Developmental Care in the Nursery

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Developmental Care in the Nursery

• June Bridgford Garber, PT.
• Emory Hospital - Midtown
• Grady Memorial Hospital
• Emory University - Professor Emerita

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Why should you care about developmentally
appropriate infant care?

• Because intentional as well as unintentional
  sensory input to the immature CNS of a preterm
  infant influences long term development!
• Because lack of sleep lack of sleep cycle
  maturation negatively influence CNS development!

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• This CNS maturation usually occurs in a uterine
  environment where the fetus is protected from
  pain, light, high-frequency, sustained or loud
  sounds as well as unrestrained movement gravity
  imposed positions.
• Graven, 2006

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What is developmental care? A philosophy of
infant care that includes

• Attention and responsiveness to the limitations
  and needs of the immature central nervous system
  developing in an extra-uterine environment.
• Energy conservation for growth maturation.
• Prevention of pain, fatigue stress responses to
  hypothermia, environmental noise light,
  invasive procedures, prolonged handling and
  unsupported positioning.

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What is developmental care? A philosophy of
infant care that includes

• Attention and responsiveness to the behavioral
  and physiologic cues of infants as a guide to ALL
  care-giving practices.
• Clustering periods of handling to meet the
  infants need for recovery during or following
  care-giving and for sustained sleep rather than
  anyone elses schedule.
• Provision of developmentally appropriate, well
  tolerated sensory input on consistent basis.

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Energy conservation for growth maturation

• Thermoregulatory support from an isolette
  intermittent gavage feeding are identified as
  primary factors minimizing energy consumption to
  enhance growth velocity.
• Blackwell, Eichenwald, McAlmon, et al (2005)
• Rapid transition to open bed all PO feedings,
  as benchmarks needed for discharge, often occur
  at the expense of growth maturation.

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Prevention of Pain, Fatigue Stress Responses

• Even term infants are unable to habituate to many
  types of sensory input.
• Wind-up phenomenon the greater the cumulative
  stress or pain experienced, the lower the
  infants threshold to irritability.
• Infants physiologic stability is enhanced
  stress diminished by graded handling with
  recovery periods.

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Support during invasive procedures includes
protection from noise light, supportive
positioning and recovery periods.
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Graded, Reciprocal Handling?

• The art of monitoring and using an infants
  behavioral responses to handling as a guide for
  titration of further handling determination of
  time for restful recovery.

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In addition to physiologic instability, recovery
periods are needed in response to floppiness,
stiffness jerky or tremulous movement patterns.
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Infants communicate a need for recovery periods
by facial expressions behavior. Signs of
tolerance, well-being or state organization
include charming behaviors that help parents fall
in love with their infants.
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Signs of stress signal a need for recovery time

• Signs of autonomic or physiologic instability
• Periodic breathing apnea
• Tachypnea
• Tachycardia
• Skin mottling
• Hiccups
• Straining or Grunting
• Tremors
• Low threshold startles
• Signs included in pain scales

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• Signs of fluctuating muscle tone or uncontrolled
  activity from stress include
• Neck trunk arching
• Frantic or jerky extremity movement
• sitting on air
• Salutes with finger splaying
• Limp extremities
• Gapping facial expression

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• Stress signs of diffuse or disorganized states
  include
• Grimaces or Frowns
• Frequent jerks or movement during sleep
• Eye floating
• Persistent gaze aversion
• Hyper-alertness or panic expression

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Protection from environmental noise and light

• Whispers may be needed for the youngest most
  fragile.
• 50-55 dB average
• Minimize gt1 second cycles gt70 dB

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Clustered Care to Support Recovery Sleep

• Scheduling touch times protecting
  sleep allows recovery time for infants
  and improves the quality duration of
  their alert periods when they occur.
• The purpose of clustering care is defeated by
  prolonged handling from multiple caregivers for
  multiple procedures without recovery time as
  stress behaviors become apparent.
• Touch times are ideally planned around a
  consistent parental visiting schedule adapted to
  the infants behavior.

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Management of the environment to fit the
capabilities of maturing infants

• Consensus group recommends reduced monotony of
  light levels in NICU environments to support
  day-night physiologic cycling.

• Light deep sleep differentiation plays a role
  in CNS maturation.
• Some studies report increased weight gain from
  consistent day-night cycles of lighting care
  giving levels.

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Supportive positioning to provide comfort
conserve energy

• Variety of nested sleeping positions need to
  support the trunk in flexion and to limit
  extension external rotation of extremities.

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Positioning Products There are a lot of them!
They dont replace skilled care-givers attention
adaptation to the infants needs!
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In Any Position

• Elevate the head of the bed
• Extremities should be supported in flexion
  rotation toward the trunk containing but not
  eliminating postural adjustment for comfort.
• Appropriately fitting diapers shouldnt limit hip
  flexion adduction to neutral.

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Extremity movement is a normal component of fetal
infant development.

• Swaddling nesting of infants to decrease stress
  promote flexed positions as well as sleep also
  limit movement.
• By decreasing active movement the strain needed
  to stimulate skeletal growth modeling is
  diminished.
• As infants adapt to supine sleeping, they also
  need to gain experience controlling extremity
  movement without swaddling.

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Keys to Supportive Prone Positioning

• Ventral support or a mommy roll elevates the
  trunk relieves pressure on the head.
• A ventral roll should not extend between the legs
  should be narrow enough to allow arms to flex
  close to the trunk.

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Keys to Supportive Side Lying

• Diapers, gel pillows or infant hats with a
  washrag inside can be used to decrease pressure
  on the side of an infants face
• Support the trunk in flexion, provide a ventral
  roll to hug maintain extremities in neutral
  rotation.

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Keys to Supported Back Lying or Supine

• Avoid a neck flexion position that diminishes the
  infants airway as well as a neck extension
  position that diminishes swallowing control.
• Maintain midline position to shift force away
  from lateral skull support extremities in
  flexion against the trunk more securely than
  other positions.

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Most infants have their own ideas about
positioning to consider! Sometimes infants move
out of our fine positioning because they are
uncomfortable, hungry, experiencing reflux and/or
working too hard to breath.
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Atypical head shapes develop from asymmetrical
forces acting on the skull.

• Same open skull sutures that facilitate vaginal
  birth make the skull vulnerable to modeling.
• With the head larger in proportion to the body
  than any other time of life, COM shifts to upper
  trunk limits head movements.
• Hard palate develops a high arch that can
  increase the challenge of nipple feeding.

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Scaphocephaly or Dolichocephaly

• Elongated along the anterior-posterior axis
• Results from prolonged temporal zygomatic
  pressure in all positions as well as devices for
  securing endotracheal tubes CPAP.

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Plagiocephaly

• Asymmetrical occipital flattening
• Secondary asymmetry of the ears eyes
• Results from prolonged supine or semi-upright
  positions with head turning preference usually
  to the right.
• With GERD, right rotation is typical may
  present like Torticollis!

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Kangaroo Care has significant benefits for both
the infant and the parents.
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Early involvement of parents in nurturing care of
their infants

• Kangaroo Care, placement of the infant
  skin-to-skin (SSC) against a parents chest, has
  beneficial short term effects on
  thermoregulation, oxygenation, weight gain
  increased quiet sleep as well as quiet alertness
  with infants at least 28 wk.s cEGA or PMA.
• Neonatal Network 27(5) 2008

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Early involvement of parents in nurturing care of
their infants

• SSC includes tactile, olfactory auditory input
  to the infants tolerance level.

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• By 37 wk.s cEGA, infants having received at least
  one hour of SSC for 14 consecutive days or more
  have better orientation habituation skills.
• Reported effects on lt28 wk.s infants are
  inconsistent.
• Once infants exhibit suckling or mouthing,
  non-nutritive sucking may be tolerated with SSC.

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Development of nipple feeding capacity

• Suck-swallow-breath (s-s-b) coordination may be
  evident inconsistently as early as 32 wk.s PMA
  but consistent 111 s-s-b ratio is typically
  present by 37 wk.s.
• By 36-37 wk.s PCA, following 1-2 weeks feeding
  experience, problems with weak expression /or
  inability to sustain a rhythmic expression
  pattern have been correlated with
  neurodevelopmental impairment at 18 months.

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Non-nutritive Sucking during Alert Periods

• Cochrane Database Systematic Review of 21 studies
  (15 randomized, controlled studies) concluded
  that consistent NNS periods decreased length of
  hospital stay, improved bottle-feeding
  performance transition from gavage to bottle.
• Pinelli, Symington (2005)

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Developmentally Appropriate Nipple Feeding
Progression

• NNS Bursts of rapid sucking are the primary
  activity. Only oral secretions sometimes drops
  of milk
  or formula need to be
  swallowed.
  The challenge of swallow-respiratory
  coordination is minimal during
  NNS.
• Drops of milk or formula are often needed to
  stimulate any sucking response from immature
  infants.

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Transition from Non-nutritive Sucking to
Nutritive Sucking

• Immature infants attempting to nipple feed are
  less adaptable in their transition from pacifier
  or non-nutritive sucking to organized nutritive
  sucking!!
• Prior to initiation of nipple feeding, NNS and/or
  perioral stimulation help some infants alert but
  may also consume limited energy reserve and/or
  
  over-stimulate many others .

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• Both NNS early NS experiences should provide
  positive experiences for the infant without
  significant stress or fatigue.
• During early NS, the QUALITY of the experience is
  significantly more important than the QUANTITY of
  milk or formula consumed.
• Growth, maturation AND practice are
  interdependent processes resulting in functional
  nipple feeding skill.
• Practice at the expense
  of growth is not
  developmentally
  appropriate care!

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On Demand Immature oral feeding

• Immature infants demand not only the beginning of
  their oral/nipple feedings but also the
  termination!
• Dont try to feed exhausted infants!
• More practice while the babys exhausted is not
  beneficial!
• Nipple feeding is an experience-expectant motor
  pattern that emerges with maturation.
• It isnt TAUGHT!

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• Disorganized, inconsistent, ineffective sucking
  is a common characteristic among ELBW infants.

• Soft, high flow rate nipples do not generally
  help infants with inconsistent sucking pressure.
• Soft, slow flow rate nipples are now available!!
• Higher flow rate of warmed milk/formula presents
  a problem for some infants with inconsistent
  sucking pressure.
• Slightly cool milk/formula helps some infants
  coordinate suck swallow timing better.

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Early Nutritive Sucking

• Side-lying controlled, slow introduction of
  milk avoid swallowing problems.
• Imposed pauses in sucking facilitate inspiration
  avoid feeding or swallowing apnea!

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Paced Feeding

• An imposed pause between cycles of 3-5 sucks
  facilitates ventilatory effort conserves
  energy.
• Tilting the bottle downward to empty the nipple
  or complete removal of the nipple from the
  infants mouth my be needed before an infant will
  swallow breath.

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Oral Feeding Progression

• There is a relationship between consistency
  continuity of feeding management practices
  improved feeding performance.
• Pickler R, Best A, Reyna B, et al 2005
• Daley H, Kennedy C, 2000.
• Some parent-infant pairs succeed in spite of us!!
• With 10-20 different caregivers each imposing
  their own feeding progression pattern during a
  5-7 day period, confusion fatigue often
  prevail.

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• 40 wk.PMA infants able to sustain conjugate gaze
  for a 2 minute period and able to sustain gaze
  fixation while following 10-15 degrees laterally
  are at lower risk for developmental delay than
  infants requiring gt40 wk. PMA to achieve these
  interactive skills.
• Glass, Fujimoto, Ceppi-Cozzio, et al (2008)

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After 32 weeks PCA, daily administration of
auditory, tactile, visual vestibular
stimulation for 15 minute periods facilitated
increased alertness, faster transition to
complete PO feeding decreased length of
hospitalization.

• Graded handling OOB including
• 10 min. of soft speaking with back rubbing
• 5 min. of horizontal rocking
• Facilitation of visual orientation as signaled by
  the infant
• White-Traut RC, Nelson, et al 2002

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• As parents other primary caregivers gain skill
  in the care-giving tasks, their own sense of
  competence increases as well as their perception
  of the infant as competent.

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Parental participation in periods of graded
infant stimulation facilitates bonding
competence. It may provide the infants CNS with
input important for CNS maturation development.

• Follow-up studies of preterm infants reveal
  alterations in CNS structure reflected in
  developmental delay, behavioral problems
  learning disabilities.

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• At 12 years of age, preterms with birth weights
  lt1250 gms, having no ultrasound evidence of IVH
  or PVL, were evaluated by DTI or diffusion tensor
  imaging.
• In comparison with controls, white matter volume
  decreases were evident in frontal, temporal
  parietal lobes and fiber tract organization was
  diminished in both the corpus callosum
  fronto-occipital fasciculus.
• Constable RT, Ment LR, et al 2008

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What are the benefits of this neonate guided
care-giving pattern?

• Preterm infants cared for with attention to their
  developmental limitations needs have better
  outcomes.

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Meta-analysis of 31 developmental care outcome
studies (Symington Pinelli, 2001)

• Although these studies have numerous
  shortcomings, benefits include the following
• Improved weight gain
• Decreased respiratory support
• Decreased length of stay
• Improved developmental outcome sustained through
  24 months in multiple studies.

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EEG and MRI evidence of improved frontal and
occipital lobe maturation as well as density of
tracts from these lobes. (Als, Duffy, 2004)
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What is NIDCAP training?

• Neonatal Individualized Developmental Care and
  Assessment Program
• Systematic method of recording observations of an
  individual infants behavioral cues 20 minutes
  before, 20 minutes during and 20 minutes after
  care procedures.
• Multiple observations are needed to provide a
  foundation for on-going caregiving modifications.
• Requires extensive training to administer and
  interpret

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Handle with care! There is a lot yet to learn
about care of the developing human brain!
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