Developmental Aspects in the NICU Jackie Sampers, Ph.D. Angie Stidham Missy Stamper

Objectives To share current thinking of developmental care in the NICU To review currently used developmental interventions for hospitalized high-risk infants To describe current developmental research at UK To familiarize the participants in current research in developmental cares nationally

Background – The New Age BASICS, Baby Awareness and Support through Interactive Computer Systems provides families of baby’s in the NICU with helpful information. Information is provided in an easy-to-use touch screen system in down to earth language. BASICS reinforces the information provided to families by medical professionals.

Background Continued All information in the systems was developed with parents who had baby’s in the NICU. BASICS helps families know what questions to ask medical professionals. Use of technology to support infant transition into community based services

Content on BASICS Medical Conditions Tips from Families NICU Equipment Reading Baby’s Cues NICU Team Members Community Services Medical Terms

Nathan’s Story

Containment Containment involves the gentle holding of the infant in the incubator or crib. It can be used when an infant is too sick to be held outside the crib or can support the infant during painful medical procedures.

Containment Tips Support can be provided when the infant is on their tummy, back or laying on their side. The legs are supported in a flexed position. The infant can stretch out, but then the caregiver can help them return to a tucked and secure position. The caregiver uses their other hand to support the upper body and arms. Some caregivers like to gently caress the top of the babies head.

Containment ApproachCuesAvoidance Cues

Nesting Babies are use to being inside their mommy with firm support, the rolls can help them to feel boundaries and they can push up against the sides of the rolls comforting them. Nesting can be done while the infant is in the NICU and placed on a monitor that helps to ensure that the baby is physiologically stable. The infant can be supported with rolls or other commercially available products.

Nesting Tips Supports can help keep the baby calm and can support good positioning of the baby. Rolls can be used to build up the sides of the bed, but you must be careful not to have any loose bedding around the face. Also, rolls must be placed under the bedding/sheets, so that the baby cannot push-up under the rolls. Remember always safety first; never let blankets, rolls or clothing get around the babies face.

Nesting Approach Cues –Good state control –Hands to face –Body relaxed (legs and hip softly flexed) –Good support of mid line motor movements Avoidance Cues –Head position too far to the side –Baby sinking into the surface –Arching positions Watch for good positioning: no frog legs

Pacifier A pacifier is a fairly common intervention with the newborn and can help the baby by providing a very supporting intervention. Research has strongly supported the use of pacifiers with infants in the NICU. Many studies suggest that pacifiers can help the infant to stay calm, support the transition to oral feeding, increase oxygenation and some even suggest that it can help with growth and development in some ill infants.

Pacifier Tips Care must be taken to find the right pacifier, just the right size Shapes should be considered Sometimes we remember to give the infant the pacifier when there is a painful procedure, be very careful, because the infant can grow to associate the pacifier with pain if that is the only time it is given. Some infants have difficulty moving from the pacifier to the breast for feeding, the lactation consultant can help.

Pacifier Approach Cues –Good physiological stability –State control Avoidance Cues –Tongue thrust –Cry –Movements into extension –Arching

Kangaroo Care Just like a Kangaroo keeps the baby close to them and provides skin-to-skin contact, parents can provide similar experiences for their babies in the NICU. Moms or Dads can provide It can help families to feel closer to their ill baby and many mothers report that it helps them relax to breastfeed.

Kangaroo Tips Safety is important and most hospitals have rules about who can participate in Kangaroo Care and how it should be done step-by-step. While the parent is seated comfortably in a semi- inclined position the nurse will place the baby to the chest. Baby is then snuggled in with the caregiver's clothing and/or covered with blankets. With early trials nurse will need to monitor the infant's temperature and stability, in the beginning the kangaroo time should be limited. Other stimulation should be limited.

Kangaroo Care Approach CuesAvoidance Cues –Arching –Physiological instability (temperature, respirations, or heart rate)

Stroking To start with keep it simple with skin-to- skin and no extras. When stroking the baby, touch from the chest out to arms and chest down to feet.

Stroking Tips Caution the infant may perceive a very light stoking as irritating, like tickling is to an adult. To get the most benefit from this intervention provide the infant with skin-to-skin contact. At first the baby may be very sensitive for smells and chemicals, so don't use lotions or perfumes. For the very fragile infants music during stroking may be too much stimulation.

Stroking Approach Cues –Visual regard to caregiver –Body tucking – nice flexion –Quiet awake –Hand clasp Avoidance Cues –Change in state control –Changes in skin color –Tremors –Startles –Hyper-alert –Jerky movements

Positioning For very ill infants there is a tendency for the infant to be supported the infant in one stable position. Some infants like to keep their legs held our stiffly or may keep their hands laying flat on the bed by their head, this can be a challenge to good positioning. Other infants may arch their backs in a C position. To support good positioning, there are both commercially available products and homemade supports.

Positioning Tips Support the infant's head to both the right and left. Place pictures in the bed or if toys are part of their environment be sure to move the toys from one side to the other. Be sure to talk to the baby from both the right and left. Side lying can support the infant's ability to see their hands and clasping their hands at midline Good position can help to prevent problems later in life.

Positioning Approach Cues –Flexion –Tuck positioning –Good visual regard in all fields –Localization of sound to both sides Avoidance Cues –Frog leg postures –Any posture that is obligatory for the infant

Reading Regular reading times can start even while the infant is in the hospital. Communication patterns develop very early and reading to your infant using with feeling, expression and varying the rhythm can keep the infant's interest. This early reading can also support very early pre-language development. Reading has other benefits to the infant, reading can give the infant practice in looking towards parent’s face and as they get older finding your voice.

Reading Tips The parent’s voice is familiar to the baby. Reading to your baby can be a soothing activity even for the very ill infant. Don't be afraid to read the same books over and over again to the child, this will support familiarity. If the parent has be away from their baby, record on a taper recorded the stories that you have read over and over to the infant, so that he can be comforted while you are away.

Reading Approach Cues –Quiet Awake State –Ohh face –Swiping movement towards book or face Avoidance Cues –Fatigue –Gaze avert –Cry –Startles –Increased tonicity

Caregiver Supported Orientation Awake times provide opportunities for brief interactions with family members, where the infant is supported in using their senses to orient to stimulation. Usually these early sights and sounds should use the caregivers face and voice. When the baby gets really good at the activity they will watch you as you move across the room, up and down, and all around. Awareness of sound is also a big step for the infant.

Caregiver Oriented Tips Use caregiver face for most interactions If toys are used, be careful that they don’t over-stimulate Be sure toys are placed in the line of vision

Caregiver Oriented Cues Approach Cues –Visual fixation –Relaxed face muscles –Engaged infant –Swiping towards caregiver face –Open hand Avoidance Cues –Gaze aversion –Hyper-alert face –Finger splay –Salute –Tremors –Fisting

Multi-modal Multi-modal is a fancy way of saying way of saying providing the infant with activities that have a sight, sound and sometimes a touch or smells to them. Multi-modal stimulation, two or more types of play, is typically reserved for the very stable infants who are about to go home free of oxygen and monitor.

Multi-modal Tips Not all infants in the NICU can tolerate this level of stimulation and may actually need to be protected from an over-stimulating environment. Usually, most ill infants can only handle one type of stimulation at a time. Some babies may become so over-stimulated that they have physiological or health problems during or following the stimulation.

Controversial Interventions Hydrotherapy –Limited research –Only recommended fro medically stable infants with good body temperature stability –Must be physician approved before initiation Waterbeds

Summary Developmental cares can support the infant and the family. Developmental interventions must be infant specific. Gestational, chronological and adjusted age must be considered as well as health status. Families should be provided information that helps them to become an active member of the care team.

Qualitative Research Parent Consumer Advisors Focus Groups Expert Reviewers Surveys

Qualitative Data from Parent Surveys

Other Focus Groups Medical Review Group Community Services Group Expert Reviews

Effectiveness of BASICS The study examines: –How information reduces stress? –Does information support interactions between medical staff and families? –How does information influence family satisfaction with hospital services?

Early Identification of Motor Problems