Care of Preterm Infants in the Neonatal Intensive Care Unit (2009)

Technologic and pharmacologic advances in neonatal intensive care and their impact on short-term and long-term outcomes have been the major focus of neonatal clinical research. Neonatal mortality reached an unsurpassable minimum by the late 1990s. However, this has been associated with high rates of neonatal morbidity and neurodevelopmental impairment.1Extremely preterm infants, many of whom spend months in the NICU, are exposed to an environment very different from that in utero. This environment includes prolonged periods of light, unnatural noise, repeated disturbances, and discomfort and pain from caretaking procedures. Thus, attempts have been made to modify the NICU environment and infant experience. The Newborn Individualized Developmental Care and Assessment Program (NIDCAP) introduced by Als et al2 in the mid 1980s is unique in that it uses a combination of strategies to decrease the stress associated with NICU care. The program includes control of external stimuli (auditory, visual, and tactile), positioning, and clustering of nursery activities on the basis of an assessment of each infant's behavioral needs. One of the hypotheses of NIDCAP care is that, in addition to providing a more humane type of care, it may also improve later neurodevelopmental outcome.3In this issue of Pediatrics, Maguire et al4 report on the results of a randomized, controlled trial of NIDCAP developmental care on the outcomes of Dutch infants born at <32 weeks’ gestation. The results indicate that the NIDCAP intervention had no effect on growth, neurologic status, or mental and psychomotor scores on the Bayley Scales of Infant Development at 1 and 2 years’ corrected age. This is the largest study performed to date, with 84 infants receiving the NIDCAP intervention and 84 infants receiving only incubator covering, “nests,” and positional aids. The population was fairly low risk, and the children had Bayley mental scores within the normal range. The neonatal course was similar between groups with the exception that those in the intervention group required significantly more indomethacin and/or surgery to close a patent ductus arteriosus. Although a patent ductus arteriosus, per se, has not been reported to be associated with poorer later outcomes, neonatal surgery has been implicated in this regard and could possibly have influenced the results.5 No information, however, is given as to the numbers of children who required patent ductus arteriosus ligation in each group.The literature on the effect of the NIDCAP on neurodevelopmental outcomes, summarized in a Cochrane review in 2006,6 has been sparse and conflicting. Previous studies included fewer than 50 children in the intervention group, and the 3 studies that had follow-up to ≥2 years of age similarly found no effect of the NIDCAP on cognition or motor function.7–9Neurodevelopment has traditionally been used to examine the longer-term outcomes of randomized perinatal interventions.10 However, I question whether this is the appropriate outcome measure for an intervention that aims to reduce stress and promote physiologic stability and well-being of the infant. An infant who is repeatedly manipulated, uncomfortable, or in pain may have fluctuations in respiration, heart rate, and blood pressure that could potentially affect cerebral blood flow and predispose to hypoxic ischemic injury. NIDCAP trials, however, have not demonstrated a decrease in such injury.6 Furthermore, any potential long-term positive effect of the NIDCAP, even behavioral, may be overwhelmed by other factors that affect child development, especially those associated with other neonatal risk factors as well as sociodemographic and individual parental and genetic effects. The fact that the NIDCAP might not improve neurodevelopmental outcomes does not, however, detract from the importance of its approach to the care of infants in a NICU. Over the years, Dr Als and her supporters have popularized the components of care included in the NIDCAP, and through her work these are applied by nurses and parents in NICUs worldwide, although the full NIDCAP protocol might not be used. Through this approach critically ill preterm infants are treated as we ourselves would hope to be treated in similar situations.