Neonatal Parent Baby Interaction Programme does not affect mental or psychomotor development of preterm infants at corrected age 2 years
- Mary Margaret Gottesman
The Ohio State University, College of Nursing, 1585 Neil Avenue, Columbus, OH 43210, USA;
The preterm infant birth rate continues to rise in the USA, particularly the late preterm infant birth rate.1 Improvements in developmental and behavioural outcomes for preterm infants have not kept pace with improvements in survival rates.2 Even late preterm infants have multiple developmental morbidities.3 Research has demonstrated the negative impact of preterm birth on the quality of parenting that preterm infants receive and on later physical and mental disability in infants.4
Intervention studies providing education and support to enhance the quality of parenting that preterm infants receive have demonstrated at least some shortterm improvements in developmental outcomes after discharge.5 Early interventions within the intensive care environment have been less numerous, particularly parent-focused, educational interventions.6 Prevention efforts aimed at limiting the negative impact of social stressors on parents and preterm infants are an important new focus for intervention research.7
Johnson and colleagues evaluated the impact of a structured parent educational intervention, the Parent Baby Interaction Programme, on mental and physical developmental outcomes for a sample of infants born at or before 32 weeks’ gestation. The random crossover design was implemented at two neonatal centres in the UK, with approximately 75% of eligible mothers consenting to participate. In addition to standard care, each week the mothers in the intervention sample (n = 112) were offered educational content on infant cues and behaviour and on appropriate parent responses by specially trained nurses who were not staff nurses in the intensive care nurseries. The goal was to enhance the quality of parent– infant interaction, minimising infant distress and preparing parents to nurture their infants successfully. Mothers in the control sample were offered standard care only. Results indicated no difference between the intervention and control group infants at 24 months’ corrected age on either the mental or physical subscale of the Bayley Scales of Infant Development.
The study has a number of notable strengths in comparison to previous in-hospital neonatal intensive care unit intervention studies. A clustered randomised controlled trial with crossover design provided a larger intervention sample than in most similar studies. The study was well powered to detect differences between groups. The intervention was a single intervention rather than a combined intervention, as found in most other studies, where significant effects could not be attributed to any specific dimension of the intervention. Finally, the gold standard of instruments for assessing early infant development, the Bayley Scales of Infant Development, was used to evaluate infant developmental outcomes and was administered, with strong inter-rater reliability, by wellprepared assessors blinded to infant group membership.
Weaknesses of the study included the lack of a guiding theoretical framework for the intervention. Adult educational theory suggests that information is best learnt when it is relevant, reinforced and applied. The content offered was relevant, and weekly meetings with mothers offered some opportunity for reinforcement and clarification of previously learnt information. Nevertheless, as most parents find the neonatal intensive care unit environ ment intimidating, parents often require the encouragement and support of the infant’s nurse to engage with the infant, and many parents fear they might cause harm by doing the simplest of care tasks, such as diaper changing. The failure to include the nurses who provided direct care in the teaching and learning intervention meant there was no ready resource for clarifying information, and it was left to the mothers to seek opportunities to practise applying the information to the care of their infants.
The authors provided no information on the ethnic and language diversity of the sample of mothers or the ability of the nurses to administer the intervention successfully. There was no evaluation of the intervention by mothers before or after it was conducted. This would have helped ensure that content was relevant, was perceived as necessary and was offered in ways that mothers found understandable and acceptable. An evaluation after the intervention would have offered guidance for improving the intervention for future studies. Finally, although the intention of the authors was to enhance the parent– infant relationship, no measures of the quality of this relationship were included in the study. Consequently, it is unclear whether the quality of the parent–infant relationship was affected by the intervention.
Systematic reviews of interventions for preterm infants while they are in hospital and after discharge show limited and usually short-term benefits to preterm infant development.5 6 Well-powered randomised trials of single interventions informed by theoretical frameworks are required to identify strategies that boost the effective parenting of preterm infants and minimise the negative impact on developmental outcomes. Evidence on such strategies remains elusive.7
Competing interests None.