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Developmentally supportive neonatal care

humane care, mother based NICUs

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Developmentally supportive neonatal care

  1. 1. Developmentally Supportive Care In NICU Dr. L S Deshmukh MD,DipNB,DM(Neo) Heinz Fellow(RCPCH, London) lsdeshmukh@indiatimes.com
  2. 2. 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
  3. 3. NICU Environment -Transition Past Present
  4. 4. NICU Care Past Present
  5. 5. 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
  6. 6. NICU Environment Effect on brain development (Gressens P, 2002)
  7. 7. “The genes are the bricks & mortar to build a brain. The environment is the architect” - Christine Hohmann
  8. 8. 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)
  9. 9. Developmentally Supportive Care - Aim
  10. 10. “War will never cease until babies begin to come into the world with larger cerebrums and smaller adrenal glands.” H L Memcken(Journalist), 1930
  11. 11. The virtues of the Womb
  12. 12. 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 )
  13. 13. 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
  14. 14. NICU Environment Infant 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
  15. 15. NICU Environment Signs 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)
  16. 16. NICU Environment Signs 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)
  17. 17. NICU Environment – Sound Adverse 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)
  18. 18. 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
  19. 19. 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)
  20. 20. 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--)
  21. 21. 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
  22. 22. NICU Environment - Sound • Monitor decibel readings & keep level < 45 db (AAP, 1997)
  23. 23. 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)
  24. 24. NICU Environment - Sound Indian classical Music- useful (Paul VK, 1999)
  25. 25. NICU Environment – Light Present 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
  26. 26. 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 )
  27. 27. 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
  28. 28. 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).
  29. 29. NICU Environment - Light Monitor NICU Light with Luxmeter
  30. 30. NICU Environment -Positioning
  31. 31. 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.
  32. 32. NICU Environment –Positioning Guidelines 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
  33. 33. 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
  34. 34. 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
  35. 35. 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)
  36. 36. NICU Interventions Supplemental stimulation • Kangaroo Mother Care ( KMC ) • Non-nutritive sucking ( NNS ) • Massage therapy • Multimodal stimulation • Breast feeding • Pain management • NIDCAP • Wee care
  37. 37. NICU Interventions Kangaroo Mother Care
  38. 38. 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)
  39. 39. NICU Interventions Kangaroo Mother Care Likely Benefits : Successful breast feeding • Better physiologic stability • Increased maternal confidence & bonding • Reduced infection rates • Cost savings (Kirsten G.F., PCNA, 2001)
  40. 40. 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)
  41. 41. NICU Interventions Massage 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)
  42. 42. NICU Interventions Massage Therapy Proposed 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)
  43. 43. 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)
  44. 44. NICU Interventions Breast Feeding
  45. 45. 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
  46. 46. NICU Interventions- NIDCAP
  47. 47. 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).
  48. 48. 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)
  49. 49. NICU Interventions - Multimodal Stimulation Mother’ voice & human face
  50. 50. NICU Interventions Pain Management
  51. 51. NICU Interventions Pain Management Neonatal 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
  52. 52. NICU Interventions Pain Management Neonatal 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
  53. 53. NICU Interventions Pain Management Non-pharmacologic Interventions • Positioning & containment • Swaddling • Non-nutritive sucking / pacifiers • Skin to skin contact • Rocking • Music • Breast milk • Oral glucose / sucrose
  54. 54. NICU Interventions Pain Management Pharmacologic interventions • Local anaesthetics (EMLA) • Regional anaesthesia • Systemic analgesia (Gilbert R, 2001)
  55. 55. 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)
  56. 56. NICU Interventions - future issues Co-bedding for twins (Dellaporta K, 1998)
  57. 57. NICU Interventions - future issues Parent focussed care (COPE) (Melnyk BM , 2001)
  58. 58. NICU Interventions - future issues Spiritual & cultural care (Catlin EA, 2001)
  59. 59. NICU Interventions - future issues Effect of NICU Env on Health-worker
  60. 60. NICU Interventions - future issues Quality Assessment & Improvement
  61. 61. NICU Interventions - future issues Early Disharge from NICU
  62. 62. NICU Interventions - future issues Use of Telemedicine in NICU (PhilipM1999)
  63. 63. NICU Interventions Other Important Issues • Ethical care issues • Involvement of physiotherapist & occupational therapist in NICU • Individual rooms in NICU (White RD, 2003)
  64. 64. NICU Interventions - Goal
  65. 65. “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
  66. 66. Let us work to help newborns
  67. 67. “The essential is invisible to the eye.” -Saint-Exupéry in The Little Prince

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