A guide to infant development in the newborn nursery by MengYao Liu

A Guide to Development in the Newborn Nursery

Inga Warren & Cherry Bond

A Guide to Infant Development in the Newborn Nursery

Inga Warren & Cherry Bond

A B

Development Care

Development

13 14 18

61 62 77 77 78 80 82 85 91 96 101 104 105 112

22 23 26 31 33 37 38 47

Developmental outcomes for Preterm Infants Perspectives on developmental care Meeting the developmental needs of preterm/newborn infants Quick look at the benefits of developmental care Research Implications for staff Individualised family centred developmental care Synactive theory What to look for: behavioural cues NIDCAP References and bibliographies

Introduction The Preterm Pathway: 23 weeks - Term Sensory Development Touch The vestibular system Taste and smell Hearing Vision Motor Development Behavioural states Attention and Interaction Additional reading on development Neonatal Assessments Developmental Care in 5 stages

C D

Adapting Procedures and Daily Care

The Nursery Environment

128 132 132 132 135 137 140 142 145 149 152 153 155 159

170 174 175 183 191 191 195 202 203 206 208 211 225

160 162

Introduction Basic strategies for comfort Step by Step Guides Routine medical procedures Emergency medical procedures Taking Blood samples All cares Nappy change Bathing Inserting nasogastric and oragastric feeding tubes ROP Screening examination Quick look at ROP Screening Evaluation of Interventions (EVIN: draft version) A quick look at sensitive managing of painful procedures Pain. Can you see it? References and Bibliography

Introduction Quick look at the nursery environment Light Sound Positioning Positioning for comfort and development Summary: pros and cons of different positions Quick look at positioning comfort Making a nest 1 Making a nest 2 (canoe nest) Co-bedding twins Nursery Checklists References and Bibliography

E F

The Family

Feeding

237 239 240 241 243 250 250 252 256 257 260 261 267 268 271 277 280 293 294

308 311 313 317 320 324 327 328 331 331 333 335 336 337 340 343

Introduction: working together The family in the NICU â&#x20AC;&#x201C; key points Communication Supporting parents Parents concerns Transcultural care Introduction Cultural awareness on the neonatal unit Language barriers Working with translators Parent infant activities - introduction Parent-Baby activities Quick look at mouth care Step by step: bathing without tears Positive touch Quick look at the 5 step dialogue Skin-to-skin / kangaroo care Baby diaries and scrapbooks References and bibliographies

Introduction Development of feeding skills Expressing breast milk Breast feeding Bottle feeding Tube feeding Non-nutritive sucking Gastroesophageal reflux Behavioural organisation during feeding Physiological stability Motor maturity State regulation Attention and interaction Oral motor skills Aversive feeding behaviour References and bibliographies

Appendix

355 362 367 374 375 383 385 387

Developmental Care Products Patterns for Incubator Cover Contacts and support networks Bibliography â&#x20AC;&#x201C; a basic developmental care library Book reviews Training / Education A charter for developmental care Index

Preface

“A Guide to Infant Development in the Newborn Nursery” was first compiled for the Winnicott Baby Unit at St. Mary’s, London as a way of making information about developmental care readily available to new staff and students. It soon became apparent that parents found it helpful too, and with each edition we are trying to make the writing more jargon free and accessible to everyone. We receive requests for information from all over the world and we hope that this compendium will be a useful resource for anyone searching for practical help with developmental care, often starting from scratch. It brings together ideas and up-to-date information from many sources to guide “best practice”. There is still much we do not know about preterm development and the impact of developmental care but this guide is based on the best available evidence. Extensive bibliographies and references are provided to set the reader on course for a more detailed exploration of theory and research. We strongly believe that the secret to successful developmental care is skilled observation and reflection on infant

behaviour coupled with supportive partnerships with parents. For this reason we would strongly recommend that every centre has NIDCAP trained professionals to lead developmental care. We recognise that in the here and now this is not always possible; we hope that the materials in this handbook will help you to travel in that direction. Part 1 (Introduction) summarises developmental outcomes for preterm infants and presents different perspectives on developmental care and its potential benefits. There are notes on the implications for staff and managing change. As the NIDCAP has the strongest evidence and is in our view the gold standard for developmental care this model is described in more detail. Behavioural cues are illustrated. Part 2 (Development) includes a stage by stage outline of preterm development followed by sections on sensory, motor and state development, and their implications for care. A range of structured newborn and preterm neurobehavioural assessments are described briefly. This part includes a five stage developmental care guide that

can be individualised for each baby at different stages of their journey through the neonatal unit. Part 3 (Procedures and Daily Care) takes a look at how to sensitively manage activities that can be challenging for any baby, but particularly for those that are born prematurely. A variety of tasks have been analysed and recommendations made for good practice. Some information about pain assessment and non-pharmacological pain management strategies are included in this edition. In Part 4 (Environment) we discuss the physical environment of the nursery and how this can be managed to facilitate the infantâ&#x20AC;&#x2122;s adaptation to the extra-uterine world. Positioning is included here with a new illustrated guide to making a nest. A checklist for evaluating all aspects of the nursery environment is provided; this can be used for benchmarking, or auditing strengths and pinpointing areas where efforts to achieve change are likely to be most successful. Part 5 (The Family) reflects the importance of the family in developmental care. Common concerns

voiced by parents are discussed. In this addition we have added more information for parents about participation in daily activities with their baby. Positive Touch and Kangaroo Care have their own sections. As many units have staff and families from diverse backgrounds, notes on transcultural care and working with translators are included. Part 6 is about feeding, the very heart of the nurturing relationship between parent and child, potentially enjoyable but a widespread cause of parental anxiety. The normal sequence of feeding development is outlined; a problem-solving guide to feeding difficulties is provided; step by step guidelines for breast, bottle and tube feeding and the use of soothers are set out. We hope that we have conveyed our confidence in the ability of preterm babies and their mothers to achieve and benefit from breast feeding. Part 7, the Appendix, is a miscellany of useful information such as equipment suppliers and helpful contacts. Patterns for incubator covers are included for those who wish to make their own. A short list of books for starting a developmental care library is given and information about training and conference is provided.

Finally we have included a Charter for Family Centred Developmental Care. The result of a consultation process involving all staff on the Winnicott Baby Unit, this marked the point at which developmental care became central to the philosophy of care, no longer an optional extra. The Charter assumes that all staff will participate in developmental care to the best of their ability, an important point because we are all at different stages in our own development. The information presented here comes from a pool of knowledge and experience that is neither perfect nor complete and the authors do not take responsibility for any actions that you may be inspired to make after reading it. The ideas we have shared and the recommendations we have made are not rules. Each practitioner will need to adapt them according to their abilities, the setting in which they work, the nature and circumstances of the child and family they are working with, and new evidence as it emerges. We have included tools that we use in our teaching that we are constantly changing and updating ourselves. You must always feel confidant that the baby is safe and while no detrimental effects

have been attributed to developmental care this is a matter for individual judgement and responsibility. The best way to ensure that developmental care is safe and appropriate is to base it on detailed observation of infant behaviour and we would recommend formal training in this skill to everyone. We have used some short case studies that are based on real life experience. Personal details have been changed except in the case of Sameera’s story, written for us by her parents. This guide was designed to be kept in the nurseries, readily accessible to nurses and students at work. The information is set out in short sections in varied styles to make it easy to dip into. In this volume we have included some “quick look” summaries to make this even easier. We hope that you will find it useful in your day-to-day contact with babies and their families. In this amended version of the 5th Edition we have made some small changes corrections, improvements and inclusions – on the January version.

A.1 13 Developmental outcomes for Preterm Infants

A.2 14 Perspectives on developmental care

A.3 18 Meeting the developmental needs of preterm and newborn infants 22 Quick look at the benefits of developmental care

A.4 23 Research

A.5 26 Implications for staff

A.6 31 Individualised family centred developmental care

Development Care A.7 33 Synactive theory 37 What to look for: behavioural cues

A.8 38 NIDCAP 47 References and bibliographies

Principle 2 Staffing of neonatal services Each network has a developmental care lead whose job plan contains identified capacity for providing coordination, training and education across the network. Each unit has an identified lead professional for developmental needs and care of the baby.

Principle 3 Care of the baby and family experience Every baby is treated with dignity and respect: • Appropriate positioning is promoted and encouraged. • Clinical interventions are managed to minimise stress, avoid pain and conserve energy. • Noise and light levels are managed to minimise stress. • Appropriate clothing is used at all times, taking into account parents’ choice. • Privacy is respected and promoted as appropriate to the baby’s condition.

Principle 5 Professional competence education and training All staff have undertaken training appropriate to their role in…. • assessing developmental needs

Extracts from <Department of Health> Toolkit for High Quality Neonatal Services 2009

A.1 Developmental Outcomes for Preterm Infants

Most babies born prematurely do well (see example 1) and develop normally. It is important not to lose sight of this fact; it is reassuring and a tribute to the excellence of modern neonatal care. Nevertheless 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 extremely prematurely (before 28 weeks gestation) will need some form of specialist help when they start school (Larroque et al 2008, Delobel-Ayoub et al 2006, 2009). For those born between 28 and 32 weeks gestation about 30% will need help. In both these groups about 10% will have significant disability, for example cerebral palsy. Even children born between 32 and 37 weeks have a higher risk of disability than their peers born at term, with a threefold risk of cerebral palsy (Goyen et al 2006, Huddy et al 2001, Petrini et al 2009).

Problem areas include:

The majority of these preterm children will have mild to moderate problems and often these are not obvious until school age. The range of problems is wide and they often overlap or present in clusters so that a child may have a complex developmental profile.

Autism

Cognitive deficits Specific learning deficits (e.g. maths) Attention deficit disorder Language delay Perceptual motor problems Co-ordination disorders Cerebral palsy Hearing loss Visual deficits Altered pain perception Memory Timidity / withdrawal Hyperactivity (related to attention deficit) Attachment disorders Anxiety and depression Behaviour problems Social isolation Feeding problems Vulnerability to abuse Sensory processing Executive functions

The number of preterm babies being born has increased and although advances in medical care have ensured that more survive this success has not been matched by improved developmental outcomes, consequently the number of children with disabilities has grown, and the demand for therapies and educational support has increased. Apart from the biological risk of early birth there are the iatrogenic effects of â&#x20AC;&#x153;high-techâ&#x20AC;? medical care to contend with. While neonatologists refine practice to minimise such problems we can supplement the traditional aspects of medical and nursing care with developmental care, which has proved to be safe when sensibly managed by appropriately trained personnel, as well as having specific health and development benefits. (See 1.4.)

Example 1 Jarvis was born at 24 weeks gestation and went home fully breast fed but with oxygen set up for him, and regular visits from the occupational therapist and community liaison nurse. He was rather small for his age and his mother was convinced that he would have long term problems. He was a bright eyed little boy who took in everything that was going on around him and by the time he was 18 months it was clear that he was able to do everything that other children of his age could be expected to do, even without allowing for his prematurity. He is a little small still, and quite shy but is capable in every way.

Example 2 Taylor was born at 25 weeks gestation. She received regular home visits from her occupational therapist as part of a developmental follow up programme offered to all extremely premature infants. Her therapist noticed that she was becoming increasingly stiff in her legs as she approached the middle of her first year and cerebral palsy was soon diagnosed. Her therapists and family worked closely together to find opportunities for Taylor to experience as many normal activities as possible. She went to the local nursery and then mainstream school, using a wheelchair. We lost track of her for a while until someone showed me a newspaper cutting â&#x20AC;&#x201C; Taylor had been elected a national student representative and was being interviewed about world affairs.

A.2 Perspectives on Developmental Care

Developmental care uses strategies derived from neurodevelopmental, environmental and human sciences to improve the potential of infants who are disadvantaged by premature birth or adverse perinatal events. It supplements and humanises high tech medical care. There are many different views on developmental care. At one end of the spectrum are GENERIC models that apply sensible measures appropriate for all babies that aim to improve the experience of infants and parents during neonatal care, for example by making the environment less stressful and facilitating parent participation. Such models require knowledge and commitment rather than skill. At the other end of the spectrum is the comprehensive NIDCAP model of individualised family centred developmental care that requires advanced skills in behavioural observation and analysis, with the purpose of improving developmental potential. (his approach has the stronger evidence base.

A.2.1 Humane Care For many people the most compelling reason for developmental care is that, at its best, it is a kinder, gentler way to care for babies. Others take this further into the realm of rights â&#x20AC;&#x201C; the rights of babies to be treated with the same respect and consideration as adults, their right not to be separated from their mother unless absolutely necessary, their right to breast feed, their right to be protected from unnecessary pain and distress, their right to have a voice, and to sleep (UNICEF 2000). The Humane Neonatal Care Initiative first promoted by Adik Levin (Levine 1999, Westrup et al 1999, Charpak 2000) includes many points that are consistent with a comprehensive model of developmental care. Alderson and colleagues, in a study covering four neonatal units, argue that babies express their needs through non-verbal language and hence they do have a voice, and a right to be heard. They showed how this was recognised particularly in units where care was strongly influenced by the NIDCAP and Brazeltonâ&#x20AC;&#x2122;s work on newborn behaviour (Alderson et al 2005). A.2.1 HUMANE CARE For many people the most compelling reason for developmental care is that, at its best, it is a kinder, gentler way to care for babies. Others take this further into the realm of rights â&#x20AC;&#x201C; the rights of babies to be treated with the same

Fig 1: Perspectives on developmental care Humane care: rights to Be protected from pain and distress Be with the mother Be listened to Breast feed Sleep Family Centred Care Parent-professional partnership Participation Parent-infant interaction Psychological support Transcultural care Information Environment: Physical Sensory Temporal Routines/procedures Social Organisational Values Direct Intervention: Positive touch Kangaroo care Positioning Sensory Stimulation Massage Individualised care: Observation and reflection All aspects of care adapted to fit the needs and progress of each infant and family NIDCAP

respect and consideration as adults, their right not to be separated from their mother unless absolutely necessary, their right to breast feed, their right to be protected from unnecessary pain and distress, their right to have a voice, and to sleep (UNICEF 2000). The Humane Neonatal Care Initiative first promoted by Adik Levin (Levine 1999, Westrup et al 1999, Charpak 2000) includes many points that are consistent with a comprehensive model of developmental care. Alderson and colleagues, in a study covering four neonatal units, argue that babies express their needs through non-verbal language and hence they do have a voice, and a right to be heard. They showed how this was recognised particularly in units where care was strongly influenced by the NIDCAP and Brazelton’s work on newborn behaviour (Alderson et al 2005). A.2.2 Family Centred Care In some centres the focus of developmental care is Family Centred Care (see part 5). Here the importance of the family as the most significant influence on the child’s well being and development is underlined and parents and professionals work in partnership, with open communication. In practice a family centred approach can mean anything from “kangaroo mother care” houses in developing countries that lack high tech medical facilities, to family rooms for intensive care in units where parents are on the NICU board and are involved in policy making and appointments of staff. In the UK the principle of open access for parents is widely approved although many units have restrictions (Greisen et al 2009, Hamiton et al 2009) particularly during ward rounds, during hand-over or even quiet hours. There are still many countries in Europe where families are only permitted in the NICU for one or two hours a day. In some countries family centred care is influencing nursery design to provide facilities for parents to be present beside their baby 24 hours a day. The Karolinska Danderyd Unit in Stockholm has been adapted for “Couplet care”; mothers

receive post natal care on the same unit as their infant receives neonatal care, so that they can be nursed together. In Uppsala, Sweden, parents have a bed next to their baby in intensive care, after which a family room is provided within the unit. Family Centred Care places the baby firmly in the context of the family, acknowledging that the family is the most constant influence on a child’s development. Adjusting to parenthood after the experience of premature or traumatic birth can be difficult. Helping mothers and fathers to adapt parenting roles to the needs of a small or sick infant is part of developmental care. Coping with the psychological needs of parents during their painfully difficult journey through neonatal care requires skilled professional help, for example there is evidence to show that psychological support can reduce the incidence of post traumatic stress disorder (Jotso and Poets 2005). Family Centred Care is sensitive to the nature of personal, social and cultural influences upon each family (see Part 5). It requires that staff be skilled at communicating and caring for parents as well as babies.

A.2.3 Environmental Adaptations Another view of developmental care puts the main focus on the environment, particularly on adapting the physical environment to provide appropriate sensory stimulation, to protect the baby from stress, and to promote sleep. The emphasis here is usually on guidelines for space, light, noise, and positioning. Evidence based guidelines for the physical and developmental environment have been agreed by a multidisciplinary consensus group that meets bi-annually at the Graven’s conference in Florida (see Appendix) (White 2007). The Vermont Oxford Network sponsors a National Quality initiative including the “Sense and Sensibilities Group” set up to explore the neonatal environment. This group identified 16 Potentially Best Practices for promoting sleep and an appropriate sensory environment for babies within two preterm age bands (Liu et al 2007). Less commonly addressed are organisational and cultural issues that determine if and how developmental care is adopted. The neonatal nursery is obviously not an optimal sensory environment for preterm and newborn development. The immature central nervous system is in a critical period of rapid growth and increasing specialisation, all designed to take place in quite a different setting, a mother’s healthy womb. New techniques and research have increased our knowledge about foetal development but much remains unknown. The infants’ behavioural cues are probably the best guide to whether or not the environment, in all its aspects (sensory, temporal and social) is in

keeping with current developmental needs. In this way we can organise a setting that is closer to the infant’s developmental expectations.

that nurses should routinely massage small babies going against the grain when a family centred approach is advocated.

A.2.4 Specific Developmental or Therapeutic Interventions The fourth perspective includes stand alone interventions that are directed at the infant. Some of these merit their own space in this volume (e.g. see Part 5 for Positive Touch and Skin-to-Skin / Kangaroo Care) others lack sufficient evidence or rationale for use. These interventions can be beneficial or detrimental depending on how and when they are implemented. For example some kinds of music may be beneficial for some babies some of the time, but there is no good reason for routine use in the nursery (see Part 4). One of the editors came across a baby arriving back from surgery and being placed next to a radio playing rock music – a clearly inappropriate interpretation of “music therapy”. Positioning is one of the most contentious interventions, and can be beneficial or detrimental to safety as well as comfort, depending on how it is applied (see Part 4). Massage also can be controversial with the idea

A.2.5 Individualised Developmental Care Individualised developmental care is adjusted to fit each baby’s needs, needs that will change according to the ups and downs of the baby’s progress, to maturation and growth. Tuning into the baby’s behaviour is the starting point. Behavioural cues help us to understand the baby’s competency, strengths, sensitivity, vulnerability, and developmental goals. Care that is responsive to those cues is care that meets individual developmental needs. This leads us towards a personal approach that is based on dialogue between infant and caregivers. Individualised developmental care is humane and family centred; it adapts the environment to fit the infant and family, and incorporates specific interventions such as kangaroo care, breast feeding and positive touch. The leading model of individualised developmental care is the NIDCAP (see 1.6 -1.8). NIDCAP provides a coherent, comprehensive framework of ideas and evidence. Uniquely it also provides quality control through rigorous training (Lawhon and Hedlund 2008).

A.3 Meeting the Developmental Needs of Preterm and Newborn Infants

Whether seeking to introduce a generic or individualised version of developmental care it can be difficult to explain to people why it is needed, what it involves and what can be achieved. The needs and potential benefits are outlined below with a “Quick Look” version (p22) that can be used to survey staff awareness and interest, and to help the team decide what aspects of developmental care it might want to prioritise. An alternative outline from the team that invented “The Universe of Developmental Care” model (Coughlin et al 2009) includes 5 core measures: protected sleep; pain and stress assessment and management; developmentally supportive activities of daily living; family centred care; and the healing environment. The Vermont Oxford Sense and Sensibilities group focused on sleep and the tactile, olfactory, auditory and visual environment.

A.3.1 Physiological Stability Physiological stability is important for brain development. The way we manage the 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, oxygen consumption (e.g. Gressens et al 2002, Bauer 2005, Limperopoulos et al 2008). Developmental care strategies have been shown to increase stability during and after medical procedures and nursing cares (e.g. Sizun and Browne, Kleberg et al 2008). A.3.2 Minimising Pain and Stress That preterm infants in intensive care are subject to many painful and distressing procedures has been well documented. The need to minimise this is obvious on humane grounds and also because of long term impact on behaviour and sensory processing (Grunau 2002). Recent work (Bartocci et al 2006, Slater et al 2006) has strengthened the view, long held by many but doubted by others, that preterm infants truly experience pain. There is a growing consensus that more must be done to avoid and treat pain in neonates (Anand et al 2006, Bellieni & Buonocore 2008). The iatrogenic effects of pharmacological pain management are also a concern and developmental care strategies are now considered an effective and important

part of pain management (Leslie and Marlow 2006). It is likely that these strategies will be most effective when coupled with skilled observation of infant behaviour (Kleberg et al 2007). Developmental care is increasingly viewed as front line defence against pain. Every procedure can be adapted to minimise, but not necessarily to eradicate, distress to the infant and in doing so the task is often accomplished more easily. Many apparently benign, routine aspects of neonatal care such as nappy change and bathing (see Part 3 ) can be stressful for preterm and newborn infants (Evans et al 1997); developmental care can make these go more smoothly (Sizun et al 2001; see Part 3 ). A.3.3 Protecting Sleep Sleep is important, not just for recovery and growth but also for brain development (Graven and Browne 2009, Simunek and Sizun 2005, Bertelle et al 2005, Periano and Algorin 2007). In the latter case it is active (REM) sleep that is most associated with neural organisation, and quiet sleep with growth (see Part 2). Sleep protection does somewhat depends on the caregiverâ&#x20AC;&#x2122;s ability to distinguish different states of arousal, a task that is not easy because preterm behavioural states tend to be diffuse and disorganised. The position a baby is in, light and noise, hunger and comfort can affect sleep patterns. Leaving a baby undisturbed for 6 hours in a minimal handling protocol may not be the right route to brain building sleep as most infants will need more attention to their comfort than this as they go through different levels of arousal.

1.3.4 Enhanced Nutrition Developmental care can support nutrition by helping the baby to conserve energy for growth, and to digest food comfortably. It can also provide effective support for breast feeding (Warren et al 2000) which has been proven to have significant health and development benefits for all infants and their mothers. Breast milk is particularly important for preterm babies (see Part 6) and there is growing evidence to indicate that it has a positive impact on development (Warren 2008). Developmental care can play an important part in preparing for and achieving successful feeding at the earliest opportunity. Developmental care tactics can also help to reduce the risk of aversive feeding disorders, which tend to occur more often in bottle fed babies. A.3.5 Approppiatesensory Experience During the last trimester of pregnancy synaptogenesis is in full spate, the growth and pruning of neuronal connections that sculpt pathways of communication within the brain that will endure throughout our lives. This process is partly dependent on external stimulation i.e. the sensory experience that the baby receives from the world around it, experience that is in part elicited by the infantâ&#x20AC;&#x2122;s own actions. It is also widely understood that there are critical periods within which certain kinds of stimulation are required to trigger normal development and that inappropriate experience or experience that is out of phase with developmental brain expectation can cause failure for systems to develop efficiently (Lickliter 2000, Schaal et al 2004, Graven and Browne 2009, Liu 2007). Much of what we know about this is derived from animal studies but there are confirming examples

from human development. One of the goals of developmental care is to ensure that the infant receives developmentally appropriate sensory experience. Als and colleagues (Als and Butler 2008) suggest that systematic observation of the infant will reveal patterns of approach and avoidance behaviour that guide us to understand what might be appropriate stimulation at the time. A.3.6 Parenting and Attachment Parenting style has been shown to have a significant impact on development (Trevaud 2009, Smith et al 2006, and Meins et al 2001). Guiding parents to understand how their baby communicates, to tune into their baby’s feelings, is potentially a potent ingredient of developmental care. Attachment is the close relationship that develops between parent and child, which gives the child the sense of security it needs to explore and learn and make successful relationships later in life. The loving touch that a parent gives their child sets up hormonal reactions that are important for development and are part of the nurturing relationship (Uvnaes Moberg 2003, Ferber and Makhoul 2004). Facilitating attachment can be a challenge when an infant in a critical condition is physically separated from the mother. Developmental care can play an important part in supporting parents through this time, helping them to get to know their baby, giving them knowledge and opportunities to grow confident, helping them to be an advocate for their baby (Kleberg et al 2000, Als et al 2003). Several studies have indicated better outcomes for parents’ psychological well being as a result of developmental care (Als et al 2003, Melnyk 2007). The experience that parents

have in the neonatal unit may have a lasting impact on their relationship with their baby, and improving that experience is one of the things that developmental care can do.

A.3.7 Protecting Postural Development Developmental care can protect infants from the acquired postural deformities that are associated with long periods lying flat on a bed either in prone or supine positions e.g. flattened head shape; retracted shoulders (arms held in the W position); legs abducted and externally rotated (“frog leg” position); and torticollis (Downs et al 1991). Positioning support that allows the baby to spontaneously get into more comfortable, functional positions together with frequent position changes can counteract these tendencies, which can otherwise delay the acquisition of skills such as sitting and walking, self comforting, feeding and fine motor coordination. A.3.8. Better Health and Development Outcomes Meta-analysis of NIDCAP studies have shown better health and development outcomes in the early years (see 1.4.) and also earlier discharge from hospital. The COPE programme also claims to achieve earlier discharge from hospital (Melnyk 2007). Very little data is available to show longer term effects although two small studies, one to school entry (Westrup et al) and the other with 8 year outcomes (McAnulty) have suggested sustained results in favour of NIDCAP. Older studies of parent – infant interaction programmes showed longer term benefits for groups of preterm infants (Achenbach et al 1995, Rauh et al 1990, Resnick et al 1987).

A.3.9 User Satisfaction Surveys of staff who have experienced individualised developmental care (NIDCAP) show approval for the programme in terms of benefits for the baby, but also express satisfaction in their work (Hamilton 2008, Mambrini et al 2002, Sell 1997, Van der Pal et al 2007, Westrup et al 2000). There can however be tensions within the team because not all staff will be at the same stage of understanding and competence and this can cause feelings of frustration among colleagues and discontent among parents (Hamilton 2008). Some nurses find the presence of parents challenging (Solhaug et al 2010). Nurses have indicated that they feel they do better developmental care when they have the backing of a developmental care team (Hendricks-Munoz & Prendergast 2007). Parents too have described benefits from developmental care, particularly in increasing their confidence as parents (Als 2003, Kleberg et al 2000, Hamilton 2009). A.3.10 Better Experience of Neonal Care There is widespread agreement that developmental care can improve the experience of neonatal care for infants and parents. As a result many Neonatal Networks now have benchmarks for developmental care that aim to do just that. The Toolkit for High Quality Neonatal Services also makes this link.

I like Developmental Care, you see me and my son as ONE and some people see me as separate, which is wrong. Quote from a parent on the Winnicott Baby Unit

A Quick Look at the Goals and Benefits of

Developmental Care Many people find the whole idea of developmental care too vague to get to grips with. This â&#x20AC;&#x153;quick lookâ&#x20AC;? has been formatted as a survey to help you to elicit a constructive response from leaders in the nursery who may not be clear about the advantages of developmental care. The term developmental care is not very picturesque - by breaking it down into areas that have specific goals they may be more able to envisage what it means and to see the point. Developmental care encompasses many strategies for which there is empirical evidence of success in achieving the goals listed below. Please indicate the level of importance that you attribute to each of these. 1 = low and 4 = high importance.

Improved Physiological Stability

Characteristics of the environment, the way we handle and position babies, the timing and pacing of interventions, and the babyâ&#x20AC;&#x2122;s own activity (e.g. movement, crying) affect physiological stability. Developmental care can adapt care to improve physiological stability.

Reduced Stress and Pain A range of non-pharmacological strategies are effective in reducing stress pain during procedures, can aid recovery after procedures, help with the management of ongoing pain and reduce need for medication.

Improved Feeding Developmental care can improve breast feeding success and energy conservation for growth. It can help to avoid aversive feeding disorders.

Improved Sleep Patterns

Developmental care can help to improve sleep patterns, which are important for neurodevelopment and growth.

Appropriate Sensory Experience Animal studies suggest that interference with expected sensory stimulation has a negative impact on brain wiring. Developmental care can provide developmentally appropriate sensory experience.

Protect Posturual Development Developmental care can help to prevent acquired postural deformities that have a negative impact on appearance and/or development.

Confident Parenting and Attachment Developmental care supports parents and helps them to feel closer to their baby and more confident in themselves and in the care we are giving. Educating parents to understand their babyâ&#x20AC;&#x2122;s behaviour can lead to better outcomes.

Staff Satisfaction Surveys in neonatal units that have adopted developmental care report high levels of staff satisfaction.

Better Development Outcomes Shorter hospital stay and better developmental outcomes in the early years are achieved with individualised, family centred developmental programmes such as the NIDCAP.

A Quick Look at

Sensitive Management of Painful Procedures

Is timing optional? Yes No

Plan time with nurse to minimise sleep disruption Choose time when room is calm if possible Discuss with parents

Wrap baby, including all limbs not required for procedure, in blanket or nest with bedding

Is help available to support baby(nurse, parent, other)? Yes No

Give baby fingers to grasp or help with hand clasping or hand to face.

Is the baby eligible for sucrose? Yes No

Give 2 mins before procedure, and during a long event. If not available consider alternatives e.g. EBM

167

Make the baby comfortable. Soft surface. Consider side lying position.

Still hands on head, bottom, tummy or feet. Help baby to retain soother.

Greet baby, touch gently and tell baby what you are going to do.

Is baby showing physiological stress e.g. HR >200, 02 drop below 80% ? Yes No

Pause procedure and soothe baby. Ask for help

Complete procedure, say goodbye and thank you to baby, make baby comfortable.

168

201

D.1 170 Introduction 174 Quick look at the nursery environment

D.2 174 Light

D.3 175 Sound

D.4 183 Positioning 191 Positioning for comfort and development 195 Summary: pros and cons of different positions

D The Nursery Environment

201 Quick look at positioning comfort

D.5

202 Making a nest 1

207

205 Making a nest 2 (canoe nest)

D.6

Co-bedding twins

210

Nursery Checklists

224

References and bibliographies

202

D.1 Introduction

Our environment affects the way we feel, think and behave. Our lives even depend on how well we adapt to our physical and social environment. This is a two way process; the environment has an effect on us but we also influence our environment. We learn and change through experience that comes from our own actions and reactions.

In the newborn developmental nursery we want to create an environment that works for the baby, the family and the staff.

THE BABY needs an environment that encourages Effortless working of bodily functions breathing, blood circulation, digestion and elimination Co-ordinated movements Restful sleep in a regulated pattern Focused, attentive alertness, Sociability Self regulation Mastery and enjoyment of feeding

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THE STAFF needs an environment that facilitates Safe practice Good communications Empathy Team work Job satisfaction

THE FAMILY needs a welcoming environment that gives them Confidence Opportunities to practice parenting skills A sense of well-being Privacy

In this section we have addressed in detail the three components of the physical environment that are most often raised in discussion about developmental care – light, sound and positioning. Tactile, olfactory and vestibular stimulation are also important and are discussed in Part B.3 under the heading of Sensory Development. THE INFANT’S EXPECTATIONS Very premature infants are poorly prepared to deal with the demands of the world outside the womb. The dark, warm, fluid filled womb with its familiar, low pitched noises is replaced with a dry, cool, draughty world where noises are often sudden and high pitched, where light is bright or chaotic, where there are unpredictable and arousing forms of touch, and open movements through space. The preterm baby’s body is adapted to moving about in a confined, cushioned space within the elastic walls of the womb, suspended in amniotic fluid. This they exchange for a landscape that is flat, hard, with ungiving boundaries, and where movement means working against the forces of gravity. In short, the biological expectations of prematurely born infants hardly match the situation in which they find themselves. In the face of such challenges it is not surprising if they seem helpless, stressed or exhausted. TECHNOLOGY He equipment we use to treat babies in the neonatal unit is a big influence on the environment. The array of technology that greets parents can be intimidating and distracting. Equipment generates noise and constructs barriers between the parent and

baby. Managing the technical aspects of intensive care requires advanced skills and the infant’s life support systems may take priority over more personal, social aspects of care. THE WORKING ENVIRONMENT Many aspects of the physical environment that are stressful for infants can also be stressful for parents and staff. Bright lighting, loud and jarring noise, visual clutter, and bustling activity can be overwhelming for parents. Working in a physically crowded, hot, noisy environment under flickering fluorescent lighting can take its toll on staff. LOCATION. Geographical features such as the location and character of the neighbourhood around the hospital also affect parents. How far do they have to travel and by what means? Can they finding parking space? Do they feel safe? How imposing or welcoming are the buildings? Is it easy to find the way to the nursery? Are signs along the way welcoming and helpful, and can parents who do not speak English understand them? Are there places for rest, for meals and drinks? PHYSICAL PROPERTIES OF THE NURSERY While we cannot expect to create the physical properties of the womb, and it would not be appropriate to do so as the preterm infant is not the same as the foetus, we can alter nursery environments to be more developmentally appropriate for the infant, and to be more comfortable for parents and staff, without obstructing necessary medical treatment. Besides attention to safety,

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efficiency, and physical comfort, design that is visually pleasing contributes to a sense of well being for everybody. Professional help to choose colour schemes, decorative details and appropriate artwork is a good investment. The size and layout of the nursery has an enormous impact on the activity that goes on within it. Many units in the UK appear to be designed to a universal template that has technological convenience rather than the comfort of the baby and family at the heart of the plan. In the USA, Sweden and other countries there has recently been a move to create space and facilities for parents to be with their baby 24 hours a day, even in intensive care. ACTIVITY AND EVENTS The foetusâ&#x20AC;&#x2122; experience is regulated by the motherâ&#x20AC;&#x2122;s bodily rhythms and activity. In the case of the preterm baby these are replaced by medical procedures and nursing routines. Traditional care is often protocol driven e.g. 6 hourly nappy changes. Routines can be helpful, for example for staff who are mastering new skills and for parents who feel that their world is out of control, but with Individualised Family Centred Developmental Care the emphasis shifts to more flexible and personal practice, responsive to each babyâ&#x20AC;&#x2122;s expressed needs, and making room for parents and babies to achieve the finely tuned mutual responses that are the essence of parenting. ORGANISATION AND CULTURE Different units have different functions. Management, teamwork and communication styles vary from unit to unit. Intensive care units

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with tightly knit teams of specialist staff, ready to respond to emergencies and technically highly proficient, can be intimidating. It can be difficult to feel at ease. This may be so not only for parents but also for allied health professionals. Parents may find it difficult to work out how everything operates - communications, rules, decision making, hierarchies and generally who does what. Understanding the organisation of the unit and how staff training takes place is important for anyone interested in implementing Developmental Care. To flourish it needs wholehearted support at all levels of the organisation, most of all at the top. Every unit has a culture, which will have evolved from its history, from the individuals working within it and the population it serves. Attitudes, values, and knowledge will determine the style of family centred care. Managing change is a significant consideration when seeking to adopt or improve developmental care. Change may be slow. Some ideas about stimulating change are suggested in Part 5. Although every step taken to make the environment more appropriate for infants and parents is important for improving comfort and well being, no single intervention is likely to make a big difference to developmental outcomes unless every other aspect of the environment is also well managed and care is individualised for each infant. THE PHYSICAL AND SENSORY ENVIRONMENT: KEY READING

Liu WF, Laudert S, Perkins B, MacMillan-York E, Martin S, Graven S for the NIC/Q 2005 Physical Environment Exploratory Group, 2007, The development of potentially better practices to support the neurodevelopment of infants in the NICU, Journal of Perinatology 27:S48-S74 Philbin MK, Graven SN, Robertson A, Eds. 2000. The influence of auditory experience on the fetus, newborn and preterm infant: report of the sound study group of the national resource centre: the physical and developmental environment of the high risk infant. Journal of Perinatology (Supplement) 20(8) White RD, Ed, 2004 The Sensory Environment of the NICU: Scientific and Design Related Aspects. Clinics in Perinatology 31(2):299-312 White RD, 2007, Recommended standards for the Newborn ICU, 2007, Journal of Perinatology 27:S4-S19

Developmental care can be practiced anywhere. The basic guiding principle is to always keep the baby and parents in mind, at the centre of everything. This applies in the maternity unit, the neonatal unit, paediatric wards and clinics.

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Quick Look at the

NURSERY ENVIRONMENT Guideline & Explanation

Noise Background noise in the nursery should be kept very quiet, average max. 45 decibels per hour Peak noises should be limited to 65 decibels

Sounds may affect behaviour by 24 weeks gestation Noise disturbs sleep that is essential for growth and development Noise makes it difficult for the baby to hear and respond to the human voice Noise is stressful for infants and adults, and interferes with job performance and communications

Light Ambient lighting below 300 lux 500 lux for worktop tasks such as measuring medications 1000 lux for fine delicate medical procedures Protect infants from light with levels below 25 lux until 32-34 weeks From 32 weeks gradually introduce moderate light exposure for 1-2 hours a day up to 8 hours Daylight preferable to artificial light

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Most activities can be carried out in moderate light (100-300 lux) Long exposure to bright light can make people feel jittery Safety is a prime consideration Pupil contraction reflex effective from 32 weeks; infant cannot regulate light entering eye before then This may have benefits for growth but daytime light exposure with darkness at light is essential from term.

Smell Avoid exposing infants to chemical smells and perfume Expose infant to motherâ&#x20AC;&#x2122;s smell

These may be irritants and can cause changes in cerebral blood flow Infant may first recognise mother by her familiar smell

Visual Array Avoid strongly contrasting visual images within infantsâ&#x20AC;&#x2122; field of view e.g. black and white designs

These can be over stimulating and fatiguing and have no developmental value in the preterm period.

The parents face is the best visual target.

Infants respond best to faces.

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Making a Nest 1 Step by Step

This way of making a nest was invented by Nova L Quiapos and demonstrated by Ana Lisa Fuentez, and Mary O’Connor, all of whom work at the Coombe Women’s Hospital in Dublin. Rosie Mendizábal and Cherry Bond devised the step by step guide and Wendy Bond did the illustrations working from mock ups using a doll.

The advantages of this style of nest are It does not require any expensive purchases It can be adjusted to fit any baby in any position. The amount of support provided for the baby can also be adjusted It can be opened up for cooling or for access It provides a steep rim around the feet that contains the baby’s legs, preventing them from riding up over the nest, and providing a firm surface for bracing. Cautions Keep an eye on the baby’s temperature and adjust nest or incubator heat as necessary. What you will need: Sheets, towels or blankets to make the nest boundary. The number and thickness will depend on the size and strength required for the baby. A soft cloth or muslin for the nest liner and carrying wrap. An extra sheet for wrapping the folded band for a smooth finish. One sheet or blanket for covering baby if permitted.

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1 Starting at the base of the triangle, make a FLATTENED FOLD. Smooth and flatten each time you make a fold. The width of the fold depends on the size of the baby with a minimum of 4â&#x20AC;? (10 cm) recommended. It needs to be high enough to contain the babyâ&#x20AC;&#x2122;s feet when he is stretching his legs.

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Arrange in an oval shape with the loose ends overlapping to form a rim around the head. This can be opened up easily if the baby gets too warm or if access to the head is needed e.g. for cranial ultrasound.

Fold a sheet / blanket into a triangle. The shape will depend on the shape and size of the sheet; do not worry if pointed ends are separate. Do the same for the second sheet, if used, and place on top. So now you have four layers of fabric to make a firmer boundary

Continue to make these folds until you form a straight band. Folding makes a firmer wall than rolling and gives the baby a more reliable surface to brace feet against than a roll. You can wrap the folded band in a sheet for a smoother, tidier finish (not shown)

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Line the nest to prevent the babyâ&#x20AC;&#x2122;s feet from slipping under the wall. Place a soft sheet or cloth (a muslin square would be ideal for a small baby) diagonally on top of the ring like this

Place the baby into the nest and adjust boundaries to suit size and position of baby. If the baby is going to lie on her side, as in this illustration, make sure the wall behind her is adjusted to provide back support. Ensure that the baby can reach the sides to brace feet and allow room for arms to move. If the baby is prone or supine ensure that the rim supports the legs to prevent hips splaying. If the baby is prone or supine make sure he has space to move his arms up to his head.

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Whenever possible cover baby with a sheet or blanket, tucking this in around the nest to make a snug cocoon. If the baby becomes too warm open the nest out.

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Fold and tuck the edges of the cloth to make it smooth and neat.

8 When the baby needs to be swaddled, for example when being lifted out of the bed, un-tuck the corners of the nest liner and wrap them around the baby (lifting in side-lying is preferable).

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Making a Nest 2: the Canoe Nest Step by Step

You will need a sheet (or gamgee) folded into a rectangle.

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Secure with two strips of tape with the tags on the outside.

Prepare four pieces of thick clear tape 10-12 cm long that have a small overlapped tags at one end.

Fold one corner of the sheet and hold it down while you fold over the second corner so that they overlap neatly.

Now do the same with the other end to make a canoe shape.

Weigh the nest and write the weight on one of the tags. Prepare a pink or blue label for the babyâ&#x20AC;&#x2122;s name.

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Take to delivery room and open up ready to receive the baby.

The baby can be popped into the nest and kept snugly curled up as he is lifted to be weighed to be greeted by his parents, and to be transferred to an incubator. All stabilising procedures can be done in the canoe nest. Release the tabs to open up as needed, and then reseal.

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