CDC Kerala 2: Developmental Intervention Package for Babies <1,800 g – Outcome at 6 mo Using DASII

Abstract

Objectives

To describe the experience of using developmental intervention package among low birth weight babies less than 1,800 g and developmental outcome at the end of 6 mo monthly intervention.

Methods

Babies below 1,800 g, discharged from neonatal intensive care unit (NICU) of Sree Avittom Thirunal (SAT) hospital, over the last 3 y, were followed at Child Development Centre (CDC) Kerala and offered monthly evaluation by different tools and developmental intervention using a package by trained developmental therapists and mothers were encouraged to continue the same at home. At the end of 6 mo the developmental outcome was assessed using Developmental Assessment Scale for Indian Infants (DASII).

Results

Out of a total of 821 babies enrolled for early stimulation program, 740 babies successfully completed 6 mo follow up and stimulation program. Comparing the outcome at 4 and 6 mo, both grading for head holding and gross motor part of DDST showed a statistically significant reduction in abnormal findings. At 6 mo assessment on DASII, motor DQ abnormalities were a high 80 % for 600–900 g, as against 17.1 % abnormalities for 1,500–1,800 g birth weight group.

Conclusions

The results of this intensive early stimulation program for babies below 1,800 g have shown the importance of monthly early intervention using a mother oriented systematic developmental stimulation package.

Appendix

CDC Kerala: Developmental Intervention Package for Low Birth Weight Babies

Domains	Item Details
Neonatal nursery period
Stimulation in NICU	Individual lightening units can be dimmed and adjusted to reflect the cycles of the days (especially during night). Reduce the unnecessary noises from the neonatal environment. Heart beat sounds, mother’s voice and music can be recorded and put the tape near the baby.
Lactation management	a) Correct positioning and attachment for breast feeding b) correction of breast or nipple problems c) expressive breast milk to preterm low birth weight babies d) correct way of burping
Positioning & Wrapping the baby	Appropriate therapeutic positioning in supine, side lying or prone according to each infant individual needs. Clothe the baby in 3–4 layers, cover head, hands and feet with cap, gloves and socks respectively; hold baby close to mother’s body.
Non – nutritive sucking	Gently hold baby’s hands together and then put them to mouth. This is calming and organizing, thereby creating neural pathways in her brain that will be the building blocks for future complex activities.
Visual stimulation	Bold patterns with strong contrast: Newborns are attracted to the edges of patterns where light and dark meet. Use simple shapes-squares, circles, and bold black and white face shapes. Making Faces: Try to catch the baby’s attention and make a face- one can stick out the tongue, make an ‘O’ with one’s lips, or raise and lower one’s eyebrows. Newborns can mimic expressions.
Auditory stimulation	Playing Music: Playing classical strains to the newborn could help lay down important spatial reasoning pathways, as well as connections within the auditory system. Talking and imitation: Talk to the baby often- when changing him or feeding him. Listen carefully to his little noises and repeat them. Even tiny babies will listen attentively to the sing-song cadences of poems and nursery rhymes.
Vestibular-kinesthetic stimulation	Every time the baby is walked, rocked, or swung, the vestibular system is stimulated. Baby swings are a good way to stimulate the vestibular system.Rocking and oscillating waterbeds can be introduced in order to stimulate the kinesthetic/vestibular senses
Baby massage	Baby Massage: Routine massaging the baby is essential for her optimum growth and development. Ideally it should be done by the mother, father or grandparents. Technique: Gentle firm strokes can be used. Do not kneed or squeeze. The stroke should not be too light or else they will cause a tickling sensation to the baby that may be discomforting. Make tiny circles on the face, then smooth the baby’s forehead with both hands at the centre. Make small circles around the baby’s jaw, massaging around the baby’s mouth. Gently stroke the baby’s chest. Stroke each arm alternately from central outwards, open the palms and massage each finger separately. Massage the tummy from baby’s right side to the left in a clockwise direction. Stroke and massage each leg and foot separately. Stroke the baby’s back- first back and forth across, then in long, sweeping lines from shoulders to feet. Stroke the buttocks in a circular motion.
Passive exercises to prevent hypertonia	Hold both legs over the knee joint. Alternatively bend one knee up to the chest, while keeping the other knee straight. With one hand under the child’s calves, the other over across his knees, gently raise the legs to the maximum while keeping both knees straight. Hold both hands over the knee joint. Bend the child’s knees on to his stomach and slowly rotate them externally (abduction and external rotation of the hip). Hold both his hands by placing our thumb across his palms. Slowly elevate his arms upwards and sideways and then draw the hands gently towards the opposite shoulders
0-2 mo period
Auditory	Make the child listen to different sounds such as squeeze toy, rattle, bell, music, high pitched & low pitched human sounds etc. Always humming in a soft low voice.
Visual	Hang brightly color clothes (red/orange/fluorescent), shining mobiles, color balls; B&W striped cloths etc. across the crib. Don’t interchange them frequently. Put the baby in a well-ventilated room having good light.
Tactile	Frequently change child’s position. Put the child on his sides, on his back, on his tummy etc. Put the baby in different surfaces like soft mattresses, form rubber mat, on soft clothes, on mother’s lap etc.
Vestibular/kinesthetic	Gently rock the child, avoid fast changes of position. Avoid sudden jerky movements, always support his head.
Other Activities	a) Always try to maintain eye-to-eye contact while communicating with the child. b) Talk and sing to baby when you bathe him, dress him, and when you feed or rock him.
2-4 mo period
Auditory	Sound producing toys are suitable for this age. Noisy toys/ squeaky rubber toys etc. can be given. Parents should spend more time with child, keep on talking with the child, pointing out the names of objects shown will help the child to use more words when he starts talking.
Visual	Hang brightly colored objects/shiny mobiles about 12–15 inches above the crib, this will enable the child to watch it constantly and slowly starts to babble. Maintain eye contact while talking with the child. Show brightly colored clothes when the child is awake.
Tactile	Give the child various things to bite and suck and paper to crumble. Give your child the experiences of soft, hard, rough, cold, warm etc. During daytime place the child on a foam rubber mat on the ground and allow him to move freely.
Other Activities	a) Child should be carried straight at shoulder with hand supported, on both sides (right and left). After the attainment of head control, child can be carried crossed astride the hips on both sides. b) Place the child on his tummy, with both hands supported. Shake a sound making rattle in front of his head and gently lift the rattle just a little to encourage the child to lift the head and upper chest. Make sure that the baby is watching the rattle. c) Rub small toys or rings across the palm of the baby’s hand to help him to grasp it. d) Place things just out of reach of baby’s hands. Stimulate him to reach out and grasp it.
4-6 mo period
Auditory	Shake a bell or a squeaky toy over his head. Then slowly shake it near to the side of his head. Encourage him to turn his head and find the sound. Repeat on the other side also.
Visual	Organize the environment in such a way that it is stimulating for the child. They love to see their own images at mirrors and will look at this for a long period. Expose the child to outside people, siblings etc.
Other Activities	a) Place the child flat on his back on the ground over a soft blanket. Sit near to the child, showing a colorful toy, slowly turn the child by flexing the far away leg, and assist him to turn over to her tummy. Repeat it on both sides. b) Make the baby sit on mother’s lap and gently bounce your knees, by singing songs. c) Encourage reaching by showing an attractive toy, just out of reach of child’s hands. d) Strengthen the leg muscles: put your hands under child’s feet and move her legs up and down as if pedaling a bicycle.