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Does a comprehensive family‐centred early intervention service affect stress reactivity and emotion regulation in very low birthweight preterm infants at toddler age?

Preterm infants have higher risk of adverse developmental outcomes compared with termborn infants, including attentional (1), cognitive and behavioural impairments at school age (2), and motor impairment throughout childhood (3). Early intervention programmes positively affect cognitive and motor outcomes in infancy, with persisting cognitive benefits at preschool age (4). However, Wu and colleagues highlight that studies investigating the efficacy of early intervention programmes for emotion regulation in preterm infants at toddler age are lacking, and Taiwanese services for VLBW infants are largely limited to in-hospital, child-centred design (5). This multicentre RCT suggests that a comprehensive clinic or home-based child, parent and dyad-focused early intervention programme improved emotion regulation for Taiwanese VLBW infants. However, the authors found no stress reactivity benefits, or enhanced regulatory strategies for either intervention group, only partly supporting this conclusion. Cognitive and language performance at 12 months CA did not differ between groups, although statistical significance is not presented. The authors identify several pertinent study limitations. Of particular interest is the demographic characteristics of VLBW families, with 73% having high maternal education level and moderate to high socio-economic status. Socioenvironmental factors play an important role in the developmental outcome of preterm infants (6,7); therefore, this factor may affect the representativeness of participants. The laboratory setting for outcome assessment and follow-up length shouldbe considered in future studydesign. Participant follow-up is another important consideration, with low follow-up rates introducing potential bias and possibly affecting the statistical power of this study. The lack of details regarding sample size calculation for stress reactivity and emotion regulation in this article is similarly important to highlight. Furthermore, at each timepoint, a proportion of infantswere not assessed due to seating difficulty. For VLBW infants, this was reported 42 times, and eight term-born toddlers at 24 months were unable to be seated. The birth and demographic characteristics of these infants were comparable with assessed infants; however, it is possible that nonparticipants may have had underlying behavioural or motor difficulties. Exclusion of these infants from assessment limits the representativeness of the VLBW population in this study. This RCT contributes to the field by exploring the important area of emotion regulation and behaviour after a comprehensive child, parent and dyad-focused early intervention programme in Taiwan. In RCTs of early intervention, all participants receive the same intensity of inhospital and post-discharge treatment; however, in clinical practice, it is important to target service provision to each family’s individual needs and resources. Future research should include highrisk pretermpopulations to identify the efficacy of intervention programmes for those infants who are likely to benefit most (4). The financial feasibility of the home-based and clinic-based interventions detailed by Wu and colleagues would be a valuable area of further study to guide future design of early intervention programmes. As both clinic-based and home-based settings were found to be beneficial for reducing stressevoked primitive behaviour when comparedwith usual care, the parental mental health, well-being and engagement in each programme could also be a valuable method of evaluating each setting.