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In this pilot study we investigated the feasibility of The Infant Behavioral Assessment and Intervention Program (IBAIP) in a group of preterm infants. At the age of 6 months, the neurobehavioural organization and self-regulatory competence of an intervention group was compared with a control group who had received the standard follow-up care. The intervention group consisted of 13 males and seven females (mean gestational age [GA] 29.2 weeks, SD 1.3wks; mean birthweight 1232g, SD 320g). The control group consisted of 11 males and nine females (mean GA 29wks, SD 1.6wks; mean birthweight 1198g, SD 397g). Inclusion criteria were: a GA of 32 weeks and family residence in the district of Amsterdam. Exclusion criteria were: severe congenital abnormalities, intraventricular haemorrhage grade III or IV, periventricular leukomalacia grade III or IV, and infants whose mothers had a history of illicit drug use. The intervention infants received 6 to 8 IBAIP interventions at home, from discharge until 6 months of age. The Neonatal Behavioral Assessment Scale was administered at term; the Infant Behavioral Assessment (IBA) at term, 3, and 6 months of age; and the Bayley Scales of Infant Development-II at 3 and 6 months (corrected age). At 6 months, intervention infants showed less stress and more approach behaviours on the IBA compared with control infants. These promising results warrant further evaluation in a randomized controlled trial.

Many low-risk preterm infants and their parents encounter interaction problems in early infancy. Characteristics of preterm infants make mutually satisfying parenting difficult to achieve and contribute to levels of parental stress (Field 1979, Minde 1983, Barnard and Kelly 1990, Singer 1999). Factors may include: a lack of physiological and state control (Fox 1983, Barr 1996), motor regulation problems (de Groot 1997, Mouradian 2000), difficulties in sensory information processing (Rose and Wallace 1985), attention or affective problems (Field 1979, Mouradian 2000), and the infant's medical condition (Singer 1999). Although these characteristics seem to be adaptive problems which disappear with time, they may be, alone or in combination, early markers of the important long-term effects of preterm birth (Perlman 2001).

Neuro and developmental deficits that become apparent in a preterm infant's later childhood adversely affect their social relations and school performance (Hille et al. 1994, Wolke and Meyer 1999, Saigal 2000, Hille et al. 2001). As the infant's developing neurobehavioural competence and later developmental outcomes may be 'buffered' by early caregiving conditions (Bakeman 1980, Shore 1997, Bronson 2000, Shonkhoff and Phillips 2001) the Infant Behavioral Assessment and Intervention Program (IBAIP; Hedlund 1998) was introduced to provide these infants and their parents with post-discharge support. The IBAIP assists parents and interventionists in adjusting their own interaction style to match the neurobehavioural needs of the infant more closely as they mature over time. The Synactive Model of Newborn Behavioural Organization and Development and the Newborn Individualized Developmental Care and Assessment Program (NIDCAP) served as the theoretical base upon which the IBAIP was developed (Als 1986, Als et al. 1986). The NIDCAP aims at reducing stress and supporting the infant's individual neurobehavioural organization throughout their stay in the neonatal intensive care unit (NICU), and enhances the parents' ability to support the neurobehavioural integrity of their baby. The few published studies on NIDCAP care describe shorter hospitalization, earlier oral feeding, decreased severity of medical problems, improved parent-infant interaction and developmental outcome in the short term (Als et al. 1986, Als 1994, Westrup 2000, Kleberg 2002). Indications of long-term positive effects on mother-child interaction and decreased behavioural problems have been reported in another recent Swedish study (Kleberg 2000). The methodological quality of these NIDCAP studies have, however, been criticized in peer reviews (Jacobs 2002, Symington and Pinelli 2002). These experts do agree that infants currently living within the hospital NICU environment may experience stress and discomfort caused by inappropriate environmental stimulation and caregiving that is not attuned to the infant's self-regulatory or co-regulatory needs. Suggestions for better designed NIDCAP-based intervention studies have been offered.

According to Als (1992), support and intervention should not end when the infant is discharged from the NICU, but must systematically link families and infants to sound models of community-based support that build on the care and intervention provided in the NICU. In addition, Singer (1999) recommends support services for mothers of preterm infants in the immediate postnatal period to be incorporated in follow-up programmes. We hypothesized that the IBAIP, serving as this neurobehavioural continuum, may prevent or restore mismatches in early interaction in the short term and may consequently protect the preterm infant from neurobehavioural and developmental deficits later in life. To date, no intervention studies using the IBAIP have been published with regards to either short- or long-term outcome; therefore, we designed two pilot studies in preparation for a larger, randomized effect study. In the first pilot study, we investigated the neurobehavioural profile of preterm infants with the Infant Behavioral Assessment (IBA; Hedlund and Tatarka 1988) and concluded that it was a valuable instrument in systematically observing and discriminating differences in self-regulation (Wolf et al. 2001, 2002). The question posed in the present pilot study was: Do preterm infants who received IBAIP intervention differ at the corrected age of 6 months in neurobehavioural outcome and self-regulatory competence from a control group of preterm infants that received standard post-discharge care?

Method

PARTICIPANTS

From January 2001 to July 2001, a group of 24 preterm infants admitted consecutively to the NICU of the Academic Medical Centre in Amsterdam, the Netherlands was recruited to form the intervention group. The intervention group was compared with a control group of 20 preterm infants who had been recruited consecutively from January 1999 to July 1999 from the NICU of the same hospital (Wolf et al. 2002). The setting was a traditional NICU in which NIDCAP formed no part of the care. Recruitment took place 1 to 2 weeks after birth. Inclusion criteria for both groups were: a gestational age of

Both the intervention and the control group received medical and feeding consultations after discharge, which are given every 2 weeks as a standard procedure by the infant's own paediatrician. Both the intervention and the control group received three home visits, at term, and at 3 and 6 months of corrected age, in order to assess neurobehavioural functioning and developmental outcomes for the study. The Neonatal Behavioral Assessment Scale (NBAS; Brazelton and Nugent 1995) was administered at term age, the Infant Behavioral Assessment (IBA) at term, 3, and 6 months, and the Bayley Scales of Infant Development-II (BSID-II; Bayley 1993) at 3 and 6 months of age. All assessments were recorded on and scored from video recordings, in addition, the intervention infants received 6 to 8 home interventions depending on the needs of the parents. These were initiated in the first week after discharge and continued until the baby was 6 months of corrected age. Each home visit lasted approximately 1 hour. After each intervention at home the parents received a written report of the infant's neurobehavioural progress with recommendations to support their infant's developing self-regulatory competence.

PROCEDURE

Home visits

All interventions and measurements were administered at home, in the presence of the infants' mother and/or father, by two specially trained paediatric physical therapists (KK, MJW) who had achieved competence in the scoring of the NBAS and the IBA at greater than 90% interrater reliability. The interventionists communicated with the parents in Dutch or English. During one home visit to a Turkish family, a friend of the family acted as an interpreter during the intervention sessions.

The Infant Behavioral Assessment and Intervention Program