Outcome of 100 randomly positioned children of very low birthweight at 2 years

Developmental care for promoting development and preventing morbidity in preterm infants

BACKGROUND

Preterm infants experience a range of morbidity related to the immaturity of their organ systems and to concurrent disease states. There is concern that an unfavourable environment in the neonatal intensive care unit (NICU) may compound this morbidity. Modification of the environment could minimize the iatrogenic effects. Developmental care is a broad category of interventions designed to minimize the stress of the NICU environment. These interventions may include elements such as control of external stimuli (vestibular, auditory, visual, tactile), clustering of nursery care activities, and positioning or swaddling of the preterm infant. Individual strategies have also been combined to form programs, such as the 'Newborn Individualized Developmental Care and Assessment Program' (NIDCAP) (Als 1986).

OBJECTIVES

In preterm infants, do developmental care interventions reduce neurodevelopmental delay, poor weight gain, length of hospital stay, length of mechanical ventilation, physiological stress and other clinically relevant adverse outcomes?

SEARCH STRATEGY

The Neonatal Review Group search strategy was utilized. Searches were made of MEDLINE from 1966 to June, 2005 and of CINAHL, The Cochrane Central Register of Controlled Trials (CENTRAL, The Cochrane Library, Issue 1, 2005), and conference and symposia proceedings in the English language from 1990 to June, 2005. A search of EMBASE was also made from 2003 to June 2005. A list of all relevant articles was sent to two experts in the field to identify any omissions or additional unpublished studies.

SELECTION CRITERIA

Randomized trials in which elements of developmental care are compared to routine nursery care for infants < 37 weeks gestation and that measured clinically relevant outcomes. Reports were in English or a language for which a translator was available. Computerized searches were conducted and all potentially relevant titles and abstracts were extracted. Retrieved articles were assessed for relevance independently by two reviewers, based on predetermined criteria. Articles that met all criteria for relevance were assessed for methodological quality based on predetermined criteria. Articles judged to have the appropriate quality by both reviewers were included in the analysis.

DATA COLLECTION AND ANALYSIS

Data were extracted independently by the two authors. Meta-analyses were conducted for each intervention where the same outcome measures and/or instruments were used within comparable time points.

MAIN RESULTS

This review detected 36 eligible randomized controlled trials involving four major groups of developmental care interventions, 19 sub-groups and multiple clinical outcomes. In addition, the long-term outcomes of a previously included trial were added to the review. The results of the review indicate that developmental care interventions demonstrate limited benefit to preterm infants with respect to: decreased moderate-severe chronic lung disease, decreased incidence of necrotizing enterocolitis and improved family outcome. Conversely, an increase in mild lung disease and an increase in the length of stay were demonstrated in infants receiving developmental care compared to controls. There is also very limited evidence of the long-term positive effect of NIDCAP on behavior and movement at 5 years corrected age but no effect on cognition. Other individualized developmental care interventions have also demonstrated some effect in enhancing neurodevelopmental outcome. Although a limited number of other benefits were demonstrated, those results were from single studies with small sample sizes. The lack of blinding of the assessors was a significant methodological flaw in half of the studies. The cost of the interventions and personnel was not considered in any of the studies.

AUTHORS' CONCLUSIONS

Because of the inclusion of multiple interventions in most studies, the determination of the effect of any single intervention is difficult. Although there is evidence of limited benefit of developmental care interventions overall, and no major harmful effects reported, there were a large number of outcomes for which no or conflicting effects were demonstrated. The single trials that did show a significant effect of an intervention on a major clinical outcome were based on small sample sizes, and the findings were often not supported in other small trials. Before a clear direction for practice can be supported, evidence demonstrating more consistent effects of developmental care interventions on important short- and long-term clinical outcomes is needed. The economic impact of the implementation and maintenance of developmental care practices should be considered by individual institutions.

Developmental care for promoting development and preventing morbidity in preterm infants

BACKGROUND

Preterm infants experience a range of morbidity related to the immaturity of their organ systems and to concurrent disease states. An unfavourable environment in the neonatal intensive care unit (NICU) may compound this morbidity. Modification of the environment could minimize the iatrogenic effects. Developmental care is a broad category of interventions designed to minimize the stress of the NICU environment. These interventions may include one or more elements such as control of external stimuli (vestibular, auditory, visual, tactile), clustering of nursery care activities, and positioning or swaddling of the preterm infant. Individual strategies have also been combined to form programs, such as the 'Neonatal Individualized Developmental Care and Assessment Program' (NIDCAP) (Als 1986).

OBJECTIVES

In preterm infants, do developmental care interventions reduce neurodevelopmental delay, poor weight gain, length of hospital stay, length of mechanical ventilation, physiological stress and other clinically relevant adverse outcomes?

SEARCH STRATEGY

The Neonatal Review Group search strategy was utilized. Searches were made of MEDLINE from 1966 to July, 2003, and of CINAHL, The Cochrane Central Register of Controlled Trials (CENTRAL, The Cochrane Library, Issue 2, 2003), and conference and symposia proceedings in the English language from 1990 to July, 2003. A list of all relevant articles was sent to two experts in the field to identify any omissions or additional unpublished studies.

SELECTION CRITERIA

Randomized trials in which elements of developmental care are compared to routine nursery care for infants < 37 weeks gestation and that measured clinically relevant outcomes. Reports were in English or a language for which a translator was available. Computerized searches were conducted and all potentially relevant titles and abstracts were extracted. Retrieved articles were assessed for relevance independently by two reviewers, based on predetermined criteria. Articles that met all criteria for relevance were assessed for methodological quality based on predetermined criteria. Articles judged to have the appropriate quality by both reviewers were included in the analysis.

DATA COLLECTION AND ANALYSIS

Data were extracted independently by the two authors. Meta-analyses were conducted for each intervention where the same outcome measures and/or instruments were used within comparable time points.

MAIN RESULTS

This review detected 32 eligible randomized controlled trials involving four major groups of developmental care interventions, 19 sub-groups and multiple clinical outcomes. The results of the review indicate that developmental care interventions demonstrate some benefit to preterm infants with respect to: improved short-term growth and feeding outcomes, decreased respiratory support, decreased length and cost of hospital stay, and improved neurodevelopmental outcomes to 24 months corrected age. These findings were based on two or three small trials for each outcome, and did not involve meta-analyses of more than two trials for any one outcome. Although a number of other benefits were demonstrated, those results were from single studies with small sample sizes. The lack of blinding of the assessors was a significant methodological flaw in half of the studies. The cost of the interventions and personnel was not considered in any of the studies.

REVIEWER'S CONCLUSIONS

Because of the inclusion of multiple interventions in most studies, the determination of the effect of any single intervention is difficult. Although there is evidence of some benefit of developmental care interventions overall, and no major harmful effects reported, there were a large number of outcomes for which no or conflicting effects were demonstrated. The single trials that did show a significant effect of an intervention on a major clinical outcome were based on small sample sizes, and the findings were often not supported in other small trials. Before a clear direction for practice can be supported, evidence demonstrating more consistent effects of developmental care interventions on important short- and long-term clinical outcomes is needed. The economic impact of the implementation and maintenance of developmental care practices should be considered by individual institutions.

Distilling the evidence on developmental care: a systematic review

PURPOSE

To determine whether developmental care interventions reduce neurodevelopmental delay, poor weight gain, length of hospital stay, length of mechanical ventilation, physiologic stress, and other clinically relevant adverse outcomes in preterm infants.

SUBJECTS

Infants born at less than 37 weeks postconceptional age. This review consisted of 31 studies in 4 categories of developmental care interventions, 19 subgroups, and multiple clinical outcomes. The total sample sizes in the individual studies ranged from 16 to 259; the sample size in 18 of the studies was less than 50.

DESIGN AND METHODS

A systematic review, based on the Cochrane Collaboration format, of all randomized trials in which elements of developmental care are compared with routine nursery care and that measured clinically relevant outcomes. Searches were made of MEDLINE from 1966 to July 2000. Additional databases were also searched electronically. Reference lists and bibliographies of relevant articles were hand-searched. Experts in the field were contracted. If more than one study in an outcome category existed, a meta-analysis was conducted.

PRIMARY OUTCOME MEASURES

Outcome measures included the following: length of hospital stay, weight at discharge, neurodevelopment, physiologic parameters, feeding growth, sleep/wake states, age at discharge, neonatal outcomes, cost of hospital stay, and death.

PRINCIPAL RESULTS

Developmental care interventions showed some benefit to preterm infants with respect to improved short-term growth outcomes, decreased respiratory support, decreased incidence of moderate to severe chronic lung disease, decreased length and cost of hospital stay, and improved neurodevelopmental outcomes to 24 months corrected age. These findings were based on 2 or 3 small trials for each outcome. Although a number of other benefits were shown, those results were from single studies with small sample sizes. The lack of blinding of the assessors of the outcome variables was a significant methodological flaw in half of the studies. The costs of the interventions and personnel were not considered in any of the studies.

CONCLUSIONS

In most studies, the inclusion of multiple interventions made the determination of the effect of any single intervention difficult. Although there is evidence of some benefit of developmental care interventions overall and no major harmful effects reported, there were a large number of outcomes for which no or conflicting effects were shown. The single trials that did show a significant effect of an intervention on a major clinical outcome were based on small sample sizes, and the findings often were not supported in other small trials. Before a clear direction for practice can be supported, evidence showing more consistent effects of developmental care interventions on important short- and long-term clinical outcomes is needed. The economic impact of the implementation and maintenance of developmental care practices should be considered by individual institutions.

Perinatal risk factors and neuromotor behaviour during the neonatal period

Preterm birth is associated with an increased risk for neurological handicaps. The purpose of the present study has been: to investigate the influence of perinatal risk factors on early neuromotor development during the neonatal period; to specify the neuromotor parameters particularly sensitive to perinatal complications; and to analyse whether the infant's age at test influences the results. Beside examination of passive/active muscle tone and automatic movements (22 parameters) was performed at 36 (101 infants) and 40 (153 infants) gestational weeks. Low birthweight and long treatment on a ventilator had a negative influence on the neuromotor behaviour at 36 weeks' gestation and white matter disturbances strongly affected the neuromotor parameters at 40 weeks. The development of rooting, sucking, swallowing and arm recoil after long-lasting ventilator treatment was affected by several neonatal risk factors. The development of passive muscle tone and several parameters measuring active muscle tone demonstrated individual consistency between tests, i.e. an infant's rank at 36 weeks' gestation was unchanged 4 weeks later, and some other parameters were not as consistent. The present study shows that several perinatal risk factors influence neuromotor behaviour already during the neonatal period. In addition, the present study provides data on the neuromotor behaviour during the neonatal period that will be related to later neurodevelopmental examinations in order to evaluate the prognostic value of testing neuromotor development.

The optimality concept and its clinical value

To verify the clinical usefulness of the optimality concept in general and its prognostic value for later outcome, all babies born at all 14 maternity hospitals in Slovenia in the period from 1987 to 1991 (124,759 newborns) have been screened. In order to get an estimate of their condition Prechtl's original list of optimality has been adapted to 51 items representing mostly obstetric variables. The median of perinatal optimality scores for all newborns was 45 (six negative points) in mature, and 41 (10 negative points) in premature infants. Girls born at term scored better than mature boys, whereas there was no sex difference in the median score in prematures. Analysis of the data has shown that the majority of items which were non-optimal and which were associated with the greatest number of other non-optimal factors had to do with disturbances in oxygen supply. Children who developed cerebral palsy had a lower optimality score at birth than the remainder of the newborns. In these children the difference between the sexes is even more pronounced, to the advantage of the girls. Prematurely born children with spastic diplegia had a lower optimality score than mature children with diplegia. The opposite was noticed in children born prematurely and at term who developed spastic tetraparesis or dyskinesia. The present follow-up study has shown that predictions of disability were most accurate in the group of newborns who were clinically at risk at birth and who also had a low optimality score. The combination of both appraisals is the best way to identify newborns who need special attention.

Assessment of Sitting in Children with Cerebral Palsy from Videofilm

The purpose of this study was to investigate the reliability of two dependent measures, (1) counting of pathologic movements (CPM) and (2) the Sitting Assessments Scale (SAS). The measures were intended for use in clinical physiotherapy practice, to provide both quantifiable and qualitative information from videofilm concerning functional sitting in children with cerebral palsy (CP). Two separate groups of final term physiotherapy students (three students in each group) tested one technique each for interrater reliability. The SAS-measure also was tested for interrater reliability. Videofilm of twelve children with CP ranging in age from 2 to 16 years were assessed. The students' results were compared to earlier results by experiences physiotherapist. The results demonstrated excellent interrater reliability for SAS (p<0.001) and good interrater reliability for the CPM technique. The degree of user experience seems to play a role in the use of the CPM measure. Considering evaluation of postural control and functional performance over all, SAS appears to be superior to CPM.