1. Early Brain development

2. Development of the Brain’s Wiring
Neurogenesis: Manufacturing of brain cells.
Migration: Moving cells to their pre-determined place on the cortex.
Neuronal differentiation and pathfinding: Growing axons and dendrites to link with other neurons.
Synaptogenesis: Developing synapses with other cells.
Maturation and pruning: Refining synapses.
Gliagenesis (Myelination): Forming of supportive tissue that surrounds neurons and promotes communication between cells.
Neurons to Neighborhoods, 2000

3. Fetal Brain Development
Neurogenesis & Neurulation
Migration
Neuronal Differentiation and Pathfinding
Synaptogenesis
Maturation and Pruning
Glialgenesis/ Mylenination
Drawing by Tom Prentiss, Cowan MW The development of the brain. Scientific American 113; 3

4. Migration Forms elevations (gyri) and depressions (sulci)
2 hemispheres bridge
6 layers of cerebral cortex divide into frontal, parietal, temporal and occipital lobes

5. Synapse Formation
Begins about 8 weeks gestation and continues as neurons proliferate, differentiate, and migrate
Both axons and dendrites grow and “branch” making connections for transmission of information
This is a prerequisite for
interaction to occur in the CNS

6. Migration Forms elevations (gyri) and depressions (sulci)
2 hemispheres bridge
6 layers of cerebral cortex divide into frontal, parietal, temporal and occipital lobes

7. Synapse Formation
Begins about 8 weeks gestation and continues as neurons proliferate, differentiate, and migrate
Both axons and dendrites grow and “branch” making connections for transmission of information
This is a prerequisite for
interaction to occur in the CNS

8. Synaptogenesis Rapid overproduction of synapses Synapse elimination
Experience dependent
Synapses are eliminated if they are not used and therefore the frequently used connection are the ones to survive. The effect of experience (normal or abnormal) on this process is increasingly irreversible over time.
Volpe,JJ: Neurology of the Newborn, 4th ed. Phiildelphia:
WB Saunders, 2001

9. Neuronal differentiation and pathfinding
Experience dependent
Effected by myelination
The stability and strength of synapses is largely determined by the firing of these connections. The speed of the conduction of the impulses is determined by the development of myelin. The rate and amount of myelination is also effected by experience
Volpe,JJ: Neurology of the Newborn, 4th ed. Phiildelphia:
WB Saunders, 2001

10. Myelination Begins at 6 months gestation & continues into adulthood
Glial cells produce myelin
Fatty covering coats & insulates axons
Speeds conduction of impulses
Allows more complex functioning
True maturity of CNS only occurs after myelineation process has fully developed
Volpe,JJ: Neurology of the Newborn, 4th ed. Phiildelphia:
WB Saunders, 2001

11. Plasticity
The capactiy to adapt in very specific ways to the changing demands
Reorganization of the brains structure and/or function
Plasticity refers to the brains capacty to reorganize the structure and/or function in response to specific events
Often occurs as a result of a change in the environment
Volpe, 2001

12. “In full term infants, axonal and dendritic proliferation … and cell growth and differentiation … occurs in an environment of mother mediated protection from environmental perturbations, with a steady supply of nutrients, temperature control, and the presence of multiple hormonal regulating systems …”
Als, 1997 12

13. STRATEGIES FOR
INDIVIDUALIZED
DEVELOPMENTAL CARE

14. Key Components of Developmentally Supportive Care
•Positioning
•Feeding support
•Kangaroo care
•Pain management
•Environmental considerations
•Parent support
•Consistency in caregiving
•Structuring caregiving
•Pacing of caregiving
•Support during transitions in care
The once-routinely hourly tasks such as pain assessment and ventilator checks are now carried out while observing and responding to the infant’s behavior.

15. Why are caregiving approaches so critical?
The newborn responds to changes in the
environment and to caregiving interventions with:
Behavioral changes
Physiological changes

16. NURSERY ENVIRONMENT weather stripping on cabinets and doors,
• increase space for each bedside area,
weather stripping on cabinets and doors,
sound absorbent materials on all surfaces that are appropriate,
rubber trash cans
carpet
incubator covers
single patient rooms.
Suggestions for environmental changes to decrease the noise level in the NICU environment include increase space for each bedside area, weather stripping on cabinets and doors, sound absorbent materials on all surfaces that are appropriate, rubber trash cans, carpet, incubator covers, single patient rooms.

17. Collaboration of Care Providers
Primary team- includes the family, nursing, medicine, respiratory therapy, social work, OT/SP
Developmental specialist support primary teams in developmental care planning and implementation; provide resources

18. DIRECT INTERVENTION BODY POSITIONING
Infants born prematurely will have an immature musculoskeletal system that can be influenced by their positioning
In utero---- the uterine walls provide ongoing containment, facilitate trunk and extremity flexion and tucking and provide reactionary forces in response to fetal movements (#55)
Preterm infants-----deal with effects of gravity, lack of fluidto support movement and no reactionary forces to support bone and joint formation
*** exposture to prolonged atypical postioning in the nicu has been associated with torticollis, positioinal plagiocephaly, reduced ;movement quality and lower extremity malalignment (59,61-63)
***** Developmentally supportive positioing on the other hand, may allow development of normal skeletal alignment and provide opportunities leading to normal movement patterns
#59

20. Positioning for Optimal development of the Neonate
Improves alertness and assists with organization
Improves alignment of hips and shoulders
Comfort
Promotes normal development
Minimizes abnormal movement patterns
Encourage balance between flex/ext
Promote symmetry

21. Developmental Abnormalities caused by poor positioning
Elevated and retracted scapula
“W” position
“Frog” position
Hyperextension
Show each of these positions and discuss the consequences in the long run. All of these positions do not allow the infant the ability to be in a tucked and rounded position, therefore making it extremely difficulty to self-regulate and obtain deep sleep and comfort. If these positions persist, these will be the synapses and connections that are re-enforced, and will effect later development and motor skills

22. PRONE Helps develop flexion pattern (Connaly, Montgomery 1987)
Facilitates development of early head control (Bobath 1972)
Improves oxygenation (Martin et al 1979)

23. PRONE Hips and knees flexed with knees under hips
Arms flexed with hands near head
Hand to mouth
Head turned to one side
Boundaries at sides and feet with foot support to allow neutral position of ankle
If not positioned correctly, infants may develop “flat” trunks with hyperextended and excessively rotated cervical spines, as well as abducted hips (horizontal roll upnder the pelvis)