madrid 2010 westrup handouts

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

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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

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<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

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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

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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

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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

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Parents’: Presence Way of care Attachment

Caregiving plans andParents’: Presence Way of care Attachment

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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