modified according to caregiver’s professional judgment. If a VS or assessment is not within defined limits (WDL), increased “events”, or rising oxygen requirements, reassess more often as needed · “Hourly visual rounding” without awakening a sleeping infant, or when an infant is awake and appears uncomfortable (crying, restless, increased HR, etc.). Check for wet diapers, evidence of pain, need for repositioning, conditions of IV sites, and parent needs. · Feedings are given at scheduled intervals (for example, every 3 hours) · RT and nursing collaborate on frequency and scheduling of CPAP/NAVA breaks · Physicians, ARNP’s and specialty providers assess infants per their schedules In summary, best practice neuroprotective strategies to support sleep include: · Protect sleep cycles, and especially REM sleep · Use spontaneous awake periods for routine caregiving whenever possible · Allow rest periods of at least 60 minutes to complete a normal sleep cycle · Promote a quiet environment without loud noises to ensure uninterrupted sleep · If necessary to wake up infant, approach using a soft voice followed by a gentle touch · Protect eyes from bright lighting at all times and avoid use of overhead spot lights · Maintain dim ambient lighting between “cares” · Use narcotics and sedatives carefully, since both interfere with REM and non-REM sleep · Facilitate prolonged skin-to-skin to promote normal sleep patterns NICU Brain Sensitive Care Committee/Terrie Lockridge/ 11-2015/Swedish Medical Center – used with permission 7 Background: When born prematurely or critically ill, gravity forces weak infants into an uncomfortable flat and extended resting posture, with the extremities abducted and externally rotated. The baby’s head falls asymmetrically to one side, usually the right side, and causes uneven flattening of the skull. Over time, neuronal connections are reinforced that support these abnormal postures as a baseline. Developmental delays and permanent disabilities may ensue. In utero, the fetus kicks and moves freely against boundaries that provide constant soma-esthetic (touch), kinesthetic (movement), and proprioceptive (position) feedback. What can we do in the NICU? · Aim for containment, rather than restraint · Flexible enough to allow spontaneous movement, firm enough to limit excessive activity · When possible, hands should be able to move towards face/mouth for self-comfort What neuro-protective strategies can we use? IVH Prevention Bundle: for infants <30 weeks GA for the first 72 hours of life: · Maintain neutral head position with head of bed up to the highest position · No daily weights until day 4 · No holding or kangaroo care, but encourage parents to provide containment (“hand hugs”) during this time as tolerated Positioning to support optimal alignment and containment should be provided for all infants. Consider utilizing this “positioning checklist” before leaving the bedside: · Shoulders softly rounded forward? · Hands towards midline, able to touch face/mouth if possible for self-comforting? · Hips aligned and pelvis tucked? · Knees, ankles, feet aligned and softly flexed? · Neck neutral or slightly flexed, no hyperextension? · Head midline, or turned slightly right or left? Avoid turning more than 45 º to either side Neuro-protective Best Practice Guidelines Part 2A: Positioning for Success Goal is to eliminate or reduce positional deformities by maintaining infants in a midline, flexed, contained, and comfortable position NICU Brain Sensitive Care Committee/Terrie Lockridge/ 11-2015/Swedish Medical Center – used with permission 8 Prone positioning: · Select appropriate size. If infant is between sizes, use smaller size to prevent abduction of legs and shoulders, and to allow shoulders and hips to flex around the positioner · Bottom of prone positioner should end around the umbilicus · Avoid turning head to a full 90º angle by allowing it to rest slightly off edge of positioner Reposition if infant appears restless, uncomfortable, and/or during “hands on care”. Teach parents how to position properly and solicit their input on baby’s comfort and preferences. Supportive containment with positioning aids to approximate the defined boundaries the fetus experiences in utero. These aids are selected based upon individual infant needs: · Bedding “nest” with horseshoe rolls and envelopes · “Freddy Frogs”: Used to maintain desired position, especially the head. Remember these weigh about 1 pound each and are extremely heavy in relation to an infant’s weight. Do Not allow them to rest on infant. · Dandle Roos: Stocked only on 6 South and used for less mature infants · XS for ><1000 grams, S for 1000-1800 grams · Dandle Wraps: Stocked on all three floors, and used for more mature infants · S for 1000-1800 grams, M for 1800-2500 grams, L for >2500 grams The lower pouch of the Roo/Wrap promotes flexion of hips, legs and ankles while allowing infant to kick and move freely against the stretchy fabric. This is especially important since tight swaddling has been associated with acquired hip dysplasia. · Reminder: Servo control temp probe must never be covered by DandleRoo/Wrap fabric, and vascular access sites must be visible at all times Please put Dandle Roos & Wraps in bright green linen hamper when soiled!!! WHY? Therapeutic positioning promotes improved rest and growth, and normalizes neurobehavioral organization. Infants who are comfortably contained are more likely to be calmer, require less medication, and gain weight more rapidly. NICU Brain Sensitive Care Committee/Terrie Lockridge/ 11-2015/Swedish Medical Center – used with permission 9 Neuro-protective Best Practice Guidelines Part 2B: Handling with Care Goal is to maintain autonomic stability throughout positioning changes and caregiving activities, as well as during periods of rest and sleep Background: Moving infants quickly may be efficient for caregivers, but is very stressful for infants and often leads to autonomic instability (i.e. apnea/bradycardia/desaturation “events”). Rapid and unsupported movement (such as the “premie flip”) triggers sensory distress and excessive motor activity, as infants attempt to stabilize themselves to a fixed surface during the vestibular disturbance. This is similar to a dizzy adult reaching for a wall to maintain balance, or grabbing the guardrails on a carnival ride. Infants may remain disorganized, nauseated, and dizzy for up to 30 minutes following a “premie flip”, and more “events” are likely to occur later in a delayed response to handling. What can we do in the NICU? Minimize stress and support autonomic stability during rest and caregiving interventions by utilizing careful handling and containment techniques. Consider using a second person to assist with position changes for intubated infants. Whenever possible, avoid disturbing infants during sleep and try to use spontaneous awake periods for caregiving. If necessary to awaken infant, start with a soft voice followed by gentle touch. “Containment”, also known as a “facilitated tuck” or “hand hugs”, refers to the parent’s or caregiver’s hands being used to maintain an infant in a flexed midline position. This technique provides support for the infant and the opportunity to control their own body. Infants who are not adequately “contained” demonstrate more physiologic instability, agitation, and stress cues. Containment is indicated for all handling, caregiving and procedures. When an additional caregiver is unavailable to assist, use Dandewraps/Roos or blanket swaddles. Intracranial pressure (ICP) is lowest when the head is midline and the HOB is elevated. Caution should be taken when changing diapers to prevent