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Am Fam Physician. 2009;80(11):1306-1308

Background: The neonatal intensive care unit (NICU) environment can be stressful for very low–birth-weight (VLBW) infants, and may contribute to the high disability rates often noted in these children. The Newborn Individualized Developmental Care and Assessment Program (NIDCAP) evaluates NICU patients on their motor and autonomic responses to the environment. It has been suggested that synchronizing NICU treatments and interventions with an infant's behavior can better support brain function and development. Previous studies on NIDCAP's effectiveness have reported mixed results. In this study, Peters and colleagues sought to determine the impact of NIDCAP-based care on the length of hospital stay of VLBW infants.

The Study: This cluster-randomized clinical trial compared length of hospital stay, additional oxygen treatment, days of ventilation, incidence of chronic lung disease, and neurodevelopmental outcomes at 18 months of age between infants cared for primarily by NIDCAP-trained NICU staff and a control group receiving standard care. Infants weighing between 500 and 1,250 g (17.64 to 44.09 oz; 3rd to 97th percentiles for gestational age) who were born at or before 32 weeks of gestation were eligible for inclusion in the trial. Exclusion criteria were major chromosomal or congenital anomalies, known maternal alcohol or drug abuse, known congenital infection, and the decision to withdraw life support before 48 hours of life. Twins who met inclusion criteria were randomized as one cluster. Infants were randomized to one of two groups and allocation was concealed, although the study was not blinded. NIDCAP-trained staff included nurses, nurse practitioners, and physicians. Parents were also expected to participate in their infant's care. The study design demanded that the intervention group be treated by NIDCAP staff at least 50 percent of the time, and that the control group receive neither NIDCAP care nor behavioral observations or care plans. The study size was powered to detect a 15 percent reduction in length of stay.

Results: Of the 201 eligible infants admitted to the NICU, 120 were enrolled; 60 infants (including five sets of twins) were randomized to each group. The intervention group received a median of 83 percent of its nursing care hours from NIDCAP-educated nurses; only one control infant received care from this staff. There were four deaths in each group during the study. Infants in the NIDCAP group had a statistically significant reduction in length of hospital stay (10 days), less chronic lung disease, and better neurodevelopmental scores at 18 months of adjusted age. There were no significant differences between groups in length of ventilation, length of other respiratory support, or in specific Psychomotor Developmental Index scores at 18 months.

Conclusion: Applying NIDCAP care shortened length of stay and reduced overall disability in VLBW infants at 18 months.

editor's note: Another NIDCAP study in this issue of Pediatrics does not show a significant difference between NIDCAP and control groups in total duration of respiratory support, growth, or neuromotor development assessed at the infants' term age.1 Two accompanying editorials discuss methodologic differences between the studies and provide contrasting philosophical views on the value of NIDCAP.2,3 It appears that behaviorally based NICU care, which often means reducing light and noise levels, helping to promote flexion and self-regulation, increasing parental involvement, and clustering care, has some beneficial effects, but further large-scale randomized trials are needed to quantify those effects.—a.c.f.

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