Role of Intervention Strategies for At-risk Preterm Infants

Abstract

See related articles, p 359 and p 366Despite increased survival rates of preterm infants, the prevalence of developmental disabilities in preterm survivors is still high.1Saigal S. Doyle L.W. An overview of mortality and sequelae of preterm birth from infancy to adulthood.Lancet. 2008; 371: 261-269Abstract Full Text Full Text PDF PubMed Scopus (1866) Google Scholar Although the rates of major handicaps have remained relatively constant in the last decade, the prevalence of milder dysfunctions seems to be increasing. Cognitive, behavioral, and mild motor problems without major motor deficits are now the most dominant neurodevelopmental sequelae in children born preterm.2Aylward G.P. Neurodevelopmental outcomes of infants born prematurely.J Dev Behav Pediatr. 2005; 26: 427-440Crossref PubMed Scopus (336) Google Scholar, 3Johnson S. Cognitive and behavioural outcomes following very preterm birth.Sem Fetal Neonatal Med. 2007; 12: 363-373Abstract Full Text Full Text PDF PubMed Scopus (247) Google Scholar These problems include learning disabilities, borderline to low IQ scores, attention-deficit, and specific neuropsychological deficits affecting visuomotor integration and executive function.3Johnson S. Cognitive and behavioural outcomes following very preterm birth.Sem Fetal Neonatal Med. 2007; 12: 363-373Abstract Full Text Full Text PDF PubMed Scopus (247) Google Scholar These abnormalities occur in >50% of children born preterm with very low birth weight (VLBW; < 1500 g) and often do not occur in isolation.2Aylward G.P. Neurodevelopmental outcomes of infants born prematurely.J Dev Behav Pediatr. 2005; 26: 427-440Crossref PubMed Scopus (336) Google Scholar The situation is further confounded by the social, ethnic, and educational background of the parents also possibly influencing the prevalence of these disabilities.In early infancy, it is difficult to identify the individual infant at highest risk for mild motor, cognitive, and behavioral problems. Models of pathogenesis include changes related to developmental disruptions and brain injury.2Aylward G.P. Neurodevelopmental outcomes of infants born prematurely.J Dev Behav Pediatr. 2005; 26: 427-440Crossref PubMed Scopus (336) Google Scholar, 4Volpe J.J. Brain injury in premature infants: a complex amalgam of destructive and developmental disturbances.Lancet Neurol. 2009; 8: 110-124Abstract Full Text Full Text PDF PubMed Scopus (1672) Google Scholar Although global white matter damage revealed with ultrasound scanning and magnetic resonance imaging is quite common in children born preterm, and volumes of gray matter are also diminished, clear associations of cognition with pathological changes on neuroimaging have not been definitely demonstrated.5Hart A.R. Whitby E.W. Griffiths P.D. Smith M.F. Magnetic resonance imaging and developmental outcome following preterm birth: review of current evidence.Dev Med Child Neurol. 2008; 50: 655-663Crossref PubMed Scopus (73) Google Scholar Another method to identify infants at risk is some form of neurobehavioral assessment at an early age.6Heineman K.R. Hadders-Algra M. Evaluation of neuromotor function in infancy—a systematic review of available methods.J Dev Behav Pediatr. 2008; 29: 315-323Crossref PubMed Scopus (99) Google Scholar Of these, the assessment of the quality of spontaneous general movements has emerged as a reliable and valid predictor of major motor deficits for the individual infant.7Einspieler C. Prechtl H.F.R. Prechtl's assessment of general movements: a diagnostic tool for the functional assessment of the young nervous system.Ment Retard Dev Disabil Res Rev. 2005; 11: 61-67Crossref PubMed Scopus (421) Google Scholar This method is based on visual Gestalt perception of the quality of general movements in the preterm, term, and post-term periods, as long as 5 months post-term. The quality of so called fidgety general movements (FMs), present between 9 and 20 weeks post-term and defined as continuous small movements of moderate speed in all directions, is a particularly accurate marker for neurological outcome. Most infants (96%) with normal FMs have normal neurological outcomes, and cerebral palsy develops in most infants (95%) in whom FMs are absent during this period.8Prechtl H.F.R. Einspieler C. Cioni G. Bos A.F. Ferrari F. Sontheimer D. An early marker for neurological deficits after perinatal brain lesions.Lancet. 1997; 349: 1361-1363Abstract Full Text Full Text PDF PubMed Scopus (463) Google Scholar An early indicator with prognostic value for the development of milder neurological deficits (eg, developmental coordination disorder [DCD]) is the concurrent motor repertoire at 3 to 4 months post-term.9Bruggink J.L.M. Einspieler C. Butcher P.R. van Braeckel K.N.J.A. Prechtl H.F.R. Bos A.F. The quality of the early motor repertoire in preterm infants predicts minor neurologic dysfunction at school age.J Pediatr. 2008; 153: 32-39Abstract Full Text Full Text PDF PubMed Scopus (92) Google Scholar When FMs are normal, a smooth, variable concurrent motor repertoire is a marker for a normal outcome, and the risk for the development of DCD is low (5%). When the concurrent motor repertoire is monotonous, the risk for the development of DCD is approximately 30%.9Bruggink J.L.M. Einspieler C. Butcher P.R. van Braeckel K.N.J.A. Prechtl H.F.R. Bos A.F. The quality of the early motor repertoire in preterm infants predicts minor neurologic dysfunction at school age.J Pediatr. 2008; 153: 32-39Abstract Full Text Full Text PDF PubMed Scopus (92) Google Scholar Although prediction of neurodevelopmental outcome at an early age is difficult, these and other neuromotor tests show that the best prediction is achieved when some form of qualitative aspect of motor behavior is considered.6Heineman K.R. Hadders-Algra M. Evaluation of neuromotor function in infancy—a systematic review of available methods.J Dev Behav Pediatr. 2008; 29: 315-323Crossref PubMed Scopus (99) Google ScholarIn this issue of The Journal, Stephens et al 10Stephens B.E. Liu J. Lester B. LaGasse L. Shankaran S. Bada H. et al.Neurobehavioral assessment predicts motor outcome in preterm infants.J Pediatr. 2010; 156: 366-370Abstract Full Text Full Text PDF PubMed Scopus (55) Google Scholar adds to our knowledge of early prediction by means of neurobehavioral assessment. They showed that their previously developed neurobehavioral scale can help to predict poor motor outcome at 24 months of age. Originally, the Neonatal Intensive Care Unit Network Neurobehavior Scales (NNNS) was developed to investigate the effects of cocaine exposure. The authors have now investigated the predictive value of the NNNS for cerebral palsy at 12 to 36 months and low psychomotor developmental index (PDI) at 24 months in a cohort of nearly 400 preterm infants, born before 36 weeks gestation. The NNNS provides a comprehensive assessment of 3 dimensions of the newborn: neurologic integrity, behavioral functioning, and stress behavior. Each dimension has a number of scores, from which 13 summary scores are calculated. Cerebral palsy and low PDI (<70) at 24 months were associated with 4 items from the NNNS administered at 4 weeks post-term: low quality of movement, high lethargy, low handling, and hypotonia. In various combinations, these items contributed 19% to the variance in cerebral palsy diagnosis and 26% in low PDI. The authors conclude that the neurobehavioral profile of under-arousal at 4 weeks post-term may predict poor motor outcome in preterm infants. This information about the risk of poor motor outcome was the addition to other predictors, such as chronic lung disease, intraventricular hemorrhage, and periventricular leukomalacia.The study by Stephens et al is part of a larger project and an extension of previously published data. There are some limitations, which the authors recognize. Approximately half the infants had been exposed to intrauterine cocaine, and further prospective studies are needed to determine the predictive value for all preterm infants. However, the under-arousal at 44 weeks as a risk factor for cerebral palsy and low PDI at follow-up is an interesting new finding. It is already known that monotonous movements (as opposed to variable and complex movements) at this age are related to cerebral palsy,8Prechtl H.F.R. Einspieler C. Cioni G. Bos A.F. Ferrari F. Sontheimer D. An early marker for neurological deficits after perinatal brain lesions.Lancet. 1997; 349: 1361-1363Abstract Full Text Full Text PDF PubMed Scopus (463) Google Scholar, 9Bruggink J.L.M. Einspieler C. Butcher P.R. van Braeckel K.N.J.A. Prechtl H.F.R. Bos A.F. The quality of the early motor repertoire in preterm infants predicts minor neurologic dysfunction at school age.J Pediatr. 2008; 153: 32-39Abstract Full Text Full Text PDF PubMed Scopus (92) Google Scholar and the low quality of movements reported in this study may reflect brain damage. The under-arousal, low movement quality, and lethargy may also reflect the role motor activity has at this early age in normal development. Rapid brain development in the early post-term months is accompanied by equally rapid motor and psychological development. The infants' exploration of their environment with several motor strategies, integrating and refining neural input and output, may lead to better neurological and cognitive development. The absence of such a variable motor repertoire at this particular age (eg, because of the under-arousal) might hamper the infants' abilities to interact with the world around them, which leads to delayed or impaired development.11Butcher P.R. Bos A.F. van Braeckel K.N.J.A. Einspieler C. Stremmelaar E.F. Bouma J.M. The quality of infants' spontaneous movements: an early predictor of intelligence and behavior at school age.J Child Psychol Psychiatry. 2009; 50: 920-930Crossref PubMed Scopus (83) Google Scholar This would imply that early intervention, aimed at stimulation of more variable motor strategies, may result in a better functional outcome.This brings us to another study in this issue of The Journal, about an early intervention program for VLBW infants.12Koldewijn K. van Wassenaer A. Wolf M.J. Meijssen D. Houtzager B. Beelen A. et al.An infant behavioral assessment and intervention program in very low birth weight infants: outcome at 24 months.J Pediatr. 2010; 156: 359-365Abstract Full Text Full Text PDF PubMed Scopus (69) Google Scholar The authors conducted a multi-center randomized controlled trial of 176 infants to determine whether the Infant Behavioral Assessment and Intervention Program (IBAIP) improved development and behavior in VLBW infants at 24 months corrected age. The intervention group received 6 to 8 post-discharge interventions until 6 months corrected age. The intervention consisted of supporting the infants' self-regulation and development and facilitating sensitive parent-infant interactions. The control infants received regular care. Unfortunately, more children in the intervention group were <28 weeks gestational age than in the control group, despite randomization. As a result, the authors had to adjust for differences in perinatal characteristics. They found an intervention effect of 6.4 points on the PDI at 24 months, favoring the intervention infants. Significant intervention effects on mental development and behavior were not found. The authors conclude that the IBAIP showed sustained motor improvement in VLBW infants until 2 years corrected age. This study adds to the growing literature on the effects of early developmental interventions in preterm infants. The authors found a positive effect on motor development, rather than on mental or behavioral development. Only subgroup analysis revealed that mental and motor outcomes improved in intervention infants with bronchopulmonary dysplasia and with combined biological and social risk factors.Early intervention programs may have positive effects, particularly on the cognitive development of preterm infants.13Orton J. Spittle A. Doyle L. Anderson P. Boyd R. Do early intervention programmes improve cognitive and motor outcomes for preterm infants after discharge? A systematic review.Dev Med Child Neurol. 2009; 51: 851-859Crossref PubMed Scopus (158) Google Scholar The effect size is approximately 0.4 to 0.5 SD, thus 6 to 8 IQ points. These effects are mostly short-term, until the age of 3 years, and not seen anymore at school age. At any age, intervention has limited effects on motor outcomes,13Orton J. Spittle A. Doyle L. Anderson P. Boyd R. Do early intervention programmes improve cognitive and motor outcomes for preterm infants after discharge? A systematic review.Dev Med Child Neurol. 2009; 51: 851-859Crossref PubMed Scopus (158) Google Scholar although specific developmental training in which parents learn how to promote infant development may produce a positive effect on motor development.14Blauw-Hospers C.H. Hadders-Algra M. A systematic review of the effects of early intervention on motor development.Dev Med Child Neurol. 2005; 47: 421-432Crossref PubMed Scopus (266) Google Scholar It would be helpful to know which particular aspects of the IBAIP produced the marked improvement of motor development. In an earlier study, the authors described the IBAIP in more detail:15Koldewijn K. Wolf M.J. van Wassenaer A. Meijssen D. van Sonderen L. van Baar A. et al.The Infant Behavioral Assessment and Intervention Program for very low birth weight infants at 6 months corrected age.J Pediatr. 2009; 154: 33-38Abstract Full Text Full Text PDF PubMed Scopus (71) Google Scholar“The intervention aims to enhance the infant's social and environmental interactions without causing distress, which reinforces the infant's motivation and autonomy to explore and learn from the information. The IBAIP builds on both the infant's and parent's strengths, seeking opportunities instead of problems in behavior, enhancing mutually satisfying interaction and parental involvement.”From this description, one may hypothesize that parental involvement, stimulating a playful and interactive environment, and promotion of self-produced motor behavior play a key role. The children from families that combine several risk factors, including low education attainment of the parents, may benefit from this type of intervention.16Bonnier C. Evaluation of early stimulation programs for enhancing brain development.Acta Paediatr. 2008; 97: 853-858Crossref PubMed Scopus (98) Google Scholar This was also the case in this study.12Koldewijn K. van Wassenaer A. Wolf M.J. Meijssen D. Houtzager B. Beelen A. et al.An infant behavioral assessment and intervention program in very low birth weight infants: outcome at 24 months.J Pediatr. 2010; 156: 359-365Abstract Full Text Full Text PDF PubMed Scopus (69) Google ScholarThere exists a large variety in early developmental intervention programs. Because of the resources required to provide early intervention, there is urgent need for further research on the identification of the children at highest risk and on the effects of early intervention throughout childhood. It will be fascinating to see whether these efforts would succeed in improving the motor, cognitive and behavioral outcome of the preterm children in the next decade. See related articles, p 359 and p 366Despite increased survival rates of preterm infants, the prevalence of developmental disabilities in preterm survivors is still high.1Saigal S. Doyle L.W. An overview of mortality and sequelae of preterm birth from infancy to adulthood.Lancet. 2008; 371: 261-269Abstract Full Text Full Text PDF PubMed Scopus (1866) Google Scholar Although the rates of major handicaps have remained relatively constant in the last decade, the prevalence of milder dysfunctions seems to be increasing. Cognitive, behavioral, and mild motor problems without major motor deficits are now the most dominant neurodevelopmental sequelae in children born preterm.2Aylward G.P. Neurodevelopmental outcomes of infants born prematurely.J Dev Behav Pediatr. 2005; 26: 427-440Crossref PubMed Scopus (336) Google Scholar, 3Johnson S. Cognitive and behavioural outcomes following very preterm birth.Sem Fetal Neonatal Med. 2007; 12: 363-373Abstract Full Text Full Text PDF PubMed Scopus (247) Google Scholar These problems include learning disabilities, borderline to low IQ scores, attention-deficit, and specific neuropsychological deficits affecting visuomotor integration and executive function.3Johnson S. Cognitive and behavioural outcomes following very preterm birth.Sem Fetal Neonatal Med. 2007; 12: 363-373Abstract Full Text Full Text PDF PubMed Scopus (247) Google Scholar These abnormalities occur in >50% of children born preterm with very low birth weight (VLBW; < 1500 g) and often do not occur in isolation.2Aylward G.P. Neurodevelopmental outcomes of infants born prematurely.J Dev Behav Pediatr. 2005; 26: 427-440Crossref PubMed Scopus (336) Google Scholar The situation is further confounded by the social, ethnic, and educational background of the parents also possibly influencing the prevalence of these disabilities. See related articles, p 359 and p 366 See related articles, p 359 and p 366 In early infancy, it is difficult to identify the individual infant at highest risk for mild motor, cognitive, and behavioral problems. Models of pathogenesis include changes related to developmental disruptions and brain injury.2Aylward G.P. Neurodevelopmental outcomes of infants born prematurely.J Dev Behav Pediatr. 2005; 26: 427-440Crossref PubMed Scopus (336) Google Scholar, 4Volpe J.J. Brain injury in premature infants: a complex amalgam of destructive and developmental disturbances.Lancet Neurol. 2009; 8: 110-124Abstract Full Text Full Text PDF PubMed Scopus (1672) Google Scholar Although global white matter damage revealed with ultrasound scanning and magnetic resonance imaging is quite common in children born preterm, and volumes of gray matter are also diminished, clear associations of cognition with pathological changes on neuroimaging have not been definitely demonstrated.5Hart A.R. Whitby E.W. Griffiths P.D. Smith M.F. Magnetic resonance imaging and developmental outcome following preterm birth: review of current evidence.Dev Med Child Neurol. 2008; 50: 655-663Crossref PubMed Scopus (73) Google Scholar Another method to identify infants at risk is some form of neurobehavioral assessment at an early age.6Heineman K.R. Hadders-Algra M. Evaluation of neuromotor function in infancy—a systematic review of available methods.J Dev Behav Pediatr. 2008; 29: 315-323Crossref PubMed Scopus (99) Google Scholar Of these, the assessment of the quality of spontaneous general movements has emerged as a reliable and valid predictor of major motor deficits for the individual infant.7Einspieler C. Prechtl H.F.R. Prechtl's assessment of general movements: a diagnostic tool for the functional assessment of the young nervous system.Ment Retard Dev Disabil Res Rev. 2005; 11: 61-67Crossref PubMed Scopus (421) Google Scholar This method is based on visual Gestalt perception of the quality of general movements in the preterm, term, and post-term periods, as long as 5 months post-term. The quality of so called fidgety general movements (FMs), present between 9 and 20 weeks post-term and defined as continuous small movements of moderate speed in all directions, is a particularly accurate marker for neurological outcome. Most infants (96%) with normal FMs have normal neurological outcomes, and cerebral palsy develops in most infants (95%) in whom FMs are absent during this period.8Prechtl H.F.R. Einspieler C. Cioni G. Bos A.F. Ferrari F. Sontheimer D. An early marker for neurological deficits after perinatal brain lesions.Lancet. 1997; 349: 1361-1363Abstract Full Text Full Text PDF PubMed Scopus (463) Google Scholar An early indicator with prognostic value for the development of milder neurological deficits (eg, developmental coordination disorder [DCD]) is the concurrent motor repertoire at 3 to 4 months post-term.9Bruggink J.L.M. Einspieler C. Butcher P.R. van Braeckel K.N.J.A. Prechtl H.F.R. Bos A.F. The quality of the early motor repertoire in preterm infants predicts minor neurologic dysfunction at school age.J Pediatr. 2008; 153: 32-39Abstract Full Text Full Text PDF PubMed Scopus (92) Google Scholar When FMs are normal, a smooth, variable concurrent motor repertoire is a marker for a normal outcome, and the risk for the development of DCD is low (5%). When the concurrent motor repertoire is monotonous, the risk for the development of DCD is approximately 30%.9Bruggink J.L.M. Einspieler C. Butcher P.R. van Braeckel K.N.J.A. Prechtl H.F.R. Bos A.F. The quality of the early motor repertoire in preterm infants predicts minor neurologic dysfunction at school age.J Pediatr. 2008; 153: 32-39Abstract Full Text Full Text PDF PubMed Scopus (92) Google Scholar Although prediction of neurodevelopmental outcome at an early age is difficult, these and other neuromotor tests show that the best prediction is achieved when some form of qualitative aspect of motor behavior is considered.6Heineman K.R. Hadders-Algra M. Evaluation of neuromotor function in infancy—a systematic review of available methods.J Dev Behav Pediatr. 2008; 29: 315-323Crossref PubMed Scopus (99) Google Scholar In this issue of The Journal, Stephens et al 10Stephens B.E. Liu J. Lester B. LaGasse L. Shankaran S. Bada H. et al.Neurobehavioral assessment predicts motor outcome in preterm infants.J Pediatr. 2010; 156: 366-370Abstract Full Text Full Text PDF PubMed Scopus (55) Google Scholar adds to our knowledge of early prediction by means of neurobehavioral assessment. They showed that their previously developed neurobehavioral scale can help to predict poor motor outcome at 24 months of age. Originally, the Neonatal Intensive Care Unit Network Neurobehavior Scales (NNNS) was developed to investigate the effects of cocaine exposure. The authors have now investigated the predictive value of the NNNS for cerebral palsy at 12 to 36 months and low psychomotor developmental index (PDI) at 24 months in a cohort of nearly 400 preterm infants, born before 36 weeks gestation. The NNNS provides a comprehensive assessment of 3 dimensions of the newborn: neurologic integrity, behavioral functioning, and stress behavior. Each dimension has a number of scores, from which 13 summary scores are calculated. Cerebral palsy and low PDI (<70) at 24 months were associated with 4 items from the NNNS administered at 4 weeks post-term: low quality of movement, high lethargy, low handling, and hypotonia. In various combinations, these items contributed 19% to the variance in cerebral palsy diagnosis and 26% in low PDI. The authors conclude that the neurobehavioral profile of under-arousal at 4 weeks post-term may predict poor motor outcome in preterm infants. This information about the risk of poor motor outcome was the addition to other predictors, such as chronic lung disease, intraventricular hemorrhage, and periventricular leukomalacia. The study by Stephens et al is part of a larger project and an extension of previously published data. There are some limitations, which the authors recognize. Approximately half the infants had been exposed to intrauterine cocaine, and further prospective studies are needed to determine the predictive value for all preterm infants. However, the under-arousal at 44 weeks as a risk factor for cerebral palsy and low PDI at follow-up is an interesting new finding. It is already known that monotonous movements (as opposed to variable and complex movements) at this age are related to cerebral palsy,8Prechtl H.F.R. Einspieler C. Cioni G. Bos A.F. Ferrari F. Sontheimer D. An early marker for neurological deficits after perinatal brain lesions.Lancet. 1997; 349: 1361-1363Abstract Full Text Full Text PDF PubMed Scopus (463) Google Scholar, 9Bruggink J.L.M. Einspieler C. Butcher P.R. van Braeckel K.N.J.A. Prechtl H.F.R. Bos A.F. The quality of the early motor repertoire in preterm infants predicts minor neurologic dysfunction at school age.J Pediatr. 2008; 153: 32-39Abstract Full Text Full Text PDF PubMed Scopus (92) Google Scholar and the low quality of movements reported in this study may reflect brain damage. The under-arousal, low movement quality, and lethargy may also reflect the role motor activity has at this early age in normal development. Rapid brain development in the early post-term months is accompanied by equally rapid motor and psychological development. The infants' exploration of their environment with several motor strategies, integrating and refining neural input and output, may lead to better neurological and cognitive development. The absence of such a variable motor repertoire at this particular age (eg, because of the under-arousal) might hamper the infants' abilities to interact with the world around them, which leads to delayed or impaired development.11Butcher P.R. Bos A.F. van Braeckel K.N.J.A. Einspieler C. Stremmelaar E.F. Bouma J.M. The quality of infants' spontaneous movements: an early predictor of intelligence and behavior at school age.J Child Psychol Psychiatry. 2009; 50: 920-930Crossref PubMed Scopus (83) Google Scholar This would imply that early intervention, aimed at stimulation of more variable motor strategies, may result in a better functional outcome. This brings us to another study in this issue of The Journal, about an early intervention program for VLBW infants.12Koldewijn K. van Wassenaer A. Wolf M.J. Meijssen D. Houtzager B. Beelen A. et al.An infant behavioral assessment and intervention program in very low birth weight infants: outcome at 24 months.J Pediatr. 2010; 156: 359-365Abstract Full Text Full Text PDF PubMed Scopus (69) Google Scholar The authors conducted a multi-center randomized controlled trial of 176 infants to determine whether the Infant Behavioral Assessment and Intervention Program (IBAIP) improved development and behavior in VLBW infants at 24 months corrected age. The intervention group received 6 to 8 post-discharge interventions until 6 months corrected age. The intervention consisted of supporting the infants' self-regulation and development and facilitating sensitive parent-infant interactions. The control infants received regular care. Unfortunately, more children in the intervention group were <28 weeks gestational age than in the control group, despite randomization. As a result, the authors had to adjust for differences in perinatal characteristics. They found an intervention effect of 6.4 points on the PDI at 24 months, favoring the intervention infants. Significant intervention effects on mental development and behavior were not found. The authors conclude that the IBAIP showed sustained motor improvement in VLBW infants until 2 years corrected age. This study adds to the growing literature on the effects of early developmental interventions in preterm infants. The authors found a positive effect on motor development, rather than on mental or behavioral development. Only subgroup analysis revealed that mental and motor outcomes improved in intervention infants with bronchopulmonary dysplasia and with combined biological and social risk factors. Early intervention programs may have positive effects, particularly on the cognitive development of preterm infants.13Orton J. Spittle A. Doyle L. Anderson P. Boyd R. Do early intervention programmes improve cognitive and motor outcomes for preterm infants after discharge? A systematic review.Dev Med Child Neurol. 2009; 51: 851-859Crossref PubMed Scopus (158) Google Scholar The effect size is approximately 0.4 to 0.5 SD, thus 6 to 8 IQ points. These effects are mostly short-term, until the age of 3 years, and not seen anymore at school age. At any age, intervention has limited effects on motor outcomes,13Orton J. Spittle A. Doyle L. Anderson P. Boyd R. Do early intervention programmes improve cognitive and motor outcomes for preterm infants after discharge? A systematic review.Dev Med Child Neurol. 2009; 51: 851-859Crossref PubMed Scopus (158) Google Scholar although specific developmental training in which parents learn how to promote infant development may produce a positive effect on motor development.14Blauw-Hospers C.H. Hadders-Algra M. A systematic review of the effects of early intervention on motor development.Dev Med Child Neurol. 2005; 47: 421-432Crossref PubMed Scopus (266) Google Scholar It would be helpful to know which particular aspects of the IBAIP produced the marked improvement of motor development. In an earlier study, the authors described the IBAIP in more detail:15Koldewijn K. Wolf M.J. van Wassenaer A. Meijssen D. van Sonderen L. van Baar A. et al.The Infant Behavioral Assessment and Intervention Program for very low birth weight infants at 6 months corrected age.J Pediatr. 2009; 154: 33-38Abstract Full Text Full Text PDF PubMed Scopus (71) Google Scholar “The intervention aims to enhance the infant's social and environmental interactions without causing distress, which reinforces the infant's motivation and autonomy to explore and learn from the information. The IBAIP builds on both the infant's and parent's strengths, seeking opportunities instead of problems in behavior, enhancing mutually satisfying interaction and parental involvement.” From this description, one may hypothesize that parental involvement, stimulating a playful and interactive environment, and promotion of self-produced motor behavior play a key role. The children from families that combine several risk factors, including low education attainment of the parents, may benefit from this type of intervention.16Bonnier C. Evaluation of early stimulation programs for enhancing brain development.Acta Paediatr. 2008; 97: 853-858Crossref PubMed Scopus (98) Google Scholar This was also the case in this study.12Koldewijn K. van Wassenaer A. Wolf M.J. Meijssen D. Houtzager B. Beelen A. et al.An infant behavioral assessment and intervention program in very low birth weight infants: outcome at 24 months.J Pediatr. 2010; 156: 359-365Abstract Full Text Full Text PDF PubMed Scopus (69) Google Scholar There exists a large variety in early developmental intervention programs. Because of the resources required to provide early intervention, there is urgent need for further research on the identification of the children at highest risk and on the effects of early intervention throughout childhood. It will be fascinating to see whether these efforts would succeed in improving the motor, cognitive and behavioral outcome of the preterm children in the next decade. Neurobehavioral Assessment Predicts Motor Outcome in Preterm InfantsThe Journal of PediatricsVol. 156Issue 3PreviewTo determine whether Neonatal Intensive Care Unit Network Neurobehavior Scales (NNNS) at 44 weeks predict motor outcome at 2 years in preterm infants from the Maternal Lifestyles Study (MLS). Full-Text PDF Renal, Pancreatic, Splenic, Mesenteric, and Portal Venous Gas as a Sign of Intestinal NecrosisThe Journal of PediatricsVol. 156Issue 6PreviewA 14-year-old boy presented with acute abdominal distention causing a severe restrictive respiratory distress that necessitated endotracheal intubation, diffuse peritoneal irritation, and profound metabolic acidosis. The boy had Waardenburg syndrome, a rare autosomal dominant inherited disorder, with severe hypopigmentation, hearing loss, limb abnormalities, and mental retardation, but without previously identified gastrointestinal involvement.1 Full-Text PDF A Neurobehavioral Intervention and Assessment Program in Very Low Birth Weight Infants: Outcome at 24 MonthsThe Journal of PediatricsVol. 156Issue 3PreviewTo determine whether the Infant Behavioral Assessment and Intervention Program (IBAIP) improves development and behavior in very low birth weight (VLBW) infants at 24-month corrected age. Full-Text PDF