Neonatal(Touch(&(Massage(Cer3ﬁcaon( Jan(Hunter,(MA,(OTR ... · Neonatal(Touch(&(Massage(Cer3ﬁcaon(By(Creave(Therapy(Consultants(Jan(Hunter,(MA,(OTR...

Neonatal Touch & Massage Cer3fica3on By Crea3ve Therapy Consultants

Jan Hunter, MA, OTR Clear Lake Regional Medical Center

These Handouts are not intended to be used outside of NTMC On-‐Line Educa3on.

Property of Crea3ve Therapy Consultants Not for Duplica3on 1

Jan Hunter, MA, OTR

Developmental Specialist Clear Lake Regional Medical Center; Assistant Professor University of Texas Medical Branch Sleep and Brain

NTMC, 2011

Sleep and Early Brain Development in the NICU

© 2011

2.  Be able to explain the critical impact of both sleep and sleep disruption on brain development and long-term function in the NICU infant.

3.  List at least three ways a NICU caregiver can purposely promote and protect sleep

1.  Discuss early brain development in terms of genetically-driven components and stimuli-dependent (endogenous and exogenous) neuronal development






© 2011

The womb allows more controlled and predictable

progression of neuronal development and

organization than does the NICU


© 2011

“In comparison to term-born infants, preterm infants at term demonstrated prominent reductions in cerebral cortical and in deep nuclear gray matter volume … The major predictors of altered cerebral volumes were gestational age at birth and the presence of cerebral white matter injury … Inder, et al, 2005

Can sleep make a difference?


© 2011

First trimester: Formation of basic structures

2 to 4 months: Proliferation of neuronal and glial cells,

which are stored in the germinal matrix

3 to 8 months: Early migration

of cells from the germinal

matrix to the cerebral cortex






© 2011

Five months gestation through childhood

Organization: Alignment, orientation, and layering of cortical neurons

Arborization: differentiation and branching of axons and dendrites to increase cell connection possibilities

Increased complexity: in brain surface convolutions (sulci and gyri) as different areas develop for specific functions.

Myelinization: 8 months gestation on …


© 2011

"   Genetically predetermined components

"   Stimuli dependent neuronal development Endogenous stimulation: activity-independent Exogenous stimulation: activity-dependent

23 weeks gestation

Term gestation


© 2011

Spontaneously firing neurons (retinal cells shown here) activate nearby neurons and create early pathways later refined by activity-dependent stimuli

Click movie to play






© 2011

Click movie to play

"   Programmed cell death, called apoptosis, occurs spontaneously during development for the purpose of synaptic pruning.

"   Preterm infants demonstrate increased apoptosis compared to normal term infants

Synaptic pruning eliminates weaker synaptic contacts while stronger connections are kept and strengthened


© 2011

Cortical neurons organize at incredible rates during early brain development. 1.8 million new synapses form

every second during the last trimester, but only during sleep

Click movie to play


© 2011

Note: If the movie clips in the previous three sides did not work in your webinar, you may pause the recording and click or paste in the following links to view the movie clips

1. Endogenous Neural Activity (retinal waves) http://www.stanford.edu/group/shatzlab/movies/retinal_waves.MPG 2. Apoptosis (programmed cell death) http://www.youtube.com/watch?v=D4nQatvbiq4 3. Neurons and How They Work (synaptogenesis) http://www.youtube.com/watc






© 2011

Neurons that fire together, wire together Neurons that don’t, won’t


© 2011

  Sensory systems have critical periods of development Somatosensory (touch), kinesthetic/proprioception; (movement,

position) chemosensory (smell & taste), auditory, visual

 Atypical onset and intensity of later-developing sensory experiences (e.g. vision) may interfere with the development or function of an earlier developing system (e.g. auditory)

  Variable impact of sensory stimuli if it occurs prior to or after term birth

  The exact amount, timing and sequence of sensory stimulation for the preterm newborn is unknown


© 2011 Liu, et.al., 2007; Laudert, et.al., 2007

Vermont Oxford Network

(Neonatal Intensive Care Quality Collaborative)

Multisite research, education and QI projects to identify, develop and implement potentially better practices that support the neuro-development of infants in the NICU

Sleep protection is identified as a recommended care practice to improve neurodevelopment for all NICU infants from birth at

any gestational age






© 2011

  Brain plasticity may lessen the negative effects of a high risk NICU environment, resulting in a measurable difference when comparing less supportive to more supportive care practices.

  Potentially better practices, demonstrated to be safe but with limited clinical evidence for long-term benefit, become more compelling when compared to existing practices with uncertain safety and no evidence of benefit.

  Implementation of “Bundles of Care” may have greater likelihood of resulting in measurable long-term benefit

Liu, et.al., 2007; Laudert, et.al., 2007


© 2011 Liu, et.al., 2007; Laudert, et.al., 2007

Bundle #1: Implemented from birth, 23 weeks GA and older

8 of the 11 care prac3ces recommended to support neurodevelopment for all NICU admissions star3ng at 23 weeks gesta3on protect or support sleep


© 2011

P

erce

nt of s

taff in

agr

eemen

t

90 80 70 60 50 40 30 20 10 0

Staff Belief that Policies and Procedures are in Place To Support or Protect Neurosensory Development

Auditory Visual Chemosensory Tactile Sleep Protection Protection Protection Protection Protection

= Before QI Project = After QI Project

Laudert, et.al., 2007; Liu, et.al., 2007






© 2011

  Developing sleep of preterm infants is very different from sleep of term infants and adults

  Sleep is not a condition of “unconsciousness”. Neural activity in the brain is very high during sleep

  Sleep of preterm and ill NICU infants is affected by multiple

factors, e.g. environmental stimuli, non-emergent staff or parent

activity that disrupts sleep cycles,

medical acuity mandating care, medications, hormones, ...


© 2011

Non-REM sleep

Stage 1 – Drowsy or sleep onset Stage 2 – Light sleep

Stage 3 – Deep sleep (slow wave sleep)

Stage 4 – Deeper sleep (slow wave sleep)

REM Sleep

Rapid eye movements Restless sleep

Paradoxical sleep


© 2011

  REM sleep initially 50% of total sleep time (TST), decreases to 30% by age one

  Brain maturation during the first year allows clearer sleep stages to emerge

  NREM deep sleep (stages 3 and 4) become prominent in young children, then will decrease over the lifespan

  Sleep cycle is shorter (50 to 60 minutes) in a term infant






© 2011

  Indeterminate state (immature sleep stage) Only sleep state on EEG prior to 28 weeks GA Gradually replaced by EEG identifiable sleep states Indeterminate state and arousals are associated with less stable oxygenation/hypoxemic episodes

  Active sleep (REM) Develops before quiet sleep May comprise up to 75% of TST Increased in SGA babies

  Quiet sleep (NREM) Better in prone (vs. supine) for less mature infants


© 2011

12-trach polysomnographic record = 8-track EEG, 2-track ocular movements, 1 track each for RR/HR. Bertelle et al, 2007

Active sleep Characteristic continuous EEG pattern, eye movements

present, irregular HR and RR

Quiet sleep Characteristic discontinuous EEG pattern, no eye movements,

regular HR and RR


© 2011

  Sleep stage scoring

Based on EEG or continuous EEG recording, polysomnography, or functional brain imaging

These methods generally correlate well with each other

Automated analysis

  Actigraph

Muscle activity recording






© 2011

Behavioral Characteristics = Most common assessment in clinical use, but does not necessarily correlate with sleep states on EEG. May include eye opening, closed eye movements, muscle tone, motor activity, respirations, heart rate, facial expressions

Indicator 0 1 2 Score

Eyes Lids closed with intermittent REM (rapid eye movement)

Lids closed; no REM observed

Lids open

Respirations Uneven respirations Relatively regular and abdominal

Regular respirations, maybe crying

Facial Expressions

Negative facial expressions (cry face or a frown)

Quiet facies, occasional sigh/startle

Interactive facies

Motor Activity

Sporadic motor movements, muscle tone low between movements

Tonic level of motor tone is maintained and motor activity is limited to startles or sighs

Motor activity varies but is usually high

< 3 = wait, don’t disturb; 3-6 = arouse gently; > 6 = ready for cares Cumulative Score =

Neo SWAT: Sleep-Wake Assessment Tool, © Caring Essentials Collaborative 2010


© 2011

Sleep studies on premies have described immature sleep state cycles after 30 weeks pca, with stability over multiple cycles only after 36 weeks (Mirmiran, Maas & Ariagno, 2003)

More recently sleep state cycles have been shown in a majority of premies between 25 and 30 weeks pca; reflects biologic rhythm

during stages of early brain development (Scher, Johnson, & Holditch-Davis, 2005)


© 2011

REM sleep deprivation in infancy can result in:

"   Disordered sensory and brain neural development

"   Disordered / disrupted learning and memory creation

"   Dif@iculties with behavior and adapting to change

"   Loss of cortical brain plasticity into adult life

"   Increased neuronal cell death with smaller adult brain size

Graven, 2006; Liu, et al, 2007; Peirano & Algarin, 2007






© 2011

Non-REM (NREM) sleep deprivation in infancy can cause:

"   Decreased learning and memory consolidation from sensory experiences (vision, hearing and touch)

"   Decreased aptitude for learning in childhood and adult life

"   Decreased brain plasticity into adult life

"   Smaller adult brain size "   Depressed immune function

Graven, 2006; Liu, et al, 2007; Peirano & Algarin, 2007


© 2011

  Activities, pain, and drugs alter REM sleep time and quality

  Minimize exposure to narcotics and other medications that may disrupt or disturb sleep cycles.

  Use non-‐pharmacologic methods for pain reduction and calming

  Time caregiving with emerging sleep cycles as much as possible

Bertelle, et al, 2005; Graven, 2006 Graven & Browne, 2008; Liu, et al, 2007


© 2011

  Therapeutic positioning with containment in body @lexion   Skin-‐to-‐skin holding

  Decrease painful and negative stimuli

  Minimize disruptive sensory stimuli

  Consider tactile component of procedures, slow/contained lifting and re -‐ positioning, odors, tastes, noise, light exposure (no direct light in eyes)

  Cue-‐based non-‐emergent care (with multidisciplinary cooperation) to minimize sleep disruption (with diurnal implementation, as possible, after 30 weeks gestation)

Bertelle, et al, 2005; Graven 2006; Graven & Browne, 2008; Liu, et al, 2007






© 2011

  Building the brain and sensory systems from 25 wks gestation to 3–5 months of age; REM sleep is speci@ically required

  Developing early brain architecture

  Learning and memory

  Preservation of lifetime brain plasticity and future learning capacity

Organized sleep is essential for:

Brain plasticity = within genetically determined limits, the capacity to modify neuronal structure and function in response to environmental factors and stressors


© 2011

  Sleep preservation is a NICU (unmet) standard of care

  Protected sleep is absolutely essential for early brain and sensory system development

  Sleep disruption and deprivation contribute to disordered brain / sensory system development

Historically, premies as a group have smaller brains, more difficulty with

abstract reasoning and adapting to

change, and less brain plasticity for life compared to those born at term.

Can we improve upon history??

… as told by Mariah

with Sarah McLachlan, “Ordinary Miracle”

”Tale of a NICU Infant” is available as a download for educational use from www.sundancesolutions.com






with Sarah McLachlan, “Ordinary Miracle”

Because all infants in the NICU are fragile. Many of my friends aren’t “broken”, they’re just not “done” yet. Other friends are very sick.

We are vulnerable; we need protection and support.

So I speak for all of us. Please listen to my story …

“ Tale of a NICU Infant”

My name is Mariah. This is my story, but not mine alone.

Once upon a time not too very long ago, a little girl was born way too early; she was gently carried to the NICU. Once she finally caught her breath . . .





“You’ll take good care of my

lungs and belly, but my brain

and the rest of me are not done

yet, either! I’m just not ready

to cope with all the stimulation

and demands of this new place.

I need kind-hearted people, my

heroes and heroines, who will

help protect me so I grow up to

be the very best I can be!”

“Help me, please help me” she cried …

The womb had everything I needed...

My physical needs were met. It was wet, warm, dark, cushioned, and protected. Sounds were muted through fluid. I moved freely, and slept undisturbed. Mom’s body and activity set day/night cycles for me.

I was learning to organize myself by bringing my hands to my mouth or face, sucking, grasping with my hands, and bracing with my feet.

I loved sleeping whenever I wanted! My brain really needs sleep to fully develop. In the

outer layer of my brain (called the cortex), neurons have

been connecting (only during sleep) at an incredible rate; 1.8 million new synapses are

being formed every second!

I really am quite an amazing baby!

23 weeks gestation

Term gestation





My sensory and nervous system development in the womb is orderly, controlled and predictable.

Tactile (touch, pain, temperature)

Vestibular (balance, movement)

Taste and Smell

Auditory (hearing)

Vision (seeing)

Except for vision, my sensory systems are all structurally complete (but still functionally immature) at the very earliest birth age I can hope to survive.

Before birth, my entire body is always supported by fluid and flexible boundaries

  Contained in flexion and midline

  Receiving support for body functions

  Able to sleep and sleep and sleep …

After I kick, stretch and squirm, the uterine wall gives me a gentle push back towards flexion

I am consistently and comfortably:

I could do everything I was supposed to do in the womb, but am just

not ready for “outside”.

These new physiologic and environmental demands far exceed my immature capabilities. It’s very scary for my family and me!





Since being born so early, my immature brain and sensory systems continue

to develop, but now in an unpredictable and much

more stimulating place.

Touch, temperature, pain, movement, smells, tastes, noise, light, handling, sleep, and daily routines are all quite different for me now!!

OUCH!

Touch

When I was a just a wee speck of a baby-to-be, my brain and skin both developed from the same layer of early cells (called the ectoderm).

This means sensations from my skin talk directly to my brain. It’s why I like comfort and being held

on your chest, and why I don’t like pain!

Turning me with a fast “premie flip” (holding my head and bottom, arms and legs dangling) can leave me disorganized

and dizzy for a long time! Please move me slowly, keeping my arms and legs tucked close to my body

and my head in midline.

Movement





I already know my mom’s scent; it’s the best! But medical smells, cigarette smoke, scented lotions, and strong aftershaves can overwhelm and stress me …

Taste and Smell

I prefer sweet tastes, and really don’t like bitter.

These meds would gag you, too!

Hearing

It can be so loud and chaotic in here! Air vents, doors, alarms, equipment, phones, pagers - - and the people! It’s hard to relax, sleep, grow, and heal when you’re so loud!

All this noise in my bedroom can:

  Increase arousal, agitation, and pressure inside my head

  Decrease my oxygen sats

  Disturb the quality of my sleep, even if I don’t “wake up”

  Make me lose weight

  Contribute to hearing loss

Before birth, my eyes developed

in darkness and during sleep. In

fact, light exposure too early now

may interfere with how I process

what I hear when I’m school age.

I can’t protect my eyes by myself.

My eyelids are thin and don’t stay

tightly closed yet. My pupil is really

big because my iris can’t make itself

smaller until 30-34 weeks.

Will you please shield my eyes?

Vision





  Sleep is more important to me than keeping a schedule!

  I really need sleep to save my energy, to help my brain and sensory systems develop, and to grow and recover

  Caregiving, pain and drugs change my amount and quality of sleep. Just like time, lost sleep is gone forever!

  Try some non-drug methods (like good positioning or a hand swaddle) to reduce discomfort and calm me. That often can help!

I need lots and lots and lots of sleep!!

I’ll do my very best to communicate, to let you know when I need extra help and when I’m doing OK for the moment.

Of course I can’t talk yet, but if you watch me carefully you’ll learn to “read” my cues of

stress and stability.

Sometimes my body doesn’t work too well yet.

Be careful with me if:

  My skin is not a healthy color (pale, dusky, blue, pale, ashen, gray, flushed, mottled, …)

  I’m working really hard to breathe, my heart rate is too slow or too fast, and if the oxygen in my blood is too low.

  I’m having trouble digesting my food, especially if my tummy gets big and discolored. Ouch!





My muscle tone and movements suggest stress if:   My body is limp or stiff when I’m resting   I forcefully extend (straighten) my arms and legs   I’m often squirming and restless   I’m frantic! Or have lots of startles and tremors

Sleep and Waking Up

I might be overstimulated if I’m restless, don’t sleep well, fuss a lot, or don’t have quiet awake times.

Sleep and Waking Up

Can you see I’m getting better?

  My skin color is healthy.

  I’m breathing pretty well on my own.

  My movements are smoother. I try to tuck in my arms and legs, and I like to hold my blanket or touch my face.

  I’m learning to feed by mouth.

  I usually go from sleep to being awake with only a little fussing, and I calm more easily.





When I’m really small or sick, please be patient! Help protect me from overstimulation, and let me sleep as much as I can.

Before too long, I’ll be able to stay awake and tolerate stimuli for a little while. I just can’t wait to look at you, and connect your face

to your voice!

Remember how the womb kept me tucked in and cozy?

I can’t do that by myself. If you’ll position me like I’m used to, maybe I can avoid problems such as wasted oxygen and calories, positional deformities, developmental

delays, and skin irritation

from squirming around. Plus, if I’m comfortable and stay asleep longer, my brain will grow better!

I can’t thank you enough when you really pay attention to these things …

  My ever-changing needs as I grow and heal …

  Letting me sleep so my brain can grow!

  My cues as I try my best to “talk” to you

  Protection from all those things that overwhelm and stress me

  And comfortable positioning that lets me think I’m back in the womb, or safe in your hands…

All said and done, this is just

good common sense, and great

developmentally supportive care!






And that’s my story, the …

Credits: Thank you!

Camille Allen sculptures, www.camilleallen.com “In the Womb”, Rocket Rights UK

Sundance Enterprises, Inc. 79 Primrose Street, White Plains, NY 10606 877-560-9871 www.sundancesolutions.com

Therapeutic Positioning and Comfort for Sick and Preterm Infants

NICU Clinically Reported Z-Flo™ Benefits NEUROMOTOR DEVELOPMENT Individually - contoured nest promotes flexion, midline, and containment in three- dimensional, flexible, responsive boundaries

PHYSIOLOGIC FUNCTION AND STABILITY Energy conservation Protection of skin integrity Less body exposure to heat loss mechanics Non-pharmacologic pain management

EMPIRICALLY OBSERVED IMPROVED SLEEP Implications for early sensory and brain development

Neonatal(Touch(&(Massage(Cer3ﬁcaon( Jan(Hunter,(MA,(OTR ... · Neonatal(Touch(&(Massage(Cer3ﬁcaon(By(Creave(Therapy(Consultants(Jan(Hunter,(MA,(OTR...

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