Background

Mortality 
Technologic
advances in
neonatal care
Survival rate 

Poor
developmental Morbidity
outcome remain high
Developmental outcome of preterm infants

• Mental retardation, sensorineural

VandenBerg deafness, blindness, cerebral palsy,&
KA. Early epilepsy  25% VLBW
Hum Dev.
2007; 83: • Learning disabilities, lower IQ, ADHD,
433-442 visual-motor impairment, behavioural
problems, speech delay  50–70%
VLBW
0 Preterm  at risk of developmental
outcome due to :
0 Their immature & inadequate
organizational system
0 Being early in the hostile extra-uterine
environment
Brain growth & development

Westrup B. Early Hum Dev. 2007; 83: 443-449

 Impact of preterm birth on
brain development

Stressfull Experiences
Intra-uterine:
in NICU
Rapid developing
brain in the last • Brain
• Cell migration development
trimester • Synaptogenesis alteration
• Myelination
Preterm birth • Organization
Long term
outcome
0 Preterm infants are fetuses, who develop
in extra-uterine settings at a time when
their brains are growing more rapidly
than at any other time throughout their
life span

0 Type of disability as the long term

developmental outcome  a desease of
neuronal connectivity (McGrath JM, Newborn Infant
Nurse Rev. 2011)
 Causes for the alteration
in brain development

Early & Prolonged exposure

0 Stress
0 Pain
0 discomfort
Reduced white matter
& subcortical grey
matter maturation
Brain network &
sensory impairment
Brummelte S, et al. Ann Neurol. 2012.
 Poor
developmental
outcome

shifted on
focus of care

Lowering mortality Improving outcome

Intra-uterine life
Positif sensory
input for
developing brain

Physiological flexion, with

circumferential boundaries
Dimp light
Muffled sounds from extra-uterine
Body contact with warm amniotic fluid
Regular sleep cycles
Unlimited access to mother
(somatosensory,
auditory, chemosensory )
Ekstra-uterin

 Procedure & activities

 Constant noise
 Constant light
 Separate from mother

Negative sensory input

for developing brain
 What can we do to improve outcomes of
the premies?
0 Neuroprotective care strategies &
neurodevelopmental support
 Brain-oriented care  Developmental care

- All interventions promote normal development of

the brain
- Prevent disabilities after neuronal injury
- Allow the brain to heal itself by developing new
pathways & connections (adaptive neuronal
connectivity)

(McGrath JM, Newborn Infant Nurse Rev. 2011)

 Developmental Care
0 Introduced in the early1980’s
0 A group of interventions designed
to modify the NICU environment 
minimize the stress

0 Decreasing external stimuli

0 Clustering nursing care activities
0 Imitate the intrauterine experience
0 Support the relationships between
the newborn & parents
Sources of stress & intervention strategies

• Light
• Noise
Makro • Smell
• Activity

• Positioning
• Containment
Mikro • Handling
• Tactile & kinestetik (touch)
 Light

Reduce light Dimming of lights or covering the

incubator or cribs
 Noise Equipment, alarms, ceiling & flooring
material, communication devices &
talking
Auditory intervention strategies
 Recommended noise level : <45 dB
(AAP)
 Fasilitated “quiet time” every day
 Not taking a shift report over, or
allowing medical rounds near the
infant’s incubator
 Minimizing equipment noise
 No tapping or banging on the
incubator
 Turn off the radio/tape
Positioning
Imitate the intrauterine
experience

(nest/boundary)  in
utero the infant is Self regulatory 
confined to enclosed space Energy saving
Physiologic flexion
  allowing for flexion & hand-
Side-lying mouth contact  self comfort &
self-regulation
 Risk of Intra-cranial pressure ↓
Prone
 NOT RECOMENDED
Supine

Avoid neck flexion & hyperextension

 airway obstruction
Head position at midline
 Activities & handling

Taktil / kinestetik ± 200x/hr

Overstimulation
Always interrupted

Procedure Hypoxia, apneu, heart rate &

(medical, blood pressure instability
nursing) In appropriate rest time
Activities & handling

INTERVENTION ??

Cue based-care
Talk to the baby

Gentle touch  decrease pain,

↑self-regulation
Identify the stress & pain  Behavioral cues
....behavioral cues
 ….Activities & handling
INTERVENTION STRATEGIES ??

During routine or medical Swaddling

procedure Hold the finger
Bring the hands to the
Body Containment midline
Cupping

Non-nutritive sucking Pacifier (empeng)

Sukrosa
Analgetic
Medication
Sedative
BODY CONTAINMENT Static positive touch

Cupping (head , buttock)

 Hold the finger Bring the hands to the
midline

Swaddling Non-nutritive sucking

Skin to skin contact (Kangaroo Care)
 Most care can be provided in the
kangaroo position
Change Give
Insert Insert
i.v. infusion i.v. injection
i.v. cannula feeding tube

Suctioning: Take
Endotracheal temperature
tube, nasal

Chest Reposition
auscultation pulse oximeter,
Tc monitor

Insert endo-
tracheal tube Change
diaper
Head CPAP Ventilator Draw
ultrasound treatment treatment blood sample
DEVELOPMENTAL CARE ???

0 Protection strategies of the developing

brain to improving developmental
outcome in preterm infants