Focused Question:
Does the use of the Newborn Individualized Developmental Care and Assessment Program
(NIDCAP) promote achievement of developmental milestones for infants treated in the NICU?
Prepared By:
Danielle Goddard, OT-S, CCLS, & Natalie Noss, OT-S
Date Review Completed:
October 13, 2014
Clinical Scenario:
The rapid development of medical sciences in the last thirty years has enabled the successful
delivery and survival of infants weeks and sometimes months before their expected due dates.
However, early birth prevents infants from achieving the final and often crucial stages of fetal
development in the womb. According to statistics from the United States Center for Disease
Control and Prevention (CDC), pre-term births currently account for over 12.5% of all births
nationwide (Center for Disease Control and Prevention [CDC], 2013). Babies who are born pretermor before the thirty-seventh week of fetal developmentare highly at risk for
developmental, neurological, respiratory, and other complications. Pre-term births are also the
most highly-correlated predictor of infant death. Twenty-five percent of infants who are born
prematurely are also underweight for their gestational age (GA) (Newborn Individualized
Developmental Care and Assessment Program [NIDCAP], 2014). Premature births and low
birth weights (LBW) can be linked to disorders such as cerebral palsy, respiratory and cardiac
conditions, feeding difficulties, hearing or vision impairments, and attentional or behavior
deficits later in life (CDC, 2013). Premature infants overall are hypersensitive, difficult to feed,
and difficult to calm (NIDCAP, 2014). These characteristics can also affect paternal/infant
bonding, especially if parents are not knowledgeable about what behaviors to expect from their
premature babies.
In addition to being generally at-risk due to their early delivery, infants who are treated in the
Adapted from AOTA Evidence-Based Literature Review Project/7 CAT Worksheet.5-05
neonatal intensive care unit (NICU) are immediately exposed to a medical environment full of
excessive and inappropriate sensory stimuli (American Occupational Therapy Association
[AOTA], 2010). Harsh lighting, excessive noise, limited caregiver contact and meaningful
touch, and painful medical procedures can all contribute to the overwhelming sensory
environment. These stimuli can cause stress for the infant and family. Extreme stress over time
can cause the newborn to become unable to self-regulate autonomic and physiological responses
and can compromise the babys already delicate immune and developmental processes. Some
studies, in fact, indicate that the overwhelming stimuli in the NICU environment may directly
affect the development, structure, and function of the infants neurological system (Kleberg,
Westrup, Stjernqvist, & Lagercrantz, 2002).
NIDCAP was developed by Heidelise Als and her associates in the early 1990s to address the
development and unique needs of the premature and LBW infant. This program utilizes infant
observation by trained professionals before, during, and after caregiving or medical procedures
in order to monitor physiological and behavioral responses as well as assess the infants ability
to modulate his or her reactions. Infants are assessed based on five subsystems, including
autonomic-physiological, motor, state organizational, attentional-interactive, and self-regulatory
systems. These systems are interrelated according to Als; therefore disruption in one system can
profoundly influence the function of the others. For example, creating an individualized plan
which helps the infant calm and regulate his movements can result in improved autonomic
function (i.e. controlled respiration and vitals) which can then in turn promote the infants ability
to interact socially with the parent or caregiver. The goal of NIDCAP is to create a personalized
plan for each infant based on individualized needs for caregiving and stimulus control (Westrup,
Kleberg, von Eichwald, Stjernqvist, & Lagercrantz, 2000).
Summary of Key Findings:
Summary of Level I findings:
Findings supporting NIDCAP:
Compared to control group infants who received standard care, infants receiving
NIDCAP showed significantly better neurobehavioral performance at 2 weeks
corrected age (CA) (i.e. three of the six Assessment of Pre-term Infant Behavior
[APIB] scores: autonomic, self-regulation, and motor system scores) (Als et al.,
2011; Als et al., 1994).
At 9 months CA, infants in both intervention and control groups presented with
comparable health. But, significantly better neurobehavioral functioning was shown
by the Bayley-II for the intervention group in various score areas (Als et al., 2011).
Infants who received NIDCAP had reduced mechanical ventilation, experienced
earlier oral feeding, and had lower incidences of intraventricular hemorrhage (IVH)
than the control group (Als et al., 1994; Westrup et al., 2000).
Intervention group infants showed favorable differences in terms of gross and fine
motor modulation, overflow postures, social play, and ability to stay engaged at 9
months (Als et al., 1994).
After receiving NIDCAP immediately after birth, infants displayed better
performance in areas of spatial visualization, mental control, attention, integrative
Adapted from AOTA Evidence-Based Literature Review Project/7 CAT Worksheet.5-05
skilled observation of newborns. They should also be familiar with learning and implementing
standardized pediatric batteries such as the APIB, the BSID-II, the Peabody Picture Vocabulary
Test (PPVT), the Wechsler Preschool and Primary Scale of Intelligence-Revised (WPPSI-R),
and the Kaufman Test of Educational Achievement (K-TEA) among others.
Refinement, revision, and advancement of factual knowledge or theory: Many of the studies
reviewed during this process postulate that the use of a NIDCAP intervention approach in the
NICU setting can and does affect physiological and developmental outcomes such as growth,
autonomic regulation, and early feeding. It should be noted that appropriate and individualized
infant treatment can positively affect serious medical, physical outcomes, and even psychosocial
outcomes such as parent-child bonding. It is believed that developmentally-appropriate and
individualized care which meets the unique needs of infants in terms of environmental stress
reduction, caregiver bonding, and promotion of growth and feeding will help minimize the
negative and potentially traumatizing effects of early hospitalization. After further studies are
completed with larger sample sizes, refinement of theory in terms of the efficacy of specific
programs (such as NIDCAP) may then be appropriate.
Review Process:
Identified focus of search as educational programs for NICU parents regarding infant
development
Discovered NIDCAP protocol and narrowed search to NIDCAP-based interventions
Refined focused search question
Identified a systematic review of NIDCAP-based randomized controlled trials (Ohlsson
& Jacobs, 2013)
Hand-searching of references in existing systematic review (Ohlsson & Jacobs, 2013)
Identified most relevant articles based on year of publication, exploration of
developmental outcomes, and availability of follow-up/longitudinal data
Articles meeting the criteria were selected for inclusion and were analyzed individually
using the McMaster University Critical Review Form (CRF) for Quantitative Studies
Summaries from each CRF were used to complete the Critically Reviewed Topic (CAT)
evidence table
The CAT worksheet was completed
Procedures for the Selection and appraisal of articles:
Inclusion Criteria:
Exclusion Criteria:
Studies published before 1994
Non Level I evidence
Studies not published in English
Search Strategies:
Categories
Patient/Client Population
Intervention
Outcomes
Results of Search:
Summary of Study Designs of Articles Selected for Appraisal:
Level of
Evidence
I
II
III
IV
V
Other
Qualitative Studies
TOTAL:
Number of Articles
Selected
10
0
0
0
0
0
10
Individualized Developmental Care and Assessment Program. Pediatrics, 123(4), 10811087. doi: 10.1542/peds.2008-1950
McAnulty, G. B., Duffy, F. H., Butler, S. C., Bernstein, J. H., Zurakowski, D., & Als, H. (2010).
Effects of the Newborn Individualized Developmental Care and Assessment Program
(NIDCAP) at age 8 years: Preliminary data. Clinical Pediatrics, 49(3), 258-270. doi:
10.1177/0009922809335668
Peters, K. L., Rosychuk, R. J., Hendson, L., Cote, J. J., McPherson, C., & Tyebkhan, J. M.
(2009). Improvement of short- and long-term outcomes for very low birth weight infants:
Edmonton NIDCAP trial. Pediatrics, 124(4), 1009-1020. doi: 10.1542/peds.2008-3808
Westrup, B., Bohm, B., Lagercrantz, H., & Stjernqvist, K. (2004). Preschool outcome in children
born very prematurely and cared for according to the Newborn Individualized
Developmental Care and Assessment Program (NIDCAP). Acta Paediatrica, 93(4), 498507.
Westrup, B., Kleberg, A., Von Eichwalk, K., Stjernqvist, K., & Lagercrantz, H. (2000). A
randomized, controlled trial to evaluate the effects of the Newborn Individualized
Developmental Care and Assessment Program in a Swedish setting. Pediatrics, 105(1),
66-72.
Other References:
American Occupational Therapy Association. (2010). Specialized knowledge and skills for
occupational therapy practice in the neonatal intensive care unit: NICU knowledge and
skills paper. Retrieved from
https://www.aota.org/~/media/Corporate/Files/Practice/Children/Browse/EI/OfficialDocs/Specialized%20KS%20NICU.ashx
Center for Disease Control and Prevention. (2013, December 9). Reproductive health. Retrieved
from http://www.cdc.gov/reproductivehealth/maternalinfanthealth/pretermbirth.htm
Newborn Individualized Developmental Care and Assessment Program (NIDCAP) Federation
International. (2014). Mission. Retrieved from http://nidcap.org/en/about-us/nfi/mission/
Ohlsson, A., & Jacobs, S. E. (2013). NIDCAP: A systematic review and meta-analyses of
randomized controlled trials. Pediatrics, 131(3), 881-893. doi: 10.1542/peds.2012-2121