Developmental Care Does Not Alter Sleep and Development of Premature Infants

ArticleinPEDIATRICS 100(6):E9 · January 1998with13 Reads
Impact Factor: 5.47 · DOI: 10.1542/peds.100.6.e9 · Source: PubMed
Abstract

The Neonatal Individualized Developmental Care Program (NIDCAP) for very low birth weight (VLBW) preterm infants has been suggested by Als et al to improve several medical outcome variables such as time on ventilator, time to nipple feed, the duration of hospital stay, better behavioral performance on Assessment of Preterm Infants' Behavior (APIB), and improved neurodevelopmental outcomes. We have tested the hypothesis of whether the infants who had received NIDCAP would show advanced sleep-wake pattern, behavioral, and neurodevelopmental outcome. Thirty-five VLBW infants were randomly assigned to receive NIDCAP or routine infant care. The goals for NIDCAP intervention were to enhance comfort and stability and to reduce stress and agitation for the preterm infants by: a) altering the environment by decreasing excess light and noise in the neonatal intensive care unit (NICU) and by using covers over the incubators and cribs; b) use of positioning aids such as boundary supports, nests, and buntings to promote a balance of flexion and extension postures; c) modification of direct hands-on caregiving to maximize preparation of infants for, tolerance of, and facilitation of recovery from interventions; d) promotion of self-regulatory behaviors such as holding on, grasping, and sucking; e) attention to the readiness for and the ability to take oral feedings; and f) involving parents in the care of their infants as much as possible. The infants' sleep was recorded at 36 weeks postconceptional age (PCA) and at 3 months corrected age (CA) using the Motility Monitoring System (MMS), an automated, nonintrusive procedure for determining sleep state from movement and respiration patterns. Behavioral and developmental outcome was assessed by the Neurobehavioral Assessment of the Preterm Infant (NAPI) at 36 weeks PCA, the APIB at 42 weeks PCA, and by the Bayley Scales of Infant Development (BSID) at 4, 12, and 24 months CA. Sleep developmental measures at 3 months CA showed a clear developmental change compared with 36 weeks PCA. These include: increased amount of quiet sleep, reduced active sleep and indeterminate sleep, decreased arousal, and transitions during sleep. Longest sleep period at night showed a clear developmental effect (increased) when comparing nighttime sleep pattern of infants at 3 months with those at 36 weeks of age. Day-night rhythm of sleep-wake increased significantly from 36 weeks PCA to 3 months CA. However, neither of these sleep developmental changes showed any significant effects of NIDCAP intervention. Although all APIB measures showed better organized behavior in NIDCAP patients, neither NAPI nor Bayley showed any developmental advantages for the intervention group. The neurodevelopmental outcome measured by the Bayley at 4, 12, and 24 months CA showed 64% of the NIDCAP intervention group at the lowest possible score compared with 33% of the control group. These findings could not be explained by the occurrence of intraventricular hemorrhage or the socioeconomic status of the parents, which showed no significant group effect. The results of this study, including measures of sleep maturation and neurodevelopmental outcome up to 2 years of age did not demonstrate that the NIDCAP intervention results in increased maturity or development. Buehler et al (Pediatrics. 1995;96:923-932) have reported that premature infants (N = 12; mean gestational age 32 weeks, mean birth weight 1700 g) who received developmental care compared with a similar group of infants who received routine care showed better organized behavioral performance on an APIB assessment at 42 weeks PCA. None of the medical outcome measures were significantly different in this study. Although our APIB results are in agreement, the results of the NAPI, the Bayley and sleep measures do not show an increase in neurodevelopmental maturation. In the earlier report by Als et al (Journal of the American Medical Associatio

    • "...When awake, however, they remained alert and attentive. In contrast, Ariagno et al. (1997) found that the infants spent a smaller percentage of time sleeping during the assessment and were more irritable when aw..."
      When awake, however, they remained alert and attentive. In contrast, Ariagno et al. (1997) found that the infants spent a smaller percentage of time sleeping during the assessment and were more irritable when awake. This state of sleep-wake transition is expected to increase until 40 weeks and decrease after 43 weeks CA (Holditch-Davis, Scher, Schwartz, & Barr, 2004 ).
    Full-text · Dataset · Jan 2014
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    • "...ficant differences in sleep organization were observed between 36 and 52 weeks post menstrual ages [25] although statistical power was decreased because of small sample sizes [26]. Three other studies re..."
      In a randomized control trial, [24] found no changes in quiet sleep percentage at 32 and 36 weeks post-menstrual age using amplitude integrated EEG (i.e. a single channel displaying both frequency and amplitude signals). No significant differences in sleep organization were observed between 36 and 52 weeks post menstrual ages [25] although statistical power was decreased because of small sample sizes [26]. Three other studies reported negative results after altered lighting conditions in the neonatal intensive care unit (NICU).
    [Show abstract] [Hide abstract] ABSTRACT: OBJECTIVE: Skin-to-skin contact (SSC) promotes physiological stability and interaction between parents and infants. Temporal analyses of predictability in EEG-sleep time series can elucidate functional brain maturation between SSC and non-SSC cohorts at similar post-menstrual ages (PMAs). METHODS: Sixteen EEG-sleep studies were performed on eight preterm infants who received 8weeks of SSC, and compared with two non-SSC cohorts at term (N=126) that include a preterm group corrected to term age and a full term group. Two time series measures of predictability were used for comparisons. RESULTS: The SSC premature neonate group had increased complexity when compared to the non-SSC premature neonate group at the same PMA. Discriminant analysis shows that SSC neonates at 40weeks PMA are closer to the full term neonate non-SSC group than to the premature non-SSC group at the same PMA; suggesting that the KC intervention accelerates neurophysiological maturation of premature neonates. CONCLUSIONS: Based on the hypothesis that EEG-derived complexity increases with neurophysiological maturation as supported by previously published research, SSC accelerates brain maturation in healthy preterm infants as quantified by time series measures of predictability when compared to a similar non-SSC group. SIGNIFICANCE: Times series methods that quantify predictability of EEG sleep in neonates can provide useful information about altered neural development after developmental care interventions such as SSC. Analyses of this type may be helpful in assessing other neuroprotection strategies.
    Full-text · Article · Sep 2012 · Clinical neurophysiology: official journal of the International Federation of Clinical Neurophysiology
    0Comments 15Citations
    • "...orted no differences in sleep organization with changes in sleep input (Becker et al 1993, Ariagno el al 1997, Hellstrom-Westas etal 2001, Brandon et al 2001, Westrup et al 2002, Mirmiran et al 2003). ..."
      Comparisons among SSC studies remain difficult because different methods to access sleep organization were used, different methods of developmental intervention were applied, and environmental variables such as light, sound, and tactile stimulation were not uniformly reported. For example, studies reported no differences in sleep organization with changes in sleep input (Becker et al 1993, Ariagno el al 1997, Hellstrom-Westas etal 2001, Brandon et al 2001, Westrup et al 2002, Mirmiran et al 2003).
    [Show abstract] [Hide abstract] ABSTRACT: Skin-to-skin contact (SSC) promotes physiological stability and interaction between parents and infants. Analyses of EEG-sleep studies can compare functional brain maturation between SSC and non-SSC cohorts. Sixteen EEG-sleep studies were performed on eight preterm infants who received 8 weeks of SSC, and compared with two non-SSC cohorts at term (N=126), a preterm group corrected to term age and a full-term group. Seven linear and two complexity measures were compared (Mann-Whitney U test comparisons p<.05). Fewer REMs, more quiet sleep, increased respiratory regularity, longer cycles, and less spectral beta were noted for SSC preterm infants compared with both control cohorts. Fewer REMs, greater arousals and more quiet sleep were noted for SSC infants compared with the non-SSC preterms at term. Three right hemispheric regions had greater complexity in the SSC group. Discriminant analysis showed that the SSC cohort was closer to the non-SSC full-term cohort. Skin-to-skin contact accelerates brain maturation in healthy preterm infants compared with two groups without SSC. Combined use of linear and complexity analysis strategies offer complementary information regarding altered neuronal functions after developmental care interventions. Such analyses may be helpful to assess other neuroprotection strategies.
    Full-text · Article · Sep 2009 · Clinical neurophysiology: official journal of the International Federation of Clinical Neurophysiology
    0Comments 70Citations
    • "...ence was observed in sleep organization at 36 and 52 weeks post-conceptional age by Ariagno et al. [20]. However, this last study were not designed primarily to analyze sleep and statistical power may ha..."
      In a randomized controlled trial by Westrup et al. [19] including 22 premature infants, using aEEG, no change in QS at 32 and 36 weeks was observed. No significant difference was observed in sleep organization at 36 and 52 weeks post-conceptional age by Ariagno et al. [20]. However, this last study were not designed primarily to analyze sleep and statistical power may have been decreased because of an insufficient number of patients in each group [21] .
    [Show abstract] [Hide abstract] ABSTRACT: Sleep is the main behavioral state of the premature infant. In adult intensive care units, sleep deprivation has been reported as one of the major stressors. Developmental care (DC) aims to decrease stressful events in neonatal intensive care unit and support well-being. To assess whether DC is accompanied by changes in sleep in preterm neonates. A prospective cross-over study included 33 preterm neonates [mean (S.D.): gestational age: 29.3 (1.8) weeks; birth weight: 1245 (336) g]. Polysomnography was performed in two randomly ordered 3-h periods with and without DC. A blinded electrophysiologist analyzed sleep. The total sleep time (TST) was the primary outcome, duration of active (AS), quiet (QS) and indeterminate sleep, and latency before sleep were the secondary outcomes. Non-parametric Wilcoxon tests and ANOVA were used. In DC condition vs. control: TST increased [in minutes, mean (S.E.M.): 156.2 (2.9) vs. 139.2 (4.6), p=0.002], with increase in AS [86.6 (3.7) vs. 77.0 (4.2), p=0.024] and in QS [47.1 (4.1) vs. 36.9 (4.2), p=0.015], and sleeping latency decreased (2.1 (0.7) vs. 10.5 (2.0), p=0.0005]. DC promoted sleep in our study. The impact of DC on the neuro-behavioral outcome needs futures studies.
    Full-text · Article · Aug 2005 · Early Human Development
    0Comments 58Citations
    • "...pt underlying maturation of sleep patterns when delivered to convalescing preterm infants (Ariagno et al. 1997). Although we sampled sleep over two 45-minute periods rather than conducting 24-hour studies, it i..."
      By contrast, the percentage of alertness did not correlate with duration of hospital stay for the control group until after 35 weeks' PCA. These findings are consistent with previous literature in that the intervention did not disrupt underlying maturation of sleep patterns when delivered to convalescing preterm infants (Ariagno et al. 1997). Although we sampled sleep over two 45-minute periods rather than conducting 24-hour studies, it is likely that the loss of quiet sleep in the study group was compensated for in subsequent sleep periods and did not represent any real deprivation of a developmentally important stage of sleep.
    [Show abstract] [Hide abstract] ABSTRACT: This study determined whether an auditory, tactile, visual, and vestibular intervention (ATVV) reduced the length of hospitalization of 37 preterm infants by increasing the proportion of alert behavioral states, thereby improving their feeding progression. Participants comprised 12 infants born between 23 and 26 weeks' gestation with normal head ultrasounds and 25 CNS-injured infants born between 23 and 31 weeks' gestation. Infants were randomly assigned to the control group (11 males, five females) or study group (seven males, 14 females) at 32 weeks' postconceptional age. ATVV intervention was administered to the study group for 15 minutes, twice daily, 5 days per week, from 33 weeks of age until discharge. The study group demonstrated increased alertness during the first 5 minutes of intervention, which was significantly correlated to length of stay (p<0.05). The proportion of nippled (teat) intake increased significantly faster for the study group (p=0.0001). Infants in the study group were discharged at a mean of 36.54 weeks, 1.6 weeks earlier than control infants (p<0.05). ATVV intervention facilitated increased alertness, faster transition to complete nipple feeding, and decreased length of hospitalization.
    Full-text · Article · Feb 2002 · Developmental Medicine & Child Neurology
    0Comments 56Citations
    • "...pt underlying maturation of sleep patterns when delivered to convalescing preterm infants (Ariagno et al. 1997). Although we sampled sleep over two 45-minute periods rather than conducting 24-hour studies, it i..."
      By contrast, the percentage of alertness did not correlate with duration of hospital stay for the control group until after 35 weeks' PCA. These findings are consistent with previous literature in that the intervention did not disrupt underlying maturation of sleep patterns when delivered to convalescing preterm infants (Ariagno et al. 1997). Although we sampled sleep over two 45-minute periods rather than conducting 24-hour studies, it is likely that the loss of quiet sleep in the study group was compensated for in subsequent sleep periods and did not represent any real deprivation of a developmentally important stage of sleep.
    [Show abstract] [Hide abstract] ABSTRACT: This study determined whether an auditory, tactile, visual, and vestibular intervention (ATVV) reduced the length of hospitalization of 37 preterm infants by increasing the proportion of alert behavioral states, thereby improving their feeding progression. Participants comprised 12 infants born between 23 and 26 weeks’gestation with normal head ultrasounds and 25 CNS-injured infants born between 23 and 31 weeks’gestation. Infants were randomly assigned to the control group (11 males, five females) or study group (seven males, 14 females) at 32 weeks’postconceptional age. ATVV intervention was administered to the study group for 15 minutes, twice daily, 5 days per week, from 33 weeks of age until discharge. The study group demonstrated increased alertness during the first 5 minutes of intervention, which was significantly correlated to length of stay (p<0.05). The proportion of nippled (teat) intake increased significantly faster for the study group (p=0.0001). Infants in the study group were discharged at a mean of 36.54 weeks, 1.6 weeks earlier than control infants (p<0.05). ATVV intervention facilitated increased alertness, faster transition to complete nipple feeding, and decreased length of hospitalization.
    Full-text · Article · Jan 2002 · Developmental Medicine & Child Neurology
    0Comments 16Citations
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