“Providing Individualized Developmental, Family-Centered care in the Neonatal Intensive Care Unit” Bonni Moyer, MSPT, Developmental Coordinator, NIDCAP Trainer St. Joseph’s Hospital and Medical Center St. Joseph’s NIDCAP Training Center

Babies are such a nice way to start people Don Herald

Objectives Trainees with become familiar with concepts involving: • Brain development Sensory-Motor development Infant behavior-both full-term and preterm Developmental Care and Evidence-based Practice Relationship Based Caregiving and Implications

“One brain for life” Als …and the way that we protect their brains. The NIDCAP program offers us an evidenced based tool that allows us to assess and offer suggestions for making each baby’s life have the greatest quality that we can in this early critical period of development. Developmental Care IS brain protection ! The brain controls the whole body!

Incidence of Prematurity- U.S.A. 12.7 % 1/8 infants African American -18% of all live births 4 million live births/year, 520,000 premature www.cdc.gov Enlarge text 5

Incidence of Prematurity-Arizona Premature infants born each week in AZ: 243 < 37 weeks 128 < 2500 grams 13.2 % of live births (1 in 8) is preterm www.marchofdimes.com With medical advances over the last 30 plus years, including the technology of ventilators and medications such as surfactant, younger and younger infants are surviving.

Outcomes of Prematurity: Developmental outcomes Poor school performance Lower IQ scores Behavioral problems (ADHD, affective disorders) LBW children score significantly lower on intelligence tests as compared to children of normal birth weight. The vulnerability of these infants to weaknesses in perceptual-performance skills is consistent with evidence showing the early neurological insults are associated with deficits in this area vs deficits in language or more general cognitive abilities Studies of this area have looked at VLBW and ELBW outcomes. There has been found that there is in increased risk of behavioral problems, esp with boys Behav problems have been described in children with cognitive deficits and neuromotor dysfunction, suggesting brain injury as the cause of these problems The types of behav problems included conduct disorder, hyperactivity and difficulties maintaining attention. Hack,M Adult Outcomes of Preterm Children; J Dev Behav Pediatr; 30:460-470, 2009

Outcomes of Prematurity: Neurosensory outcomes Cerebral palsy is the most common major neurological diagnosis seen in LBW children (5-8% for VLBW AND 12-13% IN ELBW) Increased incidence of diagnoses: CP, hydrocephalus, microcephaly, blindness, deafness, seizures (4% for births 23-27 weeks) M. Hack (2002)

• Paying attention • Prioritizing • Planning • Imposing structure Neurodevelopmental Outcomes: “They survive and make the best of it… yet at what cost?” Als Most premies survive, but nearly ½ will have difficulties later in life. They are bright, but they can’t hold their own in the second grade…they may have trouble with… • Paying attention • Prioritizing • Planning • Imposing structure • Learning It has been suggested that the premature experience of an extrauterine environment at a time of rapid brain development may alter brain differentiation and influence later development. Animal studies of neuronal development during critical periods support such a hypothesis. D.Buehler Premature, LBW children tend to demonstrate more generalized learning problems rather than specific learning disabilities (only a reading problem, for example). This supports the theory that their learning problems are caused by a global processiing deficit rather than difficulties with isolated skills. (Medscape)

Factors effecting long-term developmental outcomes social and environmental factors (maternal education, race, social class) Biological factors are important influences on the outcomes social risk factors have a greater effect on the long-term cognitive outcomes than do biological risk factors Smith, Butler, Als; 2008 In: R. Martin,AA. Fanaroff, MC Walsh, Fanaroff and Martin’s Neonatal-Perinalat Medicine; Vol. Two, Diseases of the Fetus and Infance (8th edition). Pp 1051-1068 Biological factors are more important influences on the outcomes and are more pronounced with severe neurological insult or extremely low birth weight For most LBW children, social risk factors have a greater effect on the long-term cognitive outcomes than do biological risk factors

Why is Developmental Care Important? -Developmental care is slowly becoming a standard for care in the nursery intensive care units all around the world. Developmental care focuses on the impact and the role that the NICU plays for the family and infants. Developmental care refers to the environmental surroundings including light and noise, as well as considerations for positioning, handling of the infant, type of bed and bedding the infant is in, how health care professionals interact with the family and how the family is incorporated into care. Developmental care looks at how the environment –both of the unit and of the smaller space for the individual infants- effects the growth and development of the premature infant. Evidence- which we will discuss today is continually growing to support the ideas of the importance of dimmed lighting, diminished sound levels, positioning devices, family-centered care and the effect each has on the growth and development of the individual infants. ) Kenner, Carole, Developmental Care-Practice Strategies to Protect and Enhance Development of the Preterm Infant

Development in the extrauterine environment leads to different and potentially maladaptive developmental trajectories. Medical technology is glaringly lit and jarringly noisy, NICUs are among the most densely populated and chaotic units in hospitals. Bustling staff perform necessary but painful procedures, and the infant’s sleep is constantly interrupted. NICUs provide everything a premie needs, while simultaneously providing everything a premie doesn’t need. Preterm infants are at risk for many organ impairments and complications, including CLD, IVH, ROP, NEC. . . . . .. . . . .. It is clear that the preterm infant at school age emerges as significantly more at risk for Attention deficit disorder Lower IQ Difficulties in social-emotional functioning and self-regulation And the increased need for specialized school services. These differences may be attributable at least in part to the difference in sensory experience of the immature nervous system when cared for outside the uterus before term. Dr. Als’ hypothesis is that environmental input may lead to altered pathway development due to unexpected and overwhelming sensory experience, which in turn, may lead to deviant developmental functioning, especially of association cortical areas. Als H.1982. Toward a synactive theory of development: Promise For the assessment of infant individuality. Inf Mental Health J 3:229-243

How do we ensure the infant's smooth and balanced functioning now outside the womb? While in the NICU… Hopefully, this is what you will know more about by the time you leave here this morning. Als, 2006

Why developmental care? shown to improve preterm infants’ outcomes and have positive effects hospitalized outcomes and on their overall development improved overall physiology function improved feeding behavior, weight gain decreased length of hospitalization improved neuro-physiological outcome with improved brain structure -Preterm infants are often placed in a Nursery Intensive Care Unit (NICU) with various stimuli (lights, sounds, noxious touch, and medical procedures) that negatively affect development -Research has demonstrated that infants involved in NIDCAP show improved lung function, improved feeding behavior and growth, decreased length of hospitalization and improved neurodevelopmental function with improved brain structure, when compared to infants receiving the standard NICU care. ***I will show you data this afternoon addressing all of these outcomes Als H et al: A three-center randomized controlled trial of individualized developmental care for very low birth weight preterm infants: Medical, neuordevelopmental, parenting and caregiving effects. J Dev Behav Pediatr 24: 399,2003

Implications Our responsibility is to improve quality of life Ensuring survival is not enough Our responsibility is to improve quality of life for these infants

NEURO-SENSORY DEVELOPMENT

Sensory development-sequence of the sensory systems Touch: Somatosensory,touch, pain, position and temperature Vestibular: motion and balance Smell Taste (gustatory) Hearing Vision When infants are born premature the sequencing of this sensory development becomes and issue because stimuli and use of these systems that are out of sequence can result in developmental deficiits. For example, the human fetus has no need for light or visual stimuli prior to birth, therefore this is the last system to develop later in the third trimester. Graven,S The Relationship between Physical Environment and Patient Medical Outcomes Journal of Healthcare Design, vol IX;15-19

SENSORY MOTOR INTEGRATION The relationship between the nerves (sensory system) and the muscles ( motor system) The process by which these two systems work together and coordinate the overall outcome of movement Develops from birth to approximately 7 years old There is a sense of things around you and then your body moves in relation to these sensations. Growth in motor, social and cognitive development is highly effected by the foundation of this sensory-motor integration. . If these sensations produce atypical movement patterns, these will be the patterns that are processed and continue throughout life www.understanding-learning-disabilities.com

Three parts of sensory integration The sense organ receives a stimulus The nerves carry the information to the brain where the information is interpreted 3. The brain decides what response should be made and relays this information to the appropriate group of muscles needed to perform this task These two systems work together as a team. If there is a problem in the nerves delivering the message, the brain will not receive the message. Or is there is a dysfunction in the motor system, the muscles will not be able to carry out to correct response www.understanding-learning-diablilities.com

Sensory Motor Development The skills of motor integration can effect a child’s learning in areas such as: 1. balance 2. left/right development 3. knowing where their body is in space 4. self confidence of being in control of the body An immature sensory motor integration system effects fine motor skills, balance, inability to sit still. These kids need extra time and effort . These children tend to have lower self confidence because their best efforts are seen as not successful www.understanding-learning-diablilities.com

Signs of immature sensory motor integration • avoids writing tasks • difficulty with hand-eye coordination • clumsy • confuses right and left • difficulty getting dressed • no development of dominant right or left hand • difficulty balancing • difficulty crossing midline The earlier we can identify any of these signs, the better outcomes www.understanding-learning-diablilities.com

Motor Control The process of the brain and spinal cord that coordinates one’s posture and movement Give examples

Motor Development •Process of change in motor behavior that occurs over relatively extended periods of time. •Results from internal and external influences: -maturation, growth and learning -can be affected by environmental influences

Factors effecting motor development •The development and quality of a child’s motor skills are influenced by many factors including: 1. Tone 2. Strength 3. Endurance 4. Motor planning 5. Sensory Integration

Motor Learning A set of processes associated with practice or experience that leads to a relatively permanent change in skilled motor behavior Isaac S.Michael WB: Handbook on Research and Evaluation