Developmental Support

1. Developmental Support Denice Gardner, MSN, NNP-BC

2. Objectives • Discuss developmental support and its effect of the newborn

3. CNS Development • Six Stages • Stages 1-3(completed before 4th month of gestation) • Dorsal Induction • Ventral Induction • Neurogenesis • Stages 4-6(continues during the time the infant is in the NICU) • Neuron migration • Organization, including synaptogenesis & arborization • myelinization

4. CNS Development • Neuronal & glial cells originate in the germinal matrix • Neuronal & glial cells migrate from germinal matrix to their eventual location within the CNS where they differentiate & take on their unique functions • Neurons formed early in life lie deeper in cortex & neurons formed later lie in more superficial layers • Cortex generally has complete component of neurons by 33 weeks gestation

5. CNS Development • Organization- “the process by which the nervous system takes on the capacity to operate as an integrated whole” (Blackburn, 2003) • begins during the 6th month of gestation and continues years after birth • Neuron growth & connections lead to development of brain gyri & sulci • Organization of the CNS is critical for cortical & cognitive development • These processes may be particularly vulnerable to insults from the effects of the NICU environment.

6. CNS Development • Arborization- “wiring of the brain” • Dendritic connections between neurons critical for processing impulses, cell-to-cell communication, and communication throughout the CNS • Lack of connections cause hypersensitivity, poorly modulated behaviors, & all-or-nothing responses, frequently seen in preterm infants in the NICU

7. CNS Development • Synaptogenesis- formation of connection between neurons & development of intracellular structures & enzymes for neurotransmitter production • Critical for integration across all areas of the nervous system • Synapses continue to restructure throughout development & is thought to be the basis for memory & learning

8. CNS Development • Organizational processes & modification of neurons continue throughout adulthood but are particularly vulnerable during infancy. • The ability of a neuron to change structure & function has been called plasticity. (Huttenlocher, 2003) • The more immature the infant at birth the greater the impact of neural plasticity.

9. CNS Development • Neuronal differentiation & organization are controlled by the interaction of genes & environment. • The environment of the immature infant in the NICU & in the early months after discharge is critical for brain development and later cognitive function. (Lickliter,200a. 200b; Sizun & Westrup, 2004)

10. CNS Development • Plasticity: 2 types • Experience-expectant: linked to brain’s developmental timetable so specific sensory experiences are needed at specific times for neural development & maturation • Experience-dependent: involves interaction with the environment to develop specific skills for later use; involves memory & learning; allows development of flexibility, adaptation, & individual differences in social & intellectual development

11. Neurobehavioral Development • Self-regulation: infant’s efforts to achieve, maintain, or regain a balanced, stable, & relaxed state of subsystem functioning & integration. • Maintaining normal body temp • Regulating day-night cycles • Learning to calm oneself & relaxing after care • Later in life, controlling one’s own emotions & managing to keep one’s attention focused

12. Neurobehavioral Development • Synactive Theory of Development (Als and colleagues) • Autonomic/physiologic • Motor • State/organizational • Attentional/interactive: involves infant’s ability to orient & focus on sensory stimuli (faces, sounds, objects; i.e., external environment) • Self-regulatory

13. Neurobehavioral Development • Signs of Stability • Autonomic system • Even, regular respirations • Pink, stable color • Stable viscera with no seizures, gagging, emesis, grunting, tremors, startles, twitches, coughing, sneezing, yawning, sighing

14. Neurobehavioral Development • Motor system • Smooth, controlled posture • Smooth movement of extremities & head • Hand clasp • Leg/foot brace • Finger folding • Hand to mouth • Grasping • Sucking • Tucking • Hand holding • Good, consistent tone throughout body

15. Neurobehavioral Development • Signs of Stability • State system • Clear, well-defined sleep states • Self-quieting consolability • Focused, clear alertness with animated expressions

16. Neurobehavioral Development • Attentional Interaction System • Responsivity to auditory & visual stimuli that is bright & long in duration • Actively seeks out sounds and shifts attention smoothly on his/her own from one stimulus to another • Face: bright-eyed, purposeful interest varying between interest and relaxation • Self-regulatory System • Able to maintain each system-autonomic, motor, state, attention

17. Neurobehavioral Development • Signs of Stress • Autonomic System • Respirations: pauses, tachypnea, gasping • Color changes: paling around nostrils, perioral cyanosis, mottling, cyanosis, gray, flushed, ruddy • Viscera: hiccups, gagging, grunting, spitting, straining • Motor: tremor/startles, twitching, coughing, sneezing, yawning, sighing

18. Neurobehavioral Development • Signs of Stress • Motor System • Fluctuating tone • Flaccidity • Hypertonicity: leg extensions, salutes, airplaning, arching, finger splays, tongue extensions, fisting • Hyperflexions: trunk; extremities; fetal tuck; frantic, diffuse activity

19. Neurobehavioral Development • State System • Diffuse states • Sleep: twitches, sounds, jerky movements, irregular respirations, grimacing, fussing while sleeping • Awake: eye floating, glassy eyed, gaze aversion, staring, worried look, irritability

20. Neurobehavioral Development • Signs of Stress • Attentional Interaction System • Stress signals from other systems: irregular respirations, yawning, gaze aversion, hiccupping, etc.. • Becomes more stressed with more than one mode of stimuli • Self-Regulatory System • May use the following to gain balance • Lower state • Postural changes • Motor strategies: leg/foot bracing, hand to mouth, sucking, etc. • Self-quieting & consoling

21. Neurobehavioral Development • Stress Reducing Strategies • Autonomic System • Modify environment (light, noise, traffic) • Positioning • Minimal stimulation • Swaddling • Motor System • Positioning • Handling to contain limbs • Slow, gentle handling • Boundary rolls • Containment/nesting

22. Neurobehavioral Development • Stress Reducing Strategies • State System • Cluster care • Primary nursing for better assessment of infant cues • Appropriate timing of activities & daily routines • Autonomic & motor subsystems must have reached stability

23. Neurodevelopmental Development • Stress Reducing Strategies • Attentional Interaction System • Adjust interactions to infant’s tolerance level • Provide supports necessary to bring out best alertness • Offer one mode of stimulation at a time • Use modulated voice, face, rattle, together (baby responds best to animate stimuli)

24. Sleep-Awake States • State- level of infant’s consciousness determined by his level of arousal and response to stimuli • Sleep States • Deep sleep: closed eyes, no eye movements, regular breathing, no spontaneous activity • Light sleep- low levels of activity, rapid eye movement may be seen, irregular respiratory movements

25. Sleep-Awake States • Transitional States • Drowsiness- activity level varies, eyes may open & close & appear dull & heavy

26. Sleep-Awake States Awake States • Quiet alert- interactive, alert & wide-eyed appearance; attention focused on stimuli, regular respirations, minimal motor activity • Active alert- increased motor activity, heightened sensitivity to stimuli, periods of fussiness but easily consoled; eyes open but less bright & attentive, irregular respirations • Crying- increased motor activity & color change, very responsive to unpleasant stimuli

27. Organization • Ability to integrate physiologic & behavioral systems in response to stimuli without disruption in the state or physiologic function • Maintains stable vital signs, smooth state transitions, even movements • Able to console himself • Ability to maintain organization depends on maturity level, overall well-being, and infant’s temperament

28. Sensory Threshold • Level of tolerance for stimuli in which infant can respond appropriately • When threshold met, becomes overstimulated and stressed • Preterm and neurologically impaired infants have low thresholds • Watch infant’s cues and respond appropriately

29. Habituation • Ability to alter response to repeated stimuli • When stimulus is repeated, the initial response to it will gradually go away • Defense mechanism for shutting out disturbing or overwhelming stimuli • Assess during light sleep or quiet alert states

30. Positioning Malformations • Muscle fiber development incomplete until term • Lower ratio of Type 1 muscle fibers to Type 2 predisposes preterm infant to muscle fatigue • Restricted movement & positioning in the NICU produce joint compression & poor refinement of mechanical receptors predisposing fragile infants to skeletal deformation, shortening of muscles, & contractures.

31. Positioning Malformations • Common “Acquired Positioning Malformations” • Hip abduction & external rotation (frog leg) • Shoulder retraction & scapular adduction (W position of arms) • Neck extension • Arching postures • Abnormal head molding

32. Positioning Malformations • Prevention of deformities • Provide support for breathing & ventilation • Promote skin integrity • Facilitate containment & security • Facilitate development of flexion in posture & movement

33. Positioning Deformities • Prevention of Deformities • Provide opportunities for midline skill development (hand to face/mouth) • Encourage alignment & symmetry • Support rest/calming/comfort & neurobehavioral organization • Counteract abnormal posturing • Support tolerated posturing

34. Positioning Guidelines • Neutral or slightly flexed neck • Gently rounded shoulders • Flexed elbows • Trunk slightly rounded with pelvic tilt • Hips partially flexed & adducted to near midline (no frog leg or externally rotated hips flat against bed) • Lower boundary for foot bracing

35. Positioning Guidelines • Bedding & positioning aids should be individually determined to meet the needs of the infant • Calm, organized behavior may be improved by • Prone position • Side-lying position, well-supported with hands to mid-line • swaddling

36. Positioning Guidelines • Reposition with hands-on care or when behavioral cues indicate discomfort • Use appropriately sized-diapers to preserve normal hip alignment • Avoid tension from lines or tubing such as ET tubes, IV lines, og tubes, etc..to prevent pressure deformities.

37. Positioning Guidelines • Use slow, gentle rolling motion with containment of extremities & providing a pacifier when repositioning sick or preterm infants. • Once repositioned, monitor breathing pattern, color, O2 Sats, HR, respiratory rate & pattern, behavioral cues, & stability of position.

38. Positioning Guidelines • Observe infant’s developmental capabilities. If infant fighting containment or boundaries, infant should be allowed to go without. Transitioning infants out of boundaries and positioning aids is required before discharge. • Supine positioning should be initiated at least 2 weeks before discharge.

39. Positioning Guidelines • AAP Recommendations • Supine position is the preferred sleeping position during infancy • Avoid use of soft/loose bedding or objects (pillows, comforters, sheepskin, stuffed toys) • Avoid use of waterbeds, sofas, or soft mattresses as a bed • Avoid bed sharing or co-sleeping even with siblings • Avoid overheating by too many clothes & overly warm bedroom temperature

40. Feedings • Key Concept: recognizing the difference between a successful feeding (volume & duration of feeding) & a successful feeder (infant competence & enjoyment). • Within this context lies the difference between task-oriented or procedural feedings & a developmental feeding.

41. Feedings • Developmental Feeding (Ancona, et al.,1998) involves 3 concepts: • Physiologic, motor, & state behavioral assessment before, during, & after feeding • Individualized feeding approach based on specific infant cues • Fostering parent competence, confidence, & enjoyment while feeding the infant

42. Feedings • Transition to oral feedings • Support sleep/wake behavioral organization • Provide proper positioning to promote neuromuscular control & postural alignment for suck, swallow, & breathing (prevent hyperextended neck or trunk & shoulder retraction) • Protect against oral aversion

43. Feedings • Transition to oral feedings • Provide pleasurable oral experiences • Offer opportunities to smell breast milk or formula • Offer a pacifier for pleasure & not just for comfort during care or painful procedures

44. Feedings • Feeding readiness behaviors • Medical status • Energy for feeding • Capable of quiet, alert state behavior • Gag response with orogastric tube insertion • Rooting & sucking behaviors • Functional sucking reflex

45. Feedings • Nonnutritive Sucking: meta-analysis of NNS literature which reviewed 13 randomized controlled trials demonstrated a significant effect on length of hospital stay. • Nutritive sucking • Requires greater coordination of suck-swallow-breathe sequence

46. Feedings • Nutritive Sucking • To encourage as normal a suck-swallow pattern as possible while infant maintains physiologic stability • very important to hold nipple as still as possible and allow infant to pace the feeding. • Allow rest between suck bursts. • Manage environmental distractions so infant can focus on feeding.

47. Feedings • Nutritive Sucking • Monitor infant for fatigue; forced feeding after an infant is tired can cause • Prolonged feeding duration • Poor weight gain • Bradycardia • Incoordination during the feeding • Aspiration • Deglutition apnea • Desaturations • Oral aversion & defensiveness

48. Feedings • Nutritive Sucking • Intervene with infants who become fatigued by oral feeding • Stop oral feeding when infant tired • Continue feeding by NG or OG tube to provide adequate intake • Decrease number of oral feedings per day or feeding duration for each feed • If feeding fatigue persists, develop plan for further evaluation and change in plan of care

49. Feedings • Maturation & Coordination • Significant correlation between maturity of the infant’s sucking ability & post conceptual age. • Neurobehavioral maturation is a developmental sequence that supports feeding progression/abilities. • Coordination of suck, swallow, & respiration is seen by 34 weeks PCA. • Milk flow volume is related to nipple hole size.

50. Feedings • Maturation & Coordination • Restricted milk flow facilitates oral feeding in preterm infants allowing rest between suck & swallow. Rapid flow may overwhelm preterm infants. • Changing nipples frequently may affect feeding organization & adaptation; identifying an appropriate nipple & using it regularly as long as an infant is successfully feeding may be more supportive