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Developmental Support

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1 Developmental Support
Denice Gardner, MSN, NNP-BC

2 Objectives Discuss developmental support and its effect of the newborn

3 CNS Development Six Stages
Stages 1-3(completed before 4th month of gestation) Dorsal Induction Ventral Induction Neurogenesis Stages 4-6(continues during the time the infant is in the NICU) Neuron migration Organization, including synaptogenesis & arborization myelinization The Central Nervous System develops in 6 overlapping stages.

4 CNS Development Neuronal & glial cells originate in the germinal matrix Neuronal & glial cells migrate from germinal matrix to their eventual location within the CNS where they differentiate & take on their unique functions Neurons formed early in life lie deeper in cortex & neurons formed later lie in more superficial layers Cortex generally has complete component of neurons by 33 weeks gestation

5 CNS Development Organization- “the process by which the nervous system takes on the capacity to operate as an integrated whole” (Blackburn, 2003) begins during the 6th month of gestation and continues years after birth Neuron growth & connections lead to development of brain gyri & sulci Organization of the CNS is critical for cortical & cognitive development These processes may be particularly vulnerable to insults from the effects of the NICU environment.

6 CNS Development Arborization- “wiring of the brain”
Dendritic connections between neurons critical for processing impulses, cell-to-cell communication, and communication throughout the CNS Lack of connections cause hypersensitivity, poorly modulated behaviors, & all-or-nothing responses, frequently seen in preterm infants in the NICU

7 CNS Development Synaptogenesis- formation of connection between neurons & development of intracellular structures & enzymes for neurotransmitter production Critical for integration across all areas of the nervous system Synapses continue to restructure throughout development & is thought to be the basis for memory & learning

8 CNS Development Organizational processes & modification of neurons continue throughout adulthood but are particularly vulnerable during infancy. The ability of a neuron to change structure & function has been called plasticity. (Huttenlocher, 2003) The more immature the infant at birth the greater the impact of neural plasticity. There is considerable evidence in animal studies that sensory input influences later neuronal structure & function; for instance, an enriched environment during infancy improves developmental outcome by maximizing brain potential. This plasticity is both an advantage and a liability. Although sensory input may increase cellular processes & interconnections, the sensory environment may also produce undesired changes in structure and function. **Plasticity(neuroplasticity): the brain’s ability to reorganize itself by forming new neuronal connections throughout life; allows neurons in the brain to compensate for injury & disease and to adjust their activities in response to new situations or changes in the environment.

9 CNS Development Neuronal differentiation & organization are controlled by the interaction of genes & environment. The environment of the immature infant in the NICU & in the early months after discharge is critical for brain development and later cognitive function. (Lickliter,200a. 200b; Sizun & Westrup, 2004)

10 CNS Development Plasticity: 2 types
Experience-expectant: linked to brain’s developmental timetable so specific sensory experiences are needed at specific times for neural development & maturation Experience-dependent: involves interaction with the environment to develop specific skills for later use; involves memory & learning; allows development of flexibility, adaptation, & individual differences in social & intellectual development

11 Neurobehavioral Development
Self-regulation: infant’s efforts to achieve, maintain, or regain a balanced, stable, & relaxed state of subsystem functioning & integration. Maintaining normal body temp Regulating day-night cycles Learning to calm oneself & relaxing after care Later in life, controlling one’s own emotions & managing to keep one’s attention focused

12 Neurobehavioral Development
Synactive Theory of Development (Als and colleagues) Autonomic/physiologic Motor State/organizational Attentional/interactive: involves infant’s ability to orient & focus on sensory stimuli (faces, sounds, objects; i.e., external environment) Self-regulatory **Synactive Theory of Development is divided into 5 subsystems which include: 1. Autonomic & Physiologic 2. Motor 3. State/organizational 4. Attentional/Interactive 5. Self-regulatory

13 Neurobehavioral Development
Signs of Stability Autonomic system Even, regular respirations Pink, stable color Stable viscera with no seizures, gagging, emesis, grunting, tremors, startles, twitches, coughing, sneezing, yawning, sighing

14 Neurobehavioral Development
Motor system Smooth, controlled posture Smooth movement of extremities & head Hand clasp Leg/foot brace Finger folding Hand to mouth Grasping Sucking Tucking Hand holding Good, consistent tone throughout body

15 Neurobehavioral Development
Signs of Stability State system Clear, well-defined sleep states Self-quieting consolability Focused, clear alertness with animated expressions

16 Neurobehavioral Development
Attentional Interaction System Responsivity to auditory & visual stimuli that is bright & long in duration Actively seeks out sounds and shifts attention smoothly on his/her own from one stimulus to another Face: bright-eyed, purposeful interest varying between interest and relaxation Self-regulatory System Able to maintain each system-autonomic, motor, state, attention

17 Neurobehavioral Development
Signs of Stress Autonomic System Respirations: pauses, tachypnea, gasping Color changes: paling around nostrils, perioral cyanosis, mottling, cyanosis, gray, flushed, ruddy Viscera: hiccups, gagging, grunting, spitting, straining Motor: tremor/startles, twitching, coughing, sneezing, yawning, sighing

18 Neurobehavioral Development
Signs of Stress Motor System Fluctuating tone Flaccidity Hypertonicity: leg extensions, salutes, airplaning, arching, finger splays, tongue extensions, fisting Hyperflexions: trunk; extremities; fetal tuck; frantic, diffuse activity

19 Neurobehavioral Development
State System Diffuse states Sleep: twitches, sounds, jerky movements, irregular respirations, grimacing, fussing while sleeping Awake: eye floating, glassy eyed, gaze aversion, staring, worried look, irritability

20 Neurobehavioral Development
Signs of Stress Attentional Interaction System Stress signals from other systems: irregular respirations, yawning, gaze aversion, hiccupping, etc.. Becomes more stressed with more than one mode of stimuli Self-Regulatory System May use the following to gain balance Lower state Postural changes Motor strategies: leg/foot bracing, hand to mouth, sucking, etc. Self-quieting & consoling

21 Neurobehavioral Development
Stress Reducing Strategies Autonomic System Modify environment (light, noise, traffic) Positioning Minimal stimulation Swaddling Motor System Handling to contain limbs Slow, gentle handling Boundary rolls Containment/nesting

22 Neurobehavioral Development
Stress Reducing Strategies State System Cluster care Primary nursing for better assessment of infant cues Appropriate timing of activities & daily routines Autonomic & motor subsystems must have reached stability

23 Neurodevelopmental Development
Stress Reducing Strategies Attentional Interaction System Adjust interactions to infant’s tolerance level Provide supports necessary to bring out best alertness Offer one mode of stimulation at a time Use modulated voice, face, rattle, together (baby responds best to animate stimuli)

24 Sleep-Awake States State- level of infant’s consciousness determined by his level of arousal and response to stimuli Sleep States Deep sleep: closed eyes, no eye movements, regular breathing, no spontaneous activity Light sleep- low levels of activity, rapid eye movement may be seen, irregular respiratory movements *Deep sleep: will have delayed response to external stimuli & will then only have brief response before returning back to deep sleep **Light sleep: may startle or make brief fussing & crying noises; delaying response to these brief episodes allows infant to go back to deep sleep

25 Sleep-Awake States Transitional States
Drowsiness- activity level varies, eyes may open & close & appear dull & heavy **Drowsiness- response to stimuli is delayed; infant may either wake up or go back to sleep

26 Sleep-Awake States Awake States
Quiet alert- interactive, alert & wide-eyed appearance; attention focused on stimuli, regular respirations, minimal motor activity Active alert- increased motor activity, heightened sensitivity to stimuli, periods of fussiness but easily consoled; eyes open but less bright & attentive, irregular respirations Crying- increased motor activity & color change, very responsive to unpleasant stimuli **Quiet alert: state in which infant interacts with the environment the most; term infant exhibit this state in the first few hours after delivery; preterm infants have difficulty maintaining this state for long periods & become “hyperalert” (they appear awake and alert but are unable to involve with interaction **Active alert: term infant my be able to console himself but preterm infant may become distressed & unable to organize himself **Crying: some infant s may be able to console themselves; preterm infants may cry weakly or may be unable to cry; not only do preterm infants experience color changes but may also experience apnea, vomiting, desaturations, etc.

27 Organization Ability to integrate physiologic & behavioral systems in response to stimuli without disruption in the state or physiologic function Maintains stable vital signs, smooth state transitions, even movements Able to console himself Ability to maintain organization depends on maturity level, overall well-being, and infant’s temperament **Physiologic system: HR, respirations, O2 Sats, etc. **Behavioral system- state (attention & self-regulation) & motor activity (tone, movements, & posture) **Disorganized infants: reacts to stimuli with sudden state changes; frantic, jerky movements; color changes; irregular respirations; some react with hypotonia

28 Sensory Threshold Level of tolerance for stimuli in which infant can respond appropriately When threshold met, becomes overstimulated and stressed Preterm and neurologically impaired infants have low thresholds Watch infant’s cues and respond appropriately **Approach behaviors: alert, focused gaze, regular breathing, dilated pupils, grasping, sucking, hand-to-mouth movements **Avoidance behaviors: averting gaze, frowning, sneezing, vomiting, finger splaying, hiccupping, arching, stiffening, crying

29 Habituation Ability to alter response to repeated stimuli
When stimulus is repeated, the initial response to it will gradually go away Defense mechanism for shutting out disturbing or overwhelming stimuli Assess during light sleep or quiet alert states **assessing habituation: visual- hold light inches away from infant & briefly shine it into infant’s eyes several times & observe response; when infant is able to habituate his movements will become delayed and response will stop, usually within 5-9 flashes; auditory is assessed with things that make sound; tactile assessed by pressing sole of foot with a smooth object

30 Positioning Malformations
Muscle fiber development incomplete until term Lower ratio of Type 1 muscle fibers to Type 2 predisposes preterm infant to muscle fatigue Restricted movement & positioning in the NICU produce joint compression & poor refinement of mechanical receptors predisposing fragile infants to skeletal deformation, shortening of muscles, & contractures. *Type 1 Muscle Fibers: appears red because it contains myoglobin, an oxygen binding protein; uses oxidative metabolism to generate energy so are suitable for endurance and is slow to fatigue *Type 2 Muscle Fibers: appears white due to absence of myoglobin and relies on relies on glycolytic enzymes for energy; can use oxidative and anaerobic metabolism; suitable for short bursts of energy and is quick to fatigue

31 Positioning Malformations
Common “Acquired Positioning Malformations” Hip abduction & external rotation (frog leg) Shoulder retraction & scapular adduction (W position of arms) Neck extension Arching postures Abnormal head molding

32 Positioning Malformations
Prevention of deformities Provide support for breathing & ventilation Promote skin integrity Facilitate containment & security Facilitate development of flexion in posture & movement

33 Positioning Deformities
Prevention of Deformities Provide opportunities for midline skill development (hand to face/mouth) Encourage alignment & symmetry Support rest/calming/comfort & neurobehavioral organization Counteract abnormal posturing Support tolerated posturing

34 Positioning Guidelines
Neutral or slightly flexed neck Gently rounded shoulders Flexed elbows Trunk slightly rounded with pelvic tilt Hips partially flexed & adducted to near midline (no frog leg or externally rotated hips flat against bed) Lower boundary for foot bracing

35 Positioning Guidelines
Bedding & positioning aids should be individually determined to meet the needs of the infant Calm, organized behavior may be improved by Prone position Side-lying position, well-supported with hands to mid-line swaddling

36 Positioning Guidelines
Reposition with hands-on care or when behavioral cues indicate discomfort Use appropriately sized-diapers to preserve normal hip alignment Avoid tension from lines or tubing such as ET tubes, IV lines, og tubes, prevent pressure deformities.

37 Positioning Guidelines
Use slow, gentle rolling motion with containment of extremities & providing a pacifier when repositioning sick or preterm infants. Once repositioned, monitor breathing pattern, color, O2 Sats, HR, respiratory rate & pattern, behavioral cues, & stability of position.

38 Positioning Guidelines
Observe infant’s developmental capabilities. If infant fighting containment or boundaries, infant should be allowed to go without. Transitioning infants out of boundaries and positioning aids is required before discharge. Supine positioning should be initiated at least 2 weeks before discharge.

39 Positioning Guidelines
AAP Recommendations Supine position is the preferred sleeping position during infancy Avoid use of soft/loose bedding or objects (pillows, comforters, sheepskin, stuffed toys) Avoid use of waterbeds, sofas, or soft mattresses as a bed Avoid bed sharing or co-sleeping even with siblings Avoid overheating by too many clothes & overly warm bedroom temperature

40 Feedings Key Concept: recognizing the difference between a successful feeding (volume & duration of feeding) & a successful feeder (infant competence & enjoyment). Within this context lies the difference between task-oriented or procedural feedings & a developmental feeding.

41 Feedings Developmental Feeding (Ancona, et al.,1998) involves 3 concepts: Physiologic, motor, & state behavioral assessment before, during, & after feeding Individualized feeding approach based on specific infant cues Fostering parent competence, confidence, & enjoyment while feeding the infant

42 Feedings Transition to oral feedings
Support sleep/wake behavioral organization Provide proper positioning to promote neuromuscular control & postural alignment for suck, swallow, & breathing (prevent hyperextended neck or trunk & shoulder retraction) Protect against oral aversion

43 Feedings Transition to oral feedings
Provide pleasurable oral experiences Offer opportunities to smell breast milk or formula Offer a pacifier for pleasure & not just for comfort during care or painful procedures

44 Feeding readiness behaviors
Feedings Feeding readiness behaviors Medical status Energy for feeding Capable of quiet, alert state behavior Gag response with orogastric tube insertion Rooting & sucking behaviors Functional sucking reflex As nurses, we are instrumental in the transition to oral feedings. We are instrumental in helping the parents become familiar with their infant’s cues and also with guiding and monitoring the feeding skill and progression.

45 Feedings Nonnutritive Sucking: meta-analysis of NNS literature which reviewed 13 randomized controlled trials demonstrated a significant effect on length of hospital stay. Nutritive sucking Requires greater coordination of suck-swallow-breathe sequence

46 Feedings Nutritive Sucking
To encourage as normal a suck-swallow pattern as possible while infant maintains physiologic stability very important to hold nipple as still as possible and allow infant to pace the feeding. Allow rest between suck bursts. Manage environmental distractions so infant can focus on feeding.

47 Feedings Nutritive Sucking
Monitor infant for fatigue; forced feeding after an infant is tired can cause Prolonged feeding duration Poor weight gain Bradycardia Incoordination during the feeding Aspiration Deglutition apnea Desaturations Oral aversion & defensiveness

48 Feedings Nutritive Sucking
Intervene with infants who become fatigued by oral feeding Stop oral feeding when infant tired Continue feeding by NG or OG tube to provide adequate intake Decrease number of oral feedings per day or feeding duration for each feed If feeding fatigue persists, develop plan for further evaluation and change in plan of care

49 Feedings Maturation & Coordination
Significant correlation between maturity of the infant’s sucking ability & post conceptual age. Neurobehavioral maturation is a developmental sequence that supports feeding progression/abilities. Coordination of suck, swallow, & respiration is seen by 34 weeks PCA. Milk flow volume is related to nipple hole size.

50 Feedings Maturation & Coordination
Restricted milk flow facilitates oral feeding in preterm infants allowing rest between suck & swallow. Rapid flow may overwhelm preterm infants. Changing nipples frequently may affect feeding organization & adaptation; identifying an appropriate nipple & using it regularly as long as an infant is successfully feeding may be more supportive

51 Feedings Studies (Arvedson et al, 1994; Comrie & Helm, 1997) have shown that ~94% of aspiration in infants and children evaluated by video fluoroscopy is “silent.” Feeding success is directly related to an infant’s ability to maintain physiologic stability, a flexed posture, and an alert state while feeding.

52 Feedings Infants provided 5 minutes of NNS prior to feeding demonstrate more alert & quiet awake states during feeding than those who do not receive the intervention NNS infants also demonstrate higher O2 saturations before & after feedings.

53 Feedings Ross & Browne (2002) suggest that oral cheek & jaw support remove the infant’s own ability to pace the feeding & also increased milk volume; both experiences may lead to negative feedback during a feeding increasing oral aversion & defensiveness.

54 Feedings Pacing supports feeding success by allowing breathing breaks to slow sucking or successive swallowing & allowing adequate breathing opportunity for infants who are having difficulty with stability during a feeding. Pacing is achieved by tilting the bottle slightly so that the milk drains out of the nipple & does not continue to flow. This is preferred to removing the bottle from the mouth which may result in difficulty reestablishing the latch onto the nipple.

55 Feedings Assessment Physiologic assessment (HR, respiratory pattern, color, oxygenation, vigor, stable digestion) Maintenance of physiologic stability during oral feeding Choking or gagging during feeding Apnea or bradycardia O2 Sats & WOB Signs of fatigue Weight gain with adequate caloric intake Physiologic stability provides the safe foundation for feeding with the overall integration of physiologic, motor, & state systems working together to support success.

56 Feedings Motor assessment General tone & posture
Changes in muscle tone, posture, & movements with handling Maturity of sucking Coordination of suck/swallow/breathing Control of milk bolus

57 Feedings Assessment Behavioral state assessment
Timing, duration, & quality of arousal Sensitivity to environment &/or stimulation Response to touch, handling, & position changes Interest in feeding by facial expression or stress

58 Feedings Endurance Volume taken Time frame for feeding
Vigor during feeding

59 Feedings Assessment Evaluation of a successful feeding
Physiologic & behavioral cost of feeding is minimal (vital signs maintained with good oxygenation, stable/relaxed muscle tone, predominant state is quiet, alert & is interested) Little or no recovery time for physical or behavioral return to baseline. Energy & vigor maintained during feeding.

60 Feedings Evaluation of a successful feeding
Infant participates in feeding with interest, energy, & enjoyment. Adequate intake by mouth &/or mouth/gavage. Adequate weight gains. Tolerance of feedings observed by minimal residuals, soft abdomen, audible bowel sounds, and regular elimination.

61 Feeding Facilitation Techniques
Provide NNS & milk odors during gavage feedings. Avoid trial po feeds after stressful events Allow adequate time for rest after care and before feeds Provide feeds on semi-demand or demand basis depending on unit practices. Choose firmer nipples with slower flow rather than premie nipple that may result in rapid milk flow that may overwhelm infant

62 Feeding Facilitation Techniques
Be prepared to focus on infant and the feeding with ongoing observation and adaptation. Gently arouse infant to alert state; may use NNS prior to feeding Swaddle in gentle flexion with hands midline toward face Support positioning infant with infant cradled close to body semi-upright or upright position with neck in neutral to slightly flexed position

63 Feeding Facilitation Techniques
Continually observe physiologic, behavioral, & oral-motor functioning, careful to respond appropriately to subtle cues when needed to modify or terminate feeding Provide breathing/rest periods for infants who need assistance with pacing Provide gentle jaw/cheek support discriminately for problems with latching onto nipple, weak seal, or loss of milk bolus

64 Feeding Facilitation Techniques
Use “developmental burping” on shoulder with postural support & gentle back rubbing in an upward motion to stimulate burp; avoid sitting infant upright & leaning infant forward or patting the back because this is an unstable position with tactile stimulation that is often disorganizing for the preterm infant. Recognize the infant’s limits and when to stop the feeding (fatigue, aversion, etc.)

65 Feeding Facilitation Techniques
Gavage remainder of feeding as needed based on infant cues Reduce energy expenditure Promote a positive feeding experience & minimize feeding aversion Schedule plenty of undisturbed rest between feedings

66 Feeding Facilitation Techniques
Evaluate feeding tolerance (abdominal exam, stools, emesis, bowel sounds, residuals, interest in feeding, vigor during feeding, etc..) Document volume, duration of feeding, feeding behaviors (autonomic, state, & motor) & interventions required.

67 Breastfeeding Provide skin-to skin holding or kangaroo care
Provide privacy and comfort to mother & infant Provide easy access to pumping equipment & breast milk storage. Provide easy access to lactation consultants.

68 Breastfeeding Provide training in proper breastfeeding positions
Cradle-classic holding position Clutch-infant’s body rests across mother’s chest or is tucked (football style ) underneath her arm Infant position- comfortable alignment, gentle flexion of extremities, & slight extension of neck for full jaw excursion; well supported flexion & containment

69 Breastfeeding Share feeding readiness cues and teach mother to assess for signs of stability and stress Allow plenty of time for feeding: Avoid rushing or appearing hurried The most common problem with breastfeeding with preterm infant is maintaining secure attachment to nipple and areola so may need to use silicone nipple shields.

70 Breastfeeding Assist mother with evaluating successful feeding with objective rather than subjective measures. Prompt evaluation & correction of inadequate positioning or latch-on is recommended to facilitate successful breastfeeding.

71 International Association for the Study of Pain
“unpleasant sensory and emotional experience associated with actual or potential tissue damage, or described in terms of such damage” (1979) Implies that pain is subjective & must be learned through experience and expressed verbally

72 Pain Verbal Communication and self-reports are considered the Gold Standard for pain assessment

73 Pain HOWEVER…. Infants are not capable of verbally communicating pain!!! THEREFORE… Other means of pain assessment MUST be utilized with infants!!

74 Most Commonly Used Pain Assessment Tools
CRIES (crying, requires oxygen saturation, increased vital signs, expression, sleepless)-originally designed to assess post-op pain in infants weeks gestation; now useful for pain assessment in all preterm and term infants Scores range 0-10 *CRIES: Measures 5 parameters-crying, requires O2 to maintain O2 Sats >95%, increased vital signs, expression, and sleepless; can get up to 2 points for each parameter; Total scores range from 0-10; scores <4 indicate mild pain that can be treated with nonpharmacologic measures; scores ≥5 indicate moderate to severe pain that usually needs pharmacologic treatment as well as comfort measures

75 Most Commonly Used Pain Assessment Tools
PIPP (Premature Infant Pain Profile) uses 2 physiologic indicators (heart rate & O2 saturation) & 3 facial indicators (brow bulge, eye squeeze, & nasolabial furrow) Originally used to measure procedural pain; now used for routine pain assessment in all preterm and term infants **PIPP- scores are adjusted based on gestational age and chronologic age ( the lower the gestational age, the higher the score), scores are obtained at different time intervals in relation to the care/procedure (15 seconds before and 30 seconds after event); Total scores can vary from 18-21; scores of 7-12 indicate mild to moderate pain requiring nonpharmacologic measures; scores >q12 indicate moderate to severe pain requiring both pharmacologic treatment an comfort measures

76 Most Commonly Used Pain Assessment Tools
N-PASS (Neonatal Pain Agitation & Sedation Scale) – scores based on assessment of cry/irritability, behavior state, facial expression, tone, & vital signs Scores adjusted for gestational age Incorporates separate scoring system for assessment of level of sedation **N-PASS: Receives scores of 0-12 for behavioral & physiologic criteria; scores >3 indicate pain requiring nonpharmacologic &/or pharmacologic treatment *** level of sedation is scored in response to stimuli; scores range from 0 to -2 for each parameter; total scores can range from 0 to -10; scores of -10 to -5 indicate deep sedation and scores of -5 to -2 indicate light sedation

77 Most Commonly Used pain Assessment Tools
NIPS (Neonatal Infant Pain Scale)- originally used for procedural pain but now used to assess all pain in preterm and term infants Assesses pain based on facial expression, cry, breathing patterns, muscle tone in arms and legs, * state of arousal **NIPS: scores obtained before, and after event; infant does not have to be connected to a monitor or pulse oximeter for assessment; total scores can range from 0-7; does not have guidelines for treatment of pain based on scores

78 Pain Assessment Become familiar with and utilize pain assessment tool and treatment plan used by your facility Not all tools have guidelines for treatment In general, scores in the mid-range are indicative of moderate to severe pain & pharmacologic treatment is warranted

79 Physiology of Pain Peripheral Nervous System Spinal Cord
Centers at the Supraspinal/Integrative level, includes the thalamus and the cerebral cortex **Pain responses are the result of simultaneous reactions from the peripheral nervous system, the spinal cord, and supraspinal areas like the thalamus and the cerebral cortex. **Thalamus: is the “gateway” to the cerebral cortex; relays impulses to the proper area of the cerebral cortex **Cerebral cortex: AKA-cerebrum; controls thinking & reasoning

80 Peripheral Nervous System
Fully mature & functional by 20 weeks gestation Two types of neuronal afferent fibers: A-delta fibers (rapid- conducting fibers that transmit sharp pain) & C-fibers (slow-conducting fibers associated with aching, burning, & poorly localized pain) **afferent fibers: transmits impulse from the periphery toward the CNS

81 Peripheral Nervous System
Number of pain receptors is equal to or greater than those in an adult Tissue injury activates pain receptors that send pain impulses to the spinal cord & CNS Releases chemicals that increase sensitivity to painful stimuli causing decreased pain threshold that can last for days to weeks

82 Peripheral Nervous System
Dendritic spouting & hyperinnervation causes hypersensitivity and lowered pain threshold that can last into adulthood!

83 Spinal Cord Weak linkage between the PNS and the spinal cord result in prolonged or no pain response during the 1st week of life Pain impulses travels to the spinal column via efferent neurons, cross over to the opposite side of the brain to the thalamus which then relays incoming pain messages to the dorsal horn producing a reflex withdrawal Preterm infants have limited ability to modulate pain

84 Supraspinal/Integrative Level
Cerebral cortex has full supply of neurons by 20 weeks gestation & is functionally mature by 22 weeks gestation Germinal matrix is highly vascular until ~28 weeks gestation & is vulnerable to hemorrhage due to increased intracranial pressure with pain

85 Supraspinal/Integrative Level
Neonates can differentiate touch as early as 27 weeks gestation Infant can perceive, react to and remember pain as early as 30 weeks gestation

86 Nonpharmacologic Pain Management
Prevention: minimize pain & stress Behavioral measures: Facilitated tucking Blanket swaddling Pacifier Non-nutritive nursing Breast feeding Sucrose (remains controversial) **Safety of using repeated doses of sucrose in very low birth weight infants has not been confirmed. CAUTION is needed with its use.

87 Pharmacologic Pain Management
Used with moderate, severe, or prolonged pain assessed or anticipated IV opioids- most commonly used analgesic Spinal Cord- impairs/inhibits transmission of the pain impulse from the periphery to the CNS

88 Pharmacologic Pain Management
IV opioids Basal Ganglia- activates a descending inhibitory system Limbic system- alters emotional response to pain, making it more tolerable

89 Pharmacologic Pain Management
Longer dosing intervals may be needed due to longer elimination and delayed clearance Higher plasma concentration necessitate longer monitoring of patient after medication is discontinued Significantly higher doses nay be needed to achieve analgesia due to immature neural pathways

90 Pharmacologic Pain Management
Fentanyl Bolus: 1-4mcg/kg q2-4 hours Infusion: 1=5mcg/kg/hr Onset of action is immediate Adverse reactions; respiratory depression, chest wall rigidity, hypotension, tolerance & dependence, urinary retention

91 Pharmacologic Pain Management
Morphine Bolus: mg/kg/dose IV, IM, or subcutaneously as needed, usually q4hrs Infusion: loading dose of mg/kg IV over 1 hour followed by continuous infusion of mg/kg/hr

92 Pharmacologic Pain Management
Morphine Onset of action begins within a few minutes and peaks at 20 minutes Adverse reactions- respiratory depression, hypotension, bradycardia, transient hypertonia, ileus, delayed gastric emptying, urinary retention, seizures, tolerance & dependence

93 Pharmacologic Pain Management
Nonopioid Analgesics Acetaminophen: nonsteroidal anti-inflammatory drug used for short-term mild to moderate pain Lidocaine/Prilocaine (EMLA cream): mixture of local anesthetics, lidocaine, & prilocaine used topically for pain relief during procedures Adverse reaction- methemoglobinemia, redness, blanching **Methemoglobinemia: conversion of hemoglobin to methemoglobin; methemoglobin does not combine with oxygen; usually due to injury or toxic action of drugs or other agents or to a hemolytic process

94 Pharmacologic Pain Management
Liposomal lidocaine cream (LMX 4%)- Topical anesthetic with faster onset of action than EMLA and without side effect of methemoglobinemia Neuromuscular blocking agents- Chemical paralysis for severely ill neonate Masks signs of pain & agitation Should use in conjunction with analgesia &/or sedatives

95 Pharmacologic Pain Management
Sedatives Suppresses behavioral expression of pain No analgesic effect

96 References Kenner, C. & Lott, J. W. (2007). Comprehensive Neonatal Care: An Interdisciplinary Approach (4th Edition). Saunders Elseiver: St. Louis. Tappero, E.P. & Honeyfield, M.E. (2003). Physical Assessment of the Newborn (3rd Edition). NICU Ink: Santa Rosa). Pp

97 References Verklan, M.T. & Walden. M. (2004). Core Curriculum for Neonatal Intensive Care Nursing (3rd Ed). Elseiver Saunders: St. Louis.

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