Introduction

• This presentation is being provided as an example of a

staff education module.
• The material on the slide may act as a guide but is not
prescriptive. It should be adapted to your own site
using your own materials.
• The narrative on the slide notes is a guide to help guide
your own presentation.

Development and Developmental Care

 Development and Developmental Care
Supporting neonatal outcomes

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 Dreams…shattered

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 YES, we can “get” there!
One family Stats:

18 months of Breastfeeding

66 rounds presented by Mom/

Dad

372 hours of skin-to-skin by

Mom & Dad

Education, education,
education
Sending home a happy healthy family … Priceless!
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 Objectives
The importance of an environment that supports:

– neuroprotective developmental care

– appropriate positioning and handling to promote

development

– neurobehavioral stability that supports neurologic

systems

– the decrease of iatrogenic consequences

Development and Developmental Care

 Impact of prematurity

• Autonomic system is
underdeveloped
• 2 known causes for
alteration in brain
development: stress &
pain
• Fearful and vulnerable
• Sleep deprivation
• Ability to self-regulate
severely diminished

Development and Developmental Care

 High risk for a variety of problems

 musculoskeletal
development,
flexor/extensor
abnormalities
 oral aversion, skin
sensitivity (pain)
 cognitive defects
 poor academic
achievement &
behavioral disorders
 psychiatric disorders
 parenting challenges
Development and Developmental Care
 Neuro-protective developmental care

Creates an
environment that
manages the infant’s
stress and pain while
offering a calming and
soothing approach that
keeps the whole family
involved in the infant’s
care and development

Development and Developmental Care

Development and Developmental Care
Health professionals & parents working
together

Healing Environment, Partnering with Families, Positioning &

Handling, Safeguarding Sleep, Decreasing Pain & Stress,
Protecting Skin, Optimizing Nutrition
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 NICU GOAL:

…..through the dark I could be Gabriel’s

mom, I was taught touch, the feeling, the
interaction, and how all that became
Gabriel's “best medicine”

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 to help learners connect
with the baby’s experience

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 What do YOU see in the picture in your role as a nurse?
What do PARENTS see in the picture?

Development and Developmental Care

 What do YOU see in the picture in your role as a nurse?
What do PARENTS see in the picture?

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Development and Developmental Care
Development and Developmental Care
 Normal fetal development

• Musculoskeletal system develops

– In a gravity-free buoyant environment
– With freedom to move and receive developmentally
appropriate stimulation, (tactile, vestibular,
auditory and visual sensory stimulation)

• Provides positive sensory input for brain

development

Development and Developmental Care

 Full-term infant
• 3rd trimester
• neural connections
reinforced, emphasizes
flexion & midline
orientation as a normal
baseline- uterine wall
provides secure boundaries

• At birth
– Early motor control for
ongoing development

Development and Developmental Care

 Preterm infant
• Incomplete
development of muscle
tissue, joint structures,
bone density
• Muscle tone hypotonic
• Limbs abducted,
externally rotated, lie
flat in a frog leg
position
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• Spontaneous resting
position flat, extended,
asymmetrical, head to
one side (usually right)
• Difficult to maintain
flexed position, cannot
alter position for pain &
discomfort
• Lack internal or
mechanical motor
control, increased
episodes of startle,
twitches
 Preterm infant
Early neurosensory development
impacted
NOT a gravity-free & buoyant
environment
NOT a positive intrauterine environment,
(position, touch, sound, comfort and
light)
Can impact developing brain

Development and Developmental Care

 The preterm infant
• Added to the problem
– illness, energy depletion, gravity & weight of
medical lines

• Over time, active extension, arching and

asymmetry become dominant

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 Preterm infant/full-term infant

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 GOAL: 520 grams infant @ term versus
term infant at birth

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 Term-corrected

4 months corrected

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 4 months corrected

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 Expectations at 4 months-corrected
• Development of head control
– Head turns both ways (no flat head)
• Focus and follow with both eyes
• Equal movement of limbs, clasping of hands, hands to
mouth
• Early eye-hand coordination
• reach and grasp
• In prone pushes up on arms, preparing to roll
• Attends to voice, watches & begins to imitate some
sounds, laughs

Development and Developmental Care

 To optimize neuro-protective care
in the NICU
• Provide appropriate positioning/handling to
• Support infants’ state regulation
• Decrease sensory overload
• Reduce physiologic distress, reduce disorganization
• Promote development
• Therefore
• Provide care-giving slowly and confidently
• Introduce one stimulus at a time
• Allow infant to set pace, withdraw stimulus if over
stimulated & provide hands on containment
• Reinstate baseline environmental supports after any
procedure & flex the infant

Development and Developmental Care

 Position & handle in flexion, containment
& alignment
• During all care taking activities, ensure
midline, tucked position
• Bathing, weighing, feeding
• Diaper changes/temperature taking, mouth care, girth
measurement

• Avoid hyperextension of neck & shoulder

retraction
• During procedures, blood tests, lumbar puncture
• Attaching back to cpap, etc.
• Feeding, sleeping, holding

Development and Developmental Care

 Communicating

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Development and Developmental Care
Development and Developmental Care
 Handling

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 Promote development & enhance comfort
(self-regulation)

REMEMBER: Preemie flip, extremely stressful

– Supportive turning and lifting
– Facilitate smooth movement against gravity
– Avoid torque/tension from medical lines

Development and Developmental Care

 If this was a uterus, the
legs would have pushed
through the wall!

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 Should not be constrained
but lie in a flexible nest
that encourages a return
to postural flexion, as in
the uterus

Boundaries should promote

development, i.e. shoulders
forward, not in extension

Development and Developmental Care

 Allow for normal, not
stressed movement.
Should not be
constrained but occurs
in a flexible nest that
encourages a return to
postural flexion, as in
the uterus

Development and Developmental Care

 Avoid “frog-legged” position

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 Bathing

has been described in the

literature as an extremely
stressful form of stimulation
for a preterm infant due to:

• extra energy expenditure

• change in temperature
• abnormal positioning

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 Swaddle bathing

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 Educating/supporting parents

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 Teaching parents

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 Self-soothing

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 shoulders rounded, hands to
mouth/face, head in midline, slightly
flexed

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Development and Developmental Care
 Play

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 Back to sleep, prone for play

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 All positions (if no medical lines), shoulders rounded,
hands to mouth/face, head in midline, slightly flexed

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 Feeding

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 Principles of positioning promote development,
postural security, self-regulation, energy
conservation

• Encourage flexed position

• Place head in midline, slight flexion
• Support shoulders so they are forward
• Encourage hands together and near mouth
• Flex hips and knees (not frog–leg)
• Encourage midline orientation & symmetry, equal
• Use of both arms/legs, opportunity for head to be
in many positions
• Provide boundaries (rolls), until 36 weeks gest. (or
before)
• Allow to lie and be held in different positions

Development and Developmental Care

 Achieving our goals

• Communication challenges
– Lack of consistency between
staff and parents
– Avoid when difficult
– Shift change
• Must reflect a partnership
– Convey reassurance and support
– Parent the most consistent
caregiver

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Development and Developmental Care
 Consequence of asymmetry

Ignoring one side of the body

Flat misshapen head, Positional Plagiocephaly,
Decreased use of the opposite side

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 Consequence of asymmetry:
torticollis

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 “Hope”
24 weeks, 680 grams

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 Development at its best!
“Sophie”
26 weeks, 510 grams

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 “It’s like landing on a cushion before you know you are
falling”

Mount Sinai, NICU Dad

Development and Developmental Care

 Infant positioning assessment tool
Coughlin Mary RN/MS, Lohman Mary Beth OTR/BCP and
Gibbins Sharyn RN/PhD.
Reliability and Effectiveness of an Infant Positioning
Assessment Tool to Standardize Developmentally
Supportive Positioning Practices in the Neonatal
Intensive Care Unit. Newborn and Infant Nursing Reviews.
2010. 10(2): 104-106.

Development and Developmental Care

 References
• Liu WF, Laudert S, Perkins B, MacMillan-York E, Martin S and
Graven S. The development of potentially better practices to
support the neurodevelopment of infants in the NICU. Journal of
Perinatology. 2007. 27: S48-S74.
• Laudert S, Liu WF, Blackington S, Perkins B, Martin S, MacMillan-
York E, Graven S and Handyside J. Implementing potentially
better practices to support the neurodevelopment of infants in
the NICU. Journal of Perinatology. 2007. 27: S75-S93.
• Milgrom Jeannette, Newnham Carol, Anderson Peter J, Doyle Lex
W, Gemmill Alan W, Lee Katherine, Hunt Rod W, Bear Merilyn and
Inder Terrie. Early Sensitivity Training for Parents of Preterm
Infants: Impact on the Developing Brain. PEDIATRIC RESEARCH.
2010. 67(3): 330-335.
• Gibbins Sharyn RN/PhD, Hoath Steven B MD, Coughlin Mary
RN/MS, Gibbins Alan and Franck Linda RN/PhD. The Universe of
Developmental Care: A New Conceptual Model for Application in
the Neonatal Intensive Care Unit. Foundations in Newborn Care.
2008. 8(3): 141-147.

Development and Developmental Care

 References

• Coughlin Mary, Gibbins Sharyn and Hoath Steven. Core measures

for developmentally supportive care in neonatal intensive care
units: theory, precedence and practice. Journal of Advanced
Nursing. 2009. 65(10): 2239-2248.
• Oberg Gunn Kristin, Campbell Suzann K, Girolami Gay L, Ustad
Tordis, Jorgensen Lone and Kaaresen. Study protocol: an early
intervention program to improve motor outcome in preterm
infants: a randomized controlled trial and a qualitative study of
physiotherapy performance and parental experiences. BMC
Pediatrics. 2012. 12(15): 1-9.
• Watson Anne BS/PhD/BSN/RN. Understanding Neurodevelopment
Outcomes of Prematurity: Education Priorities for NICU Parents.
The Long Road Home. 2010. 10(4): 188-193.

Development and Developmental Care

 References

• Montirosso Rosario PsyD, Del Prete Alberto MD, Bellu Roberto

MD, Tronick Ed PhD and Borgatti Renato MD. Level of NICU
Qualtiy of Developmental Care and Neurobehavioral Performance
in Very Preterm Infants. PEDIATRICS. 2012. 129(5): e1129-e1137.
• Bracht Marianne RN/RSCN, O’Leary Lori MEd, Lee Shoo K
MBBS/FRCPC/PhD and O’Brien Karel MB/BCh/BAO/FRCPC/MSc.
Implementing Family-Integrated Care in the NICU: A Parent
Education and Support Program. The Long Road Home. 2013.
13(2): 115-126.
• Jeanson Elizabeth PT DPT. One-to-One Bedside Nurse Education
as a Means to Improve Positioning Consistency. Newborn and
Infant Nursing Reviews. 2013. 13: 27-30.

Development and Developmental Care

 References

• Altimier Leslie RN/MSN/DNPc/NEA-BC and Phillips Raylene M

MD/MA/IBCLC/FAAP. The Neonatal Integrative Developmental Care
Model: Seven Neuroprotective Core Measures for Family-Centered
Developmental Care. Newborn and Infant Nursing Reviews. 2013.
13: 9-22.
• McGrath Jacqueline M PhD/RN/FNAP/FAAN, Lussier Mary M
BSN/RN/IBCLC and Briere Carrie-Ellen BSN/RN/CLC. Bottlefeeding
the Breastfed Infant in the Neonatal Intensive Care Unit. Newborn
and Infant Nursing Reviews. 2013. 13: 5-6.
• Quraishy Karyn MSPT/CEMI/CST, Bowles Susan M DNP/RNC-NIC and
Moore James PhD/PT/PCS. A Protocol for Swaddled Bathing in the
Neonatal Intensive Care Unit. Newborn and Infant Nursing Review.
2013. 13: 48-50.

Development and Developmental Care

 References
• Coughlin Mary RN/MS, Lohman Mary Beth OTR/BCP and Gibbins
Sharyn RN/PhD. Reliability and Effectiveness of an Infant
Positioning Assessment Tool to Standardize Developmentally
Supportive Positioning Practices in the Neonatal Intensive Care
Unit. Newborn and Infant Nursing Reviews. 2010. 10(2): 104-106.
• Sweeney Jane K PT/PhD/PCS and Gutierrez Teresa PT/MS/PCS.
Musculoskeletal Implications of Preterm Infant Positioning in the
NICU. Journal of Perinatal and Neonatal Nursing. 2002. 16(1): 58-
70.
• Vaivre-Douret Laurence PhD/OTR and Golse Bernard MD/PhD.
Comparative Effects of 2 Positional Supports on Neurobehavioral
and Postural Development in Preterm Neonates. Journal of
Perinatal and Neonatal Nursing. 2007. 21(4): 323-330.

Development and Developmental Care

 References

• Hill Sharon MA/PT, Engle Sandra MPT, Jorgensen Jeremiah MPT,

Kralik Ann MPT and Whitman Kari MPT. Effects of Facilitated
Tucking During Routine Care of Infants Born Preterm. Pediatric
Physical Therapy. 2005. 17: 158-163.
• McMahon Susan E PT/DPT/PCS. Enhancing Motor Development in
Infants and Toddlers: A Multidisciplinary Process for Creating
Parent Education Materials. Newborn and Infant Nursing Reviews.
2013. 13: 35-41.
• Hendricks-Munoz Karen DMD/MPH/FAAP, Prendergast Carol C EdD,
Caprio Martha C MD and Wasserman Randi S MD. Developmental
Care: The Impact of Wee Care Developmental Care Training on
Short-tern Infant Outcome and Hospital Costs. Newborn and Infant
Nursing Reviews. 2(1): 39-45.
• Aucott Susan, Donohue Pamela K, Atkins Eileen and Allen Marilee
C. Neurodevelopmental Care in the NICU. Mental Retardation and
Developmental Disabilities Research Reviews. 2002. 8: 298-308.

Development and Developmental Care