Developmental Observer 20 23 | V O L 1 6 | N O . 3 The Official Publication of the NIDCAP® Federation International A philosophy….can help us choose the best approach from an ethical point of view, such as the philosophy of person/ family-centered care —Jacques Sizun 10.14434/DO.V16I3.36574 INSIDE Translating Data on Brain ............... 1 Development Into Practice Editorial .............................................................. 2 Assessment of Preterm ..................... 6 Infants' Behavior Family Voices ............................................. 10 Science Desk .............................................. 12 NIDCAP Leader Profile ........................ 14 Global Perspective ............................... 16 French Polynesia Publications ................................................. 18 34th NIDCAP Trainers Meeting ..... 21 NIDCAP on the Web ............................ 22 NIDCAP Training Centers .............. 24 O ne of the goals of the neonatal teams is to support and protect the developing brain in the Newborn Intensive Care Unit (NICU), as the baby only has ‘one brain for life’.1 Medical treatments, such as antenatal steroids and magnesium sulfate, have been shown to be effective in preventing brain damage in preterm infants. In parallel, environmental and behavioral strategies have been proposed under the generic term of ‘developmental care’ or ‘brain care’. Developmental care is an emerging science and needs to be as evidence-based as possible so that healthcare providers are in a position to choose the best strategies for care, and in order for healthcare teams to be trained effectively, and parents and families to be provided with the best and most comprehensive information available. Brain plasticity is ‘the ability of the nervous system to change its activity in response to intrinsic or extrinsic stimuli by reorganizing its structure, functions, or connections’.2 Brain plasticity is an opportunity for the newborn, as it offers a chance for rehabilitation after brain damage. Brain plasticity is also a challenge: an early hostile environment could alter the steps of brain development, such as synaptogenesis. In case of prematurity, synaptogenesis occurs while infants are hospitalized in the newborn intensive care unit. This article focusses on the effects, as described in recent systematic reviews, Translating Data on Brain Development Into Practice DOI: 10.14434/do.v16i3.36565 (continued on p.2) Jacques Sizun, MD French NIDCAP Center, Toulouse, France A summary of the presentation given at the 33rd Annual NIDCAP Trainers Meeting in Bad Bol, Germany 2022 2 • 2023 • Developmental Observer The influence of NIDCAP is steadily increasing, as evident from the comprehensive body of work it encompasses. In this edition, Jacques Sizun presents compelling proof of NIDCAP's efficacy by examining current research and practical applications. Notably, there has been a surge in publications citing NIDCAP's principles across multiple languages, underpinning its growing global recognition. The path of our global outreach remains unwavering. The NIDCAP Federation International, driven by dedicated members, continues to propel the frontiers of this approach. Through leadership, we are privileged to embark on journeys of discovery with our valued members. An insightful introduc- tion to Monique Oude Reimer-van Kilsdonk hailing from the Netherlands, offers a glimpse of our diverse membership. Joy Browne enriches our understanding of APIB through a survey of our members, providing valuable insights that deep- en our appreciation of its implementation. A pivotal facet of the NFI is our community of family mem- bers. Nina Nikolova's poignant account from Bulgaria exem- plifies how adversity can be the catalyst for assisting fellow families. I invite the members and readers of the Developmental Observer to share their journeys with developmental care. We warmly welcome your reflections on training, practice, interesting case studies, and the invaluable lessons drawn from personal experiences. Your contributions stand to strengthen the Developmental Observer and the information to move developmental care forward. Kaye Spence AM FACNN Senior Editor – Developmental Observer Adjunct Associate Professor / Clinical Nurse Consultant Australasian NIDCAP Training Centre / Sydney Children’s Hospitals Network / Western Sydney University / Australia of some approaches aimed at preventing the negative impact of frequent stressors on brain development in the NICU. The stressors are sleep deprivation, pain, mother-child separation, and sensory dysstimulation. Stressors in the NICU Sleep deprivation Animal studies, mostly conducted on rodents, have provided useful insights with regard to sleep deprivation.3 These stud- ies have shown that sleep deprivation may result in: oxidative stress, neuroinflammation via chronic microglial activation, and the accumulation of the abnormal proteins p-Tau and am- yloid-β in the cerebral cortex. These studies have also shown a neurogenesis decline via complement activation, which alters the balance of Fragile X-Mental Retardation Protein expres- sion.3 In addition, the impact of chronic sleep deprivation on behavioral development has been demonstrated. Sare et al4 found short- and long-term changes in behaviors of sleep-de- prived mice, measured by activity in an open field arena. Males demonstrated decreased sociability and increased repetitive behaviors. This data from preclinical studies show that sleep deprivation in the neonatal period has long-lasting behavioral changes, possibly modulated by gender. Pain A meta-analysis by Steinbauer et al5 concluded that neonatal pain has a large effect on neuronal cell death in rodents. The higher number of neonatal pain events was significantly asso- ciated with increased neuronal cell death, increased anxiety, and depressant-like behavior. Boggini et al6 summarized the impact of pain on preterm infants’ brain development demon- strated by MRI studies. A volume reduction of white and gray matter structures at neonatal and school ages is associated with early postnatal pain exposure. However, there is a possible bias, as the most severe clinical conditions are associated with higher exposure to painful procedures. Mother-child separation Maternal separation, an early stressful experience, can nega- tively impact the newborn’s nociceptive system development and pain responses at different levels7 (Table 1). Epigenetic mechanisms are implicated in the long-term effects of this early life stress that could also impact the next generation. Sensory Stimuli During prenatal development in mammals, the sensory sys- tems do not become functional at the same time, but rather in a specific and invariant sequence: first tactile, then vestibular > chemical > auditory > visual.8 This differential timing of sen- sory system onset could benefit the earlier developing sensory systems as it allows them to develop without competition or interference from later developing sensory systems. In the case of preterm birth, the sensory stimuli are numerous, intense, simultaneous, chaotic, and physically different from those observed in utero.9 This could negatively impact synaptogen- Editorial Cover image by Emmanuel Angelicas DOI: 10.14434/dov16i3.36574 (continued on p. 3) 2023 • Developmental Observer • 3 Jeffrey R. Alberts, PhD, is Professor of Psychological and Brain Sciences at Indiana University -- Bloomington (USA). Jeff is also a NIDCAP Professional and blends his lab studies with similar research at Cincinnati Children’s Hospital Medical Center. gretchen Lawhon, PhD, RN, FAAN, is the Clinical Nurse Scientist with Newborn special care associates, at Abington Jefferson Health and a NIDCAP Master Trainer. gretchen has reviewed articles for peer reviewed journals. gretchen has extensive experience as a clinical nurse scientist and has authored numerous articles in her areas of expertise. María López Maestro, MD, is a Neonatologist at the Hospital 12 de Octubre in Madrid, and is a NIDCAP Trainer and Member of the National Committee for the implementation of Developmental Centered Care in Spain. Maria has 10 research works. https://orcid.org/0000-0002-0545-6272. Debra Paul, OTR/L, is an occupational therapist and NIDCAP Professional at Children’s Hospital Colorado in Aurora, Colorado and the Column Editor for the Family Voices section for the Developmental Observer. Debra writes policies and guidelines which requires succinct writing and an eye for editing.  Kaye Spence AM is a clinical nurse consultant and clinical researcher with numerous publications in peer reviewed journals and several book chapters and is a peer reviewer for eight professional journals. She is a past Editor of Neonatal, Paediatric and Child Health Nursing. https://orcid.org/0000-0003-1241-9303  Diane Ballweg, MSN, is the Developmental Specialist at WakeMed Hospital in Raleigh, North Carolina, USA. Diane’s writing and editing experience also includes reviewing for several peer reviewed journals and authoring several journal publications and book chapters related to developmental care. Deborah Buehler, PhD, is a developmental psychologist and a NIDCAP Master Trainer with expertise in developmental care within newborn and infant intensive care nurseries. Her work has focused on NIDCAP research, education and mentorship, and awareness. Deborah has authored and co-authored papers and manuals pertaining to NIDCAP care. Sandra Kosta, BA, NFI Executive Director of Administration and Finance, has been an Associate Editor for the Developmental Observer since 2007. As a Research Specialist at Boston Children’s Hospital, Sandra has co-authored several papers on the effectiveness and long-term outcomes of NIDCAP Care. Editorial Board esis. According to Bourgeois, ‘experimental models provide an additional example showing that a perturbation at an early neurodevelopmental stage may have a late and long-lasting effect of disorganization despite an apparently normal inter- mediate period’.10 The research data shows evidence for the importance of prevention of pain, stress, mother-child separation and inap- propriate stimulation in the NICU. What is the evidence for the strategies that reduce these stressors? Strategies for Reducing Stress Sleep support strategies A systematic review found that swaddled preterm newborns arouse less and sleep longer.11 Swaddling stimulates sleep continuity, as shown under laboratory conditions and in descriptive studies. The effect is most consistent in periods of Quiet Sleep (QS), but not always consistent during Rapid Eye Movement (REM) sleep. Table 1: Overview of maternal separation on the nociceptive system [adapted from Melchior et al.7] Gastro-intestinal tract Dorsal root ganglion Spinal cord Higher brain centers - Increased permeability of the mucosal layer - Inflammation - Change in microbiota composition - Increased excitability of afferent neurons - Increased expression of Nav 1.8 - Decreased expression of Kv1.2 - Increased activity of superficial and deeper layers - Changes in neurotrophic factors expression - Differential activation of the pain matrix - Alteration of descending controls of pain - Central inflammation (continued on p.4) 4 • 2023 • Developmental Observer A Cochrane Review of non-nutritive sucking (NNS) found four studies reported on behavioral states with different meth- ods of reporting states.12 Two studies reported no effect, one study reported the most frequent transition was from QS to drowsy for the NNS group, and one study reported that sleep states were more frequent in the NNS group. The impact of skin-to-skin on sleep in neonates has been clearly demonstrated.13 According to a review from the Amer- ican Academy of Pediatrics,13 skin-to-skin increases frontal brain activity during both quiet and active sleep, supports a more mature sleep organization, with increased total and quiet sleep, decreased REM sleep and arousals from sleep, and improves sleep cycling. Therefore, the best strategy to protect sleep is to encourage parents to be present in the NICU and to provide extensive skin-to-skin for their infant. In a study of infants receiving regular care versus develop- mental care practices (covering the incubator, decreasing en- vironmental noise, using supportive bedding, and promoting state transition by hand swaddling, non-nutritive sucking, or grasping), sleep time was increased both in AS and QS states.14 In a systematic review of randomized control studies on the effects of music therapy on premature infants,15 recorded music interventions were not associated with a significant ef- fect on behavioral states. Live music interventions were shown to improve sleep in three out of four studies, however, behav- ioral states were defined with different non-validated tools. Due to the heterogeneity of type and duration of interventions, gestational age of the subjects, and outcome measures, there was not enough evidence to recommend music therapy. Pain control strategies Numerous clinical trials and meta-analyses have demonstrat- ed the efficacy of non-pharmacological interventions on the behavioral expression of pain in newborns: swaddling, flexed position, non-nutritive sucking, oral sucrose, breastfeeding or mother’s milk, and skin-to-skin. Association and/or superior- ity of interventions are less studied.16 More trials studying the impact of these interventions on the cortical response and the effect of structured parent involvement are needed. Maternal Separation Strategies New World Health Organization (WHO) guidelines advise that kangaroo mother care should start immediately after preterm birth without an initial period in an incubator.17 These recommendations are based on recent trials demonstrating the positive impact of very early skin-to-skin on survival or cardiorespiratory stabilization.18,19 Mother-newborn couplet care is considered the best strategy to support the zero-separation concept. However, the current evidence is scarce.20 The Stockholm Neonatal Family Centered Care Study demonstrated a 5.3-day reduction in total length of stay and a reduced risk of moderate-to-severe bron- chopulmonary dysplasia in the Couplet-care group.21 Believing that all these interventions could be integrated with an evidence-based global approach, Roué et al collabora- tors identified eight principles that do not need more research before routine use.22 These include free 24-hour parental access, pain management, environmental influences, support of skin-to-skin, and sleep protection. Science, Philosophy, and Human Rights While the scientific evidence is strong, science alone cannot guide all aspects of care for hospitalized newborns. A philoso- phy - ‘a theory that acts as a guiding principle for behavior’ - can also help us choose the best approaches from an ethical point of view, such as the philosophy of person/family-centered care. In this case, scientific evidence is not then necessary. Instead, the ethical reflection, both individually and as a group, can inspire and enrich the approach. Moreover, in a study concerning the participation of NICU parents in medical rounds, some parents argued that it was not a philosophical question, but just the expression of human rights, their ‘right’ to be present, and their ‘right’ to participate in the decisions concerning their baby.23 Although science is an important factor in determining best practice, the respect of human rights is also very important. Guidelines In order to put the science and philosophy to practice it is necessary to have access to the data and for clear guidelines/ recommendations/standards to be formulated and followed. Many guidelines are easily accessible and can guide high quali- ty care in the NICU. Gap Between Research and Practice Despite the existence of scientific evidence and easily accessible recommendations from national or international agencies and organizations, a significant gap exists between knowledge and practice. An example is a multisite survey across 13 NICUs in Paris about procedural pain in newborns.24,25 One NICU used non-pharmacological interventions for painful procedures only 2.4% of the time, whereas another NICU used these strategies 81% of the time. They also measured the difference in pain con- trol during the day and the night and found that the babies were more protected from pain during the day than at night. The only difference was parental presence. There is high evidence for the importance of parental presence, yet implementation is lacking. Why is there such a difference between these units given they all have access to the same research? Another study, the French EPIPAGE study26 showed that there was little range in difference across units on medical interventions, but there was a large difference across units in the use of behavioral strategies. It was also shown that there was no significant difference between the cluster of infants who received intensive medical intervention and those who received more behavioral interventions. Although there is a high level of research on the benefits of 2023 • Developmental Observer • 5 behavioral strategies there is great difference in the implemen- tation of these strategies which has an effect on the comfort and care of the baby and ultimately on the baby’s outcome. NIDCAP Training and implementation of brain-care practices The French EPIPAGE study gives us information on the implementation of medical and nursing practices such as skin-to-skin, breastfeeding support, and pain control, and the association with professional education and training.26,27 The authors observed large unit-level variations not explained by differences in infants’ characteristics across units, but possibly explained by neurodevelopmental care policies and training. The NIDCAP training compared with no training was signifi- cantly associated with early kangaroo-mother-care (KMC) initiation: [OR, 3.5; 95% CI, 1.8–7.0] and sufficient perceived maternal information on infants’ pain [aOR (95% CI) 2.6 (1.7–4.1)].26,27 There has been much evidence on the effective- ness of NIDCAP on the infants’ outcome, but this was one of the first studies to show the influence of NIDCAP training on evidence based care practices. How can we explain this? Dominique Haumont identified ten points where NIDCAP impacts early developmental care, including assessment of pain, kangaroo care, and sleep orga- nization.28 The tenth point identified NIDCAP training as a tool for change. NIDCAP is not a prescribed protocol, instead NIDCAP implementation is said to be ‘process-guided’: a con- tinuous process requiring flexible procedures and not proce- durally-based attitudes. NIDCAP is also ‘relationship-based’ as it provides a new way of thinking about our relationships with the babies, the parents, and our colleagues. The third aspect is ‘system-oriented’ thinking as a change in any part of the system has an effect on the whole system.29 Conclusion • Research highlights the vulnerability of the developing brain in hospitalized newborns. • Developmental care practices are evidence-based. • A research-practice gap exists. • NIDCAP could bridge this gap. References 1. Amiel-Tison C, Stewart A. The newborn infant: One brain for life. INSERM Edition, Paris 1994. 2. Mateos-Aparicio P, Rodríguez-Moreno A. The impact of studying brain plasticity. Front Cell Neurosci 2019; 13:66. DOI: 10.3389/fncel.2019.00066 3. Alrousan G, Hassan A, Pillai AA, Atrooz F, Salim S. Early life sleep deprivation and brain development: Insights from human and animal studies. Front Neurosci. 2022 16:833786. doi: 10.3389/fnins.2022.833786. 4. Saré RM, Levine M, Hildreth C, Picchioni D, Smith CB. Chronic sleep restriction during development can lead to long-lasting behavioral effects. Physiol Behav. 2016 155:208-17. doi: 10.1016/j.physbeh.2015.12.019. 5. Steinbauer P, Monje FJ, Kothgassner O, Goreis A, Eva C, Wildner B, Schned H, Deindl P, Seki D, Berger A, Olischar M, Giordano V. The consequences of neonatal pain, stress and opiate administration in animal models: An extensive meta-analysis concerning neuronal cell death, motor and behavioral outcomes. Neurosci Biobehav Rev. 2022 137:104661. doi: 10.1016/j.neubiorev.2022.104661. 6. 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