EARLY STIMULATION.pptx

newborn early stimulation till 6 months.. high risk babies stimulation

1. DEVELOPMENTAL SUPPORTIVE CARE Dr.Pramitha , IAP fellow 22-23, CDC, Kerala

2. “The genes are the bricks & mortar to build a brain. The environment is the architect” Christine Hohmann Neuroscientist

3. DEFINITION Developmentally supportive care is defined as care of an infant to support positive growth and development, while allowing stabilization of physiologic and behavioral functioning.

4. Who needs DSC? All preterms All fragile terms

5. Principles key principles of developmentally supportive care (DSC) Development-supportive environment ( simulates in utero ) Family-centered care Individualized care.

6. GOALS Maximize rest, Minimize stress, Optimize healing and growth Family participation

7. ASSESSMENT OF STRESS AND SELF-REGULATORY BEHAVIORS Stress responses - A baseline profile of an infant’s stress responses to various stimuli are assessed in the domains of autonomic, motor, state organization, and attention/interaction signs. 1. Autonomic signs - changes in color, heart rate, and respiratory patterns, as well as visceral changes such as gagging, hiccups, vomiting, and stooling. 2. Motor signs - facial grimacing, gaping mouth, twitching, hyperextension of limbs, finger splaying, back arching, flailing, and generalized hypertonia or hypotonia. 3. State alterations - diffuse sleep states, irritability, and lethargy. 4. Changes in attention or interaction - closing or blinking eyes, gaze aversion, frowning, and hyperalert or panicky facial presentation.

8. Self-regulating behavior . Preterm infants employ a number of self-consoling behaviors to cope with stress including – Hand or foot bracing; Sucking; Bringing the hands to the face; Flexed positioning; Cooing; and Grasping of linens, tubing, or own body parts

9. Components of DSC 1. Developmentally supportive activities of daily living (ADL) 2. Healing environment 3. Protected sleep 4. Pain protection 5. Family-centered care 6. Infant follow up and early Intervention programs

10. ADL Important for the infant’s growth, development, hygiene, and general well-being. These activities include 1. Dressing and undressing, 2. Diaper change, 3. Sponging, 4. Massage and skin care, 5. Non-nutritive sucking (NNS), and feeding. Involve and encourage parents and extended family members to actively participate

11. Non-nutritive Sucking • Different from nutritive sucking • On empty breast / pacifier • Provides comfort • Promotes physiological organization • Pain-reducing effect • Promotes suck- swallow co-ordination • Facilitates transition to breast feeding • Better weight gain & shorter hospital stay.

12. Massage Therapy •Tactile / Kinesthetic stimulation •Tactile stimulation only, may be aversive. •Massage therapy with moderate pressure is useful. •Stimulation of tactile , pressure and proprioceptor receptors important.

13. Hypothetical mechanisms of benefit – Touch /light pressure and warmth oxytocinergic system activation (calm) Increased vagal tone and reduced stress system Increased insulin levels Increased growth hormone secretion

14. Massage Therapy Proposed benefits : Better weight gain • More time in active, alert state • More quiet sleep • Better motor maturity scores • ?Better long-term outcome

15. ENVIRONMENT

16. HOW MANY SENSE DO WE ALL HAVE ?

17. The virtues of the Womb • Cushioned and comfortable aquatic abode • Thermal comfort • Zero insensible water losses • Shielded from light • Protected form sound ( in utero 40 – 50 db ) • Effective and safe ECMO-like oxygenation • Optimal excretion of waste products • Isolation and asepsis • Parenteral nutrition

18. NICU Environment – Sound Adverse effects of loud sound (>60 db ) Interferes with sleep Increase in Heart Rate Peripheral vasoconstriction Sudden loud noise may ICP, ? IVH Hearing loss Levels > 90 db for long times, hearing loss can occur In preterm, on aminoglycosides, even at lower db levels.

19. Sources of noise • Inside incubator, 55-88 db • Additional 10-40 db with surrounding equipments • Routine care activities, 58-76 db. • Loud, sharp sound - 100-200 db. Peak noises - 90% due to human related factors

20. Interventions to reduce noise •Decrease noise in NICU •Decrease monitor noise •Respond quickly to alarms •Rounds & reports away from bedside •Speak softly •Decrease telephone & intercom noise •Move equipments quietly, repair noisy ones •Decrease staff generated noises •Prepare medications & feedings away from bedside •Gently open doors and drawers •Follow the sound limit recommendations

21. What is the sound level recommendation? What is the instrument used to measure ?

22. Monitor decibel readings regularly Keep level < 45 db

23. Helpful Effects • Sound of mother’ voice (calming effect) • Music may be beneficial - Lullabies, womb sound, heart beat music. Better weight gain Decreased hospital stay, Better behavioral organization INDIAN CLASSICAL MUSIC preferable

24. NICU Environment – Light • Fetal life - Near darkness • NICU- Usually very bright light • Continuous light exposure • Usual range - 50-150 foot candles • Procedure & PT lights - 200-400 foot candle

25. Light effects: Effect on central visual system. Quiet sleep & physiological instability Effect on circadian rhythms Effect on Growth and development ? ↑ risk of ROP

26. Light Reduction • Shade head of crib / incubator • when required , use spot light / procedure light •Eye covers must with PT • use available Light natural light Cycled lighting better than near Darkness More time in sleep state – ↑ weight gain ↓ Motor activity levels ↓ Heart rate Safe level not established

27. What is allowable light level? What is the instrument to measure light ?

28. Monitor NICU Light with Luxmeter. The AAP guidelines for perinatal care recommend adjustable ambient light levels from 10 to 600 lux (1 to 60 foot-candles) in infant areas

29. NICU Environment -Positioning • Effect on respiratory physiology • Body alignment important • Prevent postural deformities • Promote self-soothing activities • Decided by GA, degree of illness, paralytic agents.

30. Recommendations Preferred: Prone / side lying Swaddle / cover to keep in flexed position Hand containment ( facilitated tuck ) Attempt to “nest” the infant Promote midline alignment . Avoid : - Hyperextension of neck - Frequent head turning to side - Lower extremity frogging - Bigger diaper

31. SWADDLING NESTING

32. HAND CONTAINEMENT

33. NICU Environment - Handling • Physiologic and behavioral stress • Pace the care according to baby – Individualized care • Time the care around sleep / wake cycles • No routine procedure • Provide 2-3 hrs of uninterrupted sleep

34. “Minimal Handling” or “Quiet hour” Protocol • Reduce noise • Reduce lights • Allow minimum two hours of rest • Cluster the caregiving procedure • Sensitize the nursing staff

35. TACTILE STIMULATION Gentle massage and soft bedding promote tactile stimulation Try to promote bonding whenever possible through kangaroo method. Rocking and oscillating waterbeds can be introduced in order to stimulate the kinesthetic/vestibular senses. Passive exercises for the joints in order to prevent muscle spasm.

36. NICU environment - Kangaroo Care Stimulates : Olfactory sensory system Tactile sensory system Vestibular system Likely Benefits : Successful breast feeding • Better physiologic stability • Increased maternal confidence & bonding • Reduced infection rates • Cost savings

37. Octopus Therapy for Preemies in NICU

38. Protected sleep An infant’s undisturbed sleep is very important for his/her brain growth. Apart from KC, the other measures such as providing nesting , clustering of ADL, massage, and having a healing environment help to promote sleep of infants. The containment that the uterus provides to the fetus instills a sense of safe and secure environment. The fetal position enables the fetus to develop appropriate muscle tone and patterns of movement. Unfortunately premature infants are unable to maintain this position themselves due to their low tone and the gravitational pull. Leaving an infant without boundary or nesting disturbs the infant’s sleep and aggravates pain and stress.

39. Neonatal Pain - Misconceptions • Newborns lack anatomical & physiological structures to transmit pain sensation. • Cannot express pain sensation • Have no memory of pain • Would not tolerate analgesia / anesthesia

40. Pain Management Neonatal Pain - Facts : Nociceptive mechanisms well developed even in preterm. Pain expression and assessment possible Various consequences of pain & stress Various nonpharmacologic & pharmacologic strategies useful for treatment

41. Pain Management Non-pharmacologic Interventions • Positioning & containment • Swaddling • Non-nutritive sucking / pacifiers • Skin to skin contact • Rocking • Music • Breast milk • Oral glucose / sucrose

42. Pain Management Pharmacologic interventions • Local anaesthetics (EMLA) • Regional anaesthesia • Systemic analgesia

43. Family Involvement • Provision of privacy (for bonding) – single family room [ SFR ] • Social interaction & support • Parental education & counselling • Involvement of mother in care • Mother - based NICU, need of hour

44. Evidence for DSC

45. NICU Interventions programs- Neonatal individualized developmental and assessment program (NIDCAP) Meta analysis : 1) Bayley scale showed significant improvement at 1year and 2 years 2) Infants were discharged at a younger age, had a shorter hospital stay, and lower care costs in comparison with control. Significant decrease in O2. 1 June 2009 W orld views on evidence based nursing https ://doi.org/10.1111/j.1741-6787.2009.00150.x A systematic review including 627 preterm infants did not find any evidence that NIDCAP improves long-term neurodevelopmental or short-term medical outcomes . Pediatrics,2013 Mar;131(3):e881-93.   doi: 10.1542/peds.2012-2121.   Epub 2013 Feb 18. .  

46. Recent systematic review ( GRADE process ) included 13 studies. Reported interventions in NICU intended to support development RCTs reporting Bayley Scale of infant development at 12 or 24 months, including both psychomotor and cognitive components were age appropriate compared to controls

47. What is GRADE process?

48. GRADE ( G rading of R ecommendations A ssessment, D evelopment and E valuation) is a well-developed formal process to rate the quality of scientific evidence in systematic reviews and to develop recommendations in guidelines that are as evidence based

49. Important points The sensory experiences of a preterm baby should be appropriate to the development stage, similar to in utero what the fetus would have experienced in. Developmentally supportive care aims at adapting the NICU environment and care to improve physiologic stability, decrease stress, protect sleep, and promote behavior organization . Intense stimuli like severe/frequent pain, intense light, loud sound, strong smell, and frequent sleep interventions may have devastating influence on developing brain. Evidence supports improvement in short-term development outcomes in preterm babies who receive development care.

50. Individualized care : timing of examination, feeding, care like diaper change, sampling should be based on infant cues (behavior state), rather than by schedule. Family-centered care : involve parents very early (from day1) in care of the baby, it is beneficial to both the baby and the parents. The family experiences are better and transition to home is smoother. NICU design must aim to minimize noise and optimize light to minimum , when not needed. Kangaroo care (KC) has multiple benefits and all NICUs must have policy to support and promote KC. Nonnutritive sucking, massage, swaddling, facilitated tuck, positioning to promote flexion, midline posture, and parents speaking to their baby are all supportive development

51. EARLY STIMULATION IN NEWBORN Dr.Pramitha.L IAP NDBP fellow, CDC, kerala

52. Principle of early stimulation : Neuroplasticity

53. Neuroplasticity is the ability of the brain to change its structure and function in response to new experiences, learning, or injury. It is also known as ** neural plasticity ** or ** brain plasticity**. Neuroplasticity allows the brain to adapt to different situations and challenges by forming new connections between neurons or strengthening existing ones. Neuroplasticity occurs throughout life, but it is more pronounced in childhood, when the brain is more sensitive to environmental influences.

54. Rationale Brain weight at 34 weeks is only 65% of that of the term brain. Gyri and sulcal formation is also incomplete. Cortical volume increases between 34 and 40 weeks‘ gestation. So, this period is critical. The synaptogenesis, myelination and elongation of neurons continue to occur postnatally in a preterm. But, during this 'vulnerable' period brain is sensitive to adverse environmental influences like hypoxia, ischemia, infection etc. As a result, preterm infants have worse developmental outcomes than term infants.

55. Evidence for early stimulation Cochrane review had shown that early intervention programs for late preterm infants have a positive influence on motor and cognitive development on short-medium term. CDC ES model starting from stimulation at NICU, lactation management, multisensory stimulation, activities based on developmental milestones has shown improvement in psychomotor functioning at 2 years, better parent child bonding in at risk babies RCT, Indian pediatrics,2009 Jan;46 Suppl:s20-6 . Early stimulation pivoting around parent-child in LP babies has positive influence on Neurodevelopmental outcome at 12 months of corrected age . Research Article ASAD 3 Issue 1 - February 2017 DOI: 10.19080/AJPN.2017.03.55560 . 

56. Definition Infant stimulation is a process of providing supplemental sensory stimulation in any or all of the sensory  modalities   (visual, auditory, vestibular, tactile, olfactory, gustatory) to an infant as a therapeutic intervention. The intervention uses supplemental stimulation to compensate for the lack of normal or typical environmental sensory stimulation 

57. AIMS OF EARLY STIMULATION 1. Stimulating the child through the normal developmental channels 2 . Prevention of developmental delay 3. Prevention of asymmetries and abnormalities. • to prevent atrophy of muscles • to prevent fixity of joints • to prevent contractures of the joint • to decrease the tone of the muscle • to prevent tightening of tendons 4. Detection of transient abnormalities and minimization of persistent abnormalities.

58. HEARING AND AUDITORY STIMULATION

59. Guess the burden of Newborn hearing loss in india ?

60. Burden of hearing loss Using a 3-step screening protocol, hearing impairment (abnormal auditory brainstem response/auditory steady state response) in neonates ranged between 1.59 and 8.8 per 1000 births. Among ‘at risk’ neonates , it ranged from 7 to 49.18 per 1000 births Verma RR, Konkimalla A, Thakar A, Sikka K, Singh AC, Khanna T. Prevalence of hearing loss in India. Natl Med J India 2021; 34: 216–22.

61. Best before to be diagnosed in an infant for best outcome ?

62. GOAL 1 - 3 - 6 Screen newborn babies before 1 month of age, Diagnose hearing loss before 3 months of age and Start intervention before 6 months of age Hearing is a prerequisite for the development of normal speech & language CONDITION WORDS TYPICAL HEARING 3 year old 500-900 words HI remediated at birth 300-700 words HI remediated at 6 months 150- 300 words HI remediated at 2 years 0-50 words

63. Problems “The critical period for language and speech development is the First 2 years of life” Hearing loss may result in lifelong deficits in speech and language acquisition Poor academic performance Personal-social and Behavior problems

64. OAE PASS FAIL Rescreen at 6 weeks OAE Pass Fail ABR A two-stage screening protocol with OAE as the first screen, followed by ABR for those who fail the OAE screen. All NICU babies should undergo ABR testing to rule out auditory dys -synchrony/ auditory neuropathy.

65. Early intervention Lack of auditory stimulation leads to retrograde degeneration in the cell body and axon PLAYING MUSIC • Music stimulates more than just the auditory brain centers and connects powerfully to the baby’s emotions. • Classical music is particularly good for the baby’s developing brain. Playing classical music to the newborn could help lay down important spatial reasoning pathways , as well as connections within the auditory system

66. TALKING AND IMITATION • Language development begins from the moment the baby first hears voices. • Talk to the baby often — when changing , feeding him, or walking and carrying him. Listen carefully to his little noises and repeat them; one can have baby ‘conversations’ this way, each taking a turn. • Read to the baby — look for books with rhythmic, rhyming language. Even tiny babies will listen attentively to the sing-song cadences of poems and nursery rhymes

67. Auditory stimulation 0-2 months • Make the child listen to different sounds such as squeeze toy, rattle , bell, music, high pitched and low pitched human sounds etc. • Always humming in a soft low voice. 2-4 months Sound producing toys are suitable for this age. Noisy toys/squeaky rubber toys etc. can be given. Parents should spend more time with child, keep on talking with the child, pointing out the name of objects shown will help the child to use more words when he starts talking.

68. VISION AND VISUAL STIMULATION

69. VISION DEVELOPMENT Visual acuity ( new born have 12-25 times less than a normal adult) Anatomical changes - Contribute 25% Brain Maturation - Contribute 75% They can focus about 8 inches away, and their sight is two dimensional.

70. Common causes of visual impairment in newborn : Retinopathy of prematurity (ROP), Cataracts, Cortical visual impairment (CVI) and rarely Retinoblastoma, VISION IS MAJOR MEANS FOR LEARNING

71. DEFINITION DEFINITION DEFINITION Cortical Visual Impairment (CVI) is deficiency in the function of vision due to damage to or malfunction of visual pathways and visual centres in the brain. Vision and Brain, Editors- Amanda Hall Leuck and Gordon N Dutton, AFB press, 1st edition

72. BURDEN OF CVI Katoch et al have reported that 28% children with cerebral palsy had CVI. In a recent study, it was found that CVI was the most common cause of profound visual impairment in children less than 3 years in South India. Katoch S, Devi A, Kulkarni P. Ocular defects in cerebral palsy. Indian J Ophthalmol . 2007 MarApr;55(2):154-6. Pehere NK, Asa N, Dutton GN. Profound visual impairment in children aged less than three years living in South India: Cerebral Visual Impairment is a most common cause. Indian J Ophthalmol . 2019 Oct;67(10):1544-1547

73. Visual stimulation technique Bold patterns with strong contrast: “Nursery Novel” / Paste the shapes Making Faces : one can stick out the tongue, make an ‘O’ with one’s lips, or raise and lower one’s eyebrows. Moving Objects : Lay the baby on the lap. Take a toy, small picture, or one’s hand and slowly move it in an arc from your baby’s left to right, and then back again.

74. 0-2 months Visual: Hang brightly coloured clothes (red/orange/fluorescent), shining objects, coloured balls, B&W striped cloths etc across the crib. Do not interchange them frequently. Put the baby in a well ventilated room having good light. 2-4 months Visual: Hang brightly colored objects/shiny objects about 12-15 inches above the crib, this will enable the child to watch it constantly and slowly start to babble. Maintain eye contact while talking to the child. Show brightly colored clothes when the child is awake.

75. Vestibular Kinesthetic Stimulation Rocking, Walking and Swinging : Every time the baby is rocked, or swung, the vestibular system is stimulated. Baby swings are a good way to stimulate the vestibular system. Passive range of motion exercises to prevent hypertonia

76. Vestibular and kinesthetic stimulation 0-2 months Tactile : Frequently change child’s position . Put the child on his side, on his back, on his tummy etc. Put the baby in different surfaces like soft mattresses , rubber mat, on soft clothes, on mother’s lap etc. Vestibular/kinesthetic : Gently rock the child, avoid fast changes of position. Avoid sudden jerky movements, always support the head. 2-4 months Give the child various things to bite and suck. Give paper to crumble. Give your child the experiences of soft, hard, rough,cold , warmth etc. During daytime place the children on a foam rubber mat on the ground and allow him to move freely.

77. Multimodal Stimulation Auditory, visual , tactile, olfactory , gustatory & vestibular • Soft & soothing music • Gentle touch • Use of pictures (human face), bright toys • Olfactory stimulation, use of “breast milk” (avoid cologne / spray). • Moving or swinging gently • Better weight gain and early discharge

78. Neurological examination

79. States of arousal - 1. Quiet sleep - regular breathing, no REM, no spontaneous movements. 2. Light sleep - irregular breathing, REM, spontaneous movements. 3. Transition / drowsy - variable activity, dull look 4. Awake - alert - minimal activity, bright look. 5. Awake - hyperactive - very reactive, fussy, increased motor activity. 6. Crying BRAZELTON

80. Hammersmith neonatal neurological examination Hammersmith infant neurological examination Ameil tison angles Modified Ashworth scale

81. HINE The Hammersmith Infant Neurological Examination (HINE) is a standardised and scoreable clinical neurological examination that can be used to assess infants till 2 years The HINE contains 26 items across 5 domains and summing of scores in each domain provide a global score. More than ten studies of high risk newborns (preterm and term) have demonstrated that this assessment can be used in the diagnosis of cerebral palsy (CP ).

82. HINE AGE – 2 TO 24 MONTHS ITEMS – 26 DOMAINS – 5 Cranial nerve examination , Posture , Movements, Muscle tone, reflexes and reactions SCORING – EACH ITEM 0/1/2/3 . So maximum score 78 PREDICTABILIT Y - scores greater than 64 predict independent walking with a sensitivity of 98% and specificity of 85%. Conversely, scores less than 52 were highly predictive of cerebral palsy and severe  motor impairments.

83. HINE score chart Cranial nerve function score (max 15) Posture score (max 18) Movements score (max 6) Tone score (max 24) Reflexes and reactions score (max 15) TOTAL SCORE – COMMENT

84. HNNE Hammersmith Neonatal Neurologic Examination (HNNE) is used to identify term and preterm infants at risk of neurodevelopmental disability. The test is recommended at corrected term age in preterm; and around 2 weeks postnatal age in term neonates The HNNE provides moderate predictive accuracy for motor outcome at 12 months corrected age in infants born very preterm. Fev Med Child Neurology, 2023 Aug;65(8):1061-1072.   doi: 10.1111/dmcn.15512.   Epub 2023 Jan 22 .   .

85. AMEIL TISON ANGLES Amiel-Tison method is a commonly used technique for assessing tone and neurological status of infants. (i)  Angle at hip: Adductor angle. (ii) Angle at knee: Popliteal angle. (iii) Angle at ankle: Dorsiflexion angle . (iv) Scarf sign

86. AMEIL TISON ANGLES POPLITIAL ANGLE ADDUCTOR ANGLE

87. DORSIFLEXION ANGLE SCARF SIGN

88. Instrument in the picture used to measure angles?

89. Agreement between visual and goniometric assessments of adductor and popliteal angles in infants Pediatr Neurosci .   2013 May-Aug; 8(2): 93–96.

90. Modified Ashworth scale The modified Ashworth scale is the most universally accepted clinical tool used to measure the increase of muscle tone. The MAS is the current standard for clinical assessment of extremity spasticity. T he most commonly used tool to evaluate the efficacy of pharmacologic and rehabilitation interventions for the treatment and management of spasticity. 

91. Development therapy , physiotherapy for hypertonia and hypotonia will be given.