Exposure to clinical stressors during NICU admission in preterm infants

Naomi J. Meesters; Gerbrich E. van den Bosch; Maria Luisa Tataranno; Chris H. P. van den Akker; Christ-jan van Ganzewinkel; Judith A. ten Barge; Frank A. B. A. Schuerman; Henriette van Zanten; Willem P. de Boode; Marlou M. A. Raets; Peter H. Dijk; Joost van Rosmalen; Marijn J. Vermeulen; Wes Onland; Lotte Haverman; Irwin K. M. Reiss; Anton H. van Kaam; Manon Benders; Monique van Dijk; Sinno H. P. Simons; HIPPO study Group

doi:10.1007/s00431-025-06018-7

Exposure to clinical stressors during NICU admission in preterm infants

Naomi J. Meesters, Gerbrich E. van den Bosch, Maria Luisa Tataranno, Chris H. P. van den Akker, Christ-jan van Ganzewinkel, Judith A. ten Barge, Frank A. B. A. Schuerman, Henriette van Zanten, Willem P. de Boode, Marlou M. A. Raets, Peter H. Dijk, Joost van Rosmalen, Marijn J. Vermeulen, Wes Onland, Lotte Haverman, Irwin K. M. Reiss, Anton H. van Kaam, Manon Benders, Monique van Dijk, Sinno H. P. Simons^*HIPPO study Group

^*Corresponding author for this work

Research output: Contribution to journal › Article › Academic › peer-review

Abstract

This study aims to quantify stress exposure related to clinical stressors in preterm infants during NICU admission and identify risk factors for high stress exposure. In this national cohort study, preterm infants (gestational age < 29 weeks) were prospectively followed during the first 28 days of their admission to one of the 10 NICUs in the Netherlands. The NeO-stress score, consisting of 38 clinical stressors graded with a severity index, was applied to describe stress exposure. We assessed the impact of infant characteristics at birth and postnatal age on NeO-stress scores using linear mixed modelling. In total, 446 infants were included with a median gestational age of 27+2 weeks (IQR 26+2-28+2). The median NeO-stress score per day was 61 (IQR 39-87) and highest (74, IQR 52-101) on the day of admission. Nasal/oral (37%) and endotracheal (14%) suctioning were key contributors to the cumulative NeO-stress scores. Linear mixed modelling showed that lower gestational age (B = -0.69, 95% CI - 0.94-0.44, p < 0.001), no antenatal administration of corticosteroids (B = 13.2, 95% CI 3.2-23.1, p = 0.010) and lower 5-min Apgar score (B = - 1.6, 95% CI - 3.0-0.25, p = 0.02) were significantly related with higher daily NeO-stress scores. Our model predicts that the NeO-stress score increases over time for the youngest infants. CONCLUSION: Stress exposure in preterm infants during NICU admission varies over time with infants with the lowest gestational age at risk for experiencing the highest levels of stress throughout NICU admission. This highlights the importance stress reduction and provides opportunities for future interventions aimed at reducing stress exposure. WHAT IS KNOWN: • Preterm birth and admission to a Neonatal Intensive Care Unit is very stressful. • High stress exposure in neonatal life is associated with adverse long term outcome. WHAT IS NEW: • Stress exposure is highest in infants with the youngest gestational ages where it remains high or even increases during the first month of life. • Lower gestational age, no antenatal administration of corticosteroids and lower 5-min Apgar score were significantly related with higher daily NeO-stress scores.

Original language	English
Article number	196
Number of pages	11
Journal	European Journal of Pediatrics
Volume	184
Issue number	3
DOIs	https://doi.org/10.1007/s00431-025-06018-7
Publication status	Published - 13 Feb 2025

Keywords

Prematurity
Stress
Pain
NICU
BRAIN
PAIN
IMPACT
SCALE

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Meesters, N. J., van den Bosch, G. E., Tataranno, M. L., van den Akker, C. H. P., van Ganzewinkel, C., ten Barge, J. A., Schuerman, F. A. B. A., van Zanten, H., de Boode, W. P., Raets, M. M. A., Dijk, P. H., van Rosmalen, J., Vermeulen, M. J., Onland, W., Haverman, L., Reiss, I. K. M., van Kaam, A. H., Benders, M., van Dijk, M., ... HIPPO study Group (2025). Exposure to clinical stressors during NICU admission in preterm infants. European Journal of Pediatrics, 184(3), Article 196. https://doi.org/10.1007/s00431-025-06018-7

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title = "Exposure to clinical stressors during NICU admission in preterm infants",

abstract = "This study aims to quantify stress exposure related to clinical stressors in preterm infants during NICU admission and identify risk factors for high stress exposure. In this national cohort study, preterm infants (gestational age < 29 weeks) were prospectively followed during the first 28 days of their admission to one of the 10 NICUs in the Netherlands. The NeO-stress score, consisting of 38 clinical stressors graded with a severity index, was applied to describe stress exposure. We assessed the impact of infant characteristics at birth and postnatal age on NeO-stress scores using linear mixed modelling. In total, 446 infants were included with a median gestational age of 27+2 weeks (IQR 26+2-28+2). The median NeO-stress score per day was 61 (IQR 39-87) and highest (74, IQR 52-101) on the day of admission. Nasal/oral (37%) and endotracheal (14%) suctioning were key contributors to the cumulative NeO-stress scores. Linear mixed modelling showed that lower gestational age (B = -0.69, 95% CI - 0.94-0.44, p < 0.001), no antenatal administration of corticosteroids (B = 13.2, 95% CI 3.2-23.1, p = 0.010) and lower 5-min Apgar score (B = - 1.6, 95% CI - 3.0-0.25, p = 0.02) were significantly related with higher daily NeO-stress scores. Our model predicts that the NeO-stress score increases over time for the youngest infants. CONCLUSION: Stress exposure in preterm infants during NICU admission varies over time with infants with the lowest gestational age at risk for experiencing the highest levels of stress throughout NICU admission. This highlights the importance stress reduction and provides opportunities for future interventions aimed at reducing stress exposure. WHAT IS KNOWN: • Preterm birth and admission to a Neonatal Intensive Care Unit is very stressful. • High stress exposure in neonatal life is associated with adverse long term outcome. WHAT IS NEW: • Stress exposure is highest in infants with the youngest gestational ages where it remains high or even increases during the first month of life. • Lower gestational age, no antenatal administration of corticosteroids and lower 5-min Apgar score were significantly related with higher daily NeO-stress scores.",

keywords = "Prematurity, Stress, Pain, NICU, BRAIN, PAIN, IMPACT, SCALE",

author = "Meesters, {Naomi J.} and {van den Bosch}, {Gerbrich E.} and Tataranno, {Maria Luisa} and {van den Akker}, {Chris H. P.} and {van Ganzewinkel}, Christ-jan and {ten Barge}, {Judith A.} and Schuerman, {Frank A. B. A.} and {van Zanten}, Henriette and {de Boode}, {Willem P.} and Raets, {Marlou M. A.} and Dijk, {Peter H.} and {van Rosmalen}, Joost and Vermeulen, {Marijn J.} and Wes Onland and Lotte Haverman and Reiss, {Irwin K. M.} and {van Kaam}, {Anton H.} and Manon Benders and {van Dijk}, Monique and Simons, {Sinno H. P.} and {HIPPO study Group}",

year = "2025",

month = feb,

day = "13",

doi = "10.1007/s00431-025-06018-7",

language = "English",

volume = "184",

journal = "European Journal of Pediatrics",

issn = "0340-6199",

publisher = "Springer",

number = "3",

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Meesters, NJ, van den Bosch, GE, Tataranno, ML, van den Akker, CHP, van Ganzewinkel, C, ten Barge, JA, Schuerman, FABA, van Zanten, H, de Boode, WP, Raets, MMA, Dijk, PH, van Rosmalen, J, Vermeulen, MJ, Onland, W, Haverman, L, Reiss, IKM, van Kaam, AH, Benders, M, van Dijk, M, Simons, SHP & HIPPO study Group 2025, 'Exposure to clinical stressors during NICU admission in preterm infants', European Journal of Pediatrics, vol. 184, no. 3, 196. https://doi.org/10.1007/s00431-025-06018-7

TY - JOUR

T1 - Exposure to clinical stressors during NICU admission in preterm infants

AU - Meesters, Naomi J.

AU - van den Bosch, Gerbrich E.

AU - Tataranno, Maria Luisa

AU - van den Akker, Chris H. P.

AU - van Ganzewinkel, Christ-jan

AU - ten Barge, Judith A.

AU - Schuerman, Frank A. B. A.

AU - van Zanten, Henriette

AU - de Boode, Willem P.

AU - Raets, Marlou M. A.

AU - Dijk, Peter H.

AU - van Rosmalen, Joost

AU - Vermeulen, Marijn J.

AU - Onland, Wes

AU - Haverman, Lotte

AU - Reiss, Irwin K. M.

AU - van Kaam, Anton H.

AU - Benders, Manon

AU - van Dijk, Monique

AU - Simons, Sinno H. P.

AU - HIPPO study Group

PY - 2025/2/13

Y1 - 2025/2/13

N2 - This study aims to quantify stress exposure related to clinical stressors in preterm infants during NICU admission and identify risk factors for high stress exposure. In this national cohort study, preterm infants (gestational age < 29 weeks) were prospectively followed during the first 28 days of their admission to one of the 10 NICUs in the Netherlands. The NeO-stress score, consisting of 38 clinical stressors graded with a severity index, was applied to describe stress exposure. We assessed the impact of infant characteristics at birth and postnatal age on NeO-stress scores using linear mixed modelling. In total, 446 infants were included with a median gestational age of 27+2 weeks (IQR 26+2-28+2). The median NeO-stress score per day was 61 (IQR 39-87) and highest (74, IQR 52-101) on the day of admission. Nasal/oral (37%) and endotracheal (14%) suctioning were key contributors to the cumulative NeO-stress scores. Linear mixed modelling showed that lower gestational age (B = -0.69, 95% CI - 0.94-0.44, p < 0.001), no antenatal administration of corticosteroids (B = 13.2, 95% CI 3.2-23.1, p = 0.010) and lower 5-min Apgar score (B = - 1.6, 95% CI - 3.0-0.25, p = 0.02) were significantly related with higher daily NeO-stress scores. Our model predicts that the NeO-stress score increases over time for the youngest infants. CONCLUSION: Stress exposure in preterm infants during NICU admission varies over time with infants with the lowest gestational age at risk for experiencing the highest levels of stress throughout NICU admission. This highlights the importance stress reduction and provides opportunities for future interventions aimed at reducing stress exposure. WHAT IS KNOWN: • Preterm birth and admission to a Neonatal Intensive Care Unit is very stressful. • High stress exposure in neonatal life is associated with adverse long term outcome. WHAT IS NEW: • Stress exposure is highest in infants with the youngest gestational ages where it remains high or even increases during the first month of life. • Lower gestational age, no antenatal administration of corticosteroids and lower 5-min Apgar score were significantly related with higher daily NeO-stress scores.

AB - This study aims to quantify stress exposure related to clinical stressors in preterm infants during NICU admission and identify risk factors for high stress exposure. In this national cohort study, preterm infants (gestational age < 29 weeks) were prospectively followed during the first 28 days of their admission to one of the 10 NICUs in the Netherlands. The NeO-stress score, consisting of 38 clinical stressors graded with a severity index, was applied to describe stress exposure. We assessed the impact of infant characteristics at birth and postnatal age on NeO-stress scores using linear mixed modelling. In total, 446 infants were included with a median gestational age of 27+2 weeks (IQR 26+2-28+2). The median NeO-stress score per day was 61 (IQR 39-87) and highest (74, IQR 52-101) on the day of admission. Nasal/oral (37%) and endotracheal (14%) suctioning were key contributors to the cumulative NeO-stress scores. Linear mixed modelling showed that lower gestational age (B = -0.69, 95% CI - 0.94-0.44, p < 0.001), no antenatal administration of corticosteroids (B = 13.2, 95% CI 3.2-23.1, p = 0.010) and lower 5-min Apgar score (B = - 1.6, 95% CI - 3.0-0.25, p = 0.02) were significantly related with higher daily NeO-stress scores. Our model predicts that the NeO-stress score increases over time for the youngest infants. CONCLUSION: Stress exposure in preterm infants during NICU admission varies over time with infants with the lowest gestational age at risk for experiencing the highest levels of stress throughout NICU admission. This highlights the importance stress reduction and provides opportunities for future interventions aimed at reducing stress exposure. WHAT IS KNOWN: • Preterm birth and admission to a Neonatal Intensive Care Unit is very stressful. • High stress exposure in neonatal life is associated with adverse long term outcome. WHAT IS NEW: • Stress exposure is highest in infants with the youngest gestational ages where it remains high or even increases during the first month of life. • Lower gestational age, no antenatal administration of corticosteroids and lower 5-min Apgar score were significantly related with higher daily NeO-stress scores.

KW - Prematurity

KW - Stress

KW - Pain

KW - NICU

KW - BRAIN

KW - PAIN

KW - IMPACT

KW - SCALE

U2 - 10.1007/s00431-025-06018-7

DO - 10.1007/s00431-025-06018-7

M3 - Article

SN - 0340-6199

VL - 184

JO - European Journal of Pediatrics

JF - European Journal of Pediatrics

IS - 3

M1 - 196

ER -

Exposure to clinical stressors during NICU admission in preterm infants

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Keywords

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