an evidenced based approach to therapeutic interventions in the … · an evidenced based approach...
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An Evidenced Based Approach to Therapeutic Interventions in the NICU:
By: Mary Vanesko MOT, OTR/L, CIMI
Objectives:
1.Identify theoretical concepts that have guided implementation of developmental and family -centered care.
2.Implement a healing, neuroprotective environment, fostering brain care to positively affect short term and long term outcomes.
3.Utilize age appropriate, developmentally supported, evidence-based assessment and interventions.
4.Interpret the maturation of the brain and sensory systems and the most appropriate, safe, timely and effective interventions.
5.Examine how to overcome specific challenges in the NICU related to the unique culture, families in crisis and medically fragile infants.
6.Distinguish the current evidenced based research to be an effective advocate and leader in your NICU.
7.Establish a collaborative, therapeutic NICU team and program, becoming a leader in positively impacting the long term outcomes of our patients and families.
WHAT IS THE HISTORY OF THE NICU
Timeline1880- Stephane Tierne invented the first incubator1893-First special care unit for preterm newborns in Paris (Dr. Pierre Budin)1896- Physicians Alexandre Lion, Martin Couney, and Pierre Budin continued as pioneers in the evolution of the incubator. Soon after they introduced the incubator to the United States1898-1943 – “Incubator Baby slide shows”Preterm infants coined as congenital weaklings
WHAT IS THE HISTORY OF THE NICU
Timeline1930s-1960s- Julius Hess (American Physician) known as the father of Neonatology, created advanced incubators in which oxygen can be delivered to the babies, he tied together many strands of the development of neonatology1960s-70s – Brazelton’s NBAS (Neonatal Behavior Assessment Scale)
WHAT IS THE HISTORY OF THE NICU
Timeline1985– NIDCAP (Newborn Individualized Developmental Care and Assessment Program), concern for how environmental factors effect babies outcomes (Als)1982- APIB (Assessment of Preterm Infants Behaviors)2000s-
IndividualizedRelationship-basedFamily CenteredDevelopmentally supportive care
STATISTICS
14 million pre term deliveries (any baby born less than 37 weeks GA) occur per year around the world with an overall incidence of about 12% percentIn technologically advanced areas, the incidence caries from 5-12% In areas that are less developed, it maybe as high as 40%
Infants born at 24 weeks have a survival chance of 50% in modern tertiary care centers98% of Infants born after 28 weeks surviveMajor disability rate for infants born at or below 25 weeks stands at about 25%Infants 25-27 weeks GA at about 15%
10% dc home with no major disabilities at 23 weeks25% dc home with no major disability at 24 weeks35% dc home at 25 weeks with no major disability 50% dc home at 26 weeks or greater with no major disability
Preterm Birth: Risk Factors Risk Factors:
Previous preterm birth
Multiple births
Medical conditions
UTI
Obesity
Being Under weight
Sexually transmitted diseases
Illegal drugs
Stress
Domestic Violence
Drugs
Preterm Birth: Risk Factors
Diabetes
High blood pressure
Late or no health care during pregnancy
Smoking
Certain racial and ethnic groups
Drinking alcohol
NICU Basics
NICU levels of care
Classification of age
Prematurity classification
Birth weight classification
NICU environmental considerations and equipment
NICU baby families
Common diagnoses in the NICU
NICU team
Role of the Neonatal Therapist
NICU Levels of Care
Level I: Well baby nursery>Evaluation and post natal care of newborns>Neonatal Resuscitation >Stabilization until transfer to facility at which specialty care is provided
Level II: (A-B)Transitional nursery - Need continuous ongoing care “Feeders and growers”>Level ll (A) No capabilities of ventilation >Level ll (B) can provide mechanical ventilation for brief durations ( 24 hours)>Birth weight <1500 grams >Resuscitation and stabilization before transfer to NICU
NICU Levels of CareLevel III:(A-D) Neonatal Intensive Care unitMedically complexBabies on ventilatorsBabies requiring major surgeries
>Level lll (A) hospital and or state mandated restriction on type of mechanical ventilator
>Level lll (B) No restrictions on type of mechanical ventilation >Level lll (C) Major surgery performed on site, no surgical repair of serious
congenital heart anomalies that require ECMO >Level lll (D) or Level lV Major surgical repair or serious congenital heart
anomalies that require cardiopulmonary bypass and or ECMO
Classification of Age
Gestational age (GA)
Post Conception Age
Chronological age
Corrected Age
Corrected Age Example
Example:
Infant born at 27 weeks old is now 6 weeks old (chronological age): 27 + 6 = 33 weeks
Once baby reaches 40 weeks, or his due date, then begin counting from there.
Example:
Infant has now reached his due date today, tomorrow he will be 1 day old, and next week will be 1 week old.
How long do we use corrected age?
Corrected age will be used until your infant reaches 2 years of age.
Prematurity Classification
Prematurity = 28‐37 weeks GA
Micro Premie = <28 weeks GA
Full Term = 37‐42 weeks GA
Post Term = > 42 weeks GA
Birth Weight
Normal ‐ > 2500 grams
Low birth weight‐ 1500‐2500 grams
Very low birth weight ‐ 1000<1500 grams
Extremely low birth weight ‐ <1000 grams
NICU Vital Signs
Environmental Considerations: Open Bay vs Single Room
Environmental Considerations: Equipment
Environmental Considerations: Noise
Environmental Considerations: Noise and Lighting
No noise > 45 decibals
Decrease loud noises at the bed side including our speaking voices
Avoid direct light to newborns eyes at all times.
Use natural light when able (regulates circadian function)
Cyclic lightening (12 hours on 12 hours off )
Protect and facilitate REM sleep
Know the light equipment lux levels to adjust and reduce infant exposure
Families Families in crisis
Unexpected delivery
Family unit is separated
Overwhelming NICU environment
Decreased effective communication
Financial considerations
Maternal Health
Transportation or travel issues
Loss, shock, grief
Maternal depression and coping
Systems AffectedGastrointestinal
Metabolic
Hemolytic
Dermatologic
Orthopedic
Vision
Neurologic
Musculoskeletal
Respiratory
Cardiovascular
Common issues associated with Diagnosis in the NICU Prematurity
Maternal complications
Low Apgar scores
Neurologic disorders
Meconium aspiration
Dysmorphic or genetic abnormalities
Viral bacterial Infections
Drug/Alcohol exposure
Common issues associated with Diagnoses in the NICU Prolonged rupture of membrane
Respiratory distress syndrome
Rule out sepsis
Cardiac deficits
IUGR, SGA, LGA
Neuoromuscular disorders
Infants requiring Echmo or Nitric Oxide
And the LIST GOES ON and ON
The Role of Neonatal Therapy
According to National Association of Neonatal Therapists (NANT):
Neonatal Therapy is defined as “the art of integrating Typical development of the infant and family into the environment of the NICU.”
Incorporates theories, scopes of practice from respective disciplines ( PT, OT, SLP)
It requires advanced knowledge (diagnoses, medical intervention)
It promotes optimal long term developmental outcomes and nurtures infant parent relationships
Address neurobehavioral, neuromotor, neuroendocrine musculoskeletal, sensory and psychosocial
The Role of the Neonatal Therapist
Delivers direct patient care and consultative services to premature and medically complex infants.
Uses an integrated, neuro‐protective, family centered model.
Support optimal long term development, prevent adverse sequelae, nurture the infant‐family dyad.
Provide education to the family and NICU team.
Scope of PracticeUnderlying assumptions according to NANT:
Promote safety and practice in a safe manner.
Are unique members of the NICU team and value collaboration.
Practice and advocate for age appropriate, neurodevelopemental care.
Are fervent advocates for infants and families
Respect cultural diversity
Respect the privacy rights of the infants and family and manage information accordingly
Scope of Practice
Practice within their respective disciplines scope of practice
Strive to prevent iatrogenic problems associated with prematurity and the NICU environment
Promote a healing, neuro‐protective environment in the NICU
Are cognizant of current practice trends and strive to improve neurodevelopment outcomes based on research and evidence
Identify potential ethical conflicts and access proper avenues for resolution
Practice Environments
NICU Levels I‐V
NICU follow up program
Newborn nursery
Theoretical Frameworks
Dynamic systems theory
Attachment Theory
Family centered care
Synactive Theory
Dynamic Systems Theory
Attachment Theory
“A bond between an infant and a caregiver, usually its mother.
Attachment is generally formed within the context of a family,
providing the child with the necessary feelings of safety and nurturing
at a time when the infant is growing and developing. This relationship
between the infant and his caregiver serves as a model for all future
relationships” (Gale, 2005)
Family Centered Care
Family/Caregivers are the Center
Developmental care
Parent/caregiver education
Individualized treatment plans
Supporting and Collaborate
Synactive Theory of Development
Als proposed that developmental processes are based on the nuerodevelopmental subsystems interactions with neonates internal functioning, its environment and caregivers
Hierarchical and independent organization of subsystems
Stability and differentiation of each subsystem emerges subsequently
Neurobehavioral development is influenced by environmental
Infants actively attempt to modulate their environment
Infants continue to communicate there levels of stress and stability through approach and avoidance behaviors
Synactive Theory of Development
Identifies 5 separate but interdependent subsystems of behavioral maturation:
Autonomic: breathing, HR, color, GI function, involuntary muscle actionsMotor: Infants muscle tone, posture, movement, and habituation of movmementState: deep sleep, light sleep, drowsy, quiet awake, active awake, cryingAttention -interaction Self-regulation: the task of the NICU infant
Achieved when the challenges of the task meet the competencies of the infant
Synactive Model of Infant Behavioral Organization
State & Attention
Restless, irritable, rapid state changes, eye floating, roving
eye movements, glassy-eyed alertness,
staring, hyperalert, frenzy, whimpering, crying, inconsolable
Motoric
Autonomic & Visceral
Tremors, startles, twitches, flaccidity or hyperextension,
frantic activity, gape face, stop signs, UE
high guard
HR and BP changes, increased oxygen
requirement, hypoxia, As and Bs, change of color,
coughing, sneezing, hiccups, gagging, spitting
up, grunting, straining, release of cortisol and
precursors gluconeogenesis, lypolysis, proteolysis,
immunosupression
Clear, robust sleep states, rhythmic
crying, effective self-quieting, reliable
consolability, shiny-eyed alertness, animated face,
mouth pursing, ooh-face, cooing, smiling
Smooth, well modulated posture & tone, hand/foot
clasping, grasping, finger folding, suck searching
Smooth, regular respiratory rate, stable HR, stable Sp02, pink color,
stable viscera with no hiccups, gags,
emesis or grunting
STRESS/ INSTABILITY =
Defensive, Avoidance Behaviors
STABILITY = Approach Behaviors
SELF
REGULATION
AutonomicSigns of stress:
Physiological instability including respiratory changes (Pauses, tachypnea, gasping),
Color changes (changes to mottled, flushed, pale, dusky, cyanotic, gray or ashen)
Visceral responses ( including Hiccups, gagging, spitting up, grunting, straining,
Motor (tremors, startles, twitches, coughs, sneezes, yawns, sighs, seizures)
Signs of Stability:
Smooth, regular respiratory rates, stable heart rates, stable SP02
pink in color
stable viscera with no hiccups or gags, emesis or grunting
No signs of tremors, startles, twitches, sighs, yawns or seizures.
Motor Signs of Stress:
Fluctuating tone, uncontrolled activity
Flacidity (gape face, low tone in trunk, limp lower extremities and upper exrtremities)
Hypertonicity ( leg extensions an sitting on air, upper extremity salutes, finger splays, and fisting, trunk arching and tongue extensions
Hyperflexions (trunk, lower and or upper extremities, frantic, diffuse activity extremities
Signs of stability:
Consistent tone, controlled activity, trunk and extremities appropriate for post‐conceptual age.
Smooth controlled posture, movements of extremities and head
Motor control can be used for self regulation
StateSigns of stress:
Diffuse or disorganized state including range and transition
During sleep notes twitches, sounds, whimpers, jerky movements, irregular RR, fussy, grimaces
During awake state abrupt changes, eye floating, glad eyes, gaze aversion, worried or dull look, hyper‐alert, panicked, weak cry, irritability
Signs of Stability:
Clear state
well defined sleep states, smooth transitions between states
good self quieting and consolability, focused, clear alertness, robust cry
Attention/InteractionSigns of stress:
Effort to attend and interact to specific stimulus elicits stress signals of other subsystems
Autonomic‐ irregular RR, color changes, visceral responses, coughs, yawns, sneezes, sighs, straining, tremors, twitches
Motor state‐Fluctuating tone, frantic diffuse activity, eye floating, glassy eye, hyper‐alert, panicked, worried, gaze aversion, week cry, irritability, becomes stressed If more than one type of stimulus is given at a time, abrupt state changes
Signs of stability:
Responsive to auditory, visual and social stimulation, actively see out auditory stimulus
Able to shift attention, smoothly from one stimulus to another
Face demonstrates bright‐eyed purposeful interest varying between arousal and relaxation
Self Regulation Infants use of physiologic, motor, and state strategies to move independently to a sleep or calm-alert stateInfant’s efforts to achieve, maintain or regain balance and self organization
Stress/Avoidance vs. Readiness/Approach Signs Examples
Stress/Avoidance vs. Readines/Approach Signs Examples
Stressed vs Stable
Approach vs Readiness
States/Behavioral Organization (Als.)
Deep sleep (quiet)
Light sleep (active rem)
Drowsy (sub optimal for feeding, infants may not transition to higher state, transitional state)
Quiet alert (best for treatment interventions)
Active Alert
Crying (stress)
http://www.youtube.com/watch?v=bgTVrxBfg8g
Deep Sleep
Stable and Organized: Sleeps with regular breathing, relaxed and no activity
Stress and Disorganized: Sleeps with startles, jerks and tremors, irregular breathing
Light Sleep
Organized: Low activity level, some startles and some sucking
Disorganized: Diffuse movement, whimpering, irregular breathing, facial twitching
Drowsy
Organized: Drowsy with low activity, facial grimaces, vocalization.
Disorganized: Drowsy with glassy eyed dazed look, diffuse movements, many vocalizations, newborn sounds, grimacing.
Quiet Alert
Organized: Quiet Alert, minimal activity, bright focused attention, low or minimal activity.
Disorganized: Hyper‐Alert: awake, eyes wide open, frantic look, intense. Lidded‐Alert: awake, quiet, alert, appears fatigued, eyes glossed over
Active Alert
Organized: Awake, aroused, smooth active movements
Disorganized: Awake and alert, distressed face
Crying
Organized: Strong Rythmical
Disorganized: Weak/strained cry with grimace
Theoretical Framework to NICU Practice
Developmentally supportive care has emerged from the Synactive Theory to what is now the NIDCAP (Newborn Individualized Developmental Care and Assessment Program)
It is a multidisciplinary approach to care
It begins at the birth of the infant rather than once the infant is medically stable
NIDCAP
Aims to create a relationship‐based developmentally supportive environment for preterm infants and their families
The approach is based on three assumptions (Als, 2009):
Observation of infant behavior
Care‐giving staff benefits from supportive education and guidance
Changes and adaptations of care lead to improved medical well‐being
NIDCAP Research Trials
Several Randomized Controlled Research Trials
Consistent evidence to support the following:
Improved lung function
Feeding behavior and growth
Reduced length of hospital stay
Improved neurobehavioral, neurophysiological, and neurostructural functioning
What is Developmentally Supportive Care?
Reflective, self aware practice as a framework of practice VERSUS task‐oriented, intensive care work.
Relationship engagement excellence
Technical skills in the face of physical and emotional vulnerability
Reduce the discrepancy between the womb and in the NICU environment
Take into account the infant’s current thresholds of behavioral organization
What is Developmentally Supportive Care?
Diminishing stress and supporting each infant’s strengths and competencies
Interventions tailored to meet the unique needs of infants
Each infant is an active participant in all care
Family is valued as infants most consistent nurturer
Infant and parent must receive individualized support throughout the NICU hospitalization for optimal outcomes.
Developmental Care is Family Centered Care
Recognizes family as the constant in the child’s lifeInvolves families in planning, delivery and evaluation of health care servicesFosters independence and empowerment while providing supportPromotes individualization of care
Developmental Care is Family Centered Care
Allows unrestricted access to their infantAssess the emotional well-being and competence and evolving confidence in parenting their infant Access to resources and supports that assist them in their short and long term parenting needs
Case Study
Meet baby “M”. M was born at 25 weeks GA. He spent 165 days in the hospital. M suffered from
grade three IVH as well as suffered multiple complications including GERD and NEC. M is a
survivor.
The Impact of Developmentally Supportive care on Brain and Sensory
Development Premature infants are fetuses developing rapidly in an extrauterine setting
Brain growth is developing more rapidly than any other time through out their life
Infants expect 3 secure environments, the womb, parents body and community
The intensive care unit provides challenges for the growth and development of the brain and sensory systems
The brain and the sensory systems are continuously dependent on each other for normal structural and functional development
Adverse sensory stimulation, repeated painful or stressful procedures alter intracranial pressure and cerebral blood flow
The Impact of Developmentally Supportive care on Brain and Sensory
Development The neurologic and sensory systems DO NOT exist as separate entities
Every sensory experience is recorded in the brain >behavioral
response >sensory experience.
When premature infants have sensory experiences that are
inappropriate for their stage of development > neurodevelopment
occurs differently than it would have in the womb.
Different neurosensory and neurobehavioral outcomes in premature
vs. term
Unknown
“When we touch the skin we touch the brain.”
The Brain Basics
Frontal LobeBasal GangliaParietal LobeBrainstemTemporal LobeSpinal CordOccipital LobeDuraCraniumCortexCerebellum
Brain Development
• Organization (24 weeks to post birth)- the “wiring” of the brain.
• Organizational disorders result in altered functioning and learning in the brain
• Mylenization (8 months to post birth)• Involves forming supportive tissues around nerve cell to
promote effective communication between the areas of the brain.
Wider Than The Sky
https://youtu.be/MS5HUDVNbGs
24 Weeks Versus Term
Brain Development
Brain Development
Cephalocaudal or also known as top-down; head to toe –Term infants
Development of the head and brain tends to be more advanced than the rest of the body.
Brain Development
Prematurity leads to infants initially developing Caudo-Cephalic; toe to head or also known as bottom up.Involuntary and unconscious > related to physical effects of environmental stimuli. • For example: withdrawal from heel sticks promotes
flexion of the LE’sBabies rely on the bottom up – this becomes a cycle due to the early birth which is traumatizing for the infant and then becomes a Top-Down progression
Brain Development
Cognitive structures of the brain impact the emotional and instinctive systems as well as motor development
Regulation of the Nervous System impacts Cognition
Affects the physical then the cognition - later impacts the emotional and instinctive systems
Sensory Development
Sensory Development
Develop in the following order from early gestation forward:
Tactile and ProprioceptionVestibularChemoreceptive- Gustatory and OlfactoryAuditoryVisual
Tactile System
Tactile system is fully developed at 23 weeks GA, the first system to fully developTouch Develops first around the mouth—>Head—> Toe (mouth hands and feet are most sensitive)24 weeks GA infants are sensitive all over the body Only one that is fully myelinated at birth
“Touch is the foundation of all experiences”Touch is the only sense we cannot live without!
Vestibular System
Vestibular- helps to stand up right against gravity, stabilize visual field, detect head movement and gravitational pull, impacts emotional regulationEarly in utero at 10 weeks
joined with cochlear system in the ear23-24 weeks Ga semi circular canals function moro reflex Is present at 30 weeks Ga full moro response at term
Muscle tone is influence by this system
ChemoreceptorsChemoreceptors
Recognition of parentDevelopment of attachmentFeeding and later dietary preference
Olfactory is imbedded in mucous Olfactory tract transmits the signals to the olfactory cortez and limbic systemSmell is linked to memory
Taste buds are on the Tongue and soft Palate14-17 weeks Ga taste buds are detected24-27 weeks Ga Infants react to bitter tastes28-29 weeks infants react to sweet and sour, respond to mothers milk30 weeks infants have presence for some tasteBy end of the last trimester swallow huge amounts of amniotic fluid and taste different flavors
Auditory systemAuditory
Auditory systems are in place at 24-25 wks GAAt 24 weeks GA, infant moves in response to loud noiseAt 26-28 weeks GA loud noises can produce physiological changes in HR, RR, BP and O2 saturationsAt 28 weeks GA infants can discriminate loud pure tones between mother and fatherHearing maturation for auditory processing continues to develop through 40 weeks
Visual System
VisionStructures in place 23-24 wksMaturation and differentiation active until early infancy
At term: attend to forms, objects, faces and able to track horizontal, some verticalSee object to 2.5 feet and attend best at 8-12 inchesHuman face is preferenceVision is the last system to fully develop
Muscle Tone
Physiological flexion is an excessive amount of flexor tone that is normally present at birth
Muscle tone develops between 32‐34 weeks Ga. Flexor posture begins first with the Les
Flexion begins in the Ues between 35‐38 weeks
Hypotonia is normal for premature infants
IPAT Developed to standardize best positioning practice in the NICU
A tool that is used to promote nursing education and carry over at the bedside
Used to optimize neurodevelopmental outcomes
‐See handout‐
Positioning/Lab
Prone
✴Increased oxygenation
✴Ribcage mechanically supported by surface
✴Facilitates flexion (reflexively)
✴Facilitates hand to mouth
✴Prevents GERD, improved gastric emptying
✴Improved deep sleep
How to Position in Prone
Provide circumfrential boundaries when able
Roll from head to umbilicus
Roll under chest
Swaddle
Diaper roll under hips
Prone Ideas
Prone over chest
Prone over boppy
Prone over blanket roll
Prone over leg
Sidelying
✴Maybe used to facilitate flexion
✴Encourage hands to face/mouth activity
✴May benefit infants that demonstrate arching by providing them with boundaries to support flexion
✴Encourages neutral head position or chin tuck if gravity used as an assist
✴Place toys in visual field to promote the desired head position
✴Give infant rattle or toy that they can grasp
How to Position in Sidelying
Roll between upper and lower extremities
Posterior support and roll from shoulders to hips
Midline orientation
Supine
✴Promotes development of head control in midline with proper supports
✴promotes development of visual skills
✴Supports should allow for symmetry of arms and legs, hands to mouth, physiological flexion
How to Position in Supine
Swaddle
Circumfrential boundaries
Nesting
Blanket rolls under shoulder and or knees
Positioning Equipement Recommendations
Premie nestDandle rooBendy bumpersProne pillowGel pillow/mattressGel mattressBlanket rollFreddy frogSnuggle up
Positioning Equipment Recommendations
http://www.nurturedbydesign.com/en/thezaky/medical-staff.php
http://www.dandlelionmedical.com/products/dandle-roo/
http://www.usa.philips.com/healthcare/product/HC989805606731/bendy-bumper-postnatal-positioning-aid
http://www.usa.philips.com/healthcare/solutions/mother-and-child-care/infant-soothing
http://www.usa.philips.com/healthcare/solutions/mother-and-child-care/infant-positioning
Samson and PrestonTumble Form feeding seat system
Long Term Effects of Poor Positioning
“Frog lying”
“W” Shoulders
Neck and trunk hyperextension
Unstable postures
Shoulder elevation and scapular retraction
Head shape deformities
Implications for head shape
Torticollis ‐ Head tilt to one side (lateral flexion)
Neck rotation
Limited ROM
Congenital or due to poor positioning
Torticollis Implications
Affects more than just the head and neck
Visual tracking
Visual perception
Visual awareness
Asymmetry in trunk
Head Shape Deformities
○ Plagiocephaly‐one side of occiput and diagonal frontal flattening, eyes, mouth, jaw and ears asymmetric
○ Scaphocephaly‐lateral flattening with elongated head, narrow face
○ Brachycephaly‐occiput flat, wide face
Heidelise Als
“Experience is the Sculpture”
Assessment
Environmental (including equipment)
Neurobehavioral
Neuromotor
Pre‐feeding skills
Oral feeding and swallowing
Musculoskeletal
Sensory
Family
Assessment/Formal
‐Neurobehavioral
NBAS‐Neurobehavioral Assessment Scale (Brazelton, 1973)
NNNS‐Nicu Network Neurobehavioral Assessment Scale (2o04)
APIB‐Assessment of Preterm Infant Behavior (1982)
NAPI‐ Neurobehavioral Assessment of Preterm Infant (Stanford)
‐Motor
TIMP‐ Test of Infant Motor Performance
GMs‐ Prechtl’s Assessment of General Movements
Assessment/Observational Naturalistic Observation of Newborn Behavior
Startles/tremors
Quality of movement
Stress signs
Posturing
Asymmetries
Transitions
Color changes
Fatigue
InterventionsNeurobehavioral (autonomic, Motor, state, attention/interaction and self regulation)
Neuromotor (positioning/handling, development of normal movement patterns, reflex development, tone)
Environment (modify and adapt to suit the needs of the infant’s current development)
Family (educate, promote parent participation and independence to transition home, psychological support, facilitate bonding and attachment)
Interventions
ADLs (feeding, sleep, bathing, play/interaction)
Musculoskeletal (normal posture alignment, prevent effects of iatrogenic deformities, support and facilitate development of antigravity movements, strength, improve physiology tolerance)
Sensory/pain (protect and facilitate sensory development, sensory integration and provide non‐pharmacological interventions to prevent pain)
Safety (do no harm, engage with staff to promote a safe environment, risk management)
Positive Touch/Hand Containment
Fostering Parent-Child Bonding
Kangaroo Care/Skin to Skin
Infant Massage
Infant Massage Benefits
Benefits for baby:
Relief‐Massage can relieve discomfort from teething, congestion, constipation, gas and colic.
Bonding‐More intimate interaction with parent and infant helping to foster.
Skin Stimulation‐All the physiological systems are stimulated by massage. Improves digestion for better weight gain.
Enhances neurological development.
Infant learns good touch and respect for his/her body.
Infant Massage Benefits
✴Benefits Con’t for Baby:
Better able to handle stimulation and self‐soothe.
Improves digestion for better weight gain.
Enhances neurological development.
Infant learns good touch and respect for his/her body.
Better able to handle stimulation and self‐soothe.
Infant Massage BenefitsBenefits for parents
Better understanding about their infant’s cues of responsiveness
Enhances communication and emotional ties
Increases confidence and handling skills
Improves the bond of affectional attachment
Provides a mean t develop quality interaction time
Helps parents relax and listen to their baby
Improves communication with parent and child through out development
Supporting Activities of Daily Living
Diapering
https://youtu.be/S4c-oMNCvBE
Swaddling
Facilitate flexion
Facilitate midline orientation
Soothing technique
Thermal regulation
Promotes sleep
Mimics the womb
‐Position Hips: Promote slight abduction and and slight flexion, free movement hip flexion and abduction, avoid sustained adduction and sustained passive hip extension‐
‐Position Knees: Slight flexion
http://hipdysplasia.org/developmental-dysplasia-of-the-hip/hip-healthy-swaddling/
Safe Sleep American Association of Pediatrics : Recommendations
Supine for 1 year
Firm sleep surface
No bed sharing
No pillows, blankets, bumper pads, toys
Avoid overheating
Consider pacifier nap time and bed time
Recommend breast feeding
Safe Sleep
Immunizations according to AAP and CDC
No cardiorespiratory monitors
Health care providers model
Avoid commercial devices inconsistent with safe sleep (No wedges or positioners)
Supervised awake tummy time
Conventional Bathing vs Swaddle Bathing
Swaddle Bathing
Benefits of swaddle bathing include:✴Maintaining infant’s physiological stability✴Facilitating energy conservation✴Fosters positive interaction with parents✴Improves state control✴Facilitates better temperature stability✴Increases infant comfort ✴Shown to increase overall patient satisfaction.
Swaddle Bathing RoutinePrepare the bath tub:✴Insert the disposable liner in the tub✴Fold the liner over top edge of the tub so that it is approximately 3 inches over the edge✴Place bathing hammock into the tub ✴The darts will be the foot end of the tub ✴Elastic edge goes outside the edge of the tub under the lip and over the plastic liner ✴The long piece of the elastic goes around the bottom of the tub.
Water temperature:✴Add water. The Association of Women’s Health Obstetric and Neonatal Nurses (AWHONN) state temp should be between 38-40 deg C or 100 deg to less then 104 deg F.
Prepare the infant for bathing:✴Remove all clothes ✴Remove leads✴Remove Pulse 02✴Remove diaper✴Swaddle lightly in a lightweight blanket or swaddle clothe
Bathing procedure:✴Take baby’s axillary temperature ✴Disconnect leads, pulse O2 ✴Remove all clothes, diaper, pulse O2 ✴Swaddle baby in a flexed, midline position ✴Have parents clean the baby’s face ✴Place baby in tub✴Have parent gently unwrap one of infant’s arms, and use baby wash to wash arm✴ Rinse and re-swaddle arm✴ Repeat for all extremities, including stomach, genital areas and back✴ Wash hair ✴.Unswaddle baby and place against chest on dry warm blankets ✴ Dry baby and dress with hat and clean diaper✴ Place new leads and pulse Ox✴ Prepare baby for skin-to-skin if parent/caregiver present
Gestational Development of Oral Feeding Skills
Gestational Age: Behavior:16‐17 weeks Swallowing regulates amniotic fluid23 weeks Practicing breathing by inhaling amniotic fluid28 weeks Rooting, sucking and swallowing reflexes present32 weeks Gag reflex and non‐nutritive suck present34 weeks Functional suck‐swallow‐breathe pattern, but poor
endurance36 weeks Coordinated nutritive suck
Pre-feeding Readiness
Pre-Feeding ReadinessIn preparation for oral feeding infants should achieve “pre‐feeding” goals as a means by which to determine their readiness and potential safety with oral feeds…
✴ Awake, alert and calm✴ Active rooting reflex✴ Active sucking on pacifier✴ Oral/pharyngeal reflexes✴ Strong and coordinated non‐nutritive suck✴ Demonstrates hunger signals✴ Tolerates handling and holding✴ Stable medical status. ✴ Stable airway✴ Tolerates tube feeds✴ Breathing comfortably with RR < 60‐70
Activities to Support Feeding Readiness
✴Pleasant stimulation to face, mouth✴Hold infant during oral stimulation✴Hold infant during tube feeds✴Skin to skin with mother/father✴Non‐nutritive sucking on pacifier or breast✴Pacifier dipped in milk ✴Avoid oral/nasal suction, if possible
Successful Bottle/Breast Feeding
FOCUS ON QUALITY FIRST,
NOT QUANTITY
Instead of defining oral feeding “success” on the amount the infant takes, base it on the following:-Medical and state stability-Oral feeding coordination and safety- Feeder comfort level
Breast Feeding ✴Most complete source of nutrition for infants and is digested more easily than formula
✴Studies have shown that women who breast‐fed their children may have decreased stress and increased coping, reduced risk of developing breast and ovarian cancer, and less bone problems later in life.
✴Breast‐feeding can help new mothers and their babies bond. ✴Decreases incidence/severity of RSV, respiratory infections, gastroenteritis, ear infections, SIDS
✴Studies show infants can have improved visual acuity and achieve higher IQs
✴Infants who are receiving breast milk in the ICU may attain full enteral feeding more quickly
✴Improved gastric emptying time✴Decreased incidence of NEC and ROP
Non nutritive versus nutritive sucking
Non‐Nutritive Sucking (NNS). – 2/second– 6‐8:1 suck/swallow ratio– Maintains same number of sucks per burst throughout
– Maintains same duration of breathing breaks throughout
Nutritive Sucking– 1/second– 1:1 suck/swallow ratio– Number of sucks per burst decreases as feeding progresses
– Duration of breathing breaks lengthens as feeding progresses
Characteristics of Nutritive Sucking
✴Suck, Swallow, Breathe Bursts Patterns: How many suck, swallow, breathe sequences an infant takes prior to taking a longer breathing break✴Immature: 3‐5 suck, swallow, breathe sequences✴Transitional: 5‐7 suck, swallow, breathe sequences✴Mature: 10‐20 sucks, swallow, breathe sequence
Cue-Based Feeding
At 32 weeks gestation, sometimes earlier, and if meeting medical criteria.
Evaluate the infant using the Feeding Readiness Scale
Cue Based Feeding Protocol Feeding Readiness Scale
✴1‐ drowsy, alert or fussy prior to care. Rooting and/or hands to mouth, taking pacifier. Awakens at scheduled feeding times.
✴2‐ drowsy or alert once handled. Some rooting or taking of pacifier
✴3‐ briefly alert with care. No hunger behaviors✴4‐ sleeping through care. No hunger cues.✴5‐ needs increased O2 with care. Apnea and/or bradycardia with care. Tachypnea greater than baseline with care.
Quality Scale
Utilize and document the quality of each feedingScale used to systematically assess the quality of oral feeding:
• 1- nipples with a strong coordinated suck throughout feed• 2- nipples with a strong coordinated suck initially but fatigues with progression• 3- nipples with consistent suck but has difficulty coordinating swallow, some
loss of liquid or difficulty in pacing; benefits from external pacing• 4- nipples with a weak/inconsistent suck, little to no rhythm, may require some
rest breaks• 5- unable to coordinate suck-swallow-breathe pattern despite pacing, may
result in frequent or significant Apnea/Bradycardias or large amounts of liquid loss and/or tachypnea significantly greater than baseline with feeding
Caregiver Techniques Scale
A Modified sidelying: Position infant in inclined sidelying position with head in midline to assist with bolus management
B External Pacing: Tip bottle downward/break seal at breast to remove or decrease the flow of liquid to facilitate suck-swallow-breathe pattern
C Specialty nipple: Use nipple other than standard for specific purpose (i.e., nipple shield, slow flow, Haberman)
D Cheek support: Provide gentle unilateral support to improve intra oral pressure
E Frequent burping: burp infant based on behavioral cues not on time or volume completed
F Chin support: Provide gentle forward pressure on mandible to ensure effective latch/tongue stripping if small chin or wide jaw excursion
Interventions-Nipple Selections
• Material• Shape and size• Flow rate • Position of nipple/bottle• Parent preference
• Should be selected to:• Match the oral cavity of the infant• Be supportive of milk transfer • Facilitate safe swallow
Nipple Selection
Specialty Bottles
Feeding Interventions
Nipple Selection ‐ Flow Rate
Pacing
Modified side lying
Environment changes/modifications
External support
Manipulating Feeding Schedule
GERD
Emesis
Wet burps
Frequent spits
Milk/formula around mouth
Elevated RR
Apnea
Bradycardia
Arching
Fussiness
Head rotation during and After
Rash/excema
GERDOral aversion
Gagging
Choking
Color changes
Poor weight gain
Noisy breathing
Restless
Chronic lung problems
Cough during sleep
Parent Education TopicsCorrected age
Approach/Avoidance signs
Hand containment
Kangaroo care
Sensory
Environmental modifications
Tummy time
Habits/routines
Parent Education TopicsTherapeutic exercise/stretches
Visual activities
Developmental milestones
Positioning
Infant Massage
Prevention
Infant driven feeding
What I am ready for at 24-28 weeks GA
Containment
Possibile swaddle
Quiet periods with no touching
Move slowly
Whisper
Protect my sleep
Flexed position
Skin to Skin
Boundaries
What I am ready for at 28-30 weeks GA
Containment in a snuggle
Swaddle
Quiet time wen I am asleep
Dim environment
Flexed
Skin to skin
Let me hold your hand
Position me in prone, side‐lying, supine
Swaddle bath
Boundaries
Keep Flexed
What I am ready for at 30-34 weeks GA
Swaddled
Quiet time when I am sleeping
Flexed
Awake for short periods
Talk quiet or sing to me
Sucking on pacifier
Containment
Let me hold your finger
Let me look at you when I am awake
Keep me flexed
Swaddle bath
Move slowly
What I am ready for at 34+ weeks GA
Swaddle
Quiet time when I am sleeping
Flexed
Awake for short periods
Talk quiet or sing to me
Sucking on pacifier
Containment
Let me hold your finger
Let me look at you when I am awake
Keep me flexed
Swaddle bath
Move slowly
Let me lift my head up in prone on your chest
Let me look at your face from side to side
Interventions
Program DevelopmentTeam based approach
Policies/procedures/protocols
PMR skills checklist and competencies
Work flow
Developmental Committee
Massage classes
Parent/sibling support groups
Billing
Transition Home
Early Intervention
Outpatient pediatrics
Follow up clinic
Long Term Care
Evidence ?
Early experience alters brain structure and function (Als 2004)
Study design: Randomized control trial tested the neurodevelopment effectiveness of the NIDCAP (Newborn Individualized Developmental Care and Assessment Plan)
Subjects: 30 preterm infants and their families
Experimental Group: 16 infants received individualized interventions to reduce infant stress by NIDCAP trained professionals
Control Group: 14 infants received standard care practice
Early experience alters brain structure and function (Als 2004)
3 aspects of Development were measured:
Neurobehavioral outcomes: (APIB) 2 weeks corrected age and the Bayley Scales of Infant Development (9 months corrected age)
Neurophysiologic outcomes: Sleep EEG cortical spectral data gathered on the same day of developmental testing
Neurostructural outcomes: 2 MRI Methods
Weight, height and head circumference also measured at 9 mos
Early Experience Alters Brain Structure and Function (Als 2004)
Developmental Outcomes
2 weeks PCA
Intervention group showed significant improvements in the Mental Development Index, Psychomotor Developmental Index, engagement, emotional regulation, motor quality (Bayley 2)
Early Experience Alters Brain Structure and Function (Als 2004).
EEG Results/Neurophysiological Outcomes
Intervention group demonstrated increase coherence between the left frontal region, occipital and parietal regions
Changes were present in functional connectivity between brain regions, with preferentially broad enhancements of frontal to occipital coherence
MRI Results/Neurostructural Outcomes
Significant improvements in maturity, with specific trends in the frontal white matter, right internal capsule and left internal capsule
Alterations in Brain Structure and Neurodevelopment Outcome in Preterm Infants Hospitalized in Different Neonatal Intensive Care Unit Environments (Pineda et
al, 2014)
Longitudinal study 136 preterm infants < 36 weeks GA(2007‐2010) in a 75 bed level 3 unit.
Evaluate between NICU room types: assigned open wards or assigned private rooms
Primary outcomes at 2 years: Significant delay in language
Alterations in Brain Structure and Neurodevelopment Outcome in Preterm Infants Hospitalized in Different Neonatal Intensive Care Unit Environments (Pineda et
al, 2014)
Study conclusion
Need for further research on the affects of different amounts of sensory exposure
Clinical Implications
Bright and noisy NICUs needed to be modified
Infant’s need their parents and families to provide appropriate stimulation for development
Appropriate and timed sensory stimulation is crucial for development
Implications for the NICUProvide infant‐driven family‐centered, developmentally supported care
NICU care is Brain Care!
We must consider the developmental age of the infant before providing interventions
Provide intentional bed side care
Understand that we are visitors in the home of these tiny newborns and their families
Collaborate with one another
Consider your team members as supportive allies rather than competition
Modify the environment
Provide Infant‐driven assessment and intervention
Conclusion
“If we are fortunate to stand on the shoulders of giants, it will allow us to see a broader vision.”
—Heidelise Als
Questions
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