Developmentally Supportive Care In NICU

Dr. L S DeshmukhMD,DipNB,DM(Neo)

Heinz Fellow(RCPCH, London)

lsdeshmukh@indiatimes.com

Developmentally Supportive Care - Introduction

• Initial premie care - intrauterine like

environment• “Masterly inactivity”• Based on three basic needs(FAT)• Quiet nursery to busy / bustling stations

• Increasing survival of smaller babies• Technology - oriented NB care.• Optimal functional outcome more important

NICU Environment -Transition Past Present

NICU Care Past Present

NICU Environment - Present Scenario

• Preterm babies with immature organ systems

• “Deprivation” or “Over-stimulation”• Inappropriate pattern of stimulation

• Immature distance receptors (e.g.hearing & vision) over stimulated.

• Mature tactile and vestibular pathways under-stimulated.

• “Robotic” care

• No parental / maternal involvement

NICU EnvironmentEffect on brain development

(Gressens P, 2002)

“The genes are the bricks & mortar to build a brain. The environment is the architect” - Christine Hohmann

Developmentally supportive care

Definition : Developmentally supportive care is defined as care of an infant to support positive growth and development, while allowing stabilization of physiologic and behavioral functioning

(National Association of Neonatal Nurses, 2000)

Developmentally Supportive Care - Aim

“War will never cease until babies

begin to come into the world with

larger cerebrums and smaller adrenal

glands.”

H L Memcken(Journalist), 1930

The virtues of the Womb

The virtues of the Womb• Cushioned and comfortable aquatic abode• Thermal comfort• Zero insensible water losses• Shielded from light• Protected form sound

• Effective and safe ECMO-like oxygenation• Optimal excretion of waste products• Isolation and asepsis• Parenteral nutrition

( Singh M, 2003 )

Dev Supp Care - Principles

• NICU design and environment

• Nursing care routines & plans

• Use of positioning aids

• Use of self regulation aids

• Feeding methods

• Management of pain

• Parental participation & support

• Neonatologist’ attitude

NICU EnvironmentInfant states

1. Quiet sleep - regular breathing, no REM, no spontaneous movements.

2. Light sleep - irregular breathing, REM, spontaneous movements.

3. Transition / drowsy - variable activity, dull look

4. Awake - alert - minimal activity, bright look.

5. Awake - hyperactive - very reactive, fussy, increased motor activity.

6. Crying

NICU EnvironmentSigns of neonatal stability

Autonomic : Stable colour, stable heart & RR, feeding tolerance.

Motor : Flexed or relaxed posture, hand to mouth / sucking

State : Clear sleep state, interaction

(Gupta G, 2001)

NICU EnvironmentSigns of neonatal stress

Autonomic : Color changes, alterations in HR & RR,

alterations in SaO2, Hiccoughs

Motor : Hypotonic, increased movements, open mouth

State : Hyperalert, fussing, diffuse sleep states

(Gupta G, 2001)

NICU Environment – SoundAdverse effects of loud sound (>60 db) Interferes with sleep

• Increase in Heart Rate

• Peripheral vasoconstriction

• Sudden loud noise may ↓ TcPo2, ICP, ? IVH

• Hearing loss

( Lefrak L, 2001)

NICU Environment - Sound

• In-utero, 40-60 db• Usual noise levels in NICU, 50-80 db• Levels > 90 db for long times, hearing loss• In PT on aminoglycosides, at lower db levels

NICU Environment – Sound

Sources of Noise• Inside incubater, 55-88 db (Peak 117)• Additional 10-40 db with surrounding equipments• Routine care activities, 58-76 db.• Loud, sharp sound - 100-200 db.• 4994 peak noises - 90% due to human related factors

(Chang et al, 2001)

NICU Environment – Sound Interventions to reduce noise

•Decrease noise in NICU•Decrease monitor noise•Respond quickly to alarms•Rounds & reports away from bedside•Speak softly•Decrease telephone & intercom noise

( Ctd--)

NICU Environment – Sound Interventions to reduce noise

( Ctd--)•Move equipments quietly, repair noisy ones •Decrease staff generated noises•Prepare medications & feedings away from bedside•Gently open doors and drawers•Follow the sound limit recommendations

NICU Environment - Sound

• Monitor decibel readings & keep level < 45 db

(AAP, 1997)

NICU Environment – Sound

Helpful Effects •Sound of mother’ voice (calming effect)

•Music may be beneficial

•Lullabies, womb sound, heart beat music.

- Better weight gain

- Decreased hospital stay,

- Better behavioral organization

(Chapman JS,1998)

NICU Environment - SoundIndian classical Music- useful

(Paul VK, 1999)

NICU Environment – LightPresent scenario•Fetal life - near darkness (ND)•NICU- Usually very bright light•Continuous light exposure•Usual range - 50-150 foot candles•Procedure & PT lights - 200-400 foot candle

NICU Environment – Light

Light effects:•Effect on central visual system•“Shutting out” behavior

∀↓ Quiet sleep & physiological instability•Effect on circadian rhythms •Effect on G & D

•? ↑ risk of ROP

( Slevin M, 2000 )

NICU Environment – Light

Light Reduction

Safe level not established• Shade head of crib / incubator• when required , use spot light / procedure light •Eye covers must with PT• use available natural light

NICU Environment – Light Light Reduction

Cycled lighting better than near Darkness

- More time in sleep state

- ↑ weight gain

- ↓ Motor activity levels

- ↓ Heart rate

(Brandon HD et al, 2002).

NICU Environment - Light

Monitor NICU Light

with Luxmeter

NICU Environment -Positioning

NICU Environment -Positioning

• Effect on respiratory physiology• Body alignment important• Prevent postural deformities• Promote self-soothing activities• Decided by GA, degree of illness, paralytic agents.

NICU Environment –PositioningGuidelines Preferred, Prone / side lying• Swaddle / cover to keep in flexed position• Attempt to “nest” the infant• Promote midline alignment

• Head support

• Avoid :- Hyperextension of neck

- Frequent head turning to side

- Lower extremity frogging

- Bigger diaper

NICU Environment - Handling

• Physiologic and behavioral stress

• Pace the care according to baby• Time the care around sleep / wake cycles• No routine procedure

• Provide 2-3 hrs of uninterrupted sleep

• Watch for S/o stress

NICU Environment - “Minimal Handling” or “Quiet hour” Protocol

• Reduce noise

• Reduce lights

• Allow minimum two hours of rest

• Cluster the caregiving procedure

• Sensitize the nursing staff

NICU Interventions - Stimulation

• Should begin in the womb.• Fetuses known to respond to mother’s heart beats and voice.• Indian mythology - Abhimanyu learnt to enter Chakaryuh in his mother’s womb.• Any stimulation through special senses during fetal / neonatal life beneficial

(Singh M, 2003)

NICU InterventionsSupplemental stimulation • Kangaroo Mother Care ( KMC )• Non-nutritive sucking ( NNS )• Massage therapy• Multimodal stimulation• Breast feeding• Pain management• NIDCAP• Wee care

NICU Interventions

Kangaroo Mother Care

NICU Interventions

Kangaroo Mother Care• Skin to skin contact• Practiced in many cultures

Components :

• Kangaroo positioning• Kangaroo feeding• Kangaroo discharge

Forms :

• Hospitals with no / poor facilities

• Insufficient technical & human resources

• In tertiary level NICUs

(Kirsten G.F., PCNA, 2001)

NICU Interventions

Kangaroo Mother CareLikely Benefits :

Successful breast feeding• Better physiologic stability• Increased maternal confidence & bonding• Reduced infection rates• Cost savings

(Kirsten G.F., PCNA, 2001)

NICU Interventions

Non-nutritive Sucking• Different from nutritive sucking• On empty breast / pacifier• Provides comfort• Promotes physiological organization

• Pain-reducing effect

• Promotes suck- swallow co-ordination• Facilitates transition to breast feeding• Better weight gain & shorter hospital stay.

(Field TM, 2003)

NICU InterventionsMassage Therapy•Tactile / Kinesthetic stimulation

•Tactile stimulation only, may be aversive.•Massage therapy with moderate pressure may be useful.•Stimulation of tactile and pressure receptors important.

•Hypothetical mechanisms of benefit

- Touch - Growth gene interaction

- Increased vagal tone

- Increased insulin levels

- Increased growth hormone secretion

(Field TM, 2003)

NICU Interventions

Massage TherapyProposed benefits :

Better weight gain• More time in active, alert state• More quiet sleep• Better motor maturity scores• ? Better long-term outcome

(Mathai S. et al, 2001)

NICU Interventions

Massage Therapy Unresolved Issues :

•Collapse / disorganization due to over-stimulation•Response of full term Vs preterm infants•Response of SGA Vs AGA babies•Maternal Vs nurse’ touch

(Feldman R et al, 1998)

NICU Interventions

Breast Feeding

NICU Interventions

Breast Feeding• Humanized and natural• Species specific & baby specific• Minimal enteral feeds (Trophic feeds)• Multiple benefits of MEN• Early contact and bonding

Support and encourage breast feeding

NICU Interventions- NIDCAP

NICU Interventions- NIDCAP•Neonatal individualized developmental and assessment program (NIDCAP)•Developed by Als et al

•Four standards of care - Structuring the environment

- Timing, organizing & giving direct care

- Working collaboratively

- Supporting & strengthening family relationships.•Individualized plan for each baby

•Meta-analysis : Significant decrease in O2 requirement

: Improved outcome at 12 mths.

(Jacobs SE et al, J Ped, 2002).

NICU Interventions -Multimodal Stimulation• ATVV - Auditory, tactile, visual & vestibular

• Soft & soothing music• Gentle touch• Use of pictures (human face), bright toys

• Olfactory stimulation, use of “breast milk” (avoid cologne / spray).

• Better weight gain and early discharge

(Standly JM, 1998)

NICU Interventions -Multimodal StimulationMother’ voice & human face

NICU Interventions Pain Management

NICU Interventions Pain ManagementNeonatal Pain - Misconceptions• Newborns lack anatomical & physiological structures to transmit pain sensation.• Can not express pain sensation• Have no memory of pain• Would not tolerate analgesia / anesthesia

NICU Interventions Pain ManagementNeonatal Pain - Facts :

Nociceptive mechanisms well developed even in preterm.• Pain expression and assessment possible• Various consequences of pain & stress• Various nonpharmacologic & pharmacologic strategies useful for treatment

NICU Interventions Pain ManagementNon-pharmacologic Interventions

• Positioning & containment• Swaddling• Non-nutritive sucking / pacifiers• Skin to skin contact

• Rocking• Music• Breast milk• Oral glucose / sucrose

NICU Interventions Pain ManagementPharmacologic interventions

• Local anaesthetics (EMLA)

• Regional anaesthesia

• Systemic analgesia(Gilbert R, 2001)

NICU Interventions -

Family Involvement• NICU - a barrier• Provision of privacy (for bonding)• Social interaction & support• Parental education & counselling• Involvement of mother in care

• Mother - based NICU, need of hour

(Cisler - Cahill et al 2002)

NICU Interventions - future issues

Co-bedding for twins

(Dellaporta K, 1998)

NICU Interventions - future issuesParent focussed care (COPE)

(Melnyk BM , 2001)

NICU Interventions - future issues

Spiritual & cultural care

(Catlin EA, 2001)

NICU Interventions - future issuesEffect of NICU Env on Health-worker

NICU Interventions - future issuesQuality Assessment & Improvement

NICU Interventions - future issues

Early Disharge from NICU

NICU Interventions - future issuesUse of Telemedicine in NICU

(PhilipM1999)

NICU Interventions Other Important Issues

• Ethical care issues

• Involvement of physiotherapist & occupational therapist in NICU

• Individual rooms in NICU (White RD, 2003)

NICU Interventions - Goal

“The prematurely born infant emerges into a hectic, cold, noisy and bright environment filled with mysterious equipment and peopled by masked strangers who try to help. Almost everything done to or for the infant is painful, and that pain can be certainly felt, although it can not be communicated. The infant who must have an endotracheal tube cannot cry and is not fed by mouth for weeks. His or her feet are slashed periodically for blood samples. The infant’s respirator roars away night and day, keeping his or her lungs inflated and sustaining life - but at what price ?” Dr. Jerry Lucey, Editor of Pediatrics

Let us work to help newborns

“The essential is invisible to the eye.”

-Saint-Exupéry in The Little Prince