Preventive interventions with low birth weight premature infants: an evaluation of their success

Desenvolvimento motor na infância

Objetivos. Fornecer informações quanto ao desenvolvimento motor infantil, especificar os fatores de risco ambientais e biológicos que podem influenciar a seqüência típica do desenvolvimento, além de investigar os efeitos de programas de intervenção motora. Método. Foi realizada a captação de publicações através de bancos de dados científicos eletrônicos (Medline, Pubmed e SciELO), além de livros voltados à área da neuropediatria. Conclusão. Diversos fatores podem interferir no curso normal do desenvolvimento motor. Contudo, há diversas pesquisas que demonstram que a intervenção adequada pode ser benéfica para prevenir, minimizar ou até mesmo reverter o atraso no desenvolvimento.

Metaanálisis: efecto de las intervenciones para disminuir el nivel de estrés en padres de prematuros

Introducción: El nacimiento prematuro de un bebé genera estrés en los padres, por el riesgo de aumento en la morbimortalidadque esto conlleva. Existen intervenciones que disminuyen el nivel de estrés en los padres beneficiando a su vez el neurodesarrollo delrecién nacido. Objetivo: Categorizar los principales componentes de los programas de intervención temprana y determinar el efecto deestas intervenciones en la disminución del nivel de estrés en padres de prematuros hospitalizados. Método: Meta-análisis con 9 ensayosclínicos controlados, que cumplieron los criterios de rigurosidad metodológica. Resultados: las intervenciones aplicadas a los padresde prematuros hospitalizados, mostraron efecto de intensidad media-baja sobre el nivel de estrés percibido (d=0,36 IC [-0.68, -0,05]).Sin embargo, las pruebas de heterogeneidad indican alta variabilidad inter-estudio (Q(df=8) = p-val: <0,00001), I2=85% ), explicadaparcialmente por las características moderadoras codificadas para los estudios. Conclusiones: aunque las intervenciones mostraronefectos positivos en la disminución del nivel de estrés en los padres, se evidencia que la educación y el apoyo emocional en conjunto logranun mejor efecto. Las futuras investigaciones deben analizar aspectos como calidad de los estudios, intervenciones con apoyo emocional,edad de los padres y diversidad en los contextos de aplicación.

Key components of early intervention programs for preterm infants and their parents: a systematic review and meta-analysis

BACKGROUND

Preterm infants are at greater risk for neurodevelopmental disabilities than full term infants. Interventions supporting parents to improve the quality of the infant's environment should improve developmental outcomes for preterm infants. Many interventions that involve parents do not measure parental change, nor is it clear which intervention components are associated with improved parental outcomes. The aim of this review was to categorize the key components of early intervention programs and determine the direct effects of components on parents, as well as their preterm infants.

METHODS

MEDLINE, EMBASE, CINAHL, ERIC, and Cochrane Database of Systematic Reviews were searched between 1990 and December 2011. Eligible randomized controlled trials (RCTs) included an early intervention for preterm infants, involved parents, and had a community component. Of 2465 titles and abstracts identified, 254 full text articles were screened, and 18 met inclusion criteria. Eleven of these studies reported maternal outcomes of stress, anxiety, depressive symptoms, self-efficacy, and sensitivity/responsiveness in interactions with the infant. Meta-analyses using a random effects model were conducted with these 11 studies.

RESULTS

Interventions employed multiple components categorized as (a) psychosocial support, (b) parent education, and/or (c) therapeutic developmental interventions targeting the infant. All interventions used some form of parenting education. The reporting quality of most trials was adequate, and the risk of bias was low based on the Cochrane Collaboration tool. Meta-analyses demonstrated limited effects of interventions on maternal stress (Z = 0.40, p = 0.69) and sensitivity/responsiveness (Z = 1.84, p = 0.07). There were positive pooled effects of interventions on maternal anxiety (Z = 2.54, p = 0.01), depressive symptoms (Z = 4.04, p <.0001), and self-efficacy (Z = 2.05, p = 0.04).

CONCLUSIONS

Positive and clinically meaningful effects of early interventions were seen in some psychosocial aspects of mothers of preterm infants. This review was limited by the heterogeneity of outcome measures and inadequate reporting of statistics. IMPLICATIONS OF KEY FINDINGS: Interventions for preterm infants and their mothers should consider including psychosocial support for mothers. If the intervention involves mothers, outcomes for both mothers and preterm infants should be measured to better understand the mechanisms for change.

Early interventions involving parents to improve neurodevelopmental outcomes of premature infants: a meta-analysis

OBJECTIVE

To determine in a systematic review, whether interventions for infant development that involve parents, improve neurodevelopment at 12 months corrected age or older.

STUDY DESIGN

Randomized trials were identified where an infant intervention was aimed to improve development and involved parents of preterms; and long-term neurodevelopment using standardized tests at 12 months (or longer) was reported.

RESULT

Identified studies (n=25) used a variety of interventions including parent education, infant stimulation, home visits or individualized developmental care. Meta-analysis at 12 months (N=2198 infants) found significantly higher mental (N=2198) and physical (N=1319) performance scores favoring the intervention group. At 24 months, the mental (N=1490) performance scores were improved, but physical (N=1025) performance scores were not statistically significant. The improvement in neurodevelopmental outcome was not sustained at 36 months (N=961) and 5 years (N=1017).

CONCLUSION

Positive clinically meaningful effects (>5 points) are seen to an age of 36 months, but are no longer present at 5 years.

Evaluation of early stimulation programs for enhancing brain development

The term 'early intervention' designates educational and neuroprotection strategies aimed at enhancing brain development. Early educational strategies seek to take advantage of cerebral plasticity. Neuroprotection, a term initially used to characterize substances capable of preventing cell death, now encompasses all interventions that promote normal development and prevent disabilities, including organisational, therapeutic and environment-modifying measures, such as early stimulation programs. Early stimulation programs were first devised in the United States for vulnerable children in low-income families; positive effects were recorded regarding school failure rates and social problems. Programs have also been implemented in several countries for premature infants and low-birth-weight infants, who are at high risk for neurodevelopmental abnormalities. The programs target the child, the parents or both. The best evaluated programs are the NIDCAP (Newborn Individualized Developmental Care and Assessment Program) in Sweden for babies<1500 g in neonatal intensive care units and the longitudinal multisite program IHDP (Infant Health and Development Program) created in the United States for infants<37 weeks or <2500 g.

CONCLUSION

Although the NIDCAP and the IHDP targeted different populations, they produced similar effects in several regards: efficacy was greatest with programs involving both the parents and the child; long-term stimulation improved cognitive outcomes and child-parent interactions; cognition showed greater improvements than motor skills and larger benefits were obtained in families that combined several risk factors including low education attainment by the mothers.

[<< Early stimulation >> programs evaluation]

Early intervention include educational and neuroprotection strategies. Early educational strategies are based on the cerebral plasticity concept. Neuroprotection, initially reserved for molecules preventing cell death phenomena, can be extended now to all actions promoting harmonious development and preventing handicaps, and include organisational, therapeutic and environmental aspects. Early stimulation programs have been first devised in United States for vulnerable children who belong to an unfavorable socio-economic category ; positive effects were recorded in school failure rates and social problems ; programs have also been launched in several countries for premature infants and infants with a low birth weight, population exposed to a high risk of deficiencies. The programs are targetted either to the child, or to the parents, or combined to provide assistance for both the child and the parents. The programs given the best evaluation are NIDCAP Program in Sweden (Newborn Individualized Developmental Care and Assessment Program), intended for babies < 1500 g in neonatal intensive care units, then a longitudinal, multisite program, known as IHDP (Infant Health and Development Program). It was launched in United States for infants < 37 weeks or < 2500 g. Results show that combined parent-child programs are the most useful. Effects on parent- child relationships and on child's cognitive development are especially effective if stimulation is maintained and when mothers have a low level of education.

Staff opinions regarding the Newborn Individualized Developmental Care and Assessment Program (NIDCAP)

This study explored the opinions of (para)medical and nursing staff in two Dutch Neonatal Intensive Care Units (NICU's). A questionnaire was used that measured: a) the perceived impact of NIDCAP on several NICU conditions, b) attitudes, subjective norm, perceived behavioral control, knowledge and abilities of using the NIDCAP method (based on the Theory of Planned Behavior) and c) training interest, requirements, information sources and the relevance of the NIDCAP method for different groups of NICU patients. Respondents were positive about NIDCAP and felt that using NIDCAP is fulfilling and leads to improvement of the infant's development, health and well-being. However, NIDCAP was also thought to be time-consuming and might worsen job conditions. The nursing staff, compared to the medical staff, had a more positive attitude (p=.004), higher perceived behavioral control (p=.004) and perceived a more positive impact of NIDCAP on NICU conditions (p=.008).

Memory in Early Adolescents Born Prematurely: A Functional Magnetic Resonance Imaging Investigation

This study employed functional magnetic resonance imaging to examine the functional neuroanatomy of the hippocampus and head of the caudate nucleus during 2 different types of memory tasks in a sample of 9 early adolescent children who were born preterm (neonatal intensive care unit [NICU] sample) and a group of 9 age-matched control children who were born at term. The investigation employed delayed match to sample (DMS), delayed nonmatch to sample (DNMS), and spatial memory span tasks, as well as 2 analogous perceptuomotor tasks that placed no demands on memory. The general question examined was whether preterm children show different levels of hippocampal and caudate activation during these tasks when compared to children born at term. The findings indicated that the 2 groups did not differ in functional activation of the hippocampus during the DMS and DNMS tasks. During the encoding phase of the spatial memory span task, the DMS perceptuomotor task, and the spatial memory span perceptuomotor task, the NICU sample showed greater activation change in the right caudate nucleus, and less right caudate activation change during the test phase. During the spatial span perceptuomotor task, the preterm group showed reduced activation change in the left caudate nucleus during both the encoding and test phase. Also, during the DMS perceptuomotor task, the NICU group showed increased activation change in the left caudate nucleus during encoding and decreased activation change at test. The implications of these findings for understanding the functional neuroanatomy of memory deficits are discussed, as is the potential for distinguishing the effects of neural plasticity from those of typical brain maturational processes.

Randomised trial of parental support for families with very preterm children: outcome at 5 years

AIMS

To test the effectiveness of a home based developmental education intervention in improving outcome at 5 years for very preterm infants.

METHODS

The Avon Premature Infant Project (APIP) is a randomised controlled trial in which the parents of 284 babies born <33 weeks gestational age received a developmental education programme, a social support intervention, or standard care. A term reference population was also recruited. This study reports outcomes at 5 years (mean age 58 months 15 days) for 187 (66%) of these children without disability. Outcomes were assessed using the British Ability Scales II for cognitive development, the Movement ABC for motor impairment, and the Child Behavior Checklist for behavioural problems.

RESULTS

Preterm infants showed poorer cognitive performance than their term peers. Mean (SD) general conceptual ability (GCA) scores were: Portage 99.2 (15.7); parent adviser 100.3 (14.8); preterm control 101.1 (15.0); term reference 107.2 (13.4). There were no significant differences between preterm groups in GCA scores indicating no effect of either intervention. Similarly, there was no significant effect of intervention on behavioural or motor outcomes. Further analyses, in which outcome data were adjusted for social factors, did not reveal any differences between the three preterm groups or by subgroups classified by a range of perinatal variables.

CONCLUSION

The small advantage shown at 2 years of age is no longer detectable at 5 years. These results question the effectiveness of early intervention in enhancing cognitive, behavioural, and motor function at 5 years.

Severity of neonatal retinopathy of prematurity is predictive of neurodevelopmental functional outcome at age 5.5 years. Behalf of the Cryotherapy for Retinopathy of Prematurity Cooperative Group

OBJECTIVE

The purpose of this study was to assess the relation between neonatal retinopathy of prematurity (ROP) in very low birth weight infants and neurodevelopmental function at age 5.5 years.

METHODS

Longitudinal follow-up of children occurred in 2 cohorts of the Multicenter Cryotherapy for Retinopathy of Prematurity Study. The extended natural history cohort followed 1199 survivors of <1251 g birth weight from 5 centers. The threshold randomized cohort (ThRz) followed 255 infants <1251 g from 23 centers who developed threshold ROP and who consented to cryotherapy to not more than 1 eye. At 5.5 years both cohorts had ophthalmic and acuity testing and neurodevelopmental functional status determined with the Functional Independence Measure for Children (WeeFIM).

RESULTS

Evaluations were completed on 88.7% of the extended natural history cohort; 87% had globally normal functional skills (WeeFIM: >95). As ROP severity increased, rates of severe disability increased from 3.7% among those with no ROP, to 19.7% of those with threshold ROP. Multiple logistic regression analysis demonstrated that better functional status was associated with favorable visual acuity, favorable 2-year neurological score, absence of threshold ROP, having private health insurance, and black race. Evaluations were completed on 87.4% of the ThRz children. In each functional domain, the 134 children with favorable acuity in their better eye had fewer disabilities than did the 82 children with unfavorable acuity: self-care disability 25.4% versus 76.8%, continency disability 4.5% versus 50.0%, motor disability 5.2% versus 42.7%, and communicative-social cognitive disability 22.4% versus 65.9%, respectively.

CONCLUSION

Severity of neonatal ROP seems to be a marker for functional disability at age 5. 5 years among very low birth weight survivors. High rates of functional limitations in multiple domains occur in children who had threshold ROP, particularly if they have unfavorable visual acuity.

A critical evaluation of the evidence on the association between type of infant feeding and cognitive development

This paper presents a critical evaluation of 24 studies on the association between type of infant feeding and cognitive development published over the past 20 years. Validity and generalisability of study findings were assessed according to three methodological standards: clearly defined outcome, specification of partial vs. exclusive breast feeding and control of confounding. Only six of the 24 investigations met all three standards. The most frequent study flaw was failure to distinguish between partial and exclusive breast feeding. Studies which made this distinction found larger IQ advantages to breast-fed infants than studies that did not. Four of the six studies meeting all three standards found an advantage in cognitive development to breast-fed infants of the order of two to five IQ points for term infants and eight points for low birthweight infants. We conclude that the question of whether breast feeding and formula feeding have differential effects on cognitive development has not yet been comprehensively answered. Research to date provides only an indication of the effect of relatively brief durations of partial breast feeding and even briefer durations of exclusive breast feeding. Future studies should measure breast feeding as a continuous dose-type variable, examine longer durations of breast feeding and control for a full range of confounders using techniques that deal appropriately with multicollinearity.

[Nursing care to premature children: a review of the literature about follow up]

Neonatal care has improved greatly in recent years, focusing its efforts on low weight and premature children. Literature has considered prematurity under several focuses, recommending the following of growth and development in a systematic way. The present study tries to present a review of the literature on nursing care in the follow-up to premature children, in order to promote a reflection about the health care given to this customers. Authors searched in the data bank of the University of São Paulo, international periodicals and recent books. In general, studies focus on nursing role and strategies, such as home visits, in order to provide follow-up for the children and give orientations to mothers, as well as give support to the families. Studies emphasize the importance of multiprofessional teams working with mothers, children and families from neonatal intensive care to the post-neonatal period. The following of children brings out the need of reorganization and integration of health services, as well as the improvement of the relationships between professionals and families. Therefore, it is important to characterize the follow-up of this children, enabling the way for a more effective role in nursing care.

Early intervention for low-birth-weight premature infants: what can we achieve?

Low-birth-weight (LBW) premature infants are at increased risk for abnormal development. It is unclear whether intervention programs designed to prevent the disabilities in preterm children are efficacious. This paper reviews the settings in which interventions take place (e.g. nursery, home) and to whom they are directed (e.g. infant, parent). One intervention program, the Infant Health and Development Program (IHDP) is reviewed in detail. The IHDP was a multisite randomized clinical trial to evaluate the efficacy of combining developmental and support services along with paediatric follow-up to reduce the developmental problems seen among LBW preterm infants. Results from all studies suggest that preventive developmental interventions for LBW, premature infants have thus far demonstrated only modest success. Future research endeavours should investigate the type, duration, critical age onset, and intensity of the intervention as well as which subgroups of LBW infants most benefit from such programs.