Effects of the Newborn Individualized Developmental Care and Assessment Program (NIDCAP) at age 8 years: preliminary data

The newborn individualised developmental care and assessment program: A model of care for infants and families in hospital settings

AIM

The Newborn Individualised Developmental Care and Assessment Program (NIDCAP) is an intervention and education programme that uses developmental observation for multidisciplinary healthcare professionals (HCP) caring for high-risk infants and families. Infants prosper with the ongoing co-regulation process of infant and family that is influenced by the physical and social environment.

METHODS

The Template for Intervention Description and Replication (TIDieR) Guidelines were applied to the NIDCAP intervention. The estimation of the individual infant's current goals is described from direct observation of behaviour in the context of ongoing care delivery. The infant's behaviour guides all caregivers to articulate current strengths and functioning for the development of individualised plans of care and support. The NIDCAP Nursery Program supports the full integration of NIDCAP into the healthcare system.

RESULTS

NIDCAP is a system-based, process-oriented, attuned and responsive intervention for individualised developmental care for infants and families. Evidence shows NIDCAP significantly improves medical outcomes, with less time on the ventilator, improved weight gain, decreased length of stay, improved developmental outcomes and enhanced infant and family relationships. Evidence suggests that NIDCAP as an intervention improves parental competence, decreases stress for HCP teams and improves HCP satisfaction.

CONCLUSION

NIDCAP improves outcomes for infants and families requiring hospital care.

Autonomic measures identify stress, pain, and instability associated with retinopathy of prematurity ophthalmologic examinations

BACKGROUND

Retinopathy of prematurity (ROP) ophthalmologic examinations cause stress and pain. Infants' stress and pain can be measured non-invasively using skin conductance (SC) and high frequency heart rate variability (HF-HRV), reflecting sympathetic-mediated sweating and parasympathetic activity, respectively.

OBJECTIVES

To test the utility of SC to detect sympathetic activation during ROP examination, and the contribution of HF-HRV to predict stability post-examination.

METHODS

In this prospective, single center study, we measured SC continuously pre-, during, and post-examination, and HRV at 24 h pre-ROP examination. Clinical data included stability [apneas, bradycardias, and desaturations (A/B/Ds)], and interventions post-examination.

RESULTS

SC increased 56% above baseline during ROP examination (p = 0.001) and remained elevated post-examination (p = 0.02). Post-hoc analysis showed higher illness acuity, represented by need for respiratory support, was associated with lower HF-HRV at 24 h pre-ROP examination (p = 0.001). Linear regression indicated lower HF-HRV at 24 h pre-examination contributed to the need for higher intervention (i.e., stimulation to breathe, oxygen support) particularly among infants with higher illness acuity [F(1, 15) = 5.05, p = 0.04; β = -1.33, p = 0.04].

CONCLUSION

ROP examination induced a 2-fold increase in sympathetic activation which remained above baseline in recovery. Also, we propose that the low parasympathetic tone associated with autonomic imbalance contributes to instability and need for higher intervention to assure stabilization with A/B/D events. Our findings provide insight into the underestimation of adverse events associated with ROP examination and identification of infants who may be more vulnerable to potential sequelae following ROP examinations.

Osteopathic Manipulative Treatment Regulates Autonomic Markers in Preterm Infants: A Randomized Clinical Trial

Osteopathic manipulative treatment (OMT) has been found to be effective in the context of premature infants. Nonetheless, no studies have investigated the immediate effects of OMT on heart rate variability (HRV). As altered HRV reflects poor or worsening newborn's clinical conditions and neurodevelopment, should OMT improve HRV fluctuations, it could become a relevant intervention for improving the care of preterm newborns. Therefore, this study aimed to evaluate whether OMT could affect HRV. The study was carried out at the Buzzi Hospital in Milan. From the neonatal intensive care unit, ninety-six preterm infants (41 males) were enrolled and were randomly assigned to one of two treatment groups: OMT or Static Touch. The infants were born at 33.5 weeks (±4.3) and had a mean birth weight of 2067 g (±929). The study had as primary outcome the change in the beat-to-beat variance in heart rate measured through root mean square of consecutive RR interval differences (RMSSD); other metrics were used as secondary and exploratory analyses. Despite the lack of statistically significant results regarding the primary outcomeand some study limitations, compared to static touch, OMT seemed to favor a parasympathetic modulation and improved HRV, which could reflect improvement in newborn's clinical conditions and development.

Developmental Care Practice and Documentation Variability in the Cardiac ICU

OBJECTIVES

Describe variability in developmental care practices, as documented in the electronic health record, for infants undergoing congenital heart surgery.

DESIGN

Multicenter, retrospective, cohort study.

SETTING

Six pediatric cardiac centers.

PATIENTS

One hundred eighty-two infants undergoing one of three index operations: Norwood palliation, aortic arch reconstruction with ventricular septal defect closure, or arterial switch.

INTERVENTIONS

None.

MEASUREMENTS AND MAIN RESULTS

Core domains of developmental care encompassing pain assessment, feeding, infant holding, caregiver involvement, therapy, and psychosocial services were reviewed. Practices varied across individuals, institutions, and the hospital stay. At five of six sites, greater than 90% of individuals had physical or occupational therapy services as part of their care, but the day of first evaluation ranged from day of admission to postoperative day 28. Similar patterns were seen in feeding team and social work involvement. Consistent documentation of developmental care was dependent on the domain and site. Of the total days reviewed (n = 1,192), pain scores were documented in 95%. In those same days, documentation of whether or not a patient was out of the crib to be held varied by site from 11% to 93%. Type of oral feeding, breast versus bottle, was documented on the day prior to discharge 48% of the time.

CONCLUSIONS

There are significant, quantifiable variations in documented developmental care practices at both the individual and site level. More reliable documentation of developmental care practices is required to associate these variables with later outcomes and investigate disparities in individualized developmental care practices.

When can I hold my baby? An audit of time to first cuddle for preterm babies (<32 weeks) pre introduction and post introduction of a Family-Integrated Care model

AIM

The audit examined time to first cuddle between preterm babies (born < 32 weeks) and their parent pre- and post-introduction of a family-integrated care model. Secondary outcomes included time to full feeds and length of neonatal intensive care stay.

BACKGROUND

Parental separation due to neonatal intensive care unit admission is known to negatively affect parental and baby wellbeing.

DESIGN

A "before-after" design compared outcomes for babies admitted pre- (2015) and post (2018)-implementation of the model in a Western Australian neonatal intensive care unit.

METHODS

A retrospective medical record audit included babies from two gestational age groups in 2015 and 2018, born ≤27 + 6 weeks and 28-31 + 6 weeks. SQUIRE checklist guided reporting of the audit.

RESULTS

One hundred fifty-three babies were included in the audit, 79 from 2015 (≤27 + 6 weeks n = 39 and 28-31 + 6 weeks n = 40) and 74 from 2018 (≤27 + 6 weeks n = 35 and 28-31 + 6 weeks n = 39). Babies in both years were born at similar median gestational ages with comparable birthweights. Babies born ≤27 + 6 weeks in 2018 were cuddled earlier (median = 141 h old) compared with those in 2015 (median = 157 h old). Median time to reach full feeds decreased and was significant in the ≤27 + 6-week group: 288 h (12 days) in 2015 to 207.5 h (8.6 days) in 2018. Length of stay was longer for the ≤27 + 6-week gestation 2018 group (median = 64 days) and 28-31 + 6-week gestation 2018 group (median = 22 days).

CONCLUSION

Family-integrated care models may decrease the time to first cuddle and full feeds. Further research on outcomes such as breastfeeding, infant weight gain and length of stay can extend existing knowledge.

RELEVANCE TO CLINICAL PRACTICE

Family-integrated care models may offer benefits to families of hospitalised preterm babies and investigating barriers to its implementation and creation of solutions to overcome barriers warrants attention.

Variations in practice in cardiac neurodevelopmental follow-up programs

Over the last two decades, heart centres have developed strategies to meet the neurodevelopmental needs of children with congenital heart disease. Since the publication of guidelines in 2012, cardiac neurodevelopmental follow-up programmes have become more widespread. Local neurodevelopmental programmes, however, have been developed independently in widely varying environments. We sought to characterise variation in structure and personnel in cardiac neurodevelopmental programmes. A 31-item survey was sent to all member institutions of the Cardiac Neurodevelopmental Outcome Collaborative. Multidisciplinary teams at each centre completed the survey. Responses were compiled in a descriptive fashion. Of the 29 invited centres, 23 responded to the survey (79%). Centres reported more anticipated neurodevelopment visits between birth and 5 years of age (median 5, range 2-8) than 5-18 years (median 2, range 0-10) with 53% of centres lacking any standard for routine neurodevelopment evaluations after 5 years of age. Estimated annual neurodevelopment clinic volume ranged from 85 to 428 visits with a median of 16% of visits involving children >5 years of age. Among responding centres, the Bayley Scales of Infant and Toddler Development and Wechsler Preschool and Primary Scale of Intelligence were the most routinely used tests. Neonatal clinical assessment was more common (64%) than routine neonatal brain imaging (23%) during hospitalisation. In response to clinical need and published guidelines, centres have established formal cardiac neurodevelopment follow-up programmes. Centres vary considerably in their approaches to routine screening and objective testing, with many centres currently focussing their resources on evaluating younger patients.

A Collaborative Learning Assessment of Developmental Care Practices for Infants in the Cardiac Intensive Care Unit

OBJECTIVE

Assess differences in approaches to and provision of developmental care for infants undergoing surgery for congenital heart disease.

STUDY DESIGN

A collaborative learning approach was used to stratify, assess, and compare individualized developmental care practices among multidisciplinary teams at 6 pediatric heart centers. Round robin site visits were completed with structured site visit goals and postvisit reporting. Practices of the hosting site were assessed by the visiting team and reviewed along with center self-assessments across specific domains including pain management, environment, cue-based care, and family based care coordination.

RESULTS

Developmental care for infants in the cardiac intensive care unit (CICU) varies at both a center and individual level. Differences in care are primarily driven by variations in infrastructure and resources, composition of multidisciplinary teams, education of team members, and use of developmental care champions. Management of pain follows a protocol in most cardiac intensive care units, but the environment varies across centers, and the provision of cue-based infant care and family-based care coordination varies widely both within and across centers. The project led to proposed changes in clinical care and center infrastructure at each participating site.

CONCLUSIONS

A collaborative learning design fostered rapid dissemination, comparison, and sharing of strategies to approach a complex multidisciplinary care paradigm. Our assessment of experiences revealed marked variability across and within centers. The collaborative findings were a first step toward strategies to quantify and measure developmental care practices in the cardiac intensive care unit to assess the association of complex inpatient practices with long-term neurodevelopmental outcomes.

Reduction of visual and auditory stimuli to reduce pain during venipuncture in premature infants. Study protocol for a randomized controlled trial

AIM

To evaluate the efficacy of the reduction of visual and auditory stimuli on pain during venipuncture in premature newborns of 32-36 weeks of gestation.

DESIGN

Open, randomized, non-blind parallel clinical trial.

METHOD

Study to take place at the neonatal intensive care unit of a University Hospital in 2019-2021. Fifty-six recently born babies between 32-36 weeks of gestation will participate. The dependent variable is the level of pain determined using the premature infant pain profile instrument. The intervention will be assigned randomly using the random.org software. Data analysis will be carried out using the IBM SPSS v.25 software assuming a level of significance of 5%.

DISCUSSION

The evidence for the efficacy of reducing sensory stimulation and its effect on pain in minor procedures has not been studied in depth. There are no studies that evaluate the reduction of visual and auditory stimuli in a combined way.

IMPACT

It is easy to incorporate the reduction of visual and auditory stimuli into nursing practice. The results of this study could have a direct impact on clinical practice. Trial registered at clinicaltrials.gov: NCT04041635.

[Research advances in the effect of environmental stress in the neonatal intensive care unit on the neurodevelopment of preterm infants and its epigenetics]

Adverse environmental stimulation in the neonatal intensive care unit (NICU) can affect neurodevelopment through epigenetic modification and thus has adverse effects on the long-term developmental outcome of preterm infants. Developmental care can reverse epigenetic changes in genes and promote neurodevelopment in preterm infants. This article reviews the influence of environmental stress in the NICU and developmental care on neurodevelopment in preterm infants, as well as related epigenetic effects, in order to provide a reference for epigenetic studies of preterm infants.

[Research advances in the effect of environmental stress in the neonatal intensive care unit on the neurodevelopment of preterm infants and its epigenetics]

Adverse environmental stimulation in the neonatal intensive care unit (NICU) can affect neurodevelopment through epigenetic modification and thus has adverse effects on the long-term developmental outcome of preterm infants. Developmental care can reverse epigenetic changes in genes and promote neurodevelopment in preterm infants. This article reviews the influence of environmental stress in the NICU and developmental care on neurodevelopment in preterm infants, as well as related epigenetic effects, in order to provide a reference for epigenetic studies of preterm infants.

Behavioural and cognitive outcomes following an early stress-reduction intervention for very preterm and extremely preterm infants

BACKGROUND

The landmark findings of the Mother-Infant Transaction Program (MITP) showing improved neurodevelopment of preterm infants following parent-sensitivity training delivered in the neonatal intensive care unit have not been consistently replicated. This study evaluated an MITP-type intervention in terms of neurobehavioural development to preschool age.

METHODS

A randomised controlled trial involved 123 very preterm and extremely preterm infants allocated to either a parent-sensitivity intervention (PremieStart, n = 60) or to standard care (n = 63). When children were 2 and 4.5 years corrected age, parents completed the Child Behavior Checklist (CBCL). General development was assessed at 2 years with the Bayley Scales of Infant Development (Bayley-III). At 4.5 years, cognitive functioning was assessed with the Wechsler Preschool and Primary Scale of Intelligence (WPPSI-III) and executive functioning with the NEPSY-II.

RESULTS

There were no significant between-group differences in behaviour problems at 2 or 4.5 years, general development at 2 years, or cognitive and executive functioning at 4.5 years.

CONCLUSION

Advances in the quality of neonatal intensive care may mean that MITP-type interventions now have limited additional impact on preterm infants' long-term neurobehavioural outcomes. The gestational age of infants and the exact timing of intervention may also affect its efficacy.

Dysmaturation of Premature Brain: Importance, Cellular Mechanisms, and Potential Interventions

Prematurity, especially preterm birth (less than 32 weeks' gestation), is common and associated with high rates of both survival and neurodevelopmental disability, especially apparent in cognitive spheres. The neuropathological substrate of this disability is now recognized to be related to a variety of dysmaturational disturbances of the brain. These disturbances follow initial brain injury, particularly cerebral white matter injury, and involve many of the extraordinary array of developmental events active in cerebral white and gray matter structures during the premature period. This review delineates these developmental events and the dysmaturational disturbances that occur in premature infants. The cellular mechanisms involved in the genesis of the dysmaturation are emphasized, with particular focus on the preoligodendrocyte. A central role for the diffusely distributed activated microglia and reactive astrocytes in the dysmaturation is now apparent. As these dysmaturational cellular mechanisms appear to occur over a relatively long time window, interventions to prevent or ameliorate the dysmaturation, that is, neurorestorative interventions, seem possible. Such interventions include pharmacologic agents, especially erythropoietin, and particular attention has also been paid to such nutritional factors as quality and source of milk, breastfeeding, polyunsaturated fatty acids, iron, and zinc. Recent studies also suggest a potent role for interventions directed at various experiential factors in the neonatal period and infancy, i.e., provision of optimal auditory and visual exposures, minimization of pain and stress, and a variety of other means of environmental behavioral enrichment, in enhancing brain development.

Psychometric Properties of the Italian Perceived Maternal Parenting Self-Efficacy (PMP S-E)

To validate the Italian Perceived Maternal Parenting Self-Efficacy (PMP S-E), the first questionnaire specifically developed for mothers of preterm neonates hospitalized in the Neonatal Intensive Care Unit. Two hundred mothers filled the PMP S-E, the General Self-Efficacy Scale (GSES), the Edinburgh Postnatal Depression Scale (EPDS), the Parental Distress Index (PSI-SF/Pd). The Explanatory Factor Analysis outlined four factors: care-taking procedures, evoking behaviours, reading and managing bodily cues, reading and managing emotional cues. This factor-solution demonstrated adequate goodness of fit when the Confirmatory Factor Analysis was carried out. Internal consistency was high for the overall scale (α = 0.932), and the all the factors (all α > 0.80). There was a moderate correlation with GSES (r = .438; p < .001), while the associations with EPDS (r = .295; p < .001) and PSI-SF/Pd (r = .193; p = .006) were low. Good test-retest reliability was found over 2 weeks (r = .73; p < .001). These findings support the validity and reliability of the Italian PMP S-E.

Developmental Outcomes, Attachment and Parenting: Study of a Sample of Spanish Premature Children

The aim of this study is to provide an overview of the development of premature children, including attachment, child psychological adjustment and parental variables. 130 children < 1,500 g or < 32 weeks at birth from two public hospitals, assessed at two years corrected age, together with their parents. Parental socio-demographic data was collected. Infant development, attachment and child psychological adjustment were evaluated, as was parental stress. The percentage of preterm children with developmental delays ranged from 5% to 21%. Girls tend to show higher levels of development than boys with effect sizes ranging from small, η2p = .02, to medium, η2p = .07. Secure attachment was the most frequent pattern in the sample. No significant differences, p < .05, between preterm children and the normative population were found on children´s behavioral problems and maternal stress levels. Despite the fact prematurity is considered to be a risk factor for a child´s development, a significant proportion of these children do not show problems in terms of developmental levels, attachment pattern and maternal stress. However, socio-emotional and affective domains, as well as psychological support programs for parenthood, should be followed up from a multidisciplinary perspective.

Family nurture intervention in preterm infants increases early development of cortical activity and independence of regional power trajectories

AIM

Premature delivery and maternal separation during hospitalisation increase infant neurodevelopmental risk. Previously, a randomised controlled trial of Family Nurture Intervention (FNI) in the neonatal intensive care unit demonstrated improvement across multiple mother and infant domains including increased electroencephalographic (EEG) power in the frontal polar region at term age. New aims were to quantify developmental changes in EEG power in all brain regions and frequencies and correlate developmental changes in EEG power among regions.

METHODS

EEG (128 electrodes) was obtained at 34-44 weeks postmenstrual age from preterm infants born 26-34 weeks. Forty-four infants were treated with Standard Care and 53 with FNI. EEG power was computed in 10 frequency bands (1-48 Hz) in 10 brain regions and in active and quiet sleep.

RESULTS

Percent change/week in EEG power was increased in FNI in 132/200 tests (p < 0.05), 117 tests passed a 5% False Discovery Rate threshold. In addition, FNI demonstrated greater regional independence in those developmental rates of change.

CONCLUSION

This study strengthens the conclusion that FNI promotes cerebral cortical development of preterm infants. The findings indicate that developmental changes in EEG may provide biomarkers for risk in preterm infants as well as proximal markers of effects of FNI.

Developmentally Supportive Care in Congenital Heart Disease: A Concept Analysis

THEORETICAL PRINCIPLES

Improved survival of infants and children with congenital heart disease experience has led to recognition that up to half of congenital heart disease survivors also experience developmental delay. Developmentally supportive care is a care model shown in Neonatal Intensive Care Units to be associated with improved outcomes, but developmentally supportive practices with premature infants may not be equally effective in the cardiac population that includes all ages.

PHENOMENA ADDRESSED

The purpose of this paper is to present a concept analysis using the Walker and Avant method in order to identify and define characteristics of developmentally supportive care as it may be applied to the population of neonates, infants, and children with congenital heart disease. A theoretical definition of developmentally supportive care is presented.

RESEARCH LINKAGES

This concept analysis will provide nurses and allied health professionals with a theoretical basis to implement high quality, family-centered care that meets individual developmental needs in a population at high risk for developmental sequelae. Nursing implications for developmentally supportive care as it applies to infants and children with heart disease are discussed.

A Narrative Synthesis of the Components of and Evidence for Patient- and Family-Centered Care

A narrative synthesis was conducted to determine typical patient- and family-centered care (PFCC) components and their link to outcomes in pediatric populations. 68 studies with PFCC interventions and experimental designs were included. Study features were synthesized based on 5 core PFCC components (i.e., education from the provider to the patient and/or family, information sharing from the family to the provider, social-emotional support, adapting care to match family background, and/or s decision-making) and 4 outcome categories (health status; the experience, knowledge, and attitudes of the patient/family; patient/family behavior; or provider behavior). The most common PFCC component was education; the least common was adapting care to family background. The presence of social-emotional support alone, as well as educational interventions augmented with shared decision-making, social-emotional support, or adaptations of care based on family background, predicted improvements in families' knowledge, attitudes, and experience. Interventions that targeted the family were associated with positive outcomes.

Preterm infants' behaviors and skin conductance responses to nurse handling in the NICU

Stress response patterns are indicative of the neonate's unique ability to cope with environmental demands and can be evaluated through autonomic and behavioral response parameters.

OBJECTIVE

To characterize stress responses during tactile stimulation to standard nurse handling in the NICU, and their association with severity of illness in preterm infants.

METHODS

Thirty preterm neonates were studied at postnatal day 4-5 during standard nurse caregiving. Heart rate (HR), respiratory rate (RR), skin conductance responses per second (SCR/s), and NIDCAP® stress behaviors were recorded before and during care. Non-parametric tests were used to assess differences from before to during care. Pearson's correlations were used to determine the association of biological and behavioral variables to the score for neonatal acute physiology (SNAP), a severity of illness index.

RESULTS

HR, RR, SCR/s and NIDCAP® behaviors (motor and attentional cues, and ability to self-console) increased from before to during the care (p < 0.01). NIDCAP® behaviors showed a significant negative association to the SNAP score (R = -0.45, p < 0.05).

CONCLUSIONS

HR, RR, SCR/s and NIDCAP® behaviors significantly increased during care. NIDCAP® stress behaviors were influenced by the severity of illness of the infant, while SCR/s was not influenced by severity of illness.

Relation of neural structure to persistently low academic achievement: a longitudinal study of children with differing birth weights

OBJECTIVE

This study examined the relation of cerebral tissue reductions associated with VLBW to patterns of growth in core academic domains.

METHOD

Children born <750 g, 750 to 1,499 g, or >2,500 g completed measures of calculation, mathematical problem solving, and word decoding at time points spanning middle childhood and adolescence. K. A. Espy, H. Fang, D. Charak, N. M. Minich, and H. G. Taylor (2009, Growth mixture modeling of academic achievement in children of varying birth weight risk, Neuropsychology, Vol. 23, pp. 460-474) used growth mixture modeling to identify two growth trajectories (clusters) for each academic domain: an average achievement trajectory and a persistently low trajectory. In this study, 97 of the same participants underwent magnetic resonance imaging (MRI) in late adolescence, and cerebral tissue volumes were used to predict the probability of low growth cluster membership for each domain.

RESULTS

Adjusting for whole brain volume (wbv), each 1-cm(3) reduction in caudate volume was associated with a 1.7- to 2.1-fold increase in the odds of low cluster membership for each domain. Each 1-mm(2) decrease in corpus callosum surface area increased these odds approximately 1.02-fold. Reduced cerebellar white matter volume was associated specifically with low calculation and decoding growth, and reduced cerebral white matter volume was associated with low calculation growth. Findings were similar when analyses were confined to the VLBW groups.

CONCLUSIONS

Reduced volume of structures involved in connectivity, executive attention, and motor control may contribute to heterogeneous academic trajectories among children with VLBW.

Human infancy…and the rest of the lifespan

Human infancy has been studied as a platform for hypothesis and theory testing, as a major physiological and psychological adjustment, as an object of adults' effects as well as a source of effects on adults, for its comparative value, as a stage of life, and as a setting point for the life course. Following an orientation to infancy studies, including previous reviews and a discussion of the special challenges infants pose to research, this article focuses on infancy as a foundation and catalyst of human development in the balance of the life course. Studies of stability and prediction from infancy illustrate the depth and complexity of modern research on infants and provide a long-awaited reply to key philosophical and practical questions about the meaningfulness and significance of infancy.

Early communication in preterm infants following intervention in the NICU

BACKGROUND

Despite ongoing improvements in clinical care, preterm infants experience a variety of stressors in the first weeks of life, including necessary medical procedures, which may affect development. Some stress-reduction programmes based in the Neonatal Intensive Care Unit (NICU) have reported a positive impact on development. In particular, trials of the Mother-Infant Transaction Program (MITP) have shown positive short and longer term effects, and are based on training parents to recognise and minimise stress responses in preterm infants.

AIMS

To evaluate the impact on early developmental milestones of an enhanced MITP (PremieStart) delivered over an extended period in the NICU.

STUDY DESIGN

This was a parallel 2-group randomised controlled trial involving 109 women with 123 infants born at <30weeks gestation assessed initially at term-equivalent age and then at 6 months' corrected-age.

RESULTS

Intervention mothers were more sensitive in providing infant care, stressed their infants less, showed greater awareness of, and responded more appropriately to, negative infant cues (p < 0.05 in each case). Intervention infants displayed significantly lower stress when being bathed by mothers at term-equivalent age (p < 0.05). At 6 months corrected-age, intervention infants showed higher mean scores on the Communication and Symbolic Behavior Scales Developmental Profile Infant-Toddler Checklist. The strongest effects appeared in Symbolic behaviour (p = 0.05) and this was reflected in the Total score (p < 0.05).

CONCLUSIONS

As significant cognitive and language deficits are reported in longitudinal studies of preterm children, an intervention that improves early infant communication abilities is promising, especially since previous research suggests that the strongest benefits may emerge at later ages.

Sustained developmental effects of the infant behavioral assessment and intervention program in very low birth weight infants at 5.5 years corrected age

OBJECTIVE

To evaluate the effect of the Infant Behavioral Assessment and Intervention Program (IBAIP) in very low birth weight (VLBW) infants on cognitive, neuromotor, and behavioral development at 5.5 years corrected age (CA).

STUDY DESIGN

In a randomized controlled trial, 86 VLBW infants received post discharge IBAIP intervention until 6 months CA, and 90 VLBW infants received standard care. At 5.5 years CA, cognitive and motor development, and visual-motor integration were assessed with the Wechsler Preschool and Primary Scale of Intelligence, third Dutch version, the Movement Assessment Battery for Children, second edition, and the Developmental Test of Visual Motor Integration. Neurologic conditions were assessed with the neurologic examination according to Touwen, and behavior with the Strengths and Difficulties Questionnaire.

RESULTS

At 5.5 years CA, 69 children in the intervention and 67 children in the control group participated (response rate 77.3%). Verbal and performance IQ-scores<85 occurred significantly less often in the intervention than in the control group (17.9% vs 33.3%, P=.041, and 7.5% vs 21.2%, P=.023, respectively). However, after adjustment for differences, only the OR for performance IQ was significant: 0.24, 95% CI: 0.06-0.95. Adjusted mean scores on Wechsler Preschool and Primary Scale of Intelligence, third version subtasks block design and vocabulary, the Movement Assessment Battery for Children, second edition component aiming and catching, and the Developmental Test of Visual Motor Integration were significantly better in the intervention group. No intervention effect was found on the Strengths and Difficulties Questionnaire.

CONCLUSION

The IBAIP leads, 5 years after the early neurobehavioral intervention, to improvements on performance IQ, ball skills, and visual-motor integration at 5.5 years CA.

Brain development in infants born preterm: looking beyond injury

Infants born very preterm are high risk for acquired brain injury and disturbances in brain maturation. Although survival rates for preterm infants have increased in the last decades owing to improved neonatal intensive care, motor disabilities including cerebral palsy persist, and impairments in cognitive, language, social, and executive functions have not decreased. Evidence from neuroimaging studies exploring brain structure, function, and metabolism has indicated abnormalities in the brain development trajectory of very preterm-born infants that persist through to adulthood. In this chapter, we review neuroimaging approaches for the identification of brain injury in the preterm neonate. Advances in medical imaging and availability of specialized equipment necessary to scan infants have facilitated the feasibility of conducting longitudinal studies to provide greater understanding of early brain injury and atypical brain development and their effects on neurodevelopmental outcome. Improved understanding of the risk factors for acquired brain injury and associated factors that affect brain development in this population is setting the stage for improving the brain health of children born preterm.

NIDCAP: a systematic review and meta-analyses of randomized controlled trials

BACKGROUND AND OBJECTIVE

The "synactive" theory of neurobehavioral development forms the basis of the Newborn Individualized Developmental Care and Assessment Program (NIDCAP). Our objective was to assess the effectiveness of NIDCAP in improving outcomes in preterm infants.

METHODS

Medline, CINAHL, Embase, PsychInfo, The Cochrane Library, Pediatric Academic Societies' Abstracts and Web of Science were searched in July 2010 and February 2012. The studies selected were randomized controlled trials testing the effectiveness of NIDCAP on medical and neurodevelopmental outcomes. The authors abstracted baseline characteristics of infants and outcomes. The risk of bias was assessed by using Cochrane criteria. RevMan 5.1 was used to synthesize data by the use of relative risk and risk difference for dichotomous outcomes and mean or standardized mean difference for continuous outcomes.

RESULTS

Eleven primary and 7 secondary studies enrolling 627 neonates were included, with 2 of high quality. The composite primary outcomes of death or major sensorineural disability at 18 months corrected age or later in childhood (3 trials, 302 children; relative risk 0.89 [95% confidence interval 0.61 to 1.29]) and survival free of disability at 18 months corrected age or later in childhood (2 trials, 192 infants; relative risk 0.97 [95% confidence interval 0.69 to 1.35]), were not significantly different between the NIDCAP and control groups. With the sensitivity analysis that excluded the 2 statistically heterogeneous outlying studies, there were no significant differences between groups for short-term medical outcomes.

CONCLUSIONS

This systematic review including 627 preterm infants did not find any evidence that NIDCAP improves long-term neurodevelopmental or short-term medical outcomes.

School-age effects of the newborn individualized developmental care and assessment program for preterm infants with intrauterine growth restriction: preliminary findings

BACKGROUND

The experience in the newborn intensive care nursery results in premature infants' neurobehavioral and neurophysiological dysfunction and poorer brain structure. Preterms with severe intrauterine growth restriction are doubly jeopardized given their compromised brains. The Newborn Individualized Developmental Care and Assessment Program improved outcome at early school-age for preterms with appropriate intrauterine growth. It also showed effectiveness to nine months for preterms with intrauterine growth restriction. The current study tested effectiveness into school-age for preterms with intrauterine growth restriction regarding executive function (EF), electrophysiology (EEG) and neurostructure (MRI).

METHODS

Twenty-three 9-year-old former growth-restricted preterms, randomized at birth to standard care (14 controls) or to the Newborn Individualized Developmental Care and Assessment Program (9 experimentals) were assessed with standardized measures of cognition, achievement, executive function, electroencephalography, and magnetic resonance imaging. The participating children were comparable to those lost to follow-up, and the controls to the experimentals, in terms of newborn background health and demographics. All outcome measures were corrected for mother's intelligence. Analysis techniques included two-group analysis of variance and stepwise discriminate analysis for the outcome measures, Wilks' lambda and jackknifed classification to ascertain two-group classification success per and across domains; canonical correlation analysis to explore relationships among neuropsychological, electrophysiological and neurostructural domains at school-age, and from the newborn period to school-age.

RESULTS

Controls and experimentals were comparable in age at testing, anthropometric and health parameters, and in cognitive and achievement scores. Experimentals scored better in executive function, spectral coherence, and cerebellar volumes. Furthermore, executive function, spectral coherence and brain structural measures discriminated controls from experimentals. Executive function correlated with coherence and brain structure measures, and with newborn-period neurobehavioral assessment.

CONCLUSION

The intervention in the intensive care nursery improved executive function as well as spectral coherence between occipital and frontal as well as parietal regions. The experimentals' cerebella were significantly larger than the controls'. These results, while preliminary, point to the possibility of long-term brain improvement even of intrauterine growth compromised preterms if individualized intervention begins with admission to the NICU and extends throughout transition home. Larger sample replications are required in order to confirm these results.

CLINICAL TRIAL REGISTRATION

The study is registered as a clinical trial. The trial registration number is NCT00914108.

Maturation of corpus callosum anterior midbody is associated with neonatal motor function in eight preterm-born infants

Background. The etiology of motor impairments in preterm infants is multifactorial and incompletely understood. Whether corpus callosum development is related to impaired motor function is unclear. Potential associations between motor-related measures and diffusion tensor imaging (DTI) of the corpus callosum in preterm infants were explored. Methods. Eight very preterm infants (gestational age of 28–32 weeks) underwent the Hammersmith neonatal neurological examination and DTI assessments at gestational age of 42 weeks. The total Hammersmith score and a motor-specific score (sum of Hammersmith motor subcategories) were calculated. Six corpus callosum regions of interest were defined on the mid-sagittal DTI slice—genu, rostral body, anterior midbody, posterior midbody, isthmus, and splenium. The fractional anisotropy (FA) and mean diffusivity (MD) of these regions were computed, and correlations between these and Hammersmith measures were sought. Results. Anterior midbody FA measures correlated positively with total Hammersmith (rho = 0.929, P = 0.001) and motor-specific scores (rho = 0.857, P = 0.007). Total Hammersmith scores also negatively correlated with anterior midbody MD measures (rho = −0.714, P = 0.047). Discussion. These results suggest the integrity of corpus callosum axons, particularly anterior midbody axons, is important in mediating neurological functions. Greater callosal maturation was associated with greater motor function. Corpus callosum DTI may prove to be a valuable screening or prognostic marker.

[Development and assessment of a sensory-motor scale for the neonate: a clinical tool at the bedside]

INTRODUCTION

Improved perinatal care has increased the survival of newborns. However, neonatal intensive care is a source of nociceptive stimuli that may have a negative long-term impact on the child's neurobehavioral development. During the period of maximal brain plasticity, supportive developmental care can therefore be beneficial. The purpose of this study was to develop an assessment tool of neonatal behavior for daily use by healthcare providers and validate its content.

METHOD

A behavioral assessment tool starting off with 45 clinical variables in 6 areas of sensory-motor behavior was validated in two stages using footage of babies between 25 and 37 weeks gestational age. The intraclass correlation coefficient of 65 evaluations allowed simplification of the tool down to 23 variables, prior to a final analysis of validity and reliability.

RESULTS

For the 23 variables, the reliability between observers was low for 7 (intraclass correlation coefficient [ICC]<0.4), fair for 4 (ICC 0.4-0.5) and good for 12 (ICC>0.5). The agreement between novice and expert observers ranged from 46.7% to 98.7%. Twenty variables had a level of agreement above 60%.

CONCLUSIONS

This validation study of a newborn sensory-motor behavior assessment scale has identified pertinent variables for a structured assessment by healthcare providers.

NIDCAP improves brain function and structure in preterm infants with severe intrauterine growth restriction

OBJECTIVE

The effect of NIDCAP (Newborn Individualized Developmental Care and Assessment Program) was examined on the neurobehavioral, electrophysiological and neurostructural development of preterm infants with severe intrauterine growth restriction (IUGR).

STUDY DESIGN

A total of 30 infants, 27-33 weeks gestation, were randomized to control (C; N=17) or NIDCAP/experimental (E; N=13) care. Baseline health and demographics were assessed at intake; electroencephalography (EEG) and magnetic resonance imaging (MRI) at 35 and 42 weeks postmenstrual age; and health, growth and neurobehavior at 42 weeks and 9 months corrected age (9 months).

RESULTS

C and E infants were comparable in health and demographics at baseline. At follow-up, E infants were healthier, showed significantly improved brain development and better neurobehavior. Neurobehavior, EEG and MRI discriminated between C and E infants. Neurobehavior at 42 weeks correlated with EEG and MRI at 42 weeks and neurobehavior at 9 months.

CONCLUSION

NIDCAP significantly improved IUGR preterm infants' neurobehavior, electrophysiology and brain structure. Longer-term outcome assessment and larger samples are recommended.

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.

Neonatal intensive care unit stress is associated with brain development in preterm infants

OBJECTIVE

Although many perinatal factors have been linked to adverse neurodevelopmental outcomes in very premature infants, much of the variation in outcome remains unexplained. The impact on brain development of 1 potential factor, exposure to stressors in the neonatal intensive care unit, has not yet been studied in a systematic, prospective manner.

METHODS

In this prospective cohort study of infants born at <30 weeks gestation, nurses were trained in recording procedures and cares. These recordings were used to derive Neonatal Infant Stressor Scale scores, which were employed to measure exposure to stressors. Magnetic resonance imaging (brain metrics, diffusion, and functional magnetic resonance imaging) and neurobehavioral examinations at term equivalent postmenstrual age were used to assess cerebral structure and function. Simple and partial correlations corrected for confounders, including immaturity and severity of illness, were used to explore these relations.

RESULTS

Exposure to stressors was highly variable, both between infants and throughout a single infant's hospital course. Exposure to a greater number of stressors was associated with decreased frontal and parietal brain width, altered diffusion measures and functional connectivity in the temporal lobes, and abnormalities in motor behavior on neurobehavioral examination.

INTERPRETATION

Exposure to stressors in the Neonatal Intensive Care Unit is associated with regional alterations in brain structure and function. Further research into interventions that may decrease or mitigate exposure to stressors in the neonatal intensive care unit is warranted.

A new neurological focus in neonatal intensive care

Advances in the care of high-risk newborn babies have contributed to reduced mortality rates for premature and term births, but the surviving neonates often have increased neurological morbidity. Therapies aimed at reducing the neurological sequelae of birth asphyxia at term have brought hypothermia treatment into the realm of standard care. However, this therapy does not provide complete protection from neurological complications and a need to develop adjunctive therapies for improved neurological outcomes remains. In addition, the care of neurologically impaired neonates, regardless of their gestational age, clearly requires a focused approach to avoid further injury to the brain and to optimize the neurodevelopmental status of the newborn baby at discharge from hospital. This focused approach includes, but is not limited to, monitoring of the patient's brain with amplitude-integrated and continuous video EEG, prevention of infection, developmentally appropriate care, and family support. Provision of dedicated neurocritical care to newborn babies requires a collaborative effort between neonatologists and neurologists, training in neonatal neurology for nurses and future generations of care providers, and the recognition that common neonatal medical problems and intensive care have an effect on the developing brain.

The Newborn Individualized Developmental Care and Assessment Program (NIDCAP) with Kangaroo Mother Care (KMC): Comprehensive Care for Preterm Infants

State-of-the-art Newborn Intensive Care Units (NICUs), instrumental in the survival of high-risk and ever-earlier-born preterm infants, often have costly human repercussions. The developmental sequelae of newborn intensive care are largely misunderstood. Developed countries eager to export their technologies must also transfer the knowledge-base that encompasses all high-risk and preterm infants' personhood as well as the neuro-essential importance of their parents. Without such understanding, the best medical care, while assuring survival jeopardizes infants' long-term potential and deprives parents of their critical role. Exchanging the womb for the NICU environment at a time of rapid brain growth compromises preterm infants' early development, which results in long-term physical and mental health problems and developmental disabilities. The Newborn Individualized Developmental Care and Assessment Program (NIDCAP) aims to prevent the iatrogenic sequelae of intensive care and to maintain the intimate connection between parent and infant, one expression of which is Kangaroo Mother Care. NIDCAP embeds the infant in the natural parent niche, avoids over-stimulation, stress, pain, and isolation while it supports self-regulation, competence, and goal orientation. Research demonstrates that NIDCAP improves brain development, functional competence, health, and life quality. It is cost effective, humane, and ethical, and promises to become the standard for all NICU care.