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, strategy 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 satisfaction 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 training hospitalizations Positioning Environment (States, Sound, Lighting) Kangaroo Care Family Involvement Teaching Modules Procedural Support/ Pain Swaddled Bathing Feeding 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” position. 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, 2002. Implementing Positioning Guidelines 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 regulation. Swaddling maybe used to support muscular development and for infants that are difficult to console. Infants may continue to use gel pillows that have skull deformations or are vent dependent. www.cademedia.com >35 weeks CGA or Prior to Discharge 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 sleep. Blankets should not be used over crib or infants face to shield light or noise. Remove rolls, extra bedding, toys, positional equipment, and nests. 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 Back 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 Preferential Boundaries Too Head Turning Small 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 sucking enhanced ability to participate in breast or bottle feeding immediately after the bath promotes feeling of security in infant despite change in environment 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 attachment enhanced interaction with the baby decreased parental stress 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 securely. 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.