Developmental Care
- Summary
- Introduction
- Interventions in Developmental Care
- Principles of developmental care
- Areas Of Uncertainty In Clincial Practice
- References
Summary
- premature neonates are born before brain maturation is complete
- the stressful and abnormal environment of the nursery may contribute to altered brain development
- modification of the nursery environment may reduce long term morbidity
- light protection should not prevent adequate visualisation of the infant
Introduction
While advances in biomedical technology and improvements in care have led to a decrease in mortality rates in premature and extremely low birth weight neonates, there has not been a corresponding change in morbidity. Comprehensive long term follow up of these infants has lead to the recognition of new morbidities
- including learning and attention deficit disorders
- language comprehension and speech problems
- and visual and motor impairments
The focus of neonatal care must now extend beyond simply achieving survival. The challenge now is to optimise infants’ developmental course and long term outcome.
Developmental problems resulting from damage to the cerebral cortex may not become evident for some months or even years after birth. Infants 'at risk' therefore require long term developmental follow up.
Interventions in Developmental Care
The aim of developmental care is to modify the environment of the nursery utilising a broad range of strategies designed to
-
reduce stress and prevent agitation
- preserve energy and promote growth
- enhance recovery
- facilitate self regulatory capabilities
- promote C.N.S. organisation
Individualised strategies such as the 'Neonatal Individualised Developmental Care and Assessment Program' (NIDCAP) have also been used.
Principles of developmental care
- recognise physiological stressors
- certain sensory and motor stimuli may cause physiological changes such as fluctuations in heart rate and oxygen saturation, and/or apnoea
- such stimuli include handling, painful procedures, or sudden loud noise
- protect from light
- constant bright light in the nursery can interfere with the development of natural diurnal rhythms and have an arousing effect on the C.N.S.
- reducing light levels may prevent sensory overload and facilitate rest
- cover incubator hoods to reduce exposure to bright overhead lights
- dim the lights at night to assist in establishing day/ night patterns
Light protection should not preclude adequate visualisation of the sick or potentially sick infant.
- protect from noise
- noise (above 80-85decibels) has the potential for damage to the cochlea & hearing loss in adults. The immature cochlea is more sensitive to damage
- closing portholes with a 'snap', dropping the head of the mattress and tapping or placing bottles on the Plexiglas top of the incubator all have a sound level above 80db
- noise may also cause agitation, irritability and crying, which may result in increased intra-cranial pressure and decreased oxygen saturation
- interventions to reduce noise include
- turn the radio down or off
- have a designated 'quiet time' daily
- avoid banging bin lids
- remove bubbling water in oxygen/ventilator tubing
- close incubator portholes gently
- give 'handover' away from the infant’s bedside
- avoid talking loudly, especially across open care beds
- protect from over-stimulation
- handling can effect physiological stability and cause hypoxaemia, especially in the extremely premature, unstable or ill neonate
- provide 'time out'/ recovery time when the infant demonstrates avoidance or 'stress' behaviour. Signs of stress behaviour include
- colour changes: mottled, dusky, cyanosed
- apnoea, bradycardia, desaturation
- hiccoughing, sneezing, yawning, gagging, regurgitating feeds
- tremors, twitches, frantic activity, arching, frowning, gaze averting
- completely flaccid trunk, extremities & face
-
easy fatiguability
(take care as these behaviours are non-specific and may have other causes that require specific treatment)
- introduce sensory stimuli slowly: eg one toy or picture in the incubator (too many are overwhelming) and be sensitive to the infant’s response
- alter patterns of care to allow maximum time for sleep and growth
- clustering of cares/ minimum handling approach
- positioning: prone or side lying to enhance flexion, bring the shoulders forward and the hands to the midline
- provide boundaries and use rolls/nesting to maintain desired posture, reduce agitation, conserve energy and create a feeling of 'security' for the infant
- avoid moving an infant who has sought out his own boundaries (eg foot against a porthole door)
- establish day and night patterns (diurnal rhythm)
- dim the lights at night and turn the radio off
- remind staff to talk & walk quietly around the nursery
- avoid non-emergency interventions during the night: eg bathing & weighing
- normalise parent expectations
- promote parent understanding of their infant’s behaviour, including signs and manifestations of stress
- provide opportunities for Kangaroo Care, Non-nutritive sucking and other forms of sensory stimuli as the infant matures and is able to maintain physiological homeostasis
- use SIDS guidelines for posturing infants during convalescent care
Areas Of Uncertainty In Clinical Practice
- Does developmental care lead to the hypothesised measurable outcomes of
- reduction in incidence and severity of developmental delay
- improved weight gain
- decreased length of hospital stay
- less days of mechanical ventilation
- less days of oxygen dependence?
A Cochrane review of 31 eligible randomised control trials found evidence of some benefit from developmental interventions, with no major harmful effects reported. However, there were a large number of outcomes for which conflicting effects or no effects were demonstrated.
- Is developmental care cost effective?
Broad interventions such as reducing light and noise in a nursery are easily implemented, of negligible cost and not harmful; however implementing and maintaining a formal developmental care program (such as NIDCAP) has a significant economic impact. Symington & Pinelli (2001) suggest that further evidence of the efficacy of developmental care is required before a clear direction for practice can be supported.
References
Als, H., Lawhon, G., Brown, E., Gibes, R., Duffy, F.H., McAnulty, G., & Blickman, J.G. (1986). Individualised behavioural and environmental care for the very low birth weight preterm infant at high risk of Bronchopulmonary Dysplasia: Neonatal Intensive Care Unit and developmental outcome. Pediatrics. 78(6): 1123-1132.
Blackburn, S.T. & VandenBerg, K.A.(1993). Assessment and management of neonatal neurobehavioral development. In: Kenner, C., Brueggemeyer,A. & Gunderson, L.P. (eds). Comprehensive Neonatal Nursing: A Physiological Perspective. Philadelphia: WB Saunders, 1094-1134.
Buehler,D.M., Als, H., Duffy, F.H., McAnulty,G.B. & Liederman, J. (1995). Effectiveness of individualised developmental care for low risk preterm infants: Behavioural and electrophysiologic evidence. Pediatrics. 96(5): 923-932.
Symington, A. & Pinelli, J. ((2001). Developmental care for promoting development and preventing morbidity in preterm infant (Cochrane Review). The Cochrane Library, 2, 2001. Oxford: Update Software.
VandenBerg, K.A. (1995). Behaviourally supportive Care for the Extremely Premature Infant. In: Gunderson, L.P. & Kenner, C. (eds). Care of the 24-25 Week Gestational Age Infant. 2nd Ed. Petaluma: NICU INK, 145-171.
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