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Developmental Enhancement: Implementing a Program for the NICU
Developmental Intervention of Low Birth Weight Infants: Improved Early Developmental Outcome
Effects of Developmental Care on Behavioral Organization in Very-Low-Birth-Weight Infants
Individualized Developmental Care for the Very-Low-Birth-Weight Preterm Infant
Outcomes of Developmentally Supportive Nursing Care for Very Low Birth Weight Infants
Authors
Grunwald, Becker
Description
This is a description of the process by which a program of developmentally
supportive care was successfully implemented in an NICU. There is
also a brief summary of some preliminary results of an associated
research project looking at the impact of this program on the outcome
of the NICU infants.
Methods
- Obtained nursing support and the ability to add a formal component of nursing research to the program.
- Established a developmental resource team to assume responsibility for program development and implementation.
- Utilized NIDCAP model as primary model.
- Developed program goals
- Developed written standards of care
- Staff education on program philosophy, goals and theoretical basis,
information on
behavior and development and specific changes for nursery environment
- Developed and purchased support materials - incubator and crib covers, positioning and nesting aids, clothing to facilitate dressing and swaddling.
Results
- The majority o the staff enthusiastically supported the program and actively worked to change unit routines and their own caregiving practices.
- Problems required open communication and problem-solving by involved staff members.
- Physicians did not interfere with program implementation, but also have not all enthusiastically supported it. Case-by-case problem-solving and general discussionhave usually been successful in resolving specific issues.
- The best way to deal with conflict situations was to allow time for staff members to adjust to changes in practice.
- Developed a booklet for parents on interpreting infant behavior and needs.
Conclusions
This approach to nursing care has had a positive influence on recovery
and development of infants in the NICU. Infants who received developmental
care indicate that they did better in terms of respiratory status,
feeding skills and behavioral organization than infants assessed
before implementation of the program. They were also discharged an
average of two weeks earlier. On the basis of informal feedback,
it has helped nurses feel good about the special care that they provide
for these infants.
Summary
This approach to nursing care has had a positive influence on recovery
and development of infants in the NICU. Infants who received developmental
care indicate that they did better in terms of respiratory status,
feeding skills and behavioral organization than infants assessed
before implementation of the program. They were also discharged an
average of two weeks earlier. On the basis of informal feedback,
it has helped nurses feel good about the special care that they provide
for these infants.
Authors
Resnick, Eyler, Nelson, Eitzman, Bucciarelli
Description
This is a prospective, longitudinal study of experimental and control
groups designed to evaluate the effects of a multidisciplinary infant
program on mental and physical development of low birth weight infants.
Methods
LBW infants between 500 and 1800 grams in the NICU were assigned
to a traditional control group or an experimental Infant Developmental
Program (IDP) group by even-odd number randomization. The IDP group had
124 infants, and the control had 131. Follow-up was done at one and two
years in an outpatient clinic. The IDP was interdisciplinary from psychology,
nursing, OT and early childhood education. Activities in the NICU were
done in 2, 20-minutes sessions per day to promote visual, auditory, tactile,
kinesthetic and personal-social development. Parent counseling and education
began after admission and continued at home for two years after discharge.
Results
- There were no differences in groups per birth weight, gestational age, hospital days, race, or sex.
- There were 17 deaths in each group brining the final numbers to 107 and 114.
- In the IDP group, there was a significant decrease in the incidence of developmental delay, and they scored significantly higher on mean physical and mental indices of the Bayley exam at 12 and 24 months adjusted age.
Conclusions
The results support a family-centered model of early developmental
intervention based on prevention of developmental problems related
to low birth weight.
Summary
The results support a family-centered model of early developmental
intervention based on prevention of developmental problems related
to low birth weight.
Authors
Buehler, Als, Duffy, McAnulty, Liederman
Description
A preterm control group received standard care and a preterm experimental
group received individualized developmental care at a university-affiliated
teaching hospital. Twelve health full term infants and 24 preterm
infants were randomly assigned to the control or experimental group.
Methods
Groups were assessed in terms of medical, behavioral and electrophysiological
outcomes at two weeks post-EDC. After discharge, medical records were
reviewed by trained research staff blinded to the group status. Behavioral
outcome was evaluated with the APIB and the Neurological Exam of the
Full Term Newborn Infant. Quantitative EEG with topographic mapping was
performed.
Results
- Age at assessment was comparable for the three groups. The two preterm groups were comparable on all medical, family background, pregnancy and delivery indices except that the experimental group was initially more at risk with greater degree of complications and higher oxygen requirements.
- None of the medical outcome measures showed significant between-preterm group differences. At two weeks post-term there were no significant weight differences between the two preterm groups and the full term group.
- The preterm control group showed the least well-organized behavioral performance whereas the preterm experimental and full term groups were behaviorally comparable with respect to autonomic, motor and attentional indices.
- There were no significant pairwise differences between the preterm experimental group and the full term group.
- Preterm controls showed the poorest performance on an additional 5 of 18 APIB summary variables.
- Electrophysiologically, there were differences in 41 regions. The area most frequently involved was the frontal lobe. 28 showed significant correlations with the APIB - 13 of these were between the frontal lobe features and the APIB variables measuring attentional control and state organization.
Conclusions
Individualized developmental intervention supports neurobehavioral
functioning as measured 2 weeks post-term. It appears to prevent
frontal lobe and attentional difficulties, the possible causes of
behavioral and scholastic disabilities often seen in low-risk preterm
infants at later ages.
Summary
Individualized developmental intervention supports neurobehavioral
functioning as measured 2 weeks post-term. It appears to prevent
frontal lobe and attentional difficulties, the possible causes of
behavioral and scholastic disabilities often seen in low-risk preterm
infants at later ages.
Authors
Becker, Grunwald, Moorman, Stuhr
Description
This was a continuation of the previous phase-lag randomized study.
The purpose of this part was to determine whether infants receiving
developmental care would show more optimal oxygen saturation levels,
more organized flexor and less disorganized jerky movements, more
time in flexed than extended posture and more time in low arousal
than high arousal states in early weeks and more time in alert-wake
states in later weeks. The convenience sample of infants from the
previous study was used. Oxygen saturations were recorded by direct
observation. Motor activity was coded as general, disorganized and
flexor movements. The predominant quality of motor activity was rated
every 2 minutes. Posture was rated as predominantly extended, flexed,
or mixed. Behavioral states were quiet sleep, active sleep, sleep-wake
transition, drowse, non-alert-wake, diffuse alert and alert-awake.
Control infants were assessed prior to the institution of the developmental
program and the study group afterward. The same recording procedure
was used as previously described.
Results
- Oxygen saturations were significantly higher for the study infants at 30 and 34 weeks.
- The percent of time during which movements were rated as disorganized and the frequency with which discrete jerky movements occurred were lower for study infants due to differences at 30 weeks, while flexor movements were higher at 32 and 34 weeks.
- The amount of diffuse alert state was greater in the study infants than the control due primarily to a difference at 34 weeks. Across time, active sleep decreased and both alert states increased in both groups.
Conclusions
The pattern of results seems to indicate that developmental care may
be an effective approach to improving early physiological and behavioral
organization among very low birth weight infants.
Summary
The pattern of results seems to indicate that developmental care may
be an effective approach to improving early physiological and behavioral
organization among very low birth weight infants.
Authors
Als, Lawhon, Duffy, McAnulty, Gibes-Grossman, Blickman
Description
The purpose of this study was to test the impact of individualized
developmental care with the use of a more rigorous design with random
assignment and initiation of intervention at the time of admission.
Methods
38 infants were enrolled who were consecutively admitted on
a 21 month period to a level III NICU. They were < 1250 grams, 24-30
gestation, ventilated within first three hours of birth for > 24 hours
in the first 48 hours and alive at 48 hours. Group status was determined
by sealed envelope random assignment. Experimental treatment consisted
of staffing by specially educated nurses who were with the patient for
at least one shift in a 24 hour cycle from admission. Formal observations
of the infant's behavior were conducted within 12 hours of admission
and every 10th day through discharge. Infant responses were systematically
recorded for 20 minutes before care giving, during, and for 20 minutes
after. They were used to formulate neurobehavioral reports including
specific suggestions for ways to promote stability and competence in
regulating themselves. The control group received standard care. Medical
and developmental outcomes at 2 weeks and 9 months post-EDC were evaluated.
Blinded chart reviewers collected the medical background variables. Developmental
outcome was evaluated at two weeks post-EDC with the APIB, a quantified
EEG, evoked potentials with topographic mapping. At nine months, it included
the Bayley and a videotaped 15 minute play observation.
Results
- There were no differences in background measures between the two groups.
- Of the 12 medical outcome variables, 8 were statistically significantly different favoring the experimental group - shorter duration of ventilation and oxygen support, earlier oral feeding, reduced incidence of IVH, pneumothorax and severe BPD, improved daily weight gain, shorter hospital stays, lower postconceptional age at discharge and reduced hospital charges.
- At two weeks post-EDC, 3 of 6 APIB system scores were significantly different, all favoring the experimental group. Also 4 of 8 summary variables favored the experimental group, and there were a significantly decreased number of abnormal reflexes.
- Neuroelectrophysiological testing showed five regions of significant differences. By 9 months post EDC, the experimental group had significantly higher MDI and PDIs on the Bayley and 17 of 20 variables measured in the video - play favored the experimental group.
Conclusions
The study suggests that for the VLBW, initially ill preterm infant,
individual developmental care improves outcomes medically and developmentally.
The results validate and extend the findings of the initial studies.
Summary
The study suggests that for the VLBW, initially ill preterm infant,
individual developmental care improves outcomes medically and developmentally.
The results validate and extend the findings of the initial studies.
Authors
Becker, Grunwald, Moorman, Stuhr
Description
The purpose of this study was to investigate whether individual developmental
care implemented through the program described in the previous paper
by these authors could significantly improve the short-term outcomes
during hospitalization and the behavioral organization at discharge.
A phase-lag design was used before and after implementation of the
program. Progress for the control group was monitored until the last
infant was discharged and then the second study group was monitored
through discharge of the last patient.
Methods
Infants less than 1501 grams and AGA were consecutively enrolled
as they were admitted to the NICU. There were 21 infants in the control
group and 24 in the developmental care study group. Measures were taken
of the frequency of nurse actions designed to facilitate the infants'
physiological and behavioral organization during care procedures and
of the noise and light environment. Specifically, the mean duration of
discrete facilitating actions that occurred during 18 minute observations
were recorded. These included provision of physical support, containment
with hands or swaddling, provision of aids for self-regulation, support
for flexed positioning and offering a pacifier. Noise and light levels
were assessed with a sound meter and a remote sensor light meter. Infant
status was assessed with a set of medical, growth and behavioral measures.
Behavioral organization at discharged was assessed with the NBAS, including
supplementary scales for evaluation of premature infants.
Results
- Patient-staff ratios, primary to non-primary nurse ratio and activity levels did not differ between study and control patients.
- Overall, noise and light levels were lower in the study group.
- The number of facilitating actions was higher during the study period for each gestational age grouping.
- Scores for the study group were significantly better for the level of morbidity over the first four weeks. And were more favorable for the level of morbidity for the entire hospital stay and total days on the ventilator.
- There were fewer infants on oxygen 28 days or more in the study group and fewer with both Grades I - II and III - IV IVH, but this did not reach significance.
- The age at the first oral feed and the last gavage feed were lower for the study patients and weight gain was greater but not significantly so. Length of stay was two weeks less for the study patients.
- The total NBAS score was significantly better for the study infants. The reflex score and supplementary scale for self-regulatory capacity were higher but not significantly so..
Conclusions
The findings extend previous studies showing beneficial effects of
developmental care. This can be achieved by the use of resources
available to most nurseries. The cost savings for the two week shorter
stay was about $12,250 in base hospital rate per infant, but this
does not include charges for medications, treatments or professional
fees.
Summary
The findings extend previous studies showing beneficial effects of
developmental care. This can be achieved by the use of resources
available to most nurseries. The cost savings for the two week shorter
stay was about $12,250 in base hospital rate per infant, but this
does not include charges for medications, treatments or professional
fees.
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