Supporting Neonatal Outcomes: Developmental Care and Education

1. Introduction This presentation is being provided as an example of a staff education module. The material on the slide may act as a guide but is not prescriptive. It should be adapted to your own site using your own materials. The narrative on the slide notes is a guide to help guide your own presentation.

2. Development and Developmental CareSupporting neonatal outcomes

3. Dreams…shattered

4. YES, we can “get” there! One family Stats: 18 months of Breastfeeding 66 rounds presented by Mom/ Dad 372 hours of skin-to-skin by Mom & Dad Education, education, education Sending home a happy healthy family … Priceless!

5. Objectives The importance of an environment that supports: • neuroprotectivedevelopmental care • appropriate positioning and handling to promote development • neurobehavioral stability that supports neurologic systems • the decrease of iatrogenic consequences

6. Impact of prematurity • Autonomic system is underdeveloped • 2 known causes for alteration in brain development: stress & pain • Fearful and vulnerable • Sleep deprivation • Ability to self-regulate severely diminished

7. High risk for a variety of problems • musculoskeletal development, flexor/extensor abnormalities • oral aversion, skin sensitivity (pain) • cognitive defects • poor academic achievement & behavioral disorders • psychiatric disorders • parenting challenges

8. Neuro-protective developmental care Creates an environment that manages the infant’s stress and pain while offering a calming and soothing approach that keeps the whole family involved in the infant’s care and development

10. Health professionals & parents working together Healing Environment, Partnering with Families, Positioning & Handling, Safeguarding Sleep, Decreasing Pain & Stress, Protecting Skin, Optimizing Nutrition

11. NICU GOAL:…..through the dark I could be Gabriel’s mom, I was taught touch, the feeling, the interaction, and how all that became Gabriel's “best medicine”

12. to help learners connect with the baby’s experience

13. What do YOU see in the picture in your role as a nurse? What do PARENTS see in the picture?

14. What do YOU see in the picture in your role as a nurse? What do PARENTS see in the picture?

17. Normal fetal development • Musculoskeletal system develops • In a gravity-free buoyant environment • With freedom to move and receive developmentally appropriate stimulation, (tactile, vestibular, auditory and visual sensory stimulation) • Provides positive sensory input for brain development

18. Full-term infant • 3rd trimester • neural connections reinforced, emphasizes flexion & midline orientation as a normal baseline- uterine wall provides secure boundaries • At birth • Early motor control for ongoing development

19. Preterm infant • Incomplete development of muscle tissue, joint structures, bone density • Muscle tone hypotonic • Limbs abducted, externally rotated, lie flat in a frog leg position • Spontaneous resting position flat, extended, asymmetrical, head to one side (usually right) • Difficult to maintain flexed position, cannot alter position for pain & discomfort • Lack internal or mechanical motor control, increased episodes of startle, twitches

20. Preterm infant Early neurosensory development impacted NOT a gravity-free & buoyant environment NOT a positive intrauterine environment, (position, touch, sound, comfort and light) Can impact developing brain

21. The preterm infant • Added to the problem • illness, energy depletion, gravity & weight of medical lines • Over time, active extension, arching and asymmetry become dominant

22. Preterm infant/full-term infant

23. GOAL: 520 grams infant @ term versus term infant at birth

24. Term-corrected 4 months corrected

25. 4 months corrected

26. Expectations at 4 months-corrected • Development of head control • Head turns both ways (no flat head) • Focus and follow with both eyes • Equal movement of limbs, clasping of hands, hands to mouth • Early eye-hand coordination • reach and grasp • In prone pushes up on arms, preparing to roll • Attends to voice, watches & begins to imitate some sounds, laughs

27. To optimize neuro-protective care in the NICU • Provide appropriate positioning/handling to • Support infants’ state regulation • Decrease sensory overload • Reduce physiologic distress, reduce disorganization • Promote development • Therefore • Provide care-giving slowly and confidently • Introduce one stimulus at a time • Allow infant to set pace, withdraw stimulus if over stimulated & provide hands on containment • Reinstate baseline environmental supports after any procedure & flex the infant

28. Position & handle in flexion, containment & alignment • During all care taking activities, ensure midline, tucked position • Bathing, weighing, feeding • Diaper changes/temperature taking, mouth care, girth measurement • Avoid hyperextension of neck & shoulder retraction • During procedures, blood tests, lumbar puncture • Attaching back to cpap, etc. • Feeding, sleeping, holding

29. Communicating

32. Handling

33. Promote development & enhance comfort (self-regulation) REMEMBER: Preemie flip, extremely stressful • Supportive turning and lifting • Facilitate smooth movement against gravity • Avoid torque/tension from medical lines

34. If this was a uterus, the legs would have pushed through the wall!

35. Should not be constrained but lie in a flexible nest that encourages a return to postural flexion, as in the uterus Boundaries should promote development, i.e. shoulders forward, not in extension

36. Allow for normal, not stressed movement. Should not be constrained but occurs in a flexible nest that encourages a return to postural flexion, as in the uterus

37. Avoid “frog-legged” position

38. Bathing • has been described in the literature as an extremely stressful form of stimulation for a preterm infant due to: • extra energy expenditure • change in temperature • abnormal positioning

39. Swaddle bathing

40. Educating/supporting parents

41. Teaching parents

42. Self-soothing

43. shoulders rounded, hands to mouth/face, head in midline, slightly flexed

45. Play

46. Back to sleep, prone for play

47. All positions (if no medical lines), shoulders rounded, hands to mouth/face, head in midline, slightly flexed

48. Feeding

49. Principles of positioning promote development, postural security, self-regulation, energy conservation Encourage flexed position Place head in midline, slight flexion Support shoulders so they are forward Encourage hands together and near mouth Flex hips and knees (not frog–leg) Encourage midline orientation & symmetry, equal Use of both arms/legs, opportunity for head to be in many positions Provide boundaries (rolls), until 36 weeks gest. (or before) Allow to lie and be held in different positions

50. Achieving our goals • Communication challenges • Lack of consistency between staff and parents • Avoid when difficult • Shift change • Must reflect a partnership • Convey reassurance and support • Parent the most consistent caregiver