Newborn Individualized Developmental Care and Assessment Program (NIDCAP)

Author DisclosureDr Westrup did not disclose any relationships relevant to this article.After completing this article, readers should be able to: The mortality among infants born preterm has decreased dramatically during the last decade in developed countries. The survival of very low-birthweight (VLBW) infants (<1,500 g) has increased from 50% (1) to more than 85% (2) since the initiation of neonatal intensive care in the early 1970s. However, a concomitant decrease in morbidity has not yet been documented conclusively. Pulmonary morbidity and neurodevelopmental outcome are the two major issues of concern. (3)(4) Employing the 1980 World Health Organization definition of disability, follow-up studies of VLBW infants have reported the incidence of disability to be 15% to 25%. (5)(6) A recent meta-analysis revealed that at school age, cognitive scores of former VLBW infants are approximately 10 points lower than those of matched control children (6) due to difficulties with attention, behavior, visual-motor integration, and language performance. (7)(8)Important factors related to mortality and morbidity are: gestational age, birthweight, sex, premature rupture of membranes, chorioamnionitis, and brain white matter injury. However, the intensive care environment and family involvement also affect neurodevelopmental outcome.The fundamental objective of developmental care is to support the development of the child. Thus, brain development is one of the key issues. Sensory input affects the wiring of neuronal networks and their mode of functioning as well as the behavior of the newborn. (9)(10)(11)(12) Infants born very prematurely may be overstimulated during a critical period when their brains are developing rapidly (FigureF1). In the germinal zone, neuronal multiplication and migration largely have been completed, but astrocytes still are being formed and subsequently migrating to upper cortical layers. Astrocytes destined for the white matter and the subcortical plate are derived from radial glial cells. During this same period, myelination begins, and naturally occurring neuronal death via apoptosis is more frequent than at any other time. (13) Up to 70% of the neurons in the human cortex undergo apoptosis between the 28th week of gestation and term. (14)Similarly, synaptogenesis in the brains of infants born very prematurely can be initiated after birth along with the growth of dendritic and axonal arbors. The volume of the cortical gray matter normally increases fourfold from the 30th to 40th weeks of gestation. (15) In the macaque monkey, a maximum of as many as 40,000 new synapses are formed every second in the visual cortex alone. (16) Wiring of neuronal circuits is regulated by endogenous factors as well as by sensory input and experience. (16)(17)In light of this extraordinarily rapid development, it is not surprising that the brain might be influenced negatively by preterm birth in a manner that could become increasingly severe with time if the proliferation of stem or progenitor cells is affected. Magnetic resonance imaging (MRI) of 8-year-old children who had been born preterm has demonstrated the presence of pronounced (12% to 35%) regional reductions in brain volume. (18) The extent of this reduction was correlated most strongly not with perinatal risk factors such as hemorrhage and severity of illness or with demographic factors such as sex or the level of maternal education, but with the degree of prematurity per se.Thus, the pain and discomfort caused by treatment and caregiving of VLBW infants during hospitalization is of considerable concern. These procedures make it difficult for such infants to experience undisturbed periods of restful sleep. For instance, during a 24-hour period in one investigation, it was observed that VLBW infants were handled an average of more than 200 times. (19) Furthermore, three of four hypoxemic episodes in preterm infants have been reported to be associated with caregiving, (20) and their circulating levels of stress hormones increase in association with routine nursing procedures. (21) In rodents, experience of pain during the neonatal period has been found to result in long-lasting enhancement of stress responses, (22) altered neural circuits, (23) learning deficits, and behavioral changes. (24) Similarly, variations in maternal care have been shown to promote synaptogenesis, learning, and memory (25) as well as to influence the expression of neuropeptide receptors related to normal gender-specific adult behavior. (26)Another key issue of developmental care is the importance of the role played by the family, as emphasized by the pioneering work of Klaus and Kennell. (27) Consequently, family-centered care has been strongly emphasized. (28) Minde and collaborators (29) have shown that neonatal illness may have a lasting negative effect on parent-infant interactions.Infants born at a very low birthweight are at high risk of receiving developmentally inadequate stimulation. (30) They are reported to demonstrate hypersensitivity to stimuli, greater difficulties in maintaining alertness, and a greater need for help to regain stability compared with term infants. (31)(32)(33) Preterm infants also are less responsive to interaction than are term infants and demonstrate lower levels of signaling. The difficulties involved in observing and interpreting these weak signals render the children more unpredictable for their parents and other caregivers. (29)In an attempt to address these different issues, Als and associates (34) have developed an early intervention program: the Newborn Individualized Developmental Care and Assessment Program (NIDCAP). The focus is respect for the individuality of the very tiny human being and his or her family. The program is based on the concept of newborn competence, which is conceptualized as the degree of smoothness and modulation, regulation, and differentiation of five different subsystems of functioning that are behaviorally observable: autonomic, motor, state regulatory or state organizational (ability to have well-defined sleep, awake, quiet, and crying states), attentional/interactional, and self-regulatory systems. The underlying concept is designated the “synactive theory” to emphasize the simultaneous maturation and mutual interplay of the different subsystems of behavior throughout development.The major instrument employed in the NIDCAP is repeated, formalized, naturalistic observations of the infant before, during, and after caregiving procedures (eg, feeding, collection of blood samples). These observations focus on efforts at self-regulation, as revealed by approach or avoidance behavior. When the sensory input is appropriate, the infant moves toward the stimuli and demonstrates self-regulatory behavior (ie, signs of neurobiologic stability). However, when the input is overwhelming because of too great intensity or inappropriate timing, the infant exhibits avoidance or stress behavior. In this context, the agreement between evaluations made by different observers has been reported to be greater than 85%. (35) Moreover, these behavioral signs recently were validated with a conventional pain assessment. (36) Current developmental goals for each infant are formulated on the basis of such observations. Caregiving plans, including recommendations concerning individualized care and environmental changes based on the current developmental stage of the infant and needs of the family, are designed. As the infant matures, the recommendations are modified appropriately.In addition, sensitive caregivers learn to watch carefully, note the reactions of the infant to different types of handling and care, and make appropriate adjustments continuously. Moreover, NIDCAP is family-centered. The goal is to empower the family by helping them develop appropriate care skills and techniques, thus including them as part of the health care team.Four randomized, controlled trials (RCT) have been published on the effects on VLBW infants of a full implementation of NIDCAP. (37)(38)(39)(40) In a meta-analysis, Jacobs and collaborators (41) reported separately on the earliest three RCTs and demonstrated a mean difference for days of mechanical ventilation of 25.7 days (95% confidence interval [CI]: 7.5 to 43.9) in favor of the intervention. A Cochrane Review (42) also reported a relative risk for the NIDCAP infants of moderate-to-severe pulmonary radiographic findings of 0.34 (95% CI: 0.15 to 0.81). In addition, our own calculations suggested the relative risk of intraventricular hemorrhages of grade III or more for the NIDCAP infants of 0.51 (95% CI: 0.23 to 1.1). The recently published three-site trial demonstrated very similar outcomes (TableT1). (40)Jacobs and coworkers (41) also reported a mean difference in the mental developmental index at 9 to 12 months of age of +16.6 (95% CI: 9.3 to 23.8) in favor of the NIDCAP infants. In this meta-analysis, the longest follow-up period of a single study was 2 years of corrected age. (43) The mental indices in this study were in favor of the NIDCAP group, but the difference was not statistically significant. However, because this study was not designed for the follow-up phase of the study, the power of the analysis was low. Furthermore, one third of the original sample was lost at the assessment.A recent report (39) from a 5-year follow up of the Swedish RCT demonstrates a significant impact on the NIDCAP group only in the behavioral aspect of development, with the odds ratio (OR) for surviving without abnormal behavior of 19.9 (95% CI: 1.1 to >100). The corresponding OR for survival without mental retardation was 3.5 (95% CI: 0.7 to >100) and without overall disability was 14.7 (95% CI: 0.8 to >100). No patients were lost in this follow-up, but because the original sample was small, the power was very low for detecting differences in this secondary outcome of the original study.Neurophysiologic functions have been assessed in three RCTs, and all revealed significant differences in favor of NIDCAP intervention. (37)(45)(46) Interestingly, in the study of the more mature, low-risk infants, the largest differences were observed in the frontal lobe area, where neuronal organization occurs relatively late. Moreover, the most recent study, employing quantitative three-dimensional MRI techniques and diffusion tensor imaging of the brain at term age, demonstrated beneficial structural changes in the NIDCAP infants compared with a control group in tissue distributions as well as in microstructural development of the white matter. (46)Very recently, a group from Edmonton presented preliminary short-term outcome data from a large NIDCAP RCT on VLBW infants that confirm the findings of significantly less mechanical ventilation, lower incidence of chronic lung disease, and shorter hospitalization noted in the earlier smaller trials. (47)In addition, studies on effects of NIDCAP components in specific caregiving situations have been reported. Sizun and coworkers (48) demonstrated decreased pain response and fewer hypoxic events during a routine nursing procedure in medically stable preterm infants. A preliminary report from the same group of investigators also indicated increased duration of sleep with NIDCAP. (49)NIDCAP is a multidisciplinary process involving not only medicine and nursing, but also family and developmental psychology. The aim of family-centered developmentally supportive care is, above all, to alter the focus from the traditional procedure-oriented emphasis on care to processes and relationships, including increased involvement of families. Such a philosophical goal is difficult to investigate with conventional scientific methods. Therefore, studies on NIDCAP to date have concentrated primarily on the postulated secondary effects on neonatal morbidity and developmental outcome.Evaluation of this holistic, highly complex intervention is fraught with a number of methodologic problems. One obstacle is the shortage of certified NIDCAP practitioners, although this situation has improved considerably since the first study in the mid-1980s. Furthermore, how can the quality of the intervention be monitored? Is a newly certified NIDCAP observer as good as one who has 1 or 2 years of experience? How long does it take for a nursery to make the necessary physical arrangements and acquire enough knowledge to implement the recommendations of the NIDCAP observer adequately?Because of the relatively low incidence of extreme prematurity, multicenter trials are necessary, but how can we control for other differences in clinical and nursing practices in the various nurseries? Considering the altruistic overall aim of NIDCAP, how can the issue of a control group be addressed from an ethical point of view? Is there a commonly accepted definition of traditional/conventional care that will remain static during the relatively long time period required for a NIDCAP study? NIDCAP intervention cannot be performed “blindly” and lasts for months, creating a risk for a “spillover” effect onto the control group. In the real life of a nursery today, it is impossible to avoid having “control” nurses take shifts in the NIDCAP room and vice versa. Moreover, parents share experiences with each other and actively seek knowledge designed to improve the treatment of their infants. In short, in studies of the present type, it is extremely difficult to achieve an infallible traditional experimental design. The complexity of developmentally supportive care and its demand for comprehensive training has raised some concern about its cost-effectiveness. (42)(50) Achieving certification as an NIDCAP observer requires an investment of approximately $5,000 in training fees alone.In a Swedish study, the total additional nursing time needed for 10 once-weekly observations of an infant born after 27 weeks of gestation corresponded to a cost of $1,000. On the other hand, it was estimated that hospital charges were reduced by approximately $10,000 per infant due to the reduced requirement of ventilatory assistance. (39) Other groups have reported that NIDCAP reduces costs by $4,000 to $120,000 per infant, depending on his or her birthweight and initial degree of illness. (37)(38)(51)(52)(53) Interestingly, after completing the large RCT in Edmonton, it was decided to train a large number of additional nurses and to implement NIDCAP throughout their services (personal communication); in Sweden, where the program was introduced in the early 1990s, approximately two thirds of all nurseries, including all university sites, now have trained or are training staff.A Swedish staff survey indicated that the “environmental” changes made in the neonatal unit in connection with the implementation of NIDCAP are not in themselves sufficient to explain the improvement observed. (54) During periods without NIDCAP observations, we have observed a decline in the quality of care. Thus, regular observations appear to be essential, although the frequency of such observations remains to be determined.Concerns also have been expressed that implementation of NIDCAP requires extra nursing time (in addition to the time spent with observations). However, it is our experience that NIDCAP increases the competence of both staff members and parents. Consequently, caregiving is adjusted specifically to the current medical and developmental status of the infant. It might be speculated that the caregivers become more skilled in detecting changes in the infant’s status at an earlier stage, allowing prompt intervention and prevention of further deterioration. In this way, the infants become more physiologically stable and actually require less nursing time, which is in agreement with the findings of others. (53)(55)As described by Als and Gilkerson, (56) successful implementation of developmentally supportive care requires full commitment from personnel at all levels. The model requires a flexible mind that can assess continuously the infant’s physiologic and behavioral needs. In addition, it requires a flexible organization that allows the caregiver to adapt caregiving to these needs. Thus, NIDCAP involves a highly coordinated approach to care that crosses discipline and shift boundaries. Caregiving becomes more process-guided, rather than task- or procedure-oriented.NIDCAP often requires a change in how people think and relate to one another. We have found this to be challenging for some people, especially those whose identity is linked substantially to competence in the areas of science and technology. This complex process requires a considerable degree of maturity and courage among both the staff and the leadership of the unit. This certainly also applies to the agent of change (ie, the developmentalist), who needs to be supportive to people at all levels in the organization from the patients to the director.In addition, it is important to emphasize that not all personnel are suited to become NIDCAP observers. It requires substantial sensitivity to interpret the subtle signs of a preterm infant and psychological skill to interact with the staff and parents in such a manner that they feel supported and not criticized.Moreover, implementation of developmental care in the hands of an unskilled person involves the potential risk of overemphasizing “protection” of the infant (ie, forgetting the individualized portion of the program). NIDCAP should not be implemented without careful individualized assessment by completely covering the incubator of an infant who is still unstable, thereby preventing necessary surveillance; by building a containing environment for the infant that is overly rigid; and by overprotecting a stable, competent baby from visual, auditory, and stimuli, thus the development of his or her to and interact intervention should be designed from the of each infant, to the light of all the including the infant’s medical is appropriate for a infant at a rapid development of in neonatal medicine has been and will to be fundamental for the improvement of the care of infants born this in some to a with the of such care. has addressed this in his for a Care in which the concept of the to and preterm we that on respect for the very tiny and often human being and his or her family not only is for the further improvement of medical care and developmental as but is important from a point of by NIDCAP could be a very in the Care The basis of developmentally supportive care is that the newborn infant is a human being in his or her own and of caregivers to be by the current needs of the infant and family. Care and intervention based on the infant’s own behavior make good and are from an ethical point of the behavior of the infant to be an with a and not as by As expressed by infant is an who regulatory and behavior of the infant is its to (34) Furthermore, for most neonatal intensive care unit care a new and to their work is as a development.The developmentally supportive care is by from scientific including developmental and family and However, the of NIDCAP involves a considerable investment at all levels of the NIDCAP requires some physical changes in the as well as substantial efforts and changes in the of care. The findings of the presented NIDCAP studies have been and NIDCAP has been very well by nursing and parents. It also is from an ethical point of It to that implement NIDCAP and investigate developmentally supportive care in different and with multicenter trials.

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