Early developmental screening and intervention for high-risk neonates - From research to clinical benefits
Introduction
Early identification of infants at high-risk of developmental delays and/or impairment is an important component of neonatal care [1]. Not only is it important to identify impairments early in development to ensure early intervention can commence in a timely manner, but it is also important for counselling and supporting parents [2]. Recent research has assisted with the identification of which infants are considered high-risk of developmental delay and/or impairments [3]. Moreover, there is mounting evidence for early interventions to improve outcomes of these infants [4,5]. Over the past decade, the implementation of research findings into clinical practice for some high-risk infant groups, such as those born very preterm (<32 weeks’ gestational age), having better access to developmental screening and early intervention [6,7]. However, there are many high-risk infants who are still not receiving timely access to developmental screening and early intervention; in part as a consequence of varying clinical practice recommendations throughout the world [3,8,9]. In this review we will discuss which infants are considered high-risk for developmental delay and/or impairment, the role of research in informing which high-risk infants should receive developmental screening and intervention, what areas of development should be assessed during the early years (up to age 2), and the challenges of implementing evidenced-based medicine into practice in this field. Further, we will discuss future research directions including the cost-effectiveness of developmental screening and early intervention.
Section snippets
Which infants are considered high-risk?
The American Academy of Pediatrics defines four broad categories of high-risk neonates including: i) infants born preterm (<37 weeks' gestation), ii) infants with special health care needs or dependence on technology, iii) infants at risk due to social issues and iv) infants where early death is anticipated [10]. For the purpose of this review we will focus predominantly on infants born preterm, as they make up the greatest proportion of high-risk neonates and the majority of research to date
What areas of development should we screen for in infancy?
Care should continue well after discharge from the NICU. It is crucial for NICU graduates to have access to comprehensive long-term follow-up, and timely targeted developmental interventions. Independent groups of international experts from the USA, UK and Australia/New Zealand recommend that longitudinal follow-up of these at-risk EP/VP infants should be considered as a standard of care [3,8,14]. Whilst there are some common recommendations for follow-up by these expert groups, there are
Early intervention for infants to improve developmental outcomes
Early developmental interventions have be trialled for many years but implementation into clinical practice is variable with many preterm infants never receiving any intervention [5,32,33]. This is despite guidelines by Wang et al. in the USA recommending that early intervention is commenced within two months of a developmental delay/impairment being identified [14]. Further, early intervention can actually commence whilst infants are still in hospital. Rather than waiting until developmental
Early intervention for parents to improve psychological adjustment following birth of high-risk infants
It is important to work closely with parents and caregivers, where possible, including after discharge from the NICU. When considering early developmental screening and interventions it's essential to consider parental well-being [2]. Parents of infants at high-risk of developmental delay/impairment are themselves at risk of poorer psychological outcomes including symptoms of depression and anxiety [36,37]. Further, poorer parental mental health is associated with worse infant outcomes,
Challenges of developmental follow-up and early intervention in clinical practice
High attrition rate of clinical follow-up remains a significant hurdle to overcome. In a retrospective study by Orton and colleagues(40), there was a substantial difference in follow-up rates of children at a single tertiary center, with follow up rates of up to 98% for infants who were enrolled in a research program, compared with 32% for infants who returned for a standard clinical follow-up. Similar results were reported by The New England follow-up network with follow-up rates of 52%
Future research
The cost-effectiveness of neurodevelopmental follow-up is yet to be determined but is likely to be inexpensive compared with the cost of care in the NICU and the costs associated with preterm-related long-term impairments. However, any model of care designed to improve long-term outcomes should be evaluated from a health economics perspective. An economic evaluation involves obtaining the costs of implementing the model of care per infant who receives that care, then dividing the costs by the
Conclusions
Overall, developmental screening and early intervention in high-risk infants, such as those born preterm, are targeted health interventions aimed to improve long-term neurodevelopment and are essential. Care for high-risk infants need to continue after hospital discharge, and it is important to improve access to follow-up and early intervention services by identifying causes of non-attendance, strengthening partnerships with parents, enhancing access to healthcare services, and minimizing the
Declaration of competing interest
Alicia Spittle is a tutor of the General Movements Trust and has no other conflicts of interests. No other authors have a conflict of interest.
Acknowledgments
This work is supported by grants from the National Health and Medical Research Council of Australia (Centre of Research Excellence #1060733; Career Development Fellowship #1141354 to JC; Career Development Fellowship #1108714 to AS), and the Victorian Government’s Operational Infrastructure Support Program.
References (50)
- et al.
The role of early developmental intervention to influence neurobehavioral outcomes of children born preterm
Semin Perinatol
(2016) - et al.
Single blind randomised controlled trial of GAME (Goals - activity - Motor Enrichment) in infants at high risk of cerebral palsy
Res Dev Disabil
(2016) - et al.
Global, regional, and national estimates of levels of preterm birth in 2014: a systematic review and modelling analysis
Lancet Glob Health
(2019) - et al.
Early emergence of behavior and social-emotional problems in very preterm infants
J Am Acad Child Adolesc Psychiatry
(2009) - et al.
Optimality score for the neurologic examination of the infant at 12 and 18 months of age
J Pediatr
(1999) - et al.
Understanding barriers to early intervention services for preterm infants: lessons from two states
Acad Pediatr
(2015) - et al.
Early developmental interventions for infants born very preterm - what works?
Semin Fetal Neonatal Med
(2020) - et al.
Parental perspectives on diagnosis and prognosis of neonatal intensive care unit graduates with cerebral palsy
J Pediatr
(2018) Cost evaluation of intensive care for extremely tiny babies
Semin Neonatol
(1996)- et al.
Rates and stability of mental health disorders in children born very preterm at 7 and 13 years
Pediatrics
(2020)
Long term follow up of high risk children: who, why and how?
BMC Pediatr
Early, accurate diagnosis and early intervention in cerebral palsy: advances in diagnosis and treatment
JAMA Pediatr
Early developmental intervention programmes provided post hospital discharge to prevent motor and cognitive impairment in preterm infants
Cochrane Database Syst Rev
NICU graduates: the role of the allied health team in follow-up
Pediatr Ann
Developmental follow-up of children and young people born preterm, NICE guideline 2017
Arch Dis Child Educ Pract Ed
Optimizing high-risk infant follow-up in nonresearch-based paradigms: the new England follow-up network
Pediatr Qual Saf
Newborn. Hospital discharge of the high-risk neonate
Pediatrics
Cognitive outcomes of children born extremely or very preterm since the 1990s and associated risk factors
JAMA Pediatr
Temporal trends in cerebral palsy by impairment severity and birth gestation
Dev Med Child Neurol
Quality-of-care indicators for the neurodevelopmental follow-up of very low birth weight children: results of an expert panel process
Pediatrics
A longitudinal study of very low-birthweight infants. I: study design and mortality rates
Dev Med Child Neurol
A longitudinal study of very low-birthweight infants. II: results of controlled trial of intensive care and incidence of handicaps
Dev Med Child Neurol
Changing neurodevelopment at 8 Years in children born extremely preterm since the 1990s
Pediatrics
Impact of extreme prematurity or extreme low birth weight on young adult health and well-being
the Victorian Infant Collaborative Study (VICS) 1991-1992 Longitudinal Cohort study protocol
Trends in executive functioning in extremely preterm children across 3 birth eras
Pediatrics
Cited by (9)
Early intervention to improve neurodevelopmental outcomes for high-risk infants
2024, Paediatrics and Child Health (United Kingdom)Early developmental intervention programmes provided post hospital discharge to prevent motor and cognitive impairment in preterm infants
2024, Cochrane Database of Systematic ReviewsVariation in follow-up for children born very preterm in Europe
2024, European Journal of Public Health