Developmentally Supportive Care and the

Late Preterm Infant

Michele PrenticeDevelopmental and Family-centred Care Project Officer

Neonatology ServicesMater Mothers’ Hospitals

Brisbane

2009

The Late Preterm Infant

• Definition

• Review of the literature

• Brain development and early life experience

• Developmental care

• Behavioural cues

• Positioning

• Implications for practice

The Late Preterm Infant (continued)

• Definition (replaces “Near Term Infant”): Infants born between

34 and 36 weeks + 6 days.

(others may use 32-34 wks)

Reference: American National Institute of Child Health and Human Development. 2003

Literature Review• Merriman, 2009 “Serious neurological risks” • Petrini et al, 2009 “Increased Risk of Adverse Neurological

Development”• Chyi et al, 2008 - 140,000 babies [USA; 2000 – 2004] ....

↑ x 3 times cerebral palsy if preterm ↑developmental delay ↑ mental retardation .... Therefore ....

“delivery less than 39 weeks not desirable”• Hubbard et al, 2007 “A little baby with big needs” • Stellwagen, 2007 “...may look like a full-term baby” • Levitt, 2006 “Early events affect growing brains”

(interview: www.developingchild.net)• Hawley et al, 2000 “Starting Smart” (Zero to Three)

Brain Development & Early Experiences...

• Brain function altered... Neurochemistry changes → → → →

• Brain structure altered... → → → Architecture → → →

PERMANENT CHANGES in structure and function

• Early touch, pain, hearing, muscle tone, motor function, stress reactivity and competence

Risks

• Hyperbilirubinaemia• Hypoglycaemia• Hypothermia• Immature self-regulation• Sepsis

• Airway instability• Apnoea and

bradycardia• Respiratory distress• Excessive sleepiness• Excessive weight loss• Feeding intolerance• Weak sucking

Cue Based Care:What is it?

To follow the principles of Developmental Care it is important to grasp an understanding of what state a baby is in and the optimal times to interact with them, which leads to a need to understand their behaviour cues. These are their way of communicating.

Cue Based Care:How do we understand Behaviour Cues?

Behaviour cues are...

the signs and signals given to us by babies

They are their way of communicating... when they are calm, ...when they need time out and ...when they are ready to interact.

Understanding Behaviour Cues Summarised:

• A calm baby will show signs such as:- puts hand to mouth- curls up- will grasp & hold a finger or toy- will bring hands together- will softly close eyes

Understanding Behaviour Cues:Cues for a Calm Baby

*pictures used with permission of the author, Developmental Care Plan, Royal Women’s Hospital Melbourne.

Understanding Behaviour Cues Summarised:

• A baby that needs time out shows: Motor signs - splays fingers

- has a stiff arching posture- is flailing and disorganised- the sitting on air sign (arms

& legs in air)Autonomic sign - YawningAttention / Interaction signs

- turns away / looks away- Hyper alert (staring wide eyed)

Other Signs - crying- fluctuating heart rate- oxygen desaturation- colour changes- closes eyes

Understanding Behaviour Cues:Cues a baby needs time out

*pictures used with permission of the author, Developmental Care Plan, Royal Women’s Hospital Melbourne.

Understanding Behaviour Cues Summarised:

• A baby is ready to engage when it:- is smiling- has a relaxed posture and face- is cooing / babbling- is making eye contact

Understanding Behaviour Cues:Cues a baby is ready to Engage

*pictures used with permission of the author, Developmental Care Plan, Royal Women’s Hospital Melbourne.

SIDS the prevention campaign:1) put baby on back to sleep from birth 2) sleep baby with face uncovered3) cigarette smoke is bad for baby4) safe sleeping environment for baby, night &

day: safe cot, safe mattress, safe bedding

Why?Since the SIDS and Kids Safe Sleeping Campaigns began in the early 1990's...

>4,000 Australian babies savedreduced the rate of SIDS by 84%.

www.sidsandkids.org

Infant Positioning

*pictures used with permission of the author, Developmental Care Plan, Royal Women’s Hospital Melbourne.

Infant Positioning when awake:• Prone (“tummy time”):

– Clean, flat surface (pad on floor) – No sharp angles (furniture) nearby– Pillows NOT recommended

• Side Lying:– put a pillow at the baby’s back only

to support position to encourage hands in view

• Supine (back):– Create a nest using a rolled blanket

and ensure it remains close to the baby’s body and under legs

Key points... • Supervision of infant is MANDATORY

• Flexed and curled up positions are encouraged as these reflect the environment of the womb

• Ensure:- shoulders forward

- hands towards midline in supine & side lying

- hips and knees tucked

- alternate positioning of head side-to-side when asleep (supine)

LPI’s are special!

• Essentially a preterm infant in a term infant’s body↓↓↓

• Poor immunity• Poor feeding • Parents unprepared, stressed• Delayed discharge home or...

difficulty with normal care at home

IMPLICATIONS FOR PRACTICE

• Midwives• Neonatal Nurses• Parents• Multidisciplinary Team• GP Practice/ Community Health agencies• Follow Up? (Service provision is poor)• Early Intervention Services?

The Late Preterm Infant

• POOR OUTCOMES

• MISS OUT ON SERVICES

• PROBLEMS AT SCHOOL AGE

• FUTURE DIRECTION OF RESOURCE ALLOCATION AND FUNDING ?