Developmental Care
- Summary
- Introduction
- Interventions in Developmental Care
- Implemenation of developmental care
- References
Summary
- preterm infants are born prior to or during critical periods of brain development
- the third trimester of foetal development is a period of rapid brain growth and environmental influences eg noise or handling may impact on the developing brain
- developmental care is an approach to individualise care of infants
- modifications to nursery environment and care practices that may reduce morbidity can easily be implemented.
Introduction
While advances in perinatal care have resulted in decreased mortality rates in preterm neonates, morbidity rates remain significantly high. In addition to cerebral palsy, hearing loss, visual impairments and developmental delay, long term follow up studies have identified other important neurosensory impairments that may not become evident until preschool or school age such as cognitive and behavioural problems.
Interventions inDevelopmental Care
Goals
Infant
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reduce stress
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conserve energy and enhance recovery
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promote growth and well being
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support of emerging behaviours at each stage of neurodevelopmental maturation
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Family
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encouragement and support of parents in the primary caregiver role
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enhance family emotional and social wellbeing
Definition of Commonly used Terms
Developmental Care
The process of developmental care involves creating an environment for the infant that minimises stress while providing developmentally appropriate experience for the infant and family.
Developmental care refers to interventions that
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support the behavioral organisation of the individual infant
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enhance physiological stability
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protect sleep rhythms
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promote growth and maturation.
These interventions include
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optimal handling and positioning measures
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reduction of noxious environmental stimuli
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cue based care
The education and involvement of the parents or carers is critical to the infant's social, emotional and physical well being and is a crucial factor in the process of family centred developmental care.
NIDCAP (Newborn Individualised Developmental Care and Assessment Program)
This is a comprehensive program of systematic behavioural observation methodology. Observations of the infant occur before and during care giving and are used as a measure of the infant's tolerance to the environment and caregiving activities. They become the basis for individualised goals and developmental interventions that are aimed at reducing the detrimental effects of a NICU environment. Implementation of NIDCAP requires NICU developmental care teams and training and certification of staff. There are currently no facilities for this training in Australia.
Behavioural Organisation
This refers to the ability of the infant to maintain a balance between the five subsystems
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autonomic/physiologic
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motor
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state organisation
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attention / interaction
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self regulation
Examples would include the infant's respiratory status, muscle tone, posture, facial expressions, colour, visceral responses and visual attention. How these behaviours are affected by external stimuli, either positive or negative, give information about the infant's ability to cope and organise their responses.
Cue Based Care
This is a system of care giving in response to the infant's behavioural cues, including the appropriate provision and modification of sensory stimulation
Implementation of developmental care
Assessment
This includes the
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nursery environment -including the acoustic environment, aspects of lighting, general layout and furnishings
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infants - including regular review and modification depending on
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condition of the infant
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infant's level of maturity and gestational age
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behavioural responses to care
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Nursery Environment
Noise
The threshold for cochlear damage for adults is 80-85 decibels and the newborn will have a lower threshold than this as the immature cochlear is more sensitive. In the nursery noises of this magnitude include closing portholes with a snap or placing bottles on the top of the plexiglass incubator.
Ssound level recommendations for the nursery environment (Aust and NZ guidelines) - background noise should not exceed an hourly Leq 40-45 DB(A).
Interventions to reduce noise include
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turning radio volume down or off
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having designated quiet times during the day (while also remembering to keep to limits at all times)
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close incubator portholes quietly
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encourage staff and visitors to talk quietly, and avoid talking over the infant in an open cot
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avoid banging bin lids
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set monitor alarm limits and tone at appropriate levels and try to silence alarms as soon as possible
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monitor noise levels periodically to identify times and causes of high levels
Light
Lighting should be adjustable - the adjustment level range of 100-600 lux is recommended ( Aust and NZ guidelines). Constant bright light in the nursery can interfere with natural diurnal rhythms and overstimulate the infant.
Interventions to maintain appropriate individualised light environment include
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adjustable light levels within each cot bay plus procedure light for observation and procedures
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monitor ambient light levels
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shield infants from bright light with cot covers, eye covers and dimmed lights
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reduce light levels generally in the nursery, maintaining a safe level for accurate clinical observation as necessary
Positioning
Infants are positioned with
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symmetrical postures
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trunk flexion, shoulder and hip flexion and adduction
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shoulder protraction, hands near face
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neutral alignment of ankles and hips
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neutral alignment of head and neck whenever possible
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the use of swaddling or nesting to provide boundaries
Parental Involvement
Parents are involved in decisions about interventions where possible. This promotes their understanding of their infant's behaviour and allows them also to practice cue based care. This allows them to experience positive interactions with their baby and empowers them to recognize behavioural cues and become more confident caring for their baby.
Nursery Practices
Cue based care and clustering of cares
This involves caring for the infant while recognizing the behavioural cues or stress responses and providing an appropriate strategy such as timeout or modification of care as appropriate.
Clustering of cares encourages a minimum handling approach and protects periods of deep sleep by minimizing the number of times an infant needs to be woken up or disturbed. If an infant is unable to cope with a particular cluster of care (observation of stress cues) then cluster fewer care procedures next time if possible.
Stressful / painful procedures
Minimise painful procedures and provide appropriate pain relief measures.
During these procedures the use of some comforting techniques can reduce stress responses. These include non-nutritive sucking (dummy, cotton bud with breast milk or sucrose), containment of infant's arms and or legs (swaddle or gently holding hands together on chest and/or hold legs tucked up), or grasping a finger.
Noxious stimuli
Minimize the infant's exposure to noxious stimuli such as strong fragrances, open alcohol swabs outside incubator, clinical procedures and adhere to lighting and noise guidelines.
Feeding support
Support for breast feeding or alternatives as required with the emphasis again on individualized family centred care. Follow the infant's cues and pace the feeds, according to the infant's capacity to organise sucking, swallowing and breathing.
Non-nutritive sucking
Offer the infant opportunities to suck on a dummy or other suitable object, such as a finger, her own hands or a suitable toy. Use of non-nutritive sucking during tube feeding is helpful in the transition to suck feeds.
Staffing practices
Provide continuity of caregivers whenever possible. Develop caregiver groups for longer stay infants.
Handling
Handling of infants to minimise stress and uncontrolled responses. Contain the infant using hands or a light swaddle to keep them in a flexed and contained position. Move infant slowly and keep them in contact with the supporting surface whenever possible. Introduce touch slowly and allow time for the infant to respond and adjust to a change in position.
Kangaroo care
Provide opportunities for kangaroo care when possible.
Kangaroo care is early, prolonged and continuous skin to skin contact between a parent and a low birth weight infant. It has been shown to
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improve state organisation
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reduce oxygen needs, improve respiratory patterns
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reduce apnoeas and bradycardias
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improve thermal regulation
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enhance parent infant bonding, parental sense of competence
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enhance cognitive and motor development
References
Als H, Duffy FH, McAnulty GB, Rivkin MJ, Vajapeyam S, Mulkern RV, et al. Early experience alters brain function and structure. Pediatrics. 2004;113:846-857.
Graven SN. The full-term and premature newborn. Sound and the developing infant in the NICU: conclusions and recommendations for care. J Perinatol. 2000;20:S88-S93.
Saigal S, Doyle LW. An overview of mortality and sequelae of preterm birth from infancy to adulthood. Lancet. 2008;371:261-269.
Symington A, Pinelli J. Developmental care for promoting development and preventing morbidity in preterm infants.[update in Cochrane Database Syst Rev. 2003;(4):CD001814; PMID: 14583939][update of Cochrane Database Syst Rev. 2000;(4):CD001814; PMID: 11034730]. 2003;4:CD001814, 002001.
Aucott S, Donohue PK, Atkins E, Allen MC. Neurodevelopmental care in the NICU. Mental Retardation and Developmental Disabilities. 2002;8:298-308.
White R. Recommended standards for newborn ICU design. J Perinatol. 2006;26:S2-S18.
Feldman R, Eidelman AI. Skin-to-skin contact (kangaroo care) accelerates autonomic and neurobehavioural maturation in preterm infants. Dev Med Child Neurol. 2003;45:274-281. 10 Pinelli J, Symington A. Non-nutritive sucking for promoting physiologic stability and nutrition in preterm infants (Review) Cochrane Database of Systematic Reviews. 2005;4: 1-24
Updated 01/12/2010
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