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

Over-reaching with causality language in neurodevelopmental infant research: A methodological literature review

BACKGROUND

A methodological review of 78 empirical articles focusing on the neurodevelopmental outcomes of at-risk infants was conducted.

AIMS

To examine ways language and terminology are used to describe methods, present results, and/or state conclusions in studies published during 1994-2005, a decade reflecting major advances in neurodevelopmental research and in medical intervention. More specifically, to investigate to what extent the design of the study and the language in the results section aligned in regard to causality.

METHODS

A process of search and selection of studies published in pediatric journals was conducted through Google Scholar. Criteria of inclusion and exclusion, following PRISMA, were used. Selected studies reported neurodevelopmental outcomes of infants and young children considered at-risk, and were further categorized accordingly to their study designs. Language use in regard to whether the presentation and interpretation of results may convey causal relationships between birth risk factors and neurodevelopmental outcomes was examined following two analytical steps.

RESULTS

Forty out of 78 studies, (51.28 %) used causality-implying language (e.g., effect, predict, influence) notwithstanding that the study design was non-causal.

CONCLUSIONS

Anticipating the next generation of neurodevelopmental-outcomes research, a framework that aims to raise awareness of the importance of language use and the impact of causality-related terms often used in longitudinal studies is proposed. The objective is to avoid ambiguities and misunderstandings around causal or non-causal connections between birth risk factors and developmental outcomes across diverse audiences, including early intervention practitioners working directly with infants and their families.

Changes of Infant- and Family-Centered Care Practices Administered to Extremely Preterm Infants During Implementation of the NIDCAP Program

Introduction: Many studies have evaluated the Neonatal Individualized Developmental Care and Assessment Program (NIDCAP), but few studies have assessed changes in infant- and family-centered developmental care (IFCDC) practices during its implementation. Objectives: The primary objective of this single center study was to investigate the impact of the implementation of the NIDCAP program on IFCDC practices used for management of extremely preterm infants (EPIs). The secondary objective was to determine during implementation the impact of this program on the short-term medical outcomes of all EPIs hospitalized at our center. Methods: All EPIs (<28 weeks gestational age) who were hospitalized at Strasbourg University Hospital from 2007 to 2014 were initially included. Outborn infants were excluded. The data of EPIs were compared for three time periods: 2007 to 2008 (pre-NIDCAP), 2010 to 2011, and 2013 to 2014 (during-NIDCAP implementation) using appropriate statistical tests. The clinical and caring procedures used during the first 14 days of life were analyzed, with a focus on components of individualized developmental care (NIDCAP observations), infant pain management (number of painful procedures, clinical pain assessment), skin-to-skin contact (SSC; frequency, day of initiation, and duration), and family access and involvement in the care of their children (duration of parental presence, parental participation in care). The short-term mortality and morbidity at discharge were evaluated. Results: We examined 228 EPIs who received care during the three time periods. Over time, painful procedures decreased, but pain evaluations, parental involvement in care, individualized observations, and SSC increased (all p < 0.01). In addition, the first SSC was performed earlier (p = 0.03) and lasted longer (p < 0.01). There were no differences in mortality and morbidity, but there were reductions in the duration of mechanical ventilation (p = 0.02) and the time from birth to first extubation (p = 0.02), and an increase of weight gain at discharge (p = 0.02). Conclusion: NIDCAP implementation was accompanied by progressive, measurable, and significant changes in IFCDC strategies. There were, concomitantly, moderate but statistically significant improvements in multiple important outcome measures of all hospitalized EPI.

Paper-based biosensor based on phenylalnine ammonia lyase hybrid nanoflowers for urinary phenylalanine measurement

The Phenylketonuria (PKU) is an inborn defect of phenylalanine (Phe) metabolism, in which Phe accumulated in the blood causing alterations at the central nervous system. Therefore, the detection of PKU is very important for the early diagnosis of PKU patients. However, existing tests for PKU are time-consuming and require high-resource laboratories. In this study, a novel paper-based biosensor based on phenylalnine ammonia lyase (PAL) hybrid nanoflowers was constructed that provides a semi-quantitative output of the concentration of Phe from urine samples. PAL@Ca₃(PO₄)₂ hybrid nanoflowers (PAL@NF) were first prepared using PAL and Ca²⁺. Synthesis conditions of the PAL@NF on the formation of the PAL@NF were optimized. The PAL@NF exhibited 90% activity recovery under optimal condition. Compared with free PAL, the PAL@NF displayed good storage stability and increased tolerance to proteolysis. After five consecutive operating cycles, the PAL@NF still retained 73% of its initial activity, indicating excellent reusability. Furthermore, the paper-based biosensor was able to detect Phe concentration in urine samples, and exhibited good linearity to the Phe concentrations in the range from 60 to 2400 μM and the response time was only about 10 min. Therefore, the paper-based biosensor can be a promising candidate as a biosensor for the detection of PKU.

Systematic review of maternal voice interventions demonstrates increased stability in preterm infants

We systematically reviewed how effectively maternal voice interventions supported the clinical outcomes and development of preterm infants. A total of 512 preterm infants were included in 15 studies with different designs, from January 2000 to July 2015. Live and recorded maternal voice interventions were associated with the physiologic and behavioural stabilisation of preterm infants, with fewer cardiorespiratory events, but the evidence was insufficient to evaluate the long-term effects. Well-defined determinants and clear setting conditions are needed for such interventions.

CONCLUSION

Further research that investigates the long-term efficacy and effects of live maternal voices on preterm infant development is needed.

Individualized Developmental Care in the NICU: A Concept Analysis

BACKGROUND

Individualized developmental care (IDC) is a collection of evidence-based practices that include adapting care practices based on the infant's behavioral and developmental state, involving parents and families in the infant's care, and providing an environment that minimizes over stimulation of the infant.

PURPOSE

To clarify the definition of IDC in the neonatal intensive care unit (NICU) and to provide guidelines for implementation of IDC for healthcare professionals through a concept analysis.

METHOD/SEARCH STRATEGY

A literature review involving a search of multiple electronic databases from January 1982 to November 2016 was performed along with presentation of a model case and attributes of IDC.

CONCLUSIONS

This concept analysis defines and provides guidelines for implementing an individualized developmentally sound environment for infants born premature and their families.

IMPLICATIONS FOR PRACTICE

All NICUs need to strive to provide an environment that supports and promotes IDC. Education needs to be provided to healthcare providers and parents regarding IDC practices.

IMPLICATIONS FOR RESEARCH

Further research into short- and long-term outcomes of IDC is needed. Research into whether IDC is being implemented by NICUs is also needed.

Mothering a Preterm Infant Receiving NIDCAP Care in a Level III Newborn Intensive Care Unit

The purpose of the study is to describe the unique meaning and significance of the essential elements of mothering a preterm infant receiving Newborn Individualized Developmental Care and Assessment Program (NIDCAP) care in a level III NICU. The overall aim was to promote an increased understanding among healthcare practitioners of the experience of this group of women.

DESIGN AND METHODS

The authors utilized an existential-phenomenologic method to investigate the experience of 7 mothers of a preterm infant 30weeks gestation or less at birth.

RESULTS

Analysis of interview transcripts revealed one overarching theme, parenting with permission, and three essential themes with nine underlying subthemes: choosing to participate (subthemes: managing, settling in, making friends), dealing with people (subthemes: meeting needs, facing judgment, and recognizing not everyone is 'on board,' and coming to feel like a mother (subthemes: overcoming fear, gaining understanding, and feeling empowered).

CONCLUSIONS/PRACTICE IMPLICATIONS

Mothers universally praised NIDCAP for the education and support it provided them. However findings also suggest that great sensitivity and patience is required by professionals to assist mothers to overcome their fear, gain confidence, and participate in NIDCAP without feeling judged. In addition private rooms were found to hold great significance for mothers and should be maintained for the entire hospitalization whenever possible. Finally, ongoing NIDCAP education/support for staff and regular team meetings to discuss and problem-solve concerns are suggested. This might address inconsistent adherence to the NIDCAP care plan by some nurses, which is the greatest source of maternal conflict and frustration.

[Variables determining the amount of care for very preterm neonates: the concept of medical stance]

OBJECTIVE

To compare the amount of medical interventions on very preterm neonates (24-31 weeks of gestation) in two French university tertiary care centers, one of which is involved in a Neonatal Developmental Care program. A secondary objective is to assess whether this difference in medical interventions can be linked to a difference in mortality and morbidity rates.

METHODS

We prospectively included all very preterm neonates free from lethal malformation born live in these two centers between 2006 and 2010. These inclusion criteria were met by 1286 patients, for whom we compared the rate of five selected medical interventions: birth by caesarean section, chest intubation in the delivery room, surfactant therapy, pharmacological treatment of patent ductus arteriosus, and red blood cell transfusion.

RESULTS

The rates of the five medical interventions were systematically lower in the center that is involved in Neonatal Developmental Care. There was no significant difference in survival at discharge with no severe cerebral ultrasound scan abnormalities between the two centers. There were, however, significantly higher rates of bronchopulmonary dysplasia and nosocomial sepsis and longer hospital stays when the patients were not involved in a Neonatal Developmental Care program.

DISCUSSION

This benchmarking study shows that in France, in the first decade of the 21st century, there are as many ways to handle very preterm neonates as there are centers in which they are born. This brings to light the concept of medical stance, which is the general care approach prior to the treatment itself. This medical stance creates the overall framework for the staff's decision-making regarding neonate care. The different parameters structuring medical stance are discussed. Moreover, this study raises the problematic issue of the aftermath of benchmarking studies when the conclusion is an increase of morbidity in cases where procedure leads to more interventions.

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.

A model of neurodevelopmental risk and protection for preterm infants

The purpose of this article is to introduce a model of neurodevelopmental risk and protection that may explain some of the relationships among biobehavioral risks, environmental risks, and caregiving behaviors that potentially contribute to neurobehavioral and cognitive outcomes. Infants born before 30 weeks of gestation have the poorest developmental prognosis of all infants. These infants have lengthy hospitalization periods in the neonatal intensive care unit (NICU,) an environment that is not always supportive of brain development and long-term developmental needs. The model supports the premise that interventions focused on neuroprotection during the neonatal period have the potential to positively affect long-term developmental outcomes for vulnerable very preterm infants. Finding ways to better understand the complex relationships among NICU-based interventions and long-term outcomes are important to guiding caregiving practices in the NICU.

Newborn Individual Development Care and Assessment Program (NIDCAP): a systematic review of the literature

BACKGROUND

Important advancements have been made in the care of preterm infants. Health services have introduced various methods aimed at promoting attachment, breastfeeding, and neurological development. The Newborn Individualized Developmental Care and Assessment Program (NIDCAP), developed to stimulate preterm infants at levels adapted to the child's degree of neurological maturity, is increasingly being used.

OBJECTIVES

The aim was to investigate the impact of NIDCAP on the psychomotor development, neurological status, medical/nursing care outcomes, and parental perceptions. A further aim was to evaluate the cost-related effects of NIDCAP.

DATA EXTRACTION AND ANALYSIS

A literature search up to September 2007 was performed. The reviewed papers were assessed for methodological quality and only statistically significant findings were extracted.

FINDINGS

The evidence compiled on the effects of NIDCAP is based on 12 articles from six randomized controlled trials that included approximately 250 children. Each of the studies was assessed as having medium quality. Most of the studies were small and many investigated a huge number of outcome variables, which decreased their scientific strength. On outcome variables in which a significant difference was found between the intervention (NIDCAP) and control groups, most studies showed better results for the NIDCAP group. This was particularly valid for cognitive and psychomotor development. Four studies also showed a reduced need for respiratory support for the NIDCAP group. No studies were identified that weighed the total cost of NIDCAP against its effects.

CONCLUSIONS

Despite promising findings, primarily on cognitive and motor development, the scientific evidence on the effects of NIDCAP is limited. Shortcomings in design and methods in the reviewed studies hamper far-reaching claims on the effectiveness of the method. Scientific grounds for assessing the effects of NIDCAP would be substantially enhanced by a sufficiently comprehensive study with extended follow-up and a clear focus on a few important outcome variables.

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.

Development and growth in very preterm infants in relation to NIDCAP in a Dutch NICU: two years of follow-up

AIM

To study development and growth in relation to newborn individualized developmental and assessment program (NIDCAP) for infants born with a gestational age of less than 30 weeks.

METHODS

Developmental outcome of surviving infants, 25 in the NIDCAP group and 24 in the conventional care group, in a prospective phase-lag cohort study performed in a Dutch level III neonatal intensive care unit (NICU) was compared. Main outcome measure was the Bayley scales of infant development-II (BSID-II) at 24 months corrected age. Secondary outcomes were neurobehavioral and developmental outcome and growth at term, 6, 12 and 24 months.

RESULTS

Accounting for group differences and known outcome predictors no significant differences were seen between both care groups in BSID-II at 24 months. At term age NIDCAP infants scored statistically significant lower on neurobehavioral competence; motor system (median [IQR] 4.8 [2.9-5.0] vs. 5.2 [4.3-5.7], p = 0.021) and autonomic stability (median [IQR] 5.7 [4.8-6.7] vs. 7.0 [6.0-7.7], p = 0.001). No differences were seen in other developmental outcomes. After adjustment for background differences, growth parameters were comparable between groups during the first 24 months of life.

CONCLUSION

At present, the strength of conclusions to be drawn about the effect of NIDCAP on developmental outcome or growth at 24 months of age is restricted. Further studies employing standardized assessment approaches including choice of measurement instruments and time points are needed.