.44) | |
| Normal Delivery | 1(5.56) | |
| Complications during pregnancy | - | |
| Hypothyroidism | 2(11.11) | |
| Pregnancy Induced Hypertension | 6(33.33) | |
| Pregnancy Induced Hypertension with Gestational Diabetes Mellitus | 2(11.11) | |
| No complications | 8(44.44) | |
| Socioeconomic Status | - | |
| Upper middle class | 3 (16.67) | |
| Upper lower class | 3 (16.67) | |
| Lower middle class | 12(66.67) | |
Association of GMA with different demographic like Socioeconomic status, birth weight, length of NICU stay, gestational age was done. The association was not statistically significant for any of the characteristics. However, some increment in values was obtained. In gestational age, in < 36 weeks group, at recruitment 6 (50.00%) subjects have shown normal GMs and 4 (66.67%) have shown poor repertoire. The percentage increase is from 50–58.33% to eventually 66.67% at the 5th month. In > 36 weeks GA category, at recruitment, 6 (50.00%) subjects showed normal GMs. The percentage of subjects with normal FMs however decreased from 50.00–33.33% till 5th month as there were 3 infants dropped out by 5th month.
In the birth weight group, < 1.5 kg category showed improvement to normal fidgety movements 33.33% increased to 46.67%. Similarly in > 2.5kg group percentage of normal fidgety movements increased from 8.33–20%. This was not the case with 1.5–2.5 kg category as there were 3 drop outs percentage deteriorated from 58.33–33.33%.
When compared GMA with length of the stay, no significant results were obtained. The percentage of normal fidgety movements improved from 58.33% to 11 (73.33% in > 15days category. <15days category however has shown decreased percentage due to 3 drop outs (41.67–26.67%).
Even with increased percentage of normal fidgety movements, association of SES upper middle, upper lower and lower middle class with GMA was not found to be statistically significant.
Comparison of GMA at recruitment, at 3rd month and at 5th month time points by Wilcoxon matched pairs test: The total number to normal GMs at recruitment improved from 12 infants (66.67%) to 15 infants (83.33%). The 6 subjects had shown PR in the first assessment improved to normal fidgety movements hence no abnormal movement subject at the 5th month. There was 1 drop out after first assessment and 2 dropped out before the final assessment. Nonetheless, GMA from 3rd month to 5th month shows significant improvement as p = 0.0431. Overall from recruitment to 5th month p value shows statistically significance p = 0.0277. (Table 2)
| GMA | Number | Percent |
|---|---|---|
| At recruitment | ||
| Normal | 12 | 66.67 |
| Poor Repertoire | 6 | 33.33 |
| At 3rd month | ||
| Normal Fidgety | 12 | 66.67 |
| Abnormal Fidgety | 5 | 27.78 |
| At 5th month | ||
| Normal Fidgety | 15 | 83.33 |
| Abnormal Fidgety | 0 | 0.00 |
| Overall, Q = 8.857142, p = 0.0119* | ||
| At recruitment vs At 3rd month | Z = 0.5345, p = 0.5930 | |
| At recruitment vs At 5th month | Z = 2.2014, p = 0.0277* | |
| At 3rd month vs At 5th month | Z = 2.0226, p = 0.0431* | |
| *p < 0.05 | ||
Comparison GMA at recruitment with scaled scores of BSID III by Mann-Whitney U test: Receptive communication and Expressive communication scores do not show statistical significant difference with if whether at recruitment infant had normal or poor GMs. For receptive p = 0.1753 and for expressive p = 0.4437. (Table 3)
| BSID III | Normal GMA | Poor Repertoire | U-value | Z-value | P-value | ||||
|---|---|---|---|---|---|---|---|---|---|
| Mean | SD | Mean rank | Mean | SD | Mean rank | ||||
| Receptive communication | 6.11 | 1.45 | 6.00 | 4.67 | 1.37 | 9.33 | 15.00 | -1.3553 | 0.1753 |
| Expressive communication | 6.89 | 0.33 | 9.17 | 7.33 | 0.82 | 7.22 | 20.00 | 0.7660 | 0.4437 |
| Total | 13.00 | 1.41 | 6.83 | 12.00 | 1.67 | 8.78 | 20.00 | -0.7660 | 0.4437 |
Comparison GMA at 3rd month with scaled scores of BSID III by Mann-Whitney U test: Receptive communication and Expressive communication scores do not show statistical significant difference with if whether at 3rd month infant had normal fidgety movements or abnormal movements. For receptive p = 0.0758 and for expressive p = 0.4260. (Table 4)
| BSID III | Normal Fidgety | Abnormal Fidgety | U-value | Z-value | P-value | ||||
|---|---|---|---|---|---|---|---|---|---|
| Mean | SD | Mean rank | Mean | SD | Mean rank | ||||
| Receptive communication | 6.10 | 1.37 | 9.50 | 4.40 | 1.34 | 5.00 | 10.00 | 1.7759 | 0.0758 |
| Expressive communication | 6.90 | 0.32 | 7.30 | 7.40 | 0.89 | 9.40 | 18.00 | -0.7961 | 0.4260 |
| Total | 13.00 | 1.33 | 8.95 | 11.80 | 1.79 | 6.10 | 15.50 | 1.1023 | 0.2703 |
When compared GMA at recruitment normal and poor repertoire show z=-0.7319, p = 0.4642. When compared GMA at 3rd month normal fidgety movements and abnormal fidgety movements show z = 1.0030, p = 0.3159. The composite scores of BSID III do not depict statistical significant association with GMs at recruitment and 3rd month. (Table 5)
| GMA | Mean | SD | Mean rank | U-value | Z-value | P-value | |
|---|---|---|---|---|---|---|---|
| GMA at recruitment | Normal | 80.25 | 4.40 | 5.90 | |||
| Poor Repertoire | 76.80 | 5.50 | 7.69 | 14.50 | -0.7319 | 0.4642 | |
| GMA at 3rd month | Normal Fidgety | 80.11 | 4.14 | 7.78 | |||
| Abnormal Fidgety | 76.25 | 6.18 | 5.25 | 11.00 | 1.0030 | 0.3159 |
Objective of this study was to assess effectiveness of Reach Out and Read literacy program in infants of NICU using GMA and BSID III. In this study, there were more number of subjects that were born early preterm showing poor repertoire in their GMs when compared to subjects born late preterm. This is supported by the previous evidences present. A study conducted to determine the GMs and Motor Optimality Score of 40 early preterm infants concluded that in preterm at writhing age, poor repertoire is common. At fidgety age however, majority, normal fidgety movements are seen.[12] The reason could be, physiologically, the complete development of the structures of the inner ear occurs between 24–26 weeks of gestational age, and gaining auditory stimuli begins during this time period. As a result, when the infant is taken out of that environment and placed in the NICU, neural differentiation is altered, which may affect forthcoming development. The sensory environment influences brain growth, structures, connectivity and function throughout the first three years of life, making this a critical period of brain plasticity.[13]
As studies suggest, the commonest cause of NICU stay in India is low birth weight (< 1500gms).[14] It therefore also increases the number of days in NICU causing increased exposure of NICU environment. NICU architecture promotes social seclusion, language deprivation, and the likelihood of atypical language development. Ambient noise blocks most human discussions in a multi-bed NICU, robbing the infant of relevant linguistic input. Human speech exposure during the neonatal period, particularly the voice of the mother, imparts linguistic richness that can be critical for the brain's early wiring for language development.[3] The demographics of our study has shown similar results. There were more number of participants in the low birth weight category (< 1500grams) that showed poor repertoire than the subjects with birth weight 2.5kg and above.
Current studies on the influence of SES on language outcomes continue to comprehend the significance of educational qualifications.[5] Evidence suggests that low SES infants encounter considerable discrepancy in linguistic exposure during beginning of childhood and perhaps therefore have lower levels of vocabulary growth, school keenness, and reading skills.[6] The variation in the words used or auditory stimuli given is more in higher SES. In our current study, PR seen at early stage was more in subjects with lower middle SES. This is supported by evidences [6] hence predicting its ill effects at preschool age.
As Infant’s Nervous System is immature at the beginning and as the infant nears the term age, plasticity of the brain is enhanced which demands the need to incorporates an enriched intervention to positively influence the development of child. Early intervention is essential in modifying the underlying neural mechanism in the context of myelination, creation and sprouting of neural projections for development of the child.[13]
Previous research revealed ELBW infants vocalise as early as 8 weeks before their expected date of delivery; parent talk is a significant predictor of both infant vocalisations and Conversation Turns at 32 and 36 weeks' gestation. Furthermore, every 100 AWC/h increase in the NICU at 32 weeks' gestation was linked to a 2-point rise in the Bayley III, language composite score at 18 months (p 5.04). At 36 weeks' gestation, every 100 AWC/h improvement was linked with a 1.2-point rise in the BSID, cognitive composite score (p 5.004) and a 0.3-point increase in expressive communication at 18 months. This strongly suggests that parents converse in the NICU during the weeks leading up to an infant's expected date have a significant effect on their later cognitive and linguistic abilities.[15] On this background, in our study, BSID III was assessed at 5month-6month time period and was correlated with GMA at recruitment and CA 3 months. However statistical significant changes were not obtained.
The GMA outcome utilised to evaluate early motor repertoire in this study is a valid instrument for determining the infant's neurological functioning. Absent FMs exhibited a high specificity, NPV, and accuracy for motor, language, and cognitive scores of < 70 at two years, according to a study. [8] Contrary to this, the relationship between inadequate repertoire and fidgety movements and the BSID III scaled score for its receptive and expressive communication language components was not found to be statistically significant our study. This difference may be noted because the quoted article has used BSID at 2 years of age whereas in the current study assessment was done at CA 5months − 6months.
In present study as GMs has improved at the third assessment, these findings back up the idea of executing care giving programs with involvement of the family in the neonatal ICUs, implying that early born babies avail to the benefit from increased parental involvement and contact, such as caretaking, kangaroo care, snuggling, conversing, singing a song, and reading. ROR was instrumental in incorporating parts of early intervention in the current study by adhering to that. It was valuable in obtaining active engagement of the mother and family in the intervention.
Early reading activities that strengthen parent-child relationships can play an important role in developing emergent literacy abilities and preparing children for school.[6] With caring bonds between parents and newborns, early literacy starts in a child's initial days. ROR is a programme that focuses on giving resources, information, and assistance to low-income families so that they can concentrate on books and reciting loudly as one of the most crucial parenting skills in parent-child interaction. The assessment of the intended infant and the parent for reading experience is the first step in promoting literacy development. [4]
This study however has a few limitations; the infants those had minimal complications, hence fewer days in NICU, revisited hospital for follow-up less frequently than others. Due to travel and budgetary constraints, a poor retention rate was seen during follow-up visits. Due to smaller sample size association of GMA with other primary complications of the infant could not be analysed. Nonetheless, strength of the study was active participation of mother and family was encouraged for this intervention. ROR intervention was implemented from the early days of NICU encouraging stimulating environment and improving GMs.
Reach Out and Read training program that actively involves parents by providing literacy rich waiting room, anticipatory guidance and a book to take home confirms its feasibility and effectiveness in promoting developmental trajectories of infants admitted in NICU.
FUNDING:
Self-funded research.
COMPETING INTEREST:
No conflict of interest to declare with respect to research, authorship and/or publication of this article. The authors have no relevant financial or non-financial interests to disclose.
AUTHOR CONTRIBUTION:
All authors contributed to the study conception and design. Material preparation, data collection and analysis were performed by Kale Shriya and Deshpande Vinuta. The first draft of the manuscript was written by Kale Shriya and all authors commented on previous versions of the manuscript. All authors read and approved the final manuscript.
ETHICAL APPROVAL:
Ethical clearance was obtained from the Institutional Ethical Committee of KLE Institute of Physiotherapy (KIPT/704/7-08-2020), Belagavi, Karnataka. Clinical Trial Registration was done (CTRI/2021/10/037539).
CONSENT TO PARTICIPATE:
Written informed consent was obtained from participants.
CONSENT TO PUBLISH:
N/A