Presented by: Maila K.G

Sponsored by: Sihlangu

Introduction Uterine environment Preterm infant

BirthNeurodevelopmentSurvival and challenges

Considerate care The environment and homeostasis Conclusion

Introduction Neurodevelopmental care is a broad term applied to

physician- physical environmental elements and family involvement that may favourably impact the neurodevelopment of premature newborns.

This include: position strategies, modulation of light and sound exposure and emphasis on the need to preserve sleep

Focus of NICU: physiological support of respiratory, cardiac etc..

An effort to improve outcomes have shifted attention towards neuroprotective strategies and Neurodevelopmental support

Neuroprotection includes meds, and modifying resp and CVS strategies to prevent or ameliorate CNS injury

Uterine environment The uterus is the optimal environment for

development from conceptionFrom conception onwards, the foetus is thought to be

organising five distinct but interrelated subsystems: ANS, motor (governs posture and movements), state (sleep to wakefulness), attention and self-regulatory

Infants born prematurely have an interrupted maturation of the five subsystems

Premature infants have an ongoing maturation of each subsystem while infant negotiates more independent functioning e.g breathing, maintaining postures while also facing challenges like enduring bright light, harsh noises, frequent handling etc.

Preterm infant<37/40The extra-uterine environment is not similar to

the intrauterine, infant is continuously exposed to stressful environment in stark sensory mismatch to the developing nervous system’s biological needs

The brain is a fragile, immature organ at high risk of haemorrhage and neurological impairment

Preterm birth further disrupts the development ofal progression of brain structures and affects development of the sensory system

Preterm survivalSurvival rate due to an improvement in perinatal care

techniques, technology such as ventilation and meds like surfactant and other pharmacological advances

However, there has not been a corresponding improvement in the long term developmental outcomes for these surviving infants

Development and functionality during these life periods impact directly on the social and economic structures of the country, with a poor functionality resulting in a socio-economic burden

More babies survive due to technological advances, but their quality of developmental outcomes may be a burden to society

Survival Has been addressed by implementing

NIC, but the preterm infant remains at risk for a range of morbidity related to the immaturity of organ systems assoc. with prematurity

Leading to physical and developmental challenges

An approach using a range of EBM (medical interventions) aiming to decrease the stress of preterm infants in NICU

It provides care in a manner in which the environment and process of care is adjusted and individualised in response to development and tolerance

Incl. Communication abilities to enhance optimal neurodevelopmental outcomes

Interventions are designed to simulate the intra-uterine environment

To promote normal neonatal development

Remembering the intrauterine environment which is where the preterm infant should be: Noise, light, temperature, touch and smell will have a big

impact on the infant. Pain and discomfort are sensations that the infant has not

experienced before. The fight for survival starts at birth, with possible

respiratory complications, challenges of feeding, and maintaining homeostasis

Remember: by 20 weeks, the total number of nerve cells in the brain will have been developed

From 20 weeks gest. age to 2 years, brain growth is significant

There are more synapses in the brain at term than any other time in life

As a baby grows, myelination helps them process information more quickly. There are as many neurons in the brain as the number of leaves on trees in the amazon rain forest

Neuro-developmentAround 28 weeks, tremendous refinement and

restructuring of neuronal connections occur. There is a phase of rapid synaptogenesis, sensitive or

critical period where environmental factors may have detrimental influences on brain development

Neurons forming the visual cortex are in place at 26/4028-34/40 visual neuronal connections undergo rapid

development28-30/40: rapid maturation of cochlea and auditory nerveHearing threshold 40dB by 28-34/40, decreasing with

maturity

Neurodevelopment The more preterm infant will show less mature response than term

babies. Neurological assessment evaluates: reflexes, neonatal state which

maybe sleep or awake state Preterm infants are not able to cope with many simultaneous

sources of stimuli The infant <32 gestation weeks who is experiencing a disorganised

autonomic nervous system will become pale, dusky or cyanotic At <35 weeks gestation age motor development may interfere with

physiologic homeostasis resulting in Vomiting, change of colour, apnoea and bradycardia the infant has more defined states –sleep, crying, awake

At term gestation, the infant is able to maintain alertness, interact with objects and cope with external stress

The NICU environment

Dark, quiet and warmThe developmental appropriate approach

should include environmental manipulation like light, noise, positioning, positive touch and pain management

This is a place where the preterm infant is deprived of the normal stimuli that it should experience

Instead they suffer sensory bombardment like: intrusive procedures, sleep disturbances and deprivation

The environment and homeostasisThe ICU is a place where a preterm infant is

deprived of the normal stimuli that it should experience.

Instead, the infant suffers sensory bombardment: noise, light, tactile stimulation, intrusive procedures, multiple care givers and sleep disturbance and deprivation.

No infant should receive ‘routine care’. Give care according to signals given by the infant

What is considered careOur present NICU care practices, marked by persistent

scheduled and unintended, disturbances of infant sleepAre inattentive to preservation of sleep, and at worst overtly

comprises optimal sleep cycles, with potential disruption of normal brain development

The presence of normal sleep organization in the preterm infant may have prognostic significance for neuro-developmental outcome.

Normal sleep cycles, with a predominance of REM sleep, are necessary for early brain development

Recommendations: promote strategies that preserve newborn sleep

HGH is released by the brain into he blood stream during sleep

Intrusive proceduresHCP lack knowledge about the newborn’s ability to feel

pain, inadequately trained in pain assessment techniques, effective Rx and prevention strategies, and fear S/E of analgesics.

Preterm infants undergo frequent painful experiences during NICU stay.

Analgesia for specific procedures:1. Non-pharmacological: pacifier use, sucrose admininstration,

swaddling etc2. Topical anaesthesia (lidocaine spray)3. Paracetamol4. Slow iv infusion of opiods e.g morphine5. S/c lidocaine6. Deep sedation

Pain backgroundPain control and prevention have been

underutilised in neonates because of the ff misconceptions: Their pain pathways are unmyelinated or otherwise

immature and cannot transmit painful stimuliNo alternative for verbal self-reportNewborn infants are at greater risk for developing

the adverse effects of analgesia or sedative agents, or these drugs have adverse long term effects on brain development or behaviour

However both term and preterm infants experience pain and stress in response to noxious stimuli

analgesics Most effective method to

reduce neonatal pain is to reduce the no. Of procedures and episode of patient handling

Nonphamarcological are more effective when used in combination

Non-nutritive sucking: patients have lower increase in HR, and decreased duration of crying in response to painful stimuli compared to no intervention

Swaddling or facilitated tucking

Systemic analgesia NSAIDS: reluctance of use in

infants because of S/E e.g GI bleeding, platelet dysfunction, decreased GFR

Morphine: most commonly used in neonates It improves ventilator

synchrony and sedate Fentanyl: rapid analgesia

with minimal hemodynamic effects

Fentanyl is associated with less sedative effects, effects on GI motility etc

Let there be Light? A preterm’s ability to protect their eyes is complicated by

their physiologic immaturity. Infants with no pupillary reflex had a larger pupillary

diameter, therefore receives a large retinal light dose than older counterparts.

Bright light may have a damaging effect on the development of the immature visual system

Constant light may keep the infants from opening their eyes and looking around, preventing exploration and interaction

Constant light may slow normal development of sleep wake cycle.

Bright light disrupts the release of growth hormone, which is enhanced with cycling lighting, resulting in altered infant growth

Positioning in NICU

Positioning, nesting and handlingBecause of the fragility of preterm infants, most NICU have

adopted a minimal handling and stimulation approach for very immature infants

The most effective breathing and oxygenation in preterm with lung disease is the prone position

In-utero the fetus is confined to an enclosed space with well-defined boundaries to support development of physiological flexion

The boundaries allow fetus to extend his arms and legs meet resistance and subsequently recoil his extremities into gentle flexed position

This physiological flexion is necessary for development of normal posture movement control

Nesting recommendationsProvide boundaries that will maintain and encourage flexion,

allowing the infant room for extensionProvide covering and light swaddling to comfort the infantUse soft mattresses to support the infant’s head and

reposition frequently to avoid flattening of the head. Utilise prone and side lying positions whenever possible

Environmental noiseExposure to noise in the NICU has the potential to affect

neonatal auditory development, sleep patterns and physiological stability, thus impacting on developmental progress

Noise exposure has the potential to influence the process of neural organisation, reinforcing inappropriate neural pathways and placing the neonate at risk of auditory processing disorders and future learning disabilities

The majority of noise sources identified were human generated

Minimising these need strategies like: decrease the levels of staff conversation, turning down volumes of telephones and alarms etc

Effects of environmental noise Hearing impairment (from exposure of immature cochlea to

loud noise) Sudden loud sounds may initiate startles, signs of autonomic

instability and state disruption May include: apnoea, bradycardia, colour changes, desaturations in

response to loud sounds Quality of sleep and alert state may be affected by noise Prematurely born infants experience anxiety due to certain

types of sound (high pitched noises) Recommendations:

Position conversations and cell phones away from bedside Softly open and close incubators Utilize “quiet” signs raise staff and parent awareness to control

environmental noise Respond rapidly to alarms or crying infants

Take home messageRemember it is the family who will take the infant homeThere is no doubt that one of the most effective

Neurodevelopmental interventions in NICU is to promote family involvement and guidance regarding Neurodevelopmental support.

Pain occurs routinely in the NICU and its control is an important clinical goal

This is an evolving science, with only partial answers that demand further questions

References and acknowledgements Assessment of neonatal pain: uptodate 2012Prevention and treatment of neonatal pain:

uptodate 2012Neurodevelopmental care in the NICU: Susan

Aucott; Euwood division of Neonatology; The John Hopkins University School of Medicine

Journal of Perinatology; Neurodevelopment of Infants in NICU: WF Liu et al

Dr Sihlangu

NICU graduatesMe too!!!! I made it.