J. ChildPsychol. Psychiat. Vol. 32, No. 5, pp. 723-741, 1991 Printed in Great Britain.

0021 9630/91 $3.00 + 0.00 Pergamon Press pic © 1991 Association for Child Psychology and Psychiatry

Annotation: Supporting the Development of Low Birthw^eight Infants Dieter Wolke History The term "premature infant" only entered the English language some 120 years ago. Prior to the last quarter of the previous century, infants who were born before term were referred to as "weaklings" or "congenitally debilitated" babies (Helders, 1989). Before the introduction of more widely available treatment of sick babies in incubators by Carl Crede in Leipzig in 1884 (Brimblecombe, 1983) and the establishment of the first premature baby unit in 1895 by Pierre Budin at the Hospital Port Royale in Paris, these weaklings were allowed to "pine away" and die (Budin, 1900). The principles of care for premature infants changed little from the turn of the century until the 1950s. They consisted of minimal handling, insurance of adequate feeding, control of chilling or overheating and control of access to the infants because of the risk of infections (Cross, 1945). Parents were discouraged from visiting and prohibited from sharing any care (Klaus & Kennell, 1970). In Great Britain, initial interest in providing special care facilities can be dated to the mid-1940s (Ministry of Health, 1944). Scientific research on temperature and physiological control and the availability of more sophisticated technology resulted in steep falls of neonatal mortality (Hodgman, 1985). However, it was not until 1961 that a memorandum recommended, as a national policy, the establishment of special care nurseries in the larger maternity units in Britain (Central Health Services Council, 1961). In contrast, a large number of special care units were already established in the 1930s in the United States (Silverman, 1979). Neonatalogy has become the most rapidly developing subspeciality in paediatrics (Pharoah, 1986). Today's special and intensive care units are highly equipped and busy working environments (Gottfried & Gaiter, 1985). As a consequence, infants are now reared in illuminated and noisy nurseries and are handled frequently for various medical and routine care procedures (Wolke, 1986, 1987a,b). Concern for the psychological well-being of preterm infants Keywords: Developmental outcome, intervention studies, individualized care, preterm infants Accepted manuscript received 2b June 1990

University of London Institute of Child Health and University of Munich Children's Hospital. Requests for reprints to: Dr Dieter Wolke, Dr von Haunersches Children's Hospital, University of Munich, Lindwurmstrasse 4, D-8000 Munich 2, F.R.G.

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and their parents was raised as long ago as 1900 (Budin, 1900), but the implementation of parent support and supplementary stimulation programmes for preterm infants is only a relatively recent endeavour (Fanaroff, Kennell & Klaus, 1972). Terminology Unfortunately, the terms preterm and low birthweight (LBW) are frequently used interchangeably. Preterm or premature infants are those who are born before term, i.e. before 37 weeks of gestation. Low birthweight infants are those who are born at a weight of less than 2500 g. LBW infants are thus either born too soon (preterm) or too small for their gestational age. About 18-40% of low birthweight infants are small for their gestational age (Brothwood, Wolke, Gamsu & Cooper, 1988; Chiswick, 1985). Although the use of ultrasound has improved the determination of gestational age of foetuses, the assessment of birthweight remains a more reliable measure and has been adopted for use in annual mortality and morbidity statistics (Pharoah & Alberman, 1990), and by most research groups (Aylward, Pfeiffer, Wright & Verhulst, 1989).

Prevalence Low birthweight infants (LBW < 2500 gm) make up about 7% of all annual live births in Great Britain and the U.S.A. (Alberman, 1980; Bauchner, Brown & Peskin, 1988). Roughly 10-15% of LBW infants or 0.9% (G.B.) to 1.1% (U.S.A.) of all annual live births are of very low birthweight (VLBW; < 1500 g) (Behrman, 1985; Pharoah & Alberman, 1990). The care of VLBW infants comprises the major workload in modern neonatal intensive care units. (See Table 1 for a full list of abbreviations used and their definitions.)

Table 1. Abbreviations used in text Abbreviation

Meaning

Defmition

LBW VLBW ELBW AGA

Low birthweight Very low birthweight Extremely low birthweight Appropriate for gestational

Birthweight < 2500 g Birthweight < 1500 g Birthweight < 1000 g The foetus/newborn has a weight corresponding to his gestational age (i.e. above the 10th percentile on standard weight charts) The foetus/infant has a weight below that expected for his gestational age (i.e. below the 10th percentile on standard weight charts)

age

SGA

Smcill for gestational age

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Survival The survival of LBW and VLBW infants has improved markedly over the last 15 years. Infants of > 23 weeks gestation and more than 500 g are now considered viable. Although recent study reports vary in regard to their birthweight bands and are mainly based on studies in well equipped regional centres, their findings are consistent in showing that survival is generally > 25% for infants between 500 and 750 g, > 50% for infants of 751-1000 g (Bauchner et ai, 1988), around 90% for infants weighing 1001-1500 g, and more than 95% for infants weighing 15002499 g at birth (Pharoah & Alberman, 1990). Greater survival rates imply that paediatricians are now caring for more preterm infants requiring longer periods of hospitalization and more resources than ever before (Bloom, 1984; Boyle, Torrance, Sinclair & Horwood, 1983).

Is there a Need for Developmental Support? It is important to review the developmental outcome of low birthweight survivors to assess the need and feasibility of any prevention and intervention programmes for these infants and their families. A review of the current evidence is complicated by the fact that findings from most studies are based on samples from teaching hospitals rather than from whole populations (Lloyd, 1984). Furthermore sample sizes vary greatly between reports with some studies also reporting a high percentage of subjects lost (Wariyar & Richmond, 1989). Some studies have included control groups while most follow-up studies have not and the data sources and assessment instruments differ greatly between different follow-up investigations (see Aylward, 1988). These methodological problems and the continuous changes in neonatal care practices make it difficult to draw firm conclusions about the outcome of these children and an update of findings is periodiccilly necessary.

Developmental Sequelae Impairment and long-term medical complications

The last 15 years has seen a marked reduction in the relative number of VLBW survivors with neurological impairments such as cerebral palsy, neurosensory hearing loss, blindness and a developmental quotient or I Q below 70 (corrected for prematurity)* (Brothwood, Wolke, Gamsu, Benson & Cooper, 1986; Stewart, 1985). The rate of major impairment in VLBW survivors has reduced from a level of 20-30% in the early 1970s (Stewart, Reynolds & Lipscomb, 1981) to 10-15% in more recent reports (Brothwood et ai, 1986; Costello et ai, 1988). Advances have also been made in the reduction of major impairments in the group of extremely low birthweight * The corrected age is the postnatal age less the number of weeks the child was premature. For example, an infant born at 28 weeks of gestation (i.e. 12 weeks preterm) and seen at a chronological age of 64 weeks has a corrected age of 52 weeks.

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infants (ELBW; < 1000 g). Recent reports quote rates of 17-27% (Brothwood et ai, 1988; Lefebvre, Bard, Veilleux & Martel, 1988). Furthermore, "milder" neurological problems such as epilepsy, hydrocephalus, abnormal muscle tone and moderate developmental delay (DQ70-85 corrected for prematurity) (Orgill, Astbury, Bajuk & Yu, 1982) are found in an additional 4-10% of VLBW infants (Brothwood etai, 1988) and 10-20% of ELBW infants (Brothwood etai, 1988; Portnoy, Callias, Wolke & Gamsu, 1988). Although many more VLBW infants are free of moderate to severe neurological impairment, the live-born prevalence of cerebral palsy remains 10-40 times higher in VLBW than in normal birthweight infants (Hagberg, Hagberg & Zetterstrom, 1989). There is evidence that with increased survival of VLBW infants, the overall rate of cerebral palsy in the community has remained stable or may even have increased (Atkinson & Stanley, 1983; Emond, Golding & Peckham, 1989). Furthermore, preterm infants are at an increased risk in terms of other morbidities during the first few years of life. Long-term medical complications include chronic lung disease such as bronchopulmonary dysplasia, recurrent infections and otitis media (Fitzhardinge et ai, 1976; Levene & Dubowitz, 1982). Visual impairments ranging from retrolental fibroplasia or retinopathy of prematurity to delayed visual development are markedly more frequent in VLBW infants (Fielder, Ng & Levene, 1986; Van Hof-Van Duin, Evenhuis-van Leunen, Mohn, Baerts & Fetter, 1989). Preterm infants are also more likely to be rehospitalized (McCormick, 1985), often for recurrent infections or the repair of structural damage such as hernia (Mutch, Newdick, Lodwick & Chalmers, 1986). Studies in the 1970s suggested that the growth pattern of appropriate for gestational age preterm infants, when plotted by postconceptual (corrected) age rather than chronological age, follows the same curve as that of appropriate for gestational age (AGA) full-term infants (Brandt, 1986). More recent studies show that when ELBW and VLBW infants are considered, then AGA VLBW infants show the best catchup growth in the first years, small for gestational age preterm infants show delayed catch-up growth and neurologically impaired infants often show significant growth retardation (Bauchner et ai, 1988; Brothwood et ai, 1988). Cognitive and behavioural development

With increased survival of LBW infants, the interest has moved away from mortality statistics and monitoring of major neurological problems to the study of cognitive, language, behavioural and motor functioning. Subtle developmental deficits of LBW infants have been noted in a variety of domains. The developmental and intelligence quotients of those VLBW infants who do not suffer major neurological, hearing or visual impairment have generally been found to be in the normal range, although V2 to 1 SD lower than full-term control infants (see Aylward et ai, 1989). Low and very low birthweight infants have been found to have poorer perceptual motor skills (Siegel, 1983, 1984) and show particular problems in visual motor integration (Marlow, Roberts & Cooke, 1989). Significant language delay in LBW infants including both comprehension and expressive language have also been noted in a number of longitudinal studies (Byers-

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Brown, Bendersky & Chapman, 1986; Vohr, Garcia Coll & Oh, 1988). Furthermore, LBW and, in particular, VLBW infants have been found to have more motor problems causing them to be more clumsy children (Marlow et ai, 1989; Valvano & DeGangi, 1986). VLBW infants also manifest soft neurological signs more frequently than fullterm AGA infants (Hertzig, 1981; Marlow et ai, 1989). Investigations of LBW infants born before 1965, when neonatal intensive care was not widely available, indicated that LBW infants have generally more behaviour and emotional problems (see Minde, 1984). Various retrospective and prospective studies suggested that LBW infants are more prone to be subjected to abuse due to their prolonged hospitalization and separation from their parents (e.g. Collingwood & Alberman, 1979; Jeffcoate, Humphrey & Loyd, 1979). Direct observations of motherinfant interaction during the first year of LBW infants usually indicate that their mothers are either more passive and less affectionate in interaction (Barnard, Bee & Hammond, 1984; Davis & Thoman, 1988; Field, 1977, 1980b; Jarvis, Myers & Creasey, 1989) or overstimulating (Brachfeld, Goldberg & Sloman, 1980). LBW infants, in particular those who suffered severe neonatal illness, have repeatedly been observed to be more passive and less socially engaging in interaction (Crnic, Ragozin, Greenberg, Robinson & Basham, 1983b; Greene, Fox & Lewis, 1983; Malatesta, Grigoryev, Lamb, Albin & Culver, 1986; Minde, Whitelaw, Brown & Fitzhardinge, 1983b). Paradoxically, the poorer synchrony in mother-infant interaction of LBW dyads (Lester, Hoffman & Brazelton, 1985) is not reflected in poorer attachment relationships with their mothers at 1 year as measured in the laboratory with the Ainsworth Strange Situation. Several studies (Easterbrooks, 1989; Field, Dempsey & Shuman, 1981; Frodi & Thompson, 1985; Goldberg, Perrotta, Minde & Corter, 1986) did not find more insecure attachment in LBW infants relative to those born at normal weight. Gaensbauer & Harmon (1982) concluded that "attachment behavior as observed in the laboratory may not be a true reflection of the caretaker-child relationship" in at risk groups (p. 277). Subtle and specific deficits that interfere with schooling have been noted consistently. Lloyd (1984), Lloyd, Wheldall and Perks (1988), Hertzig (1981) and Klein (1984) have all showed that VLBW children perform significantly poorer at school and more frequently require remedial teaching despite having cognitive abilities within the normal range (see also Melvin & Lukeman, in press). This is mainly due to the poorer attention span, task orientation and overactivity noted in these small children from infancy through to middle childhood (Field et ai, 1981; Hertzig & Mittlelman, 1984; Meisels, Cross & Plunkett, 1987; Minde et ai, 1989; Portnoy et ai, 1988; Schraeder & Tobey, 1989). Low birthweight children are more likely to fail when required to perform within a stressful environment (i.e. school) where no adjustment is made for their particular behavioural deficits.

Implications for Intervention A number of general conclusions can be drawn from the findings of outcome studies. 1. A significant minority of LBW infants suffer intellectual and, in particular, behavioural deficits.

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2. Birthweight per se is not a good predictor of motor, cognitive and behavioural development (Wolke, Brothwood, Gamsu & Cooper, 1986). The severity and chronicity of neonatal illness are more potent predictors of infant development. 3. Prediction of abnormal outcome in LBW children from peri- and neonatal complications is far from perfect, despite better diagnostic techniques for brain lesions such as ultrasound (Costello et ai, 1988). As the child grows older, socio-environmental factors explain more of the variance in cognitive and behavioural assessments than the biological risk factors (Beckwith & Parmalee, 1986; Escalona, 1982; Werner & Smith, 1982; Wilson, 1985). LBW infants from low socio-economic or unstimulating backgrounds are at a double hazard for poor outcome (Lloyd et ai, 1988; Parker, Greer & Zuckerman, 1988). The caretaking environment has a profound effect on the low birthweight infant's long-term development (Minde et ai, 1989; Siegel, et ai, 1982). An infant's resilience to biological insults can be ameliorated by a supportive and stimulating environment, or exacerbated by inadequate caretaking and family stresses (Bauchner et ai, 1988; Beckwith & Cohen, 1987; Beckwith & Parmalee, 1986; Rauh, 1989; Rocissano & Yatchmink, 1983; Sameroff & Chandler, 1975; Siegel, 1984; Slater, Naqvi, Andrew & Haynes, 1987). Better survival of ever smaller infants means that the best efforts should now be turned to the quality of survival (Stahlman, 1984). As Mitchell (1985) phrased it: "if they (neonatologists) take the long view . . . they will realise the futility of achieving so much for an infant only to plunge him into a hostile environment that will nullify much of what they have accomplished. It is necessary to match the increasing resources required for perinatal care with greater expenditure on environmental improvement and preventative measures" (p. 933).

Intervention Programmes A whole range of primary and secondary prevention studies has been reported.* Most intervention work has focussed on supporting the development of the LBW infant while in special care in hospital. Fewer studies have evaluated the support provided to preterm infants and parents after their discharge from hospital, and some of these latter evaluation studies used an integrated approach combining stimulation programmes in the special care baby unit with continued support in the community. Developmental support programmes have been guided by different theoretical models. Nurcombe et ai (1984) and Wolke (1987a) distinguished between five major theoretical approaches: (a) programmes that aim to counteract neonatal sensory deprivation or overload; (b) programmes that aim to prevent faulty mother-infant bonding; (c) programmes that aim to help parents resolve the emotional crisis of premature delivery; (d) programmes that aim to help parents to be more sensitive and responsive to their baby's cues and improve the mother-child interaction; and (e) compensatory programmes which are aimed at infants identified later in the first year as having general or specific developmental or motor problems. * Studies aiming at the prevention of preterm labour and the birth of low birthweight infants (truly primary prevention; e.g. Mueller-Heubach, Reddick, Barnett & Bente, 1989) are not considered.

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Hospital-Based Programmes Newborn sensory stimulation

Since the 1960s, most efforts have been invested in providing preterm infants with less or extra sensory stimulation via different sensory mod2ilities. The aim of these investigations has been to determine the effects of environmental manipulations on the behaviour and development of preterm infants (Cornell & Gottfried, 1976). Most of these sensory stimulation studies are rooted in one of two "easy recipe" models (Wolke, 1987a, 1986). The first theoretical position states that the preterm infant is deprived from his final weeks in utero (e.g. mother's heartbeat sounds, vestibular experiences) or may be deprived of appropriate extra-uterine stimulation (Field, 1980b). Others, in contrast, have suggested that the LBW infant is overstimulated in the busy SCBU environment and needs protection from these stimuli (Cornell & Gottfried, 1976). Supplemental stimulation is usually applied as soon as possible after birth and continues until the infant approximates term gestational age (Field, 1980a; Masi, 1979). The stimuli either try to mimic the stimulation in the womb (i.e. heartbeat sounds) or of the extra-uterine world (see Field, 1980a; Schanberg & Field, 1987, for detailed reviews). Supplemental programmes have focussed on unimodal sensory stimulation such as extra sensory suck stimulation during tube-feeding or painful procedures (Bernbaum, Pereira, Watkins & Peckham, 1983), extra tactile stimulation provided to preterm infants ranging from bedding on lambskin (Scott, Lucas, Cole & Richards, 1983), nursing in hammocks (Helders, 1989), baby massages to gentle human touch provided by nursing staff and/or mothers (e.g. Rice, 1977; Jay, 1982), extra auditory stimulation including the playing of mother's or any woman's voice or heartbeat (Katz, 1971; Malloy, 1979) and added vestibular stimulation through the use of extra rocking, most frequently provided by oscillating waterbeds (e.g. Barnard & Bee, 1983; Korner, 1981; Korner, Guilleminault, Van den Hoed & Baldwin, 1978; Korner, Kraemer, Haffner & Cosper, 1975; Korner, Schneider & Forrest, 1983; Tuck, Monin, Duvivier, May & Vert, 1982). Other programmes have involved multimodal stimulation including auditory, tactile and vestibular stimulation for the preterm infant (Field et ai, 1986; White & Labarba, 1976). Interpreting the findings from these various studies is difficult due to the vast variations in the composition of study groups, sample sizes, the duration of the programmes, follow-up periods and outcome measures used (Field, 1980a; Helders, 1989). Overall, nearly all of these extra sensory stimulation studies found some positive short-term effects in terms of the preterm infant's improvement of weight gain, onset of oral feeding or behavioural organization (e.g. increased sleeping; reduction of crying, apnoea or bradycardia). The effects were generally small to moderate and often shortlived, indicating that not all preterm infants benefit from extra sensory stimulation. It seems that any type of stimulation works, independent of the sensory modality. This suggests that the effects are unspecific. Richards (1984) speculated that the common pathway may be a Hawthorne effect, i.e. the special attention given to the infants by the nurses and experimenters may be the factor that explains small positive gains. Furthermore, some studies reported adverse effects of extra stimulation on the small newborn Qones, 1981; Korner, 1981; White-Traut & Carrier Goldman, 1988).

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The major problem of this line of research is that its theoretical foundations are poor. The studies were initiated without having carried out descriptive studies of the neonatal intensive care unit environment (Field, 1980b; Gottfried & Gaiter, 1985). Recent systematic studies of the ecology of neonatal intensive and special care facilities (reviewed by Wolke, 1986, 1987a,b; Wolke & Eldridge, in press) have shown that preterm infants are not under- or over-, but inappropriately, stimulated. There is a mismatch between the type, intensity and patterning of the stimulation in neonatal intensive care units (e.g. handling, noise, light levels, social contacts) and the infant's developmental status. Some of the extra stimulation programmes worked, not because they had a stimulating (arousing) effect but because they pacified the small infant or provided the preterm infant with a predictable pattern of stimulation (Mann, Haddow, Stokes, Goodley & Rutter, 1986). Different types of interventions, ranging from supporting the infant's state (including pacifying) and graded arousing and social stimulation, are appropriate at different stages of the LBW infant's development in hospital (Wolke, 1987a, Wolke & Eldridge, in press). Als et al. (1986) evaluated an individual care approach for preterm infants. VLBW infants, ventilated and at high risk for chronic lung disease, received a detailed behavioural evaluation. Based on these observations, an individual careplan was designed which aimed at providing the infant with an appropriate proximal environment (e.g. reduced noise and light for the sick infant) and caregiving which was sensitive to the infant's medical and behavioural state. Als et ai (1986) reported that the infants enrolled in the programme were ventilated on average 24 days less, needed oxygen therapy for 34 days less, and changed on to full oral feeding 30 days sooner than a matched control group. The treatment also resulted in long-term gains including significantly higher mental development scores and more reciprocal interaction at 9 months of age. An individual care approach, educating nurses and parents on how to contain and promote the individual infant's behavioural organization, appears to be the most promising approach for direct developmental support of the very sick infant in hospital. Promoting parenting of the LBW infant

While researchers often centred on direct stimulation of the infant, clinicians have advocated that "if you want to improve the lives of children, improve the situation of the caregivers" (Klaus & Kennell, 1982a, p. 189). Bonding

Early calls for improvements included the demand for unrestricted visiting and physical contact between parents and their offspring (Fanaroff f/ ai, 1972). The simple underlying idea that facilitation of contact shortly after birth (sensitive period) leads to bonding of the mother with the infant and more optimal caretaking in the future has not been upheld (Richards, 1985a,b). While the bonding idea led to many improvements of the nursery environment and access for parents (e.g. Fanaroff ^^ ai, 1972; Hawthorne, Richards & Callon, 1978; Zeskind & Iacino, 1984), there have also been backlashes because of this highly publicized idea. Parents started to feel

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guilty because they could not be with their baby immediately after birth (Redshaw, Rivers & Rosenblatt, 1985; Richards, 1985a). Furthermore, parents often felt compelled to handle their small fragile infant even if they intuitively felt that looking at him or her would be enough (Papousek & Papousek, 1987). Some fragile infants reacted with adverse physiological responses to this handling (Wolke, 1987a). Recently, bonding theory had a revival with media reports of the positive effect of skin to skin contact where the VLBW infant is packed close to their mother right next to the breast (kangaroo method) (Whitelaw & Sleath, 1985). A subsequent controlled study found little positive effects on the infants' development (Whitelaw, Heisterkamp, Sleath, Acolet & Richards, 1988). The kangaroo method is a safe method which helps to prolong lactation in mothers but does not seem to have other advantages to the ordinary hospital care of infants and mothers (Mondlane, De Graca & Ebrahim, 1989; Whitelaw et ai, 1988). Increased lactation may similarly be achieved by helping mothers relax while expressing milk for their preterm babies (Feher, Berger, Johnson & Wilde, 1989). Coping with the emotional crisis

Premature delivery represents a severe life stress for many parents (Minde, 1984) interfering with their potential for appropriate caretaking (Crnic, Greenberg, Ragozin, Robinson & Basham, 1983a). Thus it has been argued that dealing with the resolution of the emotional crisis will indirectly benefit the relationship with the infant and lead to developmental gains (Boukydis, 1986; Klaus & Kennell, 1982b; Sammons & Lewis, 1985). One way of helping parents is the facilitation of parent meetings where they can share their emotional and practical problems and search for solutions (Dammers & Harpin, 1982; McGuire & Gottlieb, 1979; Minde etai, 1980). Minde, Shosenberg, Thompson and Marton (1983a) evaluated the short- and long-term effects of a parent self-help group on the parent-infant relationship in the hospital and beyond. Seven to 12 weekly sessions helped the mother to feel more competent and resulted in more visiting and interaction with the infant. The short-term effects were not maintained to 1 year of age (Minde el ai, 1980, 1983a). It is common sense that everything should be done to encourage parental visiting, encourage contact with their infant and to deal with the parents' anxieties and financial worries (see Minde, 1984; Klaus & Kennell, 1982b; Wolke & Eldridge, in press). However, this support for parents may not automatically lead to better caregiving. Parental education

Parents need not only to feel competent but may need the skills to understand and interact with the small infant appropriately (Heifer, 1987). The Neonatal Behavioral Assessment Scale (NBAS; Brazelton, 1984) has been used as a tool to demonstrate to parents the newborn's competence and weaknesses. The NBAS demonstration provides a platform for discussions with parents about caretaking approaches suited to the individual infant's behavioural organization (see Cardone & Gilkerson, in press; Nugent, 1985; Widmayer & Field, 1980, 1981; Worobey, 1985). Widmayer & Field (1980, 1981) demonstrated that maternal observation and administration of the NBAS

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to preterm infants was reflected in more optimal face-to-face interaction at 1 month and increased mental developmental scores at 1 year. Culp, Culp & Harmon (1989) also reported that an adapted version of the NBAS for preterm infants, the Assessment of Preterm Infants' Behavior (Als, Lester, Tronick & Brazelton, 1982), is a good way of educating parents about the preterm infant's abilities. Overall, demonstrating and explaining the preterm newborn's behaviour to parents and discussing its implications for caretaking and interaction has some small to moderate effects on the preterm infant's development.

Home Interventions and Integrated Approaches A range of well planned studies have evaluated the effect of providing a wide range of socicd and practical support and structured interaction and developmental coaching to parents of LBW infants. Most of the programmes aimed to reach socially deprived, young and often single mothers. Home visiting programmes

Ross (1984) showed that monthly home visits by a nurse and occupational therapist, teaching the mother about infant development and instructing her in games, led to significant gains in the infant's mental development. The mothers were observed to be more involved, organized and provided more appropriate play stimulation (Ross, 1984). Similar improvements in the families' home environment were reported by Barrera, Rosenbaum and Cunningham (1986). However, Barrera et ai (1986) failed to demonstrate significant gains in mental development and in face-to-face interaction over the 16-month follow-up period. Overall, they concluded that the gains were greater in their interaction coaching treatment group than in a second treatment consisting of developmental teaching to the parents. Two other recent clinical studies of home monitoring and teaching programmes which commenced shortly after discharge of the infants from hospital reported positive effects on the preterm infants' development (Barnard et ai, 1987), or on the parents' psychological adaptation (Lennard, Scott & Scotsman, 1989). In contrast, two other studies found no positive effects of interaction coaching on the mother-infant relationship or cognitive development (Bromwich & Parmalee, 1979; Parker-Loewen & Lytton, 1986). The negative findings by Bromwich & Parmalee (1979) are likely to be due to the timing of the intervention (the programme began at 10 months, well after early interactional patterns were established) and the nature of the selection criteria—programme availability was established in part by delayed cognitive development at 9 months. Parker-Loewen & Lytton's (1986) study was not a home-based study, the interaction coaching being carried out in the laboratory. The procedure was directive and instructions were radioed to the mother during interaction using the "bug in the ear method". Again, the interaction coaching commenced a considerable time after the infant had been discharged from hospital. Affleck, Tennen, Rowe, Roscher and Walker (1989) also reported no main effects of a 15-week home visiting programme on maternal adaptation following the discharge

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of the LBW infant from the special care baby unit. They found, however, that maternal need for support at the onset of the intervention programme and the severity of infant medical complications predicted the outcome. Improved adaptation was found for mothers who had a great need for support or a very ill infant, while negative effects were found for mothers who had little need for support. The intervention programme appeared to have undermined their optimistic outlook for their LBW children. Affleck et al.'s (1989) study underlines that support programmes should be tailored to the individual's needs. Integrated support programmes

Three recent studies reported on the effectiveness of integrated intervention approaches, combining sensory stimulation in the neonatal intensive care unit with parent centred interventions in hospital and continuing support at home (Nurcombe et ai, 1984; Rauh, Achenbach, Nurcombe, Howell & Teti, 1988; Resnick, Davis, Eyler, Nelson, Eitzman & Bucciarelli, 1987; Scarr-Salapatek & Williams, 1973). All three studies found statistically and clinically significant gains relative to LBW control groups of 10-13 points in cognitive developmental scores at ages ranging from 12 to 48 months. Rauh et ai (1988), in particular, demonstrated the need for longer term follow-up. They found significant effects on maternal adaptation 6 months after discharge, but failed to demonstrate significant sensorimotor or cognitive gains for the infants in the first year (Nurcombe et ai, 1984). The differences between treatment and control groups increased over time and were highly significant at 3 and 4 years of age, although the home intervention programme had long since finished (90 days after discharge of the infant from hospital). Furthermore, Rauh et al. 's (1988) design included an additional full-term control group. The preterm intervention group had, on average, identical IQscores to those of the full-term children at 4 years, while the preterm infants who did not receive any intervention were significantly delayed.

Conclusions 1. There is a need for theoretically founded developmental support programmes for LBW infants to prevent some of the likely adverse outcomes. Brief, and not individualized interventions, such as extra stimulation programmes, are likely to provide only short-term gains. They are usually inexpensive to administer and their place appears to be mainly confined to short-term improvements of physiological functioning, the promotion of sucking and weight gain. As Field et ai (1982) pointed out, this is an important aim in itself as even one day less spent in hospital means important savings. Similarly, interventions centred on helping parents cope with the emotional crisis seem to have little effect on the LBW infants' developmental outcome. In contrast, some short-term behavioural and cognitive gains have been demonstrated using brief interventions centred on parent education using the NBAS (e.g. Widmayer & Field, 1981). Longer term positive effects on the maternal interaction style and cognitive development have been demonstrated most consistently when comprehensive intervention models have been applied which were rooted in developmental principles

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and previous basic research (Als et ai, 1986; Rauh et ai, 1988; Resnick et ai, 1987; Scarr-Salapatek & Williams, 1973). These interventions require individual careplans, centred on the infant's behavioural organization, the mother-child interaction and the parents' needs (see Wolke, 1986; Wolke & Eldridge, in press). 2. Invention programmes should be timed to start as soon as possible in the neonatal intensive care unit. Preventive measures implemented after caretaking patterns are established or developmental delay has been diagnosed have been found to be less successful (Bromwich & Parmalee, 1979; Heinicke, Beckwith & Thompson, 1988). 3. More research is needed to: (a) replicate findings where small samples have been studied (e.g. Als et ai, 1986); (b) ascertain that developmental gains from intervention programmes will be maintained into the school years—a time when individual vulnerabilities of apparently healthy preterm children are often noticed (Lloyd et ai, 1988). Overall, small and inexpensive changes in the physical and social environment and nursing care patterns should be implemented in all special care baby units to help reduce unnecessary suffering of the smallest infants (primary intervention) (see Wolke & Eldridge, in press; Wolke, 1986). These include changes in nursing practices (i.e. handling patterns), noise and light, pollution and the positioning of infants. Self-help of LBW parents should be encouraged and regular professional contacts and followup of the LBW children should be made available to allow parents to seek support if subsequent problems arise. Complex individual care programmes, centring on the developing infant's behavioural organization, the parent-child interaction and the parents' needs (e.g. Als et ai, 1986; Rauh et ai, 1988) show promise in promoting the development of the smallest and sickest infants living with socially deprived parents (Ross, 1984). Extended individual care should be available for the neediest mothers and sickest newboms (Affleck et ai, 1989). These programmes, although not cheap (c. 4000 U.S.$ per subject; Resnick et ai, 1987), are much less expensive than later remedial programmes and the medical care provided to neonates. In the long term, developmental support may be a financially cheap option for health professionals to take. Acknowledgement—Preparation of this paper was supported by a grant from the Wellcome Trust.

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