Developmental Care Lecture April 2008


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Created for residents of Hinsdale Hospital. Normal gross motor development in the first year.

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  • Developmental Care Lecture April 2008

    1. 1. Developmental Care & Research
    2. 2. Early Experience Alters Brain Structure and Function Heidelise Als, et. Al. <ul><li>Question: Does developmental intervention truly change the brain structure and function? </li></ul><ul><li>Results: </li></ul><ul><ul><li>Premature infants in the developmental care group showed improved state stability, intensity and threshold of responsiveness </li></ul></ul><ul><ul><li>EEG pattern of neurophysiologic differences supported behavioral findings </li></ul></ul><ul><ul><ul><li>MRI correlation of the brain structure and function showed that improved behavior regulation was associated with more mature frontal brain structural development (frontal lobe development and differentiation does occur later in development) </li></ul></ul></ul><ul><ul><li>MRI revealed differences in brains of developmental care group versus control group </li></ul></ul><ul><ul><ul><li>Findings correlate with improved motor system organization, symmetry and expression of attention </li></ul></ul></ul><ul><ul><ul><li>Involved mainly the left frontal lobe and some extend to the occipital and parietal regions </li></ul></ul></ul><ul><li>Conclusion: Actual positive changes in brain structure are observed in developmentally cared for premature infants versus those who are not cared for in a developmentally supportive manner. </li></ul>
    3. 3. The Effect of Developmental Care on Preterm Infant Outcome Brown and Heermann <ul><li>Question: Are outcomes for premature infants and families different even though only 10% of nursing staff is officially trained and the rest of the nurses were trained by the NIDCAP certified nurses? </li></ul><ul><li>Results: </li></ul><ul><ul><li>Reduced incidence and severity of IVH </li></ul></ul><ul><ul><li>Decrease length of mechanical ventilation </li></ul></ul><ul><ul><li>Reduce time spent hospitalized </li></ul></ul><ul><ul><li>Increase rate of weight gait in preterm infants </li></ul></ul><ul><li>Conclusion: Developmentally supportive nursing interactions with families and neonates in the NICU influenced the outcomes of the infants and in turn the cost of hospitalization </li></ul>
    4. 4. Preschool Outcome in Children Born Very Prematurely and Cared for According to NIDCAP Westrup et al <ul><li>Question: Are changes still observed between developmentally cared for and control group premature infants at pre-school age? </li></ul><ul><li>Results </li></ul><ul><ul><li>Positive impact by NIDCAP cared group on important aspects of behavior at preschool age </li></ul></ul><ul><ul><li>Not a significant cognitive difference between control and NIDCAP groups in terms of cognition at 5 years </li></ul></ul><ul><ul><li>60% of the NIDCAP cared group survived without moderate to severe disability </li></ul></ul><ul><ul><li>40% of the control group survived without moderate to severe disability </li></ul></ul><ul><li>Conclusion: There are observable differences in ability to regulate state/behavior at preschool age as a result of developmentally supportive care for premature infants. </li></ul>
    5. 5. The NIDCAP is Not Supported by Meta-Analysis Jacobs et al <ul><li>Question: When looking at all studies on NIDCAP (before 2002) analyzed together, do they report changes for premature infants? </li></ul><ul><li>Conclusion: Infants cared for using NIDCAP did have changes in neurobehavioral development and respiratory status, but it was not sustained through development. </li></ul><ul><ul><li>The authors report that there is a need for increased study in this area. </li></ul></ul>
    6. 6. Benefits of Developmental Care - Overview Sehgal, Stack <ul><li>Decreased length of ventilation </li></ul><ul><li>Reduced duration of oxygen requirement </li></ul><ul><li>Mean difference in mental developmental index at 9-12 months of age </li></ul><ul><li>Positive impact on tube to bottle transition </li></ul><ul><li>Behavior improvements – improved sleep states, decreased stress behavior during gavage feedings </li></ul><ul><li>Length of hospital stay decreased </li></ul>
    7. 7. Why is there a PT in our NICU?
    8. 8. Synactive Theory of Development A clue into the connect or disconnect between the premature infant’s world and our world
    9. 9. The infant’s response to the environment is our only insight to whether the environment is appropriate and supportive for the infant.
    10. 10. Synactive Theory of Development
    11. 11. Behaviors of Premature Infants in a NICU <ul><li>Approach/Groping behavior </li></ul><ul><ul><li>when stimulation is within the infant’s ability to organize </li></ul></ul><ul><li>Avoidance/Withdrawal behavior </li></ul><ul><ul><li>When stimulation is beyond the infant’s level of organizational function </li></ul></ul><ul><ul><li>Observed as stressor </li></ul></ul><ul><li>These behaviors are a response to the appropriateness of the stimulation </li></ul>
    12. 12. According to the Synactive Theory: <ul><li>What is organized behavior? </li></ul><ul><li>What is disorganized behavior? </li></ul>
    13. 13. Autonomic System <ul><li>Organized </li></ul><ul><ul><li>Even Respiration </li></ul></ul><ul><ul><li>Good, Stable Color </li></ul></ul><ul><ul><li>Stable Digestion </li></ul></ul><ul><li>Disorganized </li></ul><ul><ul><li>Respiratory Pauses </li></ul></ul><ul><ul><li>Tachypnea </li></ul></ul><ul><ul><li>Grunting </li></ul></ul><ul><ul><li>Breath holding </li></ul></ul><ul><ul><li>Gagging/gasping </li></ul></ul><ul><ul><li>Color changes </li></ul></ul><ul><ul><li>Spitting up </li></ul></ul><ul><ul><li>Hiccupping </li></ul></ul><ul><ul><li>Sighing </li></ul></ul><ul><ul><li>Yawning </li></ul></ul><ul><ul><li>Straining </li></ul></ul><ul><ul><li>Tremoring </li></ul></ul><ul><ul><li>Startling </li></ul></ul><ul><ul><li>Twitching </li></ul></ul><ul><ul><li>Coughing </li></ul></ul><ul><ul><li>Sneezing </li></ul></ul>
    14. 14. State System <ul><li>Organized </li></ul><ul><ul><li>Clear robust sleep state </li></ul></ul><ul><ul><li>Rhythmical/robust crying </li></ul></ul><ul><ul><li>Good self quieting and consolability </li></ul></ul><ul><ul><li>Robust/focused/shiny eyed alertness </li></ul></ul><ul><ul><li>Animated facial expression </li></ul></ul><ul><ul><li>Frowning, cheek softening/ooh face, cooing, attentional smiling </li></ul></ul><ul><li>Disorganized </li></ul><ul><ul><li>Diffuse sleep/awake states </li></ul></ul><ul><ul><li>Whimpering sounds </li></ul></ul><ul><ul><li>Facial twitches and discharge smiling </li></ul></ul><ul><ul><li>Eye floating </li></ul></ul><ul><ul><li>Strained or fussy crying </li></ul></ul><ul><ul><li>Staring </li></ul></ul><ul><ul><li>Active averting </li></ul></ul><ul><ul><li>Panicked or worried alertness </li></ul></ul><ul><ul><li>Glassy-eyed or low key alertness </li></ul></ul><ul><ul><li>Rapid state oscillations </li></ul></ul><ul><ul><li>Irritability </li></ul></ul>
    15. 16. Motor System <ul><li>Organized </li></ul><ul><ul><li>Smooth, modulated posture </li></ul></ul><ul><ul><li>Well modulated tone </li></ul></ul><ul><ul><li>Smooth movements </li></ul></ul><ul><ul><li>Efficient movement strategies – hand on face, hand clasping, foot clasping, finger folding </li></ul></ul><ul><li>Disorganized </li></ul><ul><ul><li>Hypertonicity with hyperextensions </li></ul></ul><ul><ul><li>Protective maneuvers (hand on face, high guard (salute), fisting </li></ul></ul><ul><ul><li>Flaccidity (hypotonic) </li></ul></ul><ul><ul><li>Frantic/diffuse activity </li></ul></ul><ul><ul><li>Unstable tone </li></ul></ul>
    16. 18. I know the baby is stressed, what can I do about it . . . .
    17. 19. Supporting the motor system assists to support all other systems . . . .
    18. 20. Preterm vs. Full Term Infant
    19. 21. Why is positioning SO important? <ul><li>Infants learn to move based on their early experiences </li></ul><ul><ul><li>The ability to recruit certain muscles is based on early positioning </li></ul></ul><ul><ul><li>Early experiences in the NICU can dramatically alter how an infant learns to activate their muscles </li></ul></ul><ul><ul><li>Early experiences may result in over activation of certain muscle groups resulting in atypical movement </li></ul></ul><ul><ul><li>Proper positioning – in physiologic flexion can dramatically affect the infants ability to recruit the diaphragm, allowing them to oxygenate with less oxygen!! </li></ul></ul>
    20. 22. Why is a flexed posture so important? <ul><li>This position allows infants in the NICU to activate the correct muscles </li></ul><ul><ul><li>Strengthens neurological connections </li></ul></ul><ul><ul><li>Strengthens muscles </li></ul></ul><ul><ul><li>Places diaphragm at proper position to work appropriately </li></ul></ul><ul><li>Posture has an effect on physiologic stability </li></ul><ul><ul><li>Due to decreased tone infants hang on joints and enter into a closed packed position which results in painful but stable positions </li></ul></ul><ul><ul><ul><li>These postures drive sympathetic tone (fight or flight) </li></ul></ul></ul><ul><ul><li>Physiologic flexion puts joints in a loose packed posture – which is a point at which all forces in the joint allow the most non physiologic reaction </li></ul></ul><ul><ul><ul><li>Position of comfort at rest </li></ul></ul></ul><ul><ul><ul><li>Drives parasympathetic tone </li></ul></ul></ul><ul><ul><ul><li>Does not place undue stress on joints and musculature </li></ul></ul></ul>
    21. 23. What postures can premature infants attain on their own <ul><li>Due to overall decreased tone and difficulties with motor control and strength, premature infants get into postures that use compressive joint forces to bond with gravity to hold stable postures at the expense of physiologic control </li></ul><ul><ul><li>A premature infant cannot effectively change their position, therefore, when in a position for a long period of time, changes occur in the properties of muscles and tendons that lead to structural changes (Wilhelm) </li></ul></ul><ul><ul><li>Infants who may be able to attain a flexed posture but will return to positions that they are more familiar with due to the changes in properties of musculature as well as the established neurological changes and ability to activate muscles based on early experiences </li></ul></ul><ul><ul><li>Structural, neurological and joint problems can be PREVENTED with proper attention to positioning from day one </li></ul></ul>
    22. 24. How do infants learn to move?
    23. 25. How do infants learn to move? <ul><li>Infants learn to move by pushing through and against a supportive surface. </li></ul><ul><ul><li>Pushing through the supportive surface results in activation of muscles and strengthening of muscle/brain connections </li></ul></ul><ul><ul><li>The input from the infant pushing through the surface strengthens the connections of the muscle groups </li></ul></ul><ul><ul><li>In the NICU infants are often positioned such that the connections that they strengthen are inappropriate and result in poor movement balance and asymmetries </li></ul></ul>
    24. 26. Why do former preemies extend so much? <ul><li>Former premature infants demonstrate an imbalance of flexors (muscle on the front) and extensors (muscles on the back </li></ul><ul><ul><li>This imbalance is due to early experience and positioning </li></ul></ul><ul><ul><li>Infant’s in the NICU are often placed in supine (unsupported) during the first few days when they are unstable, upper extremities are abducted and externally rotated and lower extremity hips are flexed abducted and widely externally rotated </li></ul></ul><ul><ul><li>They do not look like full term infants with the tight flexed posture (called physiologic flexion) </li></ul></ul>
    25. 27. Why do former preemies extend so much? <ul><ul><li>Remember infants learn to move by pushing </li></ul></ul><ul><ul><li>THROUGH the surface . . . </li></ul></ul><ul><ul><li>So, preemies are strengthening the EXTENSOR muscles in early days of positioning and whenever they are placed in supine </li></ul></ul><ul><ul><ul><li>Premature infants do not have the strength to move versus gravity, therefore they move into gravity </li></ul></ul></ul><ul><ul><li>Full term infants strengthen their FLEXOR muscles </li></ul></ul><ul><ul><ul><li>Pushing on the uterus strengthens flexor muscles </li></ul></ul></ul><ul><ul><ul><li>The full term infant is not able to move into extension therefore there is a flexion bias </li></ul></ul></ul><ul><ul><li>This is one of the primary movement differences between full term and premature infants. It greatly impacts movement </li></ul></ul>
    26. 28. Maladaptive Postures that premature infants demonstrate . . . A case for better positioning <ul><li>Cervical Extension </li></ul><ul><ul><li>Musculoskeletal Issues </li></ul></ul><ul><ul><li>Why do they choose this position: </li></ul></ul><ul><ul><ul><li>Closed pack position, mechanically stable, offers increased ventilation at first </li></ul></ul></ul><ul><ul><li>Developmental Issues: </li></ul></ul><ul><ul><ul><li>Difficulties with: head centering, head control, hands to midline, downward gaze, reaching, social interaction </li></ul></ul></ul><ul><ul><li>Physiologic Issues </li></ul></ul><ul><ul><ul><li>Changes overall alignment of upper trunk, difficulties with full expansion of upper chest results in stiffness and ultimate lack of upper chest breathing </li></ul></ul></ul>
    27. 29. Maladaptive Postures that premature infants demonstrate . . . A case for better positioning <ul><li>Elevated and retracted scapulae </li></ul><ul><ul><li>Musculoskeletal Issues </li></ul></ul><ul><ul><li>Developmental Consideration </li></ul></ul><ul><ul><ul><li>Difficulties with: hands to midline, use of upper extremities, reaching, attachment </li></ul></ul></ul><ul><ul><li>Physiologic Consideration </li></ul></ul><ul><ul><ul><li>Changes overall alignment of upper trunk, difficulties with full expansion of upper chest results in stiffness and ultimate lack of upper chest breathing </li></ul></ul></ul>
    28. 30. Maladaptive Postures that premature infants demonstrate . . . A case for better positioning <ul><li>Externally rotated hips (frog legged) </li></ul><ul><ul><li>Musculoskeletal Considerations </li></ul></ul><ul><ul><li>Developmental Considerations: </li></ul></ul><ul><ul><ul><li>Interferes with: movement transitions, crawling, prolonged wide base of support in walking, pronated feet bilaterally needing corrective orthotics </li></ul></ul></ul><ul><ul><li>Physiologic Considerations </li></ul></ul><ul><ul><ul><li>Places the trunk into extension which ultimately is a poor place for the diaphragm to be. The diaphragm works best in flexion, not extension </li></ul></ul></ul>
    29. 31. Maladaptive Postures that premature infants demonstrate . . . A case for better positioning <ul><li>Decreased spinal curvature/reversed spinal curvature – Extension </li></ul><ul><ul><li>Musculoskeletal Considerations </li></ul></ul><ul><ul><li>Developmental Considerations </li></ul></ul><ul><ul><ul><li>Interferes with: attachment, developmental of flexion, sitting, crawling, promotes extension of legs, difficulties with rotation and dissociated movement, imbalance flexor and extensor muscles </li></ul></ul></ul><ul><ul><li>Physiologic Considerations </li></ul></ul><ul><ul><ul><li>Does not allow for effortless breathing or eating. </li></ul></ul></ul><ul><ul><ul><li>Extension of trunk results in poor position of diaphragm </li></ul></ul></ul><ul><ul><ul><li>Extension of upper chest results in difficulties with expansion/tightness if upper trunk musculature </li></ul></ul></ul><ul><ul><ul><li>Oral motor structures in poor alignment </li></ul></ul></ul>
    30. 32. Maladaptive Postures that premature infants demonstrate . . . A case for better positioning <ul><li>Asymmetrical Head Shape </li></ul><ul><ul><li>Musculoskeletal Considerations </li></ul></ul><ul><ul><li>Developmental Considerations: </li></ul></ul><ul><ul><ul><li>Difficulties with: symmetrical movement, cranial and skull asymmetries with long term cosmetic consequences, difficulties with visual strength </li></ul></ul></ul><ul><ul><li>Physiologic Considerations </li></ul></ul><ul><ul><ul><li>Poor posture for midline orientation and state interaction. </li></ul></ul></ul><ul><ul><ul><li>Closed packed posture – hyper rotation of the head in either direction affects the sympathetic nervous system. </li></ul></ul></ul>
    31. 37. Positioning Principles <ul><li>Avoid Supine Position (Fay, Wilhelm, Sweeny) </li></ul><ul><ul><li>Prolonged supine position has been noted to increased muscle tone, promote severe hyperextension of head and neck, promote frog legged posture, promote scapular retraction and elevation, promote asymmetrical head shape </li></ul></ul><ul><ul><li>Many of the afore mentioned issues can be eliminated with the minimal use of supine positioning! </li></ul></ul><ul><li>Position in side-lying and prone as much as possible, especially early in NICU stay </li></ul><ul><ul><li>Side lying and prone positions are associated with improved digestion, respiration, oxygenation and improved quiet sleep (Wilhelm, Fay) </li></ul></ul>
    32. 38. Positioning Principles <ul><li>The infant is does not assume maladaptive postures because they are more comfortable or because they can breath better in these positions </li></ul><ul><ul><li>Recognize that maladaptive postures are actually harming the physiologic stability of the infant. </li></ul></ul><ul><li>Consistently facilitate flexion in the trunk and limbs in positioning and care giving efforts </li></ul><ul><li>Do not allow closed packed postures/maladaptive postures </li></ul><ul><li>Use gentle swaddling and nesting to facilitate flexed posture </li></ul><ul><li>Use crumpled blanketing in front of infant when in side-lying to facilitate flexed posture/grasping </li></ul><ul><li>Encourage symmetrical postures </li></ul><ul><li>Eliminate typical postural deformities </li></ul>
    33. 39. Problems with Supine Positioning
    34. 40. Positioning Essentials <ul><li>Inappropriate Prone Position Appropriate Prone Position </li></ul>
    35. 41. Positioning Essentials <ul><li>Inappropriate Side-lying position Appropriate Side-lying position </li></ul>
    36. 42. Any Questions?