family centered developmental care in the nicu

Jennifer LaRocca, PT
Deborah Powers, OT
How can we implement Family
Centered Developmental Care
Program (FCDCP) in our NICU?
 Reviewed Journal Articles
 Survey results analyzed &
reviewed by developmental
 Created Developmental Care
care team to determine
Team with neonatologists,
developmental pediatrician,
nurse practitioner, PT, OT, ST,  Initiated developmental care
nurse educator, & RN
rounds and team meetings to
meet monthly
 Survey developed &
distributed to support staff &
families to assess current
care & environment
Summary of Results
need to improve
medical outcomes
& family/staff
teaching modules
developed covering
different aspects of
developmental care
design individualized
modules to be used
developmental care
as part of nursing
plans for complex
annual competencies/
infants with prolonged
(States, Sound,
OT developed positioning
guidelines for caregivers
Therapeutic positioning and
developmental support have
been proven to have positive
effects on functional
outcomes of NICU graduates.
Hunter, 2004.
Negative Impacts of Positioning
in the NICU
 Development of postural and skeletal deformities including skull
deformations, abnormal spine curvatures, preferential head turning to
the one side.
 Fine motor delays due to shoulder girdle tightness. Arms are
positioned in external rotation and retraction also known as the “W”
 Developmental delays including visual and functional preference for
the right hand, inability to perform midline skills, or poor selfregulation.
 Gross motor delays including lower extremity tightness at hips,
knees, and ankles. Legs positioned in abduction and external
rotation also known as “frogged” or “M” position. All of which can
influence rolling, sitting, walking, and crawling.
Boere-Boonekamp, van der Linden-Kuiper, & van Es, 1997; Davis, Robinson, Harris, &
Cartlidge, 1993; Fay, 1988; Hunter, 2004; Sweeney & Gutierrez, 2002.
Positive Influences of Positioning
in the NICU
 Provide postural and structural alignment to prevent the
development of abnormal postures.
 Encourage self-regulation by impacting hand to mouth activity that
leads to less crying and conservation of calories needed for growth.
 Influence the development of neuronal pathways and CNS
organization. Pathways that are rarely used weaken and disappear
while others that are frequently activated become dominant.
 Promote neurobehavioral organization by decreasing stress and
agitation that lead to physiological instability.
 Development of fine motor skills and shoulder girdle strength and
stability. This allows the infant to reach against gravity to bring
hands to midline and mouth.
 Development of gross motor skills that allows the infant to reach
motor milestones that will lead to walking independently.
Hunter, 2004; van Heijst, Touwen, & Vos, 1999; Penn & Schatz, 1999; Sweeney & Gutierrez,
Implementing Positioning
32-35 weeks CGA and or
> 1500 grams
Begin transitioning to supine
position for sleep when infant is
moved to an open crib.
Hats and layered blankets
maybe used for thermal
Swaddling maybe used to
support muscular development
and for infants that are difficult to
Infants may continue to use gel
pillows that have skull
deformations or are vent
>35 weeks CGA or Prior to
All babies should be placed on
their backs to sleep unless
contraindicated by airway
obstruction or birth defects as
determined by a physician.
Encourage use of clothing to
regulate temperature.
Hats should not be used during
Blankets should not be used
over crib or infants face to shield
light or noise.
Remove rolls, extra bedding,
toys, positional equipment, and
Blankets should come no higher
than infants shoulders
Family-Centered Developmental Care Program
Positioning in the NICU
ENCOURAGE: flexed position with support from blankets/ boundaries, rotate baby in
different positions to promote head shaping, gross motor strengthening, self-calming, and
ability to participate in fine motor and developmental activities
Supervised Tummy Time
Side Lying
AVOID: positioning without support/boundaries which can result in asymmetrical postures, skull
deformations, delayed fine and gross motor development
“W” Position
of Arms
“M” Position No Boundaries
of Legs
D. Powers & E. Williamson 2008
Boundaries Too
Head Turning
PT developed module on
swaddled bathing
Benefits for Baby
 decreased physiological &
motor stress
 conserved energy
 improved state control (less
crying & agitation)
 facilitated social interaction by
keeping baby in calm quiet
alert state
 increased self-regulatory
behaviors such as hand
clasping, hands to face, and
 enhanced ability to participate
in breast or bottle feeding
immediately after the bath
 promotes feeling of security in
infant despite change in
 evidence suggests that
infants tend to maintain
greater temperature stability
in an immersion bath
compared to traditional
sponge bath
adapted from “Swaddled Bathing in
the NICU” by Fern D. & Graves C.
Swaddled Bathing Continued
Benefits for Caregivers
 increased comfort
level in handling the
infant during bath
 increased confidence
in parenting skills
 facilitated parent
 enhanced interaction
with the baby
 decreased parental
 positive feeding
experience after bath
Guidelines for Swaddled Bathing
1. Modify environment to
provide quiet, dim area
free from drafts
2. Take infant’s axillary
temperature to ensure it is
within normal range
3. Set up within reach, the
tub, soap, wash cloth,
pacifier, & warmed blankets
for drying
4. Undress infant,
remove diaper, turn off
monitor, & remove leads
& probes
5. Swaddle infant securely
keeping arms & legs tucked
into a flexed, midline
position with hands to face
6. Using a cloth with warm
clean water (no soap), gently
wipe baby’s face from nose
towards ears. Clean outer
ear only. Pat face and ear dry
7. Place swaddled infant
in tub. Slowly immerse in
water to shoulder level.
8. Gently clean neck area
first. Slowly unswaddle
one part of the infant at a
time to wash. Reswaddle
9. End the bath with
shampoo. Gently
unswaddle the baby &
place in warm blanket.
Pat dry. Dress & diaper.
Adapted from CHOP guidelines
“In recent years, research examining the effectiveness of
individualized, developmentally supportive care to
premature infants in the NICU has demonstrated a
variety of positive effects . . . Significantly improved
medical outcomes, including reduced dependence on
respiratory support, improved weight gain, earlier
accomplishment of nipple feedings, shortened lengths
of stay, and reduced costs of care”
Journal of Perinatology. 27, S12-S18.