Late preterm and dev care 2009


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The late preterm infant group is at risk of being forgotten!

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Late preterm and dev care 2009

  1. 1. Developmentally Supportive Care and the Late Preterm Infant <ul><li>Michele Prentice </li></ul><ul><li>Developmental and Family-centred Care Project Officer </li></ul><ul><li>Neonatology Services </li></ul><ul><li>Mater Mothers’ Hospitals </li></ul><ul><li>Brisbane </li></ul><ul><li>2009 </li></ul>
  2. 2. The Late Preterm Infant <ul><li>Definition </li></ul><ul><li>Review of the literature </li></ul><ul><li>Brain development and early life experience </li></ul><ul><li>Developmental care </li></ul><ul><li>Behavioural cues </li></ul><ul><li>Positioning </li></ul><ul><li>Implications for practice </li></ul>
  3. 4. The Late Preterm Infant (continued) <ul><li>Definition (replaces “Near Term Infant”): </li></ul><ul><li>Infants born between </li></ul><ul><li>34 and </li></ul><ul><li>36 weeks + 6 days. </li></ul><ul><li>(others may use 32-34 wks) </li></ul><ul><li>Reference: American National Institute of Child Health and Human Development. 2003 </li></ul>
  4. 5. Literature Review <ul><li>Merriman, 2009 “Serious neurological risks” </li></ul><ul><li>Petrini et al, 2009 “Increased Risk of Adverse Neurological Development” </li></ul><ul><li>Chyi et al, 2008 - 140,000 babies [USA; 2000 – 2004] .... </li></ul><ul><li>↑ x 3 times cerebral palsy if preterm </li></ul><ul><li> ↑ developmental delay </li></ul><ul><li> ↑ mental retardation .... Therefore .... </li></ul><ul><li> “ delivery less than 39 weeks not desirable” </li></ul><ul><li>Hubbard et al, 2007 “A little baby with big needs” </li></ul><ul><li>Stellwagen, 2007 “...may look like a full-term baby” </li></ul><ul><li>Levitt, 2006 “Early events affect growing brains” </li></ul><ul><li> (interview: </li></ul><ul><li>Hawley et al, 2000 “Starting Smart” (Zero to Three) </li></ul>
  5. 6. Brain Development & Early Experiences... <ul><li>Brain function altered... </li></ul><ul><li> Neurochemistry changes -> -> -> -> </li></ul><ul><li>Brain structure altered... “building” & “pruning” </li></ul><ul><li> -> -> -> Architecture -> -> -> </li></ul><ul><li>PERMANENT CHANGES in STRUCTURE AND FUNCTION </li></ul><ul><li>Early touch, pain, hearing, muscle tone, motor function, stress reactivity and competence </li></ul>
  6. 7. Risks <ul><li>Hyperbilirubinaemia </li></ul><ul><li>Hypoglycaemia </li></ul><ul><li>Hypothermia </li></ul><ul><li>Immature self-regulation </li></ul><ul><li>Sepsis </li></ul><ul><li>Airway instability </li></ul><ul><li>Apnoea and bradycardia </li></ul><ul><li>Respiratory distress </li></ul><ul><li>Excessive sleepiness </li></ul><ul><li>Excessive weight loss </li></ul><ul><li>Feeding intolerance </li></ul><ul><li>Weak sucking </li></ul>
  7. 8. Cue Based Care: What is it? <ul><li>To follow the principles of Developmental Care it is important to grasp an understanding of what state a baby is in and the optimal times to interact with them, which leads to a need to understand their behaviour cues. These are their way of communicating. </li></ul>
  8. 9. Cue Based Care: How do we understand Behaviour Cues? <ul><li>Behaviour cues are... </li></ul><ul><li>the signs and signals given to us by babies </li></ul><ul><li>They are their way of communicating </li></ul><ul><li>... when they are calm, </li></ul><ul><li>...when they need time out and </li></ul><ul><li>...when they are ready to interact. </li></ul>
  9. 10. Understanding Behaviour Cues Summarised: <ul><li>A calm baby will show signs such as: - puts hand to mouth - curls up - will grasp & hold a finger or toy - will bring hands together - will softly close eyes </li></ul>
  10. 11. Understanding Behaviour Cues: Cues for a Calm Baby *pictures used with permission of the author, Developmental Care Plan, Royal Women’s Hospital Melbourne.
  11. 12. Understanding Behaviour Cues Summarised: <ul><li>A baby that needs time out shows: Motor signs - splays fingers - has a stiff arching posture - is flailing and disorganised - the sitting on air sign (arms & legs in air) </li></ul><ul><li>Autonomic sign - Yawning </li></ul><ul><li>Attention / Interaction signs - turns away / looks away - Hyper alert (staring wide eyed) Other Signs - crying - fluctuating heart rate - oxygen desaturation - colour changes - closes eyes </li></ul>
  12. 13. Understanding Behaviour Cues: Cues a baby needs time out *pictures used with permission of the author, Developmental Care Plan, Royal Women’s Hospital Melbourne.
  13. 14. Understanding Behaviour Cues Summarised: <ul><li>A baby is ready to engage when it: - is smiling - has a relaxed posture and face - is cooing / babbling - is making eye contact </li></ul>
  14. 15. Understanding Behaviour Cues: Cues a baby is ready to Engage *pictures used with permission of the author, Developmental Care Plan, Royal Women’s Hospital Melbourne.
  15. 16. SIDS <ul><li>the prevention campaign: </li></ul><ul><li>1) put baby on back to sleep from birth </li></ul><ul><li>2) sleep baby with face uncovered </li></ul><ul><li>3) cigarette smoke is bad for baby </li></ul><ul><li>4) safe sleeping environment for baby, night & day: safe cot, safe mattress, safe bedding </li></ul><ul><li>Why? </li></ul><ul><li>Since the SIDS and Kids Safe Sleeping Campaigns began in the early 1990's... </li></ul><ul><li>>4,000 Australian babies saved </li></ul><ul><li>reduced the rate of SIDS by 84%. </li></ul><ul><li> </li></ul>
  16. 17. Infant Positioning *pictures used with permission of the author, Developmental Care Plan, Royal Women’s Hospital Melbourne.
  17. 18. Infant Positioning when awake: <ul><li>Prone (“tummy time”): </li></ul><ul><ul><li>Clean, flat surface (pad on floor) </li></ul></ul><ul><ul><li>No sharp angles (furniture) nearby </li></ul></ul><ul><ul><li>Pillows NOT recommended </li></ul></ul><ul><li>Side Lying: </li></ul><ul><ul><li>put a pillow at the baby’s back only </li></ul></ul><ul><ul><li> to support position </li></ul></ul><ul><ul><li> to encourage hands in view </li></ul></ul><ul><li>Supine (back): </li></ul><ul><ul><li>Create a nest using a rolled blanket and ensure it remains close to the baby’s body and under legs </li></ul></ul>
  18. 19. <ul><li>Key points... </li></ul><ul><li>Supervision of infant is MANDATORY </li></ul><ul><li>Flexed and curled up positions are encouraged as these reflect the environment of the womb </li></ul><ul><li>Ensure: </li></ul><ul><ul><li>- shoulders forward </li></ul></ul><ul><ul><li>- hands towards midline in supine & side lying </li></ul></ul><ul><ul><li>- hips and knees tucked </li></ul></ul><ul><ul><li>- alternate positioning of head side-to-side </li></ul></ul><ul><ul><li>when asleep (supine) </li></ul></ul>
  19. 20. LPI’s are special! <ul><li>Essentially a preterm infant in a term infant’s body </li></ul><ul><li>↓↓↓ </li></ul><ul><li>Poor immunity </li></ul><ul><li>Poor feeding </li></ul><ul><li>Parents unprepared, stressed </li></ul><ul><li>Delayed discharge home or... </li></ul><ul><li>difficulty with normal care at home </li></ul>
  20. 21. IMPLICATIONS FOR PRACTICE <ul><li>Midwives </li></ul><ul><li>Neonatal Nurses </li></ul><ul><li>Parents </li></ul><ul><li>Multidisciplinary Team </li></ul><ul><li>GP Practice/ Community Health agencies </li></ul><ul><li>Follow Up? (Service provision is poor) </li></ul><ul><li>Early Intervention Services? </li></ul>
  21. 22. The Late Preterm Infant <ul><li>POOR OUTCOMES </li></ul><ul><li>MISS OUT ON SERVICES </li></ul><ul><li>PROBLEMS AT SCHOOL AGE </li></ul><ul><li>FUTURE DIRECTION OF RESOURCE ALLOCATION AND FUNDING ? </li></ul>