Developmental Care - an overview
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Developmental support integrates the developmental needs of the infant in NICU within the framework of medical care.
Key concepts for delivery of developmental care include promoting organised infant neurobehavioral and physiological function and tailoring the physical environment, such as light and sound, to protect vulnerable developing sensory systems, all within a context of family centred care.
When providing developmental care for infants two overriding principles need to be considered:
- First, that infants are unique and can display a wide variety of behaviours.
- Second, that the physiological condition of infants differs widely. For example, a baby born at term who becomes critically ill will have different developmental needs to an infant who is term but born prematurely.
Hence these recommendations are a guide not a rigid prescription for every baby. Assessment of infant cues remains central in the provision of developmental care.
Developmental Care Guidelines
More detailed information can be found in the following guidelines:
- The Early Preterm Infant (24-27 weeks gestation)
- The Developing Preterm Infant (28-32 weeks gestation)
- The Growing Preterm Infant (33-36 weeks gestation)
- The Older Preterm Infant (37 plus weeks corrected gestation)
Referral to NICU Developmental Therapists
- Designated time for this service is Thursday morning each week with capacity to respond to urgent referrals within 48 hours as necessary.
- Referrals are accepted by phone call or for a faxed internal referral form.
- A developmental assessment and intervention service is provided by an occupational therapist and physiotherapist for infants who meet the following criteria:
- Less than 1000g birthweight. These referrals are automatic via FLN
The following four criteria are via medical team referral:
- Infants with clearly defined special needs e.g. neuromuscular disease and chromosomal abnormalities
- Infants having suffered perinatal asphyxia with HIE
- Preterm infants with extra risk factors e.g. grade IV IVH, PVL, difficult or complex course
- Long stay infants e.g. 3 months or more with developmental needs
This service may apply to infants described in the "expected" and "at risk" groups outlined in the Community Child Development Service guideline.
Other specific interventions such as splinting or strapping with known diagnoses will occur following discussion with the medical team.
If a child who has been seen by the developmental therapists, requires an outpatient referral to Newborn Services Community Child Development Services, the developmental therapists will liaise with the appropriate agency and will complete the appropriate referral.
Sensory Pathway Development
- Neuromuscular immaturity, weak muscle tone and the effects of gravity on the preterm infant can lead to positioning disorders such as widely abducted hips (frog-leg position),retracted and abducted shoulders, increased trunk extension with arching of back and ankle and foot eversion.26
- These complications may lead to difficulties with normal development of body movement and control in childhood.
- Persistent or favoured positions can lead to a flattened posture and right head preference and occipital plagiocephaly (flattened head).20
- Postural support should therefore be considered to reduce postural complications as well as for promoting physiologic / autonomic stability.
- Research promotes the use of a variety of positions for preterm infants.
- Prone positioning in some infants may enhance oxygenation and promote quiet sleep.
- Side-lying positioning, with the back well supported in a nest, provides opportunities for limb and trunk flexion and hand to mouth contact.
- The less favoured position is the supine position that requires 'nesting' with close but flexible boundaries around the infant's body.
- A soft blanket rolled into a nest encourages flexion of lower limbs, brings shoulders forward and offers containment boundaries.6
Noise Levels in NICU
The American Academy of Pediatrics recommends that noise levels not exceed 40-45 dB in NICU. <35 dB is desired for sleep.
Examples of Recorded Noise Levels in NICU
|Telephone ringing||80 db|
|Dash Alarms (set at 70%)||70 dB at 1 metre distance|
|Closing incubators doors||100-135 dB|
|Bubbling in ventilator circuit||62-87dB|
|Tapping incubator with fingers||80 dB|
|Talking around the bedside (normal level)||60 dB|
(From M. Darin Cass Medical, and Kenner & Lott, 2003)
- The value of music therapy for the preterm infant is yet to be clearly determined with research methods and findings contradictory.
- Concern is voiced around offering sound stimulation without evaluating the appropriate levels of music or the developmental stage of the preterm infant receiving the stimulation.
- Also from a behavioural perspective, where preterm infant states vary, continuous playing of music therapy may offer stimulation when the infant requires sleep.12
- Als, H.(1986). A synactive model of neonatal behavioural development: a framework for assessment of neurobehavioral development in the premature infant and for support of infants and parents in the neonatal intensive care environment. Physical and occupational therapy in pediatrics,6,(3-4),3-53
- Taquino, L.T. & Lockeridge, T.(1999).Caring for Critically Ill Infants: Strategies to Promote Physiologic Stability and Improve Developmental Outcomes
- Turner, A., & Santangelo, S. Developmental and Behavioral Characteristics of the preterm infants. Santa Rosa: NICU INK.
- Peters, K.L.(1999). Infant Handling in the NICU: Does Developmental Care Make a Difference? An Evaluative Review of the Literature. Journal of Perinatal Nursing,13(3) 83-109
- Hinkler, P.K. & Moreno, L. A. Developmentally Supportive Care. Theory Application - A self study guide module. Childrens Medical Venture.
- Reid, T & Freer, Y. (2001). Developmentally Focused Nursing Care. In G. Boxwell. Neonatal Intensive Care Nursing (pp.14-44).London: Routledge.
- Short, M.A., Brooks-Brunn, J. A., Reeves, D. S., Yeager, J. & Thorpe, J. A. (1996). The Effects of Swaddling Versus Standard Positioning on Neuromuscular Development in Very Low Birth Weight Infants. Neonatal Network, 15,(4) 25-31.
- Ludington-Hoe, S., Ferreira, C., Swinth, J & Ceccardi, J.(2003). Safe criteria and procedure for kangaroo care with intubated infants. JOGNN, 32, 579-588.
- Oehler, J.M.(1993) Developmental Care of the Low Birth Weight Infants. Nursing Clinics of North America, 28, (2), 289-301.
- Fielder, A.R., & Moseley, M. J. (2000). Environmental Light and the Preterm Infant Seminars in Perinatology, 24 (4), 291-298.
- Moore K.L. & Persuad, T.V. N. (1998) The Developing Human. Philadelphia: Saunders.
- Kenner, C. & Wright Lott, J. (2003). Comprehensive Neonatal Nursing (3rd ed.). Philadelphia: Saunders.
- Gewolb, I., Vice, H., Frank L., Schweitzer-Kenney, E. L., Taciak, V. L, Bosma L.& James F.( 2001). Developmental patterns of rhythmic suck and swallow in preterm infants. Developmental Medicine & Child Neurology 43:22-27.
- Wolf, L. S.& Glass, R.(1992). Feeding and Swallowing Disorders in Infancy. Therapy Skill Builders:San Antonio
- Oetter, P., Richter E. W., Frick, & Sheila, M.(1995). M.O.R.E. Integrating the Mouth with Sensory and Postural Functions. (2nd ed.)Hugo, Minnesota: PDP Press.
- Brandon, D. H., Holditch-Davis, D. & Belyea, M. (2002). Preterm infants born at less than 31 weeks gestation have improved growth in cycled light compared with continuous near darkness. Journal of Pediatrics, Feb, 192-199.
- Mirmiran, M., & Ariagno, R. L. (2000). Influence of Light in NICU on the 'Development of Circadian Rhythms in Preterm Infants. Seminars in Perinatology, 24, (4), 247-257.
- Glass, P. (1999). The Vulnerable Neonate and the Neonatal Intensive Care Environment. In G. Avery, M. A. Fletcher & M. MacDonald (5th ed.). Neonatology Pathophysiology and Management of the Newborn (pp.91-108). Philadephia: Lippincott Williams & Wilkins.
- Pinelli, J. & Symington A.(2002). Non-nutritive sucking for promoting physiologic stability and nutrition in preterm infants. The Cochrane Library 4:54.
- Duber, K. & Flake, M. (2003). Occipital flattening of positional origin. Canadian Nurse, 99, (1) 16-21.
- World Health Organisation (2003). Kangaroo mother care: a practical guide.
- Altimer, L. B. (2003). Management of the NICU Environment. In C. Kenner & J Wright Lott (3rd ed.). Comprehensive Neonatal Nursing, (pp.229-237). Philadelphia: Saunders.
- Pinelli, J. & Symington, A.( 2000). How Rewarding Can a Pacifier Be? A Systematic Review of Nonnutritive Sucking in Preterm Infants. Neonatal Network, 19,(8):41-48
- American Academy of Paediatrics. (1997). Noise: A Hazard for the Fetus and Newborn.-Policy Statement. Pediatrics,. 100, (4),1-9
- Cattaneo,A., Davanzo,R., Uxa, F., & Tamburlini,G. (1998) Recommendations for the implementation of Kangaroo Care for low birth weight infants. Acta Paediatr, 87, (4),440-445.
- Monterosso, L., Kristjanson, L., & Cole, J. (2002).Neurodevelopment and the Physiologic Effects of Positioning in Very Low Birth Weight Infants. JOGNN, 31 ,(2), 138-146.
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- Date last published: 31 December 2004
- Document type: Clinical Guideline
- Services responsible: Neonatology
- Owner: Newborn Services Clinical Practice Committee
- Editor: Sarah Bellhouse
- Review frequency: 2 years
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