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 Table of Contents  
Year : 2018  |  Volume : 23  |  Issue : 1  |  Page : 22-29

Neurobehavioral response to multisensory stimulation programme in high-risk neonates

1 Department of Physical Therapy for Paediatrics, Faculty of Physical Therapy, Cairo University, Cairo, Egypt
2 Department of Paediatrics, Faculty of Medicine, University of Mansoura, Mansoura, Egypt; Department of Neonatal Perinatal Medicine, HSC, University of Toronto, Toronto, Canada

Date of Submission18-Mar-2018
Date of Acceptance10-Jun-2018
Date of Web Publication8-Aug-2018

Correspondence Address:
Eman K Mohamed
7 Ahmed Elzaiat Street, Ben Elsaryat, El-Dokki, Giza, 02612
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Source of Support: None, Conflict of Interest: None

DOI: 10.4103/bfpt.bfpt_5_18

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Context High-risk neonates admitted to the neonatal intensive care unit (NICU) are suffering from lack of sensory experiences that are vital for normal brain development, rather are exposed to excessive or inappropriately timed stimulation in the NICU that leads to deleterious effects on premature infants whose brains are immaturely developed.
Aim The aim of this study was to investigate the effect of multisensory stimulation programme on neurobehavioral development in high-risk neonates.
Settings and design A prospective randomized controlled trial was conducted on 40 high-risk neonates, who were selected from NICUs, with mean gestational age of33±1.03 weeks according to new Ballard score and mean weight 1442±228.5 g. They were allocated into either the control group or the study group.
Participants and methods The control group received routine medical and nursery care in the NICU, whereas the study group received the same programme given to the control group in addition to the multisensory stimulation programme given daily for 2 successive weeks. The outcomes were measured before and after the intervention by Morgan neonatal neurobehavioral examination and Brazelton neonatal behavioural assessment scale.
Results There was a significant improvement in all measured variables in the study group after the intervention programme (P<0.05) except in the state regulation and autonomic system, whereas the control group showed no significant difference in all measured variables except in weight gain.
Conclusion Multisensory stimulation improved neurobehavioral development in high-risk neonates. This could be a vital part of the routine neonatal physiotherapy for preterm and high-risk neonates.

Keywords: early neurobehavioral intervention, high-risk neonates, multisensory stimulation, neonatal intensive care unit

How to cite this article:
Mohamed EK, Abdelazeim F, Elshafey MA, Nasef N. Neurobehavioral response to multisensory stimulation programme in high-risk neonates. Bull Fac Phys Ther 2018;23:22-9

How to cite this URL:
Mohamed EK, Abdelazeim F, Elshafey MA, Nasef N. Neurobehavioral response to multisensory stimulation programme in high-risk neonates. Bull Fac Phys Ther [serial online] 2018 [cited 2020 Oct 24];23:22-9. Available from: http://www.bfpt.eg.net/text.asp?2018/23/1/22/238775

  Introduction Top

High-risk neonates are newborn babies who are likely to face the threats of health problems than any normal babies of their age. Also, they may have the hazard of suffering from co-morbidity and possibly fatal complications because of prenatal, natal, or postnatal conditions [1]. The high-risk period starts from the time when the gestational age is 23 weeks up to 28 days after birth and interferes with normal development and threats to life and health [2].

High-risk neonates are nurtured in the neonatal intensive care unit (NICU) for the first few days or weeks of their life, which are different from that of the intrauterine environment and pose risk to fragile neonates [3]. They have to adapt to the extrauterine environment with immature body systems, resulting in increased biological risk for complications of prematurity [4].

Prematurity causes many neurobehavioral disabilities such as cerebral palsy, attention deficit hyperactivity disorder, autism, deafness and blindness occurring in up to 15% of preterm children [5]. The rates of milder neurobehavioral disabilities occurred in areas including language, attention, social–emotional development and executive function, and developmental coordination disorder additionally occurs in higher rates in children born preterm [6].

The risk of neurobehavioral disabilities not only increases with decreased gestational age, but also with issues related to perinatal (e.g. brain injury and infection) and the environment (e.g. lower financial status and parenting) impacts. Both the neurological and the medical factors play a vital role, and so the environmental and social factors become progressively critical [7].

Despite the notable progression in obstetric and neonatal care that has improved the neurobehavioral results for preterm children over the past few decades, the rates of disabilities stay high as well, and early developmental interventions are required not only during the neonatal intensive care period, but also during the early years of life to optimise the outcomes [8].

Early intervention (EI) consists of multidisciplinary services that are given to newborn from birth to the early years of life [9]. Interventions are mirroring the intrauterine environment that may have an advantageous impact on the development of preterm infants and help them to cope up better with the unfavourable environment [10].

Multisensory stimulation is considered to be an intervention that is closely related to the principles of sensory stimulation therapy [11], which is characterized by the arrangement of developmentally appropriate sensory inputs including tactile, vestibular, kinaesthetic, auditory, oral and visual, to preserve and encourage the development of existing simple abilities and to avoid or minimize the deleterious effects of the environment [12].

On one hand, there has been a study on preterm infants that illustrated different techniques of multisensory stimulations that are accompanied by positive outcomes in the development, including weight gain, positive changes in behaviour, reduced stress levels and heart rate, useful for modification of few undesirable neurological impacts of preterm birth and negative complications of long-term hospitalization. As a result, multisensory stimulations have been recommended as strategies in the NICU to promote growth and development [13].

On the other hand, the study asserted that there is no significant effect of multisensory stimulations on premature development, another one showed that there was a short-term effect of multisensory stimulations on weight gain and neuromotor development [14],[15].

Systematic review reported that there was a weak evidence of physiological and behavioural readiness of preterm infants to multisensory exposures [16]. Hence, the purpose of this study aims to investigate the effect of multisensory stimulation on neurobehavioral development in high-risk neonates.

  Participants and methods Top

Study design

A prospective randomized controlled trial has been performed from December 2017 till February 2018. The procedures were carried out according to the Research Ethical Committee (No: P.T.REC/012/001847) of Faculty of Physical Therapy − Cairo University and was registered on Pan African clinical trials registry with the approval number PACTR201804003308495. Written informed consent was taken from the parents and legal guardians of the children.


A total of 40 high-risk neonates from both sexes participated in this study. They were selected from NICU of Mansoura New General Hospital, Mansoura Insurance Hospital and Talkha Central Hospital. The neonates were allocated by simple randomization via sealed envelopes into two matched groups (control group and study group) by an independent person who took the sealed opaque envelope from a box following a numerical sequence; the envelope contained a letter indicating whether the participants would be allocated to the study or the control group.

As for the main criteria of the selected neonates in the study, the gestational age ranged from 32 to 36 weeks according to the new Ballard score, their weight ranged from 1000 to 2000 g and their Apgar score in 5 min ranged from 4 to 6. The neonates were excluded if they had congenital malformation, chromosomal anomaly, inborn errors of metabolism, seizure disorders, chronic medical complications including severe pulmonary dysplasia, interventricular haemorrhage grades II, III and IV, periventricular leukomalacia, required mechanical life support (ventilation) and deemed medically unstable by the neonatologist.


Each neonate was evaluated individually before and after 2 weeks of intervention in the NICU by the following:
  1. Morgan neonatal neurobehavioral examination (MNNE), which is a valid and reliable test in tone and motor patterns, primitive reflexes and behavioural responses [17]. It consists of three sections, each section containing nine items. Each item is scored with a three-point system [18]. The scores of the nine items in each section were summed to provide section scores in addition to a total score for all 27 items [17].
  2. Brazelton neonatal behavioural assessment scale (NBAS), which is a valid and reliable test for assessing the premature infants’ neurobehavioral development [19],[20]. The multidimensional multi-item scales the basic score sheet that includes 28 behavioural items and 18 reflex items; the behavioural items of NBAS are scored on nine points. Reflex items are scored on four points ranging from 0 to 3 [19].


The assessment of the neonates has been carried out in midway between the feeds with stable medical condition in a quiet incubator. The neonates’ weight was measured at 8 a.m. daily by the neonatal digital scale.


Both groups have received routine medical and nursery care in incubators for 2 successive weeks. A neonatologist has reviewed the medical charts daily and also has prescribed the necessary volume of intake to ensure adequate caloric intake to achieve a minimum weight gain of 15–20 g/day. Nursery staff is responsible for stress reduction and avoidance of sleep cycle disruption.

Moreover, the study group has also received the same treatment protocol of the control group in addition to multisensory stimulation programme. The multisensory stimulations programme was provided during a quiet alert state of the preterm neonate, before feeding. It was given for a duration of 45 min daily for 2 successive weeks. During intervention, the neonate was examined for signs of stress, and in case of observing one of the signs of stress, the intervention was stopped for 15 min and was started again after that. If any sign of stress was noticed to be repeated for the third time, the intervention was supposed to be stopped.

Before applying the intervention procedure, gentle massage was applied with the soft parts of two or three fingers by six strokes with moderate pressure, each stroke lasted for 10 s, in the following areas (head from crown to neck, then the external side of the upper and lower limbs). Total duration was 5 min [21].

The multisensory stimulation protocol according to Fucile and Gisel [22] include the following ([Figure 1] and [Figure 2]):
  1. Tactile stimulation with warm palms: the neonate’s body was gently stroked from head followed by the neck, then upper extremity, then lower extremity and then returns back for 10 min.
  2. Vestibular stimulation: the neonate was placed in a hammock in supine position and was elevated slowly to a semisitting position, after which the infant was lowered back to the supine position. This activity was done slowly to fully elicit the desired head righting reaction for 5 min.
  3. Kinaesthetic stimulation: the stimulation in which the neonate was placed in supine position. It consisted of passive exercises (flexion and extension) of upper and lower limbs; one of the hand supported the stimulated limb, whereas the other hand performed the movements for 5 min.
  4. Auditory stimulation through recorded mother’s voice for each neonate then played it through the intervention programme.
  5. Oral stimulation: the perioral structures were stroked by gently tapping the cheeks, lips and jaw by the index and middle finger for 7 min and stroking the intraoral structures by rubbing the gum and applying downward pressure of the tongue for 5 min, ending with non-nutritive sucking on a pacifier or the little finger for 3 min.
Figure 1 Flowchart of study participants.

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Figure 2 Multisensory stimulation program.

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Data analysis

All statistical measurements have been carried out using the statistical package for the social sciences version 23 (SPSS Inc., Chicago, Illinois, USA). In this study, mean±SD was calculated for all neonates. Descriptive statistics and t-test were used for comparing mean demographic data between both the groups. χ2-Value was applied for comparison between both groups by sex. Paired t-test was applied for comparison within the same group. Independent t-test was applied for comparison between both the groups before and after the intervention. Cronbach’s α was applied for measuring internal consistency, the statistical power and minimal clinical difference depending on the anchor method calculated. A value of P less than 0.05 was considered statistically significant.

Sample size calculation was done by comparing the neurodevelopmental scales between before and after intervention in a selected sample of neonates as it was the primary outcome of the study. The two scales under consideration were MNNE and NBAS. Searching of the literature failed to find any previous results that can be used to build up the sample size. Hence, a pilot study as performed to get the usable results. As reported in the pilot study, the mean±SD of MNNE scale before intervention was ∼12±2.9, whereas after intervention, it was ∼20.2±3.1. Similarly, the NBAS scale achieved 12.2±7 and 24.8±4.4 before and after the intervention, respectively. Accordingly, the minimum proper sample size was calculated to be 11 cases based on MNNE scale and nine cases based on the NBAS scale to be able to reject the null hypothesis with 95% power at α=0.05 level using Student’s t-test for independent samples. Thus, we decided to recruit 20 cases for each group. Sample size calculation was done using Stats Direct statistical software version 2.7.2 for MS Windows (StatsDirect Ltd, Cheshire, UK).

  Results Top

Demographic and clinical characteristics of neonates

The baseline characteristics of the participants showed that no statistically significant differences existed between both the groups (P>0.05), as shown in [Table 1]. There was, also, no significant difference between both the groups by sex, the χ2 value was 0.9 (P>0.05).
Table 1 General characteristics of neonates in both the groups

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Pretreatment comparison between both the groups

No statistically significant differences were noticed regarding the pretreatment between the two groups in all measured variables (P>0.05), as shown in [Table 2].
Table 2 Comparison between both groups in all measured variables

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Pretreatment and post-treatment comparison in each group

A significant improvement in all measured variables (P<0.05) was marked, except in state regulation and autonomic system (P>0.05) in the study group, as shown in [Table 2] and [Figure 3]. However, there were no statistically significant differences in all measured variables, except weight gain in the control group (P>0.05), as shown in [Table 2] and [Figure 4].
Figure 3 Comparison between Mean±SD values of Pre and Post-treatment of tone and motor pattern in Study group. (Bar represents mean values & Error bar represents standard deviation).

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Figure 4 Comparison between Mean±SD values of Pre and Post-treatment of Weight in Control group. (Bar represents mean values & Error bar represents standard deviation).

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Post-treatment comparison between both the groups

There was a statistically significant improvement in all measured variables between both the groups (P<0.05), except in state regulation, autonomic system and weight gain (P>0.05), as shown in [Table 2] and [Figure 5]. The minimal clinical difference was less than or equal to 0.5 SD, representing a moderate effect size, and this is corresponding to the minimal important difference ([Table 3]).
Figure 5 Comparison between Mean±SD values of Post-treatment of Social interactive in both groups. (Bar represents mean values & Error bar represents standard deviation).

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Table 3 Statistical power and minimal clinical difference for both the groups

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  Discussion Top

High-risk neonates with poor growth and development that frequently extend beyond neonatal period are likely to face health threats. The current challenge confronting professionals in NICUs is not only to ensure survival, but also to facilitate neurobehavioral development in preterm infants [23]. Hence, there is an essential requirement for an EI aiming at improving the neurobehavioral development [24]. The objective of this study was to investigate the effect of multisensory stimulation on neurobehavioral development in high-risk neonates.

The result of this study found that high-risk neonates who have received multisensory stimulation showed significant improvement in the MNNE in the areas of tone and motor pattern, primitive reflexes and total behaviour response after 2 weeks from the intervention, than the high-risk neonates who have not received such stimulation. They showed more mature mobility pattern in their movement, more capable of responding to their environment, more visually alert and showed fewer signs of irritability.

These findings are very promising in the field of neurorehabilitation. Multisensory stimulation upgrades high potential neuroplasticity, moreover encouraging the process of maturation of the brain electrical activity, similarly to that observed (in utero) in term infants, improved motor development and language of preterm infants, and contributes to the decrease in parental stress levels [25].

The development of the normal tone in the neonates who received multisensory stimulation could be credited to the effect of vestibulo-proprioceptive input that develops flexor tone in preterm infants. The development of flexor tone reduces the incidence of secondary complications and prevents delay in motor milestones [26]. Multisensory stimulation improves the development of the musculoskeletal system particularly, head and trunk control, postural alignment, as well as limb movement [27].

Overloading of sensory stimulations in NICU adversely influence the delicate physical of preterm infants, and immature organ systems, which could result in maladaptive motor behaviours, [28]. Whereas environmental modifications and EIs encourage positive stability, self-regulatory behaviours and help to decrease stress in preterm infants particularly during handling for NICU procedures. Therefore, positive sensory interventions such as multisensory stimulation in NICU owe to the advantageous impacts on behavioural development in preterm infants [29].

A significant improvement in habituation, social interaction, motor system, state organization and reflexes behaviour was noticed in the study group on Brazelton scale after the intervention. The findings of the study explained by Aliabadi and Askary [30] showed that tactile stimulation leads to decrease stress and anxiety level. Therefore, neonates could adjust better in many stressful circumstances. It was found that the neonates in the control group spent more time in the quiet state, whereas neonates in the study group were active and spent more time in a state of alertness [30]. Positive effects of vestibular stimulation on arousal level, visual exploratory behaviour, motor development and reflex integration have been detailed in the literature [31]. John et al. [31] hypothesized that vestibular stimulation decreases the intensity of internal needs that permits the infant to turn outward and be present at external events through the encouragement of quiet alertness.

A significant number of investigations showed that auditory stimulation had a positive effect on preterm infants, including reduced behavioural stress responses, improved parent–infant interaction and reduced length of hospitalization [32]. Also, these finding agree with Taneja et al. [33] who demonstrated that multisensory intervention affects physical, behaviour, social and mental development.

State regulation consisted of: cuddliness (infant’s response to being held), consolability (which allows baby quit), self-quieting and hand-to-mouth, whereas autonomic system evaluates tremulousness, startles, liability of skin colour and smiles of the neonates. The results of the present study revealed that there were no statistically significant in-state regulation and autonomic system behaviour. These findings are in line with the study conducted by Fiaenza et al. [34], who explained that excessive environmental stimuli in the NICU may disrupt the development of the autonomic system. The failure to decrease such stimuli may meddle with the infant’s self-regulatory capacities [34].The study by Ferreira and Bergamasco [35] counteracted the present result, they reported that greater alertness and motor activity of the premature infants who received tactile stimulation contributed to their more organized autonomic system that regulates their state responding to stimulation.

The result of this study revealed that there was a significant improvement in weight gain in both the groups, in favour of the study group. However, the post-treatment comparison revealed that there was no significant improvement in both groups, despite such a regulation in the level of calories received by both the groups. It appears that when stimulated, the neonates in the study group gained more weight than those in the control group. Moreover, this improvement in weight gain explained that multisensory stimulation stimulates the vagus nerve by stimulating the peripheral nerves, which releases gastric and intestinal hormones such as gastrin and cholecystokinin, and facilitates digestion and absorption of food and improves weight gain [36]. The results of the present study are inconsistent with those of Rocha et al. [37] who proved that multisensory stimulation stimulations did not have significant effects on weight gain in the first week.


This study was limited by small sample size because of time-bounded study and unstable vital signs during the intervention programme.

  Conclusion Top

Multisensory stimulation improved neurobehavioral development in high-risk neonates. It could be a vital part of routine neonatal physiotherapy for preterm and high-risk neonates.

Declaration of patient consent

The authors certify that they have obtained all appropriate patient consent forms. In the form the patient(s) has/have given his/her/their consent for his/her/their images and other clinical information to be reported in the journal. The patients understand that their names and initials will not be published and due efforts will be made to conceal their identity, but anonymity cannot be guaranteed.

Financial support and sponsorship


Conflicts of interest

There are no conflicts of interest.

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  [Figure 1], [Figure 2], [Figure 3], [Figure 4], [Figure 5]

  [Table 1], [Table 2], [Table 3]


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