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While the best way to decrease developmental and physical morbidity due to prematurity would be to reduce the number of such births, our current understanding of the causes of pre-term delivery is too limited to make this feasible. However, there are a number of promising avenues for mitigating adverse outcomes.
First, whenever possible, pre-term infants should be delivered in a hospital equipped to deal with both mother and infant to ensure high quality health services and reduce the risk of complications. Second, continued attention is needed to support normal physical and psychological development in the intensive care unit, for example by ensuring that the infant is not overexposed to loud noises or intense light. Finally, continued attention is needed to identify appropriate support measures for the family during and after the infant’s stay in the intensive care unit.
Two of the most thoroughly researched family-centred interventions for pre-term infants are the Newborn Individualized Developmental Care and Assessment Program (NIDCAP), which starts at birth and ends at hospital discharge, and the Infant Health and Development Program (IHDP), which begins at hospital discharge and ends at the child’s third birthday.
The goal of NIDCAP is to prevent unexpected sensory overload and pain, and enhance strengths and competence. The approach focuses on a detailed reading of each individual infant’s behavioural cues. Repeated formalized observations of the infant’s reaction to different types of stimulus (e.g. caregiving,) are used to help caregivers make appropriate and continuous adjustments. Environment and care are adapted to enhance each infant’s strengths and self-regulation collaboratively with the infant and parents, who play the primary role in providing daily nurturance and helping their infant develop trust.
The program has shown positive effects on indices of infant health, with some studies reporting improved lung function, feeding behaviour and growth, and shorter hospital stays. There have also been reports of positive effects on cognitive and behavioural outcomes, as well as on the brain structure itself, still in development at this early age. Because it helps lower parental stress and enhances parental competence, NIDCAP is also likely to foster more functional mother-infant relationships and better parenting. This may in turn have an impact on the developing brain, enhancing the child’s cognitive, motor, behavioural and psychosocial development later in childhood. Randomized control studies on NIDCAP should focus on assessing these outcomes.
Introduction of NIDCAP, however, is not a trivial process and involves investment at all levels of the organization, from physical changes in the neonatal intensive care unit to substantial educational efforts and changes in the practice of care. As well, the complexity of the intervention makes it difficult to achieve an optimal experimental design for evaluation.
The Infant Health and Development Program (IHDP) was a multi-site, randomized clinical trial carried out in the United States in the late 1980s, aimed at reducing developmental problems in premature infants. It sought to enhance parenting resources for families and the development status of infants by providing pediatric, educational and family support services (e.g. home visiting, educational programs, support groups for parents). By teaching appropriate developmental stimulation and interactional skills, the goal of the program was to maximize positive social interactions between the child and his or her care-giving environment within the first three years of life.
At age three, when the intervention ended, results showed that the IHDP was effective in improving cognitive and behavioural development, especially for the heavier infants (those weighing between 2001 and 2500 grams at birth) and those at higher socio-economical risk. Fewer behavioural problems, more pro-social and mother-infant interactions, as well as better parenting skills were found. The effects appeared to have attenuated by five and eight years of age, although this may have been because families living in poverty were unable to sustain the enriched environmental supports needed.
It is unlikely that any single intervention would developmentally “inoculate” a child permanently. The combined action and interaction of multiple factors – biological and socio-environmental –need to be taken into account. The research suggests that there needs to be a commitment to a developmentally sensitive continuum of support from birth through adolescence.
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