Published online December 1, 2004
PEDIATRICS Vol. 114 No. 6 December 2004, pp. 1739 (doi:10.1542/peds.2004-1938)
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Early Intervention in Preterm Infants After Discharge From Hospital: In Reply

Heidelise Als, PhD
Department of Psychiatry
Harvard Medical School and Children's Hospital Boston
Boston, MA 02115

In Reply.—

The letter by Wolf et al raises the important point of the effectiveness of neurobehavioral intervention after discharge from the neonatal intensive care unit (NICU) for early-born preterm infants. The data presented are difficult to evaluate, as the authors acknowledge, given the methodologic shortcomings; these include, among others, the historical design and the lack of protection against examiner bias in terms of the outcome assessments.

If one were to assume that a methodologically well-executed study would yield similar results, the degree and specificity of intervention effects found might indeed shed light on the nature of plasticity that the infant brain possesses in the last trimester of pregnancy compared with the 6 months after term. Of interest is that the Holland study described by Wolf et al did not find motor-organization improvement in their experimental group, whereas in Newborn Individualized Developmental Care and Assessment Program (NIDCAP) studies, such effects typically are among the most robust findings.1–5 It may well be that association motor cortical areas have a more limited window of modifiability than other association cortical areas potentially enjoy.

To explore such questions, desirable would be a randomized, controlled trial with 4 preterm groups and a term comparison group as follows: group 1, neurodevelopmental care (NIDCAP) in the NICU to 2 weeks' corrected age; group 2, NIDCAP to 2 weeks' corrected age plus infant behavioral assessment intervention from 2 weeks' to 6 months' corrected age; group 3, infant behavioral assessment intervention from 2 weeks to 6 months; group 4, neither in NICU nor postdischarge interventions; and group 5, a medically healthy, term comparison group. In addition to the Bayley II6 behavior rating scales, the Bayley II mental developmental and psychomotor developmental indexes would be of importance to collect, and regional brain structural and neurophysiological measures would be of great interest in this context.

We encourage such studies and thank the authors for their thoughtful comments.

REFERENCES

  1. Als H, Lawhon G, Brown E, et al. Individualized behavioral and environmental care for the very low birth weight preterm infant at high risk for bronchopulmonary dysplasia: neonatal intensive care unit and developmental outcome. Pediatrics. 1986;78 :1123 –1132[Abstract/Free Full Text]
  2. Als H, Lawhon g, Duffy FH, McAnulty GB, Gibes-Grossman R, Blickman JG. Individualized developmental care for the very low-birth-weight preterm infant. Medical and neurofunctional effects. JAMA. 1994;272 :853 –858[Abstract]
  3. Mouradian LE, Als H. The influence of neonatal intensive care unit caregiving practices on motor functioning of preterm infants. Am J Occup Ther. 1994;48 :527 –533[ISI][Medline]
  4. Buehler DM, Als H, Duffy FH, McAnulty GB, Liederman J. Effectiveness of individualized developmental care for low-risk preterm infants: behavioral and electrophysiologic evidence. Pediatrics. 1995;96 :923 –932[Abstract/Free Full Text]
  5. Als H, Duffy FH, McAnulty GB, et al. Early experience alters brain function and structure. Pediatrics. 2004;113 :846 –857[Abstract/Free Full Text]
  6. Bayley N. Bayley Scales of Infant Development. 2nd ed. San Antonio, TX: The Psychological Corporation; 1993
PEDIATRICS (ISSN 1098-4275). ©2004 by the American Academy of Pediatrics

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