Presentation on theme: "Developmental Support"— Presentation transcript:
1Developmental Support Denice Gardner, MSN, NNP-BC
2ObjectivesDiscuss developmental support and its effect of the newborn
3CNS Development Six Stages Stages 1-3(completed before 4th month of gestation)Dorsal InductionVentral InductionNeurogenesisStages 4-6(continues during the time the infant is in the NICU)Neuron migrationOrganization, including synaptogenesis & arborizationmyelinizationThe Central Nervous System develops in 6 overlapping stages.
4CNS DevelopmentNeuronal & glial cells originate in the germinal matrixNeuronal & glial cells migrate from germinal matrix to their eventual location within the CNS where they differentiate & take on their unique functionsNeurons formed early in life lie deeper in cortex & neurons formed later lie in more superficial layersCortex generally has complete component of neurons by 33 weeks gestation
5CNS DevelopmentOrganization- “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 birthNeuron growth & connections lead to development of brain gyri & sulciOrganization of the CNS is critical for cortical & cognitive developmentThese processes may be particularly vulnerable to insults from the effects of the NICU environment.
6CNS Development Arborization- “wiring of the brain” Dendritic connections between neurons critical for processing impulses, cell-to-cell communication, and communication throughout the CNSLack of connections cause hypersensitivity, poorly modulated behaviors, & all-or-nothing responses, frequently seen in preterm infants in the NICU
7CNS DevelopmentSynaptogenesis- formation of connection between neurons & development of intracellular structures & enzymes for neurotransmitter productionCritical for integration across all areas of the nervous systemSynapses continue to restructure throughout development & is thought to be the basis for memory & learning
8CNS DevelopmentOrganizational 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.
9CNS DevelopmentNeuronal 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)
10CNS Development Plasticity: 2 types Experience-expectant: linked to brain’s developmental timetable so specific sensory experiences are needed at specific times for neural development & maturationExperience-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
11Neurobehavioral Development Self-regulation: infant’s efforts to achieve, maintain, or regain a balanced, stable, & relaxed state of subsystem functioning & integration.Maintaining normal body tempRegulating day-night cyclesLearning to calm oneself & relaxing after careLater in life, controlling one’s own emotions & managing to keep one’s attention focused
12Neurobehavioral Development Synactive Theory of Development(Als and colleagues)Autonomic/physiologicMotorState/organizationalAttentional/interactive: involvesinfant’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 & Physiologic2. Motor3. State/organizational4. Attentional/Interactive5. Self-regulatory
13Neurobehavioral Development Signs of StabilityAutonomic systemEven, regular respirationsPink, stable colorStable viscera with no seizures, gagging, emesis, grunting, tremors, startles, twitches, coughing, sneezing, yawning, sighing
14Neurobehavioral Development Motor systemSmooth, controlled postureSmooth movement of extremities & headHand claspLeg/foot braceFinger foldingHand to mouthGraspingSuckingTuckingHand holdingGood, consistent tone throughout body
15Neurobehavioral Development Signs of StabilityState systemClear, well-defined sleep statesSelf-quieting consolabilityFocused, clear alertness with animated expressions
16Neurobehavioral Development Attentional Interaction SystemResponsivity to auditory & visual stimuli that is bright & long in durationActively seeks out sounds and shifts attention smoothly on his/her own from one stimulus to anotherFace: bright-eyed, purposeful interest varying between interest and relaxationSelf-regulatory SystemAble to maintain each system-autonomic, motor, state, attention
17Neurobehavioral Development Signs of StressAutonomic SystemRespirations: pauses, tachypnea, gaspingColor changes: paling around nostrils, perioral cyanosis, mottling, cyanosis, gray, flushed, ruddyViscera: hiccups, gagging, grunting, spitting, strainingMotor: tremor/startles, twitching, coughing, sneezing, yawning, sighing
18Neurobehavioral Development Signs of StressMotor SystemFluctuating toneFlaccidityHypertonicity: leg extensions, salutes, airplaning, arching, finger splays, tongue extensions, fistingHyperflexions: trunk; extremities; fetal tuck; frantic, diffuse activity
19Neurobehavioral Development State SystemDiffuse statesSleep: twitches, sounds, jerky movements, irregular respirations, grimacing, fussing while sleepingAwake: eye floating, glassy eyed, gaze aversion, staring, worried look, irritability
20Neurobehavioral Development Signs of StressAttentional Interaction SystemStress signals from other systems: irregular respirations, yawning, gaze aversion, hiccupping, etc..Becomes more stressed with more than one mode of stimuliSelf-Regulatory SystemMay use the following to gain balanceLower statePostural changesMotor strategies: leg/foot bracing, hand to mouth, sucking, etc.Self-quieting & consoling
21Neurobehavioral Development Stress Reducing StrategiesAutonomic SystemModify environment (light, noise, traffic)PositioningMinimal stimulationSwaddlingMotor SystemHandling to contain limbsSlow, gentle handlingBoundary rollsContainment/nesting
22Neurobehavioral Development Stress Reducing StrategiesState SystemCluster carePrimary nursing for better assessment of infant cuesAppropriate timing of activities & daily routinesAutonomic & motor subsystems must have reached stability
23Neurodevelopmental Development Stress Reducing StrategiesAttentional Interaction SystemAdjust interactions to infant’s tolerance levelProvide supports necessary to bring out best alertnessOffer one mode of stimulation at a timeUse modulated voice, face, rattle, together (baby responds best to animate stimuli)
24Sleep-Awake StatesState- level of infant’s consciousness determined by his level of arousal and response to stimuliSleep StatesDeep sleep: closed eyes, no eye movements, regular breathing, no spontaneous activityLight 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
25Sleep-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
26Sleep-Awake States Awake States Quiet alert- interactive, alert & wide-eyed appearance; attention focused on stimuli, regular respirations, minimal motor activityActive alert- increased motor activity, heightened sensitivity to stimuli, periods of fussiness but easily consoled; eyes open but less bright & attentive, irregular respirationsCrying- 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.
27OrganizationAbility to integrate physiologic & behavioral systems in response to stimuli without disruption in the state or physiologic functionMaintains stable vital signs, smooth state transitions, even movementsAble to console himselfAbility 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
28Sensory ThresholdLevel of tolerance for stimuli in which infant can respond appropriatelyWhen threshold met, becomes overstimulated and stressedPreterm and neurologically impaired infants have low thresholdsWatch 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
29Habituation Ability to alter response to repeated stimuli When stimulus is repeated, the initial response to it will gradually go awayDefense mechanism for shutting out disturbing or overwhelming stimuliAssess 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
30Positioning Malformations Muscle fiber development incomplete until termLower ratio of Type 1 muscle fibers to Type 2 predisposes preterm infant to muscle fatigueRestricted 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
31Positioning Malformations Common “Acquired Positioning Malformations”Hip abduction & external rotation (frog leg)Shoulder retraction & scapular adduction (W position of arms)Neck extensionArching posturesAbnormal head molding
32Positioning Malformations Prevention of deformitiesProvide support for breathing & ventilationPromote skin integrityFacilitate containment & securityFacilitate development of flexion in posture & movement
33Positioning Deformities Prevention of DeformitiesProvide opportunities for midline skill development (hand to face/mouth)Encourage alignment & symmetrySupport rest/calming/comfort & neurobehavioral organizationCounteract abnormal posturingSupport tolerated posturing
34Positioning Guidelines Neutral or slightly flexed neckGently rounded shouldersFlexed elbowsTrunk slightly rounded with pelvic tiltHips partially flexed & adducted to near midline (no frog leg or externally rotated hips flat against bed)Lower boundary for foot bracing
35Positioning Guidelines Bedding & positioning aids should be individually determined to meet the needs of the infantCalm, organized behavior may be improved byProne positionSide-lying position, well-supported with hands to mid-lineswaddling
36Positioning Guidelines Reposition with hands-on care or when behavioral cues indicate discomfortUse appropriately sized-diapers to preserve normal hip alignmentAvoid tension from lines or tubing such as ET tubes, IV lines, og tubes, etc..to prevent pressure deformities.
37Positioning 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.
38Positioning 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.
39Positioning Guidelines AAP RecommendationsSupine position is the preferred sleeping position during infancyAvoid use of soft/loose bedding or objects (pillows, comforters, sheepskin, stuffed toys)Avoid use of waterbeds, sofas, or soft mattresses as a bedAvoid bed sharing or co-sleeping even with siblingsAvoid overheating by too many clothes & overly warm bedroom temperature
40FeedingsKey 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.
41FeedingsDevelopmental Feeding (Ancona, et al.,1998) involves 3 concepts:Physiologic, motor, & state behavioral assessment before, during, & after feedingIndividualized feeding approach based on specific infant cuesFostering parent competence, confidence, & enjoyment while feeding the infant
42Feedings Transition to oral feedings Support sleep/wake behavioral organizationProvide proper positioning to promote neuromuscular control & postural alignment for suck, swallow, & breathing (prevent hyperextended neck or trunk & shoulder retraction)Protect against oral aversion
43Feedings Transition to oral feedings Provide pleasurable oral experiencesOffer opportunities to smell breast milk or formulaOffer a pacifier for pleasure & not just for comfort during care or painful procedures
44Feeding readiness behaviors FeedingsFeeding readiness behaviorsMedical statusEnergy for feedingCapable of quiet, alert state behaviorGag response with orogastric tube insertionRooting & sucking behaviorsFunctional sucking reflexAs 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.
45FeedingsNonnutritive Sucking: meta-analysis of NNS literature which reviewed 13 randomized controlled trials demonstrated a significant effect on length of hospital stay.Nutritive suckingRequires greater coordination of suck-swallow-breathe sequence
46Feedings Nutritive Sucking To encourage as normal a suck-swallow pattern as possible while infant maintains physiologic stabilityvery 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.
47Feedings Nutritive Sucking Monitor infant for fatigue; forced feeding after an infant is tired can causeProlonged feeding durationPoor weight gainBradycardiaIncoordination during the feedingAspirationDeglutition apneaDesaturationsOral aversion & defensiveness
48Feedings Nutritive Sucking Intervene with infants who become fatigued by oral feedingStop oral feeding when infant tiredContinue feeding by NG or OG tube to provide adequate intakeDecrease number of oral feedings per day or feeding duration for each feedIf feeding fatigue persists, develop plan for further evaluation and change in plan of care
49Feedings 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.
50Feedings 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
51FeedingsStudies (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.
52FeedingsInfants provided 5 minutes of NNS prior to feeding demonstrate more alert & quiet awake states during feeding than those who do not receive the interventionNNS infants also demonstrate higher O2 saturations before & after feedings.
53FeedingsRoss & 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.
54FeedingsPacing 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.
55FeedingsAssessmentPhysiologic assessment (HR, respiratory pattern, color, oxygenation, vigor, stable digestion)Maintenance of physiologic stability during oral feedingChoking or gagging during feedingApnea or bradycardiaO2 Sats & WOBSigns of fatigueWeight gain with adequate caloric intakePhysiologic stability provides the safe foundation for feeding with the overall integration of physiologic, motor, & state systems working together to support success.
56Feedings Motor assessment General tone & posture Changes in muscle tone, posture, & movements with handlingMaturity of suckingCoordination of suck/swallow/breathingControl of milk bolus
57Feedings Assessment Behavioral state assessment Timing, duration, & quality of arousalSensitivity to environment &/or stimulationResponse to touch, handling, & position changesInterest in feeding by facial expression or stress
58Feedings Endurance Volume taken Time frame for feeding Vigor during feeding
59Feedings 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.
60Feedings 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.
61Feeding Facilitation Techniques Provide NNS & milk odors during gavage feedings.Avoid trial po feeds after stressful eventsAllow adequate time for rest after care and before feedsProvide 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
62Feeding 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 feedingSwaddle in gentle flexion with hands midline toward faceSupport positioning infant with infant cradled close to body semi-upright or upright position with neck in neutral to slightly flexed position
63Feeding Facilitation Techniques Continually observe physiologic, behavioral, & oral-motor functioning, careful to respond appropriately to subtle cues when needed to modify or terminate feedingProvide breathing/rest periods for infants who need assistance with pacingProvide gentle jaw/cheek support discriminately for problems with latching onto nipple, weak seal, or loss of milk bolus
64Feeding 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.)
65Feeding Facilitation Techniques Gavage remainder of feeding as needed based on infant cuesReduce energy expenditurePromote a positive feeding experience & minimize feeding aversionSchedule plenty of undisturbed rest between feedings
67Breastfeeding Provide skin-to skin holding or kangaroo care Provide privacy and comfort to mother & infantProvide easy access to pumping equipment & breast milk storage.Provide easy access to lactation consultants.
68Breastfeeding Provide training in proper breastfeeding positions Cradle-classic holding positionClutch-infant’s body rests across mother’s chest or is tucked (football style ) underneath her armInfant position- comfortable alignment, gentle flexion of extremities, & slight extension of neck for full jaw excursion; well supported flexion & containment
69BreastfeedingShare feeding readiness cues and teach mother to assess for signs of stability and stressAllow plenty of time for feeding: Avoid rushing or appearing hurriedThe most common problem with breastfeeding with preterm infant is maintaining secure attachment to nipple and areola so may need to use silicone nipple shields.
70BreastfeedingAssist 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.
71International 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
72PainVerbal Communication and self-reports are considered the Gold Standard for pain assessment
73PainHOWEVER…. Infants are not capable of verbally communicating pain!!! THEREFORE… Other means of pain assessment MUST be utilized with infants!!
74Most 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 infantsScores 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
75Most 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
76Most 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 signsScores adjusted for gestational ageIncorporates 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
77Most 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 infantsAssesses 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
78Pain AssessmentBecome familiar with and utilize pain assessment tool and treatment plan used by your facilityNot all tools have guidelines for treatmentIn general, scores in the mid-range are indicative of moderate to severe pain & pharmacologic treatment is warranted
79Physiology 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
80Peripheral Nervous System Fully mature & functional by 20 weeks gestationTwo 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
81Peripheral Nervous System Number of pain receptors is equal to or greater than those in an adultTissue injury activates pain receptors that send pain impulses to the spinal cord & CNSReleases chemicals that increase sensitivity to painful stimuli causing decreased pain threshold that can last for days to weeks
82Peripheral Nervous System Dendritic spouting & hyperinnervation causes hypersensitivity and lowered pain threshold that can last into adulthood!
83Spinal CordWeak linkage between the PNS and the spinal cord result in prolonged or no pain response during the 1st week of lifePain 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 withdrawalPreterm infants have limited ability tomodulate pain
84Supraspinal/Integrative Level Cerebral cortex has full supply of neurons by 20 weeks gestation & is functionally mature by 22 weeks gestationGerminal matrix is highly vascular until ~28 weeks gestation & is vulnerable to hemorrhage due to increased intracranial pressure with pain
85Supraspinal/Integrative Level Neonates can differentiate touch as early as 27 weeks gestationInfant can perceive, react to and remember pain as early as 30 weeks gestation
86Nonpharmacologic Pain Management Prevention: minimize pain & stressBehavioral measures:Facilitated tuckingBlanket swaddlingPacifierNon-nutritive nursingBreast feedingSucrose (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.
87Pharmacologic Pain Management Used with moderate, severe, or prolonged pain assessed or anticipatedIV opioids- most commonly used analgesicSpinal Cord- impairs/inhibits transmission of the pain impulse from the periphery to the CNS
88Pharmacologic Pain Management IV opioidsBasal Ganglia- activates a descending inhibitory systemLimbic system- alters emotional response to pain, making it more tolerable
89Pharmacologic Pain Management Longer dosing intervals may be needed due to longer elimination and delayed clearanceHigher plasma concentration necessitate longer monitoring of patient after medication is discontinuedSignificantly higher doses nay be needed to achieve analgesia due to immature neural pathways
91Pharmacologic Pain Management MorphineBolus: mg/kg/dose IV, IM, or subcutaneously as needed, usually q4hrsInfusion: loading dose of mg/kg IV over 1 hour followed by continuous infusion of mg/kg/hr
92Pharmacologic Pain Management MorphineOnset of action begins within a few minutes and peaks at 20 minutesAdverse reactions- respiratory depression, hypotension, bradycardia, transient hypertonia, ileus, delayed gastric emptying, urinary retention, seizures, tolerance & dependence
93Pharmacologic Pain Management Nonopioid AnalgesicsAcetaminophen: nonsteroidal anti-inflammatory drug used for short-term mild to moderate painLidocaine/Prilocaine (EMLA cream): mixture of local anesthetics, lidocaine, & prilocaine used topically for pain relief during proceduresAdverse 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
94Pharmacologic Pain Management Liposomal lidocaine cream (LMX 4%)-Topical anesthetic with faster onset of action than EMLA and without side effect of methemoglobinemiaNeuromuscular blocking agents-Chemical paralysis for severely ill neonateMasks signs of pain & agitationShould use in conjunction with analgesia &/or sedatives
95Pharmacologic Pain Management SedativesSuppresses behavioral expression of painNo analgesic effect
96ReferencesKenner, 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
97ReferencesVerklan, M.T. & Walden. M. (2004). Core Curriculum for Neonatal Intensive Care Nursing (3rd Ed). Elseiver Saunders: St. Louis.