The care of sick newborn and premature infants has undergone major developments in recent years. Various methods aimed at promoting bonding, breastfeeding, and neurological development have been introduced by neonatal health care providers. These methods include kangaroo care and family-centered neonatal care (Beal 2005; Griffin 2006). However, scientific evidence for the effects of these methods has often been lacking. One common property of these methods is their focus on the infant as an individual with the ability to interact with its surroundings, which is in sharp contrast to earlier ideas in which it was assumed that the newborn infant was principally controlled by reflexes and innate behavior.
Over the past 20 to 30 years, the incidence of preterm birth in most developed countries has been between 5% and 7% of live births. The incidence in the United States is higher at about 12%. (Tucker & McGuire 2004). Medical and technological advances have led to the survival of an ever greater number of infants with low birth weight and those born after even shorter periods of gestation (Hack & Fanaroff 2000), implying that the infant and the families will be in contact with intensive care facilities for a long period. This is often a distressing and stressful period for the family members (Dudek-Shriber 2004; Franck et al. 2005).
Premature infants have a higher neonatal morbidity than full-term infants, where an increase in risk is inversely correlated with the length of gestation. Problems that may arise include those of the central nervous system, eyes, and lungs. There are also negative long-term effects on school achievement and behavior (Hack & Fanaroff 2000).
The Neonatal Individualized Developmental Care and Assessment Program (NIDCAP) is an interventional model that has been developed with the aim of providing adequate sensorial stimulation to premature infants at a level that is adapted to the degree of neurological maturity of the infant. NIDCAP is a registered trademark, with training offered by certified NIDCAP centers, mainly in the U.S. but also in Argentina, Belgium, France, Sweden, the Netherlands, and United Kingdom (Als 2007).
NIDCAP requires extensive training and education of the NICU staff, which is provided by the NIDCAP centers. The NIDCAP Federation International suggests a 5-year strategically planned process to implement NIDCAP in a neonatal setting. At least two developmental care specialists should be trained at each unit that wants to implement NIDCAP. In addition, a core group of nursing staff should take the introductory course or the full training in NIDCAP, and a multidisciplinary leadership support team should be formed. Protected time for regular observations of targeted preterm infants must be reserved after introduction. Refresher courses are necessary in order to ensure that the method continues to be applied correctly (Als 2007).
The NIDCAP Intervention
NIDCAP has been developed at the Children's Hospital in Boston (Als 2007). Briefly, the method involves premature infants undergoing systematic observation of their behavior at intervals of 7 to 10 days. The results of these observations form the basis for the design of individual care plans that describe how the infant should be cared for and how the care can be designed such that it provides stimuli that he or she can cope with.
The theoretical background of NIDCAP is known as the “synactive theory,” a conceptual foundation that describes the neurological development of the fetus and infant (Als 1982). The theory proposes that neurological subsystems (the autonomic, motor, state organizational, and attentional systems) develop in a certain order. These subsystems interact and influence each other, and the infant attempts to maintain balance within and between the subsystems by self-regulation.
The infant is observed by a specific schedule in 2-minute cycles before, during, and after a care procedure, such as change of diaper (Als et al. 2005). The observer notes the existence of physiological and behavioral parameters grouped into the following areas: respiration, color and visceral parameters, motor functions, facial features, state, and attention. Other factors noted are the posture of the infant, the care manipulations that are performed, and any stimuli (sound, light, activity) that are present in the surroundings. Observation is carried out for approximately 10 minutes before the intervention that will be studied in order to obtain baseline values. The infant is then observed throughout the complete procedure and for about 10 to 15 minutes after the intervention is finished or until the infant has returned to its initial status.
After the observation is complete, the observed neurological signals are summarized and related to what happened with the infant and in surroundings. Observed behavior and physiological reactions are classified as signs either of approach/self-regulation on the one hand, or of avoidance/inadequate self-regulation on the other.
The observer then draws up care recommendations that are based on the assessment of which situations the infant “coped with” and which situations produced signs of avoidance. These recommendations normally deal with:
- • the surroundings in the room (location of the incubator relative to windows, sinks, desks, etc., lighting, sound, and activities),
- • the environment in the incubator or bed (use of nest and incubator cover),
- • aids to self-regulation (positioning, aids for sucking or gripping, and eye protection),
- • timing and coordination of care operations, the daily rhythm, and
- • facilitating the transition between different events.
The care plan should be passed on verbally and in writing to those who care for the infant and the infant's parents. The infant is continuously developing neurologically and thus the observation is repeated at intervals of 7–10 days, at which time a new or modified care plan is drawn up.
Relationship with Other Methods
Conventional neonatal care, that is, care without the use of NIDCAP, has changed since the first NIDCAP study was published in 1986. At that time, premature infants were kept naked in intensely lit incubators, on smooth mattresses, often with the head and extremities in a fixed position. The environment in many neonatal wards has changed since then. Such items as incubator covers, nests, and subdued illumination are now used, even if NIDCAP observations are not carried out.
Kangaroo care (skin-to-skin care; World Health Organisation 2003) is a method of care that, as it is used in the western world, emphasizes contact between the infant and the parents and support for breastfeeding. The kangaroo method can be used on its own, as is done in many parts of the world, or it may form one component of NIDCAP. A further concept that supports the contact between the infant and his/her parents is family-centered care, which is defined by such properties as unlimited visiting hours, participation of the parents in the planning of care, and an adaptation of the surroundings such that they stimulate parent's presence and participation (Harrison 1993; Levin 1999; Sizun et al. 1999).
Previous Reviews of NIDCAP
Two previous reviews on the effects of NIDCAP have been published. Jacobs and colleagues (2002) included five articles from randomized controlled studies (RCT) and three articles from historical phase-lag design studies. A Cochrane report by Symington and Pinelli (2006) that examines a wide spectrum of developmental supportive interventions, including NIDCAP, was first published in 2003. Its latest version included nine articles; all RCTs. Both reviews perform meta-analysis where outcomes and time points were comparable. Compared to these reviews, the current review adds an exclusive focus on NIDCAP (not assessing other interventions). It also includes additional studies on the NIDCAP intervention.
This systematic literature review addresses the question of what effects the use of NIDCAP will have on the premature infant regarding psychomotor development, neurological status, medical/nursing care outcomes, and parental perceptions during the inpatient period. The review, which was originally carried out as a project within The Swedish Council on Technology Assessment in Health Care (SBU; Wallin & Eriksson 2006), also addresses the cost-related effects of the NIDCAP intervention.