A systems perspective of
developmentally supportive
family centered care
Cuidados Centrados en
el Desarrollo y en la famil...
The ultimate objective of neonatology
Can developmental care help us to get there?
KapellouKapellou
20062006
Impact of rearing conditions during the
neonatal period on adult brain function
”Environmental/epigenetic programming”
Maternal programming of steroid receptor expression and
phenotype through DNA methy...
A proposed link between variations in parent–offspring
interactions and the development of individual differences in
stres...
Prematurity associeted
with medical conditions in adulthood:
Hypertension
Edstedt Bonamy et al, Pediatric Research 2005
Jo...
Titus Schlinzig,
Mikael Norman et a.
Acta Pediatr 98:7,
2009
NIDCAP
Newborn
Individualized
Developmental
Care and
Assessment
Program
NIDCAP observation
Agneta Kleberg, Europe’s first
(Master) NIDCAP trainer
Implementation at Karolinska
Systems perspective
Synactive Model of Developmental Care
Systems perspective
H. AlsH. Als
Synactive Model of Developmental Care
H. AlsH. Als
Observe
interpret
Support…
… selfregulation, stability,
and possibly interaction
NIDCAP promotes resilience by providing
developmentally adequate support during:
 care-giving
 social interaction
 exam...
0
10
20
30
40
50
60
70
80
90
100
<25 25 26 27 28 29 30 31-
33
CPAPCPAP
MVMV
%
Gest. ageGest. age >> 27 – not regionalized deliveries27 – not regionalized deliveries
< 27 more proactive, regionalized deliveries< 27 more proactive, regionalized deliveries
< 25 prophylactic surfactant< 25 ...
At birth 25+1, now two days oldAt birth 25+1, now two days old
Nice, 2008-10-26
Béatrice Skiöld EAP 2008Béatrice Skiöld EAP 2008
The Stockholm cohort <27 wksThe Stockholm cohort <27 wks...
26 wks
25 wks
24 wks
23 wks
22 wks
Survival – live-born infants (n = 707)
acc. to gestational age at birth JAMA 2009
36
46
56
24
38
6
32
5
0
6 6 5
18
6
18 17
13 12 12
6
13
0
10
20
30
40
50
60
VG
region,n=74Linköping,n=41
Ö
rebro,n=16
Stock...
Karolinska-Danderyd
 Level II + - 10 000 inborn deliveries
 Infants > 27 gestational weeks
 INSURE (Intubation, Surfact...
Synactive Model of Developmental CareSynactive Model of Developmental Care
H. AlsH. Als
Minimize mother infant separationMinimize mother infant separation
Skin-to-skin
Born at 24 weeks
Now one week of age
Multipregnancies are a challange
Synactive Model of Developmental Care
H. Als, 2007H. Als, 2007
Family centered care at Level III
Karolinska-Solna
Siblings at Level III
Karolinska-Solna
Synactive Model of Developmental Care
H. AlsH. Als
Samvårdsavdelning 20Samvårdsavdelning 20
Neonatalsektionen Karolinska-DanderydNeonatalsektionen Karolinska-Danderyd
Karolinska-Huddinge
Small family room when the mother has recovered,Small family room when the mother has recovered,
e.g., from her pre-eclamp...
Family lounge.
NB the wireless monitoring of accompanying infant
Family lounge. NB the kangaroo position and the leeds
implying a saturation monitor in the mother’s pocket
Nurse station with the central for the wireless monitors
Nurse with beepers
connected to the
wireless monitors
Synactive Model of Developmental Care
H. Als
Large family room where we also care for mothers
who are in need of medical care, except intensive care
Couplet CareCouple...
Large family room where we also care for mothers
who are in need of medical care, except intensive care
Couplet CareCouple...
Large family room where we also care for mothers
who are in need of medical care, except intensive care
Couplet care
Does developmental care stop at discharge?
Home visits: NIDCAP  IBAIP
(Infant Behavioral Assessment Intervention Program)
Synactive Model of Developmental Care
H. Als, 2007
Parental benefit – extension of days
180
210
270
360
450
480
0
100
200
300
400
500
600
1974 1978 1982 1986 1990 1994 1998 ...
The Stockholm Neonatal Family
Centered Care Study:
effects on length of stay and infant morbidity
A Örtenstrand, B Westrup...
Annica Örtenstrand 70
Intervention:
True (?) family centered care
– parents could stay 24 / 7 from admission to
discharge
...
Infants randomized into the study
Randomized infants
n = 366
with congenital disease: 2
Allocated to family care: 183
Allo...
Annica Örtenstrand 72
Included infants
Family care
n = 183
Standard care
n = 182
Gestational age at birth
24 – 29, n (%) 2...
Annica Örtenstrand 73
Length of stay in hospital
Adjusted for: gestational age at birthA
, non-Swedish-speaking background...
Annica Örtenstrand 74
Length of stay in intensive care (level II and level III)
Adjusted for: gestational age at birthA
, ...
Annica Örtenstrand 75
Infant morbidity
Adjusted for: gestational age at birth, non-Swedish-speaking background, setting
Fa...
Annica Örtenstrand 76
Ventilatory assistance and supplemental oxygen
Adjusted for: gestational age at birth, non-Swedish-s...
Family care might operate through the
common pathhways of pain and stress
Parents in Family care may have a greater
opport...
Annica Örtenstrand 78
Conclusion
Family care in a level-II NICU, where parents could
stay 24 hours per day from admission ...
Time to stop?!
Photo Ann-Sofie Gustafsson, Karolinska NIDCAP Training Center
Ultra-Early Intervention
Karolinska-Danderyd, 18 November 2010
Visit the link or google and follow the conference on the i...
Staff’s (expert?) opinion
The staff’s experience of NIDCAP in
Falun, Sweden
Westrup, Kleberg, Wallin et al. Evaluation of NIDCAP in a Swedish Settin...
-5-4-3-2-1012345
-5=moinsbon,0=inchangé,5=meilleur(moyenne+/-é
The staff’s experience of NIDCAP in Brest, France
Mambrini ...
The staff’s experience of NIDCAP in Brussels
Christine Rémont & Yves Hennequin
(Int. Conf. on Infant Development in Neonat...
The staff’s experience of NIDCAP inThe staff’s experience of NIDCAP in LeidenLeiden
Van der Pal, SM et al. Early Hum Dev (...
Scandinavian NIDCAP Center
NIDCAP in Nordic countriesNIDCAP in Nordic countries
4th Nordic Neonatal Meeting, 20-21 Nov, 20...
www.nidcap.org
NIDCAP Training Centers
US: 10 Ctrs.
EU: 5 Ctrs.
S. Am: 1 Ctr.
US Training Centers
European Training Centers
UK Ctr
French
Rotterda
m
Karolinska Sthlm
Brussels
 ........20th annual NIDCAP Trainers meeting materialspresentationsSa
NIDCAP activity in Sweden
Certified
Persons (units)
Trainees
Persons (units)
2007
2006
2005
2004
54(18)
50(16)
45(16)
43(1...
Swedish neonatal units with NIDCAP
(certified professionals or persons in training)
 KUS-Solna,
 KUS-Danderyd
 KUS-Hudd...
Norwegian neonatal units with NIDCAP
Sted Introduserte Sertifiserte Trainer-in-Training
Tromsø 4 3
Trondheim 3 3
Levanger ...
Neonatal units with NIDCAP in other
nordic countries
(certified professionals or persons in training)
Denmark
 Copenhagen...
Scandinavian NIDCAP Center
Scientific context ofScientific context of
family centred developmentallyfamily centred develop...
Brain development
Evrard P, et al Acta Paediatr suppl 422,20-6. 1997
Number of
invasive
procedures
(Barker and Rutter 1995)
It is too noisy! Does it matter?
Sound and physiological responses
J Long, J Lucey, A Philip. Pediatrics 1980;65:143-45
One week old boy in an incubator, b...
Lehtonen L, et al. J Pediatr 2002;141:363-9
Relation of sleep state to hypoxemic
episodes in ventilated ELBW infants
Behavioral science:
something for ’docs’?
 "The behavior of the infant is its primary
way to communicate”
(Als – develop...
The Synactive Theory
subsystems:
• Autonomic
• Motor
• State-
• Attentional / Interactive
The synactive theory focuses on ...
Autonomic-physiologic system
• Circulation
• colour
• respiration
•Bowel movements
•Temperature control
• Tremor, jitternes
Motor system
State system
Attentional and interactive system
selfregulation
What is the scientific
support, the level of
evidence?
Short-term outcome
 A positive impact is indicated on...
Pulmonary morbidity (Als ’94, ’03, ‘04, Fleisher ’95, Westrup
’...
Long-term outcome
 A positive impact is clearly indicated on...
Mental development up to 9/12 months
(Als ’94 & ‘04, Ari...
Does NIDCAP improve outcome?
Level of evidence
Results of most RCTs point in a positive direction
Most published RCTs ar...
Sleep of preterm neonates under developmental
care or regular environmental conditions
0
20
40
60
80
100
120
140
160
180
T...
Weighing
 Lift the baby out to the scale wrapped in a soft towel to
help him maintain balance
Physiological, behavioral and biological stress expression
during a weighing procedure. Catelin et al. J Pain 2005
0
1
2
3...
Salivary cortisol (µg/dl)
0,0
0,2
0,4
0,6
0,8
1,0
before weighing 30 min after weighing
salivarycortisol
DC
Control
< 32 w...
0
2
4
6
8
10
12
V O2 V CO2
DC
Control
*
* p<0.01
* * p<0.05
ml/min
* *
Reduced O2 consumption and CO2 production when
supp...
Effect from NIDCAP-intervention
during/after eye examination for ROP
Kleberg et al. Lower stress responses after Newborn I...
Intervention scores for ”standard care” approaches
NIDCAP with increasing number of examinations in an
open study evaluati...
Support during painful procedures
Shield infant from bright light and offer
your finger to suck on
Sidelying, flexed position, support of the back
and hands in the midline by the mouth
Infants with catheters or chest tubes requires
more visual access but could be supported
The Edmonton NIDCAP Trial
Peters et al, Pediatrics Oct 2009
NIDCAP
N=56
CONTROL
N=55
OR
Gestational age 27,5 (1.4) 27.0 (2...
The Edmonton NIDCAP Trial
Peters et al, Pediatrics Oct 2009
NIDCAP
N=56
CONTROL
N=55
OR
Gestational age 27,5 (1.4) 27.0 (2...
The LeidenTrial
Maguire et al, Pediatrics Apr & Oct 2009
NIDCAP
N=81
CONTROL
N=83
OR
Gestational age 29.3 (1.8) 29.2 (1.6)...
The LeidenTrial
Maguire et al, Pediatrics Apr & Oct 2009
NIDCAP
N=81
CONTROL
N=83
OR
Gestational age 29.3 (1.8) 29.2 (1.6)...
Early experience alters brain function and structure
Als H, Duffy F, McAnulty G, Rivkin M, Hüppi P et al.
Pediatrics 2004;...
Developmental care, brain structure and function
Als H, Duffy F, McAnulty G, Rivkin M, Hüppi P et al. Early experience alt...
EEG coherence: Red=positive/increased, blue=negative,
green=decreased. Als et al 2004.
Anisotropy E1/E3 – threshold ≥ 1.3
Arrows –white : Frontal White Matter
black : Internal Capsule (posterior limbs)
at a po...
Study population
For example …
 Early experience alters brain function and structure
(Als 2004)
Gestational age: ~31 wks...
Selection/enrolment of subjects – the sample
 Bias of selection?
Inborn / Outborn
 Leiden II: ~60% / 40%
 Edmonton NID...
Intervention: fidelity and contrast
 Were the infants in the intervention group in Leiden II getting
it?
 ~15 infants we...
Intervention: fidelity and contrast
Are the infants in the control group not getting it
is there adequate contrast or
is...
Intervention scores for ”standard care” approaches
NIDCAP with increasing number of examinations in an
open study evaluati...
Cultural and demographical context
 Socioeconomic status SES
Leiden II
Education level of the mother
Low 22/66 (33.3%) vs...
Long-term effect
The Edmonton NIDCAP Trial
Peters et al, Pediatrics Oct 2009
NIDCAP
N=56
CONTROL
N=55
OR
Gestational age 27,5 (1.4) 27.0 (2...
The LeidenTrial
Maguire et al, Pediatrics Apr & Oct 2009
NIDCAP
N=81
CONTROL
N=83
OR
Gestational age 29.3 (1.8) 29.2 (1.6)...
Cognitive Indices atCognitive Indices at oneone**
andand fivefive yearsyears
Acta Paediatrica 2004;93:1-10Acta Paediatrica...
Performance IQ and mortality at 5 yearsPerformance IQ and mortality at 5 years
(WPPSI-R PIQ, corrected age)(WPPSI-R PIQ, c...
Behaviour and mortality at 5 yearsBehaviour and mortality at 5 years
Subtests of the NEPSYSubtests of the NEPSY test batte...
NEPSYNEPSY
(Korkman M 1990)(Korkman M 1990)
 Neuropsychologic test: two sub tests (level ofNeuropsychologic test: two sub...
Dev. outcome, child behaviour and mother-child
interaction at three years of age following
NIDCAP intervention.
Falun, Swe...
BEHAVIOURAL INTERVIEW*
(*Cederblad-Höök at three years)
CONTROLNIDCAP
BEHAVIORALSCORE
30
25
20
15
10
5
0
INTERNALIZING
EXT...
Family in development, Bonding / attachment
Family in development; Bonding / attachment
Agneta Kleberg et al,
Early Hum Dev 2007
Staffs’ ability to support her
motherhood
3.5 (2.9-3.9) 3.2 (2.3-3.7) 0.066
Close...
Discussion
Closeness
Anxiety
0% 20% 40% 60% 80% 100%
infant in general
safety of infant
parents participation
physician's working condition
staff's wor...
Observe
interpret
Support theSupport the …
… self-regulation, stability,
and possibly interaction
B
Dev Care is not a new
science but integrating
natural science with
behavioural science.
Is it now time to let our
actions ...
Disability and mortality at 5 years
Acta Paediatrica 2004;93:1-10
NIDCAP care Conventional care
Normal
Impaired without di...
Overall cognition and mortality at 5 years
(WPPSI-R FSIQ, corrected age) Acta Paediatrica 2004;93:1-10
NIDCAP care Convent...
The term and healthy
- the vast majority of infants!
A paper to be defended at a dissertation at the Karolinska next month...
Does infant behavior reflect
findings in brain structure?
Structural and neurobehavioral delay in
postnatal brain developm...
[Hüppi PS et al. Pediatr Res 1996;39:895-01]
 preterm group: 18 infants (30.5+1.8 wk) without
need of mechanical ventilat...
Results:
[Hüppi PS et al. Pediatr Res 1996;39:895-01]
 preterm group:
MRI-findings:
maturation over time with an increas...
Risk of High Blood Pressure among
Young Men Increases with Degree of Immaturity at Birth
0
1
2
24-28 29-32 33-36 37-41 42-...
Kangaroo-
Mother-
Care
Dean 24+6
Now one week
Kangaroo Mother Care Bogota
VLBW infants: Skin to skin 24 hrs/d, early discharge and frequent,
regular out-patient check-u...
Kangaroo Mother Care
Juan G. Ruiz - Nathalie Charpak, Bogota Colombia
(Pediatrics 1997, 1998, 2001. Infant Behaviour and D...
Videoclip:
Transition from
skin-to-skin to incubator
RCT of skin-to-skin contact from birth
versus conventional incubator care for
physiological stabilisation in
1200 - 2199-g...
SCRIP
SCORE
2 1 0
Heart rate Regular Deceleration
to 80-100
Rate <80 or
>200 bpm
Respiratory
rate
Regular Apnea <10s,
or p...
Background characteristics
Minimisation technique ensured groups balanced
for confounders.
( n = 34) Kangaroo-Mother- Conv...
STABILIZATION TREND.
SKIN-TO-SKIN (KMC): STABLE AT 6 hours
INCUBATOR INFANTS (CMC) REMAIN UNSTABLE,
WITH NO TREND TO STABI...
Stabilisation first 6 hours, average hourly SCRIP score
5.1
5.2
5.3
5.4
5.5
5.6
5.7
5.8
5.9
6
6.1
2nd 3rd 4th 5th 6th
KMC ...
The Stockholm Family Study
A Örtenstrand, B Westrup, E Berggren Broström, I Sarman, S Åkerström, T Brune,
L Lindberg, U Wa...
Moderately preterm infants and determinants of
length of hospital stay
M Altman, M Vanpée,S Cnattingius, M Norman
Arch Dis...
Outline
 Patient flow
Delivery
Maternity
Neonatal nursery
 Family centered care
 Couplet care
New units design plan...
Delivery and maternity at Karolinska-
Danderyd
 Approx 10,000 deliveries / year
230 twins, 3 triplets
400 born prematur...
Delivery and maternity at Karolinska-
Danderyd
 Approx 10,000 deliveries / year
230 twins, 3 triplets
400 born prematur...
Delivery and maternity at Karolinska-
Danderyd
 Planned C-sections: 16 beds for 26 c-sections/week
LOS: two days
week-e...
Delivery and maternity at Karolinska-
Danderyd
 Approx 10,000 deliveries / year
230 twins, 3 triplets
400 born prematur...
Delivery and maternity at Karolinska-
Danderyd
 Patient Hotel; 24 beds
Uncomplicated delivery admitted after 2-6 hours a...
Delivery and maternity at Karolinska-
Danderyd
 Approx 10,000 deliveries / year
230 twins, 3 triplets
400 born prematur...
Karolinska-Danderyd
 8 beds for mothers in need of medical care – Couplet Care
 Mean cencus 3.4 mothers (42%)
 Mean len...
Dept of Neonatology
at the Karolinska University Hospital
 Three NICU:s
(Solna, Danderyd & Huddinge)
 22 000 births/year...
Vanpee et al Acta Paediatrica 2007;96:10-16
Practice style for resuscitation
Inborn infants with GA <28 wks, 07/2001 to 06/2003
Boston
n = 70
Stockholm
n = 102
P valu...
Madrid 2010 westrup
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Madrid 2010 westrup
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Madrid 2010 westrup
Madrid 2010 westrup
Madrid 2010 westrup
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Madrid 2010 westrup
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Madrid 2010 westrup
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  • As you remember conventional images were scored and classified into 4 groups and this slide shows the incidence of the different WM abnormalitites in the cohort.
    86% of infants in the cohort had normal or mild WM abn, and only 14% had moderate- severe abn.
    Jfr INDER:
    These results are comparable to international data, for ex an Australian cohort of 100 infants where 20% had moderate-severe abnormalities and 29% had normal WM (Inder et al 2003)
    But the GA of the infants in the present cohort is lower, here 65 infants were born &amp;lt;26 w whereas, out of the 100 australian infants, only 11 were born &amp;lt;26w.
    The rates did not differ between the two groups.
    Inder 03: mean GA 27.9 ±2.4 w (23-32 w), mean BW 1063 ± 292 g
    Normal-mild 80%, Normal 29% , Mild 51%, Mod-severe non-c 16%, Mod-severe cyst 4%
    Sandras: mean GA 25.4 w (23+4 -26+6), mean BW 775 g (494-1114).
  • Detta är inne på förlossningsrummet.
    Pojken här, som behöver HJÄLP AV CPAP, har pappan har SJÄLV BURIT in till mamman,
    och LAGT BARNET till henne där hon ju OROLIGT väntat.
    Här är det också läkaren Beatrice som berättar vad som hänt och vad som händer härnäst.
  • Och så här UPPKOPPLAD med cpap och övervak på transportkuvösen kan familjen i lugn och ro HÄLSA PÅ sitt barn.
    Bättre så här än att bara få PETA lite på barnet genom en kuvöslucka.
  • Detta är en annan familj, även detta på FÖRLOSSNINGSRUMMET.
    De här föräldrarna verkade nästan GLÖMMA BORT cpapen och alla sladdar.
    De pratade om VEM HAN VAR LIK, räknade FINGRAR OCH TÅR och kändes så NORMALT det kunde bli.
    Vi personal HÅLLER KOLL på barnet, men försöker HÅLLA OSS UNDAN så mycket det går.
  • Diagrammet visar utvecklingen av antal dagar sedan fp infördes 1974.
    1974: 180 dagar (6 mån). Försäkringen har sedan kontinuerligt utökats med flera dagar. Med undantag för 1994 då nya regler om vårdnadsbidrag infördes för en kort tid.
    1995 infördes “pappamånaden”, 30 dagar ej överlåtningsbara mellan föräldrarna. Målet var att öka pappornas uttag av fp, förtydliga att hälften av dagarna tillhör vardera föräldern.
    2002 infördes ytterligare en reserverad månad, antalet fp-dagar är sedan dess 480 (16 månader), varav 2 månader är reserverade för vardera förälderna. 240 dagar var.
  • Independent of the infant’s needs of monitoring, parents had a separate room in the unit from the first day including beds for both parents and a private bathroom.
    Infants in the intensive care rooms moved into the family rooms as soon as they reached a stable state. The parents had the primary contact with the baby and call the staff when needed.
  •  Han stänger ute och visar tydligt att han inte är intresserad av mer kontakt.
  • I. The synactive model focuses on the way the individual infant appears to handle experiences of the world around him. Environment and social interaction can be supportive or disrupted to the infant’s organisation: sound, light, activity; bedspace and bedding; attention and interaction
    II. Whenever development occurs, it proceeds from a state of globality to a state of differentiation. Ex:
    Irregular breathing, deep or shallow, pauses – to smooth and regular:
    Big swiping movements – to well modulated and fine tuned;
    Diffuse sleepstates and alertness – to robust sleep and cry states and shiny alert eyes
    III. The infant always strives for smoothness of integration of the subsystems in the face of stimuli from the environment, to be able to move forward. Underlying this strivings is the tension between:
    avoid and approachavailable to take in and process or withdraw and defend
    If the stimulus is appropriate for the infant’s current developmental path, the infant wil move towards the stimulus
    If the stimulus is inappropriately timed, too complex or intense, the infant will move away from the stimulus in an attempt to avoid it.
  • NIDCAP method controversial – features that seem to be well taken – incubator covers, cycled light etc, one example
  • Ge stöd runt barnet på skötbordet, bädda in den del av kroppen som inte måste vara avklädd.
    Hjälp barnet att hålla sina händer nära munnen.
  • NIDCAP method controversial – features that seem to be well taken – incubator covers, cycled light etc, one example
  • There was a tendency that the mothers in the NIDCAP-group estimated staffs’ ability to support their motherhood somewhat higher than the mothers in the control–group. One item was significant within the subscale: The NIDCAP-mothers estimated a higher (p=0.003) degree of support according to take responsibility for the care of their infant
    The mothers’ in the NIDCAP group estimated Closeness between her and her infant higher than the control–mothers. Of the five items in the subscale: eye-contact was sign higher (p=0.05)
    No sign corr was found in the NIDCAP-group between GA and birhtweight with mothers’ perception of closeness to their babies. In the control-group however, a negative sign correlation between infants’ birhtweight with mothers’ perception of closeness was found. In the whole sample we found a neg corr between infant’s birthweight and mother’s perception of staffs’ ability to support her motherhood (r=0.43; p=0.054)
    The mothers in the NIDCAP-group also estimated fear higher than the control-mothers (p=0.033)
    Conclusion: The NIDCAP model as an early intervention appears to support mother infant contact during hospital stay.
  • no sign corr between birht-weight and GA with closeness in the NIDCAP-gr:
    The NIDCAP model regulate the balance of the infant – when in balance, the baby will be ready for interaction
    orienting behaviour
    sign more eyecontact - and sign more support from the staff to take responsibility for the care of their infant
    The staff in the NIDCAP-group have a tool that helps them guide and support parents understand their infants signals and needs over time. From very subtile to more mature signals, ready for attention and interaction
    The result correspond to our 3 year follow-up pilot study, where the mothers’ in the NIDCAP group showed sign better quality and amount of physical contact, and amount of visual contact with the child, Including better child communication in favour to the NIDCAP-group (se BW-avh).
    In the control-group however, we found a negative sign corr between infants’ birhtweight with the mothers’ perception of closeness:
    We are speculating about if the staff in the control-gr invest more time with the mothers’ of the smallest infants. They have no tool that helps them indivudualize the support of the mothers.
    Fear: the mothers in the NIDCAP-group also estimated fear higher than the control-mothers
    They had been more afraid of techn eqiupements and were still more concerned about future health of their baby.
    (no corr between BW or GA with fear, n=20). The infants in the N-gr were not physically more unstable. Quite contrary (See table) they needed sign less mechanical brethingsupport and they had better lungfunction at the time when the mothers’ answered the attitude scale. Concequently, there was no reason for the mothers in the N-group to be more afraid for their baby’s health than the C-mothers’. On the other hand, the N-mothers’ estimated more closeness to their babies compared to the C-mothers’ This might indicate that the mothers’ in the NIDCAP-group have come further in their attachment-process to theri baby and because of that expressed more fear for what could happen their baby and also experienced the equipments more threatening.
  • This slide shows the main result, that gestational age was inversely related to risk of high blood pressure.
    Those of you who familiar with the hypothesis of fetal programminng may wonder; what about low birth weight?
    Here it comes... BW for GA was only associated with systolic blood pressure and the risk associated with being small for gestational age was much less compared to the association with gestational age.
  • Madrid 2010 westrup

    1. 1. A systems perspective of developmentally supportive family centered care Cuidados Centrados en el Desarrollo y en la familia 11 y 12 de noviembre, 2010 Björn Westrup, MD Ph D Karolinska University Hospital Stockholm, Sweden
    2. 2. The ultimate objective of neonatology Can developmental care help us to get there?
    3. 3. KapellouKapellou 20062006
    4. 4. Impact of rearing conditions during the neonatal period on adult brain function
    5. 5. ”Environmental/epigenetic programming” Maternal programming of steroid receptor expression and phenotype through DNA methylation in the rat Moshe Szyf, Michael J. Meaney. McGill University, Montreal, Canada Front Neuroendocrinol 2005 •Decreased methylation of glucocorticoid receptor promoter • => increased gene expression •Decreased ACTH & cortisol responses to stress in adulthood •Increased glucocorticoid receptor & BDNF mRNA in hippocampus and CRF mRNA in hypothalamus •Decreased epinephrine release in hypothalamus •Increased cholinergic innervation and synapotgenesis in hippocampus •Decreased stress behaviors (startle responses), increased explorative behavior •Increased spatial learning and memory Consequences of natually occurring variations in pup licking/grooming (High LG vs. Low LG)
    6. 6. A proposed link between variations in parent–offspring interactions and the development of individual differences in stress responses If critical conditions are present in early life of forms of parent–offspring interactions they promote increased stress responses and chronic stress in adulthood. Szyf M, Weaver IC et al Front Neuroendocrinol 2005
    7. 7. Prematurity associeted with medical conditions in adulthood: Hypertension Edstedt Bonamy et al, Pediatric Research 2005 Johansson et al, Circulation 2005 Sympatoadrenal hyperactivity Johansson et al, J Internal Medicine 2007 Smaller vascular bed (capillary density) Edstedt Bonamy et al, J Internal Medicine 2007 Smaller aorta Edstedt Bonamy et al, Pediatric Research 2005 Edstedt Bonamy et al, Acta Paediatrica 2008 (1) Edstedt Bonamy et al, Acta Paediatrica 2008 (2) Smaller kidneys (normal GFR) Rakow et al, Pediatric Nephrology 2008 0 1 2 24-28 29-32 33-36 37-41 42-43 Diastolic BP ≥90 mm Hg Systolic BP ≥140 mm Hg gestational weeks adjusted OR
    8. 8. Titus Schlinzig, Mikael Norman et a. Acta Pediatr 98:7, 2009
    9. 9. NIDCAP Newborn Individualized Developmental Care and Assessment Program
    10. 10. NIDCAP observation Agneta Kleberg, Europe’s first (Master) NIDCAP trainer
    11. 11. Implementation at Karolinska Systems perspective
    12. 12. Synactive Model of Developmental Care Systems perspective H. AlsH. Als
    13. 13. Synactive Model of Developmental Care H. AlsH. Als
    14. 14. Observe
    15. 15. interpret
    16. 16. Support…
    17. 17. … selfregulation, stability, and possibly interaction
    18. 18. NIDCAP promotes resilience by providing developmentally adequate support during:  care-giving  social interaction  examinations and procedures The care is governed by the infant’s …  current stage of development  current medical condition
    19. 19. 0 10 20 30 40 50 60 70 80 90 100 <25 25 26 27 28 29 30 31- 33 CPAPCPAP MVMV %
    20. 20. Gest. ageGest. age >> 27 – not regionalized deliveries27 – not regionalized deliveries
    21. 21. < 27 more proactive, regionalized deliveries< 27 more proactive, regionalized deliveries < 25 prophylactic surfactant< 25 prophylactic surfactant
    22. 22. At birth 25+1, now two days oldAt birth 25+1, now two days old
    23. 23. Nice, 2008-10-26 Béatrice Skiöld EAP 2008Béatrice Skiöld EAP 2008 The Stockholm cohort <27 wksThe Stockholm cohort <27 wks White matter abnormalities on conventional MRIWhite matter abnormalities on conventional MRI Entire cohort DTI-group z-test/ n=108* n=54 t-test No WM abnormalities 43 (40%) 24 (44.5%) ns Mild WM abnormalities 50 (46%) 24 (44.5%) ns Moderate WM abnormalities 13 (12%) 6 (11%) ns Severe WM abnormalities 2 (2%) 0 ns *one MRI excluded due to artefacts
    24. 24. 26 wks 25 wks 24 wks 23 wks 22 wks Survival – live-born infants (n = 707) acc. to gestational age at birth JAMA 2009
    25. 25. 36 46 56 24 38 6 32 5 0 6 6 5 18 6 18 17 13 12 12 6 13 0 10 20 30 40 50 60 VG region,n=74Linköping,n=41 Ö rebro,n=16 Stockholm ,n=110U ppsala,n=78 U m eå,n=33 Alla,n=352 BPD IVH, gr 3-4 ROP, gr 3-4 Morbidity (%) among survivors with gest. age 25-27 weeks Swedish National Neonatal Register – PNQ (2007-2008).
    26. 26. Karolinska-Danderyd  Level II + - 10 000 inborn deliveries  Infants > 27 gestational weeks  INSURE (Intubation, Surfactant, Extubation), CPAP, chest tubes, catheters etc  24 beds for infants  8 beds for mothers in need of medical care – Couplet Care  12-14 “beds/families” in the Domiciliary Care Program  870 admitted – 8.7% 7.2% in the neonatal unit 1.5% in the maternity wards (jaundice, hypoglycemia, Down’s Syndrome …)  26 (3% of admitted, 2.6‰ of all newborn) referred to Level III  Perinatal mortality: 3 ‰ – all still births, no mortality during 1st week  Neonatal mortality: 0.6‰ (national 1.6 ‰) during 1st month
    27. 27. Synactive Model of Developmental CareSynactive Model of Developmental Care H. AlsH. Als
    28. 28. Minimize mother infant separationMinimize mother infant separation
    29. 29. Skin-to-skin Born at 24 weeks Now one week of age
    30. 30. Multipregnancies are a challange
    31. 31. Synactive Model of Developmental Care H. Als, 2007H. Als, 2007
    32. 32. Family centered care at Level III Karolinska-Solna
    33. 33. Siblings at Level III Karolinska-Solna
    34. 34. Synactive Model of Developmental Care H. AlsH. Als
    35. 35. Samvårdsavdelning 20Samvårdsavdelning 20 Neonatalsektionen Karolinska-DanderydNeonatalsektionen Karolinska-Danderyd
    36. 36. Karolinska-Huddinge
    37. 37. Small family room when the mother has recovered,Small family room when the mother has recovered, e.g., from her pre-eclampsia and/or c-sectione.g., from her pre-eclampsia and/or c-section
    38. 38. Family lounge. NB the wireless monitoring of accompanying infant
    39. 39. Family lounge. NB the kangaroo position and the leeds implying a saturation monitor in the mother’s pocket
    40. 40. Nurse station with the central for the wireless monitors
    41. 41. Nurse with beepers connected to the wireless monitors
    42. 42. Synactive Model of Developmental Care H. Als
    43. 43. Large family room where we also care for mothers who are in need of medical care, except intensive care Couplet CareCouplet Care
    44. 44. Large family room where we also care for mothers who are in need of medical care, except intensive care Couplet CareCouplet Care
    45. 45. Large family room where we also care for mothers who are in need of medical care, except intensive care
    46. 46. Couplet care
    47. 47. Does developmental care stop at discharge?
    48. 48. Home visits: NIDCAP  IBAIP (Infant Behavioral Assessment Intervention Program)
    49. 49. Synactive Model of Developmental Care H. Als, 2007
    50. 50. Parental benefit – extension of days 180 210 270 360 450 480 0 100 200 300 400 500 600 1974 1978 1982 1986 1990 1994 1998 2002 2006 Children born from 1995 - 30 days can not be transferred to the other parent. Children born from 2002 - 60 days can not be transferred to the other parent. Temporary parental benefit when the child is ill 60 + 60 days/ parent and year, can be extended if there is a life-threatening condition (~< 32+0 wks) General parental benefit:
    51. 51. The Stockholm Neonatal Family Centered Care Study: effects on length of stay and infant morbidity A Örtenstrand, B Westrup, E Berggren Broström, I Sarman, S Åkerström, T Brune, L Lindberg, U Waldenström Karolinska Institute, Stockholm Sweden Pediatrics Jan. 2010;125: e278–e285
    52. 52. Annica Örtenstrand 70 Intervention: True (?) family centered care – parents could stay 24 / 7 from admission to discharge  parents had a separate room in the unit from the first day.  The infants moved from the “acute” room into the family rooms as soon as they reached a stable state.
    53. 53. Infants randomized into the study Randomized infants n = 366 with congenital disease: 2 Allocated to family care: 183 Allocated to standard care: 183 (1 infant death) with congenital disease: 5 Analyzed by Intention-to-treat: 183 Without congenital disease: 181 Analyzed by Intention-to-treat: 182 Without congenital disease: 177
    54. 54. Annica Örtenstrand 72 Included infants Family care n = 183 Standard care n = 182 Gestational age at birth 24 – 29, n (%) 28 (15.3) 31 (17.0) 30 – 34, n (%) 102 (55.7) 103 (56.6) 35 – 36, n (%) 53 (29.0) 48 (26.4) Pair of twins 21 24
    55. 55. Annica Örtenstrand 73 Length of stay in hospital Adjusted for: gestational age at birthA , non-Swedish-speaking backgroundA,B , settingA,B Family care n = 183 Standard care n = 182 difference days All infants A , mean 27.4 32.8 -5.3 (p= .05) By gestational age B 24 – 29 w, mean 56.6 66.7 -10.1 (p= .02) 30 – 34 w, mean 19.2 23.6 -4.4 (p= .16) 35 – 36 w, mean 6.4 7.9 -1.4 (p= .39)
    56. 56. Annica Örtenstrand 74 Length of stay in intensive care (level II and level III) Adjusted for: gestational age at birthA , non-Swedish-speaking backgroundA,B , settingA,B Family care n = 183 Standard care n = 182 difference days All infants A , mean 13.3 18.0 -4.7 d (p= .02) By gestational age B 24 – 29 w, mean 32.4 43.1 -10.6 d (p= .04) 30 – 34 w, mean 6.0 8.5 -2.5 d (p= .02) 35 – 36 w, mean 1.5 2.5 -1.0 d (p= .24)
    57. 57. Annica Örtenstrand 75 Infant morbidity Adjusted for: gestational age at birth, non-Swedish-speaking background, setting Family care n = 183 Standard care n = 182 OR (95% CI)A Verified Sepsis, % 7.1 9.8 0.68 (0.3-1.6) Verified NEC, % 2.7 3.3 0.83 (0.2-2.8) Diagnosed. PDA, % 15.3 16.9 0.90 (0.4-1.9) IVH grade II-III, % 3.3 3.8 0.95 (0.3-3.2) ROP stage II-V, % 2.7 6.6 0.34 (0.1-1.1) BPD moderate-severe, % 1.6 6.0 0.18 (0.04-0.8)
    58. 58. Annica Örtenstrand 76 Ventilatory assistance and supplemental oxygen Adjusted for: gestational age at birth, non-Swedish-speaking background, setting All infants Family care n = 183 Standard care n = 182 difference Respiratory support n (%) 90 (49) 109 (60) OR: 0.65 (0.4-1.0) Mecanical ventilation days, mean 0.6 1.3 -0.7 CPAP, days, mean 6.5 8.7 -2.2 Supplimental oxygen days, mean 11.0 12.2 -1.3
    59. 59. Family care might operate through the common pathhways of pain and stress Parents in Family care may have a greater opportunity to co-regulate the caregiving with the needs of the infant time the care-giving Parental presence/skin-to-skin may contribute to better sleep organization
    60. 60. Annica Örtenstrand 78 Conclusion Family care in a level-II NICU, where parents could stay 24 hours per day from admission to discharge may reduce … length of stay for preterm infants bronchopulmonary dysplasia
    61. 61. Time to stop?! Photo Ann-Sofie Gustafsson, Karolinska NIDCAP Training Center
    62. 62. Ultra-Early Intervention Karolinska-Danderyd, 18 November 2010 Visit the link or google and follow the conference on the internet - in real time or any time later in toto or in parts for in-house education for staff or at home on your pc! http://web22.abiliteam.com/ability/show/khcichp/abbott_20101118/speed.as
    63. 63. Staff’s (expert?) opinion
    64. 64. The staff’s experience of NIDCAP in Falun, Sweden Westrup, Kleberg, Wallin et al. Evaluation of NIDCAP in a Swedish Setting. Prenatal and Neonatal Med.1997;2:366-75 -5 -4 -3 -2 -1 0 1 2 3 4 5 Parents’: Presence Way of care Attachment Caregiving plans and Parents’: Presence Way of care Attachment
    65. 65. -5-4-3-2-1012345 -5=moinsbon,0=inchangé,5=meilleur(moyenne+/-é The staff’s experience of NIDCAP in Brest, France Mambrini C, Sizun J et al. Implantation des soins de développement et comportement du personnel soignant. Arch Pediatr. 2002 May; 9 Suppl 2:104s-106s. Mean, sd Parents’:Parents’: PresencePresence AttachmentAttachment
    66. 66. The staff’s experience of NIDCAP in Brussels Christine Rémont & Yves Hennequin (Int. Conf. on Infant Development in Neonatal Intensive Care, London 2003) Parents’: Presence Attachment
    67. 67. The staff’s experience of NIDCAP inThe staff’s experience of NIDCAP in LeidenLeiden Van der Pal, SM et al. Early Hum Dev (2007) 83, 425-432.Van der Pal, SM et al. Early Hum Dev (2007) 83, 425-432. Parents’: Presence Way of caring Attachment Caregiving plans and parents’: Presence Way of caring Attachment
    68. 68. Scandinavian NIDCAP Center NIDCAP in Nordic countriesNIDCAP in Nordic countries 4th Nordic Neonatal Meeting, 20-21 Nov, 20094th Nordic Neonatal Meeting, 20-21 Nov, 2009 Björn WestrupBjörn Westrup Karolinska Institutet, Stockholm SwedenKarolinska Institutet, Stockholm Sweden Photo Ann-Sofie Gustafsson, Scandinavian NIDCAP CenterPhoto Ann-Sofie Gustafsson, Scandinavian NIDCAP Center
    69. 69. www.nidcap.org
    70. 70. NIDCAP Training Centers US: 10 Ctrs. EU: 5 Ctrs. S. Am: 1 Ctr.
    71. 71. US Training Centers
    72. 72. European Training Centers UK Ctr French Rotterda m Karolinska Sthlm Brussels
    73. 73.  ........20th annual NIDCAP Trainers meeting materialspresentationsSa
    74. 74. NIDCAP activity in Sweden Certified Persons (units) Trainees Persons (units) 2007 2006 2005 2004 54(18) 50(16) 45(16) 43(15) 29(10) 28(10) 25(8) 2003 26(11) 37(10) 2002 20(10) 36(12) 2001 17(9) 38(11) 1994 7(4) 1992 3(2)
    75. 75. Swedish neonatal units with NIDCAP (certified professionals or persons in training)  KUS-Solna,  KUS-Danderyd  KUS-Huddinge  SÖS  Uppsala  Lund  Malmö  Helsingborg  Halmstad  Borås  Möndal  Östra  Falun  Skövde  Örebro  Västerås  Linköping  Karlstad  Trollhättan  Jönköping  Växjö  Kalmar  Karlskrona  Umeå  Östersund 25 units including all universities
    76. 76. Norwegian neonatal units with NIDCAP Sted Introduserte Sertifiserte Trainer-in-Training Tromsø 4 3 Trondheim 3 3 Levanger 3 2 Ålesund 12 5 2 Førde 2 2 Bergen 4 3 Haugesund 1 1 Stavanger 4 3 Kristiansand 1 1 Lillehammer 2 2 Rikshospitalet 1 1
    77. 77. Neonatal units with NIDCAP in other nordic countries (certified professionals or persons in training) Denmark  Copenhagen 2 prof 2 trainees  Aarhus 2 prof 2 trainees  Hvidovre 1 trainee  Hilleröd 2 prof 4 units including 3 universities units Finland  Helsinki 1 trainee Iceland
    78. 78. Scandinavian NIDCAP Center Scientific context ofScientific context of family centred developmentallyfamily centred developmentally supportivesupportive coupletcouplet carecare / NIDCAP/ NIDCAP 4th Nordic Neonatal Meeting, 20-21 Nov, 20094th Nordic Neonatal Meeting, 20-21 Nov, 2009 Björn WestrupBjörn Westrup Karolinska Institutet, Stockholm SwedenKarolinska Institutet, Stockholm Sweden Photo Ann-Sofie Gustafsson, Scandinavian NIDCAP CenterPhoto Ann-Sofie Gustafsson, Scandinavian NIDCAP Center
    79. 79. Brain development Evrard P, et al Acta Paediatr suppl 422,20-6. 1997
    80. 80. Number of invasive procedures (Barker and Rutter 1995)
    81. 81. It is too noisy! Does it matter?
    82. 82. Sound and physiological responses J Long, J Lucey, A Philip. Pediatrics 1980;65:143-45 One week old boy in an incubator, born at 34 weeks, BW 2020g Heart rate Sound level Respir. Tc-pO2 Intracran. pressure
    83. 83. Lehtonen L, et al. J Pediatr 2002;141:363-9 Relation of sleep state to hypoxemic episodes in ventilated ELBW infants
    84. 84. Behavioral science: something for ’docs’?  "The behavior of the infant is its primary way to communicate” (Als – developmental psychologist at Harvard)  "Behavior is produced by networks of interacting nervcells” (Sten Grillner - Neuroscientist at Karolinska Institute
    85. 85. The Synactive Theory subsystems: • Autonomic • Motor • State- • Attentional / Interactive The synactive theory focuses on how the individual infant handles environmen- tal experiences, and social interaction which can be supportive or disrupt the infant’s balance Whenever development occurs, it proceeds to a state of increasing differentiation Breathing: irregular, deep or shallow to smooth and regular. Movements: become better modulated and fine tuned; Sleep-wake states: Diffuse to robust The infant always strives for integration of the subsystems. Appropriate stimulus - infant will move towards the stimulus Inappropriate stimulus (timing, too complex or to intense) – the infant will move away
    86. 86. Autonomic-physiologic system • Circulation • colour • respiration •Bowel movements •Temperature control • Tremor, jitternes
    87. 87. Motor system
    88. 88. State system
    89. 89. Attentional and interactive system
    90. 90. selfregulation
    91. 91. What is the scientific support, the level of evidence?
    92. 92. Short-term outcome  A positive impact is indicated on... Pulmonary morbidity (Als ’94, ’03, ‘04, Fleisher ’95, Westrup ’00, Peters ‘04) Neurophysiology (Als ’94 & ‘04, Buehler ’95) and to some degree on... Head growth (Stevens ’97, Westrup ’00, Maguire ’03, Als 03 ) Brain lesions (Als ’94, Fleisher ’95, Westrup ’00, ’02) Length of stay (Als ’94, 03 , Fleisher ’95, Westrup ’00, Peters 04) Costs (Becker ’91, Als ’94,’03, Fleisher ’95, Petryshen ’97, Brown ‘97)
    93. 93. Long-term outcome  A positive impact is clearly indicated on... Mental development up to 9/12 months (Als ’94 & ‘04, Ariagno ’97, Kleberg ’02, Peters 08) and to a some degree on... Motor development up to 9/12 months (Als ’94 & ‘04, Ariagno ’97, Kleberg ’02) Long-term behavior (Kleberg ‘02, Westrup ‘04) Performance intelligence (Westrup ‘04) Mother-infant interaction (Kleberg ‘00)
    94. 94. Does NIDCAP improve outcome? Level of evidence Results of most RCTs point in a positive direction Most published RCTs are few and with small n:s Observational studies are also supportive Clear cut study designs are difficult to achieve Most follow-up periods are short Few trials on cost-effectiveness (prim. outc.) Recommendation Acquire the “know how” in your nursery In order to be able to … Engage in future research
    95. 95. Sleep of preterm neonates under developmental care or regular environmental conditions 0 20 40 60 80 100 120 140 160 180 TST AS QS IS LAT duration(mn) DC CONTROL     V Bertelle, J Sizun et al. Early Hum Dev 2005;81:595-600V Bertelle, J Sizun et al. Early Hum Dev 2005;81:595-600
    96. 96. Weighing  Lift the baby out to the scale wrapped in a soft towel to help him maintain balance
    97. 97. Physiological, behavioral and biological stress expression during a weighing procedure. Catelin et al. J Pain 2005 0 1 2 3 4 5 6 zero* 5min 30min score < 32 w 0 1 2 3 4 5 6 zero* 5min* 30min* score 0 1 2 3 4 5 6 zero 5 min* 30 min score > 37w * ** * * 32 > GA < 37w EDIN White: dev care Black: conv. care
    98. 98. Salivary cortisol (µg/dl) 0,0 0,2 0,4 0,6 0,8 1,0 before weighing 30 min after weighing salivarycortisol DC Control < 32 w > 32 ;< 37w 0,0 0,2 0,4 0,6 0,8 1,0 Before 30 min after Salivarycortisol DC Control Physiological, behavioral and biological stress expression during a weighing procedure. Catelin et al. J Pain 2005
    99. 99. 0 2 4 6 8 10 12 V O2 V CO2 DC Control * * p<0.01 * * p<0.05 ml/min * * Reduced O2 consumption and CO2 production when supported by developmental care Impact of Developmental Care on Oxygen Consumption & CO2 emission in Preterm Neonates L.Jacquemot, T.Testa, J.Delarue, J.Sizun. Abstract: 18th Annual NIDCAP Trainers’ Meeting Combrit, October, 2007 The Green way
    100. 100. Effect from NIDCAP-intervention during/after eye examination for ROP Kleberg et al. Lower stress responses after Newborn Individualized Developmental Care and Assessment Program care during eye screening examinations for retinopathy of prematurity: a randomized study. Pediatrics. 2008 May;121(5):e1267-78.  No effect on pain scores  Salivary cortisol decreased earlier after NIDCAP- intervention
    101. 101. Intervention scores for ”standard care” approaches NIDCAP with increasing number of examinations in an open study evaluating support during ROP-examinations Examination number in study 706050403020100 Summaryofintervention 60 50 40 30 20 Intervention NIDCAP Standard care Kleberg et al,
    102. 102. Support during painful procedures
    103. 103. Shield infant from bright light and offer your finger to suck on
    104. 104. Sidelying, flexed position, support of the back and hands in the midline by the mouth
    105. 105. Infants with catheters or chest tubes requires more visual access but could be supported
    106. 106. The Edmonton NIDCAP Trial Peters et al, Pediatrics Oct 2009 NIDCAP N=56 CONTROL N=55 OR Gestational age 27,5 (1.4) 27.0 (2.3) ns Birth weight 988.2 (183.7) 927.1 (204.0) ns
    107. 107. The Edmonton NIDCAP Trial Peters et al, Pediatrics Oct 2009 NIDCAP N=56 CONTROL N=55 OR Gestational age 27,5 (1.4) 27.0 (2.3) ns Birth weight 988.2 (183.7) 927.1 (204.0) ns Length of stay (mean) 74 84 0.003 Chronic lung disease 29% 49% 0.42 (0.18-0.95) 0.035
    108. 108. The LeidenTrial Maguire et al, Pediatrics Apr & Oct 2009 NIDCAP N=81 CONTROL N=83 OR Gestational age 29.3 (1.8) 29.2 (1.6) ns Birth weight 1215 (328) 1226 (343) ns
    109. 109. The LeidenTrial Maguire et al, Pediatrics Apr & Oct 2009 NIDCAP N=81 CONTROL N=83 OR Gestational age 29.3 (1.8) 29.2 (1.6) ns Birth weight 1215 (328) 1226 (343) ns Length of stay (mean) 41.5 (30.9) 40.4 (37.9) ns Chronic lung disease 15% 19% ns
    110. 110. Early experience alters brain function and structure Als H, Duffy F, McAnulty G, Rivkin M, Hüppi P et al. Pediatrics 2004; 113: 846-857 NIDCAP N: 16 Control N: 14 Gestational age 31.2 (1.4) 31.8 (1.5) Birthweight 1648 (232) 1730 (350) SNAP-PE 8.0 (4.4) 7.4 (3.6)
    111. 111. Developmental care, brain structure and function Als H, Duffy F, McAnulty G, Rivkin M, Hüppi P et al. Early experience alters brain function and structure. Pediatrics 2004; 113: 846-857 At term  Better neurobehavioral functioning (APIB)  Increased cortical coherence (spectral EEG)  More mature fiber structure (MRI-DTI) At 9 months: improved mental, motor and behavioral function (Bayley Scale of Infant Development-II)
    112. 112. EEG coherence: Red=positive/increased, blue=negative, green=decreased. Als et al 2004.
    113. 113. Anisotropy E1/E3 – threshold ≥ 1.3 Arrows –white : Frontal White Matter black : Internal Capsule (posterior limbs) at a post menstrual age of 42 weeks Control (A) NIDCAP (B) Diffusion Tensor Imaging BA Aals H, Duffy F, Rivkin M, Hüppi P et al. Early experience alters brain function and structure. Pediatrics 2004; 113: 846-857
    114. 114. Study population For example …  Early experience alters brain function and structure (Als 2004) Gestational age: ~31 wks; birth weight: ~1700g  Leiden II Gestational age: ~29 wks; birth weight: ~1200g  Edmonton NIDCAP Trial Gestational age: ~27 wks; birth weight: ~950g
    115. 115. Selection/enrolment of subjects – the sample  Bias of selection? Inborn / Outborn  Leiden II: ~60% / 40%  Edmonton NIDCAP Trial: ~95% / 5% Periods of stopped enrolment  Edmonton NIDCAP Trial lost 39 eligible infants due to investigators were not available
    116. 116. Intervention: fidelity and contrast  Were the infants in the intervention group in Leiden II getting it?  ~15 infants were enrolled every month (2/week) “After inclusion in phase 1 was completed and before starting inclusion of infants into phase 2, we spent 2 months providing extra lessons to a team of nurses that would be primarily caring for the NIDCAP infants. … There were 5 nurses in the group who were completing NIDCAP training and who became certified and were able to assist under guidance from the developmental psychologist in carrying out NIDCAP observations and supporting the care team, infants and parents”  Only 21 NIDCAP and 23 control infants stayed more that 1½ month in the study hospitals
    117. 117. Intervention: fidelity and contrast Are the infants in the control group not getting it is there adequate contrast or is there a spill-over effect? Leiden:12 intensive care +17 high care =29 beds (184 infants during 2 years)  Leiden: 8 intensive care beds and 8 “high care” beds  The Hague: 4 intensive care beds and 9 “high care” beds Edmonton: 55 beds (110 infants during 5 years. Only one of the control infants received NIDCAP-educated nursing care hours) The Stockholm experience The Lund-London experience
    118. 118. Intervention scores for ”standard care” approaches NIDCAP with increasing number of examinations in an open study evaluating support during ROP-examinations Examination number in study 706050403020100 Summaryofintervention 60 50 40 30 20 Intervention NIDCAP Standard care Kleberg et al,Kleberg et al,
    119. 119. Cultural and demographical context  Socioeconomic status SES Leiden II Education level of the mother Low 22/66 (33.3%) vs. 19/74 (25.7%) Intermediate 23/66 (34.8%) vs. 25/74 (33.8%) High 21/66 (31.8%) vs. 30/74 (40.5%) Edmonton NIDCAP Trial SES score (Blishen) median (range) 41(21-101) vs. 39 (21-101)
    120. 120. Long-term effect
    121. 121. The Edmonton NIDCAP Trial Peters et al, Pediatrics Oct 2009 NIDCAP N=56 CONTROL N=55 OR Gestational age 27,5 (1.4) 27.0 (2.3) ns Birth weight 988.2 (183.7) 927.1 (204.0) ns Length of stay (mean) 74 84 0.003 Chronic lung disease 29% 49% 0.42 (0.18-0.95) 0.035 Mental delay at 18 months 10% 30% 0.25 (0.08-0.82) 0.017 Severe disability at 24 months 6% 20% 0.25 (0.06-0.97) 0.034
    122. 122. The LeidenTrial Maguire et al, Pediatrics Apr & Oct 2009 NIDCAP N=81 CONTROL N=83 OR Gestational age 29.3 (1.8) 29.2 (1.6) ns Birth weight 1215 (328) 1226 (343) ns Length of stay (mean) 41.5 (30.9) 40.4 (37.9) ns Chronic lung disease 15% 19% ns Mental delay at 24 months 7.9% 4.0% ns Severe disability at 24 months 19.1% 12.8% ns
    123. 123. Cognitive Indices atCognitive Indices at oneone** andand fivefive yearsyears Acta Paediatrica 2004;93:1-10Acta Paediatrica 2004;93:1-10 Bayley Mental Index;Bayley Mental Index; Wechsler Preschool and Primary Scale of IntelligenceWechsler Preschool and Primary Scale of Intelligence (WPPSI)(WPPSI) 159 1111N = five yearsone year Cognitiveindex 140 130 120 110 100 90 80 70 60 50 40 30 20 NIDCAP Conventional care *A Kleberg, B Westrup, H Lagercrantz, K Stjernqvist. Early Human Development 2002;60:123-35
    124. 124. Performance IQ and mortality at 5 yearsPerformance IQ and mortality at 5 years (WPPSI-R PIQ, corrected age)(WPPSI-R PIQ, corrected age) Acta Paediatrica 2004;93:1-10Acta Paediatrica 2004;93:1-10 NIDCAP care Conventional care normal subnormal abnormal deceased Grading of performance cognition at five years Pies show counts n=9 n=2 n=2 n=9 n=2 n=4 n=4 Odds RatioOdds Ratio for surviving …for surviving … (95% CI)(95% CI) NIDCAP / ControlNIDCAP / Control P-valueP-value with PIQwith PIQ >> 7070 6.76.7 (0.7 – >100)(0.7 – >100) 0.110.11 Exact logistic regressionExact logistic regression correcting forcorrecting for gendergender,, gest age,gest age, relative birth-weight, edurelative birth-weight, edu
    125. 125. Behaviour and mortality at 5 yearsBehaviour and mortality at 5 years Subtests of the NEPSYSubtests of the NEPSY test battery: activity and distractibilitytest battery: activity and distractibility Acta Paediatrica 2004;93:1-10Acta Paediatrica 2004;93:1-10 normal minor behavioural deficits significant behavioural deficits deceased Behaviour at five year follow-up Pies show countsn=7 n=3 n=1 n=2 NIDCAP care Conventional care n=7 n=3 n=5 n=4 Odds RatioOdds Ratio for surviving …for surviving … (95% CI)(95% CI) NIDCAP / ControlNIDCAP / Control P-valueP-value with normal behaviorwith normal behavior 19.919.9 (1.1 – >100)(1.1 – >100) 0.040.04 Exact logistic regressionExact logistic regression correcting forcorrecting for gendergender,, gest age,gest age, relative birth-weight, edurelative birth-weight, edu
    126. 126. NEPSYNEPSY (Korkman M 1990)(Korkman M 1990)  Neuropsychologic test: two sub tests (level ofNeuropsychologic test: two sub tests (level of activityactivity andand distractibilitydistractibility ) were used, which can be) were used, which can be considered as measures of overt behaviour in theconsidered as measures of overt behaviour in the test situation regardingtest situation regarding  hyperactivityhyperactivity  attentionattention  The NEPSY scale is standardised in Sweden forThe NEPSY scale is standardised in Sweden for children 4 to 7 years of age.children 4 to 7 years of age.
    127. 127. Dev. outcome, child behaviour and mother-child interaction at three years of age following NIDCAP intervention. Falun, Sweden <1500g [Kleberg A, Westrup B, Stjernqvist K Early Human Dev 2000;60:123-135]
    128. 128. BEHAVIOURAL INTERVIEW* (*Cederblad-Höök at three years) CONTROLNIDCAP BEHAVIORALSCORE 30 25 20 15 10 5 0 INTERNALIZING EXTERNALIZING TOTAL FALUN NIDCAP STUDY NIDCAP Control p-value* <1500g 1990; n:15 1992-93; n:18 Internalizing 0 (0-2) 2 (0-8) 0.02 Externalizing 2 (0-10) 4 (0-18) ns Total 6 (0-20) 16 (0-54) 0.03 median (range) * (Mann-Whitney)
    129. 129. Family in development, Bonding / attachment
    130. 130. Family in development; Bonding / attachment
    131. 131. Agneta Kleberg et al, Early Hum Dev 2007 Staffs’ ability to support her motherhood 3.5 (2.9-3.9) 3.2 (2.3-3.7) 0.066 Closeness to her infant 4 (3-4) 3.5 (2-4) 0.022 Anxiety 3.1 (2.0-3.7) 2.5 (1.3-3.3) 0.033 Mothers’ opinion NIDCAP n=10 Control n=10 P-value Median (range); Mann-whitney U test if not otherwise indicated; Fisher’s Exact-test tested for subscales with only one or two items
    132. 132. Discussion Closeness Anxiety
    133. 133. 0% 20% 40% 60% 80% 100% infant in general safety of infant parents participation physician's working condition staff's working condition costs considerably positive positive none negative considerably negative no opinion B.Westrup, K. Stjernqvist, A. Kleberg, L. Hellström-Westas,H. Lagercrantz.B.Westrup, K. Stjernqvist, A. Kleberg, L. Hellström-Westas,H. Lagercrantz. Seminars in Neonatology 2002;7:447-457.Seminars in Neonatology 2002;7:447-457. Swedish physicians’ view of NIDCAP’s influence onSwedish physicians’ view of NIDCAP’s influence on ......
    134. 134. Observe
    135. 135. interpret
    136. 136. Support theSupport the …
    137. 137. … self-regulation, stability, and possibly interaction
    138. 138. B
    139. 139. Dev Care is not a new science but integrating natural science with behavioural science. Is it now time to let our actions be geared by Seeing/observing and Respecting? Giotto 1267-1337 Capella degli Scrovegni, Padova
    140. 140. Disability and mortality at 5 years Acta Paediatrica 2004;93:1-10 NIDCAP care Conventional care Normal Impaired without disability Moderately disabled Severely disabled Deceased Outcome at five year follow-up Pies show counts n=4 n=4 n=1 n=2 n=2 n=6 n=1 n=5 n=3 n=4 Odds Ratio for surviving … (95% CI) NIDCAP / Control P-value without disability 14.7 (0.8 – >100) 0.08 Exact logistic regression correcting for gender, gest age, relative birth-weight, education of parents
    141. 141. Overall cognition and mortality at 5 years (WPPSI-R FSIQ, corrected age) Acta Paediatrica 2004;93:1-10 NIDCAP care Conventional care normal subnormal m-retarded deceased Grading of overall cognition at five years Pies show counts n=9 n=1 n=1 n=2 n=9 n=2 n=4 n=4 Odds Ratio for surviving … (95% CI) NIDCAP / Control P-value with FSIQ > 70 3.5 (0.5 – 42) 0.29 Exact logistic regression correcting for gender, gest age, relative birth-weight, education of parents
    142. 142. The term and healthy - the vast majority of infants! A paper to be defended at a dissertation at the Karolinska next month (examiner: Marshall Klaus) Effect of closeness versus separation after birth and influence of swaddling on mother-infant interaction one year later: a study in St. Petersburg Ksenia Bystrova, Kerstin Uvnäs-Moberg, Ann-Marie Widström et al (submitted - revision) Indicating the great importance of non-separation during the first couple of hours
    143. 143. Does infant behavior reflect findings in brain structure? Structural and neurobehavioral delay in postnatal brain development of preterm infants Hüppi PS et al. Pediatr Res 1996;39:895-01
    144. 144. [Hüppi PS et al. Pediatr Res 1996;39:895-01]  preterm group: 18 infants (30.5+1.8 wk) without need of mechanical ventilation or suspect neurologic conditions  term control group: 13 AGA (39.1+0.9 wk) Assessed in the1st-3rd wk postnatally & at term with  MRI  Assessment of Preterm Infant’s Behavior (APIB) Als current ability to process environmental input level of smooth balanced functioning
    145. 145. Results: [Hüppi PS et al. Pediatr Res 1996;39:895-01]  preterm group: MRI-findings: maturation over time with an increase in gray-white matter differentiation & myelination delayed in comparison with the term infants Behavioral findings: a parallel maturation of the APIB scores delayed in comparison with the term infants  increased autonomic reactivity  increased motor reactivity  delayed state organization  delayed attentional availability
    146. 146. Risk of High Blood Pressure among Young Men Increases with Degree of Immaturity at Birth 0 1 2 24-28 29-32 33-36 37-41 42-43 Diastolic BP ≥90 mm Hg Systolic BP ≥140 mm Hg Gestational Weeks AdjustedOR Johansson, Iliadou, Bergvall, Norman et al. Circulation 2005:112:3430-3436
    147. 147. Kangaroo- Mother- Care Dean 24+6 Now one week
    148. 148. Kangaroo Mother Care Bogota VLBW infants: Skin to skin 24 hrs/d, early discharge and frequent, regular out-patient check-ups Aim: lower mortality/morbidity support the bonding and prevent abandoning support breast feeding Whitelaw & Sleath 1985, Gomez, Sanabria, Marquette 1992
    149. 149. Kangaroo Mother Care Juan G. Ruiz - Nathalie Charpak, Bogota Colombia (Pediatrics 1997, 1998, 2001. Infant Behaviour and Development 2003 benefits in:  mortality  early infectious morbidity  growth and development  promotion and maintenance of breast feeding  a healthy bonding between mother and infant  a better cranial growth  neurodevelopment  the provision of nurturing home environment Applicable in more affluent societies? More research!!
    150. 150. Videoclip: Transition from skin-to-skin to incubator
    151. 151. RCT of skin-to-skin contact from birth versus conventional incubator care for physiological stabilisation in 1200 - 2199-gram newborns. Cape Town, South Africa Bergman NJ, Linley LL, Fawcus SR. Acta Paediatrica 2004, 93(6); 779-785
    152. 152. SCRIP SCORE 2 1 0 Heart rate Regular Deceleration to 80-100 Rate <80 or >200 bpm Respiratory rate Regular Apnea <10s, or periodic breathing Apnea >10s Tachypnea >80 pm Oxygen saturation Regular >87% Any fall to 80 – 87% Any fall below 80% Stability of Cardio-Respiratory system In Preterm Infants Score allocated for a five minute period of continuous observation, maximum six for period. (Fischer et al, 1988)
    153. 153. Background characteristics Minimisation technique ensured groups balanced for confounders. ( n = 34) Kangaroo-Mother- Conventional-Mother- Care KMC Care CMC Mean BW 1813g 1866g Mean GA 34.2w 35.3w Approp’ GA 65% 64% Male 60% 50% Bergman NJ et al, Acta Paediatrica 2004, 93(6); 779-785
    154. 154. STABILIZATION TREND. SKIN-TO-SKIN (KMC): STABLE AT 6 hours INCUBATOR INFANTS (CMC) REMAIN UNSTABLE, WITH NO TREND TO STABILIZATION. BIRTH RCT - SCRIP SCORES 4 5 6 60min 90min 120min 150min 180min 210min 240min 270min 300min 315min 330min 345min 360min KMC CMC Bergman NJ et al, Acta Paediatrica 2004, 93(6); 779-785
    155. 155. Stabilisation first 6 hours, average hourly SCRIP score 5.1 5.2 5.3 5.4 5.5 5.6 5.7 5.8 5.9 6 6.1 2nd 3rd 4th 5th 6th KMC all KMC <1800 CMC all CMC <1800 Bergman NJ et al, Acta Paediatrica 2004, 93(6); 779-785
    156. 156. The Stockholm Family Study A Örtenstrand, B Westrup, E Berggren Broström, I Sarman, S Åkerström, T Brune, L Lindberg, U WaldenströmKarolinska Institute N= Family Care Standard Care 182 183 Total length of hospital stay was reduced by 5.3 days: mean 32.8 (95% CI:29.6-35.9) days vs. 27.4 (23.2-31.7) days (p=0.05). Moderate to severe BPD 1.6% vs 6.0% (adjusted OR 0.18; 95% CI: 0.04-0.8).
    157. 157. Moderately preterm infants and determinants of length of hospital stay M Altman, M Vanpée,S Cnattingius, M Norman Arch Dis Child Fetal Neonatal Ed 2009;94:F414–F418 Population-based cohort including 2388 infants (2004–2005) with a gestational age of 30–34 weeks and admitted to 21 NICU:s reporting to the Swedish perinatal register.  Mean postmenstrual age (PMA) at discharge differed 2 weeks  Perinatal risk factors had small overall impact (R2 : 13%) (explains 13% of the variation)  Organizational factors in combination with perinatal risk factors had a greater impact: R2 : 21% (explains 21% of the variation).  Infants treated at NICU without fixed discharge criteria: -4.7days PMA  infants receiving domiciliary care: -9.8 days PMA  Breastfed infants also had lower PMA at discharge: -2.7 days PMA (partly explained by lower morbidity in the breastfed infants)
    158. 158. Outline  Patient flow Delivery Maternity Neonatal nursery  Family centered care  Couplet care New units design plans Team work Coaching Revenue issues
    159. 159. Delivery and maternity at Karolinska- Danderyd  Approx 10,000 deliveries / year 230 twins, 3 triplets 400 born prematurely - 5.8%
    160. 160. Delivery and maternity at Karolinska- Danderyd  Approx 10,000 deliveries / year 230 twins, 3 triplets 400 born prematurely - 5.8%
    161. 161. Delivery and maternity at Karolinska- Danderyd  Planned C-sections: 16 beds for 26 c-sections/week LOS: two days week-ends closed
    162. 162. Delivery and maternity at Karolinska- Danderyd  Approx 10,000 deliveries / year 230 twins, 3 triplets 400 born prematurely - 5.8%  Planned C-sections: 12 beds for 18 c-sections/week LOS: two days week-ends closed  Maternity and prenatal care: 24 beds
    163. 163. Delivery and maternity at Karolinska- Danderyd  Patient Hotel; 24 beds Uncomplicated delivery admitted after 2-6 hours after delivery Midwifes on each shift LOS: 2 nights for primipara. One night for multipara
    164. 164. Delivery and maternity at Karolinska- Danderyd  Approx 10,000 deliveries / year 230 twins, 3 triplets 400 born prematurely - 5.8%  Planned C-sections: 12 beds for 18 c-sections/week LOS: two days week-ends closed  Maternity and prenatal care: 24 beds  Patient Hotel; 24 beds Uncomplicated delivery admitted after 2-6 hours after delivery Midwifes on each shift LOS: 2 nights for primipara. One night for multipara
    165. 165. Karolinska-Danderyd  8 beds for mothers in need of medical care – Couplet Care  Mean cencus 3.4 mothers (42%)  Mean length of stay 1.7 days
    166. 166. Dept of Neonatology at the Karolinska University Hospital  Three NICU:s (Solna, Danderyd & Huddinge)  22 000 births/year, approx 2500 admittances/year  5% < 37 weeks  74 beds 14 beds for mechanical ventilation  37 rooms for families within the units Only 30 with private bathrooms  Political decision to provide family rooms for everyone
    167. 167. Vanpee et al Acta Paediatrica 2007;96:10-16
    168. 168. Practice style for resuscitation Inborn infants with GA <28 wks, 07/2001 to 06/2003 Boston n = 70 Stockholm n = 102 P value Bag/mask ( %) 59 (84) 79 (77) ns Intubation () 70 (100) 45 (44) P < 0.000 CPAP only (%) 0 (0) 21 (21) P<0.0001 Surfactant # doses 2.3 1.5 P<0.0001

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