The majority of babies born prematurely do well and develop normally, however, the risk of developmental problems is considerably higher than in the rest of the population and the risk increases proportionately with the degree of prematurity. About half of the infants born preterm (before 28 weeks) will require some form of specialist help when they start school: for those born between 28 and 32 weeks this figure decreases to 30%. The range of problems is wide and they often overlap or present in clusters so that a child may have a complex developmental profile. Problems include:
- Altered pain perception
- Anxiety and Depression
- Attachment disorders
- Attention deficit disorder
- Behavioural problems
- Cerebral Palsy
- Cognitive deficits
- Co-ordination disorders
- Executive Functions
- Feeding problems
- Hearing loss
- Hyperactivity (related to attention deficit)
- Language delay
- Perceptual motor problems
- Sensory Processing
- Social isolation
- Specific learning deficits (e.g maths)
- Visual deficits
Developmental care improves the potential of infants who are disadvantaged by premature birth or adverse perinatal events by supplementing and humanizing high tech medical care.
In many units the focus of developmental care is Family Centered Care (FCC). In FCC units the importance of the family as the most significant influence on the infant’s well being and development is underlined and parents and healthcare professionals work in partnership, with open communication. FCC places the infant firmly in the context of the family, acknowledging that the family is the most constant influence on an infant’s development. Adjusting to parenting in the NICU following a traumatic birth experience or pre-term delivery can be difficult. Assisting mothers and fathers adapt to their parenting roles in the NICU is part of developmental care. FCC is sensitive to the nature of personal, social and cultural influences upon each family.
Another view of developmental care focuses on the NICU environment, particularly in adapting the physical environment to provide appropriate sensory stimulation, to protect the baby from stress and to promote sleep. The immature central nervous system of the neonate is in a critical period of rapid growth and increasing specialization, all designed to take place in quite a different settling e.g. the mothers womb. The NICU is not the optimal sensory environment for preterm and newborn development. The infants’ behavioural cues are the best guide to whether or not the environment (sensory, temporal and social) is conducive to the current development needs of the infant and the environment needs to be organized in such a way to meet the infant’s developmental expectations.
Individualised developmental care is care that is responsive to the ever changing needs of the infant. Behavioural cues help us understand the infant’s competency, strengths, sensitivity, vulnerability and developmental goals. The leading mode of individualized developmental care is the NIDCAP- Newborn Individualised Developmental Care and Assessment Programme. Many of the NICUs in Ireland have NIDCAP trained professionals. To learn more about NIDCAP visit www.nidcap.org.
MEETING THE NEEDS OF THE NEONATE
Physiological stability is important for brain development. The way that the NICU environment, light and noise, the timing of events, handling and positioning can have a positive or negative effect on heart beat, respiratory pattern, oxygenation, intracranial pressure, temperature and oxygen consumption.
Minimising the pain and stress of the neonate because of the long term impact on behaviour and sensory processing is an important aspect of developmental care. Many benign routine aspects of neonatal care such as nappy change and bathing can be stressful for the premature infant and developmental care ensures that such procedures are adapted to minimize distress to the infant.
Protecting Sleep. REM or active sleep is associated with brain development whilst quiet sleep is associated with growth. Sleep protection relies on the caregiver’s ability to distinguish different states of arousal.
Enhanced nutrition. Developmental care can support nutrition by helping the infant to conserve energy and to digest food in addition to providing effective support for breast feeding.
Appropriate sensory experience. Certain kinds of stimulation are required to trigger normal development whilst inappropriate stimulation that is out of phase with developmental brain expectation can result in some systems failing to develop. By observing the infants behaviour the caregiver can learn which sensory stimulations are appropriate.
Parenting and attachment. Parenting style has a significant impact on development and learning how their infant communicates is an integral component of developmental care for families. The high tech environment of the NICU can have an adverse impact upon attachment. Developmental care facilitates this attachment process and allows the parent/infant relationship to develop, supports the parents as they get to know their infant and grows their confidence as primary caregivers.
Protecting postural development. Development care can protect infants from the acquired postural deformities that can result from long periods of lying flat on a bed (e.g flat head syndrome), retracted shoulders (e.g.arms held in the W position), legs abducted and externally rotated (e.g. frog leg position), and torticollis. Adequate positioning support combined with frequent position changes can counteract these deformities which can otherwise delay the acquisition of skills such as sitting and walking, self comforting, feeding and fine motor co-ordination.
EXAMPLES OF DEFENSIVE/AVOIDANCE BEHAVIOUR IN THE NEONATE
Bracing position of legs
High guard hands
Limp or stiff posture
Mouth hanging open
Pauses in breathing
EXAMPLES OF COPING/APPROACH BEHAVIOUR IN THE NEONATE
Hands to mouth
Hands clasped together
Moving hand to face
One foot clasping the other
Orientation to voice or sound
Perky attentive expression
Relaxed open face
Soft flexed position
Snuggling when held
The senses mature in the following order:
- Vestibular (response to movement in space)
- Chemosensory (taste and smell)
Different kinds of touch activate different sensory receptors in the skin. Light, feathery touching can be arousing and preterm infants may react irritably. Gentle deep pressure touch is more soothing for the infant. Infants may seek comfort through tactile self-regulatory strategies such as grasping and bracing. Boundaries (nesting) , wrapping and cradling the feet, head or body with still hands have an organizing input.
The vestibular apparatus located in the inner ear responds to movement through space and the effects of gravity. Vestibular input is thought to promote maturation of the other systems.
The movement experienced by infants in the NICU is often sudden and unpredictable and their fragile vestibular systems can become easily overloaded. It is important that infants are prepared for position changes by providing adequate support and moving slowly and gently.
TASTE AND SMELL
The infant is exposed to many noxious smells in the NICU. Staff should minimize unpleasant olfactory experiences e.g alcohol wipes, plaster removers, strong perfume, strong hand creams etc, deliver medications separately from milk, and facilitate positive olfactory experiences by encouraging close contact with parents.
Taste may be affected by intrusive oral experience e.g. prolonged use of endotracheal tube and this may contribute to later feeding difficulties.
Protecting sleep is an important factor in auditory development and the sound environment of the NICU should be monitored to reduce background noise (e.g bins, phones, placing objects on the incubator). Background noise should be kept very quiet, average max. 45 decibels per hour as noise makes it difficult for the infant to hear and respond to the human voice. Parents should be encouraged to speak softly with their infant.
REM sleep is essential for development of the visual system. As the eyelids of the neonate are thin and let considerable light through, the ambient lighting of the NICU should be adapted e.g placing incubator covers over the isolettes. Pupil contraction reflex is only effective from 32 weeks and the infant is unable to regulate light entering the eye before then.
ATTENTION AND INTERACTION
Up to 32 weeks
Infants are easily overloaded by sensory experience.
The infant makes efforts to interact. Begins to fix and follow in optimal conditions. Will turn to locate sound. Needs time to respond.
Good quality alertness with increasingly competent self-regulation. Periodic waking related to feeding cycle. Will turn eyes and head to follow an object or locate a sound source. Can sustain suckle feeding.
Signs that the infant is displaying readiness for Interaction include alertness, bright-eyed look, perky expression with ooh shaped mouth, softly modulated body tone.
Signs that the infant may NOT be ready include hyper-alert or strained expression, low level alertness and low body tone.