extremities, face) ◦Hypertonicity, arching ◦Finger splays, fisting ◦Facial grimace ◦Frantic, diffuse activity Behavioral/State System ◦Rapid movement between states ◦Fussing, irritability ◦Glassy-eyed, staring, gaze aversion ◦Panicked, worried alertness Physiologic/Autonomic System ◦Maintains consistent color ◦Stable respirations ◦Reduction of tremors ◦Stable digestion Behavioral/Motoric System ◦Smooth, well-modulated tone ◦Synchronous, smooth movements ◦Grasping and hand to mouth activity ◦Sucking Behavioral/State System ◦Clear, robust sleep states ◦Rhythmic, robust crying ◦Active self-quieting/consoling ◦Focused shiny-eyed alertness ◦Intent, animated facial expression Self-help Cues ◦Hand to mouth activity ◦Hands clasped ◦Grasping ◦Seeking boundaries ◦Habituating to repetitive stimulation by entering into light sleep Protect sleep by clustering of care whenever possible, but be aware that the infant may not tolerate all of the caregiving measures that have been bundled into a single session. Clustering of care is intended to provide longer rest periods but may actually result in more physiologic alterations (changes in blood pressure, cardiorespiratory stability, altered cortisol levels, and heightened pain responses) than single care-taking events. Clustered care appears to be especially stressful for preterms < 28 weeks GA, so individualized cuebased caregiving is essential to avoid overwhelming an infant. What can we do in the NICU? · Assess for stress cues, indicating need for containment and a pause to allow recovery · Assess for stability cues, indicating that it is safe to continue caregiving or interaction · Provide nurturing touch whenever possible, especially after caregiving or procedures · Safeguard sleep NICU Brain Sensitive Care Committee/Terrie Lockridge/ 11-2015/Swedish Medical Center – used with permission 15 Neuro-protective Best Practice Guidelines Part 4B: Minimizing Pain Goal is to minimize the intensity, duration and physiologic cost of the pain experience, and to maximize the infant’s ability to cope with and recover from painful experiences Background: For many years, it was believed that newborns were incapable of either experiencing or remembering pain due to central nervous system immaturity. These myths were dispelled by research over thirty years ago, but appropriate analgesia remains underutilized in many NICU’s. A prospective study in 2003 (Simons, et al) showed minimal procedural analgesia for neonates despite the perception of pain by providers. It is now understood that the ability to perceive pain at the cortical level is present early on, and that the pain experience is actually prolonged and more intense in newborns, especially for those born prematurely. A review of fetal neurophysiology helps to understand the pain experience in preterm infants. Afferent nerve pathways carry pain impulses from peripheral nociceptors (“nerve endings”) to the brain, and are fully intact by 24-26 weeks GA. Efferent nerve pathways send protective impulses back to motor neurons, and trigger reflexive withdrawal from pain. These pathways also regulate neuromodulators (such as serotonin) that control pain signals by reducing or blocking the continued transmission of painful stimuli. Unfortunately, efferent pathways are largely undeveloped until 36-40 weeks GA, and continue to mature postnatally. Because these pathways mature more slowly, infants may not withdraw in response to pain and are often unable to inhibit persistent pain signals. The lack of neuromodulators results in more sustained and severe pain, especially in preterm infants. In general, newborns are “wired” to transmit pain signals, but the wiring is still being “installed” to moderate their pain experience. Pain is known to elicit many acute physiologic changes, including elevated heart rate, respiratory rate, blood pressure and intracranial pressure. A growing body of evidence also indicates that the cumulative impact of repetitive pain on the developing brain may be greater than previously understood. Pain exposure may result in permanent structural changes to the spinal cord and brain, with adverse long-term developmental outcomes. While early pain might not be consciously “remembered” later in life, it is thought to be encoded into “procedural memory”, a type of “unconscious memory” created by repetition of an experience or activity. Pain assessment includes behavioral and physiologic indicators, which may be immediate, delayed, or absent. Preterm or ill newborns often show less robust behavioral responses. Pain triggers a “fight or flight” response with activation of the sympathetic nervous system, and release of glucocorticoids such as cortisol, epinephrine and norepinephrine. Since the sympathetic nervous system can’t cope with persistent and unrelieved pain, “protective apathy” may occur with a return to baseline physiologic parameters despite continued pain. NICU Brain Sensitive Care Committee/Terrie Lockridge/ 11-2015/Swedish Medical Center – used with permission 16 Clinical studies show that initiating analgesia prior to painful procedures is helpful to decrease both neonatal pain and stress. The timing of routine caregiving and painful procedures is important. · After pain exposure, sensitivity is accentuated by increased excitability of nociceptive neurons in the spinal cord. This hypersensitivity (known