26 P e d ia t r ic s issN 2413-6077. iJMMr 2017 Vol. 3 issue 1 Corresponding author: Iryna Sarapuk, Department of Pediatrics №2, I. Horbachevsky Ternopil State Medical University, 2 Sakharova Street, Ternopil, Ukraine, 46400 Phone number: +380502081147 E-mail: prostoirusya@ukr.net I. M. Sarapuk et al. International Journal of Medicine and Medical Research 2017, Volume 3, Issue 1, p. 26–33 copyright © 2017, TSMU, All Rights Reserved dOI 10.11603/IJMMR.2413-6077.2017.1.7063 NEUROdEVELOPmENTAL cARE Of PRETERm INfANTs ANd ITs KEY ELEmENTs I. M. Sarapuk1, H. A. Pavlyshyn1, L. Lacina2, B. Królak-Olejnik3 І. HorbAcHEvSKy TErnoPIL STATE MEDIcAL UnIvErSITy, TErnoPIL, UKrAInE1 NIDCAP CINCINNATI TRAINING CENTER, CINCINNATI CHILDREN’S HOSPITAL MEDICAL CENTER, CINCINNATI, OHIO, USA2 WROCLAW MEDICAL UNIVERSITY, WROCLAW, POLAND3 During the past few decades, advancements in the perinatal and neonatal intensive care have led to a sig- nificant survival of premature infants. However neurodevelopmental outcomes remain the major issues of concern. Developmental care is an approach that aims to reduce the mismatches between the extra- and intra- uterine environment, decrease the stress of preterm newborns in neonatal intensive care units, and thus promote optimal neurobehavioral development of the infant. The Newborn Individualized Developmental Care and Assessment Program (NIDCAP) model was developed as a clinical framework for the implementation of developmental care. The model focuses on detailed reading of each individual infant’s behavior. By observing the infant during a routine assessment (before, during and after) and a detailed description of his/her behavioral responses, a professional can assess the ability of the in- fant’s immature nervous system to tolerate the environment and care manipulations. Such evaluation will enable one to determine the adequacy of the environment and care to meet the infant’s opportunities and needs, with subsequent corrections and adaptation. NIDCAP’s aim is to support the infant in his/her interaction with the environment as an active participant in caregiving within a family. With the help of NIDCAP approaches in neonatal care medical staff will study how to read and interpret in- fants’ behavior, thus hearing their voices. KEy wORDS: developmental care, NIDCAP, preterm infants. Introduction Today the number of premature births is increasing. According to the World Health Or- ganization (2012), every year about 15 million babies are born prematurely – more than one in 10 of all babies born around the world, affec- ting the families around the world. In developed countries of Europe and USA the incidence varies from 5 to 12% [1, 2, 3], and may reach 40% in less developed regions [2]. During the past few decades, advance- ments in the perinatal and neonatal intensive care (the use of antenatal corticosteroid ther- apy, surfactant therapy, and improved ventila- tory techniques) have led to a significant sur- vival of premature infants with gestational age less than 32 weeks [4]. The percentage of new- borns with gestational age less than 32 weeks (extremely preterm and very preterm ones) is 1–2% in developed countries [1]. However, despite the positive results of survival, morbidity and complications associated with premature birth are growing rapidly [2, 3]. Preterm babies meet with a large number of negative factors, since the beginning of their extra uterine life passes in the NICU (neonatal intensive care unit) environment, where such factors as light, noise, highly advanced non- invasive and invasive manipulation and pain dramatically affect the whole immature organ- ism, resulting in early short-term and long-term complications. Neurodevelopmental outcome has become a benchmark in determining the effectiveness of medical neonatal care [5]. The incidence of disability and neurodevelopmental problems among survivors of neonatal intensive care re- mains high and problematic [2, 6, 7]. Severe neurological complications (cerebral palsy, mo- derate to severe mental retardation, epilepsy, poor motor skills, sensorineural hearing loss, blindness) still remain consistently high. More- over, by the age of 8 years, over 50% of very low birth weight preterm children require special 27 P e d ia t r ic s issN 2413-6077. iJMMr 2017 Vol. 3 issue 1 I. M. Sarapuk et al. educational services and 15% have repeated at least one grade in school [3, 8, 9]. However, these are not the only neurological problems. The implementation of extended follow-up monitoring, using modern methods and scales of neurological evaluation allow us to identify moвшіre and more neuro-develop- mental disorders in children. These disorders include learning disabilities, low average IQ scores, attention deficit, hyperactivity disorders, neuropsychological deficits, visual motor disin- tegration, executive function difficulty, varying temperament difficulties, language delays, emo- tional problems and regulatory disorders [5, 8]. 50–70% of very low birth weight premature in- fants suffer from these dysfunctions [3, 10]. In order to provide not only survival, but to optimize long-term health and development, it is necessary to know the features of brain devel- opment of the fetus in the intra-uterine envi- ronment and of the premature baby in the ex- trauterine space. The development of the brain of the full-term infant takes place in utero where the infant resides in a temperature-stable envi- ronment, receives all the nutrients, undergoes circadian rhythm, and most importantly, feels maternal presence and permanent protection [11, 12]. Prematurely born infants are deprived of all these favorable conditions in the most critical period when their brain is growing and developing most intensively [13]. At the same time, they are exposed to excessive manipulation in a high-technology medical NICU environment. The mismatch between the preterm infants’ need that are necessary for brain development, and the realities of intensive care units may cause serious problems of neuro-physiological, psycho-emotional and psychosocial develop- ment. Developmental care is an approach that uses a range of medical and nursing interven- tions that aim to reduce the mismatches be- tween extra- and intra-uterine environment, decrease the stress of preterm neonates in NICUs, and thus promote optimal neurobeha- vioral development of the infant. Review The framework of developmental care views preterm infants as fetuses who find themselves too early and unexpectedly in a technologic hospital environment instead of the evolution- arily promised mother’s womb [3, 14]. Behav- ioral individuality of each infant is the basis of neuro-developmental care. Each infant is seen as an active participant in all elements and at all stages of care. An infant's behavior provides the best information to determines the care management [14, 15]. The Newborn Individualized Develop- mental Care and Assessment Program (NI- DCAP) model was developed as a clinical fra- me work for the implementation of develop- mental care. NIDCAP is a comprehensive pro- gram which includes a behavioral observation methodology and creation of individual devel- opmental caregiving support of the infant's own developmental goals [12]. The model fo- cuses on detailed reading of each individual infant’s behavior [2]. By observing the child during a routine assessment (before, during and after) and a detailed description of his/her be- havioral responses, medical staff can assess the ability of the infant’s immature nervous system to tolerate the environment and care manipula- tions. Such evaluation will enable one to deter- mine the adequacy of the environment and care to infant’s opportunities and needs, with subse- quent corrections and adaptation [2, 15]. The infant’s ability to regulate and control the behavior occurs within continuous interac- tion with the environment (whether womb, NICU, home conditions) and is expressed through the infant's five systems: autonomic (physiolo- gical), motor, state, attention/ interaction and self-regulation. These systems are continuously interacting with one another. Each system influ- ences and supports the other, and interacts with the environment. The autonomic system functioning is manifested in an infant’s brea- thing quality and rate, color fluctuation, and visceral stability or instability. The functional state of motor system is estimated by the position, muscle tone and movement patterns of the face, trunk and extremities. State orga- nization is observable in an infant’s range of available levels of consciousness, their robust- ness and modulation of the available states, and the patterns of transition from state to state. The acti vity of attention/interaction sys- tem is manifested by infant’s look, facial expres- sions and the ability to interact [3, 12, 15]. The self-regula tion system is manifested in infant’s ability to re-balance and bring into harmony the other sys tems when they have moved out of balance [2]. NIDCAP methodology was founded by Heidelise Als (psychologist from the Harvard University) in 1986 and is based on the Synactive Theory of Development. Heidelise Als has been a pioneer in helping medical staff and parents to understand how to “read” preterm infant's 28 P e d ia t r ic s issN 2413-6077. iJMMr 2017 Vol. 3 issue 1I. M. Sarapuk et al. behavior, especially those who need intensive care [16]. The synactive theory of newborn beha- vioral organiza tion and development (synac- tion n., or synactive adj. (from the Greek syn “together” and the Latin actio “action,” result- ing in “together in action”). The synactive theo- ry of newborn behavioral organization and de- velopment suggests that development of the human fetus, and later newborn, proceeds through the constant balancing of approach and avoidance behaviors, leading to a continuous interaction of the above mentioned subsystems and their increasingly defined delineations within the organism, and the organism’s interac- tion with the environment at large [12, 17]. The synactive theory of infant development provides that there is no possibility for develop- ment without stimulation, but there is also no harmonious development if the stimuli lead to disorganization and stress [15]. Sensory inputs are the important and necessary parameters in fostering central nervous system develop- ment [3]. Inappropriate stimuli penetrate into all systems and destroy them, while adequate and timely stimuli promote and improve the infant’s growth and development [11, 15]. The infant’s response to any stimulus manifests in signs of adaptation of the foregoing systems when he or she tolerates it, or in maladaptive signs if the infant is unable to cope. The infant is able to tolerate stimuli when they are appro- priate in timing, complexity and intensity in relation to the infant’s thresholds of function- ing. If the stimuli are too intense, complex or inappropriately in time, infant either has strat- egies to move away from inputs, avoid them, or suffer from them. Such behavior is consid- ered a stressful situation for an infant [2, 12]. The aim of the NIDCAP is to support the infant in his/her growing tolerance to stimuli, and to minimize stressful events and manipulations that require energy consumption, use of calories and sometimes break the physiological homeostasis [3]. Each caregiver must recognize that for the unstable or fragile infant the best form of sensory input may necessitate a plan of reduction of surrounding stimuli [18]. Signs of autonomic system adaptation in the infant are: stable color, regular breathing and heart rate within physiological ranges and stable digestion. Self-regulatory balance of motor sys- tem is reflected by the appropriate muscle tone, harmonious and smooth movements, softly flexed posture with flexed arms and legs; hands near the face, around the mouth or inside it [12, 15]. Sleep and waking cycles develop in time to become differentiated [15, 19]. The infant actively looks for a source of stimulation and visual contact with a person who cares for him/ her, the face is open, and the infant has attentive look. This stability of the systems manifests in smooth function and reflects intact organization and central nervous system control [3]. Signs of autonomic system stress in the infant are: skin discoloration (pale, marble, red, cyanotic), breathing disorders (apnea, tachy- pnea) with or without desaturation, unstable heartbeat (bradycardia or tachycardia), functio- nal gastrointestinal disorders (hiccups, regur_ gitation, vomiting) and neurological disorders (tremors, convulsions, yawning, sighing). Motor signs of stress include: muscle hypotonia, ex- tension of the trunk (arching), ourward move- ments of limbs (splaying, airplanning, saluting, sitting on air) and tongue extensions. Sleep and waking cycles are not proper differentiated, with the infant avoiding stimulation and visual contact, there is lack of visual concentration. In general, extension behaviors are thought to reflect stress, and flexion behaviors are thought to reflect self-regulatory competence. Diffuse behaviors are thought to reflect stress, and well-defined behaviors are thought to reflect regulatory balance [12, 15]. Such stress reac- tions may indicate that environmental stimuli of light or noise or even caregiving events such as turning the infant or changing the diaper, may be overwhelming [3]. To overcome these stressful situations infant spends the energy that he needs to maintain his homeostasis [3, 15]. Another behavioral scenario is possible when the infant cannot respond to environment or handling stimuli. The infant may lie in the bed, limp and flaccid, unable to put any energy into responding to caregiver; or just develop minimal ranges of responsiveness [15, 17]. The ability to regulate or control the infant’s autonomic, motor and state organization is a requirement of early development and it is called self-regulation [20]. Early self-regulation is accomplished in the mother's body as a fetus, and continues over the course of the first three years of life after birth. the first tasks of self- regulation involve the regulation of physiologi- cal function as breathing, heart rate regulation, maintenance of visceral control, body tempera- ture and homeostasis and day–night cycles regulation. Later the infant learns to calm him- self and relax even after mild stress. As an infant matures in the context of daily interactive care from consistent primary caregivers, self regula- 29 P e d ia t r ic s issN 2413-6077. iJMMr 2017 Vol. 3 issue 1 I. M. Sarapuk et al. tion becomes the task of learning to control motor behaviors, sleep–wake cycles, attention and interaction [3, 15, 20, 21]. Eventually, these capacities merge into emotional regulation. The premature baby often needs external assistance in self-regulation. Parents and caregivers be- come the infant's “co-regulators” and support infants by accurately reading and interpreting the infant's behavioral signals [3]. How assess and interpret the child's be- havior according to NIDCAP? Developmental specialists observe an infant’s behavior weekly or every other week throughout the hospitaliza- tion, starting with the phase of the infant’s initial stabilization. During each observation, the developmental specialist systematically records an infant’s behavior for approximately 20 minutes before a planned medical or nursing caregiving interaction and continues to observe throughout the duration of the interaction and for approximately 20 minutes after it. Ninety- one behaviors, including autonomic (breathing, heart rate, color changes and visceral signs), motor (postures, muscle tone fluctuations and movements) and state organization behaviors (levels of arousal, patterns of transitions be- tween states, and clarity and robustness of sleep and awake states) are monitored every 2 minutes. Behaviors are conceptualized as regulatory and as stress according the forego- ing signs of adaptation and disadaptation and are interpreted as indices of the infants’ current strength and vulnerabilities respectively [14]. After the observation the developmental specialists write descriptive neurobehavioral reports and suggestions, which describe the infant’s strengths, current sensitivities and ap- parent goals and thresholds to stress, and the infant’s self-regulatory efforts at rest and dur- ing care manipulations. It helps to structure caregiving procedures to the infant’s sleep/ wake cycle, adapt or modify the environment and care according to the child’s needs with the aim to maintain the infant’s well-regulated behavioral balance in an effort to promote the infant’s strengths and simultaneously to reduce the infant’s self-regulatory vulnerability [2, 14]. As the infant matures, these recommendations are modified appropriately [22]. Key elements for implementation of indi- vidualized developmental family-centered care niDCaP : 1) provision of sensitive care and hand- ling for baby, 2) creation of a calm NICU environ- ment, 3) parental involvement in infant care, their support, 4) presence of infant developmen- tal specialist [3]. Provision of sensitive care and handling for the infant based on an accurate reading of infant behavioral signals and respect for the message that the infant communicates, along with recognition that the infant actively par- ticipates in all aspects of neonatal care [3]. а) Structure the infant’s 24-hour day in accor- dance with the individual infant’s sleep-wake cycles, state of alertness, medical needs and feeding competence. It may be necessary to divide or to combine procedures (eg. medical examination and care manipulations), to offer pauses according to the child’s behavioral responses or to perform care with two persons. This approach provides infant’s tranquility and thus promotes his/her growth [15]. b) Non-nutritive sucking suppors infant’s physiological stability, improves sleep/waking cycle and reduces time of hospitalization [23]. c) Infant’s flexed position reduces stress reactions, improves self-regulation, physio- logical stability and sensory stimuli tolerance and prevents the skeletal deformities [24, 25]. d) Positioning in the “nests” provides flexed position of the whole body with pelvic support (physiological position of the fetus), which pre- vents the formation of pathological extension position and hypertonus [24, 25]. e) Swaddling reduces physiological distress, maintains temperature homeostasis, improves motor development and optimizes the sleep/ waking cycle [26]. Creation of a calm NICU. It is necessary to create a supportive, gentle environment for the most fragile infants (pic. 1, 2) а) Noise reduction (reduction of alarm vol- ume, decreased ringtone volume of telephones, modification of individual and collective behav- iors – quiet conversation, avoiding the noisy gestures, individual rooms, installation of a sound measurement device. Sound levels shall Pic. 1. Incubators in the NICU are covered to reduce the light and noise, to simulate day-night cycle. 30 P e d ia t r ic s issN 2413-6077. iJMMr 2017 Vol. 3 issue 1I. M. Sarapuk et al. not exceed 45 dB and hourly L10 of 55 dB; tran- sient sounds should not exceed 70 dB; equip- ment in NICU should have noise levels of 40 dB [27, 28]. b) Reduction of the light level (avoiding direct illumination into the infants’eyes, except during examination, incubator cover adapted to the infant's awakening, individual illumination lamps at each incubator, providing circadian rhythm with decreasing light intensity at night, access to daylight) [3, 27]. Parental involvement in infant care, their support. а) Early parental involvement in caregiving and participation in all care with day-and-night access in the NICU [15]. b) Skin-to-skin contact with mother or father, including children who need invasive and non-invasive respiratory support. Such contact has significant advantages for both the infant (temperature homeostasis, respiratory stability with a decrease in apnea and brady- cardia, calm and lasting sleep, feeling of safety, positive dynamics of body weight, decreased risk of nosocomial infections) and mother (improving of lactation, stress reducing, sense of paternity) [15, 29, 30], (pic. 3, 4, 5, 6, 7). Pic. 2. The device for monitoring the volume of sounds in hospital wards (green – normal, yellow – loud, red – noice). Pic. 3. Kangaroo mother care (“skin-to-skin”contact) of the preterm infant with nCPAP. Pic. 4. Kangaroo mother care of the ELBW infant with nCPAP. Pic. 5. Kangaroo mother care of the twins. 31 P e d ia t r ic s issN 2413-6077. iJMMr 2017 Vol. 3 issue 1 I. M. Sarapuk et al. Developmental care supports the relation- ship between the child and the family [12]. For the human species, parents are the familiar, constant and steady connection in an infant’s life. They assure their infant’s safety, and assure their child’s development of trust and as a whole person [2]. The core principle of NIDCAP is the collaboration with each infant and the infant’s parents as the primary caregivers and co-regulators; and the main goal of develop- mental care in the NICU and throughout the hospital stay is to improve child and family comfort and outcomes. The presence of infant developmental spe- cialist. The developmental specialist conducts regular NIDCAP observations and staff/parent teaching, provides consistency of developmen- tal support to medical staff, family and the in- fant, articulates and adjusts the NICU in the accordance with the developmental needs of the infant [3]. Positive aspects of developmental care. the studies have documented the beneficial effect of NIDCAP in terms of shorter intensive care and overall hospital stay, decreased time on the ventilator, decreased oxygen days, shor- ter duration of parenteral feeding, shorter transition periods to full enteral feeding, better average daily weight gain, lower total hospital charges and effect in enhancing neurodevel- opmental outcome [11, 31- 4]. Some research has also documented that the NIDCAP ap- proach enhances brain structure and function when measured by sophisticated medical tech- niques such as EEG and MRI [35]. niDCaP also has significant benefits for parents. The studies of H. Als and other devel- opmental specialists show the reduction in parenting stress and enhanced parent percep- tion of the infant [31, 36, 37]. Except for short- term positive effects, neonatal care according the NIDCAP has also long-term effects on the infant’s neurological development, behavior and mother–child interaction [34, 36]. Conclusions As survival of high risk infants has contin- ued to improve, greater emphasis has now been placed on improving neurological out- comes and quality of life. The implementation of individualized developmental care encour- ages the shift from a protocol-based task and schedule oriented framework of NICU care to an individualized and relationship-based frame- work of care. The introduction of NIDCAP in the neonatal departments will reduce the mismatch between intra-uterine environment and NICU by taking into account the individual infant’s current thresholds of behavioral organization, diminishing stress, and supporting each in- fant’s strengths and competencies. 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