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
Björn 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 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
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
10. 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
12. Nice, 2008-10-26
Béatrice Skiöld EAP 2008Béatrice Skiöld 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=74Linköping,n=41
Ö
rebro,n=16
Stockholm
,n=110U
ppsala,n=78
U
m
eå,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, 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
16. Synactive Model of Developmental CareSynactive Model of Developmental Care
H. AlsH. Als
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
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 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
36. 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.
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 Örtenstrand 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 Örtenstrand 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 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 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 Örtenstrand 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 Örtenstrand 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 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
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 staff’s 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
49. 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
50. The staff’s experience of NIDCAP inThe 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 and
parents’:
Presence
Way of caring
Attachment
Editor's Notes
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 &lt;26 w whereas, out of the 100 australian infants, only 11 were born &lt;26w.
The rates did not differ between the two groups.
Inder 03: mean GA 27.9 ±2.4 w (23-32 w), mean BW 1063 ± 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).
Diagrammet visar utvecklingen av antal dagar sedan fp infördes 1974.
1974: 180 dagar (6 mån). Försäkringen har sedan kontinuerligt utökats med flera dagar. Med undantag för 1994 då nya regler om vårdnadsbidrag infördes för en kort tid.
1995 infördes “pappamånaden”, 30 dagar ej överlåtningsbara mellan föräldrarna. Målet var att öka pappornas uttag av fp, förtydliga att hälften av dagarna tillhör vardera föräldern.
2002 infördes ytterligare en reserverad månad, antalet fp-dagar är sedan dess 480 (16 månader), varav 2 månader är reserverade för vardera förälderna. 240 dagar var.
Independent of the infant’s 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.
