Early Human Development 103 (2016) 77–81

Contents lists available at ScienceDirect

Early Human Development

journal homepage: www.elsevier.com/locate/earlhumdev

Analysis of sensory processing in preterm infants

Thais Invenção Cabral, Louise Gracelli Pereira da Silva,
Cláudia Maria Simões Martinez, Eloisa Tudella
Department of Physiotherapy, Federal University of São Carlos - São Carlos / São Paulo – Brazil

a r t i c l e i n f o a b s t r a c t

Article history: Background: Premature birth suggests condition of biological vulnerability, predisposing to neurological injuries,
Received 16 December 2015 requiring hospitalization in Neonatal Intensive Care Units, which, while contributing to increase the survival
Received in revised form 20 May 2016 rates, expose infants to sensory stimuli harmful to the immature organism.
Accepted 14 June 2016 Aims: To evaluate the sensory processing at 4 and 6 months' corrected age.
Subjects and methods: This was a descriptive cross-sectional study with a sample of 30 infants divided into an
Keywords:
experimental group composed of preterm infants (n = 15), and a control group composed of full-term infants
Infant
Premature
(n = 15). The infants were assessed using the Test of Sensory Functions in Infants.
Preterm Results: The preterm infants showed poor performance in the total score of the test in reactivity to tactile deep
Neurodevelopment pressure and reactivity to vestibular stimulation. When groups were compared, significant differences in the
Sensory processing total score (p = 0.0113) and in the reactivity to tactile deep pressure (p b 0.0001) were found.
Conclusion: At 4 and 6 months of corrected age, the preterm infants showed alterations in sensory processing.
These changes were most evident in reactivity to tactile deep pressure and vestibular stimulation.
© 2015 Published by Elsevier Ireland Ltd.

1. Introduction development in the short, medium and long term [7]. Thus, the NICU
environment may be a major factor contributing to the increased inci-
Interaction with the environment requires interpretation and re- dence of behavioral and learning alterations in individuals with histo-
sponses to sensory stimuli. It involves the ability to process stimuli ries of prematurity and low birth weight, due to the immaturity of the
from all systems (tactile, olfactory, gustatory, visual, auditory, proprio- central nervous system (CNS) and the excessive sensory stimulation
ceptive and vestibular), and then interpret them and respond to them during the hospitalization period [3,8].
adaptively [1]. This process allows individuals to direct attention and The organization phase of the CNS occurs at a time of vulnerability in
continually responds to demands from the environment. Thus, all ac- preterm infants. Despite CNS organization continuing into adulthood, it
tions, not only in terms of body movements, but also those of learning enters a critical period between the 5th and 6th month of gestation up
processes and concept formation, are dependent on the ability to inter- to 1 year of age [9], when CNS organization is determined by sensory in-
pret sensory information [1]. puts that influence the neuronal selection/maintenance. Thus, the first
Children that do not process sensory information properly, mani- sensory inputs experienced by infants in the NICU and later in their
festing maladaptive responses, may have sensory processing disorders home environment will affect cerebral development. This means that
[2]. The cause of these disorders is still unknown, but they are more excessive sensory inputs from the hospital environment may strengthen
common and evident in children with a history of prematurity, low some neuronal connections that will be retained, but that will no longer
birth weight and neonatal complications, i.e., the so-called high-risk in- be the most appropriate for further development. During intrauterine
fants, who often require treatment in Neonatal Intensive Care Units life, the development of the sensory system occurs in a specific sequence.
(NICUs). Touch is the first system to be developed, while vision is the last one [10].
The implementation of NICUs was a milestone in the care of preterm Thus, the exposure of preterm infants to these stimuli alters the natural
newborns, because they reduced neonatal morbidity and mortality, process of this sequence [11–13]. Therefore, infants in a NICU are exposed
especially among extreme preterm and very low birth weight infants to a condition of multiple risks in which one risk potentiates another.
[3–6]. Thus, the long-term stays by preterm infants in NICUs is frequent- During this critical phase of brain development, excessive exposure
ly associated with factors that cause discomfort and pain, which may to stimuli must be controlled so that there is no interruption of the nor-
have negative impact on their psychological, sensory and motor mal development sequence [14]. Taylor et al. [15] examined perfor-
mance predictors of children with very low birth weight (b1500 g) at
Abbreviations: CNS, central nervous system; NICUs, Neonatal Intensive Care Units;
school age, for cognitive function, neuropsychological abilities,
TSFI, Test of Sensory Functions in Infants. academic performance and behavior. Their results showed that, even
E-mail address: [email protected] (T.I. Cabral). after controlling for socioeconomic risk factors, the neonatal risk

http://dx.doi.org/10.1016/j.earlhumdev.2016.06.010
0378-3782/© 2015 Published by Elsevier Ireland Ltd.
78 T.I. Cabral et al. / Early Human Development 103 (2016) 77–81

influenced the cognitive performance and neuropsychological abilities balance, and incoordination, compromising academic performance. In
of the children evaluated, and the greater the neonatal risk (intracranial addition, behaviours associated with poor sensory processing in these
hemorrhage, necrotizing enterocolitis, and chronic lung disease), the children include distractibility, tactile defensiveness, and problems
higher the level of developmental disability assessed at school age. with language and visual–spatial skills.
The association between the changes in sensory processing and the The impact that early sensory processing capacities on later learning
gross motor development was verified by Cabral et al. [16]. The authors and emotional development lacks clarity, mainly because of difficulty in
used the TSFI to evaluate the sensory processing and the AIMS to defining consistent constructs within the field and an absence of assess-
evaluate the motor development of preterm and term infants aged ments to detect infants with sensory dysfunctions reliably and ade-
4–6 months. The results showed that all infants who scored abnormal quately [22]. Thus, the evaluation of sensory processing is important
in the total score, subdomain 1 and subdomain 5 on TSFI presented to understand the characteristics of these infants. During hospitalization
motor performance at or below the 5th percentile on the AIMS scale. and after discharge, new treatments may be proposed for secondary
This date suggests that one risk factor appears to potentiate another, prevention, health promotion and rehabilitation of this population,
that is, tactile defensiveness (subdomain 1), associated with poor pos- aiming at a differential diagnosis, which would allow the development
tural control (subdomain 5) implies an alteration in sensory processing of individualized intervention programs. Despite this importance,
(total score), which may reflect the in global delay motor Development there are few studies evaluating the sensory processing of at-risk infants
(AIMS). in the literature.
No estudo de Chorna et al. [17] os autores observed abnormal senso- Therefore, the aim of this study was to evaluate the sensory process-
ry reactivity on TSFI score in 82% of preterm infants evaluated at ing at 4 and 6 months' corrected age. We hypothesize that preterm in-
4–12 months corrected age, and at 2 years old, these children were fants will present alterations of sensory processing in the reactivity to
found to have poor adaptive motor function in early childhood and tactile deep pressure, and the reactivity to vestibular stimulation.
worse scores on motor and language acquisition.
According to Rugolo [18], the major sequelae found in preterm new- 2. Methods
borns are severe neurosensory disorders, including blindness, deafness,
and cerebral palsy. These sequelae are detected in 6–20% of preterm This was a descriptive cross-sectional study with a sample of
infants with extreme low birth weights at a frequency that is inverse- 30 infants divided into two groups: an experimental group com-
ly proportional to gestational age. Thus, in preterm infants with posed of preterm infants (n = 15), and a control group composed
23–25 weeks of gestational age, the incidence of serious sequelae of full-term infants (n = 15) aged between 4 and 6 months
reaches 30% or more, and half of these infants show sensory and/or (22.2 ± 1.3 weeks and 19.8 ± 1.2 weeks, respectively), corrected
neurodevelopment abnormalities. for preterm infants. The characteristics of the infants studied are
Preterm infants are more vulnerable to alterations in neuro- shown in Table 1.
sensoriomotor development. Inadequate stimulation during the hospi- Preterm infants were selected from the follow-up service, and the
talization period may be related with these alterations. Hence, to control group through the waiting list for daycare and by referral by in-
verify the impact of inadequate stimulation of the immature organism dividuals known to the researcher. Inclusion criteria to the preterm in-
is important to establish which sensory systems may show greater fants were: parental consent to participation in this study evidenced
alterations on responses to the environment. by signing an Informed Consent Form, gestational age lower than
Sensory changes can negatively influence parent-child interactions 37 weeks [23], hospitalization in a NICU for at least 1 day, and within
in the short term because the infant care involves constant changes in the age range of 4 to 6 months corrected age. Infants diagnosed with
the level of the tactile system, which may result in irritability, excessive CNS alterations, congenital musculoskeletal abnormalities, genetic syn-
crying, and difficulties with sleeping, feeding and calming down. In the dromes, sensory deficits (visual or auditory) reported in medical re-
long term, sensory changes may lead to sudden changes in mood, diffi- cords, and those whose parents or guardians dropped out of in the
culties to adapt to general changes (e.g. environmental changes), lan- research were excluded.
guage difficulties, attention disorders, and inability to play alone or Infants in the full-term group had a gestational age equal to or
with other children [19]. These factors could have a substantial impact N37 weeks [23], an Apgar score equal to or N 7 in the first and fifth mi-
on global development and social interaction. nutes, adequate weight for gestational age and an age between 4 and
In the study by Wiener et al. [20], the authors determined the differ- 6 months.
ences in sensory processing among typical full-term infants, full-term The sample composition is found in Fig. 1.
infants with a regulatory disorder, and prematurely born infants. The This study was approved by the Ethics Committees of Institutional
Test of Sensory Functions in Infants (TSFI) was administered to 329 in- Research, of the Municipal Health Bureau and “Santa Casa de
fants, aged 7 to 18 months. The infants with regulatory disorders had Misericórdia” Hospital. Written informed consent was received from
problems with sleep and eating, high irritability and sever separation subjects' consenting to their children's participation.
anxiety. Prematurely born infants or those with a regulatory disorder Perinatal characteristics were extracted from the medical record. The
scored lower than the typical infants on the test. Thus, the results Brazilian Criterion for Economic Classification [24] was used for economic
suggest differences in sensory processing of infants with regulatory characterization of the sample. The Test of Sensory Functions in Infants –
disorders are evident when compared to children born prematurely. TSFI [21] was used to evaluate the sensory processing of infants.
According to DeGangi e Greenspan [21], infants with poor sensory The Test of Sensory Functions in Infants was developed to measure
processing typically exhibit delays in fine and gross motor skills, poor the sensory integration behavior of infants aged 4–18 months in the

Table 1
Characteristics of the groups: number of the sample (N), sex, mean gestational age, mean birth weight, mean Apgar score (1 and 5 min), and average hospital days.

Sex Apgar
Gestational Birth weight
Group N F M age (weeks) (grams) 1st min 5th min Hospital (days)

PTN 15 8 7 31.3 (±1.8) 1506 (± 386.5) 6.9 (± 1.6) 8.7(±1) 16.4 (±13.0)
FTN 15 7 8 39.2 (±0.8) 3047.3 (±412.7) 6.8(±3.5)⁎ 7.7(±4)⁎

PTN = Preterm newborn; FTN = Full-term newborn, N = number of sample; F = female, M = male.
⁎ For three infants, the Apgar scores were not recorded in their respective baby records.
 T.I. Cabral et al. / Early Human Development 103 (2016) 77–81 79

Therefore, TSFI provides information that allows determination of the

extent of a child's sensory deficits.
For the administration of the instrument, one researcher intensively
studied the manual and retrospectively calculated the intra-research
agreement index, which was 81.6%. All infants (the experimental and
control group) were assessed in a single assessment, always by the
same investigator. In subdomain 5, all infants were evaluated by their
mothers. With this procedure, we seek to avoid anxiety and crying of
infants, and to standardize the management.
The assessments were performed around the monthly anniversary
date of the infant (i.e., 4, 5, or 6 months), within of seven days before
or after this date. The infants should be in an active or inactive alert
state (states 3 and 4) [25]. Data were recorded on the TSFI evaluation
forms and all assessments were filmed to confirm the score, if necessary.
The assessment could be interrupted to calm down or change the
infant's diaper, and resumed as soon as possible.
For the statistical analysis between the groups studied, at first, the
frequencies of all the variables and measurement of central tendency
were verified. When crossing the data, normality was verified by
the Shapiro-Wilks test, which determined the choice of the non-
parametric Mann-Whitney. The significance level chosen was 0.05.

3. Results

The results showed that in the total score of TSFI, 73% (n = 11) of
infants from the preterm group scored “deficient” and 7% (n = 1) scored
“at-risk” (Table 2), i.e., 80% of these infants showed some risk for senso-
ry abnormalities. Comparing preterm and full-term infants, there was a
Fig. 1. Flowchart of the subject samples. significant difference in the total score of the test (p = 0.0113).
With respect to subdomain 1 (reactivity to tactile deep pressure), 93%
(n = 14) of preterm infants scored “deficient”. Comparing preterm and
full-term infants, there was a significant difference in this subdomain
following subdomains: reactivity to tactile deep pressure, adaptive (p b 0.0001) (Table 2). In subdomain 2 (adaptive motor functions), 53%
motor functions, visual-tactile integration, ocular-motor control, and re- of the preterm infants scored normal, while in subdomains 3 (visual-tac-
activity to vestibular stimulation. According to the authors test [21] the tile integration) and 4 (ocular-motor control), 93% and 87% scored “nor-
selection of these five subdomains was based on studies that describe mal”, respectively. In subdomain 5 (reactivity to vestibular stimulation),
the importance of standardizing tactile and vestibular functions for 80% (n = 12) scored “deficient” and 20% (n = 3) scored “at-risk”,
the improvement of fine and gross motor coordination and motor plan- i.e., 100% of infants had impaired postural control (Table 2).
ning skills. The instrument consists of 24 items which are divided into As for the other subdomains (adaptive motor functions, visual-
five subdomains, and was specifically developed for administration by tactile integration, ocular-motor control and reactivity to vestibular
occupational therapists, physical therapists, psychologists and infant stimulation) no significant differences were found between the groups.
educators with training and experience in the interpretation of results Regarding the subdomains 2 (adaptive motor functions), 3 (visual-
and the domain of sensory integration. According to the manual, tactile integration) and 4 (ocular-motor control), the absence of signif-
subdomain 5 (reactivity to vestibular stimulation) should be performed icant difference is in line with the validation sample of TSFI, which states
by a parent so that there is no interference in the response. The scoring that these items are not sensitive to the age group between 4 and
method uses two score forms, which show the score of each item. Each 6 months old.
form has a brief explanation of the assessment method and the sum-
ming of items of each domain and the total score. Scores were assigned
so that the indices of each subdomain could be calculated to provide di- 4. Discussion
agnostic information in the area where sensory processing shows a
delay in child development, with validity and reliability guaranteed This study aimed to evaluate the sensory processing of preterm in-
[21]. Assessment takes approximately 20 min and the total score for fants aged 4–6 months of corrected age. The preterm infants showed
all domains provides a gross index of delay or normality (deficient, at- poor performance in the total score of the test, the reactivity to tactile
risk, and normal) for each age group for screening purposes [22]. deep pressure, and the reactivity to vestibular stimulation. When the

Table 2
Number of participants for the preterm and full term infants for subdomains (SUB 1) reactivity to tactile deep pressure, (SUB 2) adaptive motor functions, (SUB 3) visual-tactile integration,
(SUB 4) ocular motor control, and (SUB 5) reactivity to vestibular stimulation, in the Test of Sensory Function in Infants (TSFI).

Total score SUB 1 SUB 2 SUB 3 SUB 4 SUB 5

Group DF AR N DF AR N DF AR N DF AR N DF AR N DF AR N

PTN 11 1 3 14 0 1 8 0 7 1 0 14 2 0 13 12 3 0
FTN 8 2 5 2 4 9 6 3 6 0 0 15 0 0 15 9 1 5

PTN = Preterm newborn; FTN = Full-term newborn; DF = deficient; AR = at-risk; N = normal.

80 T.I. Cabral et al. / Early Human Development 103 (2016) 77–81

groups were compared, significant differences in the total score and re- study had pain memory at 4 and 6 months of corrected age, perceiving
activity to tactile deep pressure were found. touches conducted in the TSFI on their forearm, hand, abdomen, foot
According to Eeles et al. [26], early childhood experience is a crucial and mouth, as aversive or painful.
determinant of health, well-being, and the attainment of competencies We believe that changes in reactivity to vestibular stimulation
at later ages. Thus, identifying sensory processing dysfunction as early subdomain is due to hypotonia, which is typical in premature infants.
as possible and providing appropriate intervention may improve devel- The hypotonia associated with stay in the NICU into a single posture,
opmental outcomes. Therefore, this study aims to bring contributions in strengthens the musculoskeletal and neuromotor immaturity. We em-
the area of sensory processing in infants. phasize that these factors can make it difficult the spontaneous move-
Most preterm infants in this study (80%) scored “deficient” or ment of the infants's head. However, it is this movement of the head
“at-risk” in the total score of the test. Since preterm infants are a popu- that stimulates the organs responsible for the vestibular system
lation with greater predisposition to neurodevelopmental abnormali- (semi-circular canals, utricle and saccule), which allows the orientation
ties, we believe that this score represents a potential problem, of the body in space. Sweeney and Guitirrez [30] and Lickliter [31]
i.e., suspected alteration or abnormality established in the sensory pro- observed that preterm infants require supports such as prolonged endo-
cessing. Similarly, Chorna et al. [17] observed abnormal sensory reactiv- tracheal intubation, umbilical catheters and drains, which favor improp-
ity on TSFI total score in 82% of very preterm infants evaluated at er posture. In addition to improper posture in the incubator, an infant is
4–12 months corrected age. deprived of body movements in space, that are normally experienced
These current results are consistent with White-Traut et al. [27]. The through basic care such as diapering, placement and removal from the
authors showed that preterm infants have different sensory processing cradle, bathing, feeding, and warmth during balancing on the lap or
patterns compared with full-term infants. They suggested that the stroller provided by a caregiver in the home environment. Thus, it is ex-
preterm infants enter the neonatal intensive unit at a time of rapid pected that the response to movement in the vertical and horizontal
brain development and when their sensory systems are exposed to planes, as well as the reactivity of the vestibular system during rotation
stimuli which are in conflict with the infant's sensory needs. Thus, this evaluated by the TSFI would be impaired.
event, at this time, can harm the sensory processing in these infants. Chorna et al. [17] have also found that deficient reactivity to sensory
Bart et al. [28] have also found differences between the two groups stimuli (tactile deep pressure, reactivity of the vestibular system) on
in all the aspects of sensory modulation – reaction to deep pressure, TSFI is associated with the perinatal characteristics (immaturity, lower
adaptive motor behavior, visual–tactile integration, and vestibular primary caregiver education). However, even after adjusting for these
reaction. These data support the notion that preterm infants are at characteristics, abnormal sensory reactivity increased the odds of hav-
higher risk than full-term infants of having sensory modulation ing poor outcomes at 2 years. This is consistent with the importance
disorder. of sensory experience in infant learning and development.
Therefore, in agreement with the authors of the TSFI [21], we believe Interestingly, despite not being a sensitive subdomain for the age
that the so-called high-risk infants should be referred for early interven- group included in this study, the majority of preterm infants (53%)
tion and followed up until preschool years. Chorna et al. [17] also showed impairment in motor response adapted to function, which cor-
showed that at 2 years old children with poor sensory processing responds to the capabilities of motor planning and praxis for manipulat-
were found to have poor adaptive motor function in early childhood ing toys of various textures. We believe that this deficiency is related to
and worse scores on motor and language acquisition. As a result, we be- the poor postural control observed in the evaluation of subdomain 5.
lieve that the early intervention can prevent the development of future According to Carvalho et al. [33], and Thelen et al. [34], between four
cognitive and motor disturbances resulting from changes in the sensory and six months of age, infants are acquiring control of flexor and exten-
processing of areas such as motor planning and bilateral motor sor muscles of the trunk, which is critical for the acquisition of manual
coordination. skills such as reach, the first manual skill to developed. Thus, we suggest
It is possible that the high incidence of “deficient” scores obtained in that, due to their poor postural control, the preterm infants in this study
the total score of the present test was influenced by the high percentage had not yet efficiently acquired control of the trunk muscles in sitting
of infants who had this classification in subdomains 1, reactivity to tac- with support, hindering the release of one or both upper limbs for ma-
tile deep pressure (93%), and 5, reactivity to vestibular stimulation nipulating toys. In addition, it is possible that change in the modulation
(80%). A similar result were found by Chorna et al. [17]. These authors of the deep tactile response represents a tactile defensiveness, which af-
found that 82% dos preterm infants evaluated at 4–12 months corrected fects an infant's ability to explore toys with the hands. Therefore, at-risk
age (median 8 months) had score deficient in one of the TSFI infants should be stimulated early, so that the deficit in postural control
subdomains. Similarly to our results, these authors also found that and/or tactile defensiveness does not impair the acquisition of new
lower gestational age was associated with abnormal reactivity to deep motor skills. Moreover, this finding suggests that the application of the
pressure and vestibular stimulation. Our results allow us to confirm test and the analysis of the results, in both research and clinical practice,
the hypothesis that preterm infants had deficient sensory processing should not be restricted to the most sensitive subdomains for the age
especially with respect to tolerating tactile deep pressure and reactivity group established by the TSFI manual.
to vestibular stimulation. According to the above, it is necessary to detect early changes in sen-
In the study of Bart et al. [28], which the aim of the study was to as- sory development through assessments of sensory processing, which
sess prospectively the differences in participation and sensory modula- may contribute not only to the establishment of a diagnosis, but also
tion between late preterm infants and full term infants, the authors to gathering information for the planning of strategies for preventive
showed that in the TSFI, significant differences were found at all the measures or, if necessary, oriented therapies to promote sensory devel-
test categories assessing different aspects of sensory modulation. opment to beneficially affect the neurosensoriomotor development of
With regard to the deficiency in the response to tactile deep pres- infants.
sure, we believe that it is a consequence of the greater responsiveness We also suggest that further studies with larger numbers of partici-
of infants to tactile stimuli in the first days of life, compared to other sen- pants and longitudinal character, be carried out to better understand the
sory modalities. This is because, in addition to tactile sense being the change of sensory processing, especially of deep pressure touch and ves-
first sensory system to developed [10], according to Gardner et al. [29] tibular stimulation in the first year of life.
and Blackburn [8], preterm infants born with b30 weeks of gestational
age have all the components of nociceptive pathways, although they Conflict of interest
do not have mechanisms sufficiently mature to inhibit or reduce the
pain sensation yet. Thus, it is possible that the preterm infants of this The authors have no conflicts of interest to disclose.
 T.I. Cabral et al. / Early Human Development 103 (2016) 77–81 81

Ethical information [15] G.H. Taylor, N. Klein, C. Schatschneider, M. Hack, Predictors of early school-age out-
comes in very-low-birth-weight children, J. Dev. Behav. Pediatr. 19 (1998) 235–243.
[16] T.I. Cabral, L.G.P. Silva, E. Tudella, C.M.S. Martinez, Motor development and sensory
The study was conducted in accordance with the Declaration of Hel- processing: a comparative study between preterm and term infants, Res. Dev.
sinki of the World Medical Association, and was approved by the Ethics Disabil. 36 (2015) 102–107.
[17] O. Chorna, J.E. Solomon, J.C. Slaughter, A.R. Stark, N.L. Maitre, Abnormal sensory re-
Committee of the Federal University of São Carlos, Brazil. activity in preterm infants during the first year correlates with adverse
neurodevelopmental outcomes at 2 years of age, Arch. Dis. Child. Fetal Neonatal
Acknowledgements Ed. (2014) 1–5.
[18] L.M.S. Rugolo, Crescimento e desenvolvimento a longo prazo do prematuro
extremo, J. Pediatr. 81 (2005) 101–110.
The authors thank the CNPq (National Counsel of Technological and [19] S.I. Greenspan, S.W. Porges, Psychopathology in infancy and early childhood: clinical
Scientific Development) for sponsoring this project, all the families who perspectives on the organization sensory and affective-thematic experience, Child
Dev. 55 (1984) 49–70.
agreed to participate and the translator.
[20] A.S. Wiener, T. Long, G. DeGangi, B. Battaile, Sensory processing of infants born pre-
maturely or with regulatory disorders, Phys. Occup. Ther. Pediatr. 16 (4) (1996)
References 1–17.
[21] G.A. Degangi, S.I. Greenspan, Test of Sensory Functions in Infants, first ed. Los
[1] A.J. Ayres, Sensory integration and learning disorders, seventh ed. Los Angeles, Angeles, Western Psychological Services, 1989.
Western Psychological Services, 1972. [22] G.A. Degangi, R.A. Berk, S.I. Greenspan, The clinical measurement of sensory func-
[2] L.C. Magalhães, Integração sensorial: uma abordagem específica da Terapia tioning in infants: a preliminary study, Phys. Occup. Ther. Pediatr. 8 (1988) 1–23.
Ocupacional, in: A.F. Drumond, M.B. Rezende (Eds.), Intervenções da Terapia [23] Organização Pan-Americana da Saúde, Rede interagencial de informações para
Ocupacional, Ed. UFMG, Belo Horizonte 2008, pp. 45–69. saúde. Demografia e saúde: contribuição para análise de situação e tendências,
[3] H. Als, L. Gilkerson, F.H. Duffy, F.H. Duffy, G.B. McAnulty, D.M. Buehler, K. first ed. Editora MS, Brasília, 2009.
Vandenberg, et al., A three-center randomized, controlled trial of individualized de- [24] Associação Brasileira de Empresas de Pesquisa, Critério classificação econômica Bra-
velopmental care for very low birth weight preterm infants: medical, sil, http://www.abep.org2008 (Accessed Jun. 06, 2010).
neurodevelopmental, parenting and caregiving effects, J. Dev. Behav. Pediatr. 24 [25] H.F.R. Prechtl, D. Beintema, Neurological examination of the full term and newborn
(2003) 399–408. infant, Clin. Dev. Med. 12 (1964) 112–118.
[4] C.G.S. Scochi, M.J.S. Riul, C.F.D. Garcia, L.S. Barradas, S.O. Pileggi, Cuidado [26] A.L. Eeles, A.J. Spittle, P.J. Anderson, N. Brown, K.J. Lee, R.N. Boyd, et al., Assessments
individualizado ao pequeno prematuro: o ambiente sensorial em unidade de terapia of sensory processing in infants: a systematic review, Dev. Med. Child Neurol. 55
intensiva neonatal, Acta Paul. Enferm. 14 (2001) 9–16. (2013) 314–326.
[5] H. Als, Towards a synactive theory of developmental care promise for the assess- [27] R.C. White-Traut, M.N. Nelson, K. Burns, N. Cunningham, Environmental influences
ment and support of infant individuality, Infant Ment. Health J. 3 (1982) 229–243. on the developing premature infant: theoretical issues and applications to practice,
[6] H. Als, G. Lawhon, F.H. Duffy, G.B. McAnulty, R. Gibes-Grossman, J.G. Blickman, Indi- J. Obstet. Gynecol. Neonatal. Nurs. 23 (1994) 393–401.
vidualized developmental care for the very low-birth-weight preterm infant. Medi- [28] O. Bart, S. Shayevits, L.V. Gabis, I. Morag, Prediction of participation and sensory
cal and neurofunctional effects, JAMA 272 (11) (1994) 853–858. modulation of late preterm infants at 12 months: a prospective study, Res. Dev.
[7] R.E. Grunau, Long-term consequences of pain in human neonates, Semin. Fetal Neo- Disabil. 32 (2011) 2732–2738.
natal Med. 11 (2006) 268–275. [29] S.L. Gardner, M.J.E. Hagedorn, L.A. Dicey, Pain and pain relief, in: G.B. Merenstein, S.L.
[8] S. Blackburn, Environmental impact of the NICU on developmental outcomes, J. Gardner (Eds.), Handbook of Neonatal Intensive Care, Mosby Elsevier, St. Louis
Pediatr. Nurs. 13 (1998) 279–289. 2006, pp. 223–272.
[9] J.J. Volpe, Cerebral white matter injury of the premature infant – more common [30] J.K. Sweeney, P. Guitirrez, Musculoskeletal implications of preterm infant position in
than you think, Pediatrics 112 (2003) 176–180. the NICU, J. Perinat. Neonatal Nurs. 16 (2002) 58–70.
[10] L.J. Miller, Sensational Kids: Help Hope for Children with Sensory Processing Disor- [31] R. Lickliter, The integrated development of sensory organization, Clin. Perinatol. 38
ders, second ed. G. P. Putnam's Sons, New York, 2006. (2011) 591–603.
[11] S. Blackburn, Problems of preterm infants after discharge, J. Obstet. Gynecol. Neona- [33] R.P. Carvalho, E. Tudella, S.R. Caljouw, G.J.P. Savelsbergh, Early control of reaching:
tal. Nurs. 24 (1995) 43–49. effects of experience and body orientation, Infant Behav. Dev. 31 (2008) 23–33.
[12] S.N. Graven, Early neurosensory visual development of the fetus and newborn, Clin. [34] E. Thelen, D. Corbetta, K. Kamm, J.P. Spencer, K. Schneider, R.F. Zernicke, The transi-
Perinatol. 31 (2004) 199–216. tion to reaching: mapping intention and intrinsic dynamics, Child Dev. 64 (1993)
[13] S.N. Gracen, Sound and the developing infant in the NICU: conclusions and recom- 1058–1098.
mendations for care, J. Perinatol. 20 (2000) 88–93.
[14] H. Als, F.H. Duffy, G.B. Mcanulty, M.J. Rivkin, S. Vajapeyam, R.V. Mulkern, et al., Early
experience alters brain function and structure, Pediatrics 113 (2004) 846–857.