School of Occupational Therapy

Touro University Nevada

OCCT 643 Systematic Reviews in Occupational Therapy

CRITICALLY APPRAISED TOPIC (CAT) WORKSHEET

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

processing, semantic processing, and organization of thought and actions than

control group infants at 8 years CA (McAnulty et al., 2010).
Compared to infants who only received standard care, pre-term infants who
received NIDCAP experienced a higher mean head growth after 36 weeks CA
(Westrup et al., 2000).
Very premature infants who received NIDCAP immediately after birth displayed
overall better cognitive development and were more likely to stay alive than control
group infants at 12 months CA (Kleberg et al., 2002).
At discharge, experimental group infants had fewer days of parenteral (IV)
feedings; shorter transition periods to full enteral (tube) feeding; better average
daily weight gain; younger ages at discharge home; fewer days in intensive care
and in the hospital; lower total hospital charges; fewer cases of necrotizing
enterocolitis; and better growth (weight, height, and head circumference) at two
weeks after the expected due date. They also performed significantly better in
terms of the six APIB system scores. Infants who began with poorer medical and
developmental outcomes overall showed greater gains than infants with higher
baselines (Als et al., 2003).
At discharge, NIDCAP infants on average had a clinically significant shorter
hospital length of stay (LOS) in the NICU (~10 days less than the control), 20%
lower incidences of chronic lung diseases, and fewer days of ventilator dependence
(~11 days less than the control group)
They also had 14-20% lower incidences of mild, moderate, and severe
cognitive and developmental delays at 18 months CA (Peters et al., 2009).

Findings not supporting NIDCAP:

At birth (Maguire, Walther, Sprij, et al., 2009):
There were no statistically significant differences in the days of intensive
care, days of respiratory support, neurologic outcomes, or growth found
between the NIDCAP and control groups.
Limitations: A large percentage of infants in the NIDCAP group
were diagnosed with patent ductus arteriosus (PDA); this may have
significantly affected the overall group outcomes such as respiratory
support dependence and total number of ICU treatment days
negatively.
Follow-up at 1 and 2 years of age (Maguire, Walther, van Zwieten, et al., 2009):
There were no statistically significant results found for differences between
control and treatment groups in growth, neurologic impairment, or cognitive
and psychomotor developmental outcomes based on the Bayley Scales of
Infant Development II (BSID-II) assessment
Follow-up at pre-school age (Westrup, Bohm, Lagercrantz, & Stjernqvist, 2004):
There were no statistically significant differences in any of the three forms
of IQ tested by the Wechsler Preschool and Primary Scale of IntelligenceRevised (WPPSI-R), though NIDCAP group children overall had higher
scores.
No statistically significant differences in survival without a significant
disability were found.
Adapted from AOTA Evidence-Based Literature Review Project/7 CAT Worksheet.5-05

 However, percentages of disability were higher in the control group

overall than in the NIDCAP group (greater than 20% difference for
disability, mental retardation, and attention deficits between the two
groups).
Results were also found to be statistically significant when other
confounding variables were controlled (gestational age, gender, growth
retardation, and parent education levels).

* No Level II, II, IV, or V studies were utilized.

* No qualitative studies were utilized.
Bottom Line for Occupational Therapy Practice:
The clinical and community-based practice of OT: Occupational therapists (OTs) working in
the NICU setting are primarily concerned with promoting optimal development, effective
feeding and weight gain, and stress reduction for LBW and premature infants. For infants who
are born well before their estimated due dates, developmental concerns and stress reduction often
take a back seat to necessary life-saving interventions. However, promoting optimal infant
development through modification of the hospital environment is key to reducing stress and
allowing the infant to rest and learn to self-regulate. Providing parental support and education
regarding what to expect from very LBW and premature infants can also help to promote
attachment and proper development. It is the role of the OT to work with the interdisciplinary
team as well as parents to ensure that these issues are being addressed in the NICU environment
(AOTA, 2010). Utilizing the NIDCAP system allows the OT or other developmental specialist
to respond to infant signals of stress by modifying the environment and providing
developmentally-appropriate support for the newborn. It provides a standardized structure for
OTs to create an individualized plan for infants and parents in order to help reach these specific
goals.
Many premature and LBW infants grow up facing significant neurological, developmental, and
behavioral impairments. These impairments may cause significant delays as the child ages and
are often the focus of OT treatment in early intervention, pediatric, and school-based settings.
The implication that NIDCAP can affect both short-term (medical and developmental) outcomes
as well as long-term developmental and disability outcomes has the potential to hugely impact
OT treatment as the child ages.
Program development: Since babies are being born earlier and earlier and are able to survive
(though not disability-free), it is important to implement highly-structured and developmentallysupportive programs such as NIDCAP in order to vastly decrease negative infant health
outcomes and associated healthcare costs. However, NIDCAP can be expensive and timeconsuming to implement in some NICU settings. The training of each individual staff member
seeking certification typically takes one to two years from the beginning of the process to
eventual full NIDCAP certification. Members must be certified in order to implement NIDCAP
interventions and utilize the Assessment of Pre-Term Infant Behaviors (APIB), a NIDCAPAdapted from AOTA Evidence-Based Literature Review Project/7 CAT Worksheet.5-05

specific assessment which is utilized in conjunction with skilled observation to create an

individualized plan of care for each infant. Continued certification also requires annual renewal
of membership through the NIDCAP Federation International. In order for a NICU to become a
NIDCAP-certified nursery, the hospital must go through an application and evaluation process,
and at least one dedicated full-time staff member must be fully NIDCAP-certified as well. Initial
nursery certification costs an estimated $29,220 and usually takes between one and two years.
Therefore, hospital administrators should carefully weigh the costs and benefits of implementing
the NIDCAP program.
Societal Needs: It is incredibly important to provide quality healthcare for at-risk babies in
order to promote their future developmental, neurological, and health success. This type of
program also helps to educate parents on what to expect from their newborn babies and can
potentially help decrease incidences of child abuse and neglect by providing education regarding
infantile behavior and stress responses. Short-term findings supporting NIDCAPs effect in
creating shorter lengths of stay, and days of ventilator dependence exponentially decrease the
cost of care for critically-ill babies. The statistically significant lower incidences of chronic lung
disease, attention deficits/mild cognitive disability, moderate disability, and severe disability
indicate that NIDCAP treatment could considerably affect long-term outcomes for children who
often require OT services. Lower levels of severe and moderate disabilities indicate more
positive outcomes in infants and young children reaching developmental milestones on time and
may often predict later social, psychological, and educational success. This is relevant to OT
practice and society as a whole as children who have more significant disabilities are less
independent and require more full-time care and supervision than their typically-developing
counterparts do. Children with severe disabilities also require more intensive therapies but often
achieve developmental milestones much more slowly and may never be able to take care of
themselves or live independently. This greatly increases care costs and decreases professional,
economic, and personal productivity.
Healthcare delivery and policy: Many of the reviewed studies indicate that NIDCAP provides
a developmentally-appropriate and ethical treatment option for newborn care which is also
beneficial for promoting positive developmental and medical outcomes. NIDCAP and other
similar programs should be implemented in all NICUs to provide the highest standard of
individualized newborn care. This will ensure that proper development (self-regulation and
motor system modulation) of all pre-term infants is promoted so that ultimately
neuropsychological aspects (e.g. attention, memory) can be unaffected from the taxing course
pre-term infants face in the NICU. Once further studies support the long-term effects of
NIDCAP, policymakers should be informed of the overall savings from not overcrowding
special resource programs and providing additional services to these infants once they reach
school age and beyond.
Education and training of OT students: The NIDCAP protocol should be taught or at least
exposed to OT students during education to fully explain the client-centered link to current OT
principles. Students should also be educated on the importance of developmentally-supportive
and family-centered care, especially in the NICU setting. Students should be well-versed in fetal
development, typical infant development and milestones, stress responses and reactions (and
how to decrease stress and sensory over-stimulation), reflexes, proper infant handling, and
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:

Studies utilizing NIDCAP as the primary experimental intervention

Studies utilizing pre-term infants as participants
Studies published between 1994-2014
Full-text articles available through Touro University Nevadas library database or free
public databases
Randomized controlled trial study designs
Adapted from AOTA Evidence-Based Literature Review Project/7 CAT Worksheet.5-05

Exclusion Criteria:
Studies published before 1994
Non Level I evidence
Studies not published in English
Search Strategies:
Categories
Patient/Client Population

Key Search Terms

NICU, premature, pre-term, infants

Intervention
Outcomes

parent education, early intervention, NIDCAP

development, developmental milestones

Databases and Sites Searched

CINHAL, PubMed, OTSearch, ProQuest, OTDBase, EBSCO, Medline, GoogleScholar
Quality Control/Peer Review Process:
The focused question was created based on topic area provided by course instructor.
Search terms were utilized to explore databases to find useful studies; collaboration took
place with course instructor to alter terms, inclusion criteria, and databases used.
After database searches yielded excessive numbers of results, hand-searching was
implemented based on realization that appropriate Level I studies could be found
efficiently from just one article (Ohlsson & Jacobs, 2013).
In order to include follow-up studies to explore the effects of the intervention overtime,
inclusion criteria such as publication date was expanded to accommodate these studies.
Ten studies were chosen by hand-searching that met inclusion criteria, and five were
assigned to each student reviewer.
Each article was reviewed using the CRF for quantitative studies.
The students agreed that the chosen articles were appropriate after CRF appraisal.
The 10 articles were summarized on the Evidence Table worksheet by both students to
highlight the main purpose, design, intervention, outcome measures, results, limitations,
and clinical importance to OT of each study.
An overall summary of the results and implications of the 10 articles were then compiled
using the Critically Appraised Topic (CAT) worksheet with both students collaboration.

Adapted from AOTA Evidence-Based Literature Review Project/7 CAT Worksheet.5-05

Results of Search:
Summary of Study Designs of Articles Selected for Appraisal:
Level of
Evidence
I
II
III
IV
V
Other

Study Design/Methodology of Selected Articles

Randomized controlled trials

Qualitative Studies
TOTAL:

Number of Articles
Selected
10
0
0
0
0
0
10

Limitations of the Studies Appraised:

Level I
Many studies had limited recruitment, some less than 30 participants.
Performance biases
Staffing shortages created opportunities for spill-over effects to the nonNIDCAP treatment groups.
NIDCAP trained nurses admitted to at times providing similar care to
control group infants due to feelings of empathy.
NIDCAP group parents communicating with non-NIDCAP group parents
could have affected the interaction, care, and handling of those infants.
Levels II, III, IV and V
No level II, III, IV, or V studies were evaluated for this CAT review
Other
Only level I evidence was evaluated for this CAT review

Adapted from AOTA Evidence-Based Literature Review Project/7 CAT Worksheet.5-05

Articles Selected for Appraisal:

Als, H., Duffy, F. H., McAnulty, G. B., Fischer, C. B., Kosta, S., Butler, S. C., . . . Ringer, S. A.
(2011). Is the Newborn Individualized Developmental Care and Assessment Program
(NIDCAP) effective for preterm infants with intrauterine growth restriction? J Perinatol,
31(2), 130-136. doi: 10.1038/jp.2010.81
Als, H., Gilkerson, L., Duffy, F. H., McAnulty, G. B., Buehler, D. M., Vandenberg, K., . . .
Jones, K. J. (2003). A three-center, randomized, controlled trial of individualized
developmental care for very low birth weight preterm infants: medical,
neurodevelopmental, parenting, and caregiving effects. J Dev Behav Pediatr, 24(6), 399408.
Als, H., Lawhon, G., Duffy, F. H., McAnulty, G. B., Gibes-Grossman, R., & Blickman, J. G.
(1994). Individualized developmental care for the very low-birth-weight preterm infant:
Medical and neurofunctional effects. The Journal of the American Medical Association,
272(11), 853-858.
Kleberg, A., Westrup, B., Stjernqvist, K., & Lagercrantz, H. (2002). Indications of improved
cognitive development at one year of age among infants born very prematurely who
received care based on the Newborn Individualized Developmental Care and Assessment
Program (NIDCAP). Early Human Development, 68, 83-91.
Maguire, C. M., Walther, F. J., Sprij, A. J., Le Cessie, S., Wit, J. M., & Veen, S. (2009). Effects
of individualized developmental care in a randomized trial of preterm infants <32 weeks.
Pediatrics, 124(4), 1021-1030. doi: 10.1542/peds.2008-1881
Maguire, C. M., Walther, F. J., van Zwieten, P. H., Le Cessie, S., Wit, J. M., & Veen, S. (2009).
Follow-up outcomes at 1 and 2 years of infants born less than 32 weeks after Newborn
Adapted from AOTA Evidence-Based Literature Review Project/7 CAT Worksheet.5-05

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

Adapted from AOTA Evidence-Based Literature Review Project/7 CAT Worksheet.5-05

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

Adapted from AOTA Evidence-Based Literature Review Project/7 CAT Worksheet.5-05