neurodevelopmental supportive care in NICU

1. Presented by: Maila K.G
Sponsored by: Sihlangu

2.  Introduction
 Uterine environment
 Preterm infant
 Birth
 Neurodevelopment
 Survival and challenges
 Considerate care
 The environment and homeostasis
 Conclusion

3. Introduction
Neurodevelopmental care is a broad term applied to physician-
physical environmental elements and family involvement that
may favourably impact the neurodevelopment of premature
newborns.
This include: position strategies, modulation of light and sound
exposure and emphasis on the need to preserve sleep
Focus of NICU: physiological support of respiratory, cardiac etc..
An effort to improve outcomes have shifted attention towards
neuroprotective strategies and Neurodevelopmental support
Neuroprotection includes meds, and modifying resp and CVS
strategies to prevent or ameliorate CNS injury

4. Uterine environment
The uterus is the optimal environment for development from
conception
From conception onwards, the foetus is thought to be
organising five distinct but interrelated subsystems: ANS,
motor (governs posture and movements), state (sleep to
wakefulness), attention and self-regulatory
Infants born prematurely have an interrupted maturation of the
five subsystems
Premature infants have an ongoing maturation of each
subsystem while infant negotiates more independent
functioning e.g breathing, maintaining postures while also
facing challenges like enduring bright light, harsh noises,
frequent handling etc.

5. Preterm infant
<37/40
The extra-uterine environment is not similar to the
intrauterine, infant is continuously exposed to stressful
environment in stark sensory mismatch to the developing
nervous system’s biological needs
The brain is a fragile, immature organ at high risk of
haemorrhage and neurological impairment
Preterm birth further disrupts the development ofal
progression of brain structures and affects development of
the sensory system

6. Preterm survival
Survival rate due to an improvement in perinatal care
techniques, technology such as ventilation and meds like
surfactant and other pharmacological advances
However, there has not been a corresponding improvement in
the long term developmental outcomes for these surviving
infants
Development and functionality during these life periods impact
directly on the social and economic structures of the country,
with a poor functionality resulting in a socio-economic burden
More babies survive due to technological advances, but their
quality of developmental outcomes may be a burden to society

7.  Survival
 Has been addressed by implementing NIC,
but the preterm infant remains at risk for a
range of morbidity related to the immaturity
of organ systems assoc. with prematurity
 Leading to physical and developmental
challenges

8.  An approach using a range of EBM (medical
interventions) aiming to decrease the stress
of preterm infants in NICU
 It provides care in a manner in which the
environment and process of care is adjusted
and individualised in response to
development and tolerance
 Incl. Communication abilities to enhance
optimal neurodevelopmental outcomes
 Interventions are designed to simulate the
intra-uterine environment
 To promote normal neonatal development

9.  Remembering the intrauterine environment which is
where the preterm infant should be:
 Noise, light, temperature, touch and smell will have a big impact
on the infant.
 Pain and discomfort are sensations that the infant has not
experienced before.
 The fight for survival starts at birth, with possible
respiratory complications, challenges of feeding, and
maintaining homeostasis
 Remember: by 20 weeks, the total number of nerve cells
in the brain will have been developed
 From 20 weeks gest. age to 2 years, brain growth is
significant
 There are more synapses in the brain at term than any
other time in life

10. As a baby grows, myelination helps
them process information more
quickly.
There are as many neurons in the
brain as the number of leaves on
trees in the amazon rain forest

11. Neuro-development
Around 28 weeks, tremendous refinement and restructuring of
neuronal connections occur.
There is a phase of rapid synaptogenesis, sensitive or critical period
where environmental factors may have detrimental influences on
brain development
Neurons forming the visual cortex are in place at 26/40
28-34/40 visual neuronal connections undergo rapid development
28-30/40: rapid maturation of cochlea and auditory nerve
Hearing threshold 40dB by 28-34/40, decreasing with maturity

12. Neurodevelopment
 The more preterm infant will show less mature response than term
babies.
 Neurological assessment evaluates: reflexes, neonatal state which
maybe sleep or awake state
 Preterm infants are not able to cope with many simultaneous sources
of stimuli
 The infant <32 gestation weeks who is experiencing a disorganised
autonomic nervous system will become pale, dusky or cyanotic
 At <35 weeks gestation age motor development may interfere with
physiologic homeostasis resulting in
 Vomiting, change of colour, apnoea and bradycardia
 the infant has more defined states –sleep, crying, awake
 At term gestation, the infant is able to maintain alertness, interact
with objects and cope with external stress

13. The NICU environment

14. Dark, quiet and warm
The developmental appropriate approach should
include environmental manipulation like light, noise,
positioning, positive touch and pain management
This is a place where the preterm infant is deprived of
the normal stimuli that it should experience
Instead they suffer sensory bombardment like:
intrusive procedures, sleep disturbances and
deprivation

15. The environment and homeostasis
The ICU is a place where a preterm infant is deprived of
the normal stimuli that it should experience.
Instead, the infant suffers sensory bombardment: noise,
light, tactile stimulation, intrusive procedures, multiple
care givers and sleep disturbance and deprivation.
No infant should receive ‘routine care’.
Give care according to signals given by the infant

16. What is considered care
Our present NICU care practices, marked by persistent scheduled and
unintended, disturbances of infant sleep
Are inattentive to preservation of sleep, and at worst overtly comprises
optimal sleep cycles, with potential disruption of normal brain
development
The presence of normal sleep organization in the preterm infant may
have prognostic significance for neuro-developmental outcome.
Normal sleep cycles, with a predominance of REM sleep, are necessary
for early brain development
Recommendations: promote strategies that preserve newborn sleep
HGH is released by the brain into he blood stream during sleep

17. Intrusive procedures
HCP lack knowledge about the newborn’s ability to feel pain,
inadequately trained in pain assessment techniques, effective Rx and
prevention strategies, and fear S/E of analgesics.
Preterm infants undergo frequent painful experiences during NICU
stay.
Analgesia for specific procedures:
1. Non-pharmacological: pacifier use, sucrose admininstration, swaddling etc
2. Topical anaesthesia (lidocaine spray)
3. Paracetamol
4. Slow iv infusion of opiods e.g morphine
5. S/c lidocaine
6. Deep sedation

18. Pain background
Pain control and prevention have been underutilised
in neonates because of the ff misconceptions:
Their pain pathways are unmyelinated or otherwise
immature and cannot transmit painful stimuli
No alternative for verbal self-report
Newborn infants are at greater risk for developing the
adverse effects of analgesia or sedative agents, or
these drugs have adverse long term effects on brain
development or behaviour
However both term and preterm infants experience pain
and stress in response to noxious stimuli

19. analgesics
 Most effective method to reduce
neonatal pain is to reduce the no.
Of procedures and episode of
patient handling
 Nonphamarcological are more
effective when used in
combination
 Non-nutritive sucking: patients
have lower increase in HR, and
decreased duration of crying in
response to painful stimuli
compared to no intervention
 Swaddling or facilitated tucking
Systemic analgesia
 NSAIDS: reluctance of use in
infants because of S/E e.g GI
bleeding, platelet dysfunction,
decreased GFR
 Morphine: most commonly
used in neonates
 It improves ventilator
synchrony and sedate
 Fentanyl: rapid analgesia with
minimal hemodynamic effects
 Fentanyl is associated with
less sedative effects, effects
on GI motility etc

20. Let there be Light?
A preterm’s ability to protect their eyes is complicated by
their physiologic immaturity.
Infants with no pupillary reflex had a larger pupillary
diameter, therefore receives a large retinal light dose than
older counterparts.
Bright light may have a damaging effect on the development
of the immature visual system
Constant light may keep the infants from opening their eyes
and looking around, preventing exploration and interaction
Constant light may slow normal development of sleep wake
cycle.
Bright light disrupts the release of growth hormone, which is
enhanced with cycling lighting, resulting in altered infant
growth

21. Positioning in NICU

22. Positioning, nesting and handling
Because of the fragility of preterm infants, most NICU have
adopted a minimal handling and stimulation approach for very
immature infants
The most effective breathing and oxygenation in preterm with
lung disease is the prone position
In-utero the fetus is confined to an enclosed space with well-
defined boundaries to support development of physiological
flexion
The boundaries allow fetus to extend his arms and legs meet
resistance and subsequently recoil his extremities into gentle
flexed position
This physiological flexion is necessary for development of
normal posture movement control

23. Nesting recommendations
Provide boundaries that will maintain and encourage flexion,
allowing the infant room for extension
Provide covering and light swaddling to comfort the infant
Use soft mattresses to support the infant’s head and
reposition frequently to avoid flattening of the head.
Utilise prone and side lying positions whenever possible

24. Environmental noise
Exposure to noise in the NICU has the potential to affect
neonatal auditory development, sleep patterns and
physiological stability, thus impacting on developmental
progress
Noise exposure has the potential to influence the process of
neural organisation, reinforcing inappropriate neural pathways
and placing the neonate at risk of auditory processing
disorders and future learning disabilities
The majority of noise sources identified were human
generated
Minimising these need strategies like: decrease the levels of
staff conversation, turning down volumes of telephones and
alarms etc

25. Effects of environmental noise
 Hearing impairment (from exposure of immature cochlea to loud
noise)
 Sudden loud sounds may initiate startles, signs of autonomic
instability and state disruption
 May include: apnoea, bradycardia, colour changes, desaturations in
response to loud sounds
 Quality of sleep and alert state may be affected by noise
 Prematurely born infants experience anxiety due to certain types
of sound (high pitched noises)
 Recommendations:
 Position conversations and cell phones away from bedside
 Softly open and close incubators
 Utilize “quiet” signs raise staff and parent awareness to control
environmental noise
 Respond rapidly to alarms or crying infants

26. Take home message
Remember it is the family who will take the infant home
There is no doubt that one of the most effective
Neurodevelopmental interventions in NICU is to promote
family involvement and guidance regarding
Neurodevelopmental support.
Pain occurs routinely in the NICU and its control is an
important clinical goal
This is an evolving science, with only partial answers that
demand further questions

27. References and
acknowledgements
Assessment of neonatal pain: uptodate 2012
Prevention and treatment of neonatal pain: uptodate 2012
Neurodevelopmental care in the NICU: Susan Aucott;
Euwood division of Neonatology; The John Hopkins
University School of Medicine
Journal of Perinatology; Neurodevelopment of Infants in
NICU: WF Liu et al
Dr Sihlangu

28. NICU graduates
Me too!!!! I made it.