Individualized Behavioral and Environmental Care for the Very Low Birth Weight Preterm Infant at High Risk for Bronchopulmonary Dysplasia: Neonatal Intensive Care Unit and Developmental Outcome

Abstract

We hypothesize that the respiratory and functional states of the very low birth weight infant with bronchopulmonary dysplasia can be improved in the neonatal intensive care unit by prevention of inappropriate sensory input. To test this hypothesis, we developed for preterm newborns a behavior observation method that catalogues specific reaction patterns according to putative stress and relaxation behaviors. We then collected behavioral information and heart rate, respiratory rate, and transcutaneous PO2 readings before, during, and after routine care-giving interventions. Eight control and eight experimental infants were selected for study based on the following criteria: birth weight <1,250 g, gestational age <28 weeks, on the respirator >24 hours in first 48 hours of life at ≥0.6O FiO2 for more than two hours during first 48 hours of life. Additionally, the two groups were comparable on other medical and demographic variables, including severity of respiratory status for the first ten days and incidence of intraventricular hemorrhage, patent ductus arteriosus, and socioeconomic status. Systematic observations were conducted on days 10, 20, and 30 after birth and at 36 and 40 weeks postconception. For the intervention infants, our observations were discussed with the infants' primary nurses, and individualized modifications for each infant's care plan were implemented based on these observations. Experimental infants showed significantly briefer stays on the respirator (P < .01) and in increased FiO2 (P < .05). Their feeding behavior was normalized significantly earlier (P < .01). Experimental infants also showed significantly better behavioral regulation scores at 1 month after their mothers' estimated dates of confinement (post-EDC), as measured with the Assessment of Preterm Infants' Behavior, significantly better Mental and Psychomotor Developmental Indices at 3, 6, and 9 months post-EDC, as measured with the Bayley Scales of Infant Development, and significantly better behavioral regulation scores at 9 months post-EDC, as measured in a videotaped play observation. Measurements of weight, height, and head circumference at 3, 6, and 9 months post-EDC showed no differences. All assessments were performed by one of two trained testers not familiar with the goals of the study or the group status of the infant. These results support the hypothesis that very low birth weight preterm babies profit significantly both medically and developmentally from individualized behavioral care in the neonatal intensive care unit.

The role of weighing‐bathing sequence and postmenstrual age in eliciting adaptive/maladaptive responses in very low birth weight preterm infants

“…The execution of each procedure was standardized (see below) and was always performed by expert nurses in neonatal care who had been working in our NICU for at least 3 years. They all had basic training in the NIDCAP approach (Als et al, 1986), although none were NIDCAP certified. Although a standardized approach to preterm infant's care may appear in contradiction with a developmentally appropriate intervention, the execution of nursing procedures was standardized to control for variations due to each nurse's individualized and unique approach to caregiving.…”

“…For the construction of this tool, the Als's Synactive Theory of Development (Als & Gilkerson, 1997;Als et al, 2005) was referenced. As previously described (Bembich et al, 2017), its items were derived from the Newborn Individualized Developmental Care and Assessment Program (NIDCAP) observation tool (Als et al, 1986). All items evaluated preterm neonates' autonomic and motor responses, referring to specific physiological or behavioral signs (Table 1).…”

“…a Source:Als et al (1986).which the neonate was moved rapidly from the crib to the scale and vice versa.…”

Certain conditions originating in the perinatal period.

“…Several researchers have proposed that the appropriateness of interventions for critically ill neonates (including protection from overstimulation as well as arousal for social interaction) be based on evaluation of the individual infant's maturation level, developmental status, tempera-ment, processing ability, behavioral state and responses, and an assessment of the ecology of the environment (Cornell & Gottfried, 1976;Gorski et al, 1983;Parmelee, 1985). Als et al (1986) designed individualized developmental care plans for very low-birthweight infants with respiratory distress syndrome, which called for modifications in the NICU environment and in caregiving to minimize stress and respond to the infants' individual needs. Infants with individualized care plans fed orally sooner, had fewer days of assisted respiration, and had better developmental scores and parental interactions at 9 months than infants in a contrast group.…”

The development of behavior before birth.

“…Intervention treatments that are designed to promote normal neonatelike responding are in widespread practice, such as intensive human handling (Schanberg & Field, 1987) or nonspecific sensory stimulation. Other approaches involve attempts to imitate features of the prenatal environment, such as floating infants on temperature-regulated, undulating water mattresses (Korner, 1980), or to provide patterned sensory stimulation that is appropriate for the neurobehavioral abilities of the infant (Als et al, 1986). The latter strategies have become practical only with advances in our understanding of the behavioral capacities and developmental requirements of the fetus in utero.…”