Experience-Informed Practices in Preterm Infant Habilitation in Neonatal Intensive Care Unit: Integrating Therapists’ Expertise and Mothers’ Lived Experiences

Experience-Informed Practices in Preterm Infant Habilitation in Neonatal Intensive Care Unit: Integrating Therapists’ Expertise and Mothers’ Lived Experiences | Research Square window.SnipcartSettings = { analytics: { enabled: false } }; (function() { var accessVector = localStorage.getItem('access_vector') || ''; window.dataLayer = window.dataLayer || []; if (accessVector) { window.dataLayer.push({ user: { profile: { profileInfo: { snid: accessVector } } } }); } })(); (function(w,d,s,l,i){w[l]=w[l]||[];w[l].push({'gtm.start':new Date().getTime(),event:'gtm.js'});var f=d.getElementsByTagName(s)[0],j=d.createElement(s),dl=l!='dataLayer'?'&l='+l:'';j.async=true;j.src='https://www.googletagmanager.com/gtm.js?id='+i+dl;f.parentNode.insertBefore(j,f);})(window,document,'script','dataLayer','GTM-K279D39R'); Browse Preprints In Review Journals COVID-19 Preprints AJE Video Bytes Research Tools Research Promotion AJE Professional Editing AJE Rubriq About Preprint Platform In Review Editorial Policies Our Team Advisory Board Help Center Sign In Submit a Preprint Cite Share Download PDF Research Article Experience-Informed Practices in Preterm Infant Habilitation in Neonatal Intensive Care Unit: Integrating Therapists’ Expertise and Mothers’ Lived Experiences Abishek J R, Vadivelan Kanniappan This is a preprint; it has not been peer reviewed by a journal. https://doi.org/ 10.21203/rs.3.rs-6121364/v1 This work is licensed under a CC BY 4.0 License Status: Posted Version 1 posted You are reading this latest preprint version Abstract Background: Preterm birth continues to be a significant public health problem in India, accounting for most neonatal morbidity and mortality. Neonatal habilitation is a crucial process involving early sensory, motor, and cognitive interventions to improve long-term developmental outcomes. High-income countries have structured frameworks for neonatal rehabilitation, whereas India has different challenges, such as workforce shortages, inconsistent integration of therapy, and poor parental education. This study aimed to explore experience-informed neonatal habilitation practices in the neonatal intensive care units of Tamil Nadu, focusing on the roles of physiotherapists, occupational therapists, speech therapists, neonatologists, and the involvement of parents in preterm infant development. Methods: A qualitative study was conducted using in-depth interviews with neonatal therapists and mothers of preterm infants across multiple NICUs. Thematic analysis was performed to identify key patterns in habilitation practices, parental engagement, and barriers to effective implementation. Results: Findings clearly depict the crucial role of multi-disciplinary teamwork in the context of NICU habilitation. Therapists indicated the most comprehensive benefits from structured interventions, which include Kangaroo Mother Care, sensory-motor stimulation, and early oral feeding strategies. Parent education with active involvement enhanced caregiver confidence and reduced NICU stress; however, lack of standardized modules for training, limited resources, and cultural barriers prevented this practice. Conclusion: To maximize the developmental outcome in preterm infants, integrating structured habilitation frameworks with therapist-led and parent-driven interventions are important. Standardized training protocols, improving collaboration, and using culturally sensitive parent education strategies will assist in improving neonatal care in Tamil Nadu. Neonatal habilitation preterm infant development NICU therapy parental involvement India Introduction Preterm birth is one of the crucial issues in global health, and it is reported that the largest number of preterm births occurs in India. Around 3.5 million babies in India are born prematurely each year, contributing towards a significant neonatal morbidity and mortality rate ( 1 ). Tamil Nadu, famous for its strong public health infrastructure, has made significant progress in decreasing its neonatal mortality, but preterm babies are still a vulnerable segment and need special care ( 2 ). The state has a neonatal mortality rate of 8 per 1,000 live births, far below the national average, but NICU access is uneven, and there are workforce shortages, and standardized neonatal habilitation protocols are lacking ( 3 ). Neonatal habilitation is the provision of early developmental interventions designed to maximize sensory, motor, cognitive, and feeding functions in preterm infants admitted to the NICU. While higher-income countries have highly structured multidisciplinary NICU-based habilitation programs, India is laden with resource constraints, burdened healthcare systems, and inconsistent parent involvement ( 4 , 5 ). Involvement of a multifaceted team consisting of neonatologists, physiotherapists, occupational therapists, speech therapists, and developmental specialists has been promising in improving neuromotor outcomes, postural development, oral feeding skills, and sensory regulation in the preterm infant ( 6 ). However, standardized neonatal habilitation programs in Indian NICUs are underdeveloped and the role of various therapists remains inconsistently integrated ( 7 , 8 ). Since India has a NICU occupancy rate estimated to range above 750,000 newborns annually, a multidisciplinary therapist-led approach with parental participation is essential in reducing long-term neurodevelopmental impairments ( 9 ). Parents, especially mothers, contribute to the filling of the gaps of therapist-led interventions by doing KMC, positioning guided, early sensory stimulation, and habilitation led by the caregivers ( 10 ). In research, systematic training and empowerment of parents through NICU habilitation programs show improvements in preterm infants, including weight gain, shorter hospital stay, and neurodevelopmental trajectory ( 11 , 12 ). This study researches the application of experience-informed approaches to neonatal habilitation in the NICU context, putting forward aspects of neonatal therapists and parental involvement with preterm babies toward their early development in Tamil Nadu. It is an attempt to introduce parent-driven habilitation as a part of evidence-based rehabilitation methods in the context of creating a neonatal habilitation model that is relevant and compatible with India's healthcare regime and its culture. Procedure Study Design A qualitative study was conducted using experience informed approach with Braun and Clarke's Thematic Analysis to understand neonatal therapists' views and mothers' experiences about early habilitation practices in India. This research method helped gather an in-depth understanding of current practices, experiences of therapists, parental involvement, and contextual factors influencing neonatal care. Participants (a) Mothers of Preterm Infants Mothers were selected with specific inclusion criteria: they should have been engaged in neonatal care, and their infant was admitted to the NICU for at least two weeks. Those mothers who were having problems with comprehension, having communication impairments, or with a history of substance abuse were excluded. In this study, participants were selected through purposive sampling, wherein participation was based on voluntary enlistment. Eighteen eligible mothers were approached within the study period. Of them, twelve mothers accepted the interview; two declined participation, and four were discharged before the date for the scheduled interview. The final sample was made up of twelve mothers between the ages of 19 to 30 years; each of whom had an infant admitted to the NICU for at least two weeks. Mothers had been involved in care with their infant for more than a week. (b) NICU Therapists The participants, the NICU therapists, were chosen according to the following requirements: at least two years of experience in the NICU and willingness to participate in the study. To gather the required participants, snowball sampling was employed since it enabled discovery of skilled practitioners in various hospitals. Among the twenty therapists contacted, sixteen agreed to participate while four claimed they could not and gave this as a personal reason and being too busy. Interview Setup (a) NICU Therapists Therapists were selected from several NICUs and were apprised of the purpose of the study beforehand. Interviews were scheduled at their convenience to avoid interference with their clinical work as much as possible. Due to time constraints, all interviews were conducted over voice call. (b) Mothers of Preterm Infants The interviews were carried out face-to-face in an environment that was comfortable and convenient for the mothers. The feeding room was preferred in most cases because it coincided with the time that the mothers thought would be the best for discussing things. Mothers were allowed to have the interview alone or with the infant or any accompanying attender. The interview could be paused if a mother felt overwhelmed and needed to stop and continue when she was ready. They had the right to withdraw from the study at any time without repercussions. At no point were participants interrupted or rushed to ensure a natural and open conversation. Interview Process Both groups were interviewed separately through in-depth interviews using semi-structured interview guides specifically for NICU therapists and mothers of preterm infants. The interview questions for NICU therapists focused on neonatal care practices and professional perspectives, including questions such as: "What are the common care techniques provided in the NICU?", "What are the common stress cues in preterm infants?", "What are your thoughts on involving mothers in neonatal care?", and "What is the scope of early stimulation in the NICU?". The interview questions for mothers explored their daily caregiving experiences, autonomy, and support needs, such as: "Can you describe a typical day in the NICU?", "What routine care activities do you perform for your baby?", "What would make you feel more involved in your baby’s care?", and "What additional support do you think is necessary for parents in the NICU?". Each interview lasted about 50 minutes, giving ample time to discuss neonatal care practices in the Indian healthcare context. All interviews were audio-recorded with consent. Transcription and Data Analysis Audio recordings were translated and transcribed into English for analysis. An iterative process was used to achieve thematic saturation, meaning that interviews were continued until no new themes emerged. Data analysis was conducted based on Braun and Clarke's six-phase thematic analysis framework, which consisted of: familiarization with data through repeated reading of transcripts, generating initial codes to identify meaningful patterns, collating codes into broader themes, reviewing and refining themes, defining and naming themes to ensure their significance, and finally reporting the findings in a structured manner. This structured approach ensured rigorous data interpretation while maintaining the authenticity of participants' experiences. Results The thematic analysis yielded 6 themes with 21 sub themes and are elaborated below. Theme 1. Preparation Phase: Laying Down the Foundations for Safe Care Sub theme 1: Medical Stability and Preliminary Interventions Therapists needed medical stability as a prerequisite to establish habilitative interventions. Indeed, most of them mentioned the value of a 72-hour follow-up period for assessing the infants' first stability at birth. Such time would allow early complications to stabilize and enable therapists to recognize any baseline behaviors or early risks. The premise for this recommendation was based on the fact that most of the infants stabilize automatically within this period, and treatment decisions can be implemented carefully. "Waiting those 72 hours really makes a difference. Often we see some of the issues resolving within that window, and it just gives everyone—parents and staff—a sense of readiness to begin gentle interventions." Therapist Sub theme 2: Hand Hygiene and Temperature Control In addition to stabilization, optimal hygiene was recommended by the therapists, with respect to the weak immunity present in a preterm baby. Therapists were careful about hand hygiene and temperature precautions; hands were warmed before touching the infant, not to cause discomfort. It was recommended that parents also observe similar hygiene practices, especially while handling or interacting with their infant. "When we touch these babies, our hands need to be warm; a cold touch can be startling, and we have seen it affect their vitals. To parents, we try to explain how that is part of bonding safely." – Therapist The use of gloves or bare hands in some interventions, like tactile stimulation, was another point of discussion during therapy. The majority were insisting that gloves posed a hindrance to skin-to-skin contact and therefore introduced limits to the sense of skin-to-skin interventions, but there were times when gloves were essential, notably when an infection or sepsis was present. For example, gloves will be required in case of infection in sepsis; for general stimulation, bare hands may be used when the individual needs to bond appropriately, and can provide the baby with the warmth and comfort they need. – Therapist "The mothers would worry about contamination, but after proper guidance on hand washing and hygiene, they were comfortable bathing their baby.". "It's all a bit overwhelming at first, all the hygiene procedures. But once health care professionals demonstrated the steps, I felt more confident. Want to make sure I do everything right to keep my baby safe." – Parent Subtheme 3: Circadian Rhythm and Vitals Monitoring The preparation stage entailed monitoring circadian rhythms as well as keeping track of the vital signs. Since preterm babies sleep for around 17–20 hours in a day, therapists recommended that the caregivers minimize disruption to the sleep of the infant by non-tangible intentions. They were instructed to observe the sleep rhythms and fine-tune responses such that feeding, stimulation, as well as other care interventions could occur at a time conducive to the infant's own internal cycles of sleep-wake. "The baby sleeps for long hours—17 to 20 hours a day. We have to make sure we do not break that rhythm, and parents learn when to interfere and when to allow the baby to sleep." — Therapist Theme 2. Sensory Stimulation: Activating Multi-sensory Development in Pre-term Infants Subtheme 1: Tactile Stimulation and Positive Touch The therapists described a number of tactics in the use of different forms of tactile stimulation techniques: massage using soft cloths and Yakson touch, a type of Korean therapeutic touch presumed to soothe and calm the baby. Using Yakson touch specifically required soft stroking applied in rhythmic motion, which proved helpful for both ventilated infants and more fragile ones who were too fragile to be subjected to other intensive treatments. "Yakson touch is soft enough for ventilated babies. We see them respond positively—it helps soothe them and can affect sensory development. It's something even parents can participate in." – Therapist Parents, who were hesitant and anxious in touching the fragile baby, began feeling confident after being introduced to such techniques. They said how truly relished participation in such minor but effective interventions. "I feel so powerless before, but learning that I could give him a soft massage was amazing. It felt like it was something good for him, though small."-Parent Sub theme 2: Visuosensory Stimulation The visual stimulation was initiated cautiously as the black-and-white toys or high contrast images like chessboards were used, and the periods remained very short so that the patient was not overstimulated. The time was gradually allowed longer for the patient as he responded more attentively. The parents as well as therapists observed that over time, the infant could concentrate for longer times on the visual stimuli, which further advanced cognitive development. We start with just a few minutes of visual stimulation—easy high-contrast images. It is amazing to see how the baby's response improves day by day." – Therapist Sub theme 3: Auditory Stimulation Because of the constant noise of the NICU, direct auditory stimulation was often very limited. Instead, therapists encouraged parents to talk softly to their infants. The mother's voice was encouraged and reassured as a soothing and familiar auditory stimulus. "Music therapy sounds wonderful in theory, but it's not always very practical with all the noise in the NICU-ventilators, alarms. That's why we focus on using the mother's voice to soothe the baby. It helps them calm down even if everything else is buzzing and beeping all around them" - Therapist "I try to talk to her as much as I can, even if she's sleeping. It helps me feel connected, and they say it helps her recognize my voice." – Parent Sub theme 4: Olfactory Stimulation: Olfactory cues are provided by the items containing the mother's scent. A cloth that is worn by the mother or a cotton ball saturated with breast milk is often placed adjacent to the infant so that they can latch onto a familiar odor to create comfort and familiarity. "Even if the mother cannot hold the baby, we put a cloth with her scent next to the baby or use breast milk to stimulate olfaction. It's a strong way to keep the baby connected to her mother." – Therapist Theme 3: Chest Physiotherapy: Techniques and Safety Considerations Sub theme 1: Gentle Chest Physiotherapy and Risk Management For the babies with respiratory problems, chest physiotherapy was implemented selectively in the form of gentle percussion and vibration exercise. This can only be done once the baby has been at least 28 weeks gestation to avoid risks such as rib fractures or pleural fluid accumulation. “Very gently, chest PT needs to be performed. Preterms are that fragile that you can just risk their having rib fractures or pleural issues by using too much force. You apply lung squeeze techniques after ascertaining safety”. – Therapist ECG leads need to be checked and the infant's vitals monitored before chest PT and also after chest PT has been conducted for the purpose of assessing if the infant tolerated the therapy well. "We monitor all the vital signs before undertaking chest PT and always keep an eye on the ECG. The baby's response can alter in a matter of seconds, so constant monitoring is essential." – Therapist Subtheme 2: Proprioceptive Neuromuscular Facilitation Therapists applied several PNF techniques that they modified to facilitate respiration in preterm babies. Some of these include: a) Intercostal Stretch: Lateral rib cage stretching to facilitate expansion of lung volume and deeper breathing. b) Perioral Pressure: The pressure applied around the mouth area elicits both sucking and breathing coordination. c) Anterior and Posterior Basal Lift: Light upward or lifting pressure at the base of the chest helped therapists to elicit basal movement from diaphragmatic activity which promoted greater, more stable breathing patterns. d) Co-contraction of the Abdomen: Mild compression to stimulate the abdominal muscles helps enhance stability of the core; such benefits would indirectly be beneficial for respiratory function. "PNF techniques, including intercostal stretches and basal lifts are gentle but potent in providing support for respiratory stability in these infants." Therapist Subtheme 3: Vertebral Pressure Techniques Therapists utilized vertebral pressure techniques through specific spinal levels to help their efforts in aligning the spine while helping their efforts at the level of providing respiratory support. The two techniques were: a) High Vertebral Pressure: Applied mildly to the superior thoracic region (T2-T6) to allow expansion of the chest and support its movements in breathing b) Low Vertebral Pressure: Applied on the inferior thoracic region (T9-T12) for promoting the movement of diaphragm and encourages abdominal support on breathing These were only applied to the stable infants; their tolerance was closely monitored. Vertebral pressure at particular points along the spine might be useful in expanding the chest, but it must be considered especially in preterm infants.". -Therapist Subtheme 4: Thoracic Squeeze Thoracic squeeze was one of the techniques used by the therapists to aid in respiratory draining mainly in cases where there was an apprehension of lung secretions or shallow respiration. The process entailed: Compression and Relaxation: The therapist applies gentle compression and letting go on either side of the rib cage on three levels. This cyclic squeezing aids in circulating the secretions and allows lung expansion. Point of Stimulation: Applied to the rib cage on three points of the thorax to achieve balanced stimulation over the upper, middle, and lower parts of the thorax. Duration: Takes approximately five minutes where each of the two hemithoraces is alternately done. Caution: Applied only for infants with mild to moderate RDS and avoided in severe cases; best used after 28 weeks gestation when the infant's lung capacity is more developed. "The thoracic squeeze is a helpful tool, but only for those infants who can tolerate it. We avoid it in severe respiratory distress cases and monitor closely for any signs of discomfort." - Therapist Subtheme 5: Prolonged Expiratory Phase Hand position and technic: The upper sternum is placed by one hand and the other hand, just below the umbilicus. Compression is synchronized with the cycle of breathing. The three-second compression cycle is accompanied by release. Monitoring of respiratory pattern: It is essential to follow the natural breathing of the infant and does not have over exertion by keeping it in pace with him. "We use a prolonged expiratory phase, hand compression synchronised to the breathing cycle so it supports natural respiratory rhythm."-Therapist Theme 4: Parent Involvement: Implementing Family-Centered Care Subtheme 1: Kangaroo Care (KC): Strengthening Family Bonds Kangaroo Care was one of the most prominent themes that were noted in the interviews, since both therapists and parents highlighted its significant benefits. Beyond its role in providing skin-to-skin contact, KMC promotes emotional bonding, sensory integration, and physiological stability in preterm infants. "Kangaroo Care is magic. It is not only the holding of the baby, but creating that emotional bond that helps in a lot of ways-emotionally and physically."-Therapist Parents noted they were empowered by using KMC and reported feeling able to contribute significantly to their baby's care despite its delivery in the NICU setting. "KMC was one of the best things for both of us-in terms of my baby, sure, but also for myself. It really made me feel like I was doing something for her growth and development." -Parent Subtheme 2: Maternal Education: Acquiring Knowledge and Confidence Educating the mothers about the setting of NICU, how to prepare and what to expect, and how to engage their babies should be recommended by the therapists. All the wires and equipment about which knowledge should be acquired, and most important, it should understand the purpose of each of them. Also, objectives of all interventions provided in NICU. "Educating mothers about what's happening in the NICU is critical. Once they understand the equipment and what we're doing, they feel much more in control and involved in their baby's care." – Therapist Subtheme 3: Emotional Support and Family Integration Follow-up support for the therapists also involves following through in providing emotional support to families as they spend time in the NICU. Such parents are usually overwhelmed, anxious or disconnected, but a follow-up from therapists, are able to learn some coping strategies as well as being shown how to engage with their babies through sensory stimulation and appropriate care techniques. "It's not just about the baby; the parents need support too. We talk to them, help them understand what their baby needs, and teach them how to be active participants in their care." – Therapist "Sometimes I feel so lost in the NICU, but when the nurses take the time to explain things to me it really helps. I need to know how to care for her when I get her home." – Parent Phototherapy was one of the treatments that eliminated excess bilirubin. Babies are not fond of the warmth and confinement; they are allowed to relax afterwards with gentle rocking or physical contact with the parents. Theme 5: Observation and Safety Precautions: Care for Baby's Well-being Subtheme 1: Behavioral Signals and Responses Observational cues in the behavioral emotions of an infant are underlined and focused on by therapists during therapy. Agitation cues include grimacing, crying, and forehead frowning. If an infant feels uncomfortable, s/he may show changes in skin color, increased heart rate, and limb withdrawal. Some noted stressors as indicators are: clenching fingers, twisting of limbs, and fisting of the hand. When these signs of stress are noted, the therapist awaits the self-regulation process of the infant before continuation of therapy. "We have to pay attention very closely to the baby's signs. If they show any kind of cues, like starting to frown, we stop and try to figure out what is going on." – Therapist Parents should also learn these cues so that they may get connected more and understand the baby's needs. "Now I know to look for signs of stress or discomfort. It helps me feel much more in tune with what my baby needs." – Parent Subtheme 2: Control of Irritability In the Intervention The intervention guidelines had a major emphasis on the infant stress signals and a good portion of it was devoted to how to sensitise the parents and staff members in the NICU towards the activities wherein the infants may be hinting discomfort, frowning, grimacing, acceleration in heart rate, and withdrawal of limbs. The therapists were asked to intervene only when such behavior cues emerged, thus giving the infant time to self-regulate without losing control. Infants often became distressed, with accelerated heart rates, labored breathing, and crying during physiotherapy. Therapists reported that waiting to have the mother present calmed babies, and therapy could continue almost without interruption. If a baby became very distressed, therapy was stopped and soothing comfort interventions, such as rocking or speaking soothingly, were used. "The smallest cues-twitching or some shift in heartbeat— are warning signs. If we see these, then we should stop and give the baby a moment." – Therapist Subtheme 4: Termination of Treatment Criteria Therapists have mentioned concrete grounds for termination of therapy interventions. These include changes in the infant's vital signs, signs of distress such as crying and refusal to move, and signs of pain. If an infant resists movement during any kinesthetic activity that generally indicates some discomfort or even pain, then that session must be halted. The main point is that nothing goes before the comfort and well being of the baby. "If there's any change in vitals or the baby shows signs of discomfort, like stiffening or crying during joint movement, we need to stop and reassess. The baby's well-being is our priority." – Therapist Theme 6: Developmentally supportive care Subtheme 1: Positioning Oxygen desaturation and respiratory distress were two of the factors which improved in both prone and side-lying positions, though a difference was suggested in this chapter. Prone positioning offered the correct relief in pressure on the posterior lung segments; however side-lying was preferred for ventilated infants. Therapists educated parents about the benefits of these postures and taught them how to support positioning at all times. "Prone and side-lying help improve oxygen levels. We instruct parents on positioning their babies, but we observe closely so that it is done safely." – Therapist "I feel like I'm really helping now that I know how to position her. It's one of the few things I can do to make her more comfortable." – Parent Positioning was modified further to foster natural, growth-promoting postures, including mild flexion at the hips and a rounded position for the shoulders. Subtheme 2: Nesting and Swaddling: Providing Comfort Nesting and swaddling became very influential in fostering a flexed posture as is necessary to both respiration and neuromuscular maturation. Therapists observed how such interventions simulated some features of the womb environment therefore decreasing the stress and comfort for the preterm baby. Nesting and swaddling support maintaining that flexed posture. It's like creating a womb for the baby, and it helps them feel safe and secure. They really appreciate learning this because it's something they can really bring to their care of their baby.-Therapist I love swaddling her. That way I feel I'm giving her the warmth and security she needs, just like she had inside me.". – Parent Subtheme 3: Frequency of Positioning and Nesting Techniques Therapists recommend changing the position every two hours to prevent health conditions like brachycephaly or plagiocephaly. They also said that frequent repositioning supports physical health but helps also in the advancement of development results since it stimulates varied sensory inputs and experiences. "We encourage changing positions often. It helps prevent flat spots on their heads and allows the baby to experience different sensations." – Therapist Subtheme 4: Environmental Considerations The environment of the NICU in and of itself was recognized as a stressor for the infants. Therapists advocated for a quiet, predictable environment. The decibel levels were kept low, without exceeding 40 to prevent overstimulation. Lighting is controlled with cycles of light and dark alternating with each other to effectuate natural lighting patterns. The positioning that was used was one that maintained rounded shoulders and mild hip flexion to aid in both sensory and musculoskeletal development. "The NICU can be overwhelming. We control the noise and light as much as possible to create a soothing environment for the babies." – Therapist "I was surprised to learn how much noise affects the babies. It makes sense to keep everything calm and quiet." – Parent Developmentally supportive care as the focus area for improving neurodevelopment for normal sensory experiences and with the least stressors in the NICU. Therapists stated that support commences from day one when the baby is admitted to the NICU. "We keep the sensory systems intact, provide supportive positioning. It's about helping the baby develop normally in an environment that's already stressful." – Therapist DSC is aimed at minimal environmental stress with NICU sound levels below 40 decibels and providing 6hour light/dark cycles to simulate natural patterns. "When they explained how all these little things help my baby grow, it made me realize how much we can do for her, even in the NICU." – Parent Discussion The results of this study establish that there is a need for integrated, multi-disciplinary habilitation in NICUs to include the expertise of neonatologists, physiotherapists, occupational therapists, speech therapists, and developmental specialists for better neurodevelopmental outcomes in preterm infants. The time the infant spends in the NICU is an opportunity for interventions that can affect significantly the infant's long-term motor, sensory, and cognitive functions. However, in Tamil Nadu, though 64 Level II & III NICUs are present, access of specialised habilitation therapists remains patchy, thereby evolving heterogeneous practices of neonatal care ( 13 , 14 ). It represents the importance of structured habilitation protocols and interdisciplinary collaboration in neonatal care. Interventions such as passive range of motion exercises, PNF, and chest physiotherapy contribute to achieving postural control, neuromuscular activation, and respiratory facilitation and thereby enhance muscle tone, prevent joint stiffness, and ensure enhanced pulmonary function ( 15 ). Occupational therapists contribute complementarily in terms of facilitating sensory regulation, early reflex integration, and readiness to feed in infants with the use of swaddling techniques, graded sensory exposures, and hand-to-mouth coordination exercises ( 16 , 17 ). Speech therapists also contribute in equal measures as they help to assess and enhance oral feeding skills, coordinating sucking-swallowing-breathing patterns, and overcome feeding challenges experienced by most preterm babies ( 18 , 19 ). One of the important findings from this study was that when therapists from different disciplines collaborated on an integrated habilitation framework, preterm infants achieved feeding milestones faster, showed better neuromotor responses, and were discharged earlier from the hospital. However, a major limitation was that there was no standardized training module for therapists working in NICUs, and thus, intervention strategies varied. This calls for specialized neonatal rehabilitation training programs for healthcare professionals to ensure that there is uniform and evidence-based habilitation practice ( 20 , 21 ). Mothers who actively participate in developmental positioning, guided sensory stimulation, and feeding interventions report higher confidence in handling their preterm infants and reduced NICU-related stress ( 22 ). In this study, parents trained by therapists showed more adherence to KMC, more engagement in the use of tactile and auditory stimulation techniques, and increased confidence regarding post-discharge care. Still, many NICUs in Tamil Nadu lack standardized parent education programs, and this is where parental empowerment and involvement are found lacking. Standardized parental training modules in NICUs could bridge such gaps and help ensure a family-integrated approach to habilitation ( 23 , 24 ). Several factors limit the effective implementation of therapist-led neonatal habilitation in Tamil Nadu despite its proven benefits. One is the critical lack of trained neonatal rehabilitation therapists, which also poses a huge challenge in government-run hospitals because NICU staff are already dealing with a very high volume of patients ( 25 ). Limited financial resources and lack of specialized rehabilitation equipment further restrict access to comprehensive habilitation services in resource-limited settings ( 26 ). In addition, cultural beliefs of newborn fragility sometimes conflict with modern habilitation practices, thereby making it hard to implement early sensory stimulation and motor activation techniques in some communities ( 27 ). Policy-driven initiatives should include structured programs for neonatal therapists, for uniform training between disciplines, develop a standardized neonatal habilitation framework for usage in NICUs, enhance the parental education program by establishing models of structured caregiver training in every NICU so that parents have a significant participation in habitation, and develop interprofessional neonatal care that encourages multidisciplinary approaches between therapists and both neonatologists and nurses offering comprehensive habilitative care for neonates. This study has a few limitations. Firstly, the study was influenced by variance in early habilitation practice used in Indian healthcare settings as a result of variation in training and the resources available. Reliance on qualitative data introduces subjectivity, and the absence of objective neurodevelopmental assessments limits the ability to measure outcomes. The study mainly focuses on therapists and mothers without considering other important professionals such as neonatologists and occupational therapists. Regional and cultural differences also restrict the generalization of findings to other contexts than the Indian context. The future studies shall work on evolving standardized guidelines on early habilitation for the health care system for Indians. It is essential to include experience-based practices in the training programs in order to build uniformity across therapists. Only through quantitative research with standardized developmental assessments can they be validated so that these approaches are further intensified. A multifaceted frame of other professionals in health would further strengthen these early intervention tactics. Additionally, structured parental education programs and long-term follow-up studies should be recommended in order to see the sustained effects of these practices on child development. The neonatal habilitation system in Tamil Nadu can be scaled up with a structured model that integrates multidisciplinary expertise and standardized parent education frameworks while incorporating global best practices. Therapist-led interventions with family-centered care will help in strengthening NICU habilitation programs, thereby promoting better neurodevelopmental outcomes and quality of life for preterm infants in India. Implications for Future Research and Practice Formalizing and validating experience-informed neonatal habilitation strategies in India requires further research. Although the practices seem to be beneficial, more systematic research should be done to establish the effectiveness of the same and bring it into standard intervention frameworks. Further studies can concentrate on culturally sensitive caregiver training programs and assessing the long-term effect on the infant's development. Moreover, policy-level changes that would promote therapist-parent collaboration in neonatal care would improve the coverage and effectiveness of early intervention services across India. This study maps the existing practices and offers a nucleus for efforts on the development of contextually relevant neonatal habilitation strategies. Recognizing and leveraging maternal caregiving practices in conjunction with professional interventions may help to create more inclusive and effective early developmental care frameworks. Improved outcomes for infants may be ensured in diverse Indian settings. Conclusion This study mapped the early habilitation practices followed by therapists in India. The use of such diverse approaches in neonatal care was highlighted during this process. Findings indicate that experience-informed practices are influential in the process of early intervention, as therapists adapt strategies in accordance with clinical exposure, availability of resources, and parental involvement. The findings of the study emphasize the necessity of standardized guidelines to ensure uniformity in early habilitation, thereby improving the developmental outcomes for at-risk infants. Future efforts should be on structured training programs, multidisciplinary collaboration, and parental education to strengthen early childhood intervention frameworks within the Indian healthcare system. Declarations Ethical Considerations The study was approved by Institutional Ethics Committee of SRM Medical College Hospital and Research and Centre, Kattankulathur.( Reg. No: ECR/8972/INST/TN/2013/RR-19) Confidentiality was strictly maintained, with all data anonymized before analysis. Informed consent was obtained from all participants before participation, and they had the right to withdraw from the study at any stage without consequences. Participants will be recruited to the study following the voluntary willingness to participate. Consent for publication: All the participants gave consent to publish Funding statements Nil Availability of data and materials The datasets used and/or analysed during the current study are available from the PI on reasonable request. Competing interests Authors declare no competing interests. Author Contributions: AJR: Conceptualization, conducting interviews, transcribing and translations, coding of responses and theme identification and Interpreting results KV: Conceptualization, coding of responses, drafting results, proof corrections, drafting manuscript All authors contributed to the revision of the protocol and read and approved the final manuscript Acknowledgements: Authors would like to extend heartfelt thanks to all the participants for spending their valuable time for the interview sessions References Blencowe H, Cousens S, Oestergaard MZ, Chou D, Moller AB, Narwal R, et al. National, regional, and worldwide estimates of preterm birth rates in the year 2010 with time trends since 1990 for selected countries: a systematic analysis and implications. Lancet. 2012 Jun 9;379(9832):2162-72. doi: 10.1016/S0140-6736(12)60820-4. Available from: https://doi.org/10.1016/S0140-6736(12)60820-4. Government of Tamil Nadu. Health and Family Welfare Department: Policy Note 2024-2025 [Internet]. Chennai: Government of Tamil Nadu; 2024 [cited 2025 Feb 8]. Available from: http://www.tn.gov.in/policynotes/hfw2024-25.pdf. Sample Registration System. SRS Bulletin: Volume 54, No. 1. New Delhi: Office of the Registrar General & Census Commissioner, India; 2024. https://censusindia.gov.in/census.website/data/SRSB World Health Organization. Standards for improving quality of maternal and newborn care in health facilities [Internet]. Geneva: WHO; 2016 [cited 2025 Feb 8]. Available from: https://www.who.int/publications/i/item/9789241511216. Lawn JE, Davidge R, Paul VK, von Xylander S, de Graft Johnson J, Costello A, et al. Born too soon: care for the preterm baby. Reprod Health. 2013 Nov 15;10(Suppl 1):S5. doi: 10.1186/1742-4755-10-S1-S5. Available from: https://reproductive-health-journal.biomedcentral.com/articles/10.1186/1742-4755-10-S1-S5. Blauw-Hospers CH, Hadders-Algra M. A systematic review of the effects of early intervention on motor development. Dev Med Child Neurol. 2005 Jun;47(6):421-32. doi: 10.1017/S0012162205000824. Available from: https://doi.org/10.1017/S0012162205000824. Dusing SC, Van Drew CM, Brown SE. Instituting parent education practices in the neonatal intensive care unit: an administrative case report of practice evaluation and state-wide action. Phys Ther. 2012 May;92(5):967-75. doi: 10.2522/ptj.20110324. Available from: https://doi.org/10.2522/ptj.20110324. National Neonatology Forum. National Neonatal-Perinatal Database Report 2020. New Delhi: NNF; 2021. https://www.newbornwhocc.org/pdf/nnpd_report_2002-03.pdf Charpak N, Ruiz-Peláez JG, Figueroa de C Z, Charpak Y. Kangaroo mother versus traditional care for newborn infants ≤2000 grams: a randomized, controlled trial. Pediatrics. 1997 Oct;100(4):682-8. doi: 10.1542/peds.100.4.682. Available from: https://doi.org/10.1542/peds.100.4.682. Boundy EO, Dastjerdi R, Spiegelman D, Fawzi WW, Missmer SA, Lieberman E, et al. Kangaroo mother care and neonatal outcomes: a meta-analysis. Pediatrics. 2016 Jan;137(1):e20152238. doi: 10.1542/peds.2015-2238. Available from: https://doi.org/10.1542/peds.2015-2238. Bera A, Ghosh J, Singh AK, Hazra A, Som T, Munian D. Effect of early developmental intervention on low-birth-weight infants: a prospective randomized controlled trial. Indian Pediatr. 2014 Aug;51(8):613-9. doi: 10.1007/s13312-014-0464-5. Available from: https://doi.org/10.1007/s13312-014-0464-5. Spittle AJ, Orton J, Anderson PJ, Boyd R, Doyle LW. Early developmental intervention programmes provided post hospital discharge to prevent motor and cognitive impairment in preterm infants. Cochrane Database Syst Rev. 2015 Nov 24;(11):CD005495. doi: 10.1002/14651858.CD005495.pub4. Available from: https://doi.org/10.1002/14651858.CD005495.pub4. National Health Mission - Tamil Nadu. Facility Based Newborn Care (FBNC) Program Report 2023. Chennai: NHM-TN; 2024. https://nhm.tn.gov.in/en/facility-based-newborn-care Melnyk BM, Feinstein NF, Alpert-Gillis L, Fairbanks E, Crean HF, Sinkin RA, et al. Reducing premature infants' length of stay and improving parents' mental health outcomes with the Creating Opportunities for Parent Empowerment (COPE) Neonatal Intensive Care Unit Program: a randomized, controlled trial. Pediatrics. 2006 May;118(5):e1414-27. doi: 10.1542/peds.2005-2580. Available from: https://doi.org/10.1542/peds.2005-2580. Sweeney JK, Heriza CB. Neonatal physical therapy. Part II: Practice frameworks and evidence-based practice guidelines. Pediatr Phys Ther. 2001 Fall;13(3):132-45. doi: 10.1097/00001577-200113030-00003. Available from: https://doi.org/10.1097/00001577-200113030-00003. Case-Smith J. Systematic review of interventions used in occupational therapy to promote motor performance for children ages birth-5 years. Am J Occup Ther. 2000 Sep-Oct;54(5):460-73. doi: 10.5014/ajot.54.5.460. Available from: https://doi.org/10.5014/ajot.54.5.460.4. Sweeney JK, Gutierrez T. Musculoskeletal implications of preterm infant positioning in the NICU. J Perinat Neonatal Nurs. 2002 Mar;15(4):58-70. doi: 10.1097/00005237-200203000-00007. Available from: https://doi.org/10.1097/00005237-200203000-00007. Arvedson JC. Swallowing and feeding in infants and young children. GI Motility online. 2006 May; doi: 10.1038/gimo17. Available from: https://doi.org/10.1038/gimo17. Shaker CS. Cue-based feeding in the NICU: using the infant’s communication as a guide. Neonatal Netw. 2013 Mar-Apr;32(2):4047. doi: 10.1891/0730-0832.32.2.4047. Available from: https://doi.org/10.1891/0730-0832.32.2.40. Campbell SK, Halinda G, Keefer CH, Allen M, Silverman WA, Bender P. Developmental therapy: a collaborative approach to the facilitation of motor development in high-risk infants. Phys Ther. 1983 Apr;63(4):512-7. doi: 10.1093/ptj/63.4.512. Available from: https://doi.org/10.1093/ptj/63.4.512. Dusing SC, Van Drew CM, Brown SE. Instituting parent education practices in the neonatal intensive care unit: an administrative case report of practice evaluation and state-wide action. Phys Ther. 2012 May;92(5):967-75. doi: 10.2522/ptj.20110324. Available from: https://doi.org/10.2522/ptj.20110324. Melnyk BM, Feinstein NF, Alpert-Gillis L, Fairbanks E, Crean HF, Sinkin RA, et al. Reducing premature infants' length of stay and improving parents' mental health outcomes with the Creating Opportunities for Parent Empowerment (COPE) Neonatal Intensive Care Unit Program: a randomized, controlled trial. Pediatrics. 2006 May;118(5):e1414-27. doi: 10.1542/peds.2005-2580. Available from: https://doi.org/10.1542/peds.2005-2580. Bera A, Ghosh J, Singh AK, Hazra A, Som T, Munian D. Effect of early developmental intervention on low-birth-weight infants: a prospective randomized controlled trial. Indian Pediatr. 2014 Aug;51(8):613-9. doi: 10.1007/s13312-014-0464-5. Available from: https://doi.org/10.1007/s13312-014-0464-5. Spittle AJ, Orton J, Anderson PJ, Boyd R, Doyle LW. Early developmental intervention programmes provided post hospital discharge to prevent motor and cognitive impairment in preterm infants. Cochrane Database Syst Rev. 2015 Nov 24;(11):CD005495. doi: 10.1002/14651858.CD005495.pub4. Available from: https://doi.org/10.1002/14651858.CD005495.pub4. National Neonatology Forum. National Neonatal-Perinatal Database Report 2020. New Delhi: NNF; 2021. Available from: https://www.nnfi.org/images/pdf/NNPD_Report_2020.pdf. World Health Organization. Standards for improving quality of maternal and newborn care in health facilities. Geneva: WHO; 2016. Available from: https://www.who.int/publications/i/item/9789241511216. Lawn JE, Davidge R, Paul VK, von Xylander S, de Graft Johnson J, Costello A, et al. Born too soon: care for the preterm baby. Reprod Health. 2013 Nov 15;10(Suppl 1):S5. doi: 10.1186/1742-4755-10-S1-S5. Available from: https://reproductive-health-journal.biomedcentral.com/articles/10.1186/1742-4755-10-S1-S5. Additional Declarations No competing interests reported. Cite Share Download PDF Status: Posted Version 1 posted You are reading this latest preprint version Research Square lets you share your work early, gain feedback from the community, and start making changes to your manuscript prior to peer review in a journal. As a division of Research Square Company, we’re committed to making research communication faster, fairer, and more useful. We do this by developing innovative software and high quality services for the global research community. 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Also discoverable on Platform About Our Team In Review Editorial Policies Advisory Board Help Center Resources Author Services Accessibility API Access RSS feed Manage Cookie Preferences © Research Square 2026 | ISSN 2693-5015 (online) Privacy Policy Terms of Service Do Not Sell My Personal Information {"props":{"pageProps":{"initialData":{"identity":"rs-6121364","acceptedTermsAndConditions":true,"allowDirectSubmit":true,"archivedVersions":[],"articleType":"Research Article","associatedPublications":[],"authors":[{"id":422217955,"identity":"157a1036-c9c4-4c79-b1c6-418983180bae","order_by":0,"name":"Abishek J R","email":"","orcid":"","institution":"SRM College of Physiotherapy, Faculty of Medicine and Health Sciences, SRM Institute of Science and Technology","correspondingAuthor":false,"prefix":"","firstName":"Abishek","middleName":"J","lastName":"R","suffix":""},{"id":422217956,"identity":"42e1ae40-5c4e-44e3-bb1b-3d3ea0571049","order_by":1,"name":"Vadivelan Kanniappan","email":"data:image/png;base64,iVBORw0KGgoAAAANSUhEUgAAAZAAAAAyAQMAAABI0h/eAAAABlBMVEX///8AAABVwtN+AAAACXBIWXMAAA7EAAAOxAGVKw4bAAAA6klEQVRIie3Ooa7CMBSA4aN6zZLaM8MzHNKkQSy5r7KGBMwEEoGYGoZkmre4CwY5sgTMCLY4EKAQ4CBZCB3Bwd3AIfqLpm365RTAZvvOKAVoES+3PjxWv54gueH9Mb1HoCQlfBzq3i+yJHP6KMRqufvbFAXwn4BgO60geaeXOTlKqbtSq4jAHR0IVP4/ccOAZuMIPakZ0yokIG2mqKiCxAdDruiJeM60XxD81hGOAaWnECVBxxBmpmAt2ffS4xwFakNUJBzMzU0VYbw9OfoDrxmbj63PRaPBh+1ke6kgTznlkn4AbDabzfaiG7G4UhjgYc6OAAAAAElFTkSuQmCC","orcid":"","institution":"SRM College of Physiotherapy, Faculty of Medicine and Health Sciences, SRM Institute of Science and Technology","correspondingAuthor":true,"prefix":"","firstName":"Vadivelan","middleName":"","lastName":"Kanniappan","suffix":""}],"badges":[],"createdAt":"2025-02-27 13:23:20","currentVersionCode":1,"declarations":"","doi":"10.21203/rs.3.rs-6121364/v1","doiUrl":"https://doi.org/10.21203/rs.3.rs-6121364/v1","draftVersion":[],"editorialEvents":[],"editorialNote":"","failedWorkflow":false,"files":[{"id":89514216,"identity":"2889482a-5cdb-41b5-9462-cd070e7f202d","added_by":"auto","created_at":"2025-08-20 19:16:29","extension":"pdf","order_by":0,"title":"","display":"","copyAsset":false,"role":"manuscript-pdf","size":1136849,"visible":true,"origin":"","legend":"","description":"","filename":"manuscript.pdf","url":"https://assets-eu.researchsquare.com/files/rs-6121364/v1/f05f3f55-5f5e-4467-aa81-aedc6e15ef01.pdf"}],"financialInterests":"No competing interests reported.","formattedTitle":"Experience-Informed Practices in Preterm Infant Habilitation in Neonatal Intensive Care Unit: Integrating Therapists’ Expertise and Mothers’ Lived Experiences","fulltext":[{"header":"Introduction","content":"\u003cp\u003ePreterm birth is one of the crucial issues in global health, and it is reported that the largest number of preterm births occurs in India. Around 3.5\u0026nbsp;million babies in India are born prematurely each year, contributing towards a significant neonatal morbidity and mortality rate (\u003cspan citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e). Tamil Nadu, famous for its strong public health infrastructure, has made significant progress in decreasing its neonatal mortality, but preterm babies are still a vulnerable segment and need special care (\u003cspan citationid=\"CR2\" class=\"CitationRef\"\u003e2\u003c/span\u003e).\u003c/p\u003e \u003cp\u003eThe state has a neonatal mortality rate of 8 per 1,000 live births, far below the national average, but NICU access is uneven, and there are workforce shortages, and standardized neonatal habilitation protocols are lacking (\u003cspan citationid=\"CR3\" class=\"CitationRef\"\u003e3\u003c/span\u003e).\u003c/p\u003e \u003cp\u003eNeonatal habilitation is the provision of early developmental interventions designed to maximize sensory, motor, cognitive, and feeding functions in preterm infants admitted to the NICU. While higher-income countries have highly structured multidisciplinary NICU-based habilitation programs, India is laden with resource constraints, burdened healthcare systems, and inconsistent parent involvement (\u003cspan citationid=\"CR4\" class=\"CitationRef\"\u003e4\u003c/span\u003e, \u003cspan citationid=\"CR5\" class=\"CitationRef\"\u003e5\u003c/span\u003e).\u003c/p\u003e \u003cp\u003eInvolvement of a multifaceted team consisting of neonatologists, physiotherapists, occupational therapists, speech therapists, and developmental specialists has been promising in improving neuromotor outcomes, postural development, oral feeding skills, and sensory regulation in the preterm infant (\u003cspan citationid=\"CR6\" class=\"CitationRef\"\u003e6\u003c/span\u003e). However, standardized neonatal habilitation programs in Indian NICUs are underdeveloped and the role of various therapists remains inconsistently integrated (\u003cspan citationid=\"CR7\" class=\"CitationRef\"\u003e7\u003c/span\u003e, \u003cspan citationid=\"CR8\" class=\"CitationRef\"\u003e8\u003c/span\u003e).\u003c/p\u003e \u003cp\u003eSince India has a NICU occupancy rate estimated to range above 750,000 newborns annually, a multidisciplinary therapist-led approach with parental participation is essential in reducing long-term neurodevelopmental impairments (\u003cspan citationid=\"CR9\" class=\"CitationRef\"\u003e9\u003c/span\u003e).\u003c/p\u003e \u003cp\u003eParents, especially mothers, contribute to the filling of the gaps of therapist-led interventions by doing KMC, positioning guided, early sensory stimulation, and habilitation led by the caregivers (\u003cspan citationid=\"CR10\" class=\"CitationRef\"\u003e10\u003c/span\u003e). In research, systematic training and empowerment of parents through NICU habilitation programs show improvements in preterm infants, including weight gain, shorter hospital stay, and neurodevelopmental trajectory (\u003cspan citationid=\"CR11\" class=\"CitationRef\"\u003e11\u003c/span\u003e, \u003cspan citationid=\"CR12\" class=\"CitationRef\"\u003e12\u003c/span\u003e).\u003c/p\u003e \u003cp\u003eThis study researches the application of experience-informed approaches to neonatal habilitation in the NICU context, putting forward aspects of neonatal therapists and parental involvement with preterm babies toward their early development in Tamil Nadu. It is an attempt to introduce parent-driven habilitation as a part of evidence-based rehabilitation methods in the context of creating a neonatal habilitation model that is relevant and compatible with India's healthcare regime and its culture.\u003c/p\u003e\n\n\n\n\n\n\n\n\n\n\n\n \n\u003ch3\u003eProcedure\u003c/h3\u003e\n\u003ch2\u003eStudy Design\u003c/h2\u003e\u003cp\u003eA qualitative study was conducted using experience informed approach with Braun and Clarke's Thematic Analysis to understand neonatal therapists' views and mothers' experiences about early habilitation practices in India. This research method helped gather an in-depth understanding of current practices, experiences of therapists, parental involvement, and contextual factors influencing neonatal care.\u003c/p\u003e\u003ch3\u003eParticipants\u003c/h3\u003e\u003ch2\u003e(a) Mothers of Preterm Infants\u003c/h2\u003e\u003cp\u003e Mothers were selected with specific inclusion criteria: they should have been engaged in neonatal care, and their infant was admitted to the NICU for at least two weeks. Those mothers who were having problems with comprehension, having communication impairments, or with a history of substance abuse were excluded. In this study, participants were selected through purposive sampling, wherein participation was based on voluntary enlistment. Eighteen eligible mothers were approached within the study period. Of them, twelve mothers accepted the interview; two declined participation, and four were discharged before the date for the scheduled interview. The final sample was made up of twelve mothers between the ages of 19 to 30 years; each of whom had an infant admitted to the NICU for at least two weeks. Mothers had been involved in care with their infant for more than a week.\u003c/p\u003e\u003ch3\u003e(b) NICU Therapists\u003c/h3\u003e\u003cp\u003eThe participants, the NICU therapists, were chosen according to the following requirements: at least two years of experience in the NICU and willingness to participate in the study. To gather the required participants, snowball sampling was employed since it enabled discovery of skilled practitioners in various hospitals. Among the twenty therapists contacted, sixteen agreed to participate while four claimed they could not and gave this as a personal reason and being too busy.\u003c/p\u003e\u003ch3\u003eInterview Setup\u003c/h3\u003e\u003ch2\u003e(a) NICU Therapists\u003c/h2\u003e\u003cp\u003eTherapists were selected from several NICUs and were apprised of the purpose of the study beforehand. Interviews were scheduled at their convenience to avoid interference with their clinical work as much as possible. Due to time constraints, all interviews were conducted over voice call.\u003c/p\u003e\u003ch3\u003e(b) Mothers of Preterm Infants\u003c/h3\u003e\u003cp\u003eThe interviews were carried out face-to-face in an environment that was comfortable and convenient for the mothers. The feeding room was preferred in most cases because it coincided with the time that the mothers thought would be the best for discussing things. Mothers were allowed to have the interview alone or with the infant or any accompanying attender. The interview could be paused if a mother felt overwhelmed and needed to stop and continue when she was ready. They had the right to withdraw from the study at any time without repercussions. At no point were participants interrupted or rushed to ensure a natural and open conversation.\u003c/p\u003e\u003ch3\u003eInterview Process\u003c/h3\u003e\u003cp\u003eBoth groups were interviewed separately through in-depth interviews using semi-structured interview guides specifically for NICU therapists and mothers of preterm infants. The interview questions for NICU therapists focused on neonatal care practices and professional perspectives, including questions such as: \"What are the common care techniques provided in the NICU?\", \"What are the common stress cues in preterm infants?\", \"What are your thoughts on involving mothers in neonatal care?\", and \"What is the scope of early stimulation in the NICU?\".\u003c/p\u003e\u003cp\u003eThe interview questions for mothers explored their daily caregiving experiences, autonomy, and support needs, such as: \"Can you describe a typical day in the NICU?\", \"What routine care activities do you perform for your baby?\", \"What would make you feel more involved in your baby’s care?\", and \"What additional support do you think is necessary for parents in the NICU?\".\u003c/p\u003e\u003cp\u003eEach interview lasted about 50 minutes, giving ample time to discuss neonatal care practices in the Indian healthcare context. All interviews were audio-recorded with consent.\u003c/p\u003e\u003ch2\u003eTranscription and Data Analysis\u003c/h2\u003e\u003cp\u003eAudio recordings were translated and transcribed into English for analysis. An iterative process was used to achieve thematic saturation, meaning that interviews were continued until no new themes emerged. Data analysis was conducted based on Braun and Clarke's six-phase thematic analysis framework, which consisted of: familiarization with data through repeated reading of transcripts, generating initial codes to identify meaningful patterns, collating codes into broader themes, reviewing and refining themes, defining and naming themes to ensure their significance, and finally reporting the findings in a structured manner. This structured approach ensured rigorous data interpretation while maintaining the authenticity of participants' experiences.\u003c/p\u003e"},{"header":"Results","content":"\u003cp\u003eThe thematic analysis yielded 6 themes with 21 sub themes and are elaborated below.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eTheme 1. Preparation Phase: Laying Down the Foundations for Safe Care\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eSub theme 1: Medical Stability and Preliminary Interventions\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eTherapists needed medical stability as a prerequisite to establish habilitative interventions. Indeed, most of them mentioned the value of a 72-hour follow-up period for assessing the infants' first stability at birth. Such time would allow early complications to stabilize and enable therapists to recognize any baseline behaviors or early risks. The premise for this recommendation was based on the fact that most of the infants stabilize automatically within this period, and treatment decisions can be implemented carefully.\u003c/p\u003e\n\u003cp\u003e\"Waiting those 72 hours really makes a difference. Often we see some of the issues resolving within that window, and it just gives everyone—parents and staff—a sense of readiness to begin gentle interventions.\" Therapist\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eSub theme 2: Hand Hygiene and Temperature Control\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eIn addition to stabilization, optimal hygiene was recommended by the therapists, with respect to the weak immunity present in a preterm baby. Therapists were careful about hand hygiene and temperature precautions; hands were warmed before touching the infant, not to cause discomfort. It was recommended that parents also observe similar hygiene practices, especially while handling or interacting with their infant.\u003c/p\u003e\n\u003cp\u003e\"When we touch these babies, our hands need to be warm; a cold touch can be startling, and we have seen it affect their vitals. To parents, we try to explain how that is part of bonding safely.\" – Therapist\u003c/p\u003e\n\u003cp\u003eThe use of gloves or bare hands in some interventions, like tactile stimulation, was another point of discussion during therapy. The majority were insisting that gloves posed a hindrance to skin-to-skin contact and therefore introduced limits to the sense of skin-to-skin interventions, but there were times when gloves were essential, notably when an infection or sepsis was present.\u003c/p\u003e\n\u003cp\u003eFor example, gloves will be required in case of infection in sepsis; for general stimulation, bare hands may be used when the individual needs to bond appropriately, and can provide the baby with the warmth and comfort they need. – Therapist\u003c/p\u003e\n\u003cp\u003e\"The mothers would worry about contamination, but after proper guidance on hand washing and hygiene, they were comfortable bathing their baby.\".\u003c/p\u003e\n\u003cp\u003e\"It's all a bit overwhelming at first, all the hygiene procedures. But once health care professionals demonstrated the steps, I felt more confident. Want to make sure I do everything right to keep my baby safe.\" – Parent\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eSubtheme 3: Circadian Rhythm and Vitals Monitoring\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe preparation stage entailed monitoring circadian rhythms as well as keeping track of the vital signs. Since preterm babies sleep for around 17–20 hours in a day, therapists recommended that the caregivers minimize disruption to the sleep of the infant by non-tangible intentions. They were instructed to observe the sleep rhythms and fine-tune responses such that feeding, stimulation, as well as other care interventions could occur at a time conducive to the infant's own internal cycles of sleep-wake.\u003c/p\u003e\n\u003cp\u003e\"The baby sleeps for long hours—17 to 20 hours a day. We have to make sure we do not break that rhythm, and parents learn when to interfere and when to allow the baby to sleep.\" — Therapist\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eTheme 2. Sensory Stimulation: Activating Multi-sensory Development in Pre-term Infants\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eSubtheme 1: Tactile Stimulation and Positive Touch\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe therapists described a number of tactics in the use of different forms of tactile stimulation techniques: massage using soft cloths and Yakson touch, a type of Korean therapeutic touch presumed to soothe and calm the baby. Using Yakson touch specifically required soft stroking applied in rhythmic motion, which proved helpful for both ventilated infants and more fragile ones who were too fragile to be subjected to other intensive treatments.\u003c/p\u003e\n\u003cp\u003e\"Yakson touch is soft enough for ventilated babies. We see them respond positively—it helps soothe them and can affect sensory development. It's something even parents can participate in.\" – Therapist\u003c/p\u003e\n\u003cp\u003eParents, who were hesitant and anxious in touching the fragile baby, began feeling confident after being introduced to such techniques. They said how truly relished participation in such minor but effective interventions.\u003c/p\u003e\n\u003cp\u003e\"I feel so powerless before, but learning that I could give him a soft massage was amazing. It felt like it was something good for him, though small.\"-Parent\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eSub theme 2: Visuosensory Stimulation\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe visual stimulation was initiated cautiously as the black-and-white toys or high contrast images like chessboards were used, and the periods remained very short so that the patient was not overstimulated. The time was gradually allowed longer for the patient as he responded more attentively. The parents as well as therapists observed that over time, the infant could concentrate for longer times on the visual stimuli, which further advanced cognitive development.\u003c/p\u003e\n\u003cp\u003eWe start with just a few minutes of visual stimulation—easy high-contrast images. It is amazing to see how the baby's response improves day by day.\" – Therapist\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eSub theme 3: Auditory Stimulation\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eBecause of the constant noise of the NICU, direct auditory stimulation was often very limited. Instead, therapists encouraged parents to talk softly to their infants. The mother's voice was encouraged and reassured as a soothing and familiar auditory stimulus.\u003c/p\u003e\n\u003cp\u003e\"Music therapy sounds wonderful in theory, but it's not always very practical with all the noise in the NICU-ventilators, alarms. That's why we focus on using the mother's voice to soothe the baby. It helps them calm down even if everything else is buzzing and beeping all around them\" - Therapist\u003c/p\u003e\n\u003cp\u003e\"I try to talk to her as much as I can, even if she's sleeping. It helps me feel connected, and they say it helps her recognize my voice.\" – Parent\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eSub theme 4: Olfactory Stimulation:\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eOlfactory cues are provided by the items containing the mother's scent. A cloth that is worn by the mother or a cotton ball saturated with breast milk is often placed adjacent to the infant so that they can latch onto a familiar odor to create comfort and familiarity.\u003c/p\u003e\n\u003cp\u003e\"Even if the mother cannot hold the baby, we put a cloth with her scent next to the baby or use breast milk to stimulate olfaction. It's a strong way to keep the baby connected to her mother.\" – Therapist\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eTheme 3: Chest Physiotherapy: Techniques and Safety Considerations\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eSub theme 1: Gentle Chest Physiotherapy and Risk Management\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eFor the babies with respiratory problems, chest physiotherapy was implemented selectively in the form of gentle percussion and vibration exercise. This can only be done once the baby has been at least 28 weeks gestation to avoid risks such as rib fractures or pleural fluid accumulation.\u003c/p\u003e\n\u003cp\u003e“Very gently, chest PT needs to be performed. Preterms are that fragile that you can just risk their having rib fractures or pleural issues by using too much force. You apply lung squeeze techniques after ascertaining safety”. – Therapist\u003c/p\u003e\n\u003cp\u003eECG leads need to be checked and the infant's vitals monitored before chest PT and also after chest PT has been conducted for the purpose of assessing if the infant tolerated the therapy well.\u003c/p\u003e\n\u003cp\u003e\"We monitor all the vital signs before undertaking chest PT and always keep an eye on the ECG. The baby's response can alter in a matter of seconds, so constant monitoring is essential.\" – Therapist\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eSubtheme 2: Proprioceptive Neuromuscular Facilitation\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eTherapists applied several PNF techniques that they modified to facilitate respiration in preterm babies. Some of these include:\u003c/p\u003e\n\u003cp\u003ea) Intercostal Stretch: Lateral rib cage stretching to facilitate expansion of lung volume and deeper breathing.\u003c/p\u003e\n\u003cp\u003eb) Perioral Pressure: The pressure applied around the mouth area elicits both sucking and breathing coordination.\u003c/p\u003e\n\u003cp\u003ec) Anterior and Posterior Basal Lift: Light upward or lifting pressure at the base of the chest helped therapists to elicit basal movement from diaphragmatic activity which promoted greater, more stable breathing patterns.\u003c/p\u003e\n\u003cp\u003ed) Co-contraction of the Abdomen: Mild compression to stimulate the abdominal muscles helps enhance stability of the core; such benefits would indirectly be beneficial for respiratory function.\u003c/p\u003e\n\u003cp\u003e\"PNF techniques, including intercostal stretches and basal lifts are gentle but potent in providing support for respiratory stability in these infants.\" Therapist\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eSubtheme 3: Vertebral Pressure Techniques\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eTherapists utilized vertebral pressure techniques through specific spinal levels to help their efforts in aligning the spine while helping their efforts at the level of providing respiratory support. The two techniques were:\u003c/p\u003e\n\u003cp\u003ea) High Vertebral Pressure: Applied mildly to the superior thoracic region (T2-T6) to allow expansion of the chest and support its movements in breathing\u003c/p\u003e\n\u003cp\u003eb) Low Vertebral Pressure: Applied on the inferior thoracic region (T9-T12) for promoting the movement of diaphragm and encourages abdominal support on breathing\u003c/p\u003e\n\u003cp\u003eThese were only applied to the stable infants; their tolerance was closely monitored.\u003c/p\u003e\n\u003cp\u003eVertebral pressure at particular points along the spine might be useful in expanding the chest, but it must be considered especially in preterm infants.\". -Therapist\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eSubtheme 4: Thoracic Squeeze\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThoracic squeeze was one of the techniques used by the therapists to aid in respiratory draining mainly in cases where there was an apprehension of lung secretions or shallow respiration. The process entailed:\u003c/p\u003e\n\u003cp\u003eCompression and Relaxation: The therapist applies gentle compression and letting go on either side of the rib cage on three levels. This cyclic squeezing aids in circulating the secretions and allows lung expansion.\u003c/p\u003e\n\u003cp\u003ePoint of Stimulation: Applied to the rib cage on three points of the thorax to achieve balanced stimulation over the upper, middle, and lower parts of the thorax.\u003c/p\u003e\n\u003cp\u003eDuration: Takes approximately five minutes where each of the two hemithoraces is alternately done.\u003c/p\u003e\n\u003cp\u003eCaution: Applied only for infants with mild to moderate RDS and avoided in severe cases; best used after 28 weeks gestation when the infant's lung capacity is more developed.\u003c/p\u003e\n\u003cp\u003e\"The thoracic squeeze is a helpful tool, but only for those infants who can tolerate it. We avoid it in severe respiratory distress cases and monitor closely for any signs of discomfort.\" - Therapist\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eSubtheme 5: Prolonged Expiratory Phase\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eHand position and technic: The upper sternum is placed by one hand and the other hand, just below the umbilicus. Compression is synchronized with the cycle of breathing. The three-second compression cycle is accompanied by release.\u003c/p\u003e\n\u003cp\u003eMonitoring of respiratory pattern: It is essential to follow the natural breathing of the infant and does not have over exertion by keeping it in pace with him. \"We use a prolonged expiratory phase, hand compression synchronised to the breathing cycle so it supports natural respiratory rhythm.\"-Therapist\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eTheme 4: Parent Involvement: Implementing Family-Centered Care\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eSubtheme 1: Kangaroo Care (KC): Strengthening Family Bonds\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eKangaroo Care was one of the most prominent themes that were noted in the interviews, since both therapists and parents highlighted its significant benefits. Beyond its role in providing skin-to-skin contact, KMC promotes emotional bonding, sensory integration, and physiological stability in preterm infants.\u003c/p\u003e\n\u003cp\u003e\"Kangaroo Care is magic. It is not only the holding of the baby, but creating that emotional bond that helps in a lot of ways-emotionally and physically.\"-Therapist\u003c/p\u003e\n\u003cp\u003eParents noted they were empowered by using KMC and reported feeling able to contribute significantly to their baby's care despite its delivery in the NICU setting.\u003c/p\u003e\n\u003cp\u003e\"KMC was one of the best things for both of us-in terms of my baby, sure, but also for myself. It really made me feel like I was doing something for her growth and development.\" -Parent\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eSubtheme 2: Maternal Education: Acquiring Knowledge and Confidence\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eEducating the mothers about the setting of NICU, how to prepare and what to expect, and how to engage their babies should be recommended by the therapists. All the wires and equipment about which knowledge should be acquired, and most important, it should understand the purpose of each of them. Also, objectives of all interventions provided in NICU.\u003c/p\u003e\n\u003cp\u003e\"Educating mothers about what's happening in the NICU is critical. Once they understand the equipment and what we're doing, they feel much more in control and involved in their baby's care.\" – Therapist\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eSubtheme 3: Emotional Support and Family Integration\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eFollow-up support for the therapists also involves following through in providing emotional support to families as they spend time in the NICU. Such parents are usually overwhelmed, anxious or disconnected, but a follow-up from therapists, are able to learn some coping strategies as well as being shown how to engage with their babies through sensory stimulation and appropriate care techniques.\u003c/p\u003e\n\u003cp\u003e\"It's not just about the baby; the parents need support too. We talk to them, help them understand what their baby needs, and teach them how to be active participants in their care.\" – Therapist\u003c/p\u003e\n\u003cp\u003e\"Sometimes I feel so lost in the NICU, but when the nurses take the time to explain things to me it really helps. I need to know how to care for her when I get her home.\" – Parent\u003c/p\u003e\n\u003cp\u003ePhototherapy was one of the treatments that eliminated excess bilirubin. Babies are not fond of the warmth and confinement; they are allowed to relax afterwards with gentle rocking or physical contact with the parents.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eTheme 5: Observation and Safety Precautions: Care for Baby's Well-being\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eSubtheme 1: Behavioral Signals and Responses\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eObservational cues in the behavioral emotions of an infant are underlined and focused on by therapists during therapy. Agitation cues include grimacing, crying, and forehead frowning. If an infant feels uncomfortable, s/he may show changes in skin color, increased heart rate, and limb withdrawal.\u003c/p\u003e\n\u003cp\u003eSome noted stressors as indicators are: clenching fingers, twisting of limbs, and fisting of the hand. When these signs of stress are noted, the therapist awaits the self-regulation process of the infant before continuation of therapy.\u003c/p\u003e\n\u003cp\u003e\"We have to pay attention very closely to the baby's signs. If they show any kind of cues, like starting to frown, we stop and try to figure out what is going on.\" – Therapist\u003c/p\u003e\n\u003cp\u003eParents should also learn these cues so that they may get connected more and understand the baby's needs.\u003c/p\u003e\n\u003cp\u003e\"Now I know to look for signs of stress or discomfort. It helps me feel much more in tune with what my baby needs.\" – Parent\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eSubtheme 2: Control of Irritability In the Intervention\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe intervention guidelines had a major emphasis on the infant stress signals and a good portion of it was devoted to how to sensitise the parents and staff members in the NICU towards the activities wherein the infants may be hinting discomfort, frowning, grimacing, acceleration in heart rate, and withdrawal of limbs. The therapists were asked to intervene only when such behavior cues emerged, thus giving the infant time to self-regulate without losing control.\u003c/p\u003e\n\u003cp\u003eInfants often became distressed, with accelerated heart rates, labored breathing, and crying during physiotherapy. Therapists reported that waiting to have the mother present calmed babies, and therapy could continue almost without interruption. If a baby became very distressed, therapy was stopped and soothing comfort interventions, such as rocking or speaking soothingly, were used.\u003c/p\u003e\n\u003cp\u003e\"The smallest cues-twitching or some shift in heartbeat— are warning signs. If we see these, then we should stop and give the baby a moment.\" – Therapist\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eSubtheme 4: Termination of Treatment Criteria\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eTherapists have mentioned concrete grounds for termination of therapy interventions. These include changes in the infant's vital signs, signs of distress such as crying and refusal to move, and signs of pain. If an infant resists movement during any kinesthetic activity that generally indicates some discomfort or even pain, then that session must be halted. The main point is that nothing goes before the comfort and well being of the baby.\u003c/p\u003e\n\u003cp\u003e\"If there's any change in vitals or the baby shows signs of discomfort, like stiffening or crying during joint movement, we need to stop and reassess. The baby's well-being is our priority.\" – Therapist\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eTheme 6: Developmentally supportive care\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eSubtheme 1: Positioning\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eOxygen desaturation and respiratory distress were two of the factors which improved in both prone and side-lying positions, though a difference was suggested in this chapter. Prone positioning offered the correct relief in pressure on the posterior lung segments; however side-lying was preferred for ventilated infants. Therapists educated parents about the benefits of these postures and taught them how to support positioning at all times.\u003c/p\u003e\n\u003cp\u003e\"Prone and side-lying help improve oxygen levels. We instruct parents on positioning their babies, but we observe closely so that it is done safely.\" – Therapist\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u0026nbsp;\"I feel like I'm really helping now that I know how to position her. It's one of the few things I can do to make her more comfortable.\" – Parent\u003c/p\u003e\n\u003cp\u003ePositioning was modified further to foster natural, growth-promoting postures, including mild flexion at the hips and a rounded position for the shoulders.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eSubtheme 2: Nesting and Swaddling: Providing Comfort\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eNesting and swaddling became very influential in fostering a flexed posture as is necessary to both respiration and neuromuscular maturation. Therapists observed how such interventions simulated some features of the womb environment therefore decreasing the stress and comfort for the preterm baby.\u003c/p\u003e\n\u003cp\u003eNesting and swaddling support maintaining that flexed posture. It's like creating a womb for the baby, and it helps them feel safe and secure. They really appreciate learning this because it's something they can really bring to their care of their baby.-Therapist\u003c/p\u003e\n\u003cp\u003eI love swaddling her. That way I feel I'm giving her the warmth and security she needs, just like she had inside me.\". – Parent\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eSubtheme 3: Frequency of Positioning and Nesting Techniques\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eTherapists recommend changing the position every two hours to prevent health conditions like brachycephaly or plagiocephaly. They also said that frequent repositioning supports physical health but helps also in the advancement of development results since it stimulates varied sensory inputs and experiences.\u003c/p\u003e\n\u003cp\u003e\"We encourage changing positions often. It helps prevent flat spots on their heads and allows the baby to experience different sensations.\" – Therapist\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eSubtheme 4: Environmental Considerations\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe environment of the NICU in and of itself was recognized as a stressor for the infants. Therapists advocated for a quiet, predictable environment. The decibel levels were kept low, without exceeding 40 to prevent overstimulation. Lighting is controlled with cycles of light and dark alternating with each other to effectuate natural lighting patterns. The positioning that was used was one that maintained rounded shoulders and mild hip flexion to aid in both sensory and musculoskeletal development.\u003c/p\u003e\n\u003cp\u003e\"The NICU can be overwhelming. We control the noise and light as much as possible to create a soothing environment for the babies.\" – Therapist\u003c/p\u003e\n\u003cp\u003e\"I was surprised to learn how much noise affects the babies. It makes sense to keep everything calm and quiet.\" – Parent\u003c/p\u003e\n\u003cp\u003eDevelopmentally supportive care as the focus area for improving neurodevelopment for normal sensory experiences and with the least stressors in the NICU. Therapists stated that support commences from day one when the baby is admitted to the NICU.\u003c/p\u003e\n\u003cp\u003e\"We keep the sensory systems intact, provide supportive positioning. It's about helping the baby develop normally in an environment that's already stressful.\" – Therapist\u003c/p\u003e\n\u003cp\u003eDSC is aimed at minimal environmental stress with NICU sound levels below 40 decibels and providing 6hour light/dark cycles to simulate natural patterns.\u003c/p\u003e\n\u003cp\u003e\"When they explained how all these little things help my baby grow, it made me realize how much we can do for her, even in the NICU.\" – Parent\u003c/p\u003e"},{"header":"Discussion","content":"\u003cp\u003eThe results of this study establish that there is a need for integrated, multi-disciplinary habilitation in NICUs to include the expertise of neonatologists, physiotherapists, occupational therapists, speech therapists, and developmental specialists for better neurodevelopmental outcomes in preterm infants. The time the infant spends in the NICU is an opportunity for interventions that can affect significantly the infant's long-term motor, sensory, and cognitive functions. However, in Tamil Nadu, though 64 Level II \u0026amp; III NICUs are present, access of specialised habilitation therapists remains patchy, thereby evolving heterogeneous practices of neonatal care (\u003cspan citationid=\"CR13\" class=\"CitationRef\"\u003e13\u003c/span\u003e, \u003cspan citationid=\"CR14\" class=\"CitationRef\"\u003e14\u003c/span\u003e).\u003c/p\u003e \u003cp\u003eIt represents the importance of structured habilitation protocols and interdisciplinary collaboration in neonatal care.\u003c/p\u003e \u003cp\u003eInterventions such as passive range of motion exercises, PNF, and chest physiotherapy contribute to achieving postural control, neuromuscular activation, and respiratory facilitation and thereby enhance muscle tone, prevent joint stiffness, and ensure enhanced pulmonary function (\u003cspan citationid=\"CR15\" class=\"CitationRef\"\u003e15\u003c/span\u003e).\u003c/p\u003e \u003cp\u003eOccupational therapists contribute complementarily in terms of facilitating sensory regulation, early reflex integration, and readiness to feed in infants with the use of swaddling techniques, graded sensory exposures, and hand-to-mouth coordination exercises (\u003cspan citationid=\"CR16\" class=\"CitationRef\"\u003e16\u003c/span\u003e, \u003cspan citationid=\"CR17\" class=\"CitationRef\"\u003e17\u003c/span\u003e). Speech therapists also contribute in equal measures as they help to assess and enhance oral feeding skills, coordinating sucking-swallowing-breathing patterns, and overcome feeding challenges experienced by most preterm babies (\u003cspan citationid=\"CR18\" class=\"CitationRef\"\u003e18\u003c/span\u003e, \u003cspan citationid=\"CR19\" class=\"CitationRef\"\u003e19\u003c/span\u003e).\u003c/p\u003e \u003cp\u003eOne of the important findings from this study was that when therapists from different disciplines collaborated on an integrated habilitation framework, preterm infants achieved feeding milestones faster, showed better neuromotor responses, and were discharged earlier from the hospital. However, a major limitation was that there was no standardized training module for therapists working in NICUs, and thus, intervention strategies varied. This calls for specialized neonatal rehabilitation training programs for healthcare professionals to ensure that there is uniform and evidence-based habilitation practice (\u003cspan citationid=\"CR20\" class=\"CitationRef\"\u003e20\u003c/span\u003e, \u003cspan citationid=\"CR21\" class=\"CitationRef\"\u003e21\u003c/span\u003e).\u003c/p\u003e \u003cp\u003eMothers who actively participate in developmental positioning, guided sensory stimulation, and feeding interventions report higher confidence in handling their preterm infants and reduced NICU-related stress (\u003cspan citationid=\"CR22\" class=\"CitationRef\"\u003e22\u003c/span\u003e). In this study, parents trained by therapists showed more adherence to KMC, more engagement in the use of tactile and auditory stimulation techniques, and increased confidence regarding post-discharge care. Still, many NICUs in Tamil Nadu lack standardized parent education programs, and this is where parental empowerment and involvement are found lacking. Standardized parental training modules in NICUs could bridge such gaps and help ensure a family-integrated approach to habilitation (\u003cspan citationid=\"CR23\" class=\"CitationRef\"\u003e23\u003c/span\u003e, \u003cspan citationid=\"CR24\" class=\"CitationRef\"\u003e24\u003c/span\u003e).\u003c/p\u003e \u003cp\u003eSeveral factors limit the effective implementation of therapist-led neonatal habilitation in Tamil Nadu despite its proven benefits. One is the critical lack of trained neonatal rehabilitation therapists, which also poses a huge challenge in government-run hospitals because NICU staff are already dealing with a very high volume of patients (\u003cspan citationid=\"CR25\" class=\"CitationRef\"\u003e25\u003c/span\u003e). Limited financial resources and lack of specialized rehabilitation equipment further restrict access to comprehensive habilitation services in resource-limited settings (\u003cspan citationid=\"CR26\" class=\"CitationRef\"\u003e26\u003c/span\u003e).\u003c/p\u003e \u003cp\u003eIn addition, cultural beliefs of newborn fragility sometimes conflict with modern habilitation practices, thereby making it hard to implement early sensory stimulation and motor activation techniques in some communities (\u003cspan citationid=\"CR27\" class=\"CitationRef\"\u003e27\u003c/span\u003e). Policy-driven initiatives should include structured programs for neonatal therapists, for uniform training between disciplines, develop a standardized neonatal habilitation framework for usage in NICUs, enhance the parental education program by establishing models of structured caregiver training in every NICU so that parents have a significant participation in habitation, and develop interprofessional neonatal care that encourages multidisciplinary approaches between therapists and both neonatologists and nurses offering comprehensive habilitative care for neonates.\u003c/p\u003e \u003cp\u003eThis study has a few limitations. Firstly, the study was influenced by variance in early habilitation practice used in Indian healthcare settings as a result of variation in training and the resources available. Reliance on qualitative data introduces subjectivity, and the absence of objective neurodevelopmental assessments limits the ability to measure outcomes.\u003c/p\u003e \u003cp\u003eThe study mainly focuses on therapists and mothers without considering other important professionals such as neonatologists and occupational therapists. Regional and cultural differences also restrict the generalization of findings to other contexts than the Indian context.\u003c/p\u003e \u003cp\u003e The future studies shall work on evolving standardized guidelines on early habilitation for the health care system for Indians. It is essential to include experience-based practices in the training programs in order to build uniformity across therapists.\u003c/p\u003e \u003cp\u003eOnly through quantitative research with standardized developmental assessments can they be validated so that these approaches are further intensified. A multifaceted frame of other professionals in health would further strengthen these early intervention tactics. Additionally, structured parental education programs and long-term follow-up studies should be recommended in order to see the sustained effects of these practices on child development.\u003c/p\u003e \u003cp\u003eThe neonatal habilitation system in Tamil Nadu can be scaled up with a structured model that integrates multidisciplinary expertise and standardized parent education frameworks while incorporating global best practices. Therapist-led interventions with family-centered care will help in strengthening NICU habilitation programs, thereby promoting better neurodevelopmental outcomes and quality of life for preterm infants in India.\u003c/p\u003e \u003cp\u003eImplications for Future Research and Practice\u003c/p\u003e \u003cp\u003eFormalizing and validating experience-informed neonatal habilitation strategies in India requires further research. Although the practices seem to be beneficial, more systematic research should be done to establish the effectiveness of the same and bring it into standard intervention frameworks. Further studies can concentrate on culturally sensitive caregiver training programs and assessing the long-term effect on the infant's development.\u003c/p\u003e \u003cp\u003eMoreover, policy-level changes that would promote therapist-parent collaboration in neonatal care would improve the coverage and effectiveness of early intervention services across India.\u003c/p\u003e \u003cp\u003eThis study maps the existing practices and offers a nucleus for efforts on the development of contextually relevant neonatal habilitation strategies. Recognizing and leveraging maternal caregiving practices in conjunction with professional interventions may help to create more inclusive and effective early developmental care frameworks. Improved outcomes for infants may be ensured in diverse Indian settings.\u003c/p\u003e"},{"header":"Conclusion","content":"\u003cp\u003eThis study mapped the early habilitation practices followed by therapists in India. The use of such diverse approaches in neonatal care was highlighted during this process. Findings indicate that experience-informed practices are influential in the process of early intervention, as therapists adapt strategies in accordance with clinical exposure, availability of resources, and parental involvement. The findings of the study emphasize the necessity of standardized guidelines to ensure uniformity in early habilitation, thereby improving the developmental outcomes for at-risk infants. Future efforts should be on structured training programs, multidisciplinary collaboration, and parental education to strengthen early childhood intervention frameworks within the Indian healthcare system.\u003c/p\u003e"},{"header":"Declarations","content":"\u003cp\u003e\u003cstrong\u003eEthical Considerations\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe study was approved by Institutional Ethics Committee of SRM Medical College Hospital and Research and Centre, Kattankulathur.( Reg. No: ECR/8972/INST/TN/2013/RR-19)\u003c/p\u003e\n\u003cp\u003eConfidentiality was strictly maintained, with all data anonymized before analysis. Informed consent was obtained from all participants before participation, and they had the right to withdraw from the study at any stage without consequences.\u003c/p\u003e\n\u003cp\u003eParticipants will be recruited to the study following the voluntary willingness to participate.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eConsent for publication:\u003c/strong\u003e All the participants gave consent to publish\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eFunding statements\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eNil\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAvailability of data and materials\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe datasets used and/or analysed during the current study are available from the PI on reasonable request.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eCompeting interests\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eAuthors declare no competing interests.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAuthor Contributions:\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eAJR: Conceptualization, conducting interviews, transcribing and translations, coding of responses and theme identification and Interpreting results\u003c/p\u003e\n\u003cp\u003eKV: Conceptualization, coding of responses, drafting results, proof corrections, drafting manuscript\u003c/p\u003e\n\u003cp\u003eAll authors contributed to the revision of the protocol and read and approved the final manuscript\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAcknowledgements:\u003c/strong\u003e Authors would like to extend heartfelt thanks to all the participants for spending their valuable time for the interview sessions\u003c/p\u003e"},{"header":"References","content":"\u003col\u003e\n\u003cli\u003eBlencowe H, Cousens S, Oestergaard MZ, Chou D, Moller AB, Narwal R, et al. National, regional, and worldwide estimates of preterm birth rates in the year 2010 with time trends since 1990 for selected countries: a systematic analysis and implications. Lancet. 2012 Jun 9;379(9832):2162-72. doi: 10.1016/S0140-6736(12)60820-4. Available from: https://doi.org/10.1016/S0140-6736(12)60820-4. \u003c/li\u003e\n\u003cli\u003eGovernment of Tamil Nadu. Health and Family Welfare Department: Policy Note 2024-2025 [Internet]. Chennai: Government of Tamil Nadu; 2024 [cited 2025 Feb 8]. Available from: http://www.tn.gov.in/policynotes/hfw2024-25.pdf. \u003c/li\u003e\n\u003cli\u003eSample Registration System. SRS Bulletin: Volume 54, No. 1. New Delhi: Office of the Registrar General \u0026amp; Census Commissioner, India; 2024. https://censusindia.gov.in/census.website/data/SRSB \u003c/li\u003e\n\u003cli\u003eWorld Health Organization. Standards for improving quality of maternal and newborn care in health facilities [Internet]. Geneva: WHO; 2016 [cited 2025 Feb 8]. Available from: https://www.who.int/publications/i/item/9789241511216. \u003c/li\u003e\n\u003cli\u003eLawn JE, Davidge R, Paul VK, von Xylander S, de Graft Johnson J, Costello A, et al. Born too soon: care for the preterm baby. Reprod Health. 2013 Nov 15;10(Suppl 1):S5. doi: 10.1186/1742-4755-10-S1-S5. Available from: https://reproductive-health-journal.biomedcentral.com/articles/10.1186/1742-4755-10-S1-S5. \u003c/li\u003e\n\u003cli\u003eBlauw-Hospers CH, Hadders-Algra M. A systematic review of the effects of early intervention on motor development. Dev Med Child Neurol. 2005 Jun;47(6):421-32. doi: 10.1017/S0012162205000824. Available from: https://doi.org/10.1017/S0012162205000824. \u003c/li\u003e\n\u003cli\u003eDusing SC, Van Drew CM, Brown SE. Instituting parent education practices in the neonatal intensive care unit: an administrative case report of practice evaluation and state-wide action. Phys Ther. 2012 May;92(5):967-75. doi: 10.2522/ptj.20110324. Available from: https://doi.org/10.2522/ptj.20110324. \u003c/li\u003e\n\u003cli\u003eNational Neonatology Forum. National Neonatal-Perinatal Database Report 2020. New Delhi: NNF; 2021. https://www.newbornwhocc.org/pdf/nnpd_report_2002-03.pdf \u003c/li\u003e\n\u003cli\u003eCharpak N, Ruiz-Pel\u0026aacute;ez JG, Figueroa de C Z, Charpak Y. Kangaroo mother versus traditional care for newborn infants \u0026le;2000 grams: a randomized, controlled trial. Pediatrics. 1997 Oct;100(4):682-8. doi: 10.1542/peds.100.4.682. Available from: https://doi.org/10.1542/peds.100.4.682. \u003c/li\u003e\n\u003cli\u003eBoundy EO, Dastjerdi R, Spiegelman D, Fawzi WW, Missmer SA, Lieberman E, et al. Kangaroo mother care and neonatal outcomes: a meta-analysis. Pediatrics. 2016 Jan;137(1):e20152238. doi: 10.1542/peds.2015-2238. Available from: https://doi.org/10.1542/peds.2015-2238. \u003c/li\u003e\n\u003cli\u003eBera A, Ghosh J, Singh AK, Hazra A, Som T, Munian D. Effect of early developmental intervention on low-birth-weight infants: a prospective randomized controlled trial. Indian Pediatr. 2014 Aug;51(8):613-9. doi: 10.1007/s13312-014-0464-5. Available from: https://doi.org/10.1007/s13312-014-0464-5. \u003c/li\u003e\n\u003cli\u003eSpittle AJ, Orton J, Anderson PJ, Boyd R, Doyle LW. Early developmental intervention programmes provided post hospital discharge to prevent motor and cognitive impairment in preterm infants. Cochrane Database Syst Rev. 2015 Nov 24;(11):CD005495. doi: 10.1002/14651858.CD005495.pub4. Available from: https://doi.org/10.1002/14651858.CD005495.pub4. \u003c/li\u003e\n\u003cli\u003eNational Health Mission - Tamil Nadu. Facility Based Newborn Care (FBNC) Program Report 2023. Chennai: NHM-TN; 2024. https://nhm.tn.gov.in/en/facility-based-newborn-care \u003c/li\u003e\n\u003cli\u003eMelnyk BM, Feinstein NF, Alpert-Gillis L, Fairbanks E, Crean HF, Sinkin RA, et al. Reducing premature infants\u0026apos; length of stay and improving parents\u0026apos; mental health outcomes with the Creating Opportunities for Parent Empowerment (COPE) Neonatal Intensive Care Unit Program: a randomized, controlled trial. Pediatrics. 2006 May;118(5):e1414-27. doi: 10.1542/peds.2005-2580. Available from: https://doi.org/10.1542/peds.2005-2580. \u003c/li\u003e\n\u003cli\u003eSweeney JK, Heriza CB. Neonatal physical therapy. Part II: Practice frameworks and evidence-based practice guidelines. Pediatr Phys Ther. 2001 Fall;13(3):132-45. doi: 10.1097/00001577-200113030-00003. Available from: https://doi.org/10.1097/00001577-200113030-00003. \u003c/li\u003e\n\u003cli\u003eCase-Smith J. Systematic review of interventions used in occupational therapy to promote motor performance for children ages birth-5 years. Am J Occup Ther. 2000 Sep-Oct;54(5):460-73. doi: 10.5014/ajot.54.5.460. Available from: https://doi.org/10.5014/ajot.54.5.460.4.\u003c/li\u003e\n\u003cli\u003eSweeney JK, Gutierrez T. Musculoskeletal implications of preterm infant positioning in the NICU. J Perinat Neonatal Nurs. 2002 Mar;15(4):58-70. doi: 10.1097/00005237-200203000-00007. Available from: https://doi.org/10.1097/00005237-200203000-00007. \u003c/li\u003e\n\u003cli\u003eArvedson JC. Swallowing and feeding in infants and young children. GI Motility online. 2006 May; doi: 10.1038/gimo17. Available from: https://doi.org/10.1038/gimo17. \u003c/li\u003e\n\u003cli\u003eShaker CS. Cue-based feeding in the NICU: using the infant\u0026rsquo;s communication as a guide. Neonatal Netw. 2013 Mar-Apr;32(2):4047. doi: 10.1891/0730-0832.32.2.4047. Available from: https://doi.org/10.1891/0730-0832.32.2.40. \u003c/li\u003e\n\u003cli\u003eCampbell SK, Halinda G, Keefer CH, Allen M, Silverman WA, Bender P. Developmental therapy: a collaborative approach to the facilitation of motor development in high-risk infants. Phys Ther. 1983 Apr;63(4):512-7. doi: 10.1093/ptj/63.4.512. Available from: https://doi.org/10.1093/ptj/63.4.512. \u003c/li\u003e\n\u003cli\u003eDusing SC, Van Drew CM, Brown SE. Instituting parent education practices in the neonatal intensive care unit: an administrative case report of practice evaluation and state-wide action. Phys Ther. 2012 May;92(5):967-75. doi: 10.2522/ptj.20110324. Available from: https://doi.org/10.2522/ptj.20110324. \u003c/li\u003e\n\u003cli\u003eMelnyk BM, Feinstein NF, Alpert-Gillis L, Fairbanks E, Crean HF, Sinkin RA, et al. Reducing premature infants\u0026apos; length of stay and improving parents\u0026apos; mental health outcomes with the Creating Opportunities for Parent Empowerment (COPE) Neonatal Intensive Care Unit Program: a randomized, controlled trial. Pediatrics. 2006 May;118(5):e1414-27. doi: 10.1542/peds.2005-2580. Available from: https://doi.org/10.1542/peds.2005-2580. \u003c/li\u003e\n\u003cli\u003eBera A, Ghosh J, Singh AK, Hazra A, Som T, Munian D. Effect of early developmental intervention on low-birth-weight infants: a prospective randomized controlled trial. Indian Pediatr. 2014 Aug;51(8):613-9. doi: 10.1007/s13312-014-0464-5. Available from: https://doi.org/10.1007/s13312-014-0464-5. \u003c/li\u003e\n\u003cli\u003eSpittle AJ, Orton J, Anderson PJ, Boyd R, Doyle LW. Early developmental intervention programmes provided post hospital discharge to prevent motor and cognitive impairment in preterm infants. Cochrane Database Syst Rev. 2015 Nov 24;(11):CD005495. doi: 10.1002/14651858.CD005495.pub4. Available from: https://doi.org/10.1002/14651858.CD005495.pub4. \u003c/li\u003e\n\u003cli\u003eNational Neonatology Forum. National Neonatal-Perinatal Database Report 2020. New Delhi: NNF; 2021. Available from: https://www.nnfi.org/images/pdf/NNPD_Report_2020.pdf. \u003c/li\u003e\n\u003cli\u003eWorld Health Organization. Standards for improving quality of maternal and newborn care in health facilities. Geneva: WHO; 2016. Available from: https://www.who.int/publications/i/item/9789241511216. \u003c/li\u003e\n\u003cli\u003eLawn JE, Davidge R, Paul VK, von Xylander S, de Graft Johnson J, Costello A, et al. Born too soon: care for the preterm baby. Reprod Health. 2013 Nov 15;10(Suppl 1):S5. doi: 10.1186/1742-4755-10-S1-S5. Available from: https://reproductive-health-journal.biomedcentral.com/articles/10.1186/1742-4755-10-S1-S5.\u003c/li\u003e\n\u003c/ol\u003e"}],"fulltextSource":"","fullText":"","funders":[],"hasAdminPriorityOnWorkflow":false,"hasManuscriptDocX":true,"hasOptedInToPreprint":true,"hasPassedJournalQc":"","hasAnyPriority":false,"hideJournal":true,"highlight":"","institution":"","isAcceptedByJournal":false,"isAuthorSuppliedPdf":false,"isDeskRejected":"","isHiddenFromSearch":false,"isInQc":false,"isInWorkflow":false,"isPdf":false,"isPdfUpToDate":true,"isWithdrawnOrRetracted":false,"journal":{"display":true,"email":"[email protected]","identity":"researchsquare","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":true,"externalIdentity":"","sideBox":"","snPcode":"","submissionUrl":"/submission","title":"Research Square","twitterHandle":"researchsquare","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"","reportingPortfolio":"","inReviewEnabled":false,"inReviewRevisionsEnabled":true},"keywords":"Neonatal habilitation, preterm infant development, NICU therapy, parental involvement, India","lastPublishedDoi":"10.21203/rs.3.rs-6121364/v1","lastPublishedDoiUrl":"https://doi.org/10.21203/rs.3.rs-6121364/v1","license":{"name":"CC BY 4.0","url":"https://creativecommons.org/licenses/by/4.0/"},"manuscriptAbstract":"\u003cp\u003e\u003cstrong\u003eBackground:\u003c/strong\u003e\u003cbr\u003e\nPreterm birth continues to be a significant public health problem in India, accounting for most neonatal morbidity and mortality. Neonatal habilitation is a crucial process involving early sensory, motor, and cognitive interventions to improve long-term developmental outcomes. High-income countries have structured frameworks for neonatal rehabilitation, whereas India has different challenges, such as workforce shortages, inconsistent integration of therapy, and poor parental education. This study aimed to explore experience-informed neonatal habilitation practices in the neonatal intensive care units of Tamil Nadu, focusing on the roles of physiotherapists, occupational therapists, speech therapists, neonatologists, and the involvement of parents in preterm infant development.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eMethods:\u003cbr\u003e\n\u003c/strong\u003eA qualitative study was conducted using in-depth interviews with neonatal therapists and mothers of preterm infants across multiple NICUs. Thematic analysis was performed to identify key patterns in habilitation practices, parental engagement, and barriers to effective implementation.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eResults:\u003c/strong\u003e\u003cbr\u003e\nFindings clearly depict the crucial role of multi-disciplinary teamwork in the context of NICU habilitation. Therapists indicated the most comprehensive benefits from structured interventions, which include Kangaroo Mother Care, sensory-motor stimulation, and early oral feeding strategies. Parent education with active involvement enhanced caregiver confidence and reduced NICU stress; however, lack of standardized modules for training, limited resources, and cultural barriers prevented this practice.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eConclusion:\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eTo maximize the developmental outcome in preterm infants, integrating structured habilitation frameworks with therapist-led and parent-driven interventions are important. Standardized training protocols, improving collaboration, and using culturally sensitive parent education strategies will assist in improving neonatal care in Tamil Nadu.\u003c/p\u003e","manuscriptTitle":"Experience-Informed Practices in Preterm Infant Habilitation in Neonatal Intensive Care Unit: Integrating Therapists’ Expertise and Mothers’ Lived Experiences","msid":"","msnumber":"","nonDraftVersions":[{"code":1,"date":"2025-03-03 17:27:48","doi":"10.21203/rs.3.rs-6121364/v1","editorialEvents":[{"type":"communityComments","content":0}],"status":"published","journal":{"display":true,"email":"[email protected]","identity":"researchsquare","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":true,"externalIdentity":"","sideBox":"","snPcode":"","submissionUrl":"/submission","title":"Research Square","twitterHandle":"researchsquare","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"","reportingPortfolio":"","inReviewEnabled":false,"inReviewRevisionsEnabled":true}}],"origin":"","ownerIdentity":"8792ebca-9578-4efc-be9f-194366185c26","owner":[],"postedDate":"March 3rd, 2025","published":true,"recentEditorialEvents":[],"rejectedJournal":[],"revision":"","amendment":"","status":"posted","subjectAreas":[],"tags":[],"updatedAt":"2025-08-20T19:08:22+00:00","versionOfRecord":[],"versionCreatedAt":"2025-03-03 17:27:48","video":"","vorDoi":"","vorDoiUrl":"","workflowStages":[]},"version":"v1","identity":"rs-6121364","journalConfig":"researchsquare"},"__N_SSP":true},"page":"/article/[identity]/[[...version]]","query":{"redirect":"/article/rs-6121364","identity":"rs-6121364","version":["v1"]},"buildId":"8U1c8b4HqxoKbykW_rLl7","isFallback":false,"isExperimentalCompile":false,"dynamicIds":[84888],"gssp":true,"scriptLoader":[]}