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A systems perspective of developmentally supportive
family centered care
Cuidados Centrados en
el Desarrollo y en la familia11 y 12 de noviembre, 2010
Björn Westrup, MD Ph D
Karolinska University Hospital
Stockholm, Sweden
KapellouKapellou20062006
Impact of rearing conditions during the neonatal period on adult brain function
A proposed link between variations in parent–offspring interactions and the development of individual differences in stress responses
If critical conditions are present in early life of forms of parent–offspring interactions they promote increased stress responses and chronic stress in adulthood. Szyf M, Weaver IC et al Front Neuroendocrinol 2005
Prematurity associetedwith medical conditions in adulthood:
HypertensionEdstedt Bonamy et al, Pediatric Research 2005Johansson et al, Circulation 2005
Sympatoadrenal hyperactivityJohansson et al, J Internal Medicine 2007
Smaller vascular bed (capillary density)Edstedt Bonamy et al, J Internal Medicine 2007
Smaller aorta Edstedt Bonamy et al, Pediatric Research 2005Edstedt Bonamy et al, Acta Paediatrica 2008 (1)Edstedt Bonamy et al, Acta Paediatrica 2008 (2)
Smaller kidneys (normal GFR)Rakow et al, Pediatric Nephrology 2008
0
1
2
24-28 29-32 33-36 37-41 42-43
Diastolic BP ≥90 mm Hg Systolic BP ≥140 mm Hg
gestational weeks
adjusted OR
NIDCAP
Newborn
IndividualizedDevelopmental
Care and
Assessment
Program
Implementation at Karolinska
Systems perspective
Synactive Model of Developmental Care
Systems perspective
H. AlsH. Als
Synactive Model of Developmental Care
H. AlsH. Als
NIDCAP promotes resilience by providing developmentally adequate support during: care-giving social interaction examinations and procedures
The care is governed by the infant’s … current stage of development current medical condition
0102030405060708090100
<25 25 26 27 28 29 30 31-33
CPAPCPAP
MVMV
%
Nice, 2008-10-26Béatrice Skiöld EAP 2008Béatrice Skiöld EAP 2008
The Stockholm cohort <27 wksThe Stockholm cohort <27 wksWhite matter abnormalities on conventional MRIWhite matter abnormalities on conventional MRI
Entire cohort DTI-group z-test/ n=108* n=54 t-test
No WM abnormalities 43 (40%) 24 (44.5%) ns
Mild WM abnormalities 50 (46%) 24 (44.5%) ns
Moderate WM abnormalities 13 (12%) 6 (11%) ns
Severe WM abnormalities 2 (2%) 0 ns
*one MRI excluded due to artefacts
26 wks
25 wks
24 wks
23 wks
22 wks
Survival – live-born infants (n = 707) acc. to gestational age at birth JAMA 2009
36
46
56
24
38
6
32
5
0
6 6 5
18
6
18 1713 12 12
6
13
0
10
20
30
40
50
60
VGregio
n, n
=74
Link
öpin
g, n
=41
Öre
bro,
n=1
6
Stock
holm
, n=11
0
Uppsala
, n=7
8
Umeå
, n=33
Alla, n
=352
BPDIVH, gr 3-4ROP, gr 3-4
Morbidity (%) among survivors with gest. age 25-27 weeksSwedish National Neonatal Register – PNQ (2007-2008).
Karolinska-Danderyd
Level II + - 10 000 inborn deliveries Infants > 27 gestational weeks INSURE (Intubation, Surfactant, Extubation), CPAP, chest tubes,
catheters etc 24 beds for infants 8 beds for mothers in need of medical care – Couplet Care 12-14 “beds/families” in the Domiciliary Care Program 870 admitted – 8.7%
7.2% in the neonatal unit1.5% in the maternity wards (jaundice, hypoglycemia, Down’s
Syndrome …) 26 (3% of admitted, 2.6‰ of all newborn) referred to Level III Perinatal mortality: 3 ‰ – all still births, no mortality during 1st week Neonatal mortality: 0.6‰ (national 1.6 ‰) during 1st month
Synactive Model of Developmental CareSynactive Model of Developmental Care
H. AlsH. Als
Synactive Model of Developmental Care
H. Als, 2007H. Als, 2007
Synactive Model of Developmental Care
H. AlsH. Als
Samvårdsavdelning 20 Samvårdsavdelning 20 Neonatalsektionen Karolinska-Danderyd Neonatalsektionen Karolinska-Danderyd
Karolinska-Huddinge
Small family room when the mother has recovered, Small family room when the mother has recovered, e.g., from her pre-eclampsia and/or c-sectione.g., from her pre-eclampsia and/or c-section
Nurse with beepers connected to thewireless monitors
Synactive Model of Developmental Care
H. Als
Large family room where we also care for mothers who are in need of medical care, except intensive care
Couplet CareCouplet Care
Large family room where we also care for mothers who are in need of medical care, except intensive care
Couplet CareCouplet Care
Does developmental care stop at discharge?
Home visits: NIDCAP IBAIP (Infant Behavioral Assessment Intervention Program)
Synactive Model of Developmental Care
H. Als, 2007
Parental benefit – extension of days
180210
270
360
450
480
0
100
200
300
400
500
600
1974 1978 1982 1986 1990 1994 1998 2002 2006
Children born from 1995 - 30 days can not be transferred to the other parent.Children born from 2002 - 60 days can not be transferred to the other parent.
Temporary parental benefit when the child is ill 60 + 60 days/ parent and year, can be extended if
there is a life-threatening condition (~< 32+0 wks)
General parental benefit:
The Stockholm Neonatal Family Centered Care Study:
effects on length of stay and infant morbidity
A Örtenstrand, B Westrup, E Berggren Broström, I Sarman, S Åkerström, T Brune, L Lindberg, U Waldenström
Karolinska Institute, Stockholm Sweden
Pediatrics Jan. 2010;125: e278–e285
Annica Örtenstrand 36
Intervention:
True (?) family centered care – parents could stay 24 / 7 from admission to discharge
parents had a separate room in the unit from the first day.
The infants moved from the “acute” room into the family rooms as soon as they reached a stable state.
Infants randomized into the study
Randomized infants n = 366
with congenital disease: 2
Allocated to family care: 183 Allocated to standard care: 183(1 infant death)
with congenital disease: 5
Analyzed byIntention-to-treat: 183
Without congenital disease: 181
Analyzed byIntention-to-treat: 182
Without congenital disease: 177
Annica Örtenstrand 38
Included infants
Family care n = 183
Standard caren = 182
Gestational age at birth
24 – 29, n (%) 28 (15.3) 31 (17.0)
30 – 34, n (%) 102 (55.7) 103 (56.6)
35 – 36, n (%) 53 (29.0) 48 (26.4)
Pair of twins 21 24
Annica Örtenstrand 39
Length of stay in hospital
Adjusted for: gestational age at birthA, non-Swedish-speaking backgroundA,B, settingA,B
Family caren = 183
Standard caren = 182
difference days
All infants A, mean 27.4 32.8 -5.3 (p= .05)
By gestational age B
24 – 29 w, mean 56.6 66.7 -10.1 (p= .02)
30 – 34 w, mean 19.2 23.6 -4.4 (p= .16)
35 – 36 w, mean 6.4 7.9 -1.4 (p= .39)
Annica Örtenstrand 40
Length of stay in intensive care (level II and level III) Adjusted for: gestational age at birthA, non-Swedish-speaking backgroundA,B, settingA,B
Family caren = 183
Standard caren = 182
difference days
All infants A, mean 13.3 18.0 -4.7 d (p= .02)
By gestational age B
24 – 29 w, mean 32.4 43.1 -10.6 d (p= .04)
30 – 34 w, mean 6.0 8.5 -2.5 d (p= .02)
35 – 36 w, mean 1.5 2.5 -1.0 d (p= .24)
Annica Örtenstrand 41
Infant morbidity
Adjusted for: gestational age at birth, non-Swedish-speaking background, setting
Family caren = 183
Standard caren = 182
OR (95% CI)A
Verified Sepsis, % 7.1 9.8 0.68 (0.3-1.6)
Verified NEC, % 2.7 3.3 0.83 (0.2-2.8)
Diagnosed. PDA, % 15.3 16.9 0.90 (0.4-1.9)
IVH grade II-III, % 3.3 3.8 0.95 (0.3-3.2)
ROP stage II-V, % 2.7 6.6 0.34 (0.1-1.1)
BPD moderate-severe, % 1.6 6.0 0.18 (0.04-0.8)
Annica Örtenstrand 42
Ventilatory assistance and supplemental oxygen Adjusted for: gestational age at birth, non-Swedish-speaking background, setting
All infants
Family caren = 183
Standard caren = 182
difference
Respiratory support n (%) 90 (49) 109 (60) OR: 0.65 (0.4-1.0)
Mecanical ventilation
days, mean 0.6 1.3 -0.7
CPAP,
days, mean 6.5 8.7 -2.2
Supplimental oxygen
days, mean 11.0 12.2 -1.3
Family care might operate through the common pathhways of pain and stress
Parents in Family care may have a greater opportunity to co-regulate the caregiving with the needs of the infant
time the care-giving
Parental presence/skin-to-skin may contribute to better sleep organization
Annica Örtenstrand 44
Conclusion
Family care in a level-II NICU, where parents could stay 24 hours per day from admission to discharge may reduce …
length of stay for preterm infants
bronchopulmonary dysplasia
Ultra-Early InterventionKarolinska-Danderyd, 18 November 2010
Visit the link or google and follow the conference on the internet - in real time or any time later in toto or in parts for in-house education for staff or at home on your pc!
http://web22.abiliteam.com/ability/show/khcichp/abbott_20101118/speed.asp
Staff’s (expert?) opinion
The staff’s experience of NIDCAP in Falun, SwedenWestrup, Kleberg, Wallin et al. Evaluation of NIDCAP in a Swedish Setting. Prenatal and Neonatal Med.1997;2:366-75
-5
-4
-3
-2
-1
0
1
2
3
4
5
Parents’: Presence Way of care Attachment
Caregiving plans andParents’: Presence Way of care Attachment
Sa
tis
fa
ctio
n d
es
so
ign
an
ts
(J
uin
20
00
)
-5
-4
-3
-2
-1
01
23
45
L'im
plan
tatio
n d
u N
ID
CA
P a eu
l'effet su
ivan
t su
r :
-5 = m
oin
s b
on
, 0 = in
ch
an
gé, 5 = m
eilleu
r (m
oyen
ne +/-écart typ
e)
The staff’s experience of NIDCAP in Brest, FranceMambrini C, Sizun J et al. Implantation des soins de développement et comportement du personnel soignant. Arch Pediatr. 2002 May; 9 Suppl 2:104s-106s.
Mean, sd
Parents’:Parents’: PresencePresence AttachmentAttachment
The staff’s experience of NIDCAP in Brussels Christine Rémont & Yves Hennequin(Int. Conf. on Infant Development in Neonatal Intensive Care, London 2003)
Parents’: Presence Attachment
The staff’s experience of NIDCAP in The staff’s experience of NIDCAP in LeidenLeiden Van der Pal, SM et al. Early Hum Dev (2007) 83, 425-432. Van der Pal, SM et al. Early Hum Dev (2007) 83, 425-432.
Parents’: Presence Way of caring Attachment
Caregiving plans andparents’: Presence Way of caring Attachment