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Madrid 2010 westrup handouts

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Ramon Perez
Ramon Perez

This document summarizes research on the staff experience with implementing the Newborn Individualized Developmental Care and Assessment Program (NIDCAP) in several neonatal intensive care units. Studies from Sweden, France, Belgium, and the Netherlands found that after NIDCAP implementation, staff generally reported improved parental presence at the bedside, stronger parental attachment to infants, and more collaborative caregiving with parents. Staff also perceived parents as having a more supportive way of caring for their infants. Overall, the research suggests NIDCAP facilitates more family-centered care by enhancing the parental role in the NICU according to staff perspectives.

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A systems perspective of developmentally supportive family centered care Cuidados Centrados en el Desarrollo y en la familia 11 y 12 de noviembre, 2010 Bj旦rn Westrup, MD Ph D Karolinska University Hospital Stockholm, Sweden
KapellouKapellou 20062006
Impact of rearing conditions during the neonatal period on adult brain function
A proposed link between variations in parentoffspring interactions and the development of individual differences in stress responses If critical conditions are present in early life of forms of parentoffspring interactions they promote increased stress responses and chronic stress in adulthood. Szyf M, Weaver IC et al Front Neuroendocrinol 2005
Prematurity associeted with medical conditions in adulthood: Hypertension Edstedt Bonamy et al, Pediatric Research 2005 Johansson et al, Circulation 2005 Sympatoadrenal hyperactivity Johansson 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 2005 Edstedt 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 Individualized Developmental 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 infants current stage of development current medical condition
0 10 20 30 40 50 60 70 80 90 100 <25 25 26 27 28 29 30 31- 33 CPAPCPAP MVMV %
Nice, 2008-10-26 B辿atrice Ski旦ld EAP 2008B辿atrice Ski旦ld EAP 2008 The Stockholm cohort <27 wksThe Stockholm cohort <27 wks White 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 17 13 12 12 6 13 0 10 20 30 40 50 60 VG region,n=74Link旦ping,n=41 rebro,n=16 Stockholm ,n=110U ppsala,n=78 U m e奪,n=33 Alla,n=352 BPD IVH, gr 3-4 ROP, gr 3-4 Morbidity (%) among survivors with gest. age 25-27 weeks Swedish 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 unit 1.5% in the maternity wards (jaundice, hypoglycemia, Downs 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
Samv奪rdsavdelning 20Samv奪rdsavdelning 20 Neonatalsektionen Karolinska-DanderydNeonatalsektionen Karolinska-Danderyd
Karolinska-Huddinge
Madrid 2010 westrup handouts
Madrid 2010 westrup handouts
Madrid 2010 westrup handouts
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
Madrid 2010 westrup handouts
Nurse with beepers connected to the wireless 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
Madrid 2010 westrup handouts
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 180 210 270 360 450 480 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 rtenstrand, B Westrup, E Berggren Brostr旦m, I Sarman, S kerstr旦m, T Brune, L Lindberg, U Waldenstr旦m Karolinska Institute, Stockholm Sweden Pediatrics Jan. 2010;125: e278e285
Annica rtenstrand 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 by Intention-to-treat: 183 Without congenital disease: 181 Analyzed by Intention-to-treat: 182 Without congenital disease: 177
Annica rtenstrand 38 Included infants Family care n = 183 Standard care n = 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 rtenstrand 39 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)
Annica rtenstrand 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 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)
Annica rtenstrand 41 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)
Annica rtenstrand 42 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
Annica rtenstrand 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 Intervention Karolinska-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.as
Staffs (expert?) opinion
The staffs experience of NIDCAP in Falun, Sweden Westrup, 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 and Parents: Presence Way of care Attachment
-5-4-3-2-1012345 -5=moinsbon,0=inchang辿,5=meilleur(moyenne+/-辿 The staffs experience of NIDCAP in Brest, France Mambrini C, Sizun J et al. Implantation des soins de d辿veloppement et comportement du personnel soignant. Arch Pediatr. 2002 May; 9 Suppl 2:104s-106s. Mean, sd Parents:Parents: PresencePresence AttachmentAttachment
The staffs experience of NIDCAP in Brussels Christine R辿mont & Yves Hennequin (Int. Conf. on Infant Development in Neonatal Intensive Care, London 2003) Parents: Presence Attachment
The staffs experience of NIDCAP inThe staffs 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 and parents: Presence Way of caring Attachment

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Madrid 2010 westrup handouts

  • 1. A systems perspective of developmentally supportive family centered care Cuidados Centrados en el Desarrollo y en la familia 11 y 12 de noviembre, 2010 Bj旦rn Westrup, MD Ph D Karolinska University Hospital Stockholm, Sweden
  • 3. Impact of rearing conditions during the neonatal period on adult brain function
  • 4. A proposed link between variations in parentoffspring interactions and the development of individual differences in stress responses If critical conditions are present in early life of forms of parentoffspring interactions they promote increased stress responses and chronic stress in adulthood. Szyf M, Weaver IC et al Front Neuroendocrinol 2005
  • 5. Prematurity associeted with medical conditions in adulthood: Hypertension Edstedt Bonamy et al, Pediatric Research 2005 Johansson et al, Circulation 2005 Sympatoadrenal hyperactivity Johansson 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 2005 Edstedt 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
  • 8. Synactive Model of Developmental Care Systems perspective H. AlsH. Als
  • 9. Synactive Model of Developmental Care H. AlsH. Als
  • 10. NIDCAP promotes resilience by providing developmentally adequate support during: care-giving social interaction examinations and procedures The care is governed by the infants current stage of development current medical condition
  • 11. 0 10 20 30 40 50 60 70 80 90 100 <25 25 26 27 28 29 30 31- 33 CPAPCPAP MVMV %
  • 12. Nice, 2008-10-26 B辿atrice Ski旦ld EAP 2008B辿atrice Ski旦ld EAP 2008 The Stockholm cohort <27 wksThe Stockholm cohort <27 wks White 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
  • 13. 26 wks 25 wks 24 wks 23 wks 22 wks Survival live-born infants (n = 707) acc. to gestational age at birth JAMA 2009
  • 14. 36 46 56 24 38 6 32 5 0 6 6 5 18 6 18 17 13 12 12 6 13 0 10 20 30 40 50 60 VG region,n=74Link旦ping,n=41 rebro,n=16 Stockholm ,n=110U ppsala,n=78 U m e奪,n=33 Alla,n=352 BPD IVH, gr 3-4 ROP, gr 3-4 Morbidity (%) among survivors with gest. age 25-27 weeks Swedish National Neonatal Register PNQ (2007-2008).
  • 15. 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 unit 1.5% in the maternity wards (jaundice, hypoglycemia, Downs 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
  • 16. Synactive Model of Developmental CareSynactive Model of Developmental Care H. AlsH. Als
  • 17. Synactive Model of Developmental Care H. Als, 2007H. Als, 2007
  • 18. Synactive Model of Developmental Care H. AlsH. Als
  • 19. Samv奪rdsavdelning 20Samv奪rdsavdelning 20 Neonatalsektionen Karolinska-DanderydNeonatalsektionen Karolinska-Danderyd
  • 24. 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
  • 26. Nurse with beepers connected to the wireless monitors
  • 27. Synactive Model of Developmental Care H. Als
  • 28. Large family room where we also care for mothers who are in need of medical care, except intensive care Couplet CareCouplet Care
  • 29. Large family room where we also care for mothers who are in need of medical care, except intensive care Couplet CareCouplet Care
  • 31. Does developmental care stop at discharge?
  • 32. Home visits: NIDCAP IBAIP (Infant Behavioral Assessment Intervention Program)
  • 33. Synactive Model of Developmental Care H. Als, 2007
  • 34. Parental benefit extension of days 180 210 270 360 450 480 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:
  • 35. The Stockholm Neonatal Family Centered Care Study: effects on length of stay and infant morbidity A rtenstrand, B Westrup, E Berggren Brostr旦m, I Sarman, S kerstr旦m, T Brune, L Lindberg, U Waldenstr旦m Karolinska Institute, Stockholm Sweden Pediatrics Jan. 2010;125: e278e285
  • 36. Annica rtenstrand 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.
  • 37. 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 by Intention-to-treat: 183 Without congenital disease: 181 Analyzed by Intention-to-treat: 182 Without congenital disease: 177
  • 38. Annica rtenstrand 38 Included infants Family care n = 183 Standard care n = 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
  • 39. Annica rtenstrand 39 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)
  • 40. Annica rtenstrand 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 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)
  • 41. Annica rtenstrand 41 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)
  • 42. Annica rtenstrand 42 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
  • 43. 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
  • 44. Annica rtenstrand 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
  • 45. Ultra-Early Intervention Karolinska-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.as
  • 47. The staffs experience of NIDCAP in Falun, Sweden Westrup, 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 and Parents: Presence Way of care Attachment
  • 48. -5-4-3-2-1012345 -5=moinsbon,0=inchang辿,5=meilleur(moyenne+/-辿 The staffs experience of NIDCAP in Brest, France Mambrini C, Sizun J et al. Implantation des soins de d辿veloppement et comportement du personnel soignant. Arch Pediatr. 2002 May; 9 Suppl 2:104s-106s. Mean, sd Parents:Parents: PresencePresence AttachmentAttachment
  • 49. The staffs experience of NIDCAP in Brussels Christine R辿mont & Yves Hennequin (Int. Conf. on Infant Development in Neonatal Intensive Care, London 2003) Parents: Presence Attachment
  • 50. The staffs experience of NIDCAP inThe staffs 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 and parents: Presence Way of caring Attachment

Editor's Notes

  • #13: As you remember conventional images were scored and classified into 4 groups and this slide shows the incidence of the different WM abnormalitites in the cohort. 86% of infants in the cohort had normal or mild WM abn, and only 14% had moderate- severe abn. Jfr INDER: These results are comparable to international data, for ex an Australian cohort of 100 infants where 20% had moderate-severe abnormalities and 29% had normal WM (Inder et al 2003) But the GA of the infants in the present cohort is lower, here 65 infants were born &amp;lt;26 w whereas, out of the 100 australian infants, only 11 were born &amp;lt;26w. The rates did not differ between the two groups. Inder 03: mean GA 27.9 賊2.4 w (23-32 w), mean BW 1063 賊 292 g Normal-mild 80%, Normal 29% , Mild 51%, Mod-severe non-c 16%, Mod-severe cyst 4% Sandras: mean GA 25.4 w (23+4 -26+6), mean BW 775 g (494-1114).
  • #35: Diagrammet visar utvecklingen av antal dagar sedan fp inf旦rdes 1974. 1974: 180 dagar (6 m奪n). F旦rs辰kringen har sedan kontinuerligt ut旦kats med flera dagar. Med undantag f旦r 1994 d奪 nya regler om v奪rdnadsbidrag inf旦rdes f旦r en kort tid. 1995 inf旦rdes pappam奪naden, 30 dagar ej 旦verl奪tningsbara mellan f旦r辰ldrarna. M奪let var att 旦ka pappornas uttag av fp, f旦rtydliga att h辰lften av dagarna tillh旦r vardera f旦r辰ldern. 2002 inf旦rdes ytterligare en reserverad m奪nad, antalet fp-dagar 辰r sedan dess 480 (16 m奪nader), varav 2 m奪nader 辰r reserverade f旦r vardera f旦r辰lderna. 240 dagar var.
  • #37: Independent of the infants needs of monitoring, parents had a separate room in the unit from the first day including beds for both parents and a private bathroom. Infants in the intensive care rooms moved into the family rooms as soon as they reached a stable state. The parents had the primary contact with the baby and call the staff when needed.