NIDCAP, battling systematic reviews.

I mentioned Arne Ohlsson’s review of the NIDCAP studies in a previous post. A new systematic review comes to different conclusions. This review (Fazilleau L, Parienti JJ, Bellot A, Guillois B: Nidcap in preterm infants and the neurodevelopmental effect in the first 2 years. Archives of Disease in Childhood – Fetal and Neonatal Edition 2013) comes to those different conclusions I think because they have mixed together a lot of outcome data that were kept separated by Ohlsson and Jacobs, for example the new review mixes in a single meta-analysis all the Bayley scores between 9 months and 2 years of age, which I think is really questionable.

I think it is important to note that, as often happens in medicine, the earliest tiny trials (with n of 38 or less in 6 of the 9 trials) are very positive, later larger trials, by other independent investigators, have much smaller, or no benefit.

When I was preparing this post, I pulled out my copy of the very first publication about NIDCAP, my marks on the paper copy (gone are the days of useful graffiti and exclamation marks on the photocopy!) reflect my scepticism at the time, the first study only included 38 babies in total, and randomized the infants after 48 hours of age; nevertheless there was a significant reduction in severe intraventricular hemorrhage, and absolutely everything else was better in the NIDCAP group.

Don’t get me wrong, I think that a more developmentally sensitive approach to care of our patients has made huge improvements in how humane our care is, and has probably contributed to the progressive improvement in outcomes over the recent past. I am very happy to see a flexed preterm infant, sleeping soundly cuddled in an incubator and being largely left alone, and the necessary interventions being performed in the least disturbing way possible. On the other hand I think the more recent larger RCTs, with longer follow up are more realistic reflections of the real-life benefits that NIDCAP may give, when compared to routine care which should always include good pain control, and reduction of excessive adverse stimulation.

Maybe some of the diminution of effect of NIDCAP over time, is that the treatment of the control groups has changed.

About Keith Barrington

I am a neonatologist and clinical researcher at Sainte Justine University Health Center in Montréal
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