Cochrane review: Early developmental intervention programs post hospital discharge to prevent motor and cognitive impairments in preterm infants

Abstract

AbstractBackgroundInfants born preterm are at increased risk of developing cognitive and motor impairments compared with infants born at term. Early developmental interventions have been used in the clinical setting with the aim of improving the overall functional outcome for these infants. However, the benefit of these programs remains unclear.ObjectivesTo review the effectiveness of early developmental intervention post‐discharge from hospital for preterm (< 37 weeks) infants on motor or cognitive development.Search strategyThe Cochrane Neonatal Review group search strategy was used to identify randomised and quasi‐randomised controlled trials of early developmental interventions post hospital discharge. Two review authors independently searched the Cochrane Central Register of Controlled Trials (CENTRAL, The Cochrane Library), MEDLINE Advanced, CINAHL, PsychINFO and EMBASE (1966 through February 2006).Selection criteriaStudies included had to be randomised or quasi‐randomised controlled trials of early developmental intervention programs that commenced within the first 12 months of life for infants born at < 37 weeks with no major congenital abnormalities. Intervention could commence as an inpatient; however, a post discharge component was necessary to be included in this review. The outcome measures were not pre‐specified other than that they had to assess cognitive and/or motor ability. The rates of intellectual impairment, cerebral palsy and development co‐ordination disorder were also documented.Data collection and analysisData were extracted and entered by two independent review authors. Cognitive and motor outcomes were pooled in three age groups ‐ infant (0 to 2 years), preschool (3 to < 5 years) or school age (5 to 17 years). Meta‐analysis was carried out using RevMan 4.2 to determine the effects of early developmental intervention in the short (0 to 2 years), medium (3 to < 5 years) and long term (5 to 17 years). Subgroup analysis was carried out in relation to; gestational age, birthweight, brain injury, commencement of intervention, focus of intervention and study quality.Main resultsSixteen studies met the inclusion criteria (2379 randomised patients). Six of these studies were RCTs and had strong methodological quality. There was variability with regard to the focus and intensity of the intervention, and in length of follow‐up. Meta‐analysis concluded that intervention improved cognitive outcomes at infant age (developmental quotient [DQ]: standard mean difference [SMD] 0.46 SD; 95% CI 0.36 0.57; P < 0.0001), and at preschool age (intelligence quotient [IQ]; SMD 0.46 SD; 95%CI 0.33, 0.59; P < 0.0001). However, this effect was not sustained at school age (IQ; SMD 0.02 SD; 95% CI ‐0.10, 0.14; P = 0.71). There was significant heterogeneity between studies for cognitive outcomes at infant and school ages. There was little evidence of an effect of early intervention on motor outcomes in the short, medium or long‐term, but there were only two studies reporting outcomes beyond 2 years.Authors' conclusionsEarly intervention programs for preterm infants have a positive influence on cognitive outcomes in the short to medium term. However, there was significant heterogeneity between the interventions included in this review. Further research is needed to determine which early developmental interventions are the most effective at improving cognitive and motor outcomes, and on the longer‐term effects of these programs. Cost‐effectiveness and access to services should also be evaluated since they are important factors when considering implementation of an early developmental intervention program for a preterm infant.Plain language summaryPreterm infants (babies born before 37 weeks) are at risk of development problems, including problems with cognitive and motor development. Cognitive development refers to thinking and learning ability and motor development refers to the way infants move, such as sitting, crawling and walking. Early developmental interventions aim to reduce cognitive and/ or motor problems; however, the benefits of these programs are not clear. A review of trials suggests early developmental intervention programs post discharge from hospital for preterm infants are effective at improving cognitive development in the short to medium term (up to preschool age). There is limited evidence that early developmental interventions improve motor outcome or long term cognitive outcome (up to school age). The early developmental intervention programs in this review had to commence within the first 12 months of life, focus on the parent‐infant relationship and/or infant development and, although they could commence while the baby was still in hospital, they had to have a component that was delivered post‐discharge from hospital. The early developmental intervention programs included in this review are different in content, frequency of intervention and focus of intervention. The variability in the intervention programs limits the conclusions that can be made about the effectiveness of early developmental interventions.