Early Human Development 139 (2019) 104852

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Early Human Development

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

Is sensory processing associated with prematurity, motor and cognitive T

development at 12 months of age?
⁎
Ana Carolina Cabral de Paula Machadoa, , Lívia de Castro Magalhãesb, Suelen Rosa de Oliveiraa,
Maria Cândida Ferrarez Bouzadaa
a
School of Medicine, Federal University of Minas Gerais, Avenida Professor Alfredo Balena, 190 - Santa Efigênia, Belo Horizonte, Minas Gerais 30130-100, Brazil
b
School of Physical Education, Physiotherapy and Occupational Therapy, Federal University of Minas Gerais, Antônio Carlos, 6627 - Pampulha, Belo Horizonte, Minas
Gerais 31270-901, Brazil

A R T I C LE I N FO A B S T R A C T

Keywords: Background: Prematurity may be a risk factor for sensory processing difficulties. Limited research has in-
Preterm infants vestigated sensory processing in preterm infants in their first year of life, when sensory processing dysfunctions
Sensory processing are more subtle and difficult to detect.
Child development Aims: The aims of this study were to investigate the association between prematurity and sensory processing and
Developmental outcomes
the associations between sensory processing and motor and cognitive development in infants at 12 months of
age.
Study design: Cross-sectional study.
Subjects: 45 infants allocated in two groups: control (37–41 weeks' gestation) and preterm (< 34 weeks' gesta-
tion).
Outcome measures: Sensory processing was assessed with the Test of Sensory Functions in Infants (TSFI). Motor
and cognitive development was assessed with the Bayley Scales of Infant and Toddler Development, Third
Edition (Bayley-III).
Results: Preterm group was associated with significant decrease in TSFI's total (p < 0.01), reactivity to deep
tactile pressure (p = 0.02) and vestibular stimulation reactivity (p = 0.03) scores. Bayley-III motor score was
positive associated with TFSI score on ocular-motor control domain (p = 0.03). Bayley-III cognitive score and
TSFI scores were not significantly associated.
Conclusions: Prematurity negatively interferes with sensory processing, especially in tactile and vestibular do-
mains, and better sensory processing in ocular-motor control contributes to better motor performance at
12 months of age. It is important to consider sensory processing in early developmental evaluation and inter-
ventions to promote better developmental outcomes in preterm infants.

1. Introduction engagement in the world and purposeful participation in daily activities

All motor, behavior, emotional and attention responses result from
the way the brain processes stimuli from the sensory systems (tactile,
olfactory, gustatory, visual, auditory, proprioceptive and vestibular).
The neural ability to organize sensations from the body and the sur-
rounding environment to respond properly is defined as sensory pro-
cessing [1]. This concept derives from the sensory integration theory,
developed by A. Jean Ayres, which proposes that adaptive behaviors,
ranging from body movements to learning processes and concept for-
mation, are dependent on the ability to organize and interpret sensory
information [2]. Good sensory processing enables the individual
within his or her social and physical environment [3,4].
Sensory processing difficulties manifest as abnormal behavioral re-
actions in response to sensory stimulation which are so severe that it
interferes with daily life routines [5]. Miller et al. [6] proposes three
categories of sensory processing disorder: sensory modulation disorder
(exaggerated aversive, withdrawal, and/or seeking behaviors asso-
ciated with difficulty grading or regulating responses to sensory sti-
muli), sensory discrimination disorder (difficulty interpreting the spe-
cific characteristics of sensory stimuli, e.g., intensity, duration, spatial,
and temporal elements of sensations) and sensory-based motor disorder
(problems in balance and core stability, and difficulties in motor

⁎
Corresponding author at: Rua Montes Claros, 1359 apt 1504 - Anchieta, Belo Horizonte, Minas Gerais 30310-702, Brazil.
E-mail address: carolaraxa.acm@gmail.com (A.C.C. de Paula Machado).

https://doi.org/10.1016/j.earlhumdev.2019.104852
Received 26 February 2019; Received in revised form 22 July 2019; Accepted 20 August 2019
0378-3782/ © 2019 Elsevier B.V. All rights reserved.
A.C.C. de Paula Machado, et al.
planning and sequencing movements). These manifestations present
impacts on the quality of life because they are associated with disrup-
tion of family routines, difficulties regarding self-care; decreased
quality and quantity of play skills and social participation [7,8].
Prematurity (i.e., birth before 37 weeks of gestation) [10] may be a
risk factor for sensory processing disorder [1]. Preterm birth occurs
when both neurological and biological systems are immature and the
majority of preterm newborns are admitted to a Neonatal Intensive
Care Unit (NICU) for survival [11]. Early experiences in the NICU, such
as sensory overstimulation (e.g. bright lights, noise, nursery handling,
repetitive pain) and understimulation (e.g. tactile, vestibular and ki-
nesthetic deprivation due to parental separation), are stressful and
occur while the central nervous system is at a critical period of ac-
celerated growth and development. The NICU's sensory environment
does not meet the needs of preterm newborns and may alter the
structure and functioning of the brain which may, in turn, lead to
atypical neurodevelopmental outcomes, including altered sensory pro-
cessing patterns [12,13]. There is evidence that NICU stressors are as-
sociated with decreased brain size and altered brain microstructure and
functional connectivity in sensory areas (respectively, parietal and
temporal regions) [13]. Furthermore, mechanisms of hypoxia-ischemia
and inflammation causing periventricular leukomalacia, periventricular
hemorrhage and widespread neural and axonal disease in preterm in-
fants generally occur in parieto-occipital, sensorimotor, and temporal
cortices [14] and may, in turn, interfere with the normal functioning of
the sensory systems or association areas.
Current evidence [15–19] shows high frequency (39% to 52%) of
sensory processing difficulties in preterm infants, with sensory mod-
ulation disorder appearing to be more prominent [1]. Atypical sensory
processing in preterm infants has been associated with male sex, longer
hospital stay, white-matter injury, and higher social risk [20]. To date,
only a few studies [18,19,21] investigated the relationship between
sensory processing and prematurity during the first year of life, when
sensory processing dysfunctions are more subtle and difficult to detect.
In addition, these studies address a wide range of ages and in none of
them the participants were assessed specifically at 12 months of age,
which is an important developmental milestone. Full understanding of
the early impact of prematurity on sensory processing is required be-
cause, in the first years of life, functional problems resulting from
sensory processing disorder are often misinterpreted as an expression of
the great variability of behaviors observed during this period. Fre-
quently, these problems will only be identified at school age, when the
child faces social, behavioral, emotional and cognitive problems as well
as communication, attention and learning disabilities [3].
Sensory experience is the basis for learning in infancy and most
activities a child does in the first seven years of life are part of the
process of organizing sensations in the nervous system to produce
adaptive responses [2]. Sensory processing contributes to daily func-
tional performance at home, school, or other settings and enables
cognitive, motor, social and emotional development [21]. Poor sensory
processing has been associated with behavioral problems, immature
social skills, impaired fine and gross motor skills, decreased academic
achievement and learning difficulties [7,8,22]. These findings highlight
the importance of sensory experience in infant learning and develop-
ment. Therefore it is important to investigate sensory processing at an
age, such as 12 months, in which many children experience a change in
their ability to explore the environment due to walking. In children
born preterm, atypical sensory processing patterns have been correlated
with poorer motor and/or cognitive development at 2–5 years age, but
no consensus has been reached in the literature [17–19,23,24].
The aims of this study were to investigate the association between
prematurity and sensory processing; and the associations between
sensory processing and motor and cognitive development in infants at
12 months old. We hypothesized that there is an association between
prematurity and poorer sensory processing; and an association between
better sensory processing and improved motor and cognitive outcomes.
2
Early Human Development 139 (2019) 104852
2. Methods
2.1. Study design
This observational, cross-sectional, quantitative and analytical-de-
scriptive study was approved by the Human Ethics Committee of the
Federal University of Minas Gerais (UFMG) in Belo Horizonte, Brazil.
The study included a subset of infants from a greater study aimed at
investigating the neural pattern of sensory processing in preterm infants
during their first 12 months of life. For the present study, we analyzed
the sensory processing, motor and cognitive development evaluated at
12 months of age. For preterm infants, we considered their corrected
age. All parents or guardians gave their written informed consent.
2.2. Participants
At 12 months, 57 infants were recruited but only 45 completed all
the evaluations. Thus, our study sample consisted of 45 infants allo-
cated in two unpaired groups: control and preterm. There were no
differences in relation to birth data, economic status and neonatal
morbidities between the participants and those infants who do not
complete all the evaluations.
All participants were born in 2013–2014 at the maternity unit of the
University Hospital (UFMG). The control group included 22 full term
infants born with gestational age 37–41 weeks and recruited in the
maternity just after birth. The 23 participants of the preterm group
were infants born prematurely recruited from a multidisciplinary de-
velopmental follow-up program, for infants born at the same maternity
unit with gestational age < 34 weeks and/or birth weight below
1500 g.
Exclusion criteria for both groups were hydrocephalus, cerebral
palsy, genetic syndromes or any malformation, congenital heart dis-
ease, major neurosensory impairment (blindness, deafness) and Apgar
score under 7 at 5 min. Participants in the preterm group with peri-
intraventricular hemorrhage grade III or IV, periventricular leukoma-
lacia and severe retinopathy of prematurity (stage ≥ 3) were also ex-
cluded. All infants underwent a cranial ultrasound to exclude mor-
phological brain abnormalities.
2.3. Outcome measures
2.3.1. Test of Sensory Functions in Infants (TSFI)
The TSFI is designed to assess the sensory processing and reactivity
in infants aged 4–18 months. The test contains 24 items grouped into
five domains: tactile deep pressure, adaptive motor function, visual-
tactile integration, ocular-motor control and vestibular stimulation.
Each domain represents processing within sensory modalities or be-
tween sensory and motor systems in response to examiner's adminis-
tered stimulus. Each item is scored on a 0–3 point scale based on
whether the infant exhibits a simple behavioral reaction (i.e., cry or
grimace) or a physiological response (i.e., nystagmus in response to a
360° spin). The score of each domain is obtained by adding the score in
specific items. The total TSFI score is obtained by adding the scores of
each domain, ranging from 0 to 49. Higher score indicates better sen-
sory processing and reactivity. Based on norm-referenced values for
typically developing North American infants in four age categories, the
TSFI scores can also be divided into three categories: (a) typical per-
formance; (b) at risk; and (c) deficient [25].
To date, the TSFI, as well as other internationally available instru-
ments to evaluate sensory processing in infants [26], has not been va-
lidated for the Brazilian population. However, the TSFI was used in a
Brazilian study [21] and the scores were shown to be sensitive to dif-
ferences in sensory processing between preterm and full-term infants.
Adopting the same procedure, to reduce the risk of bias, we used the
TSFI total and domain scores to compare the groups' sensory functions
and not the cut-off points reported in the test's manual.
A.C.C. de Paula Machado, et al. Early Human Development 139 (2019) 104852

2.3.2. Bayley Scales of Infant and Toddler Development version 3 (Bayley- Table 1
III) Descriptive analysis of preterm and control groups regarding infant birth data,
We used the motor and cognitive scales of Bayley-III [27], a stan- economic status, neonatal morbidities, motor/cognitive Bayley-III scores and
dardized test commonly used for assessing early development in 1 to the TSFI at 12 months old.
42-month-old children. There is a study that supports the validity of Control (22 infants) Preterm (23 infants) p-Value
Bayley-III for the Brazilian population [28], it is widely applied in local
researches to evaluate preterm infants and it is capable of capturing N(%) or mean (SD) N(%) or mean (SD)
or median [IQ or median [IQ
developmental changes and differences between groups [29,30]. range] range]
The motor scale includes items for the evaluation of fine and gross
motor skills, while the cognition scale evaluates skills such as concept Infant birth data
formation, memory and problem solving. The total score obtained by Age (months) 12.5 (0.3) 12.6 (0.5) 0.26a
Gestational age (weeks) 38.6 [38.0;39.6] 32.6 [30.9;32.7] < 0.01b
the infant in each scale is converted into a balanced score for each age,
Birth weight (g) 3180.0 1620.0 < 0.01b
which is converted into a standardized composite score, with normative [3091.0;3392.0] [1205.0;1802.0]
average of 100 and standard deviation of 15 points [27]. We used the Cephalic perimeter at 34.0 [33.0;34.5] 28.8 [26.2;30.2] < 0.01b
composite scores to classify the infants' motor and cognitive perfor- birth (cm)
Male sex 16 (72.7%) 9 (39.1%) 0.04c
mance.
Economic status (CCEB)
2.4. Procedure ≥$484 monthly 10 (45.5%) 7 (33.3%) 0.62c
< $484 monthly 12 (54.5%) 14 (66.7%)

All participants were selected by medical records analysis and re- Bayley-III composite scores
Motor 103 (11.8) 100 (10.8) 0.50a
cruitment occurred through personal contact. Infants of both groups
Cognitive 118 (11.7) 116 (14.6) 0.50a
were evaluated for sensory processing, motor and cognitive develop-
TSFI scores
ment by a single researcher, previously trained in the application of the
Total 49.0 [47.0;49.0] 47.0 [45.5;48.0] < 0.01b
TSFI and Bayley-III. Evaluations were performed in a room with good Reactivity to tactile deep 10.0 [10.0;10.0] 10.0 [9.00;10.0] < 0.01b
lighting and ventilation and few distraction stimuli. Infants were tested pressure
when calm and alert, positioned on the parents' or guardian's lap and/or Adaptive motor function 15.0 [15.0;15.0] 15.0 [14.5;15.0] 0.60b
on a mat. Tests were applied through simple interaction with the infant, Visual-tactile 10.0 [10.0;10.0] 10.0 [10.0;10.0] 0.56b
integration
using the original materials of standardized kit of each test. When any Ocular-motor control 2.00 [2.00;2.00] 2.00 [1.00;2.00] 0.34b
infant showed signs of fatigue, sleep, hunger or little cooperation, a Reactivity to vestibular 12.0 [12.0;12.0] 12.0 [10.0;12.0] 0.02b
pause was made and the assessment was complete as a calm state was stimulation
reestablished. Whenever necessary, evaluations were rescheduled to be Neonatal morbidities
continued another day. Days in neonatal unit n/a 9.0 [5.0;23.0] n/a
Information such as infant birth data, economic status and neonatal Intraventricular n/a 13 (56.5%) n/a
morbidities were collected from medical records. Economic status was hemorrhage (grade I
or II)
estimated by the Brazilian Economic Classification Criterion (CCEB) Retinopathy of n/a 4 (18.2%) n/a
[31]. The CCEB is an economic segmentation tool that uses household prematurity
characteristics to classify the population according to the average (stage < 3)
monthly income. The CCEB results were categorized into two groups Necrotizing enterocolitis n/a 0 (0.0%) n/a
Bronchopulmonary n/a 5 (21.7%) n/a
considering monthly income values: “monthly income ≥ US$453 and
dysplasia (mild or
“monthly income ≤ US$453.” moderate)

2.5. Sample size
Power analysis was conducted using the software G*Power 3 to
compare pairs of independent sample means. Data from the first 20
infants evaluated (10 preterm infants and 10 full-term infants) were
used to identify statistically significant difference in the mean score of
total TSFI score between the groups. Assuming an α error of 0.05, a
study power of 95% and infant ratio of 1:1, the total sample require-
ment was estimated to be 40 infants.
2.6. Data analysis
The data analysis was conducted using software R, 3.2.3 version.
Significance was set at p < 0.05. Normality of infants' birth data,
economic status, neonatal morbidities, motor/cognitive composite
scores on Bayley-III and sensory processing scores on the TSFI were
verified by the Shapiro-Wilk test. When continuous data (age at as-
sessment, gestational age, birth weight, scores on the Bayley-III, scores
on the TSFI and days in neonatal unit) were distributed normally, in-
dependent samples t-tests were used to evaluate group differences. If
the distribution of continuous data failed the Shapiro–Wilk's normality
test, nonparametric Mann–Whitney test was used to evaluate group
differences. Categorical variables (male sex, economic status and neo-
natal morbidities) were compared using Chi-square.
The TSFI and Bayley-III scores were treated as continuous variables.
Note: Number of participants (N); percentage (%); standard deviation (SD);
interquartile (IQ); Brazilian Economic Classification Criterion (CCEB); Bayley
Scales of Infant and Toddler Development version 3 (Bayley-III); Test of Sensory
Functions in Infants (TSFI); not Applicable (n/a)
p < 0.05 highlighted in bold.
a
t-Test.
b
Mann-Whitney test.
c
Chi-square test.
Linear regression analyses, performed with the total sample, were used
to verify the association between the TSFI scores and preterm/control
group. When the association was significant in the simple linear re-
gression model (p < 0.05), adjustment for possible confounding fac-
tors, as identified by the descriptive analysis, was performed in the
multiple linear regression analysis. The associations between Bayley-III
motor/cognitive composite scores and the TSFI scores were verified
within the total sample by multiple linear regression analysis with ad-
just for gestational age as a possible confounding factor.
In the preterm group, to verify the effect of the neurobiological
immaturity at birth (as expressed by gestational age) on sensory pro-
cessing, linear regression analysis was performed to investigate the
association between the total TSFI score and the gestational age, and
then the regression model was repeated with birth weight included
instead of gestational age.

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A.C.C. de Paula Machado, et al. Early Human Development 139 (2019) 104852

3. Results 4. Discussion

Table 1 provides a summary of the sample characteristics. There In this study we demonstrated that prematurity is negatively asso-
were no significant differences between preterm and control groups in ciated with sensory processing and motor development outcome is
regard to economic status, cognitive and motor development. By de- positively associated with sensory processing. We were able to accept
sign, the preterm group had lower gestational age, weight and cephalic our hypothesis that 1) there is an association between prematurity and
perimeter at birth than the control group. The difference between poorer sensory processing, and 2) better sensory processing is asso-
groups in the number of males, favoring the control group, was con- ciated with improved motor development for both preterm and full
sidered a possible confounding factor, since male sex has been reported term infants at 12 months of age.
in literature as a risk factor for sensory processing dysfunctions in Consistent with other studies [18,19,32], our results indicate that
preterm infants [19,20]. There were significant differences between prematurity is associated with poorer sensory processing in the first
groups in the sensory processing scores, with the preterm group scoring year, especially in tactile and vestibular domains. In preterm infants
significantly lower than the control group on the following TSFI scores: evaluated by the TSFI at 10–12 months, tactile processing, motor
total, reactivity to tactile deep pressure and reactivity to vestibular praxis, visual-tactile integration, and vestibular processing scores were
stimulation. lower than in term infants [32]. Chorna et al. [18], also using the TSFI,
In the preterm group, frequencies of days in neonatal unit, retino- found high rate of atypical responses to tactile deep pressure and ves-
pathy of prematurity and bronchopulmonary dysplasia were relatively tibular stimulation in preterm infants in the first year, but participants
low and there were no cases of necrotizing enterocolitis. were evaluated at 4–12 months and there was not a control group.
Wickremasinghe et al. [19] reported similar results in preterm children
evaluated at 1 to 8 years, and they show that the frequency of atypical
3.1. Prematurity and sensory processing sensory processing was similar in children evaluated at 1–4 years and at
4–8 years old. Such evidences suggest that premature infants can show
Simple linear regression models showed significant association be- early signs of sensory processing difficulties and these problems may
tween preterm group and the following TSFI scores: total (t = −2.60, persist at older ages. These early signs of poor vestibular processing
p = 0.01), reactivity to deep tactile pressure (t = −2.21, p = 0.03) might be predictive of later motor problems, such as sensory-based
and vestibular stimulation reactivity (t = −2.25, p = 0.03). After ad- motor disorder, or more broadly, developmental coordination disorder,
justing the confounding factor (male sex) in the multiple linear re- that is more prevalent among children born preterm [33]. Longitudinal
gressions, the associations remained significant (Table 2). The preterm studies are necessary to clarify this question, which has relevant im-
group was associated with significant decrease in the TSFI scores plications for early intervention.
(−2.46 points in the total score, −0.57 points in the reactivity to deep Sensory development begins in the womb and continues over time.
tactile pressure and −1.55 in the vestibular stimulation reactivity). Preterm birth creates a situation where the early sensory development
In the preterm group, the total TSFI score was not significantly as- occurs primarily in an environment with sensory information that the
sociated with gestational age (t = −0.70; p = 0.49) and birth weight infant is not yet prepared to integrated [12]. The NICU stay is char-
(t = 0.16; p = 0.87). The decrease in gestational age and birth weight acterized by multiple daily stressors from diaper changing to intuba-
was not accompanied by a significant increase in the total TSFI score tion. Increased NICU stressors are associated with altered regional brain
(Fig. 1). size, microstructure and function [13,34–36]. Owen et al. [37] de-
monstrated reduced white matter microstructure integrity in children
with sensory processing disorder, suggesting abnormal white matter as
3.2. Sensory processing and neurodevelopmental outcomes a biological basis for sensory processing difficulties.
Other studies reported that, in children born preterm, those with
Multiple linear regression models showed significant positive asso- atypical sensory processing had younger gestational age and lower birth
ciation between Bayley-III motor score and TFSI scores on the ocular- weight [9,38]. In our preterm group, the effect of the gestational age
motor control domain. For every 1-point increase in the Bayley-III and birth weight on sensory processing was not significant. Celik et al.
motor score, infants were more likely to have higher scores in this TSFI [39] also found no significant association between the TSFI total score
domain (Table 3). No significant associations were found between the and gestational age/birth weight in preterm infants at a mean age of
Bayley-III cognitive score and the TSFI scores. 10.7 months. It is possible that atypical sensory processing in preterm
infants is explained by the combination of biological and environmental
factors and not only by the neurobiological immaturity at birth [38].
Table 2
Our results demonstrated that better sensory processing is asso-
Multiple linear regression model within the full sample for adjustment of male
sex in assessment of the association between TSFI scores and prematurity at ciated with improved motor development in both preterm and full term
12 months of age. infants, especially in ocular-motor control domain. This finding is not
surprising, since vestibulo-ocular connections have a significant impact
Outcomes Explanatory β SE p-Value
on postural control, being crucial for the development of adaptive
variables
motor responses [21,25]. There is evidence that poor ocular-motor
Total TSFI score Constant 48.67 0.86 control in response to visual stimuli at a mean age of 8 months is as-
Preterm group −2.46 0.87 < 0.01 sociated to motor delays in preterm infants at the age of 2 years [18]. In
Male sex −0.98 0.87 0.26
a similar study, sensory processing and motor development were
Reactivity to deep tactile Constant 9.95 0.25
pressure score Preterm group −0.57 0.25 0.02 strongly correlated in preterm infants at a mean age of 10.7 months
Male sex −0.18 0.25 0.46 [39].
Vestibular stimulation reactivity Constant 12.08 0.67 In contrast, we are not able to accept our hypothesis that better
score Preterm group −1.55 0.68 0.03 sensory processing is associated with improved cognitive development
Male sex −0.37 0.69 0.59
for both preterm and full term infants at 12 months age. Similar result
Note: Test of Sensory Functions in Infants (TSFI); standardized coefficient (β); was found in preterm infants assessed at 2 years old [17]. However,
standard error (SE). Constant is the expected mean value of the TSFI scores in there is evidence of significant association between sensory processing
the control group. and cognitive development in preterm children at the age of 2 and
p < 0.05 highlighted in bold. 3–5 years [23,24]. In the first year of live, cognitive growth primarily

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A.C.C. de Paula Machado, et al. Early Human Development 139 (2019) 104852

Fig. 1. Scatter plots with the results of linear regression analysis for investigate the association between the total TSFI score and gestational age/birth weight within
the preterm group:

Table 3 processing problems, therefore, better training and awareness of NICU

Simple linear regression model within the full sample for assessment of the professionals concerning this issue is recommended. The implementa-
association between Bayley- III scores and TSFI scores at 12 months old. tion of strategies to adjust the NICU environment according to the
Outcome TSFI scores β SE p-Value sensory needs of the newborn can favor the development of sensory
systems and improve sensory processing outcomes in preterm infants
Bayley-III motor Constant 50.20 27.56 [41]. The evaluation of sensory processing should also be routine in
score Total 0.25 0.60 0.12
developmental follow-up programs. Early identification of sensory dif-
Gestational age 0.07 0.42 0.67
Bayley-III motor Constant 106.22 22.89 ficulties allows referral to clinical interventions that can improve the
score Reactivity to tactile deep −0.16 2.12 0.31 sensory capacities of preterm infants and favor adaptive responses.
pressure Early sensory integration intervention was shown to have positive effect
Gestational age 0.17 0.42 0.27 on the sensory processing of preterm infants, contributing to enhanced
Bayley-III motor Constant 89.17 30.85
score Adaptive motor function −0.01 1.88 0.96
cognitive, language, motor and social-emotional development [42,43].
Gestational age 0.14 0.41 0.35 This study has some limitations. Firstly, the sample was not ran-
Bayley-III motor Constant 78.06 28.20 domized, the examiner was not blinded to group assignment and en-
score Visual-tactile integration 0.06 2.40 0.68 vironmental factors, such as quality of care and stimulation at home,
Gestational age 0.14 0.41 0.34
were not controlled. However, the confounding factors were statisti-
Bayley-III motor Constant 75.76 14.95
score Ocular-motor control 0.31 3.76 0.03 cally controlled, the infants were born in the same university public
Gestational age 0.12 0.40 0.41 hospital, there was no significant difference between preterm and
Bayley-III motor Constant 80.21 14.63 control groups in regard to economic status and the control group did
score Reactivity to vestibular 0.29 0.28 0.07 not receive any intervention in this study. The study's power of 95%
stimulation
Gestational age 0.05 0.42 0.73
indicated that our sample provided less Type II error; however, the
preterm group participated in a structured follow-up with periodic or-
Note: Test of Sensory Functions in Infants (TSFI); standardized coefficient (β); ientations on child development, which may have contributed to
standard error (SE). minimize differences between the groups.
Constant is the expected mean value of the Bayley-III motor score when the It should be emphasized that infants were evaluated in a clinical
TSFI scores assume zero value. setting on a single occasion. An alternative to ensure that findings from
p < 0.05 highlighted in bold. clinical evaluation are consistent with infants' daily behaviors would be
to associate the evaluation with parents' questionnaires, already in use
involves sensory learning, perceptual-motor integration and simple at- abroad, but not yet validated for the Brazilian population. Although
tention [40]. There is evidence that the development of cognitive subjective, these questionnaires have the advantage of reporting sen-
functions is most significant between 2 and 5-year-old, possibly due to sory behaviors over a broader range of time and environmental settings.
the maturation of attention during the second year of life [40]. Atten-
tion is the primary way that infants perceive and process sensory in-
formation to selectively focus on a desired stimulus or task [2]. This 5. Conclusions
ability enables children to use symbols, rudimentary concepts, planning
and goal-directed behavior [40]. It seems that the association between The results of the present study suggest that prematurity negatively
sensory processing and cognitive performance may become evident interferes with sensory processing, especially in tactile and vestibular
after the second year of life when the emergence of attention me- domains, and better sensory processing in ocular-motor control domain
chanisms is more expressive, an interesting issue to be explored in contribute to better motor performance in preterm and full term infants
further studies. at 12 months age. It is important to include sensory processing in early
This is the first study that investigates sensory processing in infants developmental evaluation and in interventions to support the devel-
born preterm and full term specifically at 12 months of age. Based on opment of preterm infants.
well-known standardized assessments, our results add support to evi-
dences showing that preterm infants are at increased risk for sensory

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A.C.C. de Paula Machado, et al.
Declaration of competing interest
The authors of this study have no conflicts of interest to disclose.
This study received funding from the Minas Gerais State Research
Foundation – FAPEMIG (grant number APQ-01182-13) and the
National Council for Scientific and Technological Development (CNPq)
- Brazil (grant number 140675/2017-5).
Acknowledgements
We thank the infants and families who participated in our study. We
also thank the professionals of the multidisciplinary follow-up program
of risk infants in the Federal University of Minas Gerais' Clinical
Hospital (ACRIAR).
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