When Parents Are Taught to Be Part of the Treatment, the Benefit Can Still Be There Five Years Later

An Italian study followed very premature babies to age five to see whether a programme that trained parents in the intensive care nursery made a lasting difference

Researchers in Milan taught parents of very premature babies how to read their baby's signals and how to give gentle massage and face-to-face interaction during the hospital stay, then followed those children until they were five or six years old. The children whose parents had received the training scored about eight points higher on a standard developmental test than children who received the nursery's usual excellent care — and the gap between the two groups grew a little wider every year rather than fading away. The study was small, so the finding needs confirming, but it suggests that involving parents as active participants in their baby's care may have effects that last well into childhood [1].

The Problem This Research Set Out to Solve

Around 15 million babies are born too early every year around the world [2]. For most of the history of neonatal intensive care, the question that mattered most was survival, and after that, whether a child would have cerebral palsy or lose their sight or hearing. Modern care has made real progress on all of those. But as the most severe problems have become less common, a quieter one has come into focus.

Doctors now describe something called the "encephalopathy of prematurity" — a general term for the way a baby's brain, which was expecting to spend its final trimester in the womb, develops slightly differently when it finishes growing in a hospital nursery instead [3]. This is usually not visible on a brain scan. There is no single moment of injury. Instead, the effects show up years later as difficulty with language, with concentration, with organising schoolwork. Studies that pool results from many trials have found that children born prematurely score, on average, about half a standard deviation lower on thinking-and-reasoning tests than children born at term — enough to matter in a classroom [4]. Large modern studies, such as a French project that followed thousands of children to age five, confirm that today's much better intensive care has narrowed this gap but has not closed it [5].

That is discouraging news on its own. But it comes with an important piece of hope attached. Because this kind of brain difference develops slowly over months and years rather than happening all at once [6], there may be a long window during which something can be done about it. And part of what shapes it is the environment of the nursery itself — the beeping, the bright lights, the necessary but uncomfortable procedures, and the simple fact of being separated from a parent. Researchers have measured differences in how babies' brains grow depending on how much of this stress they experience [7].

That insight changed what "developmental care" means. If the nursery environment is part of the problem, then a parent — the one person in the room whose voice, smell and touch the baby already recognises — might be part of the solution. Reviews that compared many different programmes found two ingredients that reliably showed up in the ones that worked: getting parents genuinely involved, and giving the baby gentle, positive experiences for the senses [8].

For decades, though, the evidence about whether this lasts has gone back and forth. A Norwegian study found that children whose parents received this kind of training scored higher on intelligence tests at age five [9]. An Australian study using a similar programme found no benefit at four and a half years [10] — though it included babies who had experienced serious bleeding in the brain, whose outcomes are largely determined by that injury. The Milan team had already shown that their own version of the programme improved babies' vision at the time they were due to be born [11] and improved development at one and three years of age [12]. The unanswered question was whether any of it would still be visible at school age.

What the Researchers Did

Between April 2014 and January 2017, doctors at a large hospital in Milan enrolled babies born between 25 and just under 30 weeks of pregnancy — very premature, but a group chosen carefully. Babies with genetic syndromes, major birth defects, or serious complications including significant brain injury were not included, so the study looked at premature babies who were doing relatively well [1].

Once a baby was stable, the family was assigned at random — like a coin toss, so that neither the parents nor the doctors could choose — to one of two groups. Both groups received the nursery's standard care, which was already good: kangaroo care (skin-to-skin holding), keeping handling to a minimum, and managing pain without drugs wherever possible. One group received something extra. Their parents attended weekly teaching sessions throughout the hospital stay, learning to recognise their baby's cues, and were shown how to give infant massage and how to engage their baby in face-to-face visual interaction. The parents did this themselves. That is the crucial design feature: the parents were not observers of the treatment, they were the treatment.

Five to six years later, the children came back for testing. A psychologist who did not know which group any child had been in assessed them using a standard developmental scale that produces an overall score, set so that the average child scores 100. Parents also completed a questionnaire about behaviour, and the children did a movement and coordination assessment. The researchers additionally took a cheek swab to look at a chemical marker on the children's DNA.

What They Found

Of 70 babies originally enrolled, 36 came back for testing at five to six years — 21 from the training group and 15 from the standard-care group. Many families were lost to follow-up, partly because the COVID-19 pandemic made hospital visits difficult, and this is the study's biggest weakness.

Among the children who were assessed, the difference was clear. The training group's average developmental score was 90.4, which falls within the normal range. The standard-care group averaged 82.3, which falls below it. After accounting for differences in how early each baby was born and family circumstances, the training group was about 7.5 points ahead.

Looked at another way: in the training group, 85.7% of children had normal development, 14.3% had mild difficulty, and none had severe difficulty. In the standard-care group, 46.7% were in the normal range, 40% had mild difficulty and 13.3% had severe difficulty.

The most striking result was about time. At 12 months, the two groups looked much the same. The difference then grew steadily — by roughly 1.89 points each year — reaching about 8.4 points by age five to six. The advantage did not fade; it compounded. The gains were concentrated in language, in social and emotional skills, and in the foundations of learning — exactly the areas the programme was designed to support.

Some things did not differ. Physical coordination scores were similar in both groups, which is not surprising given that the programme did not focus on movement, and the study excluded the brain injuries that most often cause movement problems [13]. Behaviour questionnaire scores were in the normal range for both groups, with no statistically meaningful difference — although the training group scored better on every scale, and fewer of those children scored in the concerning range. The cheek-swab DNA marker, which had differed between the groups when the babies left hospital, showed no difference by age five.

What This Means for Families

If your baby is in a neonatal unit now, the most useful message here is that your presence and your touch are not decoration around the real medicine. In this study, teaching parents to do the caring appeared to change how their children were doing years later. Ask your unit whether it offers structured parent training — many now do, under names like Family Integrated Care, NIDCAP, or a developmental care programme — and ask to be shown how to do infant massage and visual interaction safely for your baby's stage.

Some honest limits. This was one small study at one hospital, with 36 children assessed. That is not enough to promise a particular outcome for a particular child, and the results need to be confirmed in larger trials. It also studied premature babies who did not have serious brain injuries, so it cannot tell you what to expect if your baby has had a significant brain bleed. And nothing here should be read as blame. Parents who cannot be at the bedside every week — because of work, other children, distance, or their own recovery — have not failed their baby. Neonatal units exist precisely to care for babies when families cannot be present, and every hour you are there counts.

What Researchers Are Working On Next

The obvious next step is a larger study across several hospitals, following children further into the school years, when reading, maths and organising homework place heavier demands on exactly the skills this programme seemed to help. Researchers also want to know whether "booster" sessions after discharge would strengthen the effect, since the programme currently stops when the baby goes home. There is interest in whether the benefits extend to children who did have brain injuries, and in tracking outcomes that matter to families directly — attention difficulties and autism, both of which are more common in children born prematurely [14]. And the search continues for a simple biological test that could show, early on, whether a programme like this is working — the cheek-swab marker used here did not turn out to be that test.

References

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  2. Blencowe H, Cousens S, Chou D, et al. Born Too Soon: the global epidemiology of 15 million preterm births. Reproductive Health. 2013;10(Suppl 1):S2. doi:10.1186/1742-4755-10-S1-S2 ↩
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