DEVELOPMENTAL CARE DOES NOT ALTER SLEEP AND DEVELOPMENT OF PREMATURE-INFANTS

Objective. The Neonatal Individualized Developmental Care Program (NID CAP) for very low birth weight (VLBW) preterm infants has been suggest ed by Als et al to improve several medical outcome variables such as t ime an ventilator, time to nipple feed, the duration of hospital stay, better behavioral performance on Assessment of Preterm Infants' Behav ior (APIB), and improved neurodevelopmental outcomes. We have tested t he hypothesis of whether the infants who had received NIDCAP would sho w advanced sleep-wake pattern, behavioral, and neurodevelopmental outc ome. Methods. Thirty-five VLBW infants were randomly assigned to recei ve NIDCAP or routine infant care. The goals for NIDCAP intervention we re to enhance comfort and stability and to reduce stress and agitation for the preterm infants by: a) altering the environment by decreasing excess light and noise in the neonatal intensive care unit (NICU) and by using covers over the incubators and cribs; b) use of positioning aids such as boundary supports, nests, and buntings to promote a balan ce of flexion and extension postures; c) modification of direct hands- on caregiving to maximize preparation of infants for, tolerance of, an d facilitation of recovery from interventions; d) promotion of self-re gulatory behaviors such as holding on, grasping, and sucking; e) atten tion to the readiness for and the ability to take oral feedings; and f ) involving parents in the care of their infants as much as possible. The infants' sleep was recorded at 36 weeks postconceptional age (PCA) and at 3 months corrected age (CA) using the Motility Monitoring Syst em (MMS), an automated, nonintrusive procedure for determining sleep s tate from movement and respiration patterns. Behavioral and developmen tal outcome was assessed by the Neurobehavioral Assessment of Me Prete rm Infant (NAPI) at 36 weeks PCA, the APIB at 42 weeks PCA, and by the Bayley Stales of Infant Development (BSID) at 4, 12, and 24 months CA . Results. Sleep developmental measures at 3 months CA showed a clear developmental change compared with 36 weeks PCA. These include: increa sed amount of quiet sleep, reduced active sleep and indeterminate slee p, decreased arousal, and transitions during sleep. Longest sleep peri od at night showed a clear developmental effect (increased) when compa ring nighttime sleep pattern of infants at 3 months with those at 36 w eeks of age. Day-night rhythm of sleep-wake increased significantly fr om 36 weeks PCA to 3 months CA. However, neither of these sleep develo pmental changes showed any significant effects of NIDCAP intervention. Although all APIB measures showed better organized behavior in NIDCAP patients, neither NAPI nor Bayley showed any developmental advantages for the intervention group. The neurodevelopmental outcome measured b y the Bayley at 4, 12, and 24 months CA showed 64% of the NIDCAP inter vention group at the lowest possible score compared with 33% of the co ntrol group. These findings could not be explained by the occurrence o f intraventricular hemorrhage or the socioeconomic status of the paren ts, which showed no significant group effect. Conclusion. The results of this study, including measures of sleep maturation and neurodevelop mental outcome up to 2 years of age did not demonstrate that the NIDCA P intervention results in increased maturity or development. Buehler e t al (Pediatrics. 1995;96:923-932) have reported that premature infant s (N = 12; mean gestational age 32 weeks, mean birth weight 1700 g) wh o received developmental care compared with a similar group of infants who received routine care showed better organized behavioral performa nce on an APIB assessment at 42 weeks PCA. None of the medical outcome measures were significantly different in this study. Although our API B results are in agreement, the results of the NAPI, the Bayley and sl eep measures do not show an increase in neurodevelopmental maturation. In the earlier report by Als et al (journal of the American Medical A ssociation. 1994;272:853-858), both medical and neurofunctional improv ements were found in very low birth weight premature infants (mean ges tational age 27 weeks, mean birth weight similar to S70 g) in which 20 infants who received NIDCAP were compared with 18 infants who receive d routine care. At 42 weeks PCA the APIB was better in the interventio n group as was the Bayley at 6 months CA. Later neurodevelopmental ass essments in this study population have not been reported. Furthermore, as was indicated in the editorial by Merenstein in the same issue of the Journal of the American Medical Association, a significant problem with the study was that the number of intraventricular hemorrhages wa s higher in the control group (10 of 18 vs 1 of 20) and the study was conducted before the widespread use of surfactant and prenatal steroid s. The study was performed in a single nursery with nurses who volunte ered for developmental intervention and cared for the experimental gro up. No assessment was performed on differences in nursing, interventio n, lighting, or sound between the two groups. Apnea, bradycardia, and desaturation data were not reported also. NIDCAP has been shown to red uce stress and agitation in the infants in our study (Heller C, et al. Journal of Perinatology. 1997;17:107-112); however, there was no diff erence in the incidence of apnea or bradycardia. Additional studies ar e needed to determine which specific interventions facilitate recovery in the high-risk preterm infant when interventions are efficacious, w hat may be adverse or ineffective, and what mechanisms are involved. D istinctions should be made between medical improvement, neurobehaviora l responses (APIB) and neurodevelopmental maturation. Not only the dur ation of NICU hospitalization, but indeed, long-term outcomes must be carefully evaluated. We recommend that clinicians should be aware that preterm infants who have received NIDCAP during their hospitalization do not appear to be more mature at the time of discharge home.