Developmental care for premature infants: a state of mind.

Delivering developmental care to premature infants requires a particular state of mind on the part of the entire health care team. When Heidelise Als originally developed the Neonatal Individualized Developmental Care and Assessment Program, (NIDCAP) her goal was to create a NICU environment in which nurses and other caregivers observed the behavior of premature infants to determine how to make their environment less stressful.1 She described how careful observation of an infant throughout the day can enable the caretaker to characterize the likes and dislikes of an individual infant in order to develop an appropriate developmental care plan. The importance was evident for decreasing external noxious stimuli, containing the infant in a snug and secure position, performing care activities according to a schedule and allowing the infant time for uninterrupted rest and sleep.2 Montirosso et al3 has created a scoring system to measure the quality of developmental care delivered to premature infants in several Italian NICUs, defined in terms of parental presence, infant interventions, and pain management, to assess how that care affects their neurobehavioral outcome at discharge. They found that a higher score for infant-centered care, consisting of measures of parent involvement—including ability to room in, frequency and duration of kangaroo care (ie, maternal skinto-skin contact), and nursing interventions aimed at decreasing infant energy expenditure and promoting autonomic stability (eg, infant containment, reducing tactile stimulation)—led to better neurobehavioral outcomes at discharge in infants born ,29 weeks’ gestation. Likewise, a higher score for infant pain management (ie, measures to decrease painful experiences including pharmacologic and nursing care practices) had an additive beneficial effect. The findings underscore the conclusion of Als: environment matters. If validated in independent cohorts, this developmental care scoring system should prove useful as a NICU quality improvement tool in any nursery. Thinkabout it. Premature infantsbornbetween23and32weeks’gestation spend 2 to 4 months growing and developing outside of their mothers’ wombs. They leave the quiet, dark, painless intrauterine environment much too early and enter a world filled with bright lights, noise, painful stimuli, and separation from their parents. Their immature organs are required to function long before they are ready. In addition, various organs, especially the brain, are exposed to toxic effects of medications and therapies that can interferewith normal development and function. It is no wonder that many of the tiniest premature infants, exposed to repeated aversive sensory input during the early months of brain development, are plagued with sensory integration difficulties in later life. NIDCAP and other types of developmental care have been extensively studied as ameans of individualizing care and improving outcomeswith variable results; most positive, some neutral but none negative.4–6 Multiple AUTHOR: Ricki F. Goldstein, MD, FAAP