Newborn & Infant Nursing Reviews 16 (2016) 230–244Contents lists available at ScienceDirect Newborn & Infant Nursing Reviews journal homepage: www.nainr.com The Neonatal Integrative Developmental Care Model: Advanced Clinical Applications of the Seven Core Measures for Neuroprotective Family-centered Developmental Care Leslie Altimier, DNP, RN, MSN, NE-BC a,⁎, Raylene Phillips, MD, FAAP, FABM, IBCLC b,1 a Philips Healthcare, 35 Warren St., Newburyport, MA 01950 b Loma Linda University Children's Hospital, Department of Pediatrics, Division of Neonatology, 11175 Campus Street, CP 11121, Loma Linda, CA 92354 a r t i c l e i n f o a b s t r a c t Keywords: The Neonatal Integrative Developmental Care Model, which outlines seven core measures for neuroprotective Core measures family-centered developmental care of premature infants, is a framework that guides clinical practice in many Integrative neonatal intensive care units (NICUs) around the globe. The seven neuroprotective core measures are depicted Neuroprotection as overlapping petals of a lotus as the 1) healing environment, 2) partnering with families, 3) positioning & Developmental handling, 4) safeguarding sleep, 5) minimizing stress and pain, 6) protecting skin, and 7) optimizing nutrition. Family-centered Skin to Skin Contact (SSC) is considered the foundation for care of infants in the NICU and its importance as Infant Premature the “normal environment” and the ideal place of care is described. The mother/child dyad is the center of the NICU lotus surrounded closely by symbols representing various aspects of the healing environment, highlighting the physical, extra-uterine environment in which the infant now lives, the significance of the developing infant's sensory system, and the influence of people (patient, family, and staff) who help to create a healing environment for hospitalized infants and their families. The Neonatal Integrative Developmental Care Model utilizes neuro- protective interventions as strategies to support optimal synaptic neural connections, promote normal neuro- logical, physical, and emotional development and prevent disabilities. © 2016 The Authors. Published by Elsevier Inc. This is an open access article under the CC BY-NC-ND license (http://creativecommons.org/licenses/by-nc-nd/4.0/). In the United States, approximately 500,000 babies each year are born Neurodevelopment prematurely at less than 37 weeks' gestational age (GA) or low birth weight (less than 2500 grams), and as many as 10 to 15% of these babies To better understand the developmental problems associated with require treatment in the neonatal intensive care unit (NICU).1,2 The man- prematurity and other high-risk events, it is essential to understand agement of premature infants has advanced over the past decades to the the basics of neurosensory development of the neonate, paying particu- point that infants born as early as 23 weeks' gestation now have a chance lar attention to the stage of development that occurs in the third trimes- of survival due to a multitude of technologic advances. This progress comes ter of gestation, the period of time in which preterm infant brains are with great costs as premature infants are in the NICU for many weeks or developing in the NICU, in an environment entirely different than the months, and many have impaired short and long-term outcomes.3–7 protective environment of the womb. Although physical and motor disorders may be more noticeable, The neurologic and sensory systems do not exist as separate entities, but preterm and medically fragile infants are also at greater risk for cogni- are interdependent and comprise the neurobehavioral and neurosensory de- tive, social–emotional, mental health, behavioral, speech-language, velopment of the infant. Every sensory experience is recorded in the brain, and regulatory difficulties well into school age and beyond. 8–18 leading to a behavioral response, thereby leading to yet another sensory ex- Educational attainment of young adults that began as a very low birth perience. This cyclic interdependent action and reaction is the basis for neu- weight (VLBW) infant, is also poorer than term-born adults with robehavioral and neurosensory development. When premature infants have fewer completing higher education and a greater proportion opting to sensory experiences that are inappropriate for their stage of development undertake vocational education or training.19 There is also evidence of (as often occurs in the NICU), their neurodevelopment occurs differently an increased risk for psychiatric disorders in adulthood, including ASD, than it would have in the protective environment of the womb. It is not sur- ADHD, and mood disorders.20–28 prising, then, to see different neurosensory and neurobehavioral outcomes in babies born prematurely compared to those born at term. ⁎ Corresponding author. Tel.: +1 513 706 8813. Recent evidence suggests that early preterm birth (b32 weeks GA) is E-mail addresses:
[email protected] (L. Altimier),
[email protected] (R. Phillips). a risk factor for autism spectrum disorders (ASD). ASD is a group of 1 Tel.: +1 909 226 3748 (Mobile). complex neurodevelopmental syndromes of the central nervous system http://dx.doi.org/10.1053/j.nainr.2016.09.030 1527-3369/© 2016 The Authors. Published by Elsevier Inc. This is an open access article under the CC BY-NC-ND license (http://creativecommons.org/licenses/by-nc-nd/4.0/). L. Altimier, R. Phillips / Newborn & Infant Nursing Reviews 16 (2016) 230–244 231 characterized by impaired communication, social interaction chal- injury in a way that decreases neuronal cell death and allows it to heal lenges, and restricted behaviors. Although neuropathology of ASD is through developing new connections and pathways for functionality.36 not fully understood, the most consistent pathology includes curtail- The earlier in gestation a baby is born, the more vulnerable is its fragile ment of normal development of the limbic system and abnormal devel- brain and the more critical it is to provide effective and consistent neuro- opment of the cerebellum and associated nuclei in children with a protective care from the moment of birth in order to protect and support genetic susceptibility who experience abnormal stressors during a crit- optimal brain development. As we strive to continue to improve our mor- ical period of brain development. 20–29 The prevalence of ASD has in- bidity and mortality rates, we are challenged to enhance the neuroprotec- creased over the past two decades and is estimated to affect one in 88 tive strategies for these infants, thus demonstrating the need for a children in the United States, according to the Centers for Disease Con- developmentally supportive environment that focuses on the interper- trol & Prevention (CDC).22 Estimated prevalence of ASD in all preterm sonal experiences of the preterm infant and family in the NICU. Every infants ranges from 12%–41%.22–29 baby, regardless of gestational age, deserves neuroprotective care The fetal neurologic system is in a highly active stage of develop- throughout their hospitalization due to rapid brain growth and neurologic ment during the third trimester of gestation. With volumes of research development occurring during the early neonatal period. documenting long-term disabilities in prematurely-born children, un- Family-integrated, neuroprotective, developmentally supportive care derstanding how we can better support the preterm infant's fragile neu- includes creating a healing environment that manages stress and pain rologic system can pave the way to decreasing the negative effects of while offering a calming and soothing approach that keeps the whole fetal development occurring outside the protective womb, in the family involved in the infant's care and development.37–39 Neuropro- extra-uterine environment of the NICU.30–33 tective developmental care is grounded in support by research from a Both the structural and functional development of the brain are shaped number of disciplines including nursing, medicine, neuroscience, and by the influence and interaction of several major factors. These include ge- psychology.38,40–44 Improvements in health outcomes, lengths of stays, netic endowment, internal, endogenous, or hormonal stimulation, and ex- as well as hospital costs have been documented when neuroprotective ed- ternal experiences from the environment that stimulate the sensory ucation and subsequent change of care practices were implemented.45–48 organs. Outside stimulation from the environment can influence or alter the expression or effects of genes through a process called epigenetics. Although initial stimulation of each sensory system is internal or en- The Neonatal Integrative Developmental Care Model: dogenous, at a critical or sensitive point in development, external stim- Clinical Applications ulation and experiences are needed for further development. Experiences that influence fetal, infant, and child development can The Neonatal Integrative Developmental Care Model (IDC) (Philips come from their physical, sensory, chemical, nutritional, social, and/or Healthcare Andover, MA. USA) identifies seven distinct core measures emotional environments. Events and stimuli from any of these compo- that provide clinical guidance for NICU staff in delivering neuroprotective nents of environment are capable of altering the course and outcome family-centered developmental care to preterm infants and their families of developmental processes producing changes in brain development in the NICU (See Fig. 1).37,38,39 Each core measure has a standard(s) with a that can be either positive or negative. 34 policy or protocol that guides care of the infant/family as it relates to that specific core measure. Corresponding infant characteristics, which are measurable reflections of the desired core measure outcomes, are identi- Neuroprotection in the NICU fied, and specific goals target the improvements/outcomes desired. Clini- cal applications include neuroprotective Interventions that define and Neuroprotection has been defined as strategies capable of preventing specify the actions required to meet the goal(s). 38 These must be neuronal cell death.35 Neuroprotective strategies are interventions used evidence-based, reliably applied and scientifically valid. to support the developing brain or to facilitate the brain after a neuronal To effectively implement many neuroprotective interventions, a cul- tural shift within the NICU must occur in order to adopt new evidence- based practices. Changes in care practices are usually not easy and success is dependent on introducing change in a systematic fashion. Quality im- provement (QI) methods such Plan/Do/Study/Act (PDSA) have proven ef- fective in initiating and sustaining changes that can result in improved outcomes.49 One such program is the Wee Care Neuroprotective care pro- gram. The Wee Care neuroprotective NICU Program (Wee Care; Philips Healthcare) is a multiday multidisciplinary structured program in neuroprotective family-centered developmental care, which provides eLearning, didactic education, hands-on interactive workshops, physician sessions, and in-unit consultation to all individuals who care for prema- ture infants in a NICU. This training and consultative program is an evi- dence - based quality improvement program designed to optimize the NICU environment and caregiving practices in order to facilitate the best outcomes for premature infants and their families. This unique program combines evidence-based practices with the seven neuroprotective core measures for family-centered developmentally supportive care aimed at standardizing neuroprotective care practices in the NICU. This is achieved and sustained by incorporating transformational change methodology into the training program. The Wee Care neuroprotective NICU Program, which trains all NICU staff has been shown to improve noise and light levels in the NICU, improve infant medical outcomes, improve staff satis- faction, improve family satisfaction, decrease length of stay (LOS), and de- crease hospital costs.43–46 Examples of neuroprotective interventions and sample QI projects will be further explained below and consolidated in Fig. 1. Neonatal Integrative Developmental Care Model. Appendices A and B. 232 L. Altimier, R. Phillips / Newborn & Infant Nursing Reviews 16 (2016) 230–244 Foundation for Infant Care in the NICU: Skin-to-Skin Contact (SSC) Skin-to-skin contact (SSC) is the optimal environment for any new- born, but particularly for the premature infant in the NICU. The defining feature of SSC is direct contact between parental skin and infant skin, by holding a diaper-clad infant on a parent's bare chest in an upright prone position. Essentially, this is a place of care, the "normal environment for newborns." Skin-to-skin contact provides the right environment for DNA, epigenes, neural circuits and physiological regulation to function most optimally. A mother and her baby are inextricably linked and to separate the two is highly stressful to both. Incubator care, while neces- sary if mother is unavailable, is actually abnormal to the developing brain of an infant. Skin-to-skin contact (sometimes called kangaroo care) is a fundamental, essential component of neuroprotective and pa- tient–family oriented care for hospitalized preterm infants.50,51 Being skin to skin with mother protects the newborn from the well- documented negative effects of separation, supports optimal brain de- velopment and facilitates attachment, which promotes the infant's self-regulation over time. 52 SSC became codified through the World Health Organization (WHO) into what is called “kangaroo mother care” (KMC), a full-care strategy. 51 While SSC in most NICUs in the United States is often not as comprehensive as KMC, any amount of SSC should be encouraged and facilitated. Skin-to-skin contact with mother (or father) is directly neuroprotec- tive and supports brain plasticity. 53 When practiced only six hours a Fig. 2. Core measure #1 of The Neonatal Integrative Developmental Care model: The week for 8 weeks, it has been shown to accelerate brain maturation in healing environment electroencephalogram (EEG) tracings of infant brain activity.54 Both ma- ternal and paternal oxytocin levels have been shown to significantly in- Single family room (SFR) designs continue to gain broad acceptance crease during SSC, reducing stress and anxiety responses in mothers as a way to improve the physical environment for the infant and im- and fathers of preterm infants.55 With this single activity, each of the 7 prove family accommodations for parents. Enhanced ability to control neuroprotective core measures are supported. Skin-to-skin contact with light and noise can result in improved infant sleep. SFR can also lead mother (or father) is the ultimate healing environment for newborn in- to reduced infection rates. 58 In January 2017, a new prototype room fants (Core Measure #1),51 provides an opportunity to partner with fam- (“extended family room/EFR”) will open at Memorial Children's Hospi- ilies by giving parents an active role in their infant's care and healing tal in South Bend IN, which is modeled after Sweden's University Hospi- (Core Measure #2), facilitates supportive positioning and handling tal of Karolinska. The goal is to, not only, keep mothers and infants (Core Measure #3). provides proximity to maternal odors, which contrib- together, but to accommodate the entire family unit in this new room. utes to sleep cycling, thus safeguarding sleep56 (Core Measure #4). SSC A second headwall for the mother, and space for an adult patient bed, has been shown to foster optimal autonomic and physiologic stability including the required code clearances around the bed will increased and to reduce indices of pain, helping to minimize stress and pain the size of the new EFR to 430 SF. Each room will have a dedicated kan- (Core Measure #5). It protects skin by providing humidity and supporting garoo care chair to support both mothers and fathers in providing SSC.58 thermoregulation (Core Measure #6). It increases mother's milk supply While the ideal scenario is to have families intimately involved in care of and facilitates breastfeeding, optimizing nutrition (Core Measure #7). In their babies, when families cannot be present, rather than isolating those in- all these ways, SSC promotes optimal brain development, supports fants in SFRs, which can cause developmental language delays,59 infants healing and growth, improves parental–infant bonding, reduces infection placed together in a pod arrangement can be better supported develop- rates, and decreases length of hospital stay. 50 For these reasons, SSC is mentally through appropriate sensory stimulation, such as hearing the seen as the foundation of all neuroprotective care.51 soft sounds of the human voices of staff.58 Communicating with infants in a developmentally supportive fashion remains the responsibility of the pri- mary caregiver, which when the family is not present, is the bedside nurse; Core Measure #1: Healing Environment and this appropriate age-based communication is a neuroprotective inter- vention for language development. When an adult patient is hospitalized The healing environment, Core Measure #1, addresses the physical and does not have the opportunity for family or visitors, the nurse takes environment of the NICU, including space, privacy and safety, the sensory time to talk to them, which is a practice that should be replicated with environment of temperature, touch, proprioception, smell, taste, sound, the infant. and light, as well as people (families and staff) and their interactions.39 Premature infants have demonstrated markedly improved outcomes Core Measure # 2: Partnering with Families when the stress of environmental sensory overstimulation is re- duced. This can be accomplished by incorporating neuroprotective Partnering with families, Core Measure #2, is essential in order to strategies into the care of infants and also by aspects of NICU design optimize developmental outcomes of infants in the NICU. Prematurely (Fig. 2). 57 born infants have “premature” parents who are usually unprepared NICUs should be designed to encourage family reunification and for the crisis of having their newborn in the NICU. Preterm deliveries presence, facilitate psychosocial support, address/minimize sensory im- are usually unexpected, families are often separated from their support pact, offer social connection, and enable positive parental experiences. systems when their newly born infant is admitted to the NICU, a place NICUs should also be designed to facilitate staff work and self-care, in- many parents did not even know existed before this event. For most cluding quiet rooms for respite and debriefings after stressful events. parents, the NICU is an alien environment and their first experience in Nurses working in single family room NICU's are less likely to experi- the NICU is usually a profound shock and very traumatic.60 Their infant ence burnout and more likely to rank quality of care higher. is attached to wires, cables, and equipment in a place that is far different L. Altimier, R. Phillips / Newborn & Infant Nursing Reviews 16 (2016) 230–244 233 from what they had planned. Parents of these NICU babies are likely to responsiveness and infant attachment.85 SSC helps fathers in attachment, experience greater emotional stress, depression and anxiety, uncertain- confidence, caregiving, and interactions with their premature infants. ty about their baby's future, financial stress and even post-traumatic When the quality and/or quantity of parental care toward infants is limit- stress disorder (PTSD) than do parents of term infants. 61–63 Parents ed, such as with preterm infants in the traditional NICU setting, these ad- and families worry constantly while trying to maintain optimism and verse experiences can lead to negative changes in brain structure and hope. It is important to recognize that the intensive care experience is function.86 not uniform and that family responses differ. Mental health providers The NICU environment, although initially strange and even frighten- should be integrated into the NICU caregiving team to provide psycho- ing to parents, can become comforting and inviting with attentive and social support at the level required for each individual family.64 compassionate caregivers who enable parents to be at the bedside of With every NICU admission, normal parent–infant bonding is forever their infant, coach them on how to understand their baby's behavioral altered. The experience of having an infant in an intensive care unit im- cues and how to provide appropriate caregiving. Sensitive NICU staff pacts not only the vulnerable infant and the parents' physical and emotion- can provide active listening as parents process their shock, anger, and al health, but also affects the developing bond between the newborn and grief over the loss of a normal pregnancy and/or normal healthy term in- his or her parents.65,66 The NICU experience impacts all family dynamics, fant, and empower them to be active participants on the caregiving team. not just during the intensive care unit stay, but also in the months and The family is integral to developmental care, and normal development years afterwards. For each family, the first experiences with their baby, cannot occur without the family. An example of this type of NICU care is whether in the home or the intensive care unit, can set the trajectory for seen in the Family Integrative Model (FIC), a model of care focusing on the long-term parent–child relationship and the parent's perspective of partnering with families where, the nurses support the parents through their parent roles.67 Many NICU parents leave the NICU with mental health education, coaching and mentoring, to become primary caregivers in issues either caused or exacerbated by what happens to them there.68 their infant's journey through neonatal care.87 The practice of Family Inte- The emerging concept of “trauma-informed care” is a transformative grated Care has been successful in Estonia and in Canada, and is being in- one.69 The NICU is a place of trauma and the integration of trauma- troduced in the United States.88,89 informed care into all aspects of care for infants and their families in the All families, even those who are struggling with difficulties, bring NICU can alleviate or transform some of the trauma they have experienced important strengths to their infant's experiences in the NICU. Parents in a more positive way.64,69–73 In recent years, health care organizations must be viewed as vital and essential members of the caregiving team have become increasingly aware of the importance of providing psychoso- and active partners in the care of their infant, rather than visitors to cial support for parents of hospitalized infants and to recognize the emo- the NICU, and should be given 24-hour access to their infant. Individual- tionally traumatic impacts of having an infant with medical illness. Many ized family-centered developmental care is a framework for providing parents will learn their first lessons about being a parent inside of the care that enhances the neurodevelopment of the infant through inter- NICU, and while many of these lessons will be useful in the future, an ventions that support both the infant and family unit. equal number will not only be unhelpful but potentially damaging.74 In- Creating an effective partnership between professionals and families fants who are hospitalized in intensive care experience a number of threats has shown benefits such as decreased length of stay, increased satisfac- to the establishment of secure and nurturing relationships. They are at the tion for both staff and parents, and enhanced neurodevelopmental out- mercy of their hospital environment and often experience medical proce- comes for infants.90 Having parents provide much of their infant's care dures and practices that result in altered social interactions and emotional in the NICU also improves short- and long-term outcomes among in- resilience.75 Maternal distress early in a child's life can have long-term ef- fants and reduces stress among parents.89 A comprehensive approach fects on child behavior.76 to discharge/transition planning that includes psycho-social support Attachment theory's key concept is the necessity of the formation of an and a focus on the caregiver-infant relationship offers families the sup- emotional bond between an infant and primary caregiver and how the port they need and deserve at a critical time in their lives. 91 Establishing bond affects the child's behavioral and emotional development into family-professional partnerships in the NICU environment can be chal- adulthood.77 Grounded in attachment theory, infant mental health involves lenging; however, family-centered care is recognized as a best practice giving shared attention to the infant, the parent, and the early developing which includes mutual respect, information sharing, collaboration, attachment relationship.73,78 There is increasing awareness in psychology confidence-building, and joint decision-making. 92 and obstetrics of the effect that maternal mental health has on fetal brain The concept of partnering with families in the NICU includes a development and the psychological transition that occurs during philosophy of care, which acknowledges that over time, the family pregnancy.79 With this increased awareness, there is an accompanying un- has the greatest influence over an infant's health and wellbeing. derstanding that pregnancy marks the beginning of the parent–child rela- Compassionately delivered family-integrated care, with zero- tionship that is vital for the infant's wellbeing. Even early fetal separation, where skin-to-skin contact is the norm, is the ideal environment can alter mechanisms within the fetus that persist into model of care to encourage normal development, attachment and adulthood.80 The importance of experiencing early relationships as warm, bonding, and empower parents to be equal partners on the caregiv- caring, and stable is clear, as it results in the infant's ability to develop ap- ing team. 38,39,51,89 propriate social–emotional development and long-term mental health.81 Because families are the constant in the infant's environment, help- Core Measure #3: Positioning & Handling ing families achieve a positive outcome from their NICU experience should be a priority for staff.82 Equilateral respect among all members Position and handling, Core Measure #3 has the inherent goal of involved in the partnership will promote optimal patient care, enhance supporting the premature infant's body as closely as possible to the po- family satisfaction, and engage the healthcare team in ways that in- sition the baby would have been in the womb. In utero, the infant is crease job satisfaction and a sense of fulfillment. contained in a circumferential enclosed space with 360 degrees of Zero separation from parents should be the ultimate goal to ensure well-defined boundaries. Providing developmentally supportive posi- neurodevelopment is supported to normal standards (as in optimal devel- tioning in the NICU is essential for optimal musculoskeletal develop- opment assumed for term infants), not merely protected from effects ment, which influences not only neuromotor and musculoskeletal of toxic stress.83 Early bonding with both physical and psychological development, but also physiologic function and stability, thermal components, leads to emotional connections and secure attachment.84 A regulation, bone density, neurobehavioral organization and sleep fa- baby's interaction with mother makes a significant difference in brain de- cilitation, calmness and comfort, skin integrity, optimal growth, and velopment, including brain structure and function. Reciprocal tactile stim- brain development. 93 Developmentally supportive positioning is an ulation between mother and infant contributes to increased maternal intervention that has been proven to improve postural and musculoskeletal 234 L. Altimier, R. Phillips / Newborn & Infant Nursing Reviews 16 (2016) 230–244 outcomes as well as improve physiologic outcomes and sleep states; how- handling will not only be beneficial to parents and babies, but can ever, developmental positioning has not yet become a standardized save nurses time by involving parents in caregiving tasks they can intervention.94–97 There remains a gap between what is known in the evi- competently accomplish. dence and what is practiced in some NICUs, and although it is clear that de- velopmental positioning is effective in improving outcomes, less is known Core Measure #4: Safeguarding Sleep about how to improve the developmental positioning proficiency of the nurses providing the care. Incorporating a standardized Infant Positioning Safeguarding sleep, Core Measure #4 emphasizes the multi-faceted Assessment Tool (IPAT), along with education, is effective in improving de- importance of sleep for the infant in the NICU. Sleep patterns of preterm velopmental positioning proficiency of NICU nurses, as well as improving infants undergo age-dependent maturational changes, and sleep pres- consistency in positioning.95,96 ervation is essential for the normal neurodevelopment and adequate Supporting body containment of the infant in the NICU environment growth and healing of these infants. 99,100 Quiet sleep (QS) is necessary increases the infant's feelings of security, decreases stress, and reduces for energy restoration and the maintenance of bodily homeostasis. Ac- excessive energy expenditure. Forming a “nest” with soft boundaries, tive sleep (AS) is important for sensory input processing, memory as well as a padded foot-roll for foot-bracing, provides postural, behav- encoding, and consolidation and learning. Sensory inputs, especially ioral, and physiological stability to the newborn. Infants who are during critical periods of development, may influence normal sleep– contained within soft boundaries are usually more calm, require less wake cycling.101 medication, sleep longer and gain weight more rapidly. Ensuring secure At approximately 28 weeks' gestation, individual sleep patterns containment with firm bendable positioning aids [such as with the begin to emerge characterized by rapid eye movement (REM) and Bendy Bumper, (Philips)] promotes a reflex stimulus for extremity ex- non-rapid eye movement (NREM) sleep periods. REM and NREM tension and subsequent flexion recoil, furthering the ability of the sleep cycling are essential for early neurosensory development, learning baby to remain in a midline, flexed and contained position. Therapeutic and memory, and preservation of brain plasticity for the life of the supportive positioning devices must allow spontaneous movement, individual. 99 Preservation of “brain plasticity,” the ability of the brain provide tactile and proprioceptive containment, and displace infant to constantly change its structure and function in response to environ- body weight when placed in alternative positions, such as prone. Pro- mental changes, is an essential process throughout childhood and viding ventral support [such as with the Prone Plus (Philips, Boston, adult life. Sleep deprivation (both REM and NREM) results in a loss of MA)] utilizes the natural force of gravity to assist in proper prone posi- brain plasticity which is manifested by smaller brains, altered subse- tioning and ventral support of premature infants, by making it possible quent learning, and long-term effects on behavior and brain function. to keep their shoulders rounded and hips flexed, as they would have Facilitation and protection of sleep and sleep cycles are essential to been inside the womb. The unique memory foam elevates the infant's long-term learning and continuing brain development through the upper body to promote flexion without placing excessive pressure on preservation of brain plasticity.102 Safeguarding sleep is also essential the knees and elbows. to promote healing and growth. Handling of infants should be done with slow, gentle, modulated Consideration to positioning should be given in order to promote movements, with the infant's extremities flexed and contained, which quality sleep and decrease arousals from sleep. Preterm infants are may require a four-handed technique in very fragile infants. A preterm more likely to remain in a sleeping state when they are in the prone infant, when handled for reasons such as diaper changes, feeding, bath- position. 103 The number of arousals per hour from sleep is highest in ing, diagnostic or therapeutic procedures can react negatively for sever- the supine position and least in the prone position. 104 Documentation al minutes during and after the procedure until becoming exhausted. of the infant's state, utilizing validated scales, promotes consistency in This results in an unnecessary expenditure of energy that can, even the assessment of infants' sleep states and cues, leading to more stan- well after the procedure has ended, result in signs of distress, pain dardized practices when incorporating infant cues into caregiving and/or instability that may be manifested physiologically (bradycardia, schedules. tachycardia, drop in oxygen saturation and apnea) or behaviorally (flac- The design of SFR's, where every patient room has a window can cidity, fatigue and difficulty sleeping). help maintain circadian rhythms for the baby, parents, and staff. NICU Frequent handling and touching can disturb sleep leading to de- babies and their parents may have long stays in the hospital, and day- creased weight gain, decreased state regulation, and more impor- light supports a sense of normalcy by providing connection to the tantly, detrimental effects on brain development. Attention to daily cycles of light.58 appropriate timing of caregiving according to the infant's sleep and arousal is important, as better sleep organization has been correlat- Core Measure #5: Minimizing Stress & Pain ed with improved outcomes. 98 Because infants do not always toler- ate all of the handling and care that is being clustered into one Minimizing stress and pain, Core Measure #5 is especially important caregiving period, the practice of clustering care should be based in the developmentally unexpected, and often harsh, environment of on infant's behavioral cues. Cues provide communication about an the NICU where even routine cares can be stressful, and often painful, infant's physiological status and needs at any given time. Caregiving to premature infants. From the first moments after birth, the premature based on infant cues involves a relationship where behavioral mes- infant is subjected to noxious sounds, bright lights, and a multitude of sages that the infant communicates may guide the timing for inter- stressful and painful procedures along with repetitive, non-nurturing ventions or opportunities for sensory input and interaction. These handling and usually, separation from mother. Seemingly typical han- cues also indicate how the infant tolerates stimuli and stimulation dling and caregiving by the NICU staff such as bathing, weighing, and di- and when they need a break or individualized support. aper changes are perceived as stress to the prematurely born Caregiving behaviors must be adapted to alleviate as much aver- infant.44,105 This altered sensory experience is inherently stressful and sive or negative sensory input from caregiving activities as possible. has negative effects on the infant's brain development. Collaborative interprofessional care should be coordinated to negoti- Infants who spend their first weeks or months of life in the NICU may ate timing, intensity, and appropriateness of interventions, tests, and demonstrate a developmentally unexpected sensory stress response. procedures. Altering care practices by responding to the individual Exposed to painful, repeated, and unpredictable medical procedures, infant cues requires a paradigm shift from task-oriented and sched- and possibly to physical pain or discomfort related to illness, these in- uled care toward infant-responsive care, which is needed to promote fants may not have consistent support from a parent or professional optimal developmental outcomes. Educating, coaching, and caregiver to provide a buffer to help them stay regulated and recover mentoring parents in developmentally appropriate positioning and from these stresses. Toxic stress has been linked to changes in the L. Altimier, R. Phillips / Newborn & Infant Nursing Reviews 16 (2016) 230–244 235 developing brain, negatively impacting the creation of neural connec- Core Measure # 7: Optimizing Nutrition tions, and this impact is likely to be more pronounced in preterm infants and particularly those without a supportive caregiver present. 106 Optimizing nutrition, Core Measure # 7 has well-documented ef- NICU stressors and painful interventions can raise cortisol levels, fects on infant brain development. Scientific evidence overwhelm- limiting neuroplastic reorganization and therefore, learning and memo- ingly indicates that breastfeeding is the optimal method of infant ry of motor skills. Infants who are exposed to repeated painful experi- feeding and should be promoted and supported to ensure optimal ences can have negative short- and long-term consequences for brain nutrition in for all infants whenever possible. Breastfeeding is the organization during sensitive periods of development. 107,108 Adverse single most powerful preventive modality available to health care neurodevelopmental outcomes following neonatal intensive care are providers to reduce the risk of common causes of infant morbidity well documented. Increased exposure to procedural pain has been asso- and mortality. Because breast milk is the most well-tolerated sub- ciated with poorer cognitive and motor scores, impairments of growth, strate for enteral feedings in the premature infant, full enteral feed- reduced white matter and subcortical gray matter maturation, and al- ings are reached sooner when breast milk is used, thereby tered corticospinal tract structure.109–112 decreasing the total days of total parental nutrition (TPN) needed Minimizing stress in preterm infants has many neurologic benefits and the potential for TPN-induced side effects. 125 such as reducing the likelihood of programming abnormal stress re- The protective properties of breast milk cannot be duplicated. Signif- sponsiveness which will help preserve existing neuroplastic capacity. 113 icantly decreased risks of necrotizing enterocolitis (NEC), sepsis, and Effective prevention and management of procedural and postoperative retinopathy of prematurity (ROP) have been demonstrated when breast pain in neonates are required to minimize acute physiological and milk is used for enteral feedings.126 Additionally, deeper nuclear gray behavioral distress and may also improve acute and long-term matter brain volume and better IQ, improved academic achievement, outcomes.114 working memory, and neurodevelopmental outcomes have also been To consistently manage stress and pain in neonates, accurate moni- found in preterm infants fed breast milk. 127,128 Because of the many toring of pain, as the “fifth” vital sign needs to be assessed utilizing a documented benefits of human milk for the preterm infant, supporting standardized pain assessment tool. With the assessment of pain, mothers in the initiation and maintenance of adequate breast milk comes management through pharmacologic and non-pharmacologic supply should be a major focus in the NICU. measures. For common painful procedures, such as heelsticks, When mother's own milk is not available or is contraindicated, venipunctures, orogastric tube (OG) insertions, non-pharmacological donor human milk is strongly recommended for this vulnerable pop- interventions should be the first choice in non-compromised infants.115 ulation. Even when adequate breast milk is available, most prema- Non-pharmacological interventions that have demonstrated efficacy ture neonates in the NICU learn to eat via nipple (bottle) feeding. are: maternal presence, breastfeeding, breastmilk, SSC, sucrose, non- Immature feeding is a common reason for prolonged hospital stays nutritive sucking, facilitated tucking, swaddling, and developmentally for premature infants and persistent poor feeding can result in hos- supportive positioning. 115–117 Maternal-related olfactory stimuli pital readmissions. Maturational and developmental issues in pre- (mother's milk) has been associated with comfort and diminished mature infants affect oral feeding success because only 53% of brain pain response in both term and preterm infants. 118 These findings sup- cortical volume is present at 34-week gestation when an infant is port the hypothesis that infants remember, recognize, and prefer smell just beginning oral feeds. that is associated with their prenatal environment including maternal- Oral feeding is a complex task for premature infants and requires a related olfactory stimuli (mother's milk), auditory recognition skilled caregiver in assisting the infant in achieving a safe, effective, (mother's voice, heartbeat, and music).119–121 and pleasurable feeding experience. Infant-driven feeding scales that addresses feeding readiness, quality of feeding, as well as developmen- tally supportive caregiver interventions are beneficial when initiating Core Measure # 6: Protecting Skin oral feedings in the premature neonate. Goals for successful infant- driven feedings are that oral feedings be safe, functional, nurturing, Protecting skin, Core Measure # 6 is multifaceted. Functions of and individually and developmentally appropriate.47 State organization the skin include thermoregulation, fat storage and insulation, fluid and ingestive behaviors are regulated by the same autonomic nervous and electrolyte balance, barrier protection against penetration and system. The autonomic control of the stomach includes a cephalic absorption of bacteria and toxins, sensation of touch, pressure, and phase that prepares the stomach for food, followed by a gastric phase. pain, and conduit of sensory information to the brain. Each of these The cues for these phases are primarily olfactory, but also linked to functions may impact neurodevelopment. Immature skin structures state organization; therefore, consideration should be given to matching of premature infants are very different than the skin of full-term in- the neonate's feeding schedule to his own sleep cycle, rather than the fants. The premature infant has an underdeveloped skin barrier, clock.129 which puts the infant at risk for high water loss, electrolyte imbal- Educating staff and parents about infant cues and specialized ance, thermal instability, increased permeability, additional skin feeding techniques for breastfeeding and bottle feeding are essential damage, delayed barrier maturation, and infection. 122 Infants in the as they are the foundation for continued success and prevention neonatal intensive unit are at risk for skin compromise due to imma- of future oral aversions. 130 As with the previous core measures, a val- ture skin, compromised perfusion, fluid retention, being immuno- idated tool (feeding readiness, quality of feeding, and caregiver tech- compromised, medical diagnosis, etc., as well as the presence of niques) should be utilized to promote consistency in assessing dressings, tapes, adhesives and various medical devices, such as readiness, evaluating quality, as well as caregiver efforts and IVs, and CPAP or nasal prongs, that are essential to their care. 123 techniques. 131 Skin care practices outlining bathing protocols, emollient usage, hu- Breastfeeding difficulties can impact the fragile mother–infant midity practices, and use of adhesives for babies in each stage of devel- relationship; therefore, providing support for breastfeeding mothers in opment should be incorporated into unit practices and policies. learning to feed their preterm infants at the breast, as well as learning Improved skin outcomes can be realized by utilizing the most to feed with a bottle (with expressed breast milk or preterm formula) evidence-based skin care guidelines available along with careful moni- is important and should not be left for the day of discharge. 132 Daily toring and gentle, consistent handling, positioning and cares, The key skin-to-skin contact/holding can facilitate early “practice” breastfeeding to achieving optimum skin condition is through the utilization of vali- sessions for mothers and babies. Assuring that breastfeeding infants are dated skin assessment tools to assess the skin condition and evaluate at- competent and mothers are comfortable with breastfeeding well before tributes that indicate skin compromise.124 discharge should be a priority. 236 L. Altimier, R. Phillips / Newborn & Infant Nursing Reviews 16 (2016) 230–244 Neuroprotection for NICU Staff impacted. Utilizing Edward Deming's PDSA cycle is an effective model for learning and change management. This model incorporates the ap- Working in the NICU is, by nature, a highly stressful job and rates plication of Plan, Do, Study, Act (PDSA) in order to help teams improve of burnout and compassion fatigue are high among NICU staff. the quality of care. Improving quality is about making healthcare safer, Protecting the mental health of NICU staff is not only important for more efficient, patient-centered, timely, effective and equitable. The their personal wellbeing, but ultimately protects the quality and in- PDSA cycle can help identify, describe, and provide structure for a natu- tegrity of their work in caring for babies and families. When efforts ral process whereby groups/teams initiate change within their system. are made to support staff, job satisfaction increases and employee Using this explicit framework for managing a change program ensures turnover decreases. the team does not drift from the initial objectives, and also ensures ac- Because of the highly technical nature of medical care in the NICU, tual achievable and valid measurements are identified. Clinically ad- much attention is paid to clinical training, but relatively little training vanced neuroprotective interventions related to SSC, each of the 7 is provided on optimizing interpersonal relationships, communication core measures, as well as to promote teamwork, are further outlined and teambuilding and almost no training is given on how to educate, in Appendix A.39,139,140 coach and mentor parents and families of babies in the NICU. In the in- This model of quality improvement emphasizing change manage- tegrative, family-centered developmental care model, NICU staff mem- ment principles related to neuroprotective practices has been utilized bers are asked to educate, coach and mentor parents to become active worldwide via the Wee Care Neuroprotective NICU Program (Wee participants in their infant's care and are also expected to provide active Care; Philips).141 The Wee Care training and consultative program com- listening and psychosocial support to parents as they negotiate the crisis bines evidence-based practices with seven core measures for neuropro- of having a baby in the NICU. This is a monumental task with short- and tective family-centered developmental care aimed at standardizing long-term implications for the quality of life during the NICU admission neuroprotective care practices in the NICU. The Wee Care program, for both parents and NICU staff, which can ultimately influence the which trains all NICU staff, has been shown to improve noise and light baby's health and well-being. NICU staff cannot be expected to pro- levels in the NICU, improve infant medical outcomes, improve staff sat- vide this quality of care without specific and ongoing education and isfaction/engagement, improve family satisfaction, decrease length of training. Equipping NICU staff with the skills necessary to educate, hospital stay, and decrease hospital costs. 40,44,45,47,142 Facilitating the coach, mentor and support parents to provide NICU staff with the best outcomes for premature infants and their families has been support they need, is critical to the success of family-centered de- achieved by optimizing the NICU environment, caregiving practices, velopmental care. caring for staff, as well as families. 39,40 The identification of overarching Mental health professions should be an integral part of the NICU goals with defined aim statements for each core measure has assisted team and not only support parents, but can also enhance support for many NICUs across the globe in providing a structured approach to staff. Comprehensive psychosocial support requires interdisciplinary changing and maintaining their neuroprotective family-centered devel- collaboration. 133 Providing psychosocial support to parents whose in- opmental care practices. An example of a PDSA action plan is outlined in fants are hospitalized in the NICU can provide parents' functioning as Appendix B. well as their relationships with their babies. 134 Staff members who develop burnout may have further reduced abil- Summary ity to provide effective support to parents and babies. 134 Education about self-care and recognizing signs of burnout and compassion fa- High-risk infants are both dependent on and vulnerable to the NICU tigue can be provided by mental health professions. Staff should be sup- environment. While dependent on the NICU for the maintenance of ported in ethical decision making and coached in sorting out personal their physiologic functions during recovery from the insult of being and NICU family moral values that may differ. Debriefings and “pauses” born too soon, they are also vulnerable to all the stressors inherent in after stressful events can provide peer support for NICU staff. having fetal development occur outside the womb in the artificial envi- To support the entire interdisciplinary team from a psychosocial per- ronment of the NICU. As the preterm infant matures, the quality of the spective, a multidisciplinary workgroup of professional organizations environment in which the infant resides plays a critical role in the tra- and NICU parents was convened by the National Perinatal Association, jectory of recovery, growth and development. which included six interdisciplinary committees (family-centered de- Learning the principles of neurodevelopment and understanding the velopmental care, peer-to-peer support, mental health professionals in meaning of preterm behavioral cues make it possible for NICU care- the NICU, palliative and bereavement care, follow-up support and staff givers and parents to provide individualized developmentally appropri- education and support). Each committee developed recommendations ate, neuroprotective care to each infant. Partnering with families and for program standards related to each of the above stated topics to pro- restoring parent–infant attachment supports both physiologic and mote the psychosocial support of parents with babies in the neonatal in- emotional stability of infants and their parents. Providing gentle con- tensive care unit.63,64,133–138 tainment, supportive boundaries, and flexed positions, all help to simu- Perhaps the most important aspect of “neuroprotection” for NICU late the womb that was lost prematurely. By minimizing stress and pain, staff is frequent, regular, and sincere appreciation for their dedication safeguarding sleep, protecting skin and optimizing nutrition, NICU care- and the quality of care they provide in the NCIU. Both private and public givers can enhance the daily experience of the infants in their care and acknowledgements of ongoing and extraordinary efforts can boost mo- increase the chances of achieving optimal physical, cognitive, and emo- rale and motivate staff to continue to improve the care they provide to tional outcomes. NICU staff do not learn these skills during their clinical babies and families in the NICU. training and require specific education in neuroprotective, family- centered, developmental caregiving theory and practice. They also Transforming Practices through Quality Improvement need education on how to provide psychosocial support and effectively communicate with families who are experiencing the crisis of having a Creating an organizational structure that promotes patient safety baby in the NICU. It is important to “care for the caregiver” by providing and achieves quality outcomes requires shared accountability and NICU staff with the support they need due to the stressful nature of teamwork within organizations. Applying a systematic approach to im- working in the intensive care setting. proving key processes is the most effective strategy for reliably identify- Changes in developmental care can often begin with a few moti- ing the source of problems and testing changes designed to improve and vated caregivers altering the way they care for premature infants. sustain change. It is always challenging to find ways to translate ideas Role modeling, mentoring, and collaboration are key in the promo- into actionable change at the frontline where patient care can be tion of optimal developmental care. An overarching goal is to achieve L. Altimier, R. Phillips / Newborn & Infant Nursing Reviews 16 (2016) 230–244 237 Appendix A. Advanced clinical applications of neuroprotective interventions related to the seven core measures of neuroprotective family-centered developmental care. Core measure #1: Healing environment34,37,38,51,57,133,135,139 Standard: A policy/procedure/guideline on the healing environment including physical space and privacy as well as the protection of the infant's sensory system exists and is followed throughout the infant's stay. Infant characteristics Goals Neuroprotective interventions Stability of the infant's autonomic, An environment will be maintained that General: sensory, motoric, and state regulation promotes healing by minimizing the • Educate, coach, and mentor parents on the importance of creating a systems impact of the artificial extrauterine NICU healing environment that protects the developing sensory system of the environment on the developing infant's preterm infant. Emphasize the central role of parents in the healing brain environment. Skin-to-skin contact: • Facilitate early, frequent, and prolonged skin-to-skin contact (SSC) • Encourage zero-separation between parents and infant • Provide comfortable and safe reclining chair or adult bed for early, frequent, and prolonged SSC Space: • Maintain a private and safe environment for the infant and family that consists of a minimum of 120 sq. ft. per patient • Provide organized, non-cluttered space for the family to support comfortable and private caregiving • When renovations are planned, advocate for single family rooms (SFR) and promote utilization of the latest standards from the “Recommended Standards for Newborn ICU Design” at http://www3.nd.edu/~nicudes Tactile: • Provide a neutral thermal environment for the infant incorporating the following factors: • Facilitate early, frequent, and prolonged skin-to-skin contact. • If ELBW, provide humidity during the first one - two weeks after birth • Provide care in incubator or SSC until infant can maintain own temperature Vestibular: • Change infant's position gently and slowly without sudden movements • Eliminate moving infants to different bed-spaces to accommodate staffing patterns Olfactory: • Maintain a scent-free & fragrance-free unit • Minimize exposure to noxious odors • Expose infant to mother's scent when possible via breast pad, or soft cloth, Gustatory: • Position infant with hands near face • Provide colostrum or expressed breast milk (EBM) oral care per protocol • Provide positive oral feeding experiences as outlined in “Optimizing Nutri- tion” section Auditory: • Support infants with consistently calm, relaxing environment with muted sounds during caregiving interactions • Be mindful of own voice and other sounds produced in the NICU • Monitor sounds levels to maintain average sound levels of 45 dB • Silence alarms as quickly as possible and avoid unnecessary alarms • Comfort crying infants as quickly as possible • Expose infant to audible maternal/paternal voice Visual: • Provide adjustable light levels up to a maximum of 60 fc • Gently shield infant's eyes during cares if overhead light is needed • Be mindful of structuring an infant's visual field to support alert wakefulness as appropriate, transition to sleep, or quiet, restful sleep • Minimize purposeful visual stimulation until 37 weeks gestation Overall healing environment: • Consider all sources of light, sound, movement, smell and taste confronting an infant during care, and eliminate all inappropriate or unnecessary sources of stimulation • Create and implement an individualized developmental care plan for each infant • Provide guidance to parents on how to create and sustain a healing environment with respect to sensory exposures and experiences • When renovating the NICU environment, advocate for optimal family support spaces and resources Core measure #2: Partnering with families36,49,61,81,133–135,137,141 Standard 1: A policy/procedure/guideline on partnering with families to include unlimited access to ensure around-the-clock information and access to their baby exists and is followed throughout the NICU. Standard 2: There is a specific mission statement addressing partnering with families. Standard 3: NICU staff are competent in educating, coaching and mentoring parents in infant caregiving skills and in providing psychosocial support to NICU families. Infant characteristics Goals Neuroprotective interventions Infant's response to • Family-centered care is supported • Facilitate early, frequent, and prolonged skin-to-skin contact parental interactions from birth or as soon as a NICU stay is • Encourage zero-separation between parents and infant anticipated (antenatally if possible) • Educate, coach, and mentor parents in becoming active participants in their baby's care in supporting their infant's developmental goals (continued on next page) (continued on next page) 238 L. Altimier, R. Phillips / Newborn & Infant Nursing Reviews 16 (2016) 230–244 (continued) Appendix A. (continued) Core measure #1: Healing environment34,37,38,51,57,133,135,139 • Parents will NOT be viewed as “visitors” • Support families with a warm, respectful, and welcoming manner but as equal & vital members of the • Acknowledge where the family is in regards to stages of grief and loss and caregiving team with zero-separation provide individualized and appropriate resources as needed supported and encouraged (24hr/d) • Actively listen to families' feelings and concerns (both verbal and • Parents will be supported & encouraged non-verbal) as the primary and most important • Incorporate parents as full participants in parenting their baby in the NICU caregivers for their infant, incorporating • Encourage families to personalize their infant's bed space and make them as full participatory, essential the NICU environment more home-like healing partners • Encourage participation in medical rounds and nursing hand-offs within the NICU caregiving team • Share information with families in a tone of voice that preserves • Infant will develop emotional connection confidentiality & secure attachment with parents • Honor both Health Insurance Portability and Accountability Act (HIPPA) and • Parents who lose a baby before, during, safety concerns while in the NICU or shortly after birth, or later in the NICU • Provide parents with full access and input to both written and electronic will be supported at all points of care medical records • Accommodate the presence of families in the NICU and seek ways to endure their comfort • Include and support sibling and extended family participation as desired by parents • Communicate the infant's medical, nursing, and developmental needs in a culturally appropriate and understandable way, avoiding acronyms and medical jargon • Educate parents on infant attachment, language development, developmental and safety issues and infant behavioral cues (appropriate for their infant's ges- tational age) • Support breastmilk expression and breastfeeding • Provide social networking opportunities for parents of infants in the NICU • Provide peer-to-peer support with parents who have gone through similar NICU experiences • Encourage and empower parents as they develop confidence in their own abilities to continue caring for their baby when going home • Provide anticipatory guidance regarding grieving and risks/symptoms of postpartum depression and PTST to mothers and fathers, and other family members, recognizing they all may process the NICU experience differently • Provide psychosocial support for all members of the family, including grandparents and the baby's siblings • Provide staff education related to principles of family-centered care and how to support parents' caregiving roles Core measure #3: Positioning & handling:36,37,92,133,137 Standard: A policy/procedure/guideline on positioning & handling exists and is followed throughout the infant's stay that includes educating, coaching and mentoring parents on how to position and handle their infant. Infant characteristics Goals Neuroprotective interventions • Autonomic stability • Autonomic stability will be maintained • Facilitate early, frequent, and prolonged skin-to-skin contact during handling throughout positioning changes and • Educate, coach, and mentor parents in how to position, contain • Ability to maintain handling activities as well as during and handle their infant in a developmentally appropriate manner. tone and flexed periods of rest and sleep. • Provide infants with positioning supports needed to maintain postures with and • Parents will be educated, coached, and optimal tone and position and to remain either in a quiet, without supports mentored in how to position and handle restful sleep or a relaxed, comfortable wakefulness. their infant • Utilize a validated & reliable positioning assessment tool [i.e. Infant • Preventable positional deformities will Positioning Assessment Tool (IPAT)] routinely to ensure appropriate be eliminated or minimized by main- positioning and encourage accountability. taining infants in a midline, flexed, • Maintain a midline, flexed, contained, and comfortable position at contained, and comfortable position all times utilizing appropriate positioning aids and boundaries throughout their NICU stay • Provide appropriate ventral support to ensure flexed shoulders/hips • Provide swaddling when bathing and weighing. • Avoid doing procedures with infant in a prone position where he/she is unable to use self-comforting abilities • Anticipate, prioritize, and support the infant's individualized needs during each care-giving interaction to minimize stressors known to interfere with normal development. • Engage with infant and let behavior of infant guide care. Do cares “with the infant, rather than “to” the infant. • Assess infant sleep–wake cycle to evaluate appropriate timing of positioning and care. • Reposition infant with cares and minimally every 4 hours • Provide 4-handed support during positioning and caring activities • Promote hand to mouth/face contact • When providing caregiving activities: • Collect all supplies prior to approaching infant so infant is not left unattended or unsupported once hands-on care has begun • Seek another person to support infant care during a potentially stressful experience, including bathing and weighing. • Include parents in providing support when available and willing. L. Altimier, R. Phillips / Newborn & Infant Nursing Reviews 16 (2016) 230–244 239 (continued) Appendix A. (continued) Core measure #1: Healing environment34,37,38,51,57,133,135,139 • The caregiver sees her or himself in partnership "with" the baby so that caregiving procedures are performed “with” the infant rather than “to” the infant. • Infants will be provided developmentally appropriate stimulation/play as they mature (i.e. mobiles, swings, etc.) Core measure #4: Safeguarding sleep36,96,97,133,137 Standard 1: A policy/procedure/guideline on safeguarding sleep exists and is followed throughout the infant's stay. Standard 2: A policy/procedure/guideline on back-to-sleep practices exists and is followed prior to discharge. Infant characteristics Goals Neuroprotective interventions • Infant sleep–wake states, cycles, and • Infant sleep–wake states will be • Facilitate early, frequent, and prolonged skin-to-skin contact transitions assessed before initiating all • Educate, coach, and mentor parents on sleep-wake states and how to • Infant's maturity and readiness for caregiving activities safeguard their baby’s sleep, recognizing the importance back-to-sleep protocol • Prolonged periods of uninterrupted of sleep for healing, growth and brain development sleep will be protected • Utilize a validated & reliable scale to assess sleep-wake states to promote sleep • Infants will be transitioned to • Recognize and protect sleep cycles, especially REM sleep back-to-sleep when • Promote a quiet environment to ensure uninterrupted sleep. developmentally appropriate • Avoid sleep interruptions from bright lights, loud noises, and unnecessary disturbing activities. • Protect quiet sleep states by providing flexibility in timings of care • Engage with infant and let behavior of infant guide care • Individualize all caregiving activities by clustering cares based on infant sleep–wake states. Take care not to over-stress infant with too many clustered cares at once. • If necessary to arouse a sleeping infant, approach using a soft voice/whisper followed by gentle touch • Support smooth transitions back to restful sleep before stepping away from bedside • Protect infant's eyes from direct light exposure and maintain low levels of ambient light • Use incubator covers to protect the infant from direct light • When developmentally appropriate, provide some daily exposure to light, pref- erably including shorter wavelengths, for entrainment of the circadian rhythm • Avoid (when possible) high doses of sedative and depressing drugs which can depress the endogenous firing of cells thus, thus interfering with visual development, REM, and NREM sleep cycles, and thus optimal brain development. • Provide developmental care appropriate for the age and maturation of the infant including supportive positioning to promote restful sleep • Assure infant is able to maintain normal sleep pattern during back-to- sleep well before discharge and role model this behavior in the NICU • Provide tummy-time/prone-to-play time routinely for infants that are Back-to-Sleep • Coach, educate, and mentor parents about the importance and rationale for back-to-sleep and tummy-time Core measure #5: Minimizing stress & pain36,115,133,137,142-145 Standard: A policy/procedure/guideline on the assessment and management of pain exists and is followed throughout the infant's stay. Infant characteristics Goals Neuroprotective interventions Behavioral cues indicating • Promote self-regulation and • Facilitate early, frequent, and prolonged skin-to-skin contact stress or self-regulation neurodevelopmental organization • Educate, coach, and mentor parents on infant cues related to stress and • Reduce excessive stress and pain and how to provide their infant with nonpharmacological support pain in the NICU during stressful or painful procedures • Provide individualized care in a manner that anticipates, prioritizes, and supports the needs of infants to minimize stress and pain • Utilize a validated & reliable pain assessment tool to evaluate the need for pharmacologic support • Regularly evaluate the clinical need for frequent labs and procedures, and reduce the excessive number of stressful/painful procedures whenever possible. • Provide non-pharmacologic support (breastfeeding, skin-to-skin contact, sucrose, pacifier) prior to/ with all minor invasive interventions • Provide midline, flexion, and containment with all positioning (whenever possible) to promote comfort • Provide therapeutic positioning aids to maintain supportive positioning • Provide guidance to parents on how to collaborate with NICU staff to minimize their baby's stress and pain • Invite parents to help support their baby during painful procedures if they are available and willing to participate • Reserve parenting activities for parents (feeding, diapering, etc.) Core measure #6: Protecting skin36,120,121,133,137 Standard: A policy/procedure/guideline on skin care exists and is followed throughout the infant's stay. Infant characteristics Goals Neuroprotective interventions Maturity and integrity • Reduce trans-epidermal water loss • Facilitate early, frequent, and prolonged skin-to-skin contact of infant skin of ELBW infants (continued on next page) 240 L. Altimier, R. Phillips / Newborn & Infant Nursing Reviews 16 (2016) 230–244 (continued) Appendix A. (continued) Core measure #1: Healing environment34,37,38,51,57,133,135,139 • Maintain skin integrity of the • Educate, coach, and mentor parents on skin care, swaddled infant from birth to discharge bathing, and delivery of developmentally appropriate infant massage • Provide developmentally appropriate • Utilize a validated & reliable skin assessment tool infant massage on admission and routinely according to hospital protocol • Provide humidity for ELBW infants during the first one - two weeks after birth (50% humidity is provided when infant is in skin-to-skin contact) • Provide appropriate positioning support utilizing gel products and other positioning aids to prevent skin breakdown • Examine position of nasal prongs per protocol to protect against breakdown of nasal septum • Minimize use of adhesives and use caution when removing adhesives to prevent epidermal stripping • Avoid soaps and routine use of emollients • Use only water for bathing b1000 gram infants • Use pH neutral cleansers for bathing N1000 gram infants • When bathing, do swaddled bathing in bed or tub (to reduce stress and promote relaxation) with overhead warmer (to prevent risk of hypothermia). • Provide bathing no more than every 72 to 96 hours • Priority should be given to parents to bathe their own infant whenever possible • Provide parents guidance on how to protect their baby's skin and its many functions, including its role as a conduit of neurosensory information to the brain • Teach parents how to give developmentally appropriate infant massage to promote relaxation, bonding and attachment Core measure #7: Optimizing nutrition36,61,131,133,137 Standard 1: A policy/procedure/guideline on optimizing nutrition using cue-based/infant-driven breast or bottle feeding (which includes infant readiness, quality of feeding and caregiver techniques) is followed throughout the infant's stay. Standard 2: A policy/procedure/guideline on skin-to-skin contact (kangaroo care) exists and is followed throughout the infant's stay. Infant characteristics Goals Neuroprotective interventions • Physiologic stability with • Feeding will be safe, functional, • Facilitate early, frequent, and prolonged skin-to-skin contact feeding & handling nurturing, and developmentally • Educate, coach, and mentor parents about positive oral • Feeding readiness cues appropriate stimulation, infant feeding cues, and feeding techniques • Coordinated suck/swallow/ • Optimized nutrition will be enhanced • Promote positive oral/olfactory stimulation during early breathing (SSB) throughout by individualizing all feeding care skin-to-skin contact by letting infant lick, nuzzle and breast or bottle feeding practices smell the nipple if interested • Endurance to maintain • Oral aversions will be prevented by • Minimize negative perioral stimulation (adhesives, suctioning, etc.) nutritional intake and assuring feeding is a positive experi- • Utilize indwelling gavage tubes rather than intermittent tubes. support growth ence for infant • Promote Non-Nutritive Sucking (NNS) at mother’s pumped • First oral feeds will be at the breast breast during gavage feeds for babies whose mothers are • Hold infant and use NNS with appropriate sized pacifier pumping their milk during gavage feeds when mother is not available. • Infants of breastfeeding mothers will • Provide taste and smell of breast milk, if available, be competent at breastfeeding with gavage feedings prior to discharge • Utilize validated & reliable Feeding-Readiness and Infant-Driven Feeding tools, and involve parents in assessments of feeding readiness and quality of feeds. • Ensure every feeding experience is a positive, pleasant, and nurturing experience • Educate parents about the medical importance of breast milk for most infants, especially for ELBW infants. • Support and encourage mother’s expressed breast milk (EBM) supply • Provide donor human milk for ELBW infants (whenever possible) if mother's milk is not available or is contraindication. • Ensure first oral feeding is at the breast for baby’s whose mothers have been pumping their breast milk • Support and encourage competent breastfeeding well before discharge • Promote side-lying position close to parent/caregiver when bottle-feeding • Provide guidance to parents on how to provide supportive oral feeding experiences for their infant, including positioning and pacing Teamwork & collaboration131–134,137,139 Standard 1: An interdisciplinary team of caregivers works together collaboratively to support the medical, developmental and psychosocial needs of infants and families. Standard 2: Hospital leadership facilitates staff education and training related to Neuroprotective Family-Centered Developmental Care principles and practices, including how to educate, coach and mentor parents in the care of their infants during NICU hospitalization. Standard 3: A policy/procedure/guideline on roles and responsibilities of team members and collaboration thereof exists and is followed. Infant characteristics Goals Neuroprotective interventions Infant and family are central • An individualized developmentally • Support parents as the primary caregivers by educating, to each team member's appropriate environment is coaching, and mentoring them in parenting their plans, decisions and caregiving provided for every infant and family babies in the NICU L. Altimier, R. Phillips / Newborn & Infant Nursing Reviews 16 (2016) 230–244 241 (continued) Appendix A. (continued) Core measure #1: Healing environment34,37,38,51,57,133,135,139 • Each parents is viewed as an active • Support parents in being active members of the caregiving team member of the caregiving team • Include parents in all medical decision making • All staff members are equipped with • Provide as much space and comfort as possible for family caregiving, the knowledge and skills they need to keeping charts and equipment well organized and avoiding clutter care for babies and support parents • Consistently share information about infant’s behavioral and families competencies, vulnerabilities, thresholds and parental • All staff members are supported in self- involvement when communicating with colleagues during care to medical rounds or staff shift change prevent burn-out and compassion fatigue • Prior to performing a procedure, care, or exam on an infant under the care of another team member (or parent), discuss the needs of that team member to mutually agree on the timing • Respect and support the roles of other individuals and disciplines when caring for infants – support each other through mentoring relationships • Willingly and proactively assist colleagues to provide support for infants in their care during potentially stressful procedures • Ensure all infants and families are treated consistently with support, dignity, and respect by all team members, and constructively confront team members if discrepancies are noted • Educate and train staff in all disciplines on neuroprotective family-centered developmental care principles and practices • Educate staff about methods for improving and expanding family-centered developmental care in the NICU • Educate staff on the differences and value of cultural practices other than their own • Educate staff on active listening skills and other optimal methods of communication with parents in distress • Educate staff about stages of grief and risks of postpartum depression and PTSD in NICU parents and staff • Educate and support staff on elements of self-care to proactively prevent and minimize burn-out and compassion fatigue • Have a program to regularly acknowledge and appreciate the NICU staff and the work they do for babies and families Appendix B. PDSA for Core Measure #3: Positioning and handling. Goals Aim Plan Do: (actions) Do (contact) Timeline Comments Rewards updates consequences Goal CM #3: 1. 100% of infants 1. Positioning of each 1. Educate staff on: 1. Educator/DC 1. Jan. 10–Mar. Measurement: Rewards: Staff will Positioning & will be positioned infant will be assessed a. Principles of positioning champion #1 10 1. Scoring on receive a "Shout-Out" handling in a midline, flexed and scored utilizing b. use of positioning aids (Beth/Jane) IPAT will be note from the DC team and contained the Infant Positioning c. IPAT tool 2. Jan. 5 10–12 on for scoring 100% on IPAT position with an Assessment Tool Use 2. Educator (Beth) 100% of audit scores of 10 - 12 IPAT score between (IPAT) every shift and 2. Document staff 3. Jan. 5 infants during designated audit 10 and 12. twice a week by competencies on 3. DC champion #2 period. audit team or Positioning and (Joe) 4. Jan. 10 Developmental Care handling Consequences: Staff will (DC) champion 4. DC champion #3 5. Feb. 1 be coached on any 3. Create NICU /supply tech IPAT scores of b 10 guideline on 6. Mar. 1 during the designated positioning 5. EMR rep/IS audit period. support 7. Mar. 1 If Behavior continues, 4. Create par level manager will counsel of positioning supplies 6. DC champion #4 staff and manage with appropriate (with QI support) performance. supply and access 7. DC champion #4 5. Incorportate IPAT (with QI support) into NICU documentation 8. DC lead/educator/ 6. Create audit tool for manager measuring positioning of infants 7. Prepare dashboard for reporting IPAT audit scores to enable trend analysis 8. Create communication plan for all staff/families) Status update/communication Date Update (continued on next page) 242 L. Altimier, R. Phillips / Newborn & Infant Nursing Reviews 16 (2016) 230–244 Appendix C. Quick Tips for all NICU Staff. Appendix C. (continued) c) Use extra supports during painful procedures Core Measure 1: Healing Environment • Ask staff or parent to provide 4-handed support when needed • Many parents are willing and eager to help support their baby A healing environment protects the developing sensory system of preterm infants • Give them a chance to participate if they are available and willing d) Be sure Sweet-Ease is given 2 minutes prior to painful procedures a) Protect auditory system by minimizing noise • Understand mechanism of action (activation of endogenous opioid receptors. • Talk in a “library voice” when near bedsides • Understand absorption (via buchal mucosa - not via digestion). • Keep pagers and phones on vibrate e) Be sure adequate analgesics are given for painful procedures if needed b) Protect visual system by minimizing direct light • Be proactive with post-op pain management • Cover baby’s eyes during exams and procedures f) Skin-to-skin contact reduces stress and pain – Mother’s presence is analgesic • Be sure isolette covers and blankets protect from direct light • Encourage early, frequent, and prolonged skin-to-skin contact c) Protect olfactory system by minimizing odors • Let hand sanitizers dry before putting hands inside isolette Core Measure 6: Protecting Skin • Leave perfumes and colognes at home to maintain a fragrance-free NICU d) Protect vestibular and tactile system Skin is a conduit for nerve cells to send sensory messages to the brain • Use slow gentle movements during handling a) Monitor humidity level inside incubator during first week for ELBW infants e) Skin-to-skin contact (SSC) provides the most healing environment • Be sure humidity is provided until skin is keratinized - about 5-10 days • Facilitate early, frequent, and prolonged skin-to-skin contact - Being skin to skin on mother’s chest provides about 50% humidity b) Monitor nasal septum for skin breakdown if nasal prongs are used Core Measure 2: Partnering with Families • Check prongs frequently – there should be no pressure on septum • Check septum each shift for erythema or breakdown Parents are the most important caregivers in a baby’s life c) Monitor other susceptible skin areas a) Go out of your way to make parents feel welcome in the NICU • Check mouth for oral thrush and diaper area for rash • Always greet parents and introducing yourself with name and role • Check trunk/limbs for pressure ulcers and IV sites for erythema/infiltrates • Having a baby in the NICU is usually an unexpected crisis for families d) SSC sends impulses to the brain to support maturation of the amygdala/limbic • Expect the need to repeat conversations and explanations more than once system • Use lay language free from acronyms when talking with parents • Encourage early, frequent, and prolonged skin-to-skin contact b) Involve parents as active members of the caregiving team • Educate, coach and mentor parents in caring for their baby in the NICU Core Measure 7: Optimizing Nutrition • Include parents in medical rounds and nursing shift change discussions Human milk is the optimal diet for most human infants. • Ask parents how they think their baby is doing – then listen c) Skin-to-skin contact helps to heal the wounds of interrupted bonding and attachment a) Discuss the medical need for breastmilk with parents whenever the opportunity • Recognize importance of parent-infant attachment on brain development, arises frequent, and prolonged skin-to-skin contact • Explain how breastmilk is a medicine, especially for preterm infants • Explain need for early/frequent pumping if baby is unable to breastfeed Core Measure 3: Positioning and Handling b) Support mother’s early and continued milk supply • Provide enthusiastic support for any breastmilk mother provides Positioning should mimic the fetal position in the womb • Explain the importance of ongoing pumping to maintain milk supply a) Maintain head in a midline position c) Provide ongoing breastfeeding education and support • Be extra vigilant with ventilated ELBW infants • Explain how important breastmilk is for healing and nutrition • Ask RT to help reposition ETT and/or reposition infant if needed • Explain how important breastmilk is for brain development and vision b) Maintain limbs and trunk in flexed, tucked position • Explain how important breastmilk is to decrease risk of NEC and sepsis • Gently reposition infant after extending limbs during exams/procedures d) Skin-to-skin contact increases breastfeeding initiation and duration • Reposition infant in positioning aid after exams/procedures • SSC increases prolactin and oxytocin – both needed for lactation c) Handle preterm and sick infants with slow, gentle movements • Facilitate early, frequent, and prolonged skin-to-skin contact • Ask for help with procedures or complicated handling e) Cue-based, infant-driven feeding prevents later oral aversions • Ask staff or parent to provide 4-handed support if needed • Oral feedings should be safe, developmentally appropriate and nurturing d) Skin-to-skin contact is the “natural habitat” for all newborns • Provide cue-based rather than volume feedings • Skin-to-skin contact is the closest to being back inside the womb - Monitor feeding readiness and signs of stress during feeds • Facilitate early, frequent, and prolonged skin-to-skin contact f) Support breastfeeding well before discharge • Babies can practice suckling when skin to skin whenever interested Core Measure 4: Safeguarding Sleep • The first oral feeding should be at the breast if mother has been Sleep is essential for healing, growth, and optimal brain development pumping • If term baby has excessive difficulty latching, get lactation support a) Never waken a sleeping baby unless absolutely necessary - Check mouth for anomalies, e.g. cleft such as cleft palate or ankyloglossia (tongue-tie) • Support long periods of restful, uninterrupted sleep whenever possible - If present, alert physician to get appropriate treatment • Time routine cares/exams to coincide with baby’s sleep/wake cycles b) Protect sleep states by minimizing noise and light Guiding Principles • Talk in a “library voice” when near bedsides • Be sure direct light is not shining on sleeping babies a) All infants are in a critical period of brain growth and organization c) Skin-to-skin contact promotes the most optimal sleep cycles • Everything that happens in the NICU impacts brain development • Remember - newborns sleep best when in skin-to-skin contact • Providing excellent, evidence-based medical care is always our goal • Facilitate early, frequent, and prolonged skin-to-skin contact • The manner in which we give it influences developmental outcomes b) Neuroprotective developmental care is relational Core Measure 5: Minimizing Stress and Pain • Treat every baby as a little human being who has their own unique identity Stress and pain are part of NICU life – but both can be minimized • Do exams and procedures “with” the baby, not “to” the baby a) Supporting a healing environment helps to minimize stress • Notice individual differences and preferences in each baby • Protect babies from excess noise and light c) Emotional connection with parents is essential for optimal outcomes • Talk in a “library voice” and cover baby’s eyes during exams • Parents are the most important caregivers for their baby in the long run • Watch for signs of stress during exams and pause when possible • Support parent-infant attachment in every way possible in the NICU - Extended digits and limbs indicates stress • Provide psychosocial support for NICU parents as needed - Excessive tone or absence of tone indicates stress d) Skin-to-skin contact is the most fundamental form of neuroprotective care b) Use positioning and boundaries to provide containment • Skin-to-skin contact with mother is the “natural habitat” for all newborns • Be sure baby is well-contained during exams and procedures • Skin-to-skin contact supports all 7 of the Neuroprotective Core Measures • Be sure baby is repositioned properly after exams and procedures • Encourage and facilitate skin-to-skin contact whenever possible L. Altimier, R. Phillips / Newborn & Infant Nursing Reviews 16 (2016) 230–244 243 an effectively healing, peaceful, and satisfying environment for NICU 30. Darcy-Mahoney A, et al. Probability of an autism diagnosis by gestational age. New- born Infant Nurs Rev. 2016;16. staff, families and the infants entrusted to our care. 31. Butler S, Als H. Individualized developmental care improves the lives of infants born Developmentally supportive care is sometimes perceived as preterm. Acta Paediatr. 2008;97:1173-5. “nice,” yet optional. It is sometimes thought of as “fluff” in a primarily 32. Constable RT, Ment LR, Vohr BR, et al. Pediatrics. 2008 Feb;Vol. 121(2):306-16. ISSN: 1098-4275. technologically-driven environment. Ignorance of or dismissal of the 33. Wolke D, Samara M, Bracewell M, Marlow N, EPICure Study Group. J Pediatr. 2008 growing body of evidence about the importance of providing neuro- Feb;Vol. 152(2):256-62. ISSN: 1097-6833. protective care for preterm infants is no longer acceptable. Consis- 34. Altimier L, White R. The Neonatal Intensive Care Unit (NICU) Environment. In: Kenner C, Lott J, eds. Comprehensive Neonatal Nursing Care. NY, NY.: Springer Pub- tent acceptance, practice, and accountability must be established to lishing; 2014. p. 722-38. provide the high-quality care every infant and family deserves. Use 35. Graven S, Browne JV. Sensory development in the fetus, neonate, and infant: intro- of established guidelines, policies, and procedures to guide neonatal ductions and overview. Newborn Infant Nurs Rev. 2008;8:169-72. 36. McGrath JM, Cone S, Samra HA. Neuroprotection in the preterm infant: further un- practice is essential. Healthcare professionals must be cognizant derstanding of the short- and long-term implications for brain development. New- of the growing body of research regarding the impact of the NICU born Infant Nurs Rev. 2011;11:109-12. environment on neurodevelopmental outcomes of premature and 37. Pickler RH, McGrath JM, Reyna BA, et al. Adv Neonatal Care. 2013 Oct;Vol. 13(Suppl 5): sick infants. S11-20. ISSN: 1536-0911. 38. Altimier L. Mother and child integrative developmental care model: a simple ap- proach to a complex population. Newborn Infant Nurs Rev. 2011;11:105-8. References 39. Altimier L, Phillips R. The neonatal integrative developmental care model: seven neuroprotective core measures for family centered care. Newborn Infant Nurs Rev. 2013;13:9-22. 1. MarchofDimes. March of Dimes:Peristats Premature Birth Report Card. March of 40. Altimier L. Neuroprotective core measure 1: the healing environment. Newborn In- Dimes Peristats; 2015. [cited 2016 9/9/2016]. fant Nurs Rev. 2015;15:89-94. 2. Hamilton B, Martin J, Osterman M, Curtin S, Mathews T. Births: final data for 2014. 41. Symington A, Pinelli J. Developmental Care for Promoting Development and Natl Vital Stat Rep. December 23, 2015;64(12):1-63. Preventing Morbidity in Preterm Infants, in Cochrane Review. The Cochrane Li- 3. Taylor HG. Academic Performance and Learning Disabilities. Cambridge, MA: Universi- brary: Oxford Update Software; 2002. p. 1-37. ty Press. 2010. 42. Symington A, Pinelli J. Developmental care for promoting development and 4. Grunewaldt KH, Fjørtoft T, Bjuland KJ, et al. Early Hum Dev. 2014 Oct;90(10):571-8. preventing morbidity in preterm infants. Cochrane Database Syst Rev. 2006:CD001814. ISSN: 1872-6232. 43. Symington A, Pinelli J. Distilling the evidence on developmental care: a systematic 5. Vohr B. Speech and language outcomes of very preterm infants. Semin Fetal Neona- review. Adv Neonatal Care. 2002;2:198-221. tal Med. 2014;19:78-83. 44. Jacobs S, Sokol J, Ohlsson A. The newborn individualized developmental care and 6. Als H, Duffy FH, McAnulty GB, et al. Pediatrics. 2004 Apr;Vol. 113(4):846-57. ISSN: assessment program is not supported by meta-analyses of the data. J Pediatr. 1098-4275. 2002;140:699-706. 7. Hack M, Youngstrom EA, Cartar L, et al. Pediatrics. Oct 2004;114(Supplement Part 45. Liaw JJ, Yang L, Chang LH, Chou HL, Chao SC. Appl Nurs Res. 2009 May;Vol. 22(2): 2):932-40. 9p. 86-93. ISSN: 1532-8201. 8. Moster D, Lie RT, Markestad T. Long-term medical and social consequences of pre- 46. Altimier LB, Eichel M, Warner B, Tedeschi L, Brown B. Neonatal Intensive Care. 2005 term birth. New England Journal of Medicine. 2008;359:262-73. May;18(Supplement 4):12-6. 5p. 9. Hack M. Young adult outcomes of very-low-birth-weight children. Semin Fetal Neo- 47. Hendricks-Muñoz KD, Prendergast CC, Caprio MC, Wasserman RS. Newborn Infant natal Med. 2006;11:127-37. Nurs Rev. 2002 Mar;2(1):39-45. 7p. 10. Bhutta AT, Anand KJ. Vulnerability of the developing brain: neuronal mechanisms. 48. Ludwig S, Steichen J, Khoury J, Krieg P. Newborn Infant Nurs Rev. Jun 2008;8(2): Clin Perinatol. 2002;29:357-72. 94-100. 7p. 11. Taylor H. Academic Performance and Learning Disabilities. In: Nosarti C, Murray 49. Petryshen P, Stevens B, Hawkins J, Stewart M. Neonatal Intensive Care. 1998 RM, Hack M, eds. Neurodevelopmental Outcomes of Preterm Birth: From Childhood Mar-Apr;11(2):18-24. 7p. to Adult Life. Cambridge: University Press; 2010. p. 195-218. 50. Improvement, I.O.H. PDSA cycle 2016. [cited 2016; Available from:]http://www.ihi. 12. Aarnoudse-Moens CS, Weisglas-Kuperus N, van Goudoever JB, Oosterlaan J. Pediat- org/resources/Pages/HowtoImprove/ScienceofImprovementHowtoImprove.aspx. rics. 2009 Aug;124(2):717-28. ISSN: 1098-4275. 51. Ludington-Hoe S. Kangaroo Care Is Developmental Care. In: McGrath CKJ, ed. Devel- 13. Aylward GP. Neurodevelopmental outcomes of infants born prematurely. J Dev opmental Care of Newborns and Infants: A Guide for Health Professionals. Glen- Behav Pediatr. 2014;35:394-407. view, IL: National Association of Neonatal Nurses; 2010. p. 349-88. 14. Vanderbilt D, Gleason M. Mental health concerns of the premature infant through 52. Bergman N. Skin-to-skin contact as a neurosupportive measure. Newborn Infant the lifespan. Child Adolesc Psychiatr Clin N Am. 2010;19:211-28. Nurs Rev. 2015;15:145-50. 15. Johnson S, Marlow N. Early and long-term outcome of infants born extremely pre- 53. Phillips R. The sacred hour: uninterrupted skin-to-skin contact immediately after term. Arch Dis Child. 2016. birth. Newborn Infant Nurs Rev. 2013;13:67-72. 16. Hack M, Taylor HG, Schluchter M, Andreias L, Drotar D, Klein N. J Dev Behav Pediatr. 54. Ludington-Hoe S. Kangaroo Care Is Developmental Care. In: Kenner C, McGrath J, 2009 Apr;Vol. 30(2):122-30. ISSN: 1536-7312. eds. Developmental Care of Newborns and Infants: A Guide for Health Professionals. 17. Heinonen K, Raikkonen K, Pesonen A. Behavioural symptoms of attention 2nd ed. Glenview, IL: NANN; 2010. deficit/hyperactivity disorder in preterm and term children born small and appro- 55. Scher MS, Ludington-Hoe S, Kaffashi F, Johnson MW, Holditch-Davis D, Loparo KA. priate for age: a longitudinal study. BMC Pediatr. 2010;10:91. Clin Neurophysiol. 2009 Oct;Vol. 120(10):1812-8. ISSN: 1872-8952. 18. Johnson S, Hollis C, Kochlar P. Psychiatric disorders in extremely preterm children: 56. Cong X, Ludington-Hoe SM, Hussain N, et al. Early Hum Dev. 2015 Jul;Vol. 91(7): longitudinal finding at age 11 years in the EPICure study. J Am Acad Child Adolesc 401-6. ISSN: 1872-6232. Psychiatry. 2010;49:453-463.e1. 57. Doucet S, Soussignan R, Sagot P, Schaal B. Dev Psychobiol. 2007 Mar;Vol. 49(2): 19. Johnson S, Marlow N. Early and long-term outcomes of infants born extremely pre- 129-38. ISSN: 0012-1630. term. Arch Dis Child. 2016:1-6. 58. White R, Smith J, Shepley M. Recommended standards for newborn ICU design, 20. Limperopoulos C, Bassan H, Sullivan NR, et al. Pediatrics. 2008 Apr;Vol. 121(4): eighth edition. J Perinatol. 2013;33:S2-S16. 758-65. ISSN: 1098-4275. 59. Barton S, White R. Advancing NICU care with a new multi-purpose room concept. 21. Kemper TL, Bauman M. Neuropathology of infantile autism. J Neuropathol Exp Newborn Infant Nurs Rev. 2016;16. Neurol. 1998;57:645-52. 60. Pineda RG, Stransky KE, Rogers C, et al. J Perinatol. 2012 Jul;Vol. 32(7):545-51. ISSN: 22. Browne JV, Talmi A. Developmental supports for newborns and young infants with 1476-5543. special health and developmental needs and their families: the BABIES model – 61. Twohig A, Reulbach U, Figuerdo R, McCarthy A, McNicholas F, Molloy EJ. Infant Ment body function, arousal and sleep, body movement, interaction with others, eating, Health J. 2016 Mar-Apr;Vol. 37(2):160-71. ISSN: 1097-0355. and self-soothing. Newborn Infant Nurs Rev. 2012;12:239-47. 62. Blackburn ST. Stories, Ethics and the Interpretation of Meaning: Bearing Witness to 23. Baio J. Prevalence of autism spectrum disorders – autism and developmental dis- Mothers' Stories of Their Neonatal Intensive Care Unit Experience. In: PsychInfo, ed. abilities monitoring network, 14 sites, United States, 2008. MMWR. Surveillance Order No. AAI3367164; 2010. summaries, 61(3), 1–19. MMWR Surveill Summ. 2012;61:1-19. 63. Boykova M, Kenner C. Transition from hospital to home for parent of preterm in- 24. Limperopoulos C. Extreme prematurity, cerebellar injury, and autism. Semin Pediatr fants. J Perinat Neonatal Nurs. 2012;26:81-7. Neurol. 2010;17:25-9. 64. Purdy IB, Craig JW, Zeanah P. NICU discharge planning and beyond: recommenda- 25. Limperopoulos C. Autism spectrum disorders in survivors of extreme prematurity. tions for parent psychosocial support. J Perinatol. 2015;35:S24-8. Clin Perinatol. 2009;36:791-805. 65. Hynan M, Hall SL. Psychosocial program standards for NICU parents. J Perinatol. 26. Hack M. Care of preterm infants in the neonatal intensive care unit. Pediatrics. 2015;1:S1-4. 2009;123:1246-7. 66. Anderson PJ. Neuropsychological outcomes of children born very preterm. Semin 27. Luyster RJ, Kuban KC, O'Shea TM, et al. Paediatr Perinat Epidemiol. 2011 Jul;Vol. Fetal Neonatal Med. 2014;19:90-6. 25(4):366-76. ISSN: 1365-3016. 67. Treyvaud K. Parent and family outcomes following very preterm or very low birth 28. Moore T, Johnson S, Hennessy E, Marlow N. Dev Med Child Neurol. 2012 Jun;Vol. weight birth: a review. Semin Fetal Neonatal Med. 2014;19:131-5. 54(6):514-20. ISSN: 1469-8749. 68. Tomlin A, Deloian B, Wollesen L. Infant/early childhood mental health and collabo- 29. Kuzniewicz MW, Wi S, Qian Y, Walsh EM, Armstrong MA, Croen LA. J Pediatr. 2014 rative partnerships: beyond the NICU. Newborn Infant Nurs Rev. 2016;16. Jan;Vol. 164(1):20-5. ISSN: 1097-6833. 244 L. Altimier, R. Phillips / Newborn & Infant Nursing Reviews 16 (2016) 230–244 69. Carson C, Redshaw M, Gray R, Quigley MA. BMJ Open. 2015 Dec 18;Vol. 5(12): 109. Grunau RE, Tu MT, ME W. Cortisol, behavior, and heart rate reactivity to immuniza- e007942. ISSN: 2044-6055. tion pain at 4 months corrected age in infants born very preterm. Clin J Pain. 70. Coughlin M. Transformative Nursing in the NICU: Trauma-informed Age-appropriate 2010;26:698-704. Care. Springer Publishing Company. 2014. 110. Grunau R, Whitfield M, Petrie-Thomas J. Neonatal pain, parenting stress and inter- 71. Robson M, MacMillan-York E, Dunn M. Celebration in the face of trauma: action, in relation to cognitive and motor development at 8 and 18 months in pre- supporting NICU families through compassionate facility design. Newborn Infant term infants. Pain. 2009;143:138-46. Nurs Rev. 2016;16. 111. Vinall J, Miller SP, Chau V, Brummelte S, Synnes AR, Grunau RE. Pain. 2012 Jul;Vol. 72. Oral R, Ramirez M, Coohey C, et al. Pediatr Res. Jan 2016;79(1-2):227-33. 7p. 12(7):1374-81. ISSN: 1872-6623. 73. Marsac ML, Kassam-Adams N, Hildenbrand AK, et al. JAMA Pediatr. 2016 Jan;Vol. 112. Brummelte S, Grunau RE, Chau V, et al. Ann Neurol. 2012 Mar;Vol. 71(3):385-96. 170(1):70-7. ISSN: 2168-6211. ISSN: 1531-8249. 74. Ash J, Williams ME. Policies and systems support for infant mental health in the care 113. Zwicker JG, Grunau RE, Adams E, et al. Score for neonatal acute physiology-II and of fragile infants and their families. Newborn Infant Nurs Rev. 2016;16. neonatal pain predict corticospinal tract development in premature newborns. 75. Allen E, et al. Perception of child vulnerability among mothers of former premature Pediatr Neurol. 2013:123-9. infants. Pediatrics. 2004;113:267-73. 114. Pitcher JB, Schneider LA, Drysdale JL, Ridding MC, Owens JA. Clin Perinatol. 2011 76. Browne J, Martinez D, Talmi A. Infant mental health (IMH) in the intensive care Dec;Vol. 38(4):605-25. ISSN: 1557-9840. unit: considerations for the infant, the family and the staff. Newborn Infant Nurs 115. Walker SM. Neonatal pain. Pediatr Anesth. 2014;24:39-48. Rev. 2016;16. 116. McNair C, Campbell Yeo M, Johnston C, Taddio A. Clin Perinatol. 2013 Sep;Vol. 40(3): 77. Hynan MT, Mounts KO, Vanderbilt DL. Screening parents of high-risk infants for 493-508. ISSN: 1557-9840. emotional distress: rationale and recommendations. J Perinatol. 2013;33: 117. Stevens B, Yamada J, Ohlsson A, Haliburton S, Shorkey A. Cochrane Database Syst Rev. 748-53. 2016 Jul 16;Vol. 7. ISSN: 1469-493X. 78. Bowlby J. Attachment: Attachment and Loss. , Vol. 1New York: Basic Books. 1969. 118. Johnston C, Campbell-Yeo M, Fernandes A, Inglis D, Streiner D, Zee R. Cochrane Da- 79. Bowlby J. The Origins of Attachment Theory, Lecture 2. In: Bowlby J, ed. A Secure tabase Syst Rev. 2014 Jan 23(1). ISSN: 1469-493X. Base. New York: Basic Books; 1988. 119. Rattaz C, Goubet N, Bullinger A. The calming effect of a familiar odor on full-term 80. Bonnin A, Levitt P. Fetal, maternal, and placental sources of serotonin and new newborns. J Dev Behav Pediatr. 2005;26:86-92. implications for developmental programming of the brain. Neuroscience. 120. Kurihara H, Chiba H, Shimizu Y, et al. Early Hum Dev. 1996 Sep 20;Vol. 46(1-2): 2011;197:1-7. 117-27. ISSN: 0378-3782. 81. Kapoor A, Petropoulos S, Matthews SG. Brain Res Rev. Mar 2008;Vol. 57(Issue 2): 121. Kisilevsky BS, Hains SM, Lee K, et al. Psychol Sci. 2003 May;Vol. 14(3):220-4. ISSN: 586-9510.1016/j.brainresrev.2007.06.013. 10p. 0956-7976. 82. Del Fabbro A, Cain K. Infant mental health and family mental health issues. Newborn 122. Goubet N, Strasbaugh K, Chesney J. Familiarity breeds content? Soothing effect of a Infant Nurs Rev. 2016;16. familiar odor on full-term newborns. J Dev Behav Pediatr. 2007;28:189-94. 83. Boykova M, Kenner C. Partnerships in Care: Mothers and Fathers. In: McGrath CKJ, 123. Visscher M, Narendran V. Neonatal infant skin: development, structure and func- ed. Developmental Care of Newborns and Infants: A Guide for Health Professionals. tion. Newborn Infant Nurs Rev. 2014;14:135-41. Glenview, IL: National Association of Neonatal Nurses; 2010. p. 145-60. 124. Visscher MO, Adam R, Brink S, Odio M. Newborn infant skin: physiology, develop- 84. Bergman N. The neuroscience of birth – and the case for zero separation. Curationis. ment, and care. Clin Dermatol. 2015 May-Jun;Vol. 33(3):271-80. ISSN: 1879-1131. 2014;37:1-4. 125. Visscher M. A practical method for rapid measurement of skin condition. Newborn 85. Hofer M. Psychobiological roots of early attachment. Curr Dir Psychol Sci. 2006;15: Infant Nurs Rev. 2014;14:147-52. 84-8. 126. Leaf A. Introducing enteral feeds in the high-risk preterm infant. Semin Fetal Neona- 86. Bystrova K, Ivanova V, Edhborg M. Early contact versus separation: effects on moth- tal Med. 2013. er–infant interaction one year later. Birth. 2009;36:97-109. 127. Manzoni P, Stolfi I, Luparia M, et al. Human milk feeding prevents retinopathy of pre- 87. Gudsnuk K, Champagne F. Epigenetic effects of early developmental experiences. maturity (ROP) in preterm VLBW neonates. Early Hum Dev. June 2, 2013;89:S64-8. Clin Perinatol. 2011;38:703-17. 128. Kafouri S, Kramer M, Paus T, et al. Breastfeeding and brain structure in adolescence. 88. McKechnie L. Family-integrated care in the neonatal unit. Infant. 2016;12:79-81 3p. Int J Epidemiol. February 2013;42(1):150-9. 89. O'Brien K, Bracht M, Macdonell K, et al. BMC Pregnancy Childbirth. 2013;13(1). 129. Belfort MB, Anderson P, Inder T, et al. Breast milk feeding, brain development, and S12-S12. 1p. neurocognitive outcomes: a 7-year longitudinal study in infants born at less than 90. Shoo KL, O'Brien K. Parents as primary caregivers in the neonatal intensive care unit. 30 weeks' gestation. J Pediatr. 2016. CMAJ. 2014;186:845-7. 130. Bergman N. Neonatal stomach volume and physiology suggest feeding at 1-h inter- 91. Cleveland L. Parenting in the neonatal intensive care unit. J Obstet Gynecol Neonatal vals. Acta Paediatr. 2013;102:773-7. Nurs. 2008;37:666-91. 131. Ludwig S, Waitzman K. Changing feeding documentation to reflect infant-driven 92. Murch T, Smith V. Supporting families as they transition home. Newborn Infant Nurs feeding practice. Newborn Infant Nurs Rev. 2007;7:155-60. Rev. 2016;16. 132. Waitzman K, Ludwig S, Nelson C. Contributing to content validity of the infant-driven 93. Fegram L. Nurses as moral practitioners encountering parents in the neonatal inten- feeding scales© through Delphi surveys. Newborn Infant Nurs Rev. 2014;14:88-91. sive care unit. Nurs Ethics. 2006;12:52-64. 133. Buchholz M, Dunn D, Bunik M. Integrating infant mental health with breastfeeding 94. Hunter J. Therapeutic Positioning: Neuromotor, Physiologic, and Sleep Implications. support: five years of the trifecta approach. Newborn Infant Nurs Rev. 2016;16. In: McGrath CKJ, ed. Developmental Care of Newborns and Infants. Glenview, IL: 134. Hall S, Hynan M, Phillips R, Press J, Kenner C, Ryan D. Development of program stan- National Association of Neonatal Nurses; 2010. p. 285-312. dards for psychosocial support of parents of infants admitted to a neonatal intensive 95. Hunter J, Lee A, Altimier L. Neonatal Intensive Care Unit. Occupational Therapy for care unit: a National Interdisciplinary Consensus Model. Newborn Infant Nurs Rev. Children and Adolescents. St. Louis: Elsevier; 2015. p. 595-635. March 2015;15(1):24-7. 96. Jeanson E. One-to-one bedside nurse education as a means to improve positioning 135. Hall S, Cross J, Martin M, et al. Recommendations for enhancing psychosocial sup- consistency. Newborn infant Nurs rev 2013;13(1):27–30. Newborn Infant Nurs Rev. port of NICU parents through staff education and support. J Perinatol. December 2013;13:27-30. 2015;35 Suppl 1:S29-36. 97. Spilker A, Hill C, Rosenblum R. The effectiveness of a standardised positioning tool 136. Craig J, Glick C, Phillips R, Hall S, Smith J, Browne J. Recommendations for involving the fam- and bedside education on the developmental positioning proficiency of NICU ily in developmental care of the NICU baby. J Perinatol. December 2015;35 Suppl 1:S5-8. nurses. Intensive Crit Care Nurs. 2016;35:10-5. 137. Hall SL, et al. Recommendations for peer-to-peer support for NICU parents. J 98. Picheansathian W, Woragidpoonpol P, Baosoung C. Positioning of preterm infants Perinatol. 2015:S9-S13. for optimal physiologic development: a systematic review. Joanna Briggs Inst Libr 138. Kenner C, Press J, Ryan D. Recommendations for palliative and bereavement care in Syst Rev. 2009;7:224-59. the NICU: a family-centered integrative approach. J Perinatol. 2015:S19-23. 99. Graven SN, Browne JV. Sleep and brain development: the critical role of sleep in 139. Hynan M, Steinberg Z, Stuebe A, et al. Recommendations for mental health profes- fetal and early neonatal brain development. Newborn Infant Nurs Rev. 2008;8:173-9. sionals in the NICU. J Perinatol. December 2015;35 Suppl 1:S14-8. 100. Graven S. Sleep and brain development. Clin Perinatol. 2006;33:693-706. 140. Robison LD. An organizational guide for an effective developmental program in the 101. Holditch-Davis D, Scher M, Schwartz T, Hudson-Barr D. Early Hum Dev. 2004 NICU. J Obstet Gynecol Neonatal Nurs. 2003;32:379-86. Oct;Vol. 80(1):43-64. ISSN: 0378-3782. 141. Liu W, Laudert S, Perkins B, MacMillan-York E, Martin S, Graven S. The development 102. Kuhn P, Zores C, Langlet C, Escande B, Astruc D, Dufour A. Acta Paediatr. 2013 of potentially better practices to support the neurodevelopment of infants in the Oct;Vol. 102(10):949-54. ISSN: 1651-2227. NICU. J Perinatol. December 2, 2007;27:S48-74. 103. Maquet P, Smith C, Stickgold R. Sleep and Brain Plasticity. New York: Oxford University 142. Altimier L, Kenner C, Damus K. The effect of a comprehensive developmental care Press. 2003. training program: wee care neuroprotective program (wee care) on seven neuro- 104. Peng NH, Mao HC, Chen YC, Chang YC. J Nurs Res. 2001 Jun;Vol. 9(3):333-43. ISSN: protective core measures for family-centered developmental care of premature ne- 1022-6265. onates. Newborn Infant Nurs Rev. 2015;15:6-16. 105. Modesto IF, Avelar AFM, Pedreira MdLG, Pradella-Hallinan M, Avena MJ, Pinheiro 143. Hendricks-Munoz K, Prendergast C, Caprio M, Wasserman R. Developmental care: EM. J Spec Pediatr Nurs. Jul 2016;Vol. 21(Issue 3):131-8. 8. the impact of wee care® developmental care training on short-term infant out- 106. Comaru T, Miura E. Postural support improves distress and pain during diaper comes and hospital costs. Newborn Infant Nurs Rev. March 2002;2(1):39-45. change in preterm infants. J Perinatol. 2009;29:504-7. 144. Altimier L. Compassionate family care framework: a new collaborative compassionate 107. Johnson SB, Riley AW, Granger DA, Riis J. Pediatrics. 2013 Feb;Vol. 131(2):319-27. care model for NICU families and caregivers. Newborn Infant Nurs Rev. 2015;15:33-41. ISSN: 1098-4275. 145. Benoit B, Campbell-Yeo M, Johnston C, Latimer M, Caddell K, Orr T. Staff nurse uti- 108. Anand KS. Pain, plasticity, and premature birth: a prescription for permanent suffer- lization of kangaroo care as an intervention for procedural pain in preterm infants. ing? Nat Med. 2000;6:971-3. Adv Neonatal Care. June 2016;16(3):229-38.