madrid 2010 westrup

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

The ultimate objective of neonatologyCan developmental care help us to get there?

KapellouKapellou20062006

Impact of rearing conditions during the neonatal period on adult brain function

”Environmental/epigenetic programming”

Maternal programming of steroid receptor expression and phenotype through DNA methylation in the rat

Moshe Szyf, Michael J. Meaney. McGill University, Montreal, Canada Front Neuroendocrinol 2005

•Decreased methylation of glucocorticoid receptor promoter• => increased gene expression•Decreased ACTH & cortisol responses to stress in adulthood•Increased glucocorticoid receptor & BDNF mRNA in hippocampus and CRF mRNA in hypothalamus•Decreased epinephrine release in hypothalamus•Increased cholinergic innervation and synapotgenesis in hippocampus•Decreased stress behaviors (startle responses), increased explorative behavior•Increased spatial learning and memory

Consequences of natually occurring variations in pup licking/grooming (High LG vs. Low LG)

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

Titus Schlinzig, Mikael Norman et a.Acta Pediatr 98:7, 2009

NIDCAP

Newborn

IndividualizedDevelopmental

Care and

Assessment

Program

NIDCAP observation

Agneta Kleberg, Europe’s first (Master) NIDCAP trainer

Implementation at Karolinska

Systems perspective

Synactive Model of Developmental Care

Systems perspective

H. AlsH. Als


H. AlsH. Als

Observe

interpret

Support…

… selfregulation, stability, and possibly interaction

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

0102030405060708090

100

<25 25 26 27 28 29 30 31-33

CPAPCPAP

MVMV

%

Gest. age Gest. age >> 27 – not regionalized deliveries 27 – not regionalized deliveries

< 27 more proactive, regionalized deliveries< 27 more proactive, regionalized deliveries< 25 prophylactic surfactant< 25 prophylactic surfactant

At birth 25+1, now two days At birth 25+1, now two days oldold

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

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Link

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Öre

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Stock

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10

Uppsa

la, n

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Umeå

, n=3

3

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

Minimize mother infant separationMinimize mother infant separation

Skin-to-skin

Born at 24 weeks

Now one week of age

Multipregnancies are a challange


H. Als, 2007H. Als, 2007

Family centered care at Level IIIKarolinska-Solna

Siblings at Level IIIKarolinska-Solna


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

Family lounge.NB the wireless monitoring of accompanying infant

Family lounge. NB the kangaroo position and the leeds implying a saturation monitor in the mother’s pocket

Nurse station with the central for the wireless monitors

Nurse with beepers connected to thewireless monitors


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 care

Does developmental care stop at discharge?

Home visits: NIDCAP IBAIP (Infant Behavioral Assessment Intervention Program)


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 70

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


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


Length of stay in hospital

Adjusted for: gestational age at birthA, non-Swedish-speaking backgroundA,B, settingA,B

Family care

n = 183

Standard care

n = 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)


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 care

n = 183

Standard care

n = 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)


Infant morbidity

Adjusted for: gestational age at birth, non-Swedish-speaking background, setting

Family care

n = 183

Standard care

n = 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)


Ventilatory assistance and supplemental oxygen Adjusted for: gestational age at birth, non-Swedish-speaking background, setting

All infants

Family care

n = 183

Standard care

n = 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


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

Time to stop?!

Photo Ann-Sofie Gustafsson, Karolinska NIDCAP Training Center

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

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

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1

2

3

4

5

-5

-4

-3

-2

-1

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1

2

3

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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

Scandinavian NIDCAP Center

NIDCAP in Nordic countriesNIDCAP in Nordic countries

4th Nordic Neonatal Meeting, 20-21 Nov, 20094th Nordic Neonatal Meeting, 20-21 Nov, 2009Björn Westrup Björn Westrup

Karolinska Institutet, Stockholm SwedenKarolinska Institutet, Stockholm SwedenPhoto Ann-Sofie Gustafsson, Scandinavian NIDCAP CenterPhoto Ann-Sofie Gustafsson, Scandinavian NIDCAP Center

www.nidcap.org

http://www.nidcap.org/

NIDCAP Training Centers

US: 10 Ctrs.

EU: 5 Ctrs.

S. Am: 1 Ctr.

US Training Centers

European Training Centers

UK Ctr

French

Rotterdam

Karolinska Sthlm

Brussels

..\..\..\..\20th annual NIDCAP Trainers meeting materials\presentations\Saturday\Training reports 09\2009 NIDCAP Training Update Summary.pdf

NIDCAP activity in Sweden

CertifiedPersons (units)

TraineesPersons (units)

2007

2006

2005

2004

54(18)

50(16)

45(16)

43(15)

29(10)

28(10)

25(8)

2003 26(11) 37(10)

2002 20(10) 36(12)

2001 17(9) 38(11)

1994 7(4)

1992 3(2)

Swedish neonatal units with NIDCAP (certified professionals or persons in training)

KUS-Solna, KUS-Danderyd KUS-Huddinge SÖS Uppsala Lund Malmö Helsingborg Halmstad Borås Möndal Östra Falun

Skövde Örebro Västerås Linköping Karlstad Trollhättan Jönköping Växjö Kalmar Karlskrona Umeå Östersund

25 units including all universities

Norwegian neonatal units with NIDCAP

Sted Introduserte Sertifiserte Trainer-in-Training

Tromsø 4 3

Trondheim 3 3

Levanger 3 2

Ålesund 12 5 2

Førde 2 2

Bergen 4 3

Haugesund 1 1

Stavanger 4 3

Kristiansand 1 1

Lillehammer 2 2

Rikshospitalet 1 1

Neonatal units with NIDCAP in othernordic countries(certified professionals or persons in training)

Denmark Copenhagen 2 prof 2 trainees Aarhus 2 prof 2 trainees Hvidovre 1 trainee Hilleröd 2 prof

4 units including 3 universities units

Finland Helsinki 1 trainee

Iceland

Scandinavian NIDCAP Center

Scientific context of Scientific context of family centred developmentally family centred developmentally supportive supportive coupletcouplet care care / NIDCAP/ NIDCAP

4th Nordic Neonatal Meeting, 20-21 Nov, 20094th Nordic Neonatal Meeting, 20-21 Nov, 2009Björn Westrup Björn Westrup

Karolinska Institutet, Stockholm SwedenKarolinska Institutet, Stockholm SwedenPhoto Ann-Sofie Gustafsson, Scandinavian NIDCAP CenterPhoto Ann-Sofie Gustafsson, Scandinavian NIDCAP Center

Brain development

Evrard P, et al Acta Paediatr suppl 422,20-6. 1997

Number of invasive procedures

(Barker and Rutter 1995)

It is too noisy! Does it matter?

Sound and physiological responses

J Long, J Lucey, A Philip. Pediatrics 1980;65:143-45

One week old boy in an incubator, born at 34 weeks, BW 2020g

Heart rate

Sound level

Respir.

Tc-pO2

Intracran.pressure

Lehtonen L, et al. J Pediatr 2002;141:363-9

Relation of sleep state to hypoxemic episodes in ventilated ELBW infants

Behavioral science:something for ’docs’?

"The behavior of the infant is its primary way to communicate” (Als – developmental psychologist at Harvard)

"Behavior is produced by networks of interacting nervcells” (Sten Grillner - Neuroscientist at Karolinska

Institute

The Synactive Theory subsystems:

• Autonomic• Motor• State-• Attentional / Interactive

The synactive theory focuses on howthe individual infant handles

environmen-tal experiences, and social interactionwhich can be supportive or disrupt theinfant’s balance

Whenever development occurs, itproceeds to a state of increasingdifferentiationBreathing: irregular, deep or shallow tosmooth and regular. Movements: become better modulatedand fine tuned;Sleep-wake states: Diffuse to robust

The infant always strives for integration

of the subsystems.

Appropriate stimulus - infant will movetowards the stimulus

Inappropriate stimulus (timing, too complex

or to intense) – the infant will move away

from the stimulus and avoid it

Autonomic-physiologic system

• Circulation

• colour

• respiration

•Bowel movements

•Temperature control

• Tremor, jitternes

Motor system

State system

Attentional and interactive system

selfregulation

What is the scientific support, the level of evidence?

Short-term outcome

A positive impact is indicated on...Pulmonary morbidity (Als ’94, ’03, ‘04, Fleisher ’95, Westrup

’00, Peters ‘04)

Neurophysiology (Als ’94 & ‘04, Buehler ’95)

and to some degree on...Head growth (Stevens ’97, Westrup ’00, Maguire ’03, Als 03 )

Brain lesions (Als ’94, Fleisher ’95, Westrup ’00, ’02) Length of stay (Als ’94, 03 , Fleisher ’95, Westrup ’00, Peters 04)

Costs (Becker ’91, Als ’94,’03, Fleisher ’95, Petryshen ’97, Brown ‘97)

Long-term outcome

A positive impact is clearly indicated on...Mental development up to 9/12 months

(Als ’94 & ‘04, Ariagno ’97, Kleberg ’02, Peters 08)

and to a some degree on...Motor development up to 9/12 months

(Als ’94 & ‘04, Ariagno ’97, Kleberg ’02)

Long-term behavior (Kleberg ‘02, Westrup ‘04)

Performance intelligence (Westrup ‘04)

Mother-infant interaction (Kleberg ‘00)

Does NIDCAP improve outcome?

Level of evidenceResults of most RCTs point in a positive directionMost published RCTs are few and with small n:sObservational studies are also supportiveClear cut study designs are difficult to achieveMost follow-up periods are short Few trials on cost-effectiveness (prim. outc.)

RecommendationAcquire the “know how” in your nurseryIn order to be able to … Engage in future research

Sleep of preterm neonates under developmental care or regular environmental conditions

0

20

40

60

80

100

120

140

160

180

TST AS QS IS LAT

dura

tion

(mn)

DC

CONTROL

V Bertelle, J Sizun et al. Early Hum Dev 2005;81:595-600V Bertelle, J Sizun et al. Early Hum Dev 2005;81:595-600

Weighing

Lift the baby out to the scale wrapped in a soft towel to help him maintain balance

Physiological, behavioral and biological stress expression during a weighing procedure. Catelin et al. J Pain 2005

0

1

2

3

4

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6

zero* 5min 30min

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< 32 w

0

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6

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* **

*

*

32 > GA < 37w

EDINWhite: dev careBlack: conv. care

Salivary cortisol (g/dl)

0,0

0,2

0,4

0,6

0,8

1,0

before weighing 30 min after weighing

sa

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0,2

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Physiological, behavioral and biological stress expression during a weighing procedure. Catelin et al. J Pain 2005

0

2

4

6

8

10

12

V O2 V CO2

DC

Control

*

* p<0.01

* * p<0.05

ml/m

in

* *

Reduced O2 consumption and CO2 production when supported by developmental care

Impact of Developmental Care on Oxygen Consumption & CO2 emission in Preterm Neonates L.Jacquemot, T.Testa, J.Delarue, J.Sizun. Abstract: 18th Annual NIDCAP Trainers’ Meeting Combrit, October, 2007

The Green way

Effect from NIDCAP-intervention during/after eye examination for ROPKleberg et al. Lower stress responses after Newborn Individualized Developmental Care and Assessment Program care during eye screening examinations for retinopathy of prematurity: a randomized study.

Pediatrics. 2008 May;121(5):e1267-78. No effect on pain scores Salivary cortisol decreased

earlier after NIDCAP-intervention

Intervention scores for ”standard care” approaches NIDCAP with increasing number of examinations in an open study evaluating support during ROP-examinations

Examination number in study

706050403020100

Su

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ntio

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60

50

40

30

20

Intervention

NIDCAP

Standard care

Kleberg et al,

Support during painful procedures

Shield infant from bright light and offer

your finger to suck on

Sidelying, flexed position, support of the back and hands in the midline by the mouth

Infants with catheters or chest tubes requires more visual access but could be supported

The Edmonton NIDCAP Trial

Peters et al, Pediatrics Oct 2009

NIDCAPN=56

CONTROLN=55

OR

Gestational age 27,5 (1.4) 27.0 (2.3) ns

Birth weight 988.2 (183.7) 927.1 (204.0) ns



NIDCAPN=56

CONTROLN=55

OR


Birth weight 988.2 (183.7) 927.1 (204.0) ns

Length of stay (mean) 74 84 0.003

Chronic lung disease 29% 49% 0.42 (0.18-0.95)

0.035

The LeidenTrial

Maguire et al, Pediatrics Apr & Oct 2009

NIDCAPN=81

CONTROLN=83

OR

Gestational age 29.3 (1.8) 29.2 (1.6) ns

Birth weight 1215 (328) 1226 (343) ns

The LeidenTrial


NIDCAPN=81

CONTROLN=83

OR


Birth weight 1215 (328) 1226 (343) ns

Length of stay (mean) 41.5 (30.9) 40.4 (37.9) ns

Chronic lung disease 15% 19% ns

Early experience alters brain function and structure Als H, Duffy F, McAnulty G, Rivkin M, Hüppi P et al.Pediatrics 2004; 113: 846-857

NIDCAPN: 16

ControlN: 14

Gestational age 31.2(1.4)

31.8

(1.5)

Birthweight 1648

(232)

1730(350)

SNAP-PE 8.0

(4.4)

7.4

(3.6)

Developmental care, brain structure and function Als H, Duffy F, McAnulty G, Rivkin M, Hüppi P et al. Early experience alters brain function and structure. Pediatrics 2004; 113: 846-857

At term Better neurobehavioral functioning (APIB) Increased cortical coherence (spectral EEG) More mature fiber structure (MRI-DTI)

At 9 months:

improved mental, motor and behavioral

function (Bayley Scale of Infant Development-II)

EEG coherence: Red=positive/increased, blue=negative, green=decreased. Als et al 2004.

Anisotropy E1/E3 – threshold ≥ 1.3Arrows –white : Frontal White Matter

black : Internal Capsule (posterior limbs)

at a post menstrual age of 42 weeks

Control (A) NIDCAP (B)

Diffusion Tensor Imaging

BA

Aals H, Duffy F, Rivkin M, Hüppi P et al. Early experience alters brain function and structure. Pediatrics 2004; 113: 846-857

Study population

For example … Early experience alters brain function and structure

(Als 2004)Gestational age: ~31 wks; birth weight: ~1700g

Leiden IIGestational age: ~29 wks; birth weight: ~1200g

Edmonton NIDCAP TrialGestational age: ~27 wks; birth weight: ~950g

Selection/enrolment of subjects – the sample

Bias of selection?Inborn / Outborn

Leiden II: ~60% / 40% Edmonton NIDCAP Trial: ~95% / 5%

Periods of stopped enrolment Edmonton NIDCAP Trial lost 39 eligible infants due to

investigators were not available

Intervention: fidelity and contrast Were the infants in the intervention group in Leiden II getting

it? ~15 infants were enrolled every month (2/week)

“After inclusion in phase 1 was completed and before starting inclusion of infants into phase 2, we spent 2 months providing extra lessons to a team of nurses that would be primarily caring for the NIDCAP infants. … There were 5 nurses in the group who were completing NIDCAP training and who became certified and were able to assist under guidance from the developmental psychologist in carrying out NIDCAP observations and supporting the care team, infants and parents”

Only 21 NIDCAP and 23 control infants stayed more that 1½ month in the study hospitals

Intervention: fidelity and contrast

Are the infants in the control group not getting itis there adequate contrast or is there a spill-over effect?

Leiden:12 intensive care +17 high care =29 beds (184 infants during 2 years) Leiden: 8 intensive care beds and 8 “high care” beds The Hague: 4 intensive care beds and 9 “high care” beds

Edmonton: 55 beds (110 infants during 5 years. Only one of the control infants received NIDCAP-educated nursing care hours)

The Stockholm experienceThe Lund-London experience

Intervention scores for ”standard care” approaches NIDCAP with increasing number of examinations in an open study evaluating support during ROP-examinations

Examination number in study

706050403020100

Su

mm

ary

of

inte

rve

ntio

n

60

50

40

30

20

Intervention

NIDCAP

Standard care

Kleberg et al, Kleberg et al,

Cultural and demographical context

Socioeconomic status SESLeiden II

Education level of the mother

Low 22/66 (33.3%) vs. 19/74 (25.7%)

Intermediate 23/66 (34.8%) vs. 25/74 (33.8%)

High 21/66 (31.8%) vs. 30/74 (40.5%)

Edmonton NIDCAP TrialSES score (Blishen)

median (range) 41(21-101) vs. 39 (21-101)

Long-term effect



NIDCAPN=56

CONTROLN=55

OR


Birth weight 988.2 (183.7) 927.1 (204.0) ns

Length of stay (mean) 74 84 0.003

Chronic lung disease 29% 49% 0.42 (0.18-0.95)

0.035

Mental delay at 18 months 10% 30% 0.25(0.08-0.82)

0.017

Severe disability at 24 months 6% 20% 0.25(0.06-0.97)

0.034

The LeidenTrial


NIDCAPN=81

CONTROLN=83

OR


Birth weight 1215 (328) 1226 (343) ns

Length of stay (mean) 41.5 (30.9) 40.4 (37.9) ns

Chronic lung disease 15% 19% ns

Mental delay at 24 months 7.9% 4.0% ns

Severe disability at 24 months 19.1% 12.8% ns

Cognitive Indices at Cognitive Indices at oneone* * and and fivefive years yearsActa Paediatrica 2004;93:1-10Acta Paediatrica 2004;93:1-10 Bayley Mental Index; Bayley Mental Index; Wechsler Preschool and Primary Scale of IntelligenceWechsler Preschool and Primary Scale of Intelligence (WPPSI) (WPPSI)

159 1111N =

five yearsone year

Co

gn

itive

ind

ex

140

130

120

110

100

90

80

70

60

50

40

30

20

NIDCAP

Conventional care

* A Kleberg, B Westrup, H Lagercrantz, K Stjernqvist. Early Human Development 2002;60:123-35

Performance IQ and mortality at 5 yearsPerformance IQ and mortality at 5 years(WPPSI-R PIQ, corrected age) (WPPSI-R PIQ, corrected age) Acta Paediatrica 2004;93:1-10Acta Paediatrica 2004;93:1-10

NIDCAP care Conventional care

normalsubnormalabnormaldeceased

Grading of performance cognition at five years

Pies show counts

n=9

n=2

n=2

n=9

n=2

n=4

n=4

Odds RatioOdds Ratio for surviving …for surviving …

(95% CI) (95% CI)

NIDCAP / ControlNIDCAP / Control P-valueP-value

with PIQ with PIQ >> 70 70 6.7 6.7 (0.7 – >100)(0.7 – >100) 0.110.11

Exact logistic regression Exact logistic regression correcting for correcting for gendergender,, gest age, gest age, relative birth-weight, education of parents relative birth-weight, education of parents

Behaviour and mortality at 5 yearsBehaviour and mortality at 5 yearsSubtests of the NEPSY Subtests of the NEPSY test battery: activity and distractibilitytest battery: activity and distractibility

Acta Paediatrica 2004;93:1-10Acta Paediatrica 2004;93:1-10

normalminor behavioural deficitssignificant behavioural deficitsdeceased

Behaviour at five year follow-up

Pies show countsn=7

n=3

n=1

n=2


n=7

n=3

n=5

n=4

Odds RatioOdds Ratio for surviving …for surviving …

(95% CI) (95% CI)

NIDCAP / ControlNIDCAP / Control P-valueP-value

with normal behaviorwith normal behavior 19.9 19.9 (1.1 – >100)(1.1 – >100) 0.040.04

Exact logistic regression Exact logistic regression correcting for correcting for gendergender,, gest age, gest age, relative birth-weight, education of parents relative birth-weight, education of parents

NEPSY NEPSY (Korkman M 1990)(Korkman M 1990)

Neuropsychologic test: two sub tests (level of Neuropsychologic test: two sub tests (level of activityactivity and and distractibilitydistractibility ) were used, which can be ) were used, which can be considered as measures of overt behaviour in the considered as measures of overt behaviour in the test situation regarding test situation regarding

hyperactivityhyperactivity

attentionattention

The NEPSY scale is standardised in Sweden for The NEPSY scale is standardised in Sweden for children 4 to 7 years of age.children 4 to 7 years of age.

Dev. outcome, child behaviour and mother-child interaction at three years of age following NIDCAP intervention.

Falun, Sweden

<1500g

[Kleberg A, Westrup B, Stjernqvist K Early Human Dev 2000;60:123-135]

BEHAVIOURAL INTERVIEW*

(*Cederblad-Höök at three years)

CONTROLNIDCAP

BE

HA

VIO

RA

L S

CO

RE

30

25

20

15

10

5

0

INTERNALIZING

EXTERNALIZING

TOTAL

FALUN NIDCAP STUDY NIDCAP Control p-value*<1500g 1990; n:15 1992-93; n:18

Internalizing 0 (0-2) 2 (0-8) 0.02Externalizing 2 (0-10) 4 (0-18) nsTotal 6 (0-20) 16 (0-54) 0.03 median (range) * (Mann-Whitney)

Family in development, Bonding / attachment

Family in development; Bonding / attachment

Agneta Kleberg et al, Early Hum Dev 2007

Staffs’ ability to support her motherhood

3.5 (2.9-3.9) 3.2 (2.3-3.7) 0.066

Closeness to her infant 4 (3-4) 3.5 (2-4) 0.022

Anxiety 3.1 (2.0-3.7) 2.5 (1.3-3.3) 0.033

Mothers’ opinion NIDCAP n=10

Control n=10

P-value

Median (range); Mann-whitney U test if not otherwise indicated; Fisher’s Exact-test tested for subscales with only one or two items

Discussion

Closeness

Anxiety

0% 20% 40% 60% 80% 100%

infant in general

safety of infant

parents participation

physician's working condition

staff's working condition

costs

considerablypositive

positive

none

negative

considerablynegative

no opinion

B.Westrup, K. Stjernqvist, A. Kleberg, L. Hellström-Westas,H. Lagercrantz. B.Westrup, K. Stjernqvist, A. Kleberg, L. Hellström-Westas,H. Lagercrantz. Seminars in Neonatology 2002;7:447-457.Seminars in Neonatology 2002;7:447-457.

Swedish physicians’ view of NIDCAP’s influence onSwedish physicians’ view of NIDCAP’s influence on ... ...

Observe

interpret

Support the Support the …

… self-regulation, stability, and possibly interaction

Dev Care is not a new science but integrating natural science with behavioural science.

Is it now time to let our actions be geared by

Seeing/observing and

Respecting? Giotto 1267-1337Capella degli Scrovegni, Padova

Disability and mortality at 5 years Acta Paediatrica 2004;93:1-10


NormalImpaired without disabilityModerately disabledSeverely disabledDeceased

Outcome at five year follow-up

Pies show counts

n=4

n=4

n=1

n=2

n=2

n=6

n=1

n=5

n=3

n=4

Odds Ratio for surviving …

(95% CI)

NIDCAP / Control P-value

without disability 14.7 (0.8 – >100) 0.08

Exact logistic regression correcting for gender, gest age, relative birth-weight, education of parents

Overall cognition and mortality at 5 years(WPPSI-R FSIQ, corrected age) Acta Paediatrica 2004;93:1-10


normalsubnormalm-retardeddeceased

Grading of overall cognition at five years

Pies show counts

n=9

n=1

n=1

n=2

n=9

n=2

n=4

n=4

Odds Ratio for surviving …

(95% CI)

NIDCAP / Control P-value

with FSIQ > 70 3.5 (0.5 – 42) 0.29

Exact logistic regression correcting for gender, gest age, relative birth-weight, education of parents

The term and healthy - the vast majority of infants!

A paper to be defended at a dissertation at the Karolinska next month (examiner: Marshall Klaus)

Effect of closeness versus separation after birth and influence of swaddling on mother-infant interaction one year later:

a study in St. Petersburg

Ksenia Bystrova, Kerstin Uvnäs-Moberg, Ann-Marie Widström et al (submitted - revision)

Indicating the great importance of non-separation during the first couple of hours

Does infant behavior reflect findings in brain structure?

Structural and neurobehavioral delay in postnatal brain development of preterm infants

Hüppi PS et al. Pediatr Res 1996;39:895-01

[Hüppi PS et al. Pediatr Res 1996;39:895-01]

preterm group: 18 infants (30.5+1.8 wk) without need of mechanical ventilation or suspect neurologic conditions

term control group: 13 AGA (39.1+0.9 wk)

Assessed in the1st-3rd wk postnatally & at term with MRI Assessment of Preterm Infant’s Behavior (APIB) Als

current ability to process environmental inputlevel of smooth balanced functioning

Results:[Hüppi PS et al. Pediatr Res 1996;39:895-01]

preterm group: MRI-findings:maturation over time with an increase in

gray-white matter differentiation & myelination

delayed in comparison with the term infants

Behavioral findings:a parallel maturation of the APIB scoresdelayed in comparison with the term infants

increased autonomic reactivity increased motor reactivity delayed state organization delayed attentional availability

Risk of High Blood Pressure among Young Men Increases with Degree of Immaturity at Birth

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

Ad

just

ed

OR

Johansson, Iliadou, Bergvall, Norman et al. Circulation 2005:112:3430-3436

Kangaroo-Mother-Care

Dean 24+6Now one week

Kangaroo Mother Care Bogota

VLBW infants: Skin to skin 24 hrs/d, early discharge and frequent, regular out-patient check-ups

Aim: lower mortality/morbidity support the bonding and prevent abandoningsupport breast feeding

Whitelaw & Sleath 1985, Gomez, Sanabria, Marquette 1992

Kangaroo Mother Care Juan G. Ruiz - Nathalie Charpak, Bogota Colombia (Pediatrics 1997, 1998, 2001. Infant Behaviour and Development 2003

benefits in:

mortality early infectious morbidity growth and development promotion and maintenance of breast feeding a healthy bonding between mother and infant a better cranial growth neurodevelopment the provision of nurturing home environmentApplicable in more affluent societies? More research!!

Videoclip:

Transition from

skin-to-skin to incubator

RCT of skin-to-skin contact from birth versus conventional incubator care for physiological stabilisation in 1200 - 2199-gram newborns.

Cape Town, South Africa

Bergman NJ, Linley LL, Fawcus SR.

Acta Paediatrica 2004, 93(6); 779-785

SCRIPSCORE

2 1 0

Heart rate Regular Deceleration to 80-100

Rate <80 or >200 bpm

Respiratory rate

Regular Apnea <10s, or periodic breathing

Apnea >10sTachypnea

>80 pm

Oxygen saturation

Regular >87% Any fall to 80 – 87%

Any fall below 80%

Stability of Cardio-Respiratory system In Preterm Infants

Score allocated for a five minute period of continuous observation, maximum six for period. (Fischer et al, 1988)

Background characteristics Minimisation technique ensured groups balanced for confounders.

( n = 34) Kangaroo-Mother- Conventional-Mother- Care KMC Care CMC

Mean BW 1813g 1866g

Mean GA 34.2w 35.3w

Approp’ GA 65% 64%

Male 60% 50%

Bergman NJ et al, Acta Paediatrica 2004, 93(6); 779-785

STABILIZATION TREND.

SKIN-TO-SKIN (KMC): STABLE AT 6 hours INCUBATOR INFANTS (CMC) REMAIN UNSTABLE,WITH NO TREND TO STABILIZATION.

BIRTH RCT - SCRIP SCORES

4

5

6

60min 90min 120min 150min 180min 210min 240min 270min 300min 315min 330min 345min 360min

KMC CMC


Stabilisation first 6 hours, average hourly SCRIP score

5.1

5.2

5.3

5.4

5.5

5.6

5.7

5.8

5.9

6

6.1

2nd 3rd 4th 5th 6th

KMC all

KMC <1800

CMC all

CMC <1800


The Stockholm Family StudyA Örtenstrand, B Westrup, E Berggren Broström, I Sarman, S Åkerström, T Brune,

L Lindberg, U WaldenströmKarolinska Institute

N= Family Care Standard Care

182 183

Total length of hospital stay was reduced by 5.3 days:

mean 32.8 (95% CI:29.6-35.9) days vs. 27.4 (23.2-31.7) days (p=0.05).

Moderate to severe BPD

1.6% vs 6.0% (adjusted OR 0.18; 95% CI: 0.04-0.8).

Moderately preterm infants and determinants oflength of hospital stayM Altman, M Vanpée,S Cnattingius, M NormanArch Dis Child Fetal Neonatal Ed 2009;94:F414–F418

Population-based cohort including 2388 infants (2004–2005) with a gestational age of 30–34 weeks and admitted to 21 NICU:s reporting to the Swedish perinatal register.

Mean postmenstrual age (PMA) at discharge differed 2 weeks

Perinatal risk factors had small overall impact (R2: 13%) (explains 13% of

the variation)

Organizational factors in combination with perinatal risk factors had a greater impact: R2: 21% (explains 21% of the variation).

Infants treated at NICU without fixed discharge criteria: -4.7days PMA infants receiving domiciliary care: -9.8 days PMA Breastfed infants also had lower PMA at discharge: -2.7 days PMA

(partly explained by lower morbidity in the breastfed infants)

Outline

Patient flowDeliveryMaternityNeonatal nursery

Family centered care Couplet care

New units design plansTeam workCoachingRevenue issues

Delivery and maternity at Karolinska-Danderyd

Approx 10,000 deliveries / year230 twins, 3 triplets400 born prematurely - 5.8%

Delivery and maternity at Karolinska-Danderyd Planned C-sections: 16 beds for 26 c-sections/week

LOS: two daysweek-ends closed



Planned C-sections: 12 beds for 18 c-sections/week LOS: two daysweek-ends closed

Maternity and prenatal care: 24 beds

Delivery and maternity at Karolinska-Danderyd Patient Hotel; 24 beds

Uncomplicated delivery admitted after 2-6 hours after deliveryMidwifes on each shiftLOS: 2 nights for primipara. One night for multipara



Planned C-sections: 12 beds for 18 c-sections/week LOS: two daysweek-ends closed

Maternity and prenatal care: 24 beds Patient Hotel; 24 beds

Uncomplicated delivery admitted after 2-6 hours after deliveryMidwifes on each shiftLOS: 2 nights for primipara. One night for multipara

Karolinska-Danderyd

8 beds for mothers in need of medical care – Couplet Care Mean cencus 3.4 mothers (42%) Mean length of stay 1.7 days

Dept of Neonatology at the Karolinska University Hospital

Three NICU:s (Solna, Danderyd & Huddinge)

22 000 births/year, approx 2500 admittances/year 5% < 37 weeks 74 beds

14 beds for mechanical ventilation

37 rooms for families within the unitsOnly 30 with private bathrooms

Political decision to provide family rooms for everyone

Vanpee et al Acta Paediatrica 2007;96:10-16

Practice style for resuscitation

Inborn infants with GA <28 wks, 07/2001 to 06/2003

Boston

n = 70

Stockholm

n = 102

P value

Bag/mask ( %) 59 (84) 79 (77) ns

Intubation () 70 (100) 45 (44) P < 0.000

CPAP only (%) 0 (0) 21 (21) P<0.0001

Surfactant

# doses

2.3 1.5 P<0.0001

madrid 2010 westrup

Documents

increased stress responses

hypertension edstedt

dev care black

mikael norman et

gest age

weaver ic et

edurelative birthweight

chronic stress