Early developmental screening and intervention for high-risk neonates - From research to clinical benefits

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Abstract

With advances in neonatal care there has been an increase in survival rates for infants born very preterm and/or with complex needs, such as those who require major surgery, who may not have survived decades ago. Despite advances in survival, these infants remain at high-risk for a range of neurodevelopmental delays and/or impairments including motor, cognitive and emotional/behavioural challenges. Research has improved our ability to identify which infants are at high-risk of developmental delay and/or impairments, and there is mounting evidence that early interventions can improve outcomes of these infants. However, clinical practice varies throughout the world regarding recommendations for developmental screening. Moreover, intervention, when available, is often not commenced early enough in development. Given limited resources, those infants most at risk of developmental impairments and their families should be targeted, with further research needed on the cost-effectiveness of surveillance and early interventions.

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.

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