DevelopmentalCare & Neuroprotection JPetty Advanced Neonatal Cont Ed transcript

hello and welcome to this presentation which is on neonatal developmental care using the principles of neuroprotection in the neonatal setting my name is Dr Julia Petty and I'm associate professor and Senior lecturer in children's nursing in the UK so the aims of this session are for you by the end of the session to have a good knowledge and understanding of a neurodevelopmental care model think about and understand the neuroprotective factors within the neonatal care setting think about the effect of light and sound on the developing neonate and also understand the principles of infant and family-centered developmental care in the neonatal unit so by the end of the presentation you will have an increased understanding of the Care principles of Developmental care for neonates and Families as well as the importance of reducing stress in the neonatal unit be able to practice developmental care with all neonates in partnership with their parents and ensure care is given with minimal interference to the neonates well-being and that any risk is minimized and developmental care outcomes are optimized so a definition of Developmental care 2011 in a comprehensive paper which is on the reference list defined developmental care as an approach that uses a range of Nursing and medical interventions that aim to reduce the stress of a preterm and or sick neonate in the neonatal unit and these interventions are designed to allow optimal neuro-behavioral development of the neonates in partnership with the family and that in many places is known as family integrated care sometimes known as spy care where the families are integrated into the care of the baby at all levels and at all times in a 24-hour period and the seminal work on family interactive care is listed here as a citation O'Brien hotel in 2015. so let's think about a developmental care model so here is a comprehensive model by altamir and Phillips in 2017 who developed the neurodevelopmental and family integrated model which is an excellent model and really excellent paper to to read on this subject it's fully open access so here you can see this model with the baby right at the center um with the the parent there and the family right at the center of the model and then the out on the outside the various aspects of care that are vitally important in the integrated model such as safeguarding sleep minimizing stress and pain protecting skin and optimizing nutrition positioning and handling and partnering with families as well as of course optimizing the environment to ensure that it's known as a healing environment and to avoid any undue risks to the immature and or sick baby in the neonatal units so this is a screenshot of the excellent paper by altimia and Phillips in 2017 which talks about the neonatal integrative developmental care model and the seven core principles for neuroprotective family-centered developmental care so in terms of underlying anatomy and physiology it's very important to have knowledge and understanding of the developing brain in neutral and Beyond and this includes the vulnerability of the developing brain and why it is at risk of external stresses and influences so here you can see a picture of the developing brain in neutro before full term at 40 weeks from 26 weeks before 22 weeks the brain surface area is smooth and this then this becomes much more intricate in terms of the bumps and the folds from around 22 weeks and then that type of structural brain development continues certainly the folding until 34 weeks and Beyond so what is neuroprotection in neonatal care foreign so this YouTube clip here is a comprehensive overview about seven minutes long of the factors that facilitate or hinder brain development so this is worth a watch in the slide set the video you can see is embedded here for you to click on but you can watch it in the next section of this video premature birth affects an estimated 13 million babies worldwide annually and I see you infection interventricular hemorrhage periventricular chronic lung disease necrotizing enterocolitis and retinalizes prematurity are all recognized long-term sequelae of premature birth surveillance for these early morbidities with quality improvement initiatives to prevent their occurrences a focus of nearly every NICU because cerebral palsy visual impairment hearing loss shunted hydrocephalus and cognitive impairment are early sequelae of these morbidities and seen as early as 12 to 18 months postnatal age growth failure and chronic medical sequelae for example feeding problems from gastrointestinal failure and chronic respiratory problems may result in frequent hospitalizations as well learning disabilities behavioral problems are detected at an early at a later age probably due to brain connectivity problems quite matter injury resulting from ischemia or systemic infections or meningitis affect the trajectory of brain development these and other inflammatory conditions such as coryamnionitis which is an inflammation of the membranes or necrotizing enterocolitis and inflammation in the bowel result in destructive processes leading to deletion of neurons axons and glial cells which lead to micro and indeed macro cysts in the brain milder insults however involve disruption of the maturation of the glial progenitors and neurons causing a more diffuse white matter brain injury and while some cells resist cell death they do fail to generate a normal Arbor of dendritic processes and spines in other words brain injury seems to involve primary cerebral dismaturation which may be indeed amenable to strategies promoting brain maturation and hence improve neurological outcome in our premature babies while the maximum development of brain occurs between 29 and 41 weeks gestational age a time when these babies are infrequently in the NICU noise Bright Lights ill-timed caregiving activities indeed are all known to adversely affect this brain development some medications may even affect brain development causing injuries such as steroids or amino glycosides such as Gentamicin a form of antibiotic therapy or indeed diuretic therapy in addition multiple painful and stressful stimuli are also linked to maturation in gray and white matter and impair brain function parental Stress and Anxiety also are very important determinants of outcome especially when they interfere with parental bonding developmental care aims to reduce the stress and promote neurological development in these preterm babies this requires modification to the NICU environment and indeed care practices attention to noise light and position of the new newborn can reduce stress to the infant this occurs through optimal handling and positioning measures a reduction in those noxious stimuli in the environment such as light and noise and more cue based care providing care for the baby when the baby baby is ready to receive it this also requires a lot of education and attention to the family needs in the same environment hair pictured are examples of an NICU with developmental care being practiced whether the baby is in the overbed warmer on the left hand side of the side or in the current isolate on the right hand side a great deal of attention is paid to those noxious stimuli and making sure the babies are in a safe and environment which reduces their stress you can see in the same Unit A dearth of Personnel in fact on the right hand of the slide you'll see that the nursing staff caring for these babies are paying most attention to the monitors which provide them with the physiological data so that they can monitor their babies carefully without consistently interrupting the baby's sleep another example of the same NICU clearly with the isolate covered to reduce the amount of noxious stimuli and here's an example of noise meters that are used to ensure that there are visual cues to the staff when the noise level reaches a certain high level of decibel implementation of Developmental care requires ongoing assessment of the infant positioning and parent involvement to involve them in the interventions which Empower them to recognize behavioral cues in the newborn Cubase and clustering of cares requires timeout and modification of cares to suit the babies or the infant's tolerance clustering cares to minimize handling protects deep sleep a great deal of attention is paid to stressful or painful procedures to minimize or provide appropriate pain relief measures and this would include non-nutritive sucking containment of the baby's arms and legs through swaddling grasping the finger of the mum preferably one of the parents and giving babies sucrose at the time of painful procedures Staffing required is requires modification too in an effort to provide continuity of care handling the infant to maintain the infant and the semi-swaddle position and reducing the amount of contact as much as possible I've already mentioned noxious stimuli and in fact this leads us on to the idea of kangaroo care which really does improve State organization and reduces oxygen needs including a reduction in our news and bradycardias improving thermal regulation enhances parental bonding and the parental sense of competence enhancing cognitive and motor development here's an example of a mom enjoying swaddling her baby in a kangaroo typical skin to skin or kangaroo care position [Music] thank you so also in terms of underlying anatomy and physiology it's also important to understand how the fetus is supported in utro I.E in the uterus before birth so we know that the fetal period begins after the embryonic period at the end of the eighth week of gestation and then the fetus is considered as full term between 37 and 40 weeks after much development through the three trimesters of pregnancy and at term it means that they're obviously sufficiently developed for life outside the uterus but of course many of our babies that are born prematurely are delivered much much earlier than this quite often from around about 23 24 25 weeks when born extremely prematurely and at various stages along that trajectory towards terms so it can be at any point and of course that means that there's a an immaturity of all the body systems and vulnerability due to that fact that the organ systems although they're they're formed are not sophisticated enough in terms of full amount of development that should have taken place during the in utero period before birth and that means of course that once they're born they're prone to the various risks imposed by the environment into which they're born the extra uterine environment foreign so given the context and the anatomy and physiology has just been described we can now think about the effect of the environment on the developing baby in terms of their immaturity and their vulnerability as we know this as environmental care the effect for example of light and sound on the developing premature baby foreign firstly about the uterine environment based on what's just been said about fetal development in the uterus it's obviously going to be warm dark safe and friendly environment provides boundaries any noise imposed on the developing fetus is muffled by the abdominal wall and the amniotic fluid that surrounds them and they should be comfortable at least until near term however the neonatal unit environment is called here the Nico environment in neonatal Intensive Care Unit is very opposite to that so it's noisy it's bright it's cold in comparison to the intrauterine environment it doesn't have boundaries and all of the life-saving interventions the equipment the noises the tubes the lines the interventions and the invasive procedures obviously mean that is very very stressful in terms of an environment in which to be born so thinking about the difference between term and premature babies both obviously if they're sick in any way are both vulnerable to the risks of neonatal care however the term baby will have a much more developed and organized state in terms of the behaviors of the baby and have the ability to self-quiet or calm and that means consoling they can remain in a deep sleep for up to 90 minutes and they have good muscle tone and they're much more robust whereas obviously the pre-term down the other side the other column has much poorer muscle tone has an extended posture and movement poor flexion and extension balance poor control of their movements they have a limited ability to self-quiet and calm themselves and have poorer self-regulation in sleep patterns and as said before overall their systems their biological systems are immature for example they have poor heat production and a large propensity for heat loss just to give some examples so this is quite important to think about the physiological comparison of a premature baby compared to a term foreign so let's have a closer look now then at the principles of infant and family-centered developmental care in the neonatal unit so here again is the model by ultimate and Phillips 2017. and as you can see and as stated earlier it's made up of core principles and essentially there are seven of them so again just to go through them safeguarding sleep healing environment positioning and handling minimizing stress and pain protecting skin optimizing nutrition and partnering with families and we'll go through each one foreign is safeguarding sleep so we know that sleep is essential for normal neurodevelopment and also protection of the brain it's important for adequate growth and healing and for energy restoration and the maintenance of body homeostasis from a physiological perspective it's also important for preservation of brain brain plasticity I.E the ability of the brain to constantly change its structure and function in response to environmental change and also getting enough sleep is also important for long-term learning outcome and continuing brain development so the sorts of considerations we need to factor in to safeguard sleep relate quite closely to the other core measures such as safe positioning clustering care giving some allocated quiet time and also cue based caring where care is given according to what the baby tells us in terms of their behavioral cues and that's really important but this outlines the importance of sleep for the developing baby you can see here a little diagram which is outlining the most important conditions for growth and development so obviously love and connections to parents and caregivers is really important healthy feeding from very early on as early as possible including protein for growth but sleep is there as a vitally important factor for growth and development um so this is an image depicting sleep monitoring visualization so the Sleep states are visualized over a number of hours to obtain an overview of the state patterns of premature babies additionally care feeding or other interventions can be highlighted an optimal time slots for caring can be suggested as well so parents and caregivers can plan and coordinate their care and interventions according to the premature sleep patterns and maintain an overview of any changes and incidents so as stated earlier there's increasing evidence that sleep plays a major role in the development of the neonatal brain and this is particularly important in neonates born premature because brain development mainly takes place in the last part of pregnancy as again as seen earlier so a busy environment also affects the sleep of admitted babies to a unit and so far no instrument for measuring sleep has turned out to be valid or reliable in neonates and and that's quite important there are some moves towards in terms of a research capacity towards trying to monitor sleep but actually quite often the interventions can have the opposite effect and disturb sleep however in the neonatalie energy it is possible to determine sleep States and this can lead to valuable insights and direct the performance of Developmental care and that's really looking at the baby in terms of what they're doing and that comes back to again um cue based care which is really important so again on your reading list is this really very comprehensive and very useful review systematic review how to improve sleep in a neonatal Intensive Care Unit by um Vanden who gonna tell in 2017 it's really worth having a read of this um in the journal early human development so just to summarize the conclusion of that review so many different interventions have been reported to promote sleeping babies who require intensive care but there's great variation across studies in terms of sleep assessment and the different populations so while there does seem to be insufficient evidence to recommend any new intervention to promote sleep the importance of sleep for the development of the neonatal brain remains very strongly agreed so the review overall suggests some key guidelines based on evidence expert opinion and also parents views to improve sleep on the neonatal unit and also to direct future neonatal sleep studies so in terms of some of the key guidance from the paper then it's stated that recognizing the significance of promoting sleep as a keystone of the treatment of babies on the neonatal unit via integrated teaching programs targeted to nurses Physicians and parents and that is seemed to be very important they're also the importance of incorporating sleep measurements into daily Ward round assessments to increase awareness of sleep as a key factor in neonatal health and that the authors regard this as necessary to improve sleep for neonatal patients and make regulations about elective care procedures which may be postponed during sleep and during quiet times so core measure two is the healing environment and we've already said the importance of making sure that the environment is managed appropriately to avoid any risks to the premature and or sick baby so these are some of the things to consider perhaps thinking about space and ensuring enough spacing between cots or incubators to promote privacy and safety some countries we know have a single family rooms but of course that is dependent on on the unit and the size of course of the of the actual unit we need to make sure that the environment is adequately warm that we reduce and control any lighten noise that's within the the setting do things like leg padded covers over incubators or certainly protect the baby if they're in a cot or an overhead from light and sound thinking about eye shields for phototherapy individual lighting for procedures rather than full lights um the use of opaque curtains and blinds and also again thinking about dim lights during quiet times so it's also important of course to minimize noise um in the healing environment so considering things like closing portholes of incubators and doors gently not tapping the incubator or the courts um preferably no louds or radios again having a designated quiet time removing water and tubing of ventilators and CPAP because that can be quite noisy thinking about how loud we talk um over cots and incubators or in the room turning down volumes of alarms and attend appropriately thinking about phone calls that are coming in all the time and try to answer them promptly um if we do have incubators available then it's preferable that they're double walled but again that will depend on resources and the the equipment available and thinking about um noisy Ward rounds and handovers trying to make them away from the the baby that's trying to sleep thinking also about the the decibels there's a paper there by Williams at Hal so some units will have the the capability of measuring noise levels in decibels um aiming for no higher than 45. and there's a sort of a piece of equipment that you can um put into the unit which measures the different noise levels of different things and it will alarm and go over a certain amount when it goes over a certain amount of decibels and it will indicate that the noise levels in the unit are too high so in terms of the effects of a stressful environment we know that again looking at the literature and anecdotal evidence that babies can become hypoxic if they're stressed they can become bradycardic or tachycardic they're intracranial pressure can increase they can become apneic have sleep disturbances if it's prolonged stress then they can malabsorb and they can have poor weight gain and they can end up with potential hearing problems but also General restlessness and agitation so it's important to recognize timeout signals and this relates to cue based care so I looking at when the baby is telling you that there is Time Out is needed so I sort of leave me alone if you're doing cares on them so it's things like yawning facial grimacing and finger splaying as well as things like tongue extending coughing hiccuping vomiting and any color changes can be seen as timeout signals the baby's cues are telling you to give them a little bit of rest foreign but then there are also Comfort signals as well so babe is if mature enough are able to bring up their hands to their face and their mouth and that's a comforting measure if they're looking relaxed if they're a little bit older and they and they're smiling if they're able to give you eye contacts and again that will depend on the maturity of the baby and having a relaxed posture it's just again looking at the baby's behavioral cues looking at how comfortable and how relaxed they are as opposed to the previous slide which showed you some of the small stress signs when a baby is becoming um agitated so timeout signals as well as comfort signals are both very important in terms of cues that the baby is is giving so this is core measure three now moving on to positioning and the importance of of handling so as we know the one of the earliest interventions in the neonatal unit is therapeutic positioning because premature babies miss their third trimester partly or whole so the ideal flexed position in the uterine environment and we know does promote brain growth so neonatal staff should be aware of the importance of body posture and the principles of Developmental care so regardless of prone supine or sideline and midline orientation should be aimed for with the arms and legs in a flexed position close to each other and to the body the head in the neutral position with respect to the Torso and in a slightly flexed position so these are some of the principles here so we need to position the baby as closely as possible to the position that the baby would have been in inside the uterus we know that's essential for optimal neuro um sorry musculoskeletal development and essential for physiological um stability as well and function I've got to think also alongside of that with importance of making sure the baby has good thermal regulation thinking about their bone density facilitation of sleep keeping them calm and comforted again thinking about Skin Integrity Integrity which is another call measure and optimal growth again in brain development we can use supporting um positioning AIDS but it's really the most important principle there is around supporting the body with containment so that might be roles using towels or sheets but certainly to contain the body is important and That's essential for counteracting any abnormal posture and making sure the baby has got boundaries to push against um at all times not interfering with any essential interventions that need to be um performed on the baby so we're supporting our babies that are developing their body awareness and their body movements and that's really important foreign so here is a picture of a baby in the midline Supine position and the benefits there can be ease of care and access it can prevent abnormal head molding and of course at home it's the safest sleep position in line with the guidance and the prevention of sudden infant death syndrome so again thinking about um supine so that's a picture clearly that is a premature baby all splayed out which is not the right position but then of course what you would do with that baby is Nest them bring their legs up into the midline keep them nice and flexed and of course that one is the is the better position is on the right hand side that's what you're aiming for using rolls boundaries and containment sometimes you can make a little positioning Aid out of rolls and a sheet that goes over the top picture on the right hand side in the corner is again another diagram or sort of drawing of a baby that's that's on their back supine but just slightly um slightly to the side just to give their head a little bit of a um of a reprieve a little bit of a rest think about those um pressure points so next thinking about side lying and you can see two babies here one in an open cot one in an incubator both lying on their sides and you can see again the various advantages of side lying so it can facilitate the flex position quite nicely it can help reduce reflux and it does really help facilitate that a a midline position and as well as also thinking about helping the baby to self-regulate because if you can see here both babies have their hands quite close to their mouths and we've said earlier that that's a comforting behavioral sign or a cue that the baby is able to self-regulate by bringing their their hand up to their mouth so any position that could facilitate that is is very positive for the baby foreign of a sideline baby there um that's a baby again as before that is all sort of flailing around hasn't got any boundaries and clearly that's not the right approach so what you'd need to do again side lying um this this baby needs to have a nappy obviously on and some and some covering over but it's just to illustrate how a baby is sort of nested with their legs in the midline um nicely flexed up and um in a in a sort of a boundary in a sort of containment there and then we've got prone position so you can see a baby there with their mother um in the prime position uh some of the the recorded and the documented benefits are that it can decrease unnecessary motor activity and again it can help um limits or decrease reflux it can increase the quiet sleep State and also decrease stress responses such as the starter response and also um Tremor and twitching that can sometimes be associated with stress um it can assist extra you're trying adaptation and also lying on their tummies can improve oxygenation and can can conserve their energy which is really important as well so again here you can see some um babies positioned in the probe position using lovely containment flexed positioning of their limbs um hands up to you know towards their mouths so you've got some pictures at the top there and again illustrations on the bottom there to show you nicely flexed midline prone positions babies in the neonatal unit of course as babies get older and much more much more bust I mean this would be in an older neonate you can put them all in an upright position um you know with support of course particularly nice if you're getting the baby out to hold as a parent and this can be developmentally advantageous it get again can facilitate hands to midline and again starts to think about improve the oxygenation heart rate and respiratory rate this is just a picture of some of the available positioning AIDS which are sort of on the markets globally but of course there is a cost implication with these and they're just really to illustrate um but of course the towels in the middle as well as sheets and and rolls um and things like IV bags and you can be quite creative with providing comfort and roles and nests for our babies this just shows you some of the the AIDS that have been sort of developed in various countries but it just shows you the sort of principles of sort of what we're trying to aim for roles containment nests and um ways to comfort the baby and prevent any undue pressure on their their pressure points so moving on to core measure four uh minimizing stress and pain important to think about harsh environment again of the neonatal unit um and we know that premature babies can be subject to many noxious sounds bright lights and and painful procedures um they're altered sensory experience has a negative effect on on potentially on their brain developments um and so you know Studies have shown that there is potentially poorer cognitive and motor scores when they are faced with prolonged periods of stress and pain and that can also impair their growth and also Studies have been shown um where babies have got reduced white matter and subcortical gray matter maturation in their brains so again we've always got to think about the principles of neuroprotection so in terms of Care Nursing Care clearly pain management is a as with many of the other areas or sessions in their own right but of course we've got to think about accurate monitoring of pain or assessment of pain possibly using a pain tool but certainly good comprehensive ways to assess baby's pain so that we can then manage it appropriately using either pharmacological and or non-pharmacological approaches or preferably a combination of both and some of the non-pharmacological approaches have been shown to be effective as documented in the research such as good positioning um non-nutritive sucking things like um possibly swaddling if um when appropriate for the baby's age um holding breastfeeding and the use of breast milk and of course skin to skin they're all very um well-documented approaches to to reducing stress and pain so in terms of assessing pain cues we can think about looking at the Vital sign changes such as tachycardia or desaturation facial grimacing tensing irritability inconsolability and excessive crying bringing the knees up to the chest and jitteriness we've already said about the Comfort measures that the or the Comfort signs of babies in an earlier section but again thinking about those Comfort measures skin to skin use use of a pacifier for non-nutritive sucking gentle holding um laying on of hands gently you know positive touch and reduction of stimuli of stimulation and again as mentioned before consider procedural pain relief in a non-pharmacological way such as the use of sucrose and breast milk so call measure 5 is protecting the skin you can see a diagram there of the skin to remind you of the anatomy of the skin you can see how important the skin is as a barrier to protect the the body and that includes of course thermoregulation and fluid and electrolyte balance as well as all important functions of the skin so when we're thinking about practices nursing care practices we've got to think about you know cleansing protocols for the skin humidity practices avoiding or limiting the use of adhesives to avoid any excoriation or any damage to the skin and thinking about all the lines and the pressure points and and all the the tubes that the baby may have to have and it's good to think about using an evidence-based skin care guideline if possible and even a validated skin assessment tool if that is available and there are available tools out there to guide the assessment of the skin and then of course gentle and consistent handling and positioning as well and that ties in nicely with the with the the previous uh core measure which was around you know positioning and handling and making sure that that is a gentle And Timely all right foreign six is optimizing nutrition and that's a is a session all on its own right of course as as with the other the other areas so but it's just part of the developmental care model it's one of the core measures and we know obviously that looking at all the evidence and the literature the evidence has consistently highlighted that breastfeeding is the optimal method of infant feeding and should be promoted and supported and that's really key but it's just recognizing nutrition as an essential part of Developmental care particularly in line with the need for Optimum Nutrition in terms of brain growth and development vitally important to remember that so get at us with um highlighted before we've talked about cue based care but of course it's the same as with Cue based feeding recognizing the baby's Readiness ability to feed um their their tolerance of the feeding thinking about when they're saying time out and they don't want to feed anymore and thinking about you know um tying in with what the baby is is telling us in terms of their behaviors so yes it's setting Readiness and tolerance to feed is really important and this is an area where we work very closely with the families and of course support is absolutely essential to help not only establish feeding particularly breastfeeding but also to help with milk expression and the transition from you know garage feeding when the um the parents and the family want to feed um orally um preferably via the breast and the support that goes along with that which is vitally important in order to establish good patterns and and um successful patterns of breastfeeding and finally core measure seven is partnering with families so really families need to come through the whole of the developmental care model but we have to remember that premature babies or sick babies have essentially premature parents or parents who are not ready for the role and they're not ready for the crisis of of neonatal intensive care or the DNA clear unit admission so we've got to remember the you know the the intense emotions that are likely to be present so they're likely to experience you know greater emotional stress depression and anxiety as possible um either immediately or perhaps later on we've got to think about the emotional impact of admission and the uncertainty about their baby's future and they may have other stresses as well such as financial and practical stresses that need to be dealt with as well we know also looking at the evidence that the the normal or usual or expected parent infant bonding can be altered due to separation of the baby at birth um separation meaning the admission to the neonatal unit but of course we need to make measures to um ensure that there is zero separation as much as as possible and we know that the nurse nurses and and health professionals and whoever is is working with our babies and families need to help the families to achieve a positive outcome from their neonatal experience foreign that's a really fundamental principle that needs to be aimed for and you know not only to ensure bonding and emotional connections and reduce stress and ensure well-being but it's also you know part of the bigger picture of neurodevelopment which is the you know the subject of this session so we know that early bonding for example makes a significant difference to brain development and that's borne out in the literature as well so we've got to support our parents through education coaching perhaps mentoring in terms of acquiring new skills because they are becoming the primary caregiver of their infants care and their infants Journey onwards um onwards after the neonatal unit and of course at home into the community and of course when we say neonatal setting we don't just mean the neonatal unit it's the whole trajectory of care um so we need to ensure that we are attentive and compassionate to our parents at all times and have that approach and have a really value values-based respectful approach to our parents making sure that all elements of their care and their um their wishes and their preferences are taken um on board including you know cultural and religious observances as well in terms of ensuring quality and diversity in the workplace so recognizing also that families are constant in their babies environments and helping them achieve a positive outcome from the neonatal unit should be a priority for us really to making sure that when they go home that they are able to you know function as a healthy family and you know have the their stress reduced as much as as is possible foreign so skin to skin contact here is is a little bit of a section on that as a core measure um and it can be a very important intervention or care practice um as part of us working with our families so we partner with with parents and families as staff but of course we want the parents themselves to be attached and to bond with their babies or vice versa so skin to skin contact we know look and get again at all of the evidence and the research is a very positive Intervention which you know is very much to be encouraged as an optimal environment for any newborn particularly so for premature babies and sick babies um in the neonatal unit when their physiological ready and when they're able to be bought out for skin to skin for long periods of time and it can be seen as an essential place of care particularly um where there are units that perhaps lack incubators um to keep the babies warm it has many many functions it improves physiological regulation of various functions and optimally and it's certainly an essential component of neuroprotective family-centered care for premature babies and again that there's lots of literature that supports that and of course effective skin to skin supports optimal brain development and facilitates attachments which then promotes the baby's self-regulation over time and follow-up Studies have also looked at that at the effects later in life and what the benefits that affords to both the baby and the parents themselves um so skin to skin is something that we shouldn't forget dads and partners of course it can be any any member of the family any um any caregiver um as well as the the baby's mother but it can be the baby's um uh father and or um partner depending on the family setup um we know that again some of the other benefits it can increase oxytocin levels for both um parents um it can also help the other neuroprotective core measures to be supported as well so I.E positioning um it's an optimal position when laying on a parent's chest it's and they lay in the flex position they're they're tucked up their hands are up in the midline towards their face um reducing pain and stress we know that skin to skin contact is a very effective non-pharmological approach to pain and stress reduction again looking at the the research on that so there are there are many other benefits that ties in with the whole um neurodevelopmental model it's also an ultimate healing environment for newborn babies it provides opportunities to partner with families by providing parents an active role which is the premise of what was mentioned earlier um Family integrated care as I said it facilitates supportive positioning it provides proximity to maternal loaders to contribute to sleep cycling as well so again it ties in with that sleep um that core measure as well Fosters optimal autonomic and physiological stability to reduce pain and stress providing humidity and increases mother's milk supply and the other term of course that we also use it on a global level is called it's called kangaroo mother care which is a term that um coined by the World Health Organization so these are just a couple of really nice pictures to show sleeves skin to skin um and you know a parent interacting and communicating with their baby so just again to look at to look at some of these uh these pictures you know really bring home the importance of of family involvement integration into care and the benefits for both parents and the babies themselves foreign summary learning the principles of neurodevelopmental and care and understanding the meaning of premature behavioral cues makes it possible for neonatal caregivers and parents to provide individualized developmentally appropriate neuroprotective care to each infant and their families there's just a few quiz questions to think about I should read them out and then we'll go through the answers so there's five number one of five is true or false preterm infants are deprived of the uterine development of physiological posture during the first trimester of pregnancy next one true or false appropriate positioning promote self-regulation and facilitates the infant's participation in normal sensory motor experiences such as bringing the hand to the mouth and the face number three true or false positional plagio kefirly has a negative effect on the physical development of preterm infants number four true or false there is no association between painful experiences in pre-term infants and developmental outcomes now the final quiz question true or false so a major reason for the increased risk to the developing brain is the structural differentiation I.E nerve growth and synapse formation of the central nervous system that occurs rapidly between 23 and 32 weeks of gestation and the possibility of Auto alterations in differentiation that may affect later development so I'll just leave that up for you to read so again five different statements all true or false okay let's just go through the answers now so the first one was true or false pre-term infants are deprived of the uterine development of physiological posture during the first trimester of pregnancy that of course is false because physiological flexion develops in the third trimester not the first okay so we know that physiological flexion the ability of the baby to to flex both their limbs up in the midline is is in the third trimester and they start to push against the wall of the uterus to develop their tone and from 34 weeks the baby should have inside the uterus if they're not born by then they should have sufficient flexion and sufficient muscle tone of course if the baby's born before that um they will be deficient in muscle muscle tone the second one was draw a false appropriate positioning promote self-regulation and facilitates the infant's participation in normal sensory motor experiences such as bringing the hand to the mouth and the face that's of course is true so we know that bringing um up the hands to the mouth is a healthy Behavior it's also a comforting behavior that where babies can console themselves so that answer was true the third one was true or false positional plagiocephaly has a negative effect potentially on the physical development of preterm infants and that is also true so um this term is positional pleasure carefully is known as cranial molding and so if you don't position a baby regularly and turn the baby over and they spend a long long time on in one position and their head can become molded so that's true it can potentially have a negative effect on the physical development of babies in terms of their head molding and then true or false there is no association between painful experiences and preterm infants and developmental outcomes that of course is false and we know that from a systematic review for example by Valerie atel 2015 which is on your reference list found evidence in the literature between painful experiences in premature babies an association with developmental outcomes including cognitive and motor development so that statement is false because um it's an opera it's the opposite there is an association between painful experiences in premature babies and developmental outcomes and then the final question was true or false a major reason for increased risk of Developmental of the developing brain is the structural differentiation such as nerve growth and synapse formation of the central nervous system that occurs rapidly between 23 and 32 weeks gestation and the possibility of alterations in differentiation that may affect later development and that of course is also true because this particular period here is a critical development of brain development in utero and all stages are important of course but in terms of that later gestation when the baby is born between 23 and 32 weeks it's important to know what level of immaturity their brain is at and what what the potential risks are when a baby is born prematurely in order to protect their brains so finally here is the reference list that's been um drawn upon to develop this slide set you can see here there's some key references and also on the next slide as well foreign access resources relating to Developmental and neurodevelopmental care which have hyperlinks so in the actual slide set if you click on these links it will take you through to the actual web-based either resource or article so to give you some further reading so thank you for listening to the presentation if you have any questions or you want any further information please do contact me on J dot Petty at hearts.ac.uk