Developmental Care EChO conference May 2014 Jo French RN NICU WCH - - PowerPoint PPT Presentation

Developmental Care

EChO conference May 2014 Jo French RN NICU WCH

Neurological Development

´ Central nervous system and brain development begins in the first weeks post conception

Central Nervous System at a cellular level

Science: cortisol

— Cortisol released from a stressed mother influences fetal development causing the adrenal glands to grow rapidly and potentially influence brain development from only 7 weeks gestation. — Placental enzymes act to protect the infant from maternal stress and cortisol release — In some conditions (PE, infection) this enzyme is ineffective so the infant is not protected from the cortisol — Developmental programming is affected in these circumstances and the nature of this is sex, timing and tissue dependent — Premature infants cannot modulate cortisol release ex-utero this leads to a lack of stress responses in Low GA infants which becomes genetically programmed and persists through life — Cortisol is important in memory and learning — Cortisol is released during sleep therefore sleep consolidates learning and memory

´ Neurotrophic factors (BDNF)derived from the brain are critical in facilitating cortical development and neuroplasticity ´ In prems BDNF is low and dependent on gestation this leads to the decreased neuroplasticity that evidence shows is still present in 13yrs

• ld exprems

´ lower gestation = lower BDNF ´ Ante natal corticosteriods increase BDNF in prems therefore it is potentially protective but currently unsure of the mechanics behind this

Science: BDNF

Categories of stress (Shonkoff 2011)

— Positive stress – short lived and an important part of normal development, improves regulation and coping skills, facilitates good growth, is relieved by responsive carers in a supportive environment — Tolerable stress – time limited and reduced by positive relationships with adult as buffer, develops resilience maintain good growth — Toxic stress – high levels over a long period of time contributes to mental health problems, dysfunctional family, absence of responsive care givers to buffer the stress and promotes intergenerational abuse and poor regulation, social functioning and cognition

´ To cope in an adverse environment the fetus ‘adapts’ to ensure survival – Darwinian theory ´ Male infants are less successful at this ´ The adaptation creates a risk of marked structural and functional consequences in neurodevelopment ´ Mismatched adaptation leads to long term health issues that continue into adulthood

Epigenetics: studies how an adverse environment changes the way genetic material is expressed

Infants in a high stress environment have;

´ decreased brain size ´ altered brain structure ´ reduced connectivity ´ abnormal motor and reflex development Think about the implications for premature infants, ante natal care, post natal depression, socioeconomic factors of parents, post natal and early childhood environments

´ Prematurity ´ Home environment ´ Neonatal treatment ´ Adverse intrauterine environment(infection, stress, PE – difficult to differentiate causes)

Potential risk factors for altering developmental trajectories through impacting normal brain development;

definitions

´ Sensory: perception of stimuli either external, internal or proprioreceptors ´ Motor: response to interpretation of stimuli – always occur secondary to sensory input ´ All reactions occur as a result of sensory stimulation ´ Well integrated sensory motor skills provide adaptive responses that regulate the infant or child’s environment and thus their learning and journey to self actualisation ´ Self actualisation is participating in the world and interactions with others with a minimum of defensive actions and maximum of activation, a minimum of idiosyncratic distortion and maximum of joint validation

Sensory Development

Visual

(weeks 32 to 36)

Auditory

(weeks 24 to 32)

Chemosensory

(weeks 20 to 24)

Vestibular

(weeks 16 to 20)

Somatesthetic (weeks 12 to 16)

´ Posture, movement, tone, pain, tactile ´ Important in neuro behavioural organisation such as self soothing and state regulation ´ Activity dependant formation of pathways in brain – “use it or lose it” ´ Macroenvironment and microenvironments contribute to noxious load that interfere with optimal development ´ Unsupported positions leave infants physiologically unstable ´ Important skills for motor development, play and social attachment

Somasethetic System

´ Dynamic boundaries ´ Active movement occurs in a predictable and consistent environment ´ Forceful extension is counteracted with passive return to flexion ´ Resting is flexed ´ No gravity ´ Position is midline orientated not rotated ´ Last trimester rapid organisation and specialisation of CNS occurs forming vital pathways

Somasethetic stimulation in utero

´ Enhances behaviour state, in particular sleep ´ Functions in conjunction with proprioreceptive input, vestibular stimulation from inner ear and optical stimulation ´ To work properly relies upon appropriate input that influences specific neuronal connection that lead to normal development ´ Important for balance, posture and to cope with other sensory stimulation

Vestibular System

´ Early experience is dictated by both infant and mother ´ Periodic oscillation and movement in a fluid filled space that becomes more restrictive ´ Vestibular experiences towards birth are slower ´ Behaviour state is modified through positioning, (rocking, walking, upright)

Vestibular stimulation in utero

´ Senses of smell and taste well developed ´ Strong evidence that demonstrate infants preference for maternal smells and tastes promote better oxygenation and increased mouthing and ability to self soothe ´ Exposure to biologically meaningful odour and taste are pleasurable to the infants potentially offsetting the noxious sensations of the nursery

Chemosensory Systems

´ Taste receptors are functional from 16wks gestation, babies react strongly to odour from 28wks ´ Amniotic fluid tastes and smells of the mothers diet and breast milk therefore is a source of comfort ´ Suck and swallow is practiced and coordinated ´ The fluid environment enhances smells

Chemosensory stimulation in utero

´ Physiological response to auditory stimulation are seen at 23 wks gestation; desaturation, tachycardia, apnoea and disorganised behavioural states ´ Early experiences with sounds shape higher brain functions including emotions, language and other cognitive abilities distractable, hyperactive, hyper or hypo sensitive to sensory integrated information as is linked strongly with vestibular ´ Period of greatest sensitivity to noise damage is from 24 wks gestation to 4months of age

Auditory system

´ Protective from excessive noises ´ Bone conduction rather than air conduction ´ associated with other sensory responses to give better meaning and adaption ´ Sounds are mostly speech and culturally relevant to the infant and family ´ Reponses to noise: increased ICP at 80dB, disturbed sleep state at 55dB(light) 75dB(deep). NICU 50-90dB

Auditory stimulation in utero

´ Primitive at time of birth cannot focus or make out detail fully developed by 1 year of age ´ Provides recognition, investigation, and learning discrimination ´ Works with vestibular and auditory systems to enable visual motor coordination, visual spatial recognition, visual memory, involved in higher cognitive functioning

Visual System

´ Minimal ´ Possible times of decreased darkness during the day may influence circadian rhythms ´ Significant maturation of the visual cortex occurs in later months of gestation ´ Bright lights are irritating to developing system resulting in visual motor disturbances retinal injury no requirement for sudden pupil constriction ´ No supplemental visual stimulation

Visual stimulation in utero

Sensory integration

´ Complex combination of sensory input from somatic and motor systems in the cortex of the brain ´ Sense of touch and our early experiences determine the extent of tactile sensitivity ´ Touch establishes identity and security in an environment ´ Touch is the largest sensory system and plays a vital role in both physical and mental wellbeing ´ Touch that elicits negative or abnormal responses unbalances the nervous system ´ Moving, talking and play lay the groundwork for more complex reading, writing and behaviour(executive functioning skills)

Sensory organisation

´ Sensory development occurs in a natural and sequential order ´ Threshold from integration to disorganisation can be passed if sensory stimulation is not developmentally appropriate ´ If sensory input exceeds infants ability to respond they become over stimulated ´ Sensitive caregiver is required to intervene and become the buffer for the regulatory systems resetting neural and behavioural organisation ´ 2 forms of self regulation or antagonists of behaviour; exploratory (learning testing theories) or defensive (avoiding) visible in circle of security theory

Evidence of possible sensory integration dysfunction

´ Defensive behaviour around touch ´ Difficulty establishing sleep and eating patterns ´ Overreacting to environmental stimuli poor ability to calm or console self ´ Defensive around unstable surfaces, motion sickness ´ Delayed motor skill development ´ Disorganized motor state, irritable ´ Poor motor planning skills, clumsy, uncoordinated ´ Difficulty articulating ideas ´ Fussy with textures and tastes of food, dysphagia ´ Reactive to smells ´ Poor attention span, hyperactive, uninhibited, hyper-vigilant ´ visual spatial relationships, visual motor co-ordination, visual memory

´ Premature infants are “at risk”for: ´ Learning disabilities ´ Motor delay ´ Visual-motor deficits ´ Mild to severe cognitive disability ´ Behavioural and social problems ´ Language impairment

What we know

Regulation

´ Physical, neurological, behavioural and emotional ´ Early physical regulation sets stage for later cognitive and emotional development ´ Early regulation establishes templates for later functioning and ability to develop relationships

´ Sleep cycles begin 26 to 28wks gestation ´ Sleep deprivation has a profound effect on sensory development ´ REM sleep is critical in sensory development ´ NREM sleep divided into 4stages drowsy, light deep, slow ´ Sleep cycles are vital in protection brain plasticity through BDNF

Sleep

´ Sensory development ´ Circadian rhythms and alert states ´ Motor development ´ Relationships and attachment ´ Infants seek species specific interactions demonstrating a preference for human facial expressions

Early regulation begins and is continuous from ante natal to post natal

´ Bio directional responses of infant/mother regulation(temp, perfusion, sensory, nutritional ,physical, social, emotional) ´ These are supporting regulators that promote regulatory processes through relationships with the mother – natural neuro protection ´ This facilitates the infant developing the skills to master tasks, signal needs (this needs a responsive adult to work) and develop capacity to manage physical and emotional stability and keep attention and focus ´ Infants actively elicit emotional and cognitive support and input from their environment that initiates and continues their own behavioural differentiation and organization

Effective communicator

´ m/other mostly supportive of regulatory capacity in early life and becomes less so as development occurs

development

Regulation model

m/other self

Infants who cannot regulate

´ Sleeping ´ Eating ´ Crying Have poor developmental outcomes poor regulation = poor development

The Competent Infant

´ Infants are actively protecting their development through their social interactions and behaviour ´ In relationships infants regulate their environment to maintain homeostasis which protects development ´ Infants are socially competent and an active partner in the feedback system with a responsive caregiver ´ Seeking physiological, motor, state(emotional) and attention and interaction sensory organisation to ensure self actualisation ´ Reach full potential, fulfil quest for knowledge and contribute to society

Effective care environments

´ Protect sleep ´ Assess stress ´ Support families ´ Provide a healing/protective environment

´ What are our goals? ´ What does quality developmental care look like? ´ What is developmental care-giving? ´ How do we know if we are successful?

´ zerotothree.org ´ developingchild.harvard.edu/

Developmental care: Important considerations