humane care, mother based NICUs

1. Developmentally Supportive
Care In NICU
Dr. L S Deshmukh
MD,DipNB,DM(Neo)
Heinz Fellow(RCPCH, London)
lsdeshmukh@indiatimes.com

2. Developmentally Supportive
Care - Introduction
• Initial premie care - intrauterine like
environment
• “Masterly inactivity”
• Based on three basic needs(FAT)
• Quiet nursery to busy / bustling stations
• Increasing survival of smaller babies
• Technology - oriented NB care.
• Optimal functional outcome more important

3. NICU Environment -Transition
Past Present

4. NICU Care
Past Present

5. NICU Environment -
Present Scenario
• Preterm babies with immature organ systems
• “Deprivation” or “Over-stimulation”
• Inappropriate pattern of stimulation
• Immature distance receptors (e.g.hearing &
vision) over stimulated.
• Mature tactile and vestibular pathways
under-stimulated.
• “Robotic” care
• No parental / maternal involvement

6. NICU Environment
Effect on brain development
(Gressens P, 2002)

7. “The genes are the bricks & mortar
to build a brain. The environment is
the architect” - Christine Hohmann

8. Developmentally supportive care
Definition : Developmentally supportive
care is defined as care of an infant to
support positive growth and
development, while allowing stabilization
of physiologic and behavioral functioning
(National Association of Neonatal Nurses,
2000)

9. Developmentally Supportive
Care - Aim

10. “War will never cease until babies
begin to come into the world with
larger cerebrums and smaller adrenal
glands.”
H L Memcken(Journalist), 1930

11. The virtues of the Womb

12. The virtues of the Womb
• Cushioned and comfortable aquatic abode
• Thermal comfort
• Zero insensible water losses
• Shielded from light
• Protected form sound
• Effective and safe ECMO-like oxygenation
• Optimal excretion of waste products
• Isolation and asepsis
• Parenteral nutrition
( Singh M, 2003 )

13. Dev Supp Care - Principles
• NICU design and environment
• Nursing care routines & plans
• Use of positioning aids
• Use of self regulation aids
• Feeding methods
• Management of pain
• Parental participation & support
• Neonatologist’ attitude

14. NICU Environment
Infant states
1. Quiet sleep - regular breathing, no REM, no
spontaneous movements.
2. Light sleep - irregular breathing, REM,
spontaneous movements.
3. Transition / drowsy - variable activity, dull look
4. Awake - alert - minimal activity, bright look.
5. Awake - hyperactive - very reactive, fussy,
increased motor activity.
6. Crying

15. NICU Environment
Signs of neonatal stability
Autonomic : Stable colour, stable
heart & RR, feeding tolerance.
Motor : Flexed or relaxed
posture, hand to mouth / sucking
State : Clear sleep state,
interaction
(Gupta G, 2001)

16. NICU Environment
Signs of neonatal stress
Autonomic : Color changes,
alterations in HR & RR,
alterations in SaO2, Hiccoughs
Motor : Hypotonic, increased
movements, open mouth
State : Hyperalert, fussing, diffuse
sleep states
(Gupta G, 2001)

17. NICU Environment – Sound
Adverse effects of loud sound
(>60 db)
Interferes with sleep
• Increase in Heart Rate
• Peripheral vasoconstriction
• Sudden loud noise may ↓ TcPo2,
ICP, ? IVH
• Hearing loss
( Lefrak L, 2001)

18. NICU Environment - Sound
• In-utero, 40-60 db
• Usual noise levels in NICU, 50-80 db
• Levels > 90 db for long times, hearing loss
• In PT on aminoglycosides, at lower db levels

19. NICU Environment – Sound
Sources of Noise
• Inside incubater, 55-88 db (Peak 117)
• Additional 10-40 db with surrounding
equipments
• Routine care activities, 58-76 db.
• Loud, sharp sound - 100-200 db.
• 4994 peak noises - 90% due to human related
factors
(Chang et al, 2001)

20. NICU Environment – Sound
Interventions to reduce noise
•Decrease noise in NICU
•Decrease monitor noise
•Respond quickly to alarms
•Rounds & reports away from bedside
•Speak softly
•Decrease telephone & intercom noise
( Ctd--)

21. NICU Environment – Sound
Interventions to reduce noise
( Ctd--)
•Move equipments quietly, repair noisy ones
•Decrease staff generated noises
•Prepare medications & feedings away from
bedside
•Gently open doors and drawers
•Follow the sound limit recommendations

22. NICU Environment - Sound
• Monitor decibel readings
& keep level < 45 db
(AAP, 1997)

23. NICU Environment – Sound
Helpful Effects
•Sound of mother’ voice (calming effect)
•Music may be beneficial
•Lullabies, womb sound, heart beat music.
- Better weight gain
- Decreased hospital stay,
- Better behavioral organization
(Chapman JS,1998)

24. NICU Environment - Sound
Indian classical Music- useful
(Paul VK, 1999)

25. NICU Environment – Light
Present scenario
•Fetal life - near darkness (ND)
•NICU- Usually very bright light
•Continuous light exposure
•Usual range - 50-150 foot candles
•Procedure & PT lights - 200-400
foot candle

26. NICU Environment – Light
Light effects:
•Effect on central visual system
•“Shutting out” behavior
∀↓ Quiet sleep & physiological instability
•Effect on circadian rhythms
•Effect on G & D
•? ↑ risk of ROP
( Slevin M, 2000 )

27. NICU Environment – Light
Light Reduction
Safe level not established
• Shade head of crib / incubator
• when required , use spot light /
procedure light
•Eye covers must with PT
• use available natural light

28. NICU Environment – Light
Light Reduction
Cycled lighting better than near Darkness
- More time in sleep state
- ↑ weight gain
- ↓ Motor activity levels
- ↓ Heart rate
(Brandon HD et al, 2002).

29. NICU Environment - Light
Monitor NICU
Light
with Luxmeter

30. NICU Environment -Positioning

31. NICU Environment -Positioning
• Effect on respiratory physiology
• Body alignment important
• Prevent postural deformities
• Promote self-soothing activities
• Decided by GA, degree of illness,
paralytic agents.

32. NICU Environment –Positioning
Guidelines
Preferred, Prone / side lying
• Swaddle / cover to keep in flexed position
• Attempt to “nest” the infant
• Promote midline alignment
• Head support
• Avoid :
- Hyperextension of neck
- Frequent head turning to side
- Lower extremity frogging
- Bigger diaper

33. NICU Environment - Handling
• Physiologic and behavioral stress
• Pace the care according to baby
• Time the care around sleep / wake
cycles
• No routine procedure
• Provide 2-3 hrs of uninterrupted
sleep
• Watch for S/o stress

34. NICU Environment -
“Minimal Handling” or “Quiet hour” Protocol
• Reduce noise
• Reduce lights
• Allow minimum two hours of rest
• Cluster the caregiving procedure
• Sensitize the nursing staff

35. NICU Interventions - Stimulation
• Should begin in the womb.
• Fetuses known to respond to
mother’s heart beats and voice.
• Indian mythology - Abhimanyu learnt
to enter Chakaryuh in his mother’s
womb.
• Any stimulation through special
senses during fetal / neonatal life
beneficial
(Singh M, 2003)

36. NICU Interventions
Supplemental stimulation
• Kangaroo Mother Care ( KMC )
• Non-nutritive sucking ( NNS )
• Massage therapy
• Multimodal stimulation
• Breast feeding
• Pain management
• NIDCAP
• Wee care

37. NICU Interventions
Kangaroo Mother Care

38. NICU Interventions
Kangaroo Mother Care
• Skin to skin contact
• Practiced in many cultures
Components :
• Kangaroo positioning
• Kangaroo feeding
• Kangaroo discharge
Forms :
• Hospitals with no / poor facilities
• Insufficient technical & human resources
• In tertiary level NICUs
(Kirsten G.F., PCNA, 2001)

39. NICU Interventions
Kangaroo Mother Care
Likely Benefits :
Successful breast feeding
• Better physiologic stability
• Increased maternal confidence & bonding
• Reduced infection rates
• Cost savings
(Kirsten G.F., PCNA, 2001)

40. NICU Interventions
Non-nutritive Sucking
• Different from nutritive sucking
• On empty breast / pacifier
• Provides comfort
• Promotes physiological organization
• Pain-reducing effect
• Promotes suck- swallow co-ordination
• Facilitates transition to breast feeding
• Better weight gain & shorter hospital stay.
(Field TM, 2003)

41. NICU Interventions
Massage Therapy
•Tactile / Kinesthetic stimulation
•Tactile stimulation only, may be aversive.
•Massage therapy with moderate pressure
may be useful.
•Stimulation of tactile and pressure receptors
important.
•Hypothetical mechanisms of benefit
- Touch - Growth gene interaction
- Increased vagal tone
- Increased insulin levels
- Increased growth hormone secretion
(Field TM, 2003)

42. NICU Interventions
Massage Therapy
Proposed benefits :
Better weight gain
• More time in active, alert state
• More quiet sleep
• Better motor maturity scores
• ? Better long-term outcome
(Mathai S. et al, 2001)

43. NICU Interventions
Massage Therapy
Unresolved Issues :
•Collapse / disorganization due to over-
stimulation
•Response of full term Vs preterm infants
•Response of SGA Vs AGA babies
•Maternal Vs nurse’ touch
(Feldman R et al, 1998)

44. NICU Interventions
Breast Feeding

45. NICU Interventions
Breast Feeding
• Humanized and natural
• Species specific & baby specific
• Minimal enteral feeds (Trophic feeds)
• Multiple benefits of MEN
• Early contact and bonding
Support and encourage breast
feeding

46. NICU Interventions- NIDCAP

47. NICU Interventions- NIDCAP
•Neonatal individualized developmental and assessment program
(NIDCAP)
•Developed by Als et al
•Four standards of care
- Structuring the environment
- Timing, organizing & giving direct care
- Working collaboratively
- Supporting & strengthening family relationships.
•Individualized plan for each baby
•Meta-analysis : Significant decrease in O2 requirement
: Improved outcome at 12 mths.
(Jacobs SE et al, J Ped, 2002).

48. NICU Interventions -
Multimodal Stimulation
• ATVV - Auditory, tactile, visual & vestibular
• Soft & soothing music
• Gentle touch
• Use of pictures (human face), bright toys
• Olfactory stimulation, use of “breast milk”
(avoid cologne / spray).
• Better weight gain and early discharge
(Standly JM, 1998)

49. NICU Interventions -
Multimodal Stimulation
Mother’ voice & human face

50. NICU Interventions
Pain Management

51. NICU Interventions
Pain Management
Neonatal Pain - Misconceptions
• Newborns lack anatomical &
physiological structures to transmit pain
sensation.
• Can not express pain sensation
• Have no memory of pain
• Would not tolerate analgesia /
anesthesia

52. NICU Interventions
Pain Management
Neonatal Pain - Facts :
Nociceptive mechanisms well developed
even in preterm.
• Pain expression and assessment possible
• Various consequences of pain & stress
• Various nonpharmacologic &
pharmacologic strategies useful for
treatment

53. NICU Interventions
Pain Management
Non-pharmacologic Interventions
• Positioning & containment
• Swaddling
• Non-nutritive sucking / pacifiers
• Skin to skin contact
• Rocking
• Music
• Breast milk
• Oral glucose / sucrose

54. NICU Interventions
Pain Management
Pharmacologic interventions
• Local anaesthetics (EMLA)
• Regional anaesthesia
• Systemic analgesia
(Gilbert R, 2001)

55. NICU Interventions -
Family Involvement
• NICU - a barrier
• Provision of privacy (for bonding)
• Social interaction & support
• Parental education & counselling
• Involvement of mother in care
• Mother - based NICU, need of hour
(Cisler - Cahill et al 2002)

56. NICU Interventions - future issues
Co-bedding for twins
(Dellaporta K, 1998)

57. NICU Interventions - future issues
Parent focussed care (COPE)
(Melnyk BM , 2001)

58. NICU Interventions - future issues
Spiritual & cultural care
(Catlin EA, 2001)

59. NICU Interventions - future issues
Effect of NICU Env on Health-worker

60. NICU Interventions - future issues
Quality Assessment & Improvement

61. NICU Interventions - future issues
Early Disharge from NICU

62. NICU Interventions - future issues
Use of Telemedicine in NICU
(PhilipM1999)

63. NICU Interventions
Other Important Issues
• Ethical care issues
• Involvement of
physiotherapist &
occupational therapist in
NICU
• Individual rooms in NICU
(White RD, 2003)

64. NICU Interventions - Goal

65. “The prematurely born infant emerges into a hectic,
cold, noisy and bright environment filled with
mysterious equipment and peopled by masked
strangers who try to help. Almost everything done
to or for the infant is painful, and that pain can be
certainly felt, although it can not be communicated.
The infant who must have an endotracheal tube
cannot cry and is not fed by mouth for weeks. His or
her feet are slashed periodically for blood samples.
The infant’s respirator roars away night and day,
keeping his or her lungs inflated and sustaining life
- but at what price ?”
Dr. Jerry Lucey, Editor of Pediatrics

66. Let us work to help newborns

67. “The essential is invisible
to the eye.”
-Saint-Exupéry in The Little Prince