Book Review

Helping Low Birth Weight, Premature Babies: The Infant Health and Development Program

N Engl J Med 1997; 337:1399November 6, 1997

Article

Helping Low Birth Weight, Premature Babies: The Infant Health and Development Program
Edited by Ruth T. Gross, Donna Spiker, and Christine W. Haynes. 635 pp. Stanford, Calif., Stanford University Press, 1997. $75. ISBN: 0-8047-2612-4

A large number of low-birth-weight infants (less than 2500 g) are born in the United States each year, accounting for 6.9 percent of all live births. Approximately 50,000 of these are of very low birth weight (less than 1500 g). Advances in health care in the past 30 years have resulted in a dramatic reduction in the birth-weight-specific mortality rate, and in the past decade we have seen a significant improvement in the survival of even the smallest infants. The disability rate in survivors has meanwhile remained constant and inversely related to birth weight and gestational age.

While the majority of low-birth-weight survivors are free from such major disabilities as cerebral palsy, mental retardation, and hearing and visual deficits, recent studies point to cognitive and behavioral sequelae that only become apparent in late childhood and the early school years and that lead to poor academic performance. In addition to the challenge posed by adverse biologic factors, low-birth-weight infants frequently have to contend with adverse environmental risk factors, such as young maternal age and low maternal educational level and socioeconomic status. Hence the need to develop and evaluate preventive strategies to ameliorate the sequelae of prematurity. Can intervention after hospital discharge improve the long-term outcome of these children?

The Infant Health and Development Program was a unique, large randomized clinical trial designed to test the efficacy of combining early child development and family-support services with frequent and comprehensive pediatric surveillance to reduce the prevalence of health and developmental problems in low-birth-weight, premature infants. Leading researchers in the field and numerous consultants from various disciplines were involved in the planning, development, implementation, and monitoring of the study, in which 985 low-birth-weight children in eight U.S. cities were followed from birth to three years of age. One third of the children were randomized to the intervention group and received pediatric surveillance and referrals for special evaluations and treatments and attended special child-care centers; their families received educational support through home visits and parent group meetings. The control group received pediatric surveillance and referrals only. The results demonstrated that in comparison with controls, children receiving the intervention had higher IQ scores, were at lower risk of having an IQ score in the mental-retardation range, and had fewer behavioral problems at three years of age.

Helping Low Birth Weight, Premature Babies not only brings together the results of the Infant Health and Development Program, some of which were previously published in peer-reviewed journals, but also expands many other aspects of the main trial, such as the historical background and the conceptual framework. It also presents the results of interesting ancillary studies about the growth and neurologic status of the children and data on two new instruments developed during the trial: the Adaptive Social Behavior Inventory and the Neonatal Health Index. The information is neatly organized in five separate sections, entitled “Rationale and Program Description,” “Results,” “Studies of Growth and Development,” “Operational Issues,” and “Cost Analysis.” The first chapter, a well-written historical overview of the outcomes of premature infants, provides the foundation on which the three principal research questions were developed. In the subsequent sections and chapters the authors describe in depth the research plan; the major research questions; analytic strategies and the intervention model, including detailed reviews of the home-visitation programs; and the organization and management of the child development centers. After an extensive presentation and discussion of the results, the authors probe critical issues raised by the study, such as which subgroups of children benefited most from the intervention and what changes in cognition occurred from one to three years of age and in what domains. A book of this magnitude would be incomplete without a careful assessment of health-services utilization and cost analyses, both of which are discussed in depth. Furthermore, chapters 26 to 34 present a wealth of information on operational and administrative issues pertaining to the Infant Health and Development Program. A welcome addition to the book would have been an insert with a list of the previous publications of Infant Health and Development Program data in peer-reviewed journals.

The Infant Health and Development Program study showed that participation in intensive intervention services during the first three years of life can have significant and positive effects on the cognitive development and behavior of low-birth-weight, premature children. This rich book conveys the message clearly to a worldwide audience of clinicians, researchers, educators, health planners, students, and others interested in child development. They will surely find this book to be an inspiring and precious reference source. Moreover, this is a powerful package with the potential to influence significant changes in health policy.

Oscar G. Casiro, M.D.
University of Manitoba, Winnipeg, MB R3A 1R9, Canada