Ohlsson and Jacobs1 have again examined the NIDCAP and the research on its efficacy. The Board of Directors of the NIDCAP Federation International (NFI) deems their report an invalid and misleading evaluation of a well-established and demonstrably effective program.
In fact, they summarize an array of impressive results, most from randomized controlled trials in which NIDCAP treatment of premature infants produced statistically significant effects (tables, figure, and findings all from Ohlsson & Jacobs, 2013),1 including reduced hospitalization (Table 3); earlier (younger postmenstrual age) hospital discharges (Table 3); increased weight gain (Table 4); improved neurologic markers, seen on both electroencephalography and MRI; and improvements on several standard assessment tools, including the Bayley Mental Development Index, Bayley Psychomotor Development Index, and Assessment of Preterm Infants’ Behavior (Table 2 and Fig 3).1
By applying inappropriate criteria to measure success, the authors dismiss the substantive, impressive, and clinically significant findings summarized in the report. Specifically the authors set the bar for “effectiveness of NIDCAP” in terms of “the composite of death or major sensorineural disability at 18 months” and secondary, short-term outcomes such as “in hospital deaths, chronic lung disease . . . necrotizing enterocolitis, [and] intraventricular hemorrhage.” In contrast, NIDCAP is aimed at a different array of important targets. Heidelise Als, who designed and founded NIDCAP more than 30 years ago, states, “NIDCAP’s goal is to prevent unexpected sensory overload and pain, and enhance strength and competence” of infants born prematurely.2 Such pathways are guided by a combination of observation, assessment, and nursery interactions. These guide regimens of holding, positioning and movement, environmental modification, parental involvement, and staff education that improve developmental trajectories. This is where the bar for NIDCAP should be placed. These are the standards by which NIDCAP is evaluated appropriately, with significant results in both medical and developmental parameters.
NIDCAP rests on a large body of neurodevelopmental data and evidence-based principles, particularly in areas involving sensory system development, relations between stress hormones and autonomic development, regulation of infant sleep and attention states, and the emergence of parent–infant interactions. These core areas were overlooked or even ignored in the meta-analysis. As NIDCAP professionals representing a range of relevant disciplines, along with parents who have experienced the developmental challenges of prematurely born infants, we seek to understand how NIDCAP works and the parameters affecting each of its elements. Among the research questions explicitly identified by Als et al (2004)2 and ignored by Ohlsson and Jacobs (2013)1 are “neurophysiological and brain structural outcomes,” “effects on parents,” and “effects on staff and systems.” Perhaps Ohlsson and Jacobs’ resistance to evaluating NIDCAP on relevant dimensions reflects their own resistance to system change.
NIDCAP has already changed NICU practice, contributed to novel environmental features, increased parental involvement, and improved the experiences and developmental outcomes of premature infants worldwide. We look forward to continuing to improve the future of infants and parents who experience intensive care.
Conflict of Interest:
All authors are members of the Board of Directors of NIDCAP Federation International. The federation was incorporated in 2001 as not-for-profit membership organization that educates and supports NIDCAP professionals in NICUs around the world and has certified 21 NIDCAP Training Centers in 10 countries (with more certifications under way).
- Als H,
- Duffy FH,
- McAnulty GB,
- et al
- Ohlsson A,
- Jacobs SE
- Copyright © 2013 by the American Academy of Pediatrics