Chapter Contents
Introduction 89
Brain development in relation to developmental care 89
Developmental care 90
Newborn Individualized Developmental Care and Assessment Program 91
Discussion of evidence for developmental care 92
Summary 92
Introduction
Increasing numbers of premature infants are surviving thanks to technological advances. Mortality has been dramatically reduced but morbidity remains a challenge ( ). Follow-up studies on children at school age have shown that they are more likely to have difficulties with attention, fine motor skills and interpersonal relationships ( ; ). Developmental care (more specifically, the Newborn Individualized Developmental Care and Assessment Program (NIDCAP)) has been claimed to improve outcomes ( ; ). This chapter will describe some of the developmental care practices within the context of the developing brain and the evidence behind these approaches.
Brain development in relation to developmental care
Preterm babies are projected into an alien extrauterine setting at a time when their brains are growing more rapidly than at any other time in their life. Their experience is a contrast between the expected environment of their mother’s womb and the feel of their parents’ bodies after birth and the comfort of their family and community social group ( ).
As is well known, development of the brain is influenced by predetermined genetic processing and endogenous and exogenous stimulation. The genetic processing is largely exempt from external influences as it occurs predominantly in the first 20 weeks of gestation. It is after this that the so-called critical periods of brain development occur when environmental influences shape neuronal connectivity and activity ( ). In essence, during critical periods the brain requires appropriate sensory input from external influences in order to make appropriate connections.
The neonatal intensive care unit (NICU) does not provide the sensory experience that the premature infant was expecting in terms of type, timing or intensity. Consequently there is the potential for these windows of opportunity to be missed. Furthermore, studies on preterm infants have demonstrated that the dual stress for the baby of maternal separation together with frequent painful procedures or discomfort results in potentially neurotoxic brain-altering events ( ).
Such research findings emphasise the need to recognise that both family relationships and the care given during the preterm infant’s stay in the NICU influence the infant’s neurodevelopment. Current thinking is that developmental care should be implemented alongside medical interventions in order to maximise the baby’s potential and achieve the best possible outcome.
Developmental care
Developmental care is an umbrella term for a variety of approaches used with preterm infants whilst in NICU. The aim is to adapt the infant’s sensory experience of the world positively and involve the family and care team. Developmental care includes modifications of both care-giving practices and the baby’s physical environment.
The aim of developmental care is to promote the infant’s neurodevelopment through increasing comfort, decreasing stress and promoting sleep. Key points related to the most commonly applied developmental care practices are outlined below.
The nursery environment
Environmental modifications to light and noise are those most commonly considered when the term ‘developmental care’ is used. Indeed, these aspects are important as they have significant influence on the infant’s autonomic stability and have the potential to cause harm ( ).
Light
The development of the central visual system may be disrupted by overstimulation of the eyes. Bright light disrupts release of growth hormone and may prolong the time spent in rapid-eye movement sleep ( ). Little is known about the development of circadian rhythms in premature infants. However, it has been demonstrated that babies exposed to periods of cycled versus continuous lighting have longer periods of sleep and are more efficient feeders with improved weight gain ( ).
Recommendations for modifying the nursery environment to support neurodevelopment include dimming lights whilst maintaining a safe level of accurate clinical observation as well as cycling lighting to simulate day–night patterns ( ). Individualised bedside lighting and shielding the infant from light with an incubator cover or blanket are recommended ( ). At term, the baby requires the opportunity to explore the world visually with adequate levels of lighting. This is vital for continued development of the visual system ( ).
Noise
In utero, infants are exposed to sound of 40–60 dB, yet in the NICU sound may exceed 120 db at times. Loud sound levels are known to cause stress in preterm infants. Moreover, preterm infants are unable to habituate to sound within their environment and, consequently, environmental noise interferes with sleep and creates increased distractibility which persists into childhood ( ).
Developmental care aiming to reduce auditory environmental stimuli includes noise monitors ( ), lowering the volume of monitor alarms, covering incubators with thick, padded covers and conducting teaching rounds either in an unobtrusive manner or away from the cot side ( ).
Guidelines with recommendations for nursery design, which encompass optimal light and sound levels, have been published in the USA ( ).
Family-centred care (FCC)
The family has a pivotal role within developmental care and, to reflect this, the term ‘family-centred/supportive care’ is used. In this model, families have unrestricted access to their infant. Different interpretations of this premise vary from providing seats for parents next to their baby’s incubator to providing a ‘private room’ within the nursery for the family. Here, they live with their baby until discharge, fully caring for the child with support from the team, as required ( ).
One of the key objectives of FCC is to educate and integrate parents into the newborn intensive care environment and to encourage active participation in their baby’s care. Furthermore, it aims to help parents observe and interpret their baby’s behavioural needs, thus enhancing relationships. This is particularly important given that preterm infants inevitably have lower levels of signalling ( ).
Kangaroo mother care (KMC)
Developed 30 years ago, KMC aimed to improve infant survival in the absence of incubators. Whilst wearing only a nappy, the baby is placed between the mother’s breasts in a vertical position with head and trunk aligned and limbs flexed, with supportive material binding surrounding both. Heat is transmitted from mother to baby, stabilising the baby’s temperature; her breathing provides stimulation for her infant’s respiration and the upright positioning helps minimise gastro-oesophageal reflux. Today, KMC involves relatives, fathers and same-sex partners as well as biological mothers ( Fig. 4.1 ).
It has been demonstrated that KMC has a positive effect on state organisation, physiological stability, decreased arousal and increased quiet sleep and neurodevelopment. It facilitates the family’s psychological healing, enhances parent–infant bonding and improves lactation ( ; ). Maternal benefits include increased self-confidence, less postpartum depression and better ability to respond to and care for her baby during admission and after discharge ( ).
There are published guidelines for the implementation of KMC on ventilated and non-ventilated infants ( ).
Incubator environment
Staff can increase the baby’s comfort during the lengthy periods the child is cared for in an incubator or cot by adopting relatively simple measures such as the following.
Postural support
Swaddling seems to improve sleep quality and diminish stress and pain responses in the preterm infant and it is suggested that it may also improve neuromuscular development ( ). Comfortable swaddling should avoid limb overextension, overheating or interference with respiratory effort. Alternatively, consideration may be given to positioning as, for example, prone or left side-lying may reduce gastro-oesophageal reflux ( ) whereas side-lying may enhance neuromuscular development. Supportive bedding materials, including nests, are used to help the infant maintain head and trunk alignment. The position facilitates the baby’s efforts to bring the hands together or to the mouth; these are calming strategies that promote further development.
Chemosensory support
The sensory pathways for both taste and smell develop early in utero with the fetus exposed to the mother’s diet via the amniotic fluid ( ). After birth, the infant shows preferences for these flavours, demonstrating the ability to detect and discriminate smell and taste through physiological and behavioural responsiveness. Smell has been shown to influence positively the quality of the infant’s arousal and sleep states and aid the infant’s recognition, hence encouraging relationships, particularly maternal. Noxious stimuli can have a negative effect ( ).
Exposing preterm infants to the smell of their mother’s amniotic fluid and/or colostrum as soon as possible after delivery may ameliorate the effect of separation and facilitate both bonding and later progression to oral feeding ( ). Tastes of expressed breast milk may be incorporated into mouth care even with very preterm infants.
Non-nutritive sucking (NNS)
Considerable research has been devoted to NNS whereby the infant is offered a pacifier most usually during tube feeds or as a comforter during painful procedures. The reported benefits related to NNS include earlier discharge, quicker transition to oral feeds and improved physiological stability during painful interventions, particularly when NNS is combined with expressed breast milk or sucrose ( ).
Support during cares and procedures
It is easy for parents and staff to appreciate that interventions such as blood sampling or lumbar puncture cause pain and discomfort. It is less readily appreciated that routine care procedures like weighing can also engender stress for the infant. Consideration of the following may provide developmental support.
Timing and pacing of cares
As far as possible, the baby’s sleep should be respected and protected given its importance for brain development. Whilst it may be considered advantageous to ‘cluster’ cares and procedures and then to leave the baby undisturbed, the intensity of the interventions may tax the infant physiologically more than allowing the infant to rest for a short time between activities, ideally with carer support ( ).
Gentle handling
The unborn baby lives in a warm, fluid-filled environment, gently rocked by constant oscillations of amniotic fluid. Caregiving in the NICU can be intrusive, painful and stressful. Gentle handling, avoiding sudden changes in posture, is recommended. Supporting the infant with still hands (containment holding) which are gently enveloping can help the baby endure difficult experiences and recover more quickly, particularly when combined with appropriate pacing of caregiving ( ). Parental holding in this way is probably the ideal physical contact for the preterm infant. The benefit of massage is disputed and can prove overstimulating for more fragile infants.
Pain
Pain and stress are usually recognised in preterm and term babies using pain scales that include facial expressions and physiological variables like heart rate, respiratory rate, mean blood pressure and changes in skin colour ( Ch. 25 ). Pain can be treated with medication, behavioural approaches or both. Pharmacological strategies to provide pain relief include boluses or continuous infusions of morphine, midazolam or fentanyl for ventilated babies and chloral hydrate or oral sucrose before painful procedures. Behavioural interventions include swaddling, gentle handling, NNS, breastfeeding and KMC ( ).
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