Neonatal individualized care in practice: a Swedish experience

Developmental care education in Australian surgical neonatal intensive care units: A cross-sectional study of nurses' perceptions

Background

Nurse perceptions of developmental care practices have been researched globally for almost 30 years. Yet, there is a lack of research exploring this subject in the specialised setting of the surgical neonatal intensive care unit (sNICU). This research explores the effect of developmental care education programs on sNICU nurses' perceptions of developmental care.

Objective

To determine perceptions and attitudes towards developmental care in a specialty neonatal setting.

Design

Cross-sectional study.

Settings

Two surgical neonatal intensive care units in Australia.

Participants

Registered nurses permanently employed at the study sites between May 2021 to April 2022.

Methods

A modified electronic survey explored sNICU nurse perceptions of developmental care organised around three themes: effects of developmental care on parents and infants, application of developmental care, and unit practices. Associations between site, nurse characteristics, developmental care education and nurses' perceptions were explored using logistic regression [odds ratios (OR) and 95 % confidence intervals (CI)].

Results

Of 295 sNICU nurses, 117 (40 %) participated in the survey. Seventy-five percent of respondents had attended a formal developmental care education program. High levels of agreement (>90 %) were reported regarding the benefits of developmental care for parents and infants. Exposure to developmental care education influenced perceptions of its application. Nurses without formal developmental care education were more likely to agree that it was consistently applied [OR:3.3, 95%CI:1.3-8.6], developmental care skills are valued [OR:2.7, 95%CI:1.1-6.8], and that their nursing peers offered support in its application ([OR:2.5, 95%CI:1.1-6.2].

Conclusions

The results from our research suggest sNICU nurses have a high level of awareness of developmental care and its positive impacts. Despite differences between the surveyed units' developmental care education programs, the value of developmental care in reducing stress for infants and supporting families was collectively recognised. Future research in this setting should focus on evaluating the application of developmental care in this setting.

Noise or sound management in the neonatal intensive care unit for preterm or very low birth weight infants

BACKGROUND

Infants in the neonatal intensive care unit (NICU) are subjected to different types of stress, including sounds of high intensity. The sound levels in NICUs often exceed the maximum acceptable level recommended by the American Academy of Pediatrics, which is 45 decibels (dB). Hearing impairment is diagnosed in 2% to 10% of preterm infants compared to only 0.1% of the general paediatric population. Bringing sound levels under 45 dB can be achieved by lowering the sound levels in an entire unit; by treating the infant in a section of a NICU, in a 'private' room, or in incubators in which the sound levels are controlled; or by reducing sound levels at the individual level using earmuffs or earplugs. By lowering sound levels, the resulting stress can be diminished, thereby promoting growth and reducing adverse neonatal outcomes. This review is an update of one originally published in 2015 and first updated in 2020.

OBJECTIVES

To determine the benefits and harms of sound reduction on the growth and long-term neurodevelopmental outcomes of neonates.

SEARCH METHODS

We used standard, extensive Cochrane search methods. On 21 and 22 August 2023, a Cochrane Information Specialist searched CENTRAL, PubMed, Embase, two other databases, two trials registers, and grey literature via Google Scholar and conference abstracts from Pediatric Academic Societies.

SELECTION CRITERIA

We included randomised controlled trials (RCTs) or quasi-RCTs in preterm infants (less than 32 weeks' postmenstrual age (PMA) or less than 1500 g birth weight) cared for in the resuscitation area, during transport, or once admitted to a NICU or stepdown unit. We specified three types of intervention: 1) intervention at the unit level (i.e. the entire neonatal department), 2) at the section or room level, or 3) at the individual level (e.g. hearing protection).

DATA COLLECTION AND ANALYSIS

We used the standardised review methods of Cochrane Neonatal to assess the risk of bias in the studies. We used the risk ratio (RR) and risk difference (RD), with their 95% confidence intervals (CIs), for dichotomous data. We used the mean difference (MD) for continuous data. Our primary outcome was major neurodevelopmental disability. We used GRADE to assess the certainty of the evidence.

MAIN RESULTS

We included one RCT, which enroled 34 newborn infants randomised to the use of silicone earplugs versus no earplugs for hearing protection. It was a single-centre study conducted at the University of Texas Medical School in Houston, Texas, USA. Earplugs were positioned at the time of randomisation and worn continuously until the infants were 35 weeks' postmenstrual age (PMA) or discharged (whichever came first). Newborns in the control group received standard care. The evidence is very uncertain about the effects of silicone earplugs on the following outcomes. • Cerebral palsy (RR 3.00, 95% CI 0.15 to 61.74)and Mental Developmental Index (MDI) (Bayley II) at 18 to 22 months' corrected age (MD 14.00, 95% CI 3.13 to 24.87); no other indicators of major neurodevelopmental disability were reported. • Normal auditory functioning at discharge (RR 1.65, 95% CI 0.93 to 2.94) • All-cause mortality during hospital stay (RR 2.07, 95% CI 0.64 to 6.70; RD 0.20, 95% CI -0.09 to 0.50) • Weight (kg) at 18 to 22 months' corrected age (MD 0.31, 95% CI -1.53 to 2.16) • Height (cm) at 18 to 22 months' corrected age (MD 2.70, 95% CI -3.13 to 8.53) • Days of assisted ventilation (MD -1.44, 95% CI -23.29 to 20.41) • Days of initial hospitalisation (MD 1.36, 95% CI -31.03 to 33.75) For all outcomes, we judged the certainty of evidence as very low. We identified one ongoing RCT that will compare the effects of reduced noise levels and cycled light on visual and neural development in preterm infants.

AUTHORS' CONCLUSIONS

No studies evaluated interventions to reduce sound levels below 45 dB across the whole neonatal unit or in a room within it. We found only one study that evaluated the benefits of sound reduction in the neonatal intensive care unit for hearing protection in preterm infants. The study compared the use of silicone earplugs versus no earplugs in newborns of very low birth weight (less than 1500 g). Considering the very small sample size, imprecise results, and high risk of attrition bias, the evidence based on this research is very uncertain and no conclusions can be drawn. As there is a lack of evidence to inform healthcare or policy decisions, large, well designed, well conducted, and fully reported RCTs that analyse different aspects of noise reduction in NICUs are needed. They should report both short- and long-term outcomes.

Dissemination of newborn behavior observation skills after Newborn Individualized Developmental Care and Assessment Program (NIDCAP) implementation

Aim

To assess nurses’ ability to observe newborn behaviour after in situ training provided by caregivers with advanced practice certification in the Newborn Individualized Developmental Care and Assessment Program (NIDCAP).

Design

Prospective observational study.

Methods

Twelve nurses viewed 20‐min films showing the behaviour of 10 premature newborns before, during and after the usual caregiving. The behaviour was rated on an observation sheet with 88 items distributed into six systems. The responses were compared to the reference ratings established by two professionals certified for this programme.

Results

Despite less accurate observations during care and for some components, the nurses generally showed a satisfactory ability to observe newborn behaviour after training by NIDCAP expert professionals. The dissemination of observation skills among caregivers may result in an improved quality of patient care and better communication among professionals in a department of neonatology.

Parents' Experiences of the First Year at Home with an Infant Born Extremely Preterm with and without Post-Discharge Intervention: Ambivalence, Loneliness, and Relationship Impact

With increasing survival rates of children born extremely preterm (EPT), before gestational week 28, the post-discharge life of these families has gained significant research interest. Quantitative studies of parental experiences post-discharge have previously reported elevated levels depressive symptoms, posttraumatic stress-disorder and anxiety among the parents. The current investigation aims to qualitatively explore the situation for parents of children born EPT in Sweden during the first year at home. Semi-structured interviews were performed with 17 parents of 14 children born EPT; eight parents were from an early intervention group and nine parents from a group that received treatment as usual, with extended follow-up procedures. Three main themes were identified using a thematic analytic approach: child-related concerns, the inner state of the parent, and changed family dynamics. Parents in the intervention group also expressed themes related to the intervention, as a sense of security and knowledgeable interventionists. The results are discussed in relation to different concepts of health, parent-child interaction and attachment, and models of the recovery processes. In conclusion, parents describe the first year at home as a time of prolonged parental worries for the child as well as concerns regarding the parent's own emotional state.

The effects of education levels of developmental care in Australia: Perceptions and challenges

BACKGROUND

Developmental care consists of a range of clinical, infant-focused, and family-focused interventions designed to modify the neonatal intensive care environment and caregiving practices to reduce stressors on the developing brain. Since the inception of developmental care in the early 1980s, it has been recommended and adopted globally as a component of routine practice for neonatal care. Despite its application for almost 40 y, little is known of the attitude of neonatal nurses in Australia towards the intervention.

AIMS AND OBJECTIVES

The objective of this study was to establish Australian neonatal nurse perceptions of developmental care and explore associations between developmental care education levels of the nurses and personal beliefs in the application of developmental care.

DESIGN

This involves a cross-sectional survey design.

METHODS

An online questionnaire was completed by 171 neonatal nurses. Participants were members of the Australian College of Neonatal Nursing (n = 783). Covariate associations between key components of developmental care and respondents' geographical location, place of employment, professional qualifications, and developmental care education level were analysed. The reporting of this study is in accordance with the Enhancing the Quality and Transparency of Health Research Checklist for Reporting Results of Internet E-Surveys.

RESULTS

Differences were observed between groups for geographical location, place of employment, and professional qualification level. Rural nurses were less likely to support the provision of skin-to-skin care (odds ratio [OR]: 0.6, 95% confidence interval [CI]: 0.2-1.8) than nurses in a metropolitsan unit. Nurses working in a neonatal intensive care unit and nurses with postgraduate qualifications were more likely to support parental involvement in care ([OR: 2.3, 95% CI: 0.9-6.2] and [OR: 2.1, 95% CI: 0.6-7.4], respectively). Rural respondents were more likely to have attended off-site education (OR: 3.6, 95% CI: 1.3-9.9) than metropolitan respondents.

CONCLUSION

The application of developmental care in Australia may be influenced by inadequate resources and inequitable access to educational resources, and similar challenges have been reported in other countries. Overcoming the challenges requires a focused education strategy and support within and beyond the neonatal intensive care unit.

Implementing NIDCAP training in a low-middle-income country: Comparing nurses and physicians' attitudes

BACKGROUND

The Newborn Individualized Developmental Care and Assessment Program (NIDCAP) provides developmentally supportive environment for preterm infants and their families. Few studies evaluated staff perceptions about NIDCAP implementation and its effect on infant and parents and working conditions.

AIMS

To assess the perception and experience of NICU staff during the NIDCAP implementation.

STUDY DESIGN

Cross-sectional anonymous online survey.

SUBJECTS

57 NICU staff (29 nurses and 28 doctors) who were present at least one year prior to and during the implementation of NIDCAP training in a tertiary care center.

OUTCOME MEASURES

A standard questionnaire addressing attitude, perceived behavioral control, subjective norm, intention, behavior and NIDCAP impact related to NICU conditions was used after initiating developmental care activities and NIDCAP training in the unit from June 2014 to May 2018.

RESULTS

Forty-six doctors and nurses filled the questionnaire; they scored ≥3 out of 5 on all the questionnaire items. Nurses scored significantly higher than doctors (mean 4.00 ± 036) versus (3.57 ± 0.30) (p < 0.001) on the overall NIDCAP score. Specifically, nurses scores were significantly higher for attitude (p < 0.001), perceived behavioral control (p = 0.029); subjective norm (p = 0.011), intention (p = 0.024) and behavior (p < 0.001) questions.

CONCLUSION

The implementation of NIDCAP in a low-middle income country was perceived as a positive experience for both nurses and doctors: It was thought to have improved infant care and wellbeing as well as the staff relationship with parents, however working conditions remained a challenge. More studies are needed to address areas of improvement for implementation.

Sound reduction management in the neonatal intensive care unit for preterm or very low birth weight infants

BACKGROUND

Infants in the neonatal intensive care unit (NICU) are subjected to stress, including sound of high intensity. The sound environment in the NICU is louder than most home or office environments and contains disturbing noises of short duration and at irregular intervals. There are competing auditory signals that frequently challenge preterm infants, staff and parents. The sound levels in NICUs often exceed the maximum acceptable level of 45 decibels (dB), recommended by the American Academy of Pediatrics. Hearing impairment is diagnosed in 2% to 10% of preterm infants versus 0.1% of the general paediatric population. Noise may cause apnoea, hypoxaemia, alternation in oxygen saturation, and increased oxygen consumption secondary to elevated heart and respiratory rates and may, therefore, decrease the amount of calories available for growth. Elevated levels of speech are needed to overcome the noisy environment in the NICU, thereby increasing the negative impacts on staff, newborns, and their families. High noise levels are associated with an increased rate of errors and accidents, leading to decreased performance among staff. The aim of interventions included in this review is to reduce sound levels to 45 dB or less. This can be achieved by lowering the sound levels in an entire unit, treating the infant in a section of a NICU, in a 'private' room, or in incubators in which the sound levels are controlled, or reducing the sound levels that reaches the individual infant by using earmuffs or earplugs. By lowering the sound levels that reach the neonate, the resulting stress on the cardiovascular, respiratory, neurological, and endocrine systems can be diminished, thereby promoting growth and reducing adverse neonatal outcomes.

OBJECTIVES

Primary objective To determine the effects of sound reduction on growth and long-term neurodevelopmental outcomes of neonates. Secondary objectives 1. To evaluate the effects of sound reduction on short-term medical outcomes (bronchopulmonary dysplasia, intraventricular haemorrhage, periventricular leukomalacia, retinopathy of prematurity). 2. To evaluate the effects of sound reduction on sleep patterns at three months of age. 3. To evaluate the effects of sound reduction on staff performance. 4. To evaluate the effects of sound reduction in the neonatal intensive care unit (NICU) on parents' satisfaction with the care.

SEARCH METHODS

We searched the Cochrane Central Register of Controlled Trials (The Cochrane Library), MEDLINE, EMBASE, CINAHL, abstracts from scientific meetings, clinical trials registries (clinicaltrials.gov; controlled-trials.com; and who.int/ictrp), Pediatric Academic Societies Annual meetings 2000 to 2014 (Abstracts2ViewTM), reference lists of identified trials, and reviews to November 2014.

SELECTION CRITERIA

Preterm infants (< 32 weeks' postmenstrual age (PMA) or < 1500 g birth weight) cared for in the resuscitation area, during transport, or once admitted to a NICU or a stepdown unit.

DATA COLLECTION AND ANALYSIS

We performed data collection and analyses according to the Cochrane Neonatal Review Group.

MAIN RESULTS

One small, high quality study assessing the effects of silicone earplugs versus no earplugs qualified for inclusion. The original inclusion criteria in our protocol stipulated an age of < 48 hours at the time of initiating sound reduction. We made a deviation from our protocol and included this study in which some infants would have been > 48 hours old. There was no significant difference in weight at 34 weeks postmenstrual age (PMA): mean difference (MD) 111 g (95% confidence interval (CI) -151 to 374 g) (n = 23). There was no significant difference in weight at 18 to 22 months corrected age between the groups: MD 0.31 kg, 95% CI -1.53 to 2.16 kg (n = 14). There was a significant difference in Mental Developmental Index (Bayley II) favouring the silicone earplugs group at 18 to 22 months corrected age: MD 14.00, 95% CI 3.13 to 24.87 (n = 12), but not for Psychomotor Development Index (Bayley II) at 18 to 22 months corrected age: MD -2.16, 95% CI -18.44 to 14.12 (n =12).

AUTHORS' CONCLUSIONS

To date, only 34 infants have been enrolled in a randomised controlled trial (RCT) testing the effectiveness of reducing sound levels that reach the infants' ears in the NICU. Based on the small sample size of this single trial, we cannot make any recommendations for clinical practice. Larger, well designed, conducted and reported trials are needed.

Joint observation in NICU (JOIN): study protocol of a clinical randomised controlled trial examining an early intervention during preterm care

INTRODUCTION

Preterm birth may generate significant distress among the parents, who often present with difficulties in appropriating their parental role. Parental stress and low perceived parental self-efficacy may interfere with the infant's socioemotional and cognitive development, particularly through disrupted parent-infant interactions. Perceived parental self-efficacy represents the belief of efficacy in caring for one's own infant and successful incarnation of the parental role, as well as the perception of one's own abilities to complete a specified task. Interventions to support parental role, as well as infant development, are needed, and parental self-efficacy represents a useful indicator to measure the effects of such early interventions.

METHODS AND ANALYSIS

This study protocol describes a randomised controlled trial that will test an early intervention in the neonatal intensive care unit (NICU) (JOIN: Joint Observation In Neonatology) carried out by an interdisciplinary staff team. Mothers of preterm neonates born between 28 and 32 6/7 weeks of gestational age are eligible for the study. The intervention consists of a videotaped observation by a clinical child psychologist or child psychiatrist and a study nurse of a period of care delivered to the neonate by the mother and a NICU nurse. The care procedure is followed by an interactive video guidance intended to demonstrate the neonate's abilities and resources to his parents. The primary outcome will be the difference in the perceived maternal self-efficacy between the intervention and control groups assessed by self-report questionnaires. Secondary outcomes will be maternal mental health, the perception of the parent- infant relationship, maternal responsiveness and the neurodevelopment of the infant at 6 months corrected age.

ETHICS AND DISSEMINATION

Ethical approval was granted by the Human Research Ethics Committee of the Canton de Vaud (study number 496/12). Results from this study will be disseminated at national and international conferences, and in peer-reviewed journals.

TRIAL REGISTRATION NUMBER

NCT02736136, Pre-results.

Neonatal Intensive Care Unit Nurses' Perceptions and Knowledge of Newborn Individualized Developmental Care and Assessment Program: A Multicenter Study

Background

The newborn individualized developmental care and assessment program (NIDCAP) is a new multifaceted approach, which is developmentally and functionally supportive of health especially in premature newborns at the neonatal intensive care unit (NICU). This study is designed for assessing the knowledge and perception of nurses as the most important members of the multidisciplinary team of NIDCAP about this program.

Materials and Methods

This cross-sectional study was conducted on 120 nurses working in the NICUs of Alzahra, Taleghani, and Children hospitals affiliated to the educational and treatment centers of Tabriz University of Medical Sciences as well as 29 Bahman Hospital affiliated to Tabriz Social Security Organization in 2016 using census sampling method. Three questionnaires were employed to collect demographic data and to explore the nurses' perceptions and knowledge of the NIDCAP program.

Results

Findings of the study indicated that the mean (SD) nurses' knowledge and perception scores for NIDCAP were 71.83 (1.64) and 76.80 (0.79), respectively. In the terms of knowledge, significant differences were found with regard to being married (t = -2.39, p < 0.019), having an MSc degree (t = -2.14, p = 0.034), and employment experience (t = -3.38, p = 0.001). However, there was no significant relationship between perception and demographic variables (p > 0.05), nor was there any significant relationship between perception and knowledge (p = 0.275).

Conclusions

The results of this study showed that the majority of nurses participating in the study had high knowledge about NIDCAP.

Recent advances in the management of infants born <1000 g

In this review, we survey some significant advances in the medical care of babies <1000 g and we highlight the development of care pathways that ensure optimal antenatal care, which is a prerequisite for good neonatal outcomes. We also suggest that the long overdue development of family integrated care will in the end prove at least as important as the recent medical advances.

Impact of a Developmental Care Training Course on the Knowledge and Satisfaction of Health Care Professionals in Neonatal Units: A Multicenter Study

BACKGROUND

The impact of health-related continuing education courses on knowledge acquisition and clinical practice is infrequently evaluated, despite higher numbers of people enrolling in them. The majority of health care professionals working in neonatal intensive care units (NICUs) have received no training in developmental care (DC). The purpose of this study was to determine whether participation in a theoretical-practical course on DC had an effect on the degree of knowledge possessed by professionals in general terms and with respect to neonatal intensive care. The relationship between course satisfaction and knowledge acquisition was also studied.

METHODS

This was an observational multicenter study conducted in 20 neonatal units in Madrid. A pre- and post-course questionnaire evaluated both knowledge and satisfaction levels regarding the course on DC and the Newborn Individualized Developmental Care and Assessment Program (NIDCAP). We carried out a multivariate linear regression analysis to determine whether there was a correlation between knowledge gained and satisfaction level.

RESULTS

A total of 566 professionals participated, with a 99% pre-course and a 90% post-course response rate. The mean rate of correct pre-course answers was 65%, while the mean rate of post-course correct answers was 81% (p < 0.001). Results were similar at all levels of neonatal care (Level I: 64% vs 80%; Level II: 64% vs. 83%; and

LEVEL III

65% vs. 81%). Scores on a scale of satisfaction from 1 to 5 were high (averages of above 4 for all lectures and workshops). Pre-course knowledge scores, but not satisfaction, significantly influenced post-course knowledge (β 0.499; p < 0.01).

CONCLUSION

Previous DC knowledge among Madrid health care professionals was similar, regardless of the level of neonatal care. Course attendance significantly improved the rate of correct answers. Although course satisfaction was high, there did not seem to be a correlation between knowledge gained and satisfaction.

Sound reduction management in the neonatal intensive care unit for preterm or very low birth weight infants

BACKGROUND

Infants in the neonatal intensive care unit (NICU) are subjected to stress, including sound of high intensity. The sound environment in the NICU is louder than most home or office environments and contains disturbing noises of short duration and at irregular intervals. There are competing auditory signals that frequently challenge preterm infants, staff and parents. The sound levels in NICUs often exceed the maximum acceptable level of 45 decibels (dB), recommended by the American Academy of Pediatrics. Hearing impairment is diagnosed in 2% to 10% of preterm infants versus 0.1% of the general paediatric population. Noise may cause apnoea, hypoxaemia, alternation in oxygen saturation, and increased oxygen consumption secondary to elevated heart and respiratory rates and may, therefore, decrease the amount of calories available for growth. Elevated levels of speech are needed to overcome the noisy environment in the NICU, thereby increasing the negative impacts on staff, newborns, and their families. High noise levels are associated with an increased rate of errors and accidents, leading to decreased performance among staff. The aim of interventions included in this review is to reduce sound levels to 45 dB or less. This can be achieved by lowering the sound levels in an entire unit, treating the infant in a section of a NICU, in a 'private' room, or in incubators in which the sound levels are controlled, or reducing the sound levels that reaches the individual infant by using earmuffs or earplugs. By lowering the sound levels that reach the neonate, the resulting stress on the cardiovascular, respiratory, neurological, and endocrine systems can be diminished, thereby promoting growth and reducing adverse neonatal outcomes.

OBJECTIVES

Primary objectiveTo determine the effects of sound reduction on growth and long-term neurodevelopmental outcomes of neonates. Secondary objectives1. To evaluate the effects of sound reduction on short-term medical outcomes (bronchopulmonary dysplasia, intraventricular haemorrhage, periventricular leukomalacia, retinopathy of prematurity).2. To evaluate the effects of sound reduction on sleep patterns at three months of age.3. To evaluate the effects of sound reduction on staff performance.4. To evaluate the effects of sound reduction in the neonatal intensive care unit (NICU) on parents' satisfaction with the care.

SEARCH METHODS

We searched the Cochrane Central Register of Controlled Trials (The Cochrane Library), MEDLINE, EMBASE, CINAHL, abstracts from scientific meetings, clinical trials registries (clinicaltrials.gov; controlled-trials.com; and who.int/ictrp), Pediatric Academic Societies Annual meetings 2000 to 2014 (Abstracts2View(TM)), reference lists of identified trials, and reviews to November 2014.

SELECTION CRITERIA

Preterm infants (< 32 weeks' postmenstrual age (PMA) or < 1500 g birth weight) cared for in the resuscitation area, during transport, or once admitted to a NICU or a stepdown unit.

DATA COLLECTION AND ANALYSIS

We performed data collection and analyses according to the Cochrane Neonatal Review Group.

MAIN RESULTS

One small, high quality study assessing the effects of silicone earplugs versus no earplugs qualified for inclusion. The original inclusion criteria in our protocol stipulated an age of < 48 hours at the time of initiating sound reduction. We made a deviation from our protocol and included this study in which some infants would have been > 48 hours old. There was no significant difference in weight at 34 weeks postmenstrual age (PMA): mean difference (MD) 111 g (95% confidence interval (CI) -151 to 374 g) (n = 23). There was no significant difference in weight at 18 to 22 months corrected age between the groups: MD 0.31 kg, 95% CI -1.53 to 2.16 kg (n = 14). There was a significant difference in Mental Developmental Index (Bayley II) favouring the silicone earplugs group at 18 to 22 months corrected age: MD 14.00, 95% CI 3.13 to 24.87 (n = 12), but not for Psychomotor Development Index (Bayley II) at 18 to 22 months corrected age: MD -2.16, 95% CI -18.44 to 14.12 (n =12).

AUTHORS' CONCLUSIONS

To date, only 34 infants have been enrolled in a randomised controlled trial (RCT) testing the effectiveness of reducing sound levels that reach the infants' ears in the NICU. Based on the small sample size of this single trial, we cannot make any recommendations for clinical practice. Larger, well designed, conducted and reported trials are needed.

Interdisciplinary approach to neurocritical care in the intensive care nursery

Neurocritical care is a multidisciplinary subspecialty that combines expertise in critical care medicine, neurology, and neurosurgery, and has led to improved outcomes in adults who have critical illnesses. Advances in resuscitation and critical care have led to high rates of survival among neonates with life-threatening conditions such as perinatal asphyxia, extreme prematurity, and congenital malformations. The sequelae of neurologic conditions arising in the neonatal period include lifelong disabilities such as cerebral palsy and epilepsy, as well as intellectual and behavioral disabilities. Centers of excellence have adapted the principles of neurocritical care to reflect the needs of the developing newborn brain, including early involvement of a neurologist for recognition and treatment of neurologic conditions, attention to physiology to help prevent secondary brain injury, a protocol-driven approach for common conditions like seizures and hypoxic-ischemic encephalopathy, and education of specialized teams that use brain monitoring and imaging to evaluate the effect of critical illness on brain function and development.

Necessary resources and barriers perceived by professionals in the implementation of the NIDCAP

BACKGROUND

The implementation of the Newborn Individualized Developmental Care and Assessment Program (NIDCAP) requires a significant effort from all professionals involved.

AIM

To determine the necessary requirements and barriers perceived by health professionals in the implementation of the NIDCAP.

STUDY DESIGN

A questionnaire covering requirements and obstacles perceived in the implementation of the NIDCAP was developed and validated in two Spanish level III neonatal intensive care units. The questionnaire was answered by 305 health professionals (response rate of 85%).

RESULTS

The requirements identified in the questionnaire were considered by most respondents as necessary to implementing the NIDCAP, especially more time, education, and staff. Nurses, compared to doctors, thought that more staff was necessary (93% vs. 74%; p < .01). The main obstacle identified in the survey was lack of coordination among different professionals (77%), followed by noise level in the unit (35%). Doctors, in comparison to nurses, considered noise level (61% vs. 23%; p < .01) and nursing staff (56% vs. 29%; p = .05) the most relevant obstacles to NIDCAP implementation. The more experienced professionals perceived their own colleagues as an obstacle, particularly among nursing staff.

CONCLUSIONS

The implementation of the NIDCAP requires a series of conditions that confirm it is not a trivial process but rather a somewhat laborious one. The lack of coordination among different professionals is often considered the main obstacle.

Staff perceptions on Newborn Individualized Developmental Care and Assessment Program (NIDCAP) during its implementation in two Spanish neonatal units

BACKGROUND

The implementation of the Newborn Individualized Developmental Care and Assessment Program (NIDCAP) requires great effort. Few studies evaluating staff perception of NIDCAP exist, especially in Southern Europe, and these few studies usually have a low representation of the medical staff.

AIMS

Exploration of staff perception (neonatologists, nurses and nursing assistants) of NIDCAP during its implementation and their attitude towards it and intention to put it into practice.

STUDY DESIGN

This study is a descriptive survey measuring staff perceptions of NIDCAP and its effects on their work in two Spanish neonatal level III intensive care units (NICUs). Validated questionnaires were distributed to neonatologists, nurses and nursing assistants of which 305 were completed (response rate: 85%).

RESULT

Virtually all the items which assess the infant's well being and the parents' role received a positive evaluation. However, three items got slightly negative evaluations: NIDCAP was more time consuming and nurses' working conditions and lighting in the unit were less optimal than in earlier practices. The professionals also had a positive attitude and a willingness to use the NIDCAP. Neonatologists perceived NIDCAP more positively than the nursing staff with statistically significant differences.

CONCLUSION

The neonatal unit staff in two Spanish NICUs perceived NIDCAP positively. This assessment is more positive for neonatologists than for nurses.

Skin-to-skin care in neonatal intensive care units in the Nordic countries: a survey of attitudes and practices

AIM

To investigate the application of skin-to-skin care (SSC) in the Nordic countries, the existence of guidelines for SSC and the attitudes of neonatal staff towards SSC.

METHODS

One questionnaire was distributed at unit level and one at staff level in all Nordic neonatal intensive care units (n = 109).

RESULTS

The unit questionnaire was answered by 95 (87%) units and the staff questionnaire by 1446 staff members (72%). All units offered SSC to various degrees, but guidelines only existed at 47% of them. Units in Denmark, Norway and Sweden seemed to use SSC earlier, longer and in more medically complicated situations than units in Finland and Iceland. Seventy-seven per cent of the units had private rooms where parents and infants could stay together, still the physical environment of the units limited the use of SSC. Medical risks were considered the main barrier for further implementation of SSC, while general development and early interaction were the most frequently mentioned benefits.

CONCLUSION

Skin-to-skin care is implemented in all Nordic neonatal units, but offered to various degrees, to various populations and to varying extents. Danish, Norwegian and Swedish units are offering SSC more extensively than units in Finland and Iceland.

Challenges in conducting prospective research of developmentally directed care in surgical neonates: a case study

BACKGROUND

Evaluation is fundamental to evidence-based practice. Due to practical constraints inherent in real-world clinical environments, however, innovations in clinical practice are often implemented without rigorous research. We set out to evaluate the effectiveness of developmentally directed care in surgical neonates using a randomised controlled trial with a Newborn Individualized Care and Assessment Program (NIDCAP) intervention.

AIM

The aim of this paper is to inform future studies by sharing lessons learnt in conducting prospective research of a practice-intervention in a critical care setting.

METHOD

Three intervention components were used to assess implementation: number of NIDCAP observations; infant allocation to project nurses, and consistency of care. Barriers to implementation were identified through discussions with nurses who had key roles.

RESULTS

Insufficient episodes of NIDCAP observation and infant allocation to project nurses, and lack of consistency of care indicated that the intervention had not been successfully implemented. Barriers to implementation (fast 'turnover' of patients, unpredictable changes in medical status, staff/skill shortages, and inconsistent care) were attributed to the competing demands between service provision and research in a busy critical care context.

CONCLUSIONS

The findings regarding barriers to successful implementation of NIDCAP in this case study are relevant to any critical care setting where complex interventions are under consideration, as similar challenges are plausible across a range of clinical contexts. Adopting a critical methodologically-informed approach to appraise implementation and evaluate complex interventions is essential.

Developmental care for high-risk newborns: emerging science, clinical application, and continuity from newborn intensive care unit to community

Neonatology has optimized medical outcomes for high-risk newborns yet neurodevelopmental outcomes continue to be a concern. Basic science, clinical research, and environmental design perspectives have shown the impact of the caregiving environment on the developing brain and the role of professional caregivers in providing supportive intervention to both infants and their families. This recognition has prompted a focus on early developmentally supportive care (DSC) for high-risk newborns both in the hospital and in community follow up. DSC has emerged as a recognized standard of care in most neonatal intensive care units. Still, many questions remain and much integrative research is needed.

Staff perception one year after implementation of the the newborn individualized developmental care and assessment program (NIDCAP)

The Newborn Individualized Developmental Care and Assessment Program (NIDCAP) was piloted at one NICU. Staff perception of impact and the feasibility of applying the program was explored in a survey and a focus group interview. NIDCAP was perceived to impact positively on infant well-being and parents' way of caring. Although the influence of NIDCAP on staff working conditions and job perfomance was overall positive, their perceptions varied. Presence of the NIDCAP observer and empowerment of parents was challenging to some nurses, especially in terms of decision making in care. Conflicts of interest occurred between staff member need of light and infant need of light reduction.

Parents, siblings and grandparents in the Neonatal Intensive Care Unit. A survey of policies in eight European countries

OBJECTIVE

To describe policies towards family visiting in Neonatal Intensive Care Units (NICU) and compare findings with those of a survey carried out 10 years earlier.

METHODS

A questionnaire on early developmental care practices was mailed to 362 units in eight European countries (Sweden, Denmark, the UK, the Netherlands, Belgium, France, Spain and Italy). Of them 78% responded, and among those responded, 175 reported caring for at least 50 very low birth weight infants every year and their responses were analysed further.

RESULTS

A majority of all units allowed access at any time for both parents. This was almost universal in northern Europe and the UK, whereas it was the policy of less than one-third of NICU in Spain and Italy, with France in an intermediate position. Restrictions on visiting of grandparents, siblings and friends, as well as restricting parents' presence during medical rounds and procedures followed the same pattern. A composite visiting score was computed using all the variables related to family visiting. Lower median values and larger variability were obtained for the southern countries, indicating more restrictive attitudes and lack of national policy.

CONCLUSIONS

The presence of parents and other family members in European NICUs has improved over a 10-year period. Several barriers, however, are still in place, particularly in the South European countries.

Follow-up outcomes at 1 and 2 years of infants born less than 32 weeks after Newborn Individualized Developmental Care and Assessment Program

OBJECTIVE

This was a randomized, controlled trial to investigate the effect of Newborn Individualized Developmental Care and Assessment Program on growth, cognitive, psychomotor, and neuromotor development at 1 and 2 years in infants born at <32 weeks' gestational age.

METHODS

Infants were randomly assigned within 48 hours of birth to the newborn individualized developmental care and assessment program group (intervention) or basic developmental care group (control group [ie, incubator covers and nests]). At 1 and 2 years' corrected age, growth was measured and standardized neurologic examinations were administered. Mental and psychomotor development was assessed by using the Dutch version of the Bayley Scales of Infant Development II. Neurologic outcome, Psychomotor Developmental Index, and Mental Developmental Index scores were combined a total outcome measure.

RESULTS

One hundred sixty-eight infants were recruited (intervention: 84; control: 84). Four infants (newborn intervention: 3; control: 1) were excluded because they were admitted less than or died within the first 5 days, leaving a total of 164 infants who met inclusion criteria. In-hospital mortality was 8 of 81 in the intervention group and 3 of 83 in the control group. At 1 year of age 148 children (intervention: 70; control: 78) and at 2 years of age 146 children (intervention: 68; control: 78) were assessed. There was no significant difference in growth at 1 and 2 years of age. There was no significant difference found in neurologic outcomes or mental and psychomotor development at 1 and 2 years of age. When neurologic outcome, Mental Developmental Index and Psychomotor Developmental Index scores were combined, there still remained no significant difference.

CONCLUSIONS

Newborn individualized developmental care and assessment program developmental care showed no effect on growth or neurologic, mental, or psychomotor development at 1 and 2 years of age in infants born at <32 weeks. Duration of the intervention was not associated with neurologic and developmental outcome.

Measuring developmentally appropriate practice in neonatal intensive care units

OBJECTIVE

Neonatal intensive care units (NICUs) impose stressors on development. Comparative studies have focused mostly on the units' medical qualities and less on their developmental 'ecology'. The aim of the study was to develop a tool for measuring the various domains of a developmentally appropriate practice in the NICU environment, and to assess its implementation in Israel.

STUDY DESIGN

A questionnaire, designed for NICU senior staff members, was completed by 76 respondents representing 24 NICUs in Israel. The tool that measures developmentally appropriate practice as applied in the NICU environment includes the following three domains: (a) parental and family involvement, (b) environmental control and (c) individualized care and assessment. These measures jointly produce the developmentally appropriate neonatal intensive-care practice (DANIP) index.

RESULT

High variability was found in the application of procedures and programs considered developmentally appropriate. Units with a relatively large multidisciplinary team scored high. Overall, the NICUs in Israel did not consistently follow an integrated form of the developmental care as provided by the Neonatal Individualized Developmental Care and Assessment Program. It was found that individualized care and assessment was significantly and positively linked to control of the environment (r=0.53, P<0.01) and to parental and family involvement (r=0.76, P<0.01); the latter two scales were not associated. Of the three DANIP domains, parental involvement was salient. Although the staff highly appreciated the importance of environmental control and individualized care, application was limited.

CONCLUSION

The DANIP index provides a good starting point for comparative studies.

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).

How can we evaluate developmental care practices prior to their implementation in a neonatal intensive care unit?

Developmental care is designed to allow optimal neurobehavioral development of the preterm infant. The Neonatal Individualized Developmental Care and Assessment Program (NIDCAP) associates various strategies and focuses on individualized, family-oriented care. Scientific evaluation of developmental care is needed. Randomized controlled trials are the basis for medical evaluation, but present some limitations for developmental care studies. Qualitative research and benchmarking could be of interest in this field of neonatal medicine.

Newborn Individualized Developmental Care and Assessment Program (NIDCAP) - family-centered developmentally supportive care

The theoretical framework behind family-centered, developmentally supportive care (NIDCAP) is endorsed by research from several scientific fields, including neuroscience, developmental and family psychology, medicine and nursing. However, the introduction of NIDCAP involves a considerable investment at all levels of the organization. NIDCAP requires some physical changes in the NICU as well as substantial educational efforts and changes in the practice of care. The findings of the presented NIDCAP studies have been encouraging, and NIDCAP has been very well received by nursing staff, neonatologists and parents. It also is attractive from an ethical point of view. It appears reasonable to recommend that nurseries implement NIDCAP and investigate developmentally supportive care in different cultural contexts and with diversified, randomized multicenter trials.

Shorter hospital stay for moderately preterm infants

AIM

To determine length of hospital stay (LOS) for moderately preterm infants during the last 20 years, and to identify factors affecting the number of bed-days.

METHODS

Review of LOS for all infants delivered between 30 to 34 gestational weeks during 1983, 1988, 1993, 1998 and 2002.

EXCLUSION CRITERIA

life-threatening abnormalities, chromosomal anomalies and death during hospitalization.

RESULTS

564 included infants accounted for 20% of admissions and 48% of bed-days in the neonatal unit. Between 1983 and 2002, maternal age and use of nasal continuous positive airway pressure increased, use of antibiotics and mechanical ventilation decreased, whereas distributions for gestational age, birthweight, gender, smallness for gestational age, low Apgar score or incidence of respiratory distress syndrome did not change. For healthy inborn singletons discharged home, LOS decreased from 1983 (28+/-11 d, mean+/-SD values) to 2002 (14+/-7 d, p<0.05). Infants born more immature had longer LOS, but postconceptional age at discharge did not differ between age groups.

CONCLUSION

LOS for moderately preterm infants has decreased as a result of individualized neonatal care and organization of homecare support. Shorter LOS is of benefit to the family, prevents overcrowding in the NICU and has important economic implications.

Early developmental care for preterm neonates: a call for more research

Developmental care is the use of a range of medical and nursing interventions to decrease the stress of preterm neonates in neonatal intensive care units. This article reviews the theory underlying such interventions and research based data in different scientific fields, including neuroscience, developmental and family psychology, medicine, and nursing. The conclusion is that more research is needed.

Vestibulospinal component of postural control (vestibular function) in very preterm infants (25 to 27 weeks) at 3, 6, and 12 months corrected age

Postural control, which is important for the development of all movement, balance, and locomotion, depends a great deal on the vestibulospinal component of vestibular function in early childhood. Vestibulospinal input is important for muscle power regulation, which, in turn, influences postural control. The aim of this study was to focus particularly on this component of vestibular function during the first year of life in 67 infants with a very short gestational age (25-27 weeks), to search for possible neonatal confounders, and to see whether it influences the course of muscle power development in preterm infants. Outcome was described as being optimal, suspect, or abnormal. The infants were categorized into the Neonatal Medical Index according to the severity of neonatal illness and separately into three groups for neonatal brain ultrasonography findings (normal to severe abnormalities). At the age of 3 months, 20 infants performed optimally on all items testing vestibular function, increasing to 40 at 6 months and 48 at 12 months. This significant improvement (also seen in muscle power regulation) was primarily caused by better head control (during the traction response and prone position), whereas less shoulder retraction and hyperextension were found in the sitting position. Vestibular function was significantly related to brain ultrasonography classification but not to gestational age, birthweight, the Neonatal Medical Index, or gender.

Preschool outcome in children born very prematurely and cared for according to the Newborn Individualized Developmental Care and Assessment Program (NIDCAP)

AIM

Care based on the Newborn Individualized Developmental Care and Assessment Program (NIDCAP) has been reported to exert a positive impact on the development of prematurely born infants. The aim of the present investigation was to determine the effect of such care on the development at preschool age of children born with a gestational age of less than 32 wk.

METHODS

All surviving infants in a randomised controlled trial with infants born at a postmenstrual age less than 32 wk (11 in the NIDCAP group and 15 in the control group) were examined at 66.3 (6.0) mo corrected for prematurity [mean (SD)]. In the assessment we employed the Wechsler Preschool and Primary Scale of Intelligence-Revised (WPPSI-R) for cognition, Movement Assessment Battery for Children (Movement ABC) for motor function, subtests of the NEPSY test battery for attention and distractibility, and the WHO definitions of impairment, disability and handicap. Exact binary logistic regression was employed.

RESULTS

There were no significant differences between the intervention group in Full-Scale IQ 93.4 (14.2) [mean (SD)] versus the control group 89.6 (27.2), Verbal IQ 93.6 (16.4) versus 93.7 (26.8) or Performance IQ 94.3 (14.7) versus 86.3 (24.8). In the NIDCAP group 8/13 (62%) survived without disability and for the children with conventional care this ratio was 7/19 (37%). The corresponding ratios for surviving without mental retardation were 10/13 (77%) and 11/19 (58%), and for surviving without attention deficits 10/13 (77%) and 10/19 (53%). Overall, the differences were not statistically significant, although the odds ratio for surviving with normal behaviour was statistical significant after correcting for group imbalances in gestational age, gender, growth retardation and educational level of the parents.

CONCLUSION

Our trial suggests a positive impact by NIDCAP on behaviour at preschool age in a sample of infants born very prematurely. However, due to problems of recruitment less than half of the anticipated subjects were included in the study, which implies a low power and calls for caution in interpreting our findings. Larger trials in different cultural contexts are warranted.