Current Trends in Developmental Care in the NICU March of Dimes Perinatal Nursing Conference 2009

1. Current Trends in Developmental Care in the NICUMarch of Dimes Perinatal Nursing Conference 2009 Robert White, MD South Bend, IN

2. Developmental Care – Fad or Way Overdue? • Third trimester is crucial period for brain growth and development • NIDCAP has demonstrated value (Als, et al; Cochrane Reviews) • “Conventional Care” evolved without an evidence base, for the primary purposes of survival of baby and convenience of caregivers, with little or no thought to neurodevelopment

3. Developmentally-appropriate care – why does it matter? • Brain weight increases 400% from 26 weeks to term (in 3 months!) • Brain weight increases 400% from term to adulthood (in 18 years)

4. Varieties of Developmental Care • NIDCAP – intensive training on an individual level • Wee Care – intensive training on a unit level • “We do developmental care”

5. Is a nutritional analogy appropriate for developmental care? • General agreement that nutrition is a good thing, but lots of debate about the details – what, when, how much, etc. • Breast milk is an imperfect “gold standard” – still the best we have, but exceptions must be recognized • Similarly, developmental care is made up of many practices that should be analyzed individually to assess their value

6. Developmental Sequence of the Sensory Cortex • Touch/Kinesthetic 7-18 weeks • Taste/Smell 12-14 weeks • Auditory 18-35 weeks • Visual 38 weeks – 2 years

7. Fetal Auditory Development • In utero – lots of sound, mostly low frequency, transmitted in a liquid or solid medium • Auditory cortex is in an active and critical phase of development in the third trimester • Fetus learns to recognize certain sounds from the mother in utero, and rapidly after birth

8. Auditory Development in the Preterm Infant • Occurs in an environment vastly different from the womb • Unfamiliar, inconsistent voices and sounds • Acquired through an air medium • Multisensory input common, often unpleasant

9. How would our care practices change if we had a real-time window into the brain?

10. Lighting – Circadian Rhythm • Multiple circadian rhythms established by the third trimester – heart rate, temperature, activity, and several hormones • Governed by maternal cues • Neuronal connections (RHT and SCN) are responsive by 28-32 weeks • In the absence of maternal cues, is light the best zeitgeber for preterm infants?

12. Circadian Rhythms - Babies • Biological mechanisms to respond to light as a circadian stimulus are present by ~32 weeks • Babies are exposed and entrain to circadian stimuli in utero • Day-night cycling shown superior to continuous bright or continuous dim lighting • No evidence that exposure to moderate amounts of light is harmful to premies • So day-night lighting is important, at least for premature infants >28-32 weeks gestation

13. Circadian Rhythms - Babies • But what about infants at <28 weeks? And why do premies in a cycled-light NICU fail to entrain to light? • Are there additional zeitgebers? – e.g., temp, feedings, activity, melatonin in mother’s milk

15. Optimal physical environment for developmental care circa 1986 • “

16. St. Luke’s,Cedar Rapids

22. The optimal environment for G & D of the preterm newborn • Micro – we need to improve incubators • Macro – SFR is an important step in this effort • Mother – probably the optimal “environment” for a newborn; this can be encouraged both by good design and supportive policies

23. Individualized environments for the NICUSFR = Single Family Room • Private rooms are now the standard in every area of the hospital for new construction (per AIA), and the growing trend in NICUs • Are they a good idea for NICU? What are the hazards? What are the pitfalls?

24. SFR – The Rationale • Optimal environment for the baby • Individualized lighting and sound control • Infection control • Skin-to-skin contact has substantive biological impact • Optimal environment for the family • Privacy for interaction with baby • Privacy for interaction with med staff • A sense of control, belonging, family

25. SFR Experience • France – Brest, Angers, Reims • Belgium – Brussels • Sweden - Stockholm • Switzerland – Lucerne • Netherlands – Nijmegen • Australia - Melbourne • US – Seattle, Pittsburgh, St. Paul, Des Moines, Cedar Rapids, Iowa City, Gastonia, Omaha, Lincoln, Vanderbilt, Orlando, Madison, Kalamazoo, Cleveland, and several more

26. NICU – Locus of CareRevisiting an old concept for the 21st Century • Pre-NICU (from prehistoric times): • Baby/Mother Family Community (friends, spiritual) • Early NICU (1970s – 1980s): • Baby TechnologyStaffFamily, Community • “Family-Centered” NICU (1990s – present): • Baby TechnologyStaff, FamilyCommunity • NICU of the Future? • Baby/Mother Technology Staff, Family Community

27. “That kangaroo care idea is nice for moms, but does it really matter to the baby?”

28. “The newborn’s Geneva Convention – what does that mean?”

29. Recommendations • Use a system – this is too important to not approach in an organized fashion • Encourage extensive parental interaction • Create individualized environments • Follow the literature • Increased focus by March of Dimes