Developmental Care in the Nursery

June Bridgford Garber, PT.Emory Hospital - Midtown

Grady Memorial Hospital

Emory University - Professor Emerita

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!

• 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

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.

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 infant’s

need for recovery during or following care-giving and for sustained sleep rather than anyone else’s schedule.

– Provision of developmentally appropriate, well tolerated sensory input on consistent basis.

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.

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 infant’s threshold to irritability.

• Infant’s physiologic stability is enhanced & stress diminished by graded handling with recovery periods.

Support during invasive procedures includes protection from noise & light, supportive

positioning and recovery periods.

Graded, Reciprocal Handling?

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

In addition to physiologic instability, recovery periods are needed in response to floppiness,

stiffness & jerky or tremulous movement patterns.

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.

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

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

• 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

Protection from environmental noise and light

• Whispers may be needed for the youngest & most fragile.

• 50-55 dB average• Minimize >1 second cycles >70 dB

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 infant’s behavior.

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.

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.

Positioning Products: There are a lot of them! They don’t replace skilled care-giver’s

attention & adaptation to the infant’s needs!

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 shouldn’t limit hip flexion & adduction to neutral.

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.

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.

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 infant’s face

• Support the trunk in flexion, provide a ventral roll to ‘hug’ & maintain extremities in neutral rotation.

Keys to Supported Back Lying or Supine

• Avoid a neck flexion position that diminishes the infant’s 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.

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.

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.

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.

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!

“Kangaroo Care” has significant benefits for both the infant and the parents.

Early involvement of parents in nurturing care of their infants

• Kangaroo Care, placement of the infant skin-to-skin (SSC) against a parent’s 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

Early involvement of parents in nurturing care of their infants

• SSC includes tactile, olfactory & auditory input to the infant’s tolerance level.

• 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 <28 wk.s infants are inconsistent.• Once infants exhibit ‘suckling or mouthing’, non-nutritive

sucking may be tolerated with SSC.

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 1:1:1 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.

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)

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.

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 .

• 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!

‘On Demand’ Immature oral feeding

• Immature infants demand not only the beginning of their oral/nipple feedings but also the termination!

• Don’t try to feed exhausted infants! • More practice while the baby’s

exhausted is not beneficial!• Nipple feeding is an experience-

expectant motor pattern that emerges with maturation.

• It isn’t TAUGHT!

• 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.

Early Nutritive Sucking

• Side-lying & controlled, slow introduction of milk avoid swallowing problems.

• Imposed pauses in sucking facilitate inspiration & avoid ‘feeding or swallowing apnea’!

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 infant’s mouth my be needed before an infant will swallow & breath.

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.

• 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 >40 wk. PMA to achieve these interactive skills.

• Glass, Fujimoto, Ceppi-Cozzio, et al (2008)

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

• 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’.

Parental participation in periods of graded infant stimulation facilitates bonding & competence. It

may provide the infant’s 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.

• At 12 years of age, preterms with birth weights <1250 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

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.

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.

EEG and MRI evidence of improved frontal and occipital lobe maturation as well as density of

tracts from these lobes. (Als, Duffy, 2004)

What is NIDCAP training?

• Neonatal Individualized Developmental Care and Assessment Program

• Systematic method of recording observations of an individual infant’s 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

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

References:

• Als H, Duffy FH, McAnulty GB, et al. Early experience alters brain function and structure. Pediatrics 2004: 113(4): 846-857.

• Als H, Lawhon G, Duffy FH, et al. Individualized developmental care for the very low-birth-weight preterm infant. JAMA 1994; 272: 853-858.

• Blackwell MT, Eichenwald EC, McAlmon K, et al. Interneonatal intensive care unit variation in growth rates and feeding practices in healthy moderately premature infants. J Perinatol. 2005: 25: 478-485.

• Bohnhorst B, Heyne T, Peter CS, Poets CF. Skin-to-skin care, respiratory control and thermoregulation. J Pediar 1999:138(2): 193-197.

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• Kleberg A, Westrup B, Stjernqvist K, et al. Indication of improved cognitive development at one year of age among infants born very prematurely who received care based on the Newborn Individualized Developmental Care and Assessment Program. Early Hum Dev. 2002: 68(2): 83-91.

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