We read with interest the article by Limperopoulos et al.1 who
examined the cerebral circulatory changes during routine care of preterm
neonates using near infrared spectroscopy (NIRS) . Even minor
manipulations as diaper changes seem to cause significant fluctuations of
SaO2 and cerebral hemoglobin. These changes were associated with early
parenchymal ultrasound abnormalities. Limperopoulos et al. speculated that
the underliying mechanisms could be the rapid elevation of lower
extremities.
Diaper changes have been previously associated with an increased
behavioral pain response in preterm and full term neonates (2,3) . This
effect, which was evaluated with different pain scores, was observed up to
60 min after the procedure. It was associated with oxygenation changes2.
We demonstrated in a prospective and cross-over study a significant
decrease in physiologic and behavioral pain response while using a
developmental support, which consisted in decreasing the direct light by
covering the incubator, reducing a noisy environment by closing the room
door, a lateral posture with head, back, and feet contacting supportive
bedding and opportunities for grasping. The positive impact of
developmental care was also observed in preterm and full-term neonates
during a weighing procedure with a trend of increased tissue oxygenation
index (TOI) measured by NIRS 4.
As these nursing procedures are commonly repeated in very preterm
neonates, the potential impact of developmental care on brain development
and maturation appears promising. In a randomized controlled trial, Als et
al. (reference 18 in Limperopoulos’article) demonstrated a positive effect
of an individualized developmental care program (NIDCAP) in preterm
neonates (28 to 33 weeks' gestational age) on 3 neurodevelopmental
parameters: the 9-month behavioral outcome, the anisotropy in left
internal capsule and the EEG coherence between frontal and occipital brain
regions 4.
Limperopoulos et al. recommand the use of continuous bedside
monitoring of the newborn brain during these caregiving procedures. We
would also like to suggest the routine use of behavioral observations
allowing an adapted developmental care support.
References:
1- Limperopoulos C, Gauvreau KK, O'Leary H, Moore M, Bassan H, Eichenwald
EC, Soul J, Ringer SA, Di Salvo DN and du Plessis AJ. Cerebral
hemodynamic changes during Intensive care of preterm infants. Pediatrics
2008;122 e1006-e1013
2- Sizun J, Ansquer H, Browne J, Tordjman S, Morin JF. Developmental care
decreases physiologic and behavioral pain expression in preterm neonates.
J Pain 2002; 3: 446-50
3- Mörelius E, Hellström-Westas L, Carlén C, Norman E, Nelson N. Is a
nappy change stressful to neonates? Early Hum Dev 2006; 82: 669-76.
4- Catelin C, Tordjman S, Morin V, Oger E, Sizun J. Clinical, physiologic,
and biologic impact of environmental and behavioral interventions in
neonates during a routine nursing procedure. J Pain 2005; 6: 791-7.
5-Als H, Duffy FH, McAnulty GB, Rivkin MJ, Vajapeyam S, Mulkern RV,
Warfield SK, Huppi PS, Butler SC, Conneman N, Fischer C, Eichenwald EC.
Early experience alters brain function and structure. Pediatrics 2004;
113: 846-57.
Conflict of Interest:
Jacques Sizun is the medical director of the French NIDCAP Training Center (Université de Bretagne Occidentale)
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