review of rld lit

8/7/2019 review of rld lit

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Journal of Pediatric Psychology, Vo l. 22, No. 3, 1997, pp. 281-295

Supplemental Stimulation of Premature Infants:A Treatment Model1John N. I. Dieter2 and Eugene K. EmoryEmory University

Received December 15, 1995; accepted April 1, 1996

Examined the human infant literature on supplemental stimulation to delineate acourse of intervention based no the ontogeny of the nervous system and theimpact that systematic stimulation may have on behavioral organization in thepremature infant. Effects of vestibular, tactile! kinesthetic, auditory, and oralstimulation are discussed with respect to their similarity to the intra- or extra-uterine environment. Long-standing theoretical and methodological problemsare discussed, and a "sequential multimodal treatment model" is introduced.KEY WORDS: prematurity; stimulation; tactile; vestibular; kinesthetic.

Between 5 and 15% of all live births in the U nited States are premature ( i.e ., bornbefore 38 weeks of gestation). They are disproportionately high among AfricanAmerican women with 18% of all live black births being premature. Only 8.5 % oflive births to Caucasian women are preterm. African American neonates accountfor 31 % of all premature deaths (Emory, H atch, Blackm ore, & Strock 1993). Theetiology of prematurity is not fully understood. Preterm birth is related to fetalabnorm alities, maternal age and h ealth, parity, and multiple births: other factorsinclude poor prenatal care, cigarette sm okin g, psychosocial stress, low e ducation,and socioeconomic status (SES) of the mother (Wittenberg, 1990).

'Supported by National Institute of Mental Health Fellowship 1 F3I MH11161-01 to John Dieter andGrant ROI-HD28382 to Eugene Emory. The authors express their appreciation to Tiffany Field forher thoughtful comments and suggestions.2AII correspondence should be sent to John Dieter, Department of Psychology, Emory University,Atlanta, Georgia 30322.281

OI46-8693/97rt)6


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282 Dieter and Emory

Numerous reports indicate that prematurity is associated with substantialdevelopmental impairment. Initial difficulties include problems with autonomiccontrol, state organization, and attention regulation (Als, 1986). More long-standing problems include auditory and visual deficits and delays in cross-modaltransformations (Rose, Gottfried, & Bridger, 1978); abnormal reflexes (Howard,Parmelee, Kopp, & Littman, 1976), inferior grasping and hand use; lower IQ,language and reading difficulties, academic underachievement (Cohen, Parme-lee, Beck with, & S igman, 1986); and behavioral problems such as hyperactivityand internalizing disorders (Rose, Feldm an, R ose, W allace, & McC arton, 1992).

SUPPLEMENTAL STIMULATION: AN OVERVIEWIn an effort to decrease the imm ediate adv ersities and developmental deficitsassociated with prematurity, numerous researchers have investigated the effectsof various types of supplemental stimulation. The different forms of stimulationhave included vestibular, tactile, kinesthetic, auditory, oral, and various multi-modal combinations. These interventions have been initiated to compensate forenvironmental deprivation, or to accelerate the development of the prematureinfant. A point of contention among the exponents of the various approaches hasbeen whether stimulation should attempt to capture elements of the intra- orextrauterine environments (Cornell & Gottfried, 1976).Advocates of vestibular stimulation generally view the premature infant asan "extrauterine fetus" (Als, 1986) who has been denied the full benefits of thevestibular stimulation inherent to the womb (Korner, 1990). Supplemental ves-

tibular stimulation has been provided through spinning hammocks (Neal, 1968),rocking cribs (Van den Daele, 1970), oscillating waterbeds (Korner, Kraemer,Haffner, & Cosper, 1975), and cradled rocking (Rice, 1977). Most proponents oftactile stimulation maintain that its benefits arise from the touching inherent inthe mother-infant relationship (Korner & Thoman, 1972). Supplemental tactilestimulation has included extra holding (Hasselmeyer, 1964), cephalocaudal rub-bing (Solkoff, Yaffe, Weintraub, & Blase, 1969), gentle stroking (Kramer,Chamorro, Green, & Knudtson, 1975), and passive touching (Jay, 1982). Kin-esthetic stimulation, in the form of passive limb movements, is usually adminis-tered conjointly with massage (Scafidi et al., 1986).Exponents of auditory stimulation have taken both an intra- and extrauterineapproach to treatment. Auditory stimulation is usually a component of a multi-modal protocol. Some investigators have presented recordings of heartbeat to thepreterm infant (e.g., Schmidt, Rose, & Bridger, 1980); others have used record-ings of the mother's voice (e.g., Segall, 1972) or the live speech of the therapist(e. g., L eib, Benfield, & Guidubaldi, 1980).Oral stimulation facilitates nonnutitive sucking via a pacifier. This cost-


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Supplemental Stimulation 283

effective method has proven useful for shortening the transition from tubal tobottle feeding (Porter-Measel & Anderson, 1979); maturing the suck reflex(Bembaum, Gilberto, Watkins, & Peckham, (1983); promoting oxygenation(Burroughs, Asonye, Anderson-Shanklin, & Vidyasgar, 1978) and weight gain(Field, et al., 1982); soothing preterm infants during invasive procedures (Field& Goldson, 1984), and for regulating state (Gill, Behinke, Conlon, McNeely, &Anderson, 1988).Multimodal strategies have included various combinations of vestibular,auditory, and/o r tactile (-kinesthetic) stimulation. Although visual processing hasbeen examined in premature infants (e.g., Allen & Caputo, 1986), very fewmultimodal (and apparently no unimodal) intervention studies have includedvisual stimulation. A common rationale for omitting visual stimulation is thatthis system is not fully developed at the time when most preterm infants are

born.Across studies there is considerable evidence that supplemental stimulationproduces positive effects on development which include decreased apnea, morestable organization of state, increased weight gain, a decrease in abnormal re-flexes, superior sensory and motor performance on behavioral assessments, andearlier hospital discharge (Field, 1980, 1988). Although the effects of stimulationupon later neurological and psychological development have been questioned(e.g., Russman, 1986), Harrison (1985) reported increased Bayley scores onfollow-up, accelerated social development, and higher infant intelligent scores.

Methodological ConcernsSupplemental stimulation research arose primarily from a desire for inter-vention. Considering the developmental deficits associated with prematurity, aclinically oriented approach is understandable, however, numerous authors havecriticized research on supplemental stimulation because it lacks theoretical direc-tion and sound experimental methodology (Ottenbacher et al., 1987).Subject Variables. The most persistent criticisms with regard to subjectsinclude the use of small samples, the failure to include sick preterms, and themeans with which subjects are assigned to experimental and control conditions(Harrison, 1985). An evaluation of recent studies indicates that efforts have beentaken to correct these shortcomings. A problem that persists is that the range ofgestational ages and birth weights which compose most samples is quite broad.

These samples are generally treated as homogeneous when statistical analysesare conducted. In 14 investigations in which either tactile or vestibular stimula-tion (the most common forms of intervention) was the predominant treatment,the average range of gestational ages across experimental and control subjectswas almost 5'/2 weeks. Within-sample birth weights were also quite disparate


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and varied across subjects by over 700 grams. These variations across studiesmake comparisons fairly difficult, and fail to consider maturity as a factor affect-ing the outcome of supplemental stimulation.

Design Issues. Two group designs have been the standard. In general,experimental groups receive supplemental stimulation and control groups do not.Efficacy has been evaluated with either pre- and posttests, or posttest-onlyevaluations. Dependent variables commonly include growth measures, activitylevels, sleep-wake organization, and performance on developmental assess-ments. Independent variables have been defined along four dimensions; thesensory modalities stimulated: the form of stimulation; the use of uni- or multi-modal stimulation, and the time of onset, intensity, periodicity, frequency, andduration of stimulation. The most common approach to analysis is the evaluationof the experimental and control subjects on a number of preselected variables(e.g., weight gain). Most researchers utilize various forms of analysis of varianceand covariance which are then supplemented by planned comparisons. Cornelland Gottfried (1976) raised concerns about the overreliance upon two-grouppre- and posttreatment designs: Specifically, they argued that standardized pre-treatment assessments (e.g., the Brazelton) can serve as contaminating stimula-tion. As an alternative, they recommended the four-group design of Solomon andLessac (1968) because it combines the posttest-only and pre- and posttest ap-proac hes. Wh ile a four-group design might prove fruitful, it appears that therecommendation of Cornell and Gottfried (1978) has not been followed.

Procedural Issues. Others report that common procedural inadequacies in-clude a reliance upon short-term follow-ups, and a lack of attention to individualneeds (Field, 1980). In those cases when follow-up measures are obtained, thefollow-up has been limited to the first year. A recent advance in this area hasbeen the introduction of home-based stimulation programs (Resnick, Armstrong,& C arter, 1988) which include longer assessment periods. Field (1980) criticizedindividualized approaches to stimulation for research purposes. In contrast, Les-ter and Tronick (1990) proposed that an individual infant's reaction to stimulationcan be used to guide intervention (e.g., signs of stress or avoidance). Althoughthis suggestion is important for clinical efforts, this approach would confounduniform administration of treatments across research subjects. Another pro-cedural criticism is that stimulus parameters have often been arbitrarily selected(Ross, 1984). As Rose, Schmidt, Riese, and Bridger (1980) argue, "The designof intervention programs is complicated by the fact that there is no compellingrationale for selecting any specific type, quality, or patterning of stimulation"(p . 417). Furthermore, when arbitrarily selected protocols demonstrate positiveresults, they are often adopted without additional assessment.Theoretical Concerns. While the criticism of Rose et al. (1980) may beoverstated, it does highlight the need for more theoretically oriented research.The relevant theoretical issues can be grouped under three broad concerns:


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Impact of Adverse Stimulation in the Early Preterm Neonate's Environment.This issue relates to the integrity of the premature nervous system, environmentof the neonatal intensive care unit (NICU ), and the impact of premature deliveryon social-emotional development. There has been considerable debate aboutwhether the day s or weeks that most premature infants spend in the incubator areharmful or helpful with respect to behavioral organization (Tronick, Scanlon, &Scanlon, 1990). The NICU environment can have negative effects (e.g., Law-son, Daum, & Turkewitz, 1977) although researchers have not documenteddefinitively whether developmental deficits relate to sensory deprivation, over-stimulation, or a pattern of inappropriate stimulation.Consensus Over W hich Underlying Mechan isms Are Responsible for Im-

provement. Occasional reference to the work of Hebb (1947) and Piaget (1952)indicates that stimulation may facilitate the development of associative corticaltissue via sensory-motor activation (Wright, 1971). Some support for this viewcomes from the work which examines the effects of environmental deprivationand enrichment on the neurochemistry and behavior of rodents and primates(e.g., Harlow, 1958; Schanberg, Evoniuk, & Kuhn, 1984). However, othersobject to the use of animal "brain plasticity models" to interpret the findings ofhuman stimulation programs. (Lester & Tronick, 1990). Another important de-bate is whether the benefits of intervention arise from techniques which arouse orsoothe the infant. Many investigators maintain that the benefits of interventioncome from its effect upon behavioral state (e.g., Horowitz, 1990; Tronick et al.,1990). However, the relationship between modality of stimulation and its effecton the preterm infant is not clear-cut. The complexity of this debate can beillustrated by the example of weight gain, a common benefit of supplementalstimulation. Using very different approaches both Field et al. 1986 (cephalocau-dal massage) and Field et al. (1982) (oral stimulation via a pacifier) found thattheir experimental subjects gained more weight than controls. These similarfindings were surprising given that tactile stimulation is thought to producealertness, while oral stimulation usually soothes infants and prom otes quiet atten-tiveness. Uvnas-M oberg, W ildstrom, M archini, and Winberg (1987) has specu-lated about why different forms of supplemental stimulation enhance growth.They suggest that stimulation such as massage and nonnutritive sucking activatethe vagal nerve which in turn promotes the release of gastrointestinal (GI) hor-mones such as gastrin and cholecystokinin. The effect of these hormones in-cludes the stimulation of GI motoric and secretary activity, the growth of the GItract, the promotion of glucose-induced insulin release, and the enhancement ofthe infant's energy economy. Unvnas-Moberg et al. (1987) hypothesized thatsucking enhances GI functioning through the activation of sensory nerves in theoral mucosa which stimulates the vagal nerves. Tactile stimulation is thought topromote vagal mediation via the direct stimulation of peripheral nerves such asthe sciatica.


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286 Dieter and EmoryAn Absence of Consensus Over Which Sensory Modality Should be Stimu-

lated, and When and How Much Intervention is Appropriate. The selection ofwhich sensory modality to stimulate and the course that intervention should takehas been either an arbitrary decisio n, or has been based upon whether the investi-gator believes that stimulation should mimic the intra- or extrauterine environ-ments. Korner (1984) has maintained that initial stimulation should be similar tothat experienced in the womb (e.g., oscillations that match the frequency of themother's respiration). As an added but related dimension, Korner (1990) andGreenough (in Rose, 1984) suggest that stimulation should reflect the ontogenyof the senses. However, no specific details have been provided as to how thissuggestion might be accomplished.

THE POTENTIAL ROLE OF ONTOGENYIN SUPPLEMENTAL STIMULATIONWhen reference to a possible relationship between ontogeny and supple-mental stimulation is made (e.g., Greenough in Rose, 1984), the seminal work ofGottlieb (1971) is most often cited. Gottlieb proposed a sequential developmentof sensory systems which was essentially invariant across mammalian and avianspecies. Based upon work on chick embryos, and later synthesized with findingsfrom other research, he proposed a chronological sequence of sensory develop-ment consisting of cutaneous/tactile, vestibular, auditory, and visual. Further-more, sensory stimulation plays a major role in regulating "species-typical"maturation, especially with development of perceptual abilities. Gottlieb pro-

posed that variation in the developmental rate in any one system could alter therate in another system.

An Intervention CaveatTurkewitz and Kenny (1985) warned that supplemental stimulation of im-mature sensory systems has been shown to have detrimental effects on moremature systems in animals (e.g., surgically opening the eyes of rat pups prior toage limited the rats' ability to differentiate scent and produced abnormalities inhoming patterns). These authors proposed that the sequential development ofsensory functions provide a basis for their organization and integration . Stimula-tion of a less mature system creates a condition of sensory competition which

disrupts development. In an investigation of ducklings, Gottlieb, Tomlinson, andRadell (1989) found that premature experience with pattern vision suppressedthese animals' learning of a maternal call.Findings on full-term healthy hum an newbom s further indicates that supple-


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mental simulation that is inappropriate to a system's level of maturity is detri-mental. Using a multimodal approach which consisted of vestibular (a spinninghammock), auditory (stimulated heartbeat), and tactile (massage) stimulation,Koniak-Griffin and Ludington-Hoe (1987) found that after 1 month of dailytreatment (lasting hou rs at a time), the performance by the treated infants on theBrazelton Scale (Brazelton, 1973) showed less mature orientation, motor, andstate regulation behaviors than the control group. The authors concluded thatwhile attempts to provide stimulation that is similar to that experienced in thewomb might be beneficial to the immature CNS of the preterm, such effortsappear to retard the development of full-term infants.

GUIDELINES FOR INTERVENTIONAs indicated, there is little current agreement across investigators about thecourse that premature infant stimulation should take. A uthors seem to be leaningtowards the direction that the type of stimulation may be less important thanwhether it promotes state regulation (Ho rowitz, 1990). This is typified by Ro se's(1984) statement that "intervention in any mod ality can provide the 'fuel fororganization'" (p. 97). However, others canvas for a unimodal approach (inorder to avoid overstimulation, e .g. , L ester & Tronick, 1990) and because pre-terms lack multimodal contingencies (Turkewitz & Kenny, 1985), and a fewargue for a specific treatment (e.g., Korner for vestibular). The suggestion ofThoman, Ingersoll, and Acebo (1991) that stimulation should be adapted to theindividual needs of the infant offers an important alternative to how one might

plan intervention. The best approach towards intervention m ay be one that avoidsoverstimulation of the visual and auditory systems and focuses instead uponmore mature systems (e.g., tactile and vestibular).Potential clinical guidelines for the supplemental stimulation of pretermsmay lie in an examination of the effects the different treatments have upon thebehavioral organization of the infant. The crucial factor may be how well theinfant tolerates stimulation in relationship to its gestational age and health status.Although little research has been directed towards confirming this hypothesis,the findings of representative studies of vestibular, auditory, oral, and tac-tile/kinesthetic stimulation do delineate possible treatment strategies.

Vestibular StimulationAcross full-term and preterm infants, vestibular stimulation (e.g., cradledrocking, spinning hammocks, oscillating waterbeds) reduces state level. Further-more, in full-term infants, the reduction of activity and distress appears to be a


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positive function of the speed and amplitude with which stimulation occurs (VanDen Daele, 1970). Using rocking boxes, Pederson and Ter Vrugt (1973) foundthat higher rocking amplitudes and frequencies soothed infants regardless of theirinitial state. Often infants who were awake and restless would be in quiet sleep atthe conclusion of the 15-minute treatment interval.In premature infants, Korner and associates found that protracted waterbedtreatment had profound effects upon behavioral stability across the awake andsleep domains. Beginning when preterm infants were 4 days old, and continuingvestibular stimulation (i.e., head-to-toe oscillations of 12-14 cpm, amplitude2.4 mm) until the 34th or 35th conceptual week, Korner and Schneider (1983)observed reduced irritability and/or hypertonicity, fewer and shorter incidencesof crying, and less tremulousness and frenetic activity. Furthermore, these in-fants were twice as often in a visually alert inactive state. Likewise, Korner,

Ruppel, and Rho (1982) found that 4 days of continuous waterbed stimulationsignificantly reduced the number of mixed or transitional states in preterm infantssick with respiratory distress syndrome. These preterms also fell asleep faster,exhibited greater and longer durations of quiet and active sleep, and demon-strated increased periods of rapid eye movement. From her extensive researchpro gram , K orner hypothesized that vestibular stimulation reduces the intensity ofinternal needs (e.g., crying or state disorganization) which permits the infant toturn outward and attend to external events (through the promotion of quietalertness).Although tentative, and in need of experimental confirmation, higher rock-ing speed (e.g., 25-30 cpm; Kramer & Pierpont, 1976) may produce a state of"restorative quiescence" which should promote the stability of state across the

sleep and aw ake dom ains, as well as help preserve physiological reserves. A s thepremature infant exhibits greater state organization (as assessed through formalbehavioral observation), a slower rocking speed (e.g., 12-16 cpm; Korner &Sch neid er, 1983) could be initiated in an effort to enhance the infant's interfacewith the environment through the promotion of quiet alertness. Such a statewou ld be exp ected to increase the frequency of integrated sen sory/social exp eri-ences which underlie early learning.

Auditory StimulationPreterm unimodal auditory stimulation has not been extensively studied.

The investigation of Schmidt et al. (1980) appears to be the sole experiment toexamine the impact of auditory stimulation on state. In preterm infants who hadnot received prior supplemental stimulation, a one-trial presentation of heartbeatincreased the duration of sleep states by decreasing the length of the first activesleep epoch and increasing the duration of the first quiet sleep epoch.


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Supplem ental Stimulation 289

As is the case with vestibular stimulation, auditory intervention also seemsto enhance environmental adaptation. Using a methodology offered by Katz(1971), Segall (1972) concluded that several weeks of auditory stimulation (atape-recording of the infant's mother reading a prepared monolog) enhancedadaptation as demonstrated by cardiac response. Experimental subjects showed agreater amount of cardiac acceleration (generally viewed as an avoidance re-sponse) in reaction to a novel stimulus (i.e., white noise), and greater cardiacdeceleration (accepted as an orienting response) to their mother's voice.Although in need of empirical exam ination, the similarity between auditoryand vestibular stimulation may lie in their rhythmic patterning. The fact that allof the major forms of supplemental stimulation (vestibular, auditory, oral, tac-tile/kinesthetic) involve repetition has led T. Field (personal communication,January 24, 1996) to suggest that rhythmic patterning may be a common thera-peutic parameter.Oral Stimulation

Oral stimulation focuses upon the use of pacifiers to promote nonnutritivesucking (N NS ). No nnutritive sucking also has a substantial effect upon state andbehavioral organization. As with vestibular and auditory stimulation, NNS in-creases restfulness and decreases activity (Field et al., 1982). Woodson, Drink-win, and Hamilton (1985) showed that ad lib. access to a pacifier increased thetime term and preterm infants spent in quiet states; decreased the num ber of statetransitions, and reduced motoric output.As previously indicated, the rhythmic pattern of oral stimulation m ay under-lie such imm ediate benefits as increased qu iescence. In addition, there m ay be aninherent "he do nic" quality to sucking (Crook & Lipsitt, 1 976). Although the workof Lipsitt and his colleagues focuses on the pleasures of nutritive oral stimulation

(i .e. , a pacifier delivering sucrose solution), their findings provide further evi-dence that sucking can have a significant ph ysiological impact beyond the area ofthe mouth (e .g ., on heart rate, vagal tone, respiration, and gustatory functioning;Lipsitt, Reilly, Butcher, & Greenwood, 1976; Porges & Lipsitt, 1993).Tactile!Kinesthetic Stimulation

Across investigations, tactile/kinestnetic (T/K) protocols have been quitesimilar and usually reflect minor derivations of the method introduced by Whiteand Labarba (1976). Tactile (rubbing and/or stroking) and kinesthetic (passiveflexing and extending of limbs) stimulation are administered sequentially (e.g.,first tactile, then kinesthetic) during a session and the procedural sequence isoften quite precise (e.g., Field et al., 1986).


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Early studies of tactile-only stimulation failed to include formal state anal-ysis. Regardless, there is evidence that the benefits obtained from tactile inter-vention involve heightened alertness and increased activity. Using a procedureconsisting of nonrhythmic massage of the neck, back, and arms (5 minutes,each hour of the day for 15 days), Solkoff et al. (1969) found that stimulatedinfants were more alert and active than controls. Similarly, Adamson-Macedo(1985) found that providing cephalocaudal massage to sleeping very low birthweight (VLBW) preterms produced a state change which ranged from drowsyto alert. On Brazelton exam, Solkoff and Matuszak (1975) reported that prema-ture infants who had received 1,200 minutes of extra stroking (7'/2 minutes perhour for 16 hours per day for 10 days) were more alert and changed state moreoften.

In two recent investigations, Scarfidi et al. (198 6, 1990) examined the effectof T/K on state. In both studies, it was found that during T/K stimulation,preterm s becam e m ore active as evident by significant increases in multiple limbmovements and facial expressions. Unlike vestibular and oral stimulation, T/Kdid not appear to promote an inactive alert state.

In posttreatment examinations of behavioral organization, Scafidi et al.(1986) demonstrated that stimulated infants exhibited a greater amount of awaketime. Once again, T/K did not enhance periods of inactive alertness. Overall,T/K appears to energize the infant towards activity: Scafidi et al. (1986) foundthat treated preterms exhibited an active alert state 14% of the time, whilenonstimulated infants failed to show such a state during observation.The persistent finding that during massage infants often become alert andexhibit increased motor activity raises the question of whether T/K should be

administered to preterms who are very sick or who are state disorganized. Al-though the impact of T/K on state during periods of treatment and nontreatmentneeds further investigating, it is clear that T/K can be administered to preterms ofyounger gestational ages (e.g., 23 weeks) and lower birth weights (e.g., 630grams) as long as they are clinically stable (Acolet et al., 1993); likewise,Wh eeden et al. (19 93) found that medically stable preterms who w ere exposed tococaine in utero responded positively to T/K (i.e., enhanced weight gain, fewerpostnatal complications, fewer stress responses).Along with such benefits as enhanced weight gain, T/K has been found tohave positive effects upon the biochemistry of premature infants. Kuhn et al.(1991) reported preterms who received 10 days of T/K demonstrated significantincreases in urinary excretion of norephinephrine and epinephrine. These find-ings were interpreted as indicating maturation of the sympathetic nervous sys-

tem. Massage has also been shown to reduce plasma cortisol levels. This ledAcolet et al. (1993) to conclude that the procedure is both pleasurable andvaluable for ameliorating pain. More recently, Moyer-Mileur, Luetkemeler,Broomer, and Chan (1995) found that a 4-week kinesthetic procedure (i.e.,


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passive limb movements) led to increases in bone width, mineral density, andcontent.

A PRESCRIPTION FOR STIMULATION OF PREMATURE INFANTSThe differential effects which the various interventions have upon behav-ioral state point to a "sequential multimodal approach" to the supplementalstimulation of preterms. The specific sequence and duration of each treatmentcomponent would be determined by the status of the neonate, and its reaction toeach stimulation modality (determined by formal behavioral assessment). Inconsideration of the problems that premature infants commonly encounter, thegoals of this approach might include (a) promoting state regulation, (b) facilitat-

ing the infant's interface with the environment, (c) enhancing general neuro-behavioral developm ent. W hat is unique about this hypothetical m odel is that it isdirected towards clinical treatment. Unlike most research paradigms, the courseof intervention does not rely upon the infant having reached a clinically stablestate: In fact, the early stages of treatment are aimed at assisting in achievingsuch ends.Tronick et al. (1990) reported that extremely low birth weight preterms arevery disorganized in all aspects of behavioral functioning. As these infantsbecome more homeostatic they predominately exhibit a persistent state of stillsleep which the authors have christened " protective a pathy." It is argued that thisstate protects physiological reserves, aids in the recovery from the stressors ofprematurity and the NICU, and leads to the emergence of differentiated behav-ioral states. Therefore, for premature infants who are suffering from significantbehavioral disorganization and ill health, those forms of intervention that sootheand pro mote deeper and restorative sleep states might first be initialed. Potentialregimes could include the unitary or conjoint use of auditory stimulation andstable or oscillating waterbed stim ulation . Since findings from full-term infantssuggest a positive relationship between sp eed of rocking and level of qu iescience(Van D en D aele, 1970), research is necessary to determine if less stable pretermscan tolerate higher oscillation rates (e.g., 25-30 cpm) and whether such speedspromote state organization.Once homeostasis is achieved, slow oscillating (e.g., 12-16 cpm) waterbedstimulation should further facilitate the preterm's interface with the environmentthrough the prom otion of quiet alertness and visual pu rsuit. This stage might alsointroduce oral stimulation since it too promotes environmental engagement andhas the added benefit of enhancing weight gain.

Once increased alertness is well-tolerated, T/K stimulation should be initi-ated. Besides the further promotion of weight gain, it has been argued that thereis an inherent therapeutic quality to touch (Mo ntagu, 1978). In addition, since


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T/K elicits greater activity, it may be superior to the other approaches for enhanc -ing motor development.A preterm's point of entry into this treatment model would depend upon anassessment of state regulation: For example, a very unstable infant might beginwith unitary auditory stimulation, whereas a more stable preterm might begin

with slow oscillating rocking or T/K. Furthermore, the infant's reaction to eachtreatment stage would determine its progress along the algorithmic pathway: Anadverse reaction to a newly introduced stage would result in a return to theprevious form(s) of supplemental stimulation (or in more serious cases, no stimu-lation at all).

Comm ent and Future DirectionsIn light of the considerable evidence that supplemental stimulation pro-grams are effective, it is surprising that the number of published reports on thistopic has decreased in the last decade. Theoretical and methodological problemsprobably contribute to the apparent reduction in interest. Regardless, the demon-strated decrease in length of hospitalization, enhanced development, and poten-tial financial savings should eventually capture the interest of the cost-conscioushealth care community. Moreover, supplemental stimulation of preterms infantsin a salient research avenue for furthering our knowledge of the relationshipbetween human brain plasticity and the impact of the environment on develop-ment.At present, we have undertaken a direct comparison of vestibular and tac-tile/kinesthetic stimulation on premature infants. Specifically, we are attemptingto determine if fast vestibular stimulation (i.e., waterbed oscillations of 25-30cpm) promotes more frequent and deeper sleep states; slow vestibular stimulation(i. e. , 1 2- 1 6 cpm) increases periods of quiet alertness; and if tactile/kine stheticstimulation (massage/passive limb movement) promotes alertness and motoricoutput. Support for these hypotheses will delineate the important components ofthe treatment model and lay the groundwork for its application with unstable orill premature infants. We feel an important part of this effort is to determine if thethree treatment approaches have differential effects upon development.

R E F E R E N C E SAcolet, D ., Mod i, N., Giannakoulopoulos, X. , Bond, C , Weg, W., Low, A., & Glover, V. (1993).Chan ges in plasma cortisol and catecholamine concentrations in response to massage in preterminfants. Archives in Disease in Childhood, 68, 29-31.Adamson-Macedo, E. N. (1985). Effects of tactile stimulation on low and very low birthweightinfants during the first week of life. Current Psychological Research and Reviews, 6, 305-308.


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3 - 5 3 .Bembaum , J. C , Gilberto, R., W atkins, J. B. , & Peckham, G. J. (1983). Nonnutritive suckingduring gavage feeding enhances growth and maturation in premature infants. Pediatrics, 71,41-45.Brazelton, T. B. (1973). Neonatal Behavioral Assessment Scale. Philadelphia: Lippincott.Burroughs, A. K., Asonye, U . O., Anderson-Shanklin, G. C , & Vidyasgar, D. (1978). The effect ofnonnutritive sucking on transcutaneous oxygen tension in noncrying, preterm neonates, Re -search in Nursing and Health, 1, 69-75.Cohen, S. E., Parmelee, A. H., Beckwith, L., & Sigman, M. (1986). Cognitive development inpreterm infants: Birth to 8 years. Developmental and Behavioral Pediatrics, 7, 102-110.Cornell, E. H., & Gottfried, A. W. (1976). Intervention with preterm human infants. Child Develop-ment, 47, 32-39.Crook, C. K., & Lipsitt, L. P. (1976). Neonatal nutritive sucking: Effects of taste stimulation uponsucking rhythm and heart rate. Child Development, 47, 518-522.Emory, E. K., H atch, M., Blackmore, C , & Strock, B. (1993). Psychophysiological responses tostress during pregnancy. Centers for Disease Control and Prevention, Division of ReproductiveHealth, Atlanta, GA.Field, T. (1980). Supplemental stimulation of preterm infants. Early Human Development, 4,301-314.Field, T. (1988). Stimulation of preterm infants. Pediatrics in Review, 10, 149-153.Field, T., & Goldson, E. (1984). Pacifying effects of nonnutritive sucking on term and pretermneonates during heelstick procedures. Pediatrics, 74, 1012-1015.Field, T , Ignatoff, E., Stringer, S., Brennan, J., Greenberg, R., Widmayer, S., & Anderson, G. C.(1982). Nonnutritive sucking during tube feedings: Effects on preterm neonates in an intensivecare unit. Pediatrics, 70, 381-384.Field,T., Schanberg, S. M., Scafidi, F., Bauer, C. R., Vega-Lahr, N.,Garcia, R., N ystrom,G., &K uhn ,C. M. (1986). Tactile/kinesthetic stimulation effects on preterm neonates. Pediatrics, 77, 654-658.Gill, N. E., Behinke, M., Conolon, M., McNeely, J. B., & Anderson, G. C. (1988). Effect of

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