Elsevier

Early Human Development

Volume 89, Issue 9, September 2013, Pages 755-762
Early Human Development

Early communication in preterm infants following intervention in the NICU

https://doi.org/10.1016/j.earlhumdev.2013.06.001Get rights and content

Abstract

Background

Despite ongoing improvements in clinical care, preterm infants experience a variety of stressors in the first weeks of life, including necessary medical procedures, which may affect development. Some stress-reduction programmes based in the Neonatal Intensive Care Unit (NICU) have reported a positive impact on development. In particular, trials of the Mother–Infant Transaction Program (MITP) have shown positive short and longer term effects, and are based on training parents to recognise and minimise stress responses in preterm infants.

Aims

To evaluate the impact on early developmental milestones of an enhanced MITP (PremieStart) delivered over an extended period in the NICU.

Study design

This was a parallel 2-group randomised controlled trial involving 109 women with 123 infants born at < 30 weeks gestation assessed initially at term-equivalent age and then at 6 months' corrected-age.

Results

Intervention mothers were more sensitive in providing infant care, stressed their infants less, showed greater awareness of, and responded more appropriately to, negative infant cues (p < 0.05 in each case). Intervention infants displayed significantly lower stress when being bathed by mothers at term-equivalent age (p < 0.05). At 6 months corrected-age, intervention infants showed higher mean scores on the Communication and Symbolic Behavior Scales Developmental Profile Infant–Toddler Checklist. The strongest effects appeared in Symbolic behaviour (p = 0.05) and this was reflected in the Total score (p < 0.05).

Conclusions

As significant cognitive and language deficits are reported in longitudinal studies of preterm children, an intervention that improves early infant communication abilities is promising, especially since previous research suggests that the strongest benefits may emerge at later ages.

Introduction

Preterm infants face long-term developmental difficulties across many functional domains. Despite substantial improvements in survival rates, the incidence of preterm birth has shown a steady rise in Western countries [1]. Meta-analyses of studies of very preterm infants (< 32 weeks gestational age) have found moderate-to-severe effects to school age on academic achievement, attention problems, behavioural problems and executive functioning (e.g. [2]) as well as motor impairment [3]. In a recent cohort study of 7650 children, a decrease was found in overall achievement, including mathematical abilities, social relationships and emotional development by early school age, all correlated with the level of prematurity [4].

Poor development may in part be exacerbated by the experience of acute and chronic stressors in the Neonatal Intensive Care Unit (NICU), including overstimulation and necessary medical and nursing procedures [5], [6], [7]. To address this, a number of early interventions have been developed to protect the preterm infant from stress. These are either delivered in the NICU by nursing, allied and medical staff (e.g. ‘Developmental Care’ which aims to minimise medical and nursing stressors) or via training of parents to recognise and minimise signs of infant stress. Furthermore, amongst parent-training interventions, some begin during the infants' hospitalisation and some within the first post-discharge year of life. The parent-training approach stems back to a landmark study [8], [9] of the Mother–Infant Transaction Program (MITP), a major focus of which is sensitising parents to infant cues, in particular those which signal “stimulus overload, distress, or readiness for interaction”. The MITP began during the babies' hospitalisation in the NICU and extended after discharge. Children's development was followed longitudinally and a difference of 10.6 IQ points was demonstrated favouring intervention infants at 9 years of age, but this group difference only began to emerge after 2 years of age.

The longer-term efficacy of this intervention has resulted in several research groups using MITP-type interventions and replicating positive results on cognitive development up to 5 years of age [10]. At least two studies using MITP-type interventions are in the follow-up stage [10], [11], [12], [13], [14], [15] and improvement in some earlier indices of child development is also emerging [16]. In our first application of an enhanced version of the MITP (the PremieStart programme) we extended the length of intervention and included additional targets (see Methods below). Following the first trial of PremieStart we found early communication abilities to be better developed in children of intervention mothers at 3 months corrected-age [17].

Such gains may be due to a direct effect of early stress reduction in promoting early brain development. A small number of intervention studies suggest such an effect. Using our PremieStart programme in a previous randomised trial, we found enhanced white matter connectivity at term-equivalent age [18]. This is consistent with the findings of McAnulty and colleagues [19] who found enhanced neurobehavioural scores, more mature cerebral white matter at 2 weeks corrected-age (CA) and behavioural advantages at 9 months of age in preterm infants who had received NIDCAP (Newborn Individualized Developmental Care and Assessment Program). Subsequent controlled trials of NIDCAP, delivered by nurses, have demonstrated associations (through electro-encephalography) of improved connectivity between temporal regions measured at term-equivalent age and at 8 years of age in intervention children [20]. Furthermore, very early brain structure and brain connectivity in preterm infants are known to correlate with later child outcomes [21], [22], [23].

Here we report on the earliest results from a second, larger, randomised controlled trial of PremieStart, which is currently the subject of a longer-term follow-up. The primary outcome of interest in the overall trial is the impact of the intervention on child's cognitive and behavioural development at 2 years of age. Earlier proxies of development at 6 months, along with short-term medical data, are reported in the present paper. We also report data on the efficacy of the intervention in enhancing maternal sensitivity and reducing signals of infant stress. Our main hypothesis was that the PremieStart intervention would result in improved outcomes for preterm infants compared with a control group receiving standard clinical care. Specifically, we predicted that compared to controls, the intervention group would show:

  • 1.

    Improved short-term measures of medical stability.

  • 2.

    Improvement in early communication abilities and behaviour.

Section snippets

Design and sample

The study was a parallel, two-group randomised controlled trial (RCT) of an enhanced MITP intervention (PremieStart) versus standard care (Trial Registration Number: ACTRN12606000412538), which was approved by the Human Research Ethics Committees of the Royal Women's Hospital and the Mercy Hospital for Women, both located in Melbourne, Australia. Between April 2007 and September 2009, women who delivered at < 30 weeks gestation were enrolled at the NICUs of both hospitals when infants were 30–32 

Sample

In total, 732 women (with 852 infants) were screened for eligibility by the end of the study recruitment period (Fig. 1). Screened infants had an average gestational age of 27.4 weeks and an average birth weight of 1014 g. Three hundred and seventy eight women met exclusion criteria (> 100 km from central Melbourne, n = 185; treating clinician judged infant/mother too severely ill/medically unstable, n = 76; non-English speaking, n = 32; drug and alcohol issues, n = 27; other, n = 43; multiple criteria, n = 

Discussion

Cognitive deficits, including language delay, are common problems in children born very preterm [34]. Such adverse developmental outcomes in preterm infants may be exacerbated by environmental stressors. We hypothesised that training parents of preterm infants in stress reduction in the NICU can protect infants.

We found that our parent-training programme, PremieStart, was successful in enhancing maternal sensitivity to infant cues, replicating our previous findings [17]. In the current study,

Conflict of interest statement

The authors declare no conflicts of interest.

Acknowledgements

We thank the families who took part in this study. The work was supported by a Project Grant from the National Health & Medical Research Council (ID: 364902). The funding body had no role in the study design, collection, analysis and interpretation of data; in the writing of the manuscript; or in the decision to submit the manuscript for publication. Dr Justin Biltsza generated the secure allocation schedule and translated it to sequentially numbered sealed envelopes. Thanks also to Dr

References (46)

  • K.S. Olafsen et al.

    Maternal ratings of infant regulatory competence from 6 to 12 months: influence of perceived stress, birth-weight, and intervention: a randomized controlled trial

    Infant Behav Dev

    (2008)
  • K.S. Olafsen et al.

    Regulatory competence and social communication in term and preterm infants at 12 months corrected age. Result from a randomized controlled trial

    Infant Behav Dev

    (2012)
  • N.M. Kyno et al.

    Effect of an early intervention programme on development of moderate and late preterm infants at 36 months: a randomised controlled study

    Infant Behav Dev

    (2012)
  • US Department of Health and Human Services Centres for Disease Control

    National vital statistics reports: births: final data for 2004

    (2005)
  • C.S.H. Aarnoudse-Moens et al.

    Meta-analysis of neurobehavioral outcomes in very preterm and/or very low birth weight children

    Pediatrics

    (2009)
  • J.F. de Kieviet et al.

    Motor development in very preterm and very low-birth-weight children from birth to adolescence: a meta-analysis

    JAMA

    (2009)
  • M.A. Quigley et al.

    Early term and late preterm birth are associated with poorer school performance at age 5 years: a cohort study

    Arch Dis Child Fetal Neonatal Ed

    (2012)
  • H. Als et al.

    Early experience alters brain function and structure

    Pediatrics

    (2004)
  • G.C. Smith et al.

    Neonatal intensive care unit stress is associated with brain development in preterm infants

    Ann Neurol

    (2011)
  • T.M. Achenbach et al.

    7-Year outcome of the Vermont Intervention Program for low-birthweight infants

    Child Dev

    (1990)
  • S.M. Nordhov et al.

    Early intervention improves cognitive outcomes for preterm infants: randomized controlled trial

    Pediatrics

    (2010)
  • S.M. Nordhov et al.

    Early intervention improves behavioral outcomes for preterm infants: randomized controlled trial

    Pediatrics

    (2012)
  • P.I. Kaaresen et al.

    A randomized, controlled trial of the effectiveness of an early-intervention program in reducing parenting stress after preterm birth

    Pediatrics

    (2006)
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