E-NANN Supplement to NANN Central

Winter 2005 • Volume 21 Number 1

Parents Need Developmentally Supportive Care, Too
Deborah L. Davis, PhD, and Mara Tesler Stein, PsyD

Developmentally supportive care is an important practice in modern neonatology for infants in the NICU. It is care that promotes, sustains, and enhances physical, emotional, and cognitive development. Developmentally supportive care respects the premature or sick newborn’s immature nervous system and compromised health. It includes low lights, hushed sounds, warmth, swaddling, nesting, gentle touch, and adequate pain control.

These developmentally supportive practices improve an infant’s quality of life during the NICU stay and can result in a better outcome in and beyond the NICU. Because developmentally supportive care is holistic and responsive to the baby’s needs, this type of care also reinforces the parents’ own nurturing urges. When parents are invited into the NICU and encouraged to participate in their infant’s developmentally supportive care, instead of feeling at odds with NICU policies and staff, parents feel comfortable with them and see that their instincts are valued. When the care plan includes breastfeeding and/or kangaroo care, the mother and father can experience that they are intimately necessary to their baby’s health. And in spite of the trials of hospitalization and separation, they can feel their essential role as parents, instead of merely hovering uncertainly at the sidelines.

Indeed, involving parents in their infant’s developmentally supportive care is developmentally supportive for the parents as well. When their presence, questions, and advocacy are an integral part of their NICU experience, this involvement promotes

• their developing bond and identity as parents to this child
• their developing competence as they get to know and take care of their special newborn
• their developing feelings of confidence as they see how their baby responds and calms in their presence
• their developing collaboration with NICU staff
• their developing ability to cope with intense, often-painful situations and emotions around the birth and hospitalization of their baby.

For instance, at a time when the parents’ relationship with their baby is most fragile, participating in care helps them feel competent and connected to their newborn. Their confidence grows as they practice being attuned to their baby. They can learn new skills as they collaborate with their baby’s medical caregivers. The emotional support they receive from these caregivers shows them that their feelings are normal and respected, puts them in touch with their needs, and offers guidance in how to cope and get close to their babies. In your practice of developmentally supportive care, you know that this close contact is beneficial to the baby. When you remember that close contact also builds parental bonding, confidence, competence, collaboration, and coping, you can see that it is also beneficial to the parent.

To practice this approach with families, you might start with the following framework: Developmentally supportive care for parents is any behavior, attitude, philosophy, intervention, or setting that supports the parents’ developing sense of parental identity, involvement, and emotional investment in their newborn.

Unfortunately, in far too many NICUs the default position is this: “We are the gatekeepers, and we must regulate the contact parents have with their babies. Otherwise, parents may unintentionally overstimulate and destabilize their infants.” In a developmentally supportive NICU the default position is this: “Parents are highly motivated to learn how to interact with their newborns and should immediately be shown how to touch and hold their baby and how to respond to their baby’s cues, so that they can become attuned to their baby’s needs and respond accurately.”

Become aware of your beliefs about parents’ capabilities and motivations, because these attitudes guide policy and routine practice. To integrate developmentally supportive care for parents into your NICU’s culture, here is the philosophy of care that must prevail: Precious little should come between parents and their babies.

Now, as you read this, a feeling of dread may be washing over you. You may wonder, “Isn’t my primary job to take care of the babies? What happens when parents want to touch and hold their baby when I don’t think it’s such a good idea? How will I find the time or energy to add more dealings with families?” But the beauty of providing developmentally supportive care to parents is that it involves little more than a paradigm shift. If you already embrace the philosophy of developmentally supportive care and you routinely provide it to the babies under your watch, then consider this: Developmentally supportive care for parents fits completely under the umbrella of providing developmentally supportive care for babies. It is not a burden or an additional protocol you must carry out but a framework for looking at what you already have been doing, or philosophically know you want to do, but are unsure about why it’s important or how to do it without disrupting a baby’s care. As you aim to provide developmentally supportive care for each baby, practice the following:

• Hold onto this mantra: Supporting the relationship between parent and baby benefits both of them.
• Coach the parents in their baby’s care, because parent involvement is key to providing the most comprehensive and highest quality developmentally supportive care for babies.
• Bring parents into the loop with their babies; partner with them in observing their baby’s sensitivities and preferences and learning what works to calm and soothe.
• Share your observations, as you respect and listen to theirs.
• Show them what you know about reading babies’ cues and responding; ask them to share what they know about reading their baby’s cues and responding to their baby.
• Assume that parents are devoted to their little one and competent in their ability to learn, even though they may be emotionally overwhelmed at times.
• Remember that babies respond to the parent’s gentle touch, voice, smell, and nurturing presence in ways that are healing for baby and parent.
• Value the parents’ involvement as a way to enhance the developmentally supportive aspects of care for their baby.
• Facilitate the nurturing connection between parent and baby, because this connection and the resulting attunement are the cornerstone of their successful transition to home.
• Contemplate the possibility that the more critical a baby’s condition, the more critical it is that parents hold and/or touch their baby.
• Hold the attitude that parents are not visitors; they are central members of their baby’s caregiving team in the NICU.

Your goal is not simply to discharge a healthy baby but to discharge a healthy baby to parents who feel confident and are competent to assume total care of their infant. Viewing yourself as the gatekeeper or only advocate for the baby undermines the parents’ connection, confidence, and competence and ultimately makes your job more difficult. Providing developmentally supportive care means having a connected, confident, competent parent alongside you, which makes your job much easier. It’s better for the baby, it’s better for the parent, and ultimately, it’s better for their relationship and their homecoming. This collaborative spirit is also better for your relationship with the parents. Everybody wins.

One final caveat: In order to most effectively provide developmentally supportive care to babies and parents, NICU staff must be provided with their own brand of developmentally supportive care. For example, you benefit from psychosocial rounds, where you can get peer and professional support, plus continuing education and ideas for working with stressed families. You benefit from proper staffing and reasonable hours. You benefit from acknowledgement and utilization of your personal strengths and from accommodations that fortify or compensate for your weaknesses. You benefit from NICU policies and culture that support relationship-centered care all the way through the system. Everyone—the nurses, physicians, residents, therapists, parents, and babies—is respected, heard, valued, and considered competent. Collaboration prevails. When an NICU provides developmentally supportive care for its staff members, staff members are then better equipped to provide developmentally supportive care for families.

Deborah L. Davis is a developmental psychologist, researcher, and writer. Her books include Empty Cradle, Broken Heart (Fulcrum, 1996) and Loving and Letting Go (Centering, 2002). Mara Tesler Stein is a clinical psychologist in private practice. Both Davis and Stein specialize in the emotional aspects of coping with crisis and adjustment around pregnancy and parenting. They are co-authors of Parenting Your Premature Baby and Child: The Emotional Journey (Fulcrum, 2004).   

From the AAP Liaisons
AAP Committee on Fetus and Newborn
Carol M. Wallman, MS RNC NNP
The American Academy of Pediatrics (AAP) Committee on the Fetus and Newborn (COFN) has completed several projects and has many new ones in process.

Two New Policy Statements
Two recent policy statements were published in the November 2004 issue of Pediatrics:

• The Levels of Neonatal Care carefully outlines designations for hospital facilities that care for newborn infants. The statement reviews data supporting the need for uniform nationally applicable definitions and the clinical basis for a proposed classification based on the complexity of care. The statement provides specific definitions for capabilities associated with the highest level of neonatal care within an institution.
• Age Terminology During the Perinatal Period proposes the use of standard definitions for terms including gestational age, postmenstrual age, chronological age, corrected age, adjusted age, and estimated date of delivery.

Apgar Score
COFN has also been working a joint statement with the American College of Obstetrics and Gynecology (ACOG) on appropriate use of the Apgar Score. This statement is pending final review and publication. The intent of this statement will be to place the Apgar Score in its proper perspective. It will also offer an example of an expanded Apgar Score report form documenting gestational age and resuscitation, which will provide more complete information about the status of the newborn infant and resuscitative efforts.
COFN also continues to work on an updated clinical report on Prevention of Pain and Stress in the Neonate.

Guidelines for Perinatal Care
The next large project COFN will undertake in collaboration with ACOG involves creation of the sixth edition of Guidelines for Perinatal Care. The editorial board will meet in March 2005, with revisions beginning in April 2005. Anticipated date of publication will be 2006. Now is the time to let us know of any deficits in the current Guidelines for Perinatal Care (5th edition). Please send me any requests you have for updated, new, or expanded information, and I will make sure the editors get our requests.

Carol Wallman, MS RNC NNP
NANN Liaison to the AAP Committee on the Fetus and Newborn
This e-mail address is being protected from spambots. You need JavaScript enabled to view it

AAP Perinatal Section
Robin L. Bissinger, MSN, RNC NNP
The AAP section of the Perinatal Pediatrics Executive Committee met October 8, 2004, in San Francisco to discuss current activities and issues. This liaison report summarizes the activities and issues pertinent to NANN.

Future AAP Meetings
The National AAP meetings were outlined for the next year. The 2005 meeting will be October 8–12 in Washington, DC. This meeting will focus on prematurity and will be done in collaboration with the March of Dimes. The AAP will be celebrating their 75th anniversary.

The NeoPREP Course is an intensive review course of neonatal perinatal medicine being held in San Diego, CA, September 18–24, 2005. This extensive program is open to NNPs.

The next Perinatal Section meeting will be April 1–3, 2005, at the Workshop on Perinatal Practice Strategies: “The Changing Face of Neonatology.” This workshop will offer coding seminars and discuss NNP/Physician practice and education issues.

Affiliate Membership
The executive committee would like to increase affiliate membership in the perinatal section. Anyone interested in joining the AAP or Perinatal Section can join as an affiliate member on the Web site. There will be a link from the NANN Web site to the AAP Web site.

Guidelines
New guidelines for levels of care in the NICU were approved by the AAP. Eight hundred and fifty NICUS in the USA and Canada were surveyed to provide information about the levels of care provided at their own hospitals. The document was published in the November 2004 issue of Pediatrics.

Committee on Fetus and Newborn
The report from the Committee on Fetus and Newborn was detailed and the meeting will be reported by the NANN liaison. A commentary on underwater labor and delivery has been submitted. There are several items that have been approved and will be coming after further revision and review. The AAP has developed a FAQ sheet for parents, which can be used as an educational tool along with the hyperbilirubinemia guidelines. This is located on the AAP Web site and can be freely used with families. The committee asked that the hyperbilirubinemia graphs also be posted on the Web site for clinician use.

Reimbursement
Dr. Martin has been very active with coding and reimbursement. The current codes have been changed to read “Health Care Practitioner,” a category that includes NNPs and neonatologists. The new coding toolkit is being sold by the AAP and is wonderful pocket hand tool for anyone who bills. The new vascular access codes were increased from 5 codes to 18 codes with new criteria for insertion, repair, replacement, and removal of lines. The plans for 2005 include new codes for babies over 2,500 g that are not critical but still intensive and a new code for hyperalimentation. There will be an annual review of the 5-year codes as well as new RUV values for noncritical codes.

Neonatal Resuscitation Program
The new NRP manual (5th edition) is expected in March 2006. Validation studies of tests and megacodes are currently in process. Phase I studies have been completed. A DVD will be part of the new educational materials; this will be interactive with multiple paths and guidance in resuscitation. The NRP grant program is continuing.

AAP Newsletter
NANN was able to put an article in the last newsletter about its 20th Anniversary and Web-based NNP programs.

Journal of Perinatology
There is a new look to the journal, with a yellow and blue cover. There is an increase in the number of submissions for publication and a reduction in the number of papers accepted for publication. All submissions must now be electronically submitted.

Drug Concentrations
The AAP has sent letters and is in communication with JCAHO regarding the new ruling about drug concentrations. The AAP has stated that there is a risk to patient safety with this new ruling and that the rule of 6 actually reduced the risk to neonatal patients. A response from JCAHO is expected in November, but it is believed that we will receive an extension for using the rule of 6.

Safe First Week of Life Campaign
The goal of this campaign is to improve the quality of care provided to newborns by educating physicians and other clinicians, parents and hospitals, and other caregivers about the importance of early neonatal follow-up. A second goal is to get pediatricians and other clinicians actively involved in supporting and implementing the Academy’s policies and to raise the level of awareness of parents, pediatricians and other clinicians, insurers, and employers to the fact that problems can and do occur during this critical period of an infant’s life. The Academy is planning to work collaboratively with other national organizations. NANN is currently on that list, and a meeting is proposed to map out the mission/goals/objectives and key components of the program.

2005 Calendar
Chapter Meeting Dates

2004 Annual Conference
Thank you to our 2004 Annual Conference Exhibitors.

A Fashion Hayvin
Abbott Point-of-Care
Airborne Life Support Systems/VIA Medical
ALARIS Medical Systems
ASU College of Nursing
Aureus Medical Group
Avent America, Inc.
B. Braun Medical
Banner Desert Medical Center
BD
Beevers Mfg
Bio-logic Systems Corp.
Cabocreme
Calmoseptine, Inc
Carolinas Healthcare System
CAS Medical Systems, Inc.
Centennial Medical Center
Children's Healthcare of Atlanta
Children's Hospital
Children's Hospital Boston
Children's Hospital of Wisconsin
Children's Medical Ventures
Cincinnati Children's Hospital Medical Center
CODAN US Corporation
CooperSurgical
Dartmouth-Hitchcock Medical Center
Dey, L.P.
Discovery Laboratories, Inc
Draeger Medical Infant Care, Inc.
Duke University Hospital
Early Arrival, Inc.
ENSEARCH Management Consultants
Fisher & Paykel Healthcare, Inc.
Florida Assn. of Neonatal Nurse Practitioners
Forest Pharmaceuticals, Inc
GE Healthcare
Hamilton Medical, Inc.
Hawaii Medical LLC
Healing Through Hope
Hospira Worldwide, Inc.
IMDsoft
Innovative Medical Technologies
Kay Medical
Lee Memorial Health System
Linkous and Associates
Lippincott Williams & Wilkins
March of Dimes
Masimo Corporation
Maternal Concepts
Mead Johnson Nutritionals
Medela, Inc.
Medex, Inc.
Medical Staffing Network, Inc.
MedImmune Inc.
Memories Unlimited, Inc.
Mercury Medical
Moses Cone Health System
National Institute of Child health and Human Dev.
Natus Medical
Nellcor/Tyco Healthcare
NeoCare/Arrow International
Neotech Products, Inc.
Omni Therm, Inc.
On Assignment Healthcare Staffing
Orlando Regional Healthcare
PDI-Professional Disposables International
Pediatrix Medical Group
Pitt County Memorial Hospital
Procter & Gamble
Radiometer America Inc.
RF Technologies
Ross Pediatrics
Saunders/Mosby Publishers
Scale-Tronix Inc.
Separation Technology, Inc. (STI)
Sheridan Healthcare, Inc.
Shumsky Therapeutic Pillows
Spacelabs Medical, an OSI Systems Company
Spectrum Health
Spectrum Healthcare Resources
St. Barnabas Health Care System
St. Lukes Regional Medical Center
Tarry Manufacturing
Technicuff Corporation
The Children's Hospital of Philadelphia
The Gideons International
Tyco/Healthcare/Kendall-LTP
UCI Medical Center
University of Pennsylvania Health System
Utah Medical Products
Vanderbilt University Medical Center
VAPOTHERM
Venetec International
Viasys MedSystems
Vygon Corporation
Wrapped In Comfort

Neonatal Nurse Practitioner Program
This issue of NANN Central is supported by Pitt County Memorial Hospital.