RAJIV GANDHI UNIVERSITY OF HEALTH SCIENCES,
BANGALORE, KARNATAKA.
PROFORMA FOR REGISTRATION OF SUBJECTS FOR DISSERTATION.
1 / NAME OF THE CANDIDATE:AND ADDRESS: / Ms PRIYA THOMAS
1 YEAR M.Sc. NURSING,
KEMPEGOWDA COLLEGE OF NURSING
K.R. ROAD, V.V. PURAM,
BANGALORE- 560004
2 / NAME OF THE INSTITUTION: / KEMPEGOWDA COLLEGE OF NURSING,
BANGALORE-560004.
3 / COURSE OF THE STUDY:
AND SUBJECT: / 1 YEAR M.Sc. NURSING,
PEDIATRIC NURSING.
4 / DATE OF ADMISSION TO:
COURSE: /
27-6-2012
5 / TITLE OF THE TOPIC: / “EFFECTIVENESS OF DEVELOPMENTAL CARE ON THE PHYSICAL AND PHYSIOLOGICAL PARAMETERS OF THE PRETERM AND LOW BIRTH WEIGHT BABIES IN SELECTED HOSPITALS AT BANGALORE”
6.BRIEF RESUME OF THE INTENDED WORK:
6.1.NEED FOR STUDY:
"Do not say, ’It is morning,’ and dismiss it with a name of yesterday. See it for the first time as a newborn child that has no name – RABINDRANATH TAGORE."
Regardless of whether labor is long or short, whether it is hard or easy whether a baby is born vaginally or by cesarean, most parents recall the first hours and days after birth as crystal-clear images surrounded by haze.1 Falling into the normal range for size is a good start for an infant, suggesting good health. But, each baby is different, and even those who fall a bit outside the normal range are usually fine.2 The length of the average newborn baby is from 47.5 to 53.75 cm and about two thirds of all full term infants weigh between 2700 and 3850 gm.3
During the first 5-7 days after birth, the infant tends to lose about 5 to 10 per cent of birth weight. Factors contributing to this initial loss are the withdrawal of hormones originally obtained from the mother, the low intake of fluid, and the loss of fluid in feces and urine.3
Preterm is a baby with a gestation of less than 37 completed weeks. The underlying feature is immaturity of their organ systems.4 Infants are born with low birth weight, which carries the risk of infection, developmental delays, and even death, according to the March of Dimes5. The factors like maternal malnutrition, young age of the mothers, poverty, close birth spacing, and hypertension have independent effect in causing low birth weight 6. Low birth weight infants weigh 2500 grams or less at birth3. Preterm birth and being small for gestational age, are the reasons for low-birth-weight7. LBW contributes to 60% to 80% of all neonatal deaths. The global prevalence of LBW is 15.5%, which amounts to about 20 million LBW infants born each year, 96.5% of them in developing countries7. In India about 30 to 40 percent neonates are born LBW8and has the maximum number of preterm births with 3,519,100 of them.8
Babies whose birth weight is low not only have lower odds of survival, but also face increased risk of hypothermia, heart disease and diabetes, stunted growth, low I.Q. and other problems.9 Although recent advances in neonatal intensive care have kept more of these infants alive, efforts to prevent low birth weight have lagged.9
The intensive care of the newborn babies has become mechanical or "robotic" and "stereotyped", Instead of being flexible and individualized, Technological advances have dehumanized the care of newborn babies. Hi-tech care should be provided, but comfort of the baby should not be ignored. Babies should be reared in neonatal intensive care unit (N.I.C.U), which should simulate the ecology of the womb, to ensure maximum comfort to the baby. The babies should be handled with gentle touch, love and compassion and the nurse should feel "connected" and "tuned" to the babies under their care.10
Interventions to improve care during pregnancy, childbirth and postnatal period as well as feeding are likely to improve the immediate and longer-term health and well-being of the individual infant and have a significant impact on neonatal and infant mortality7.Nurses must make complex assessments and maintain optimal respiratory, cardiac, and feeding status may result in improved development and behavior,lower levels of morbidity,shorter hospitalization. 11
During the stay in the NICU, a baby's environment is critical to the growth and development.12 Preventing hypothermia at birth in premature and low birth weight infants may be important to survival and long-term outcome. Babies rely on external help to maintain body and skin temperature particularly in the first 12 hours of life. For vulnerable infants born prematurely or that are very small, hypothermia is a worldwide issue.13 Developmental Care helps neonates with the transition from in-utero to extra-utero.12 Developmental care is the interventions taken to support the behavioral organization of each individual infant, enhancing physiological stability, protecting sleep rhythms and promoting growth and maturation. These interventions include handling and positioning, reduction of noxious environmental stimuli, and cue based care.14
Developmental care for premature infants was introduced by Dr. Heidi Als, and has become an accepted standard of care.15 Premature infants display distinct stages of neurologic development, and they face particular challenges by having to progress through these stages outside of the natural and protective environment of the maternal womb Still.15 Developmental care is a broad category of interventions that is designed to minimize the stress of the NICU environment.16
The elements included under developmental care are auditory, tactile and positioning or swaddling of the preterm infant so as to provide a sense of intrauterine experience.16 Infant responses to patterned music are different from their responses to non-patterned noise.17 Music has been shown to reduce stress, decrease heart rate and salivary cortisol, and increase oxygen saturation, nonnutritive sucking rate, and even weight gain in preterm infants. Prolonged auditory stimulation with a regular rhythm, such as lullabies, is calming and may slow heart and breathing rates.17 Touch is essential for the growing infant.18 Massage may help these neonates reduce the stress levels and has been suggested to improve the growth and development of preterm and low birth weight infants.19 Oil massage is reported to improve weight gain by better thermoregulation.20 Sunflower oil is very useful for infants to protect their tender skin from bacterial infection. 21 “Nesting” is a comfort measure that simulates in-utero feeling. The infant can be positioned prone or on the side with flexed extremities by providing a “nest” with a rolled blanket.10
Therefore the investigator decided to measure the Desirable physical and physiologic functions in preterm infants and LBW babies like weight ,oxygen saturation; heart rate, respiratory rate and intending at prevention of weight loss during the first few days by implementing the interventions of developmental care, such as giving oil massage , nesting and playing soft music.
6.2.REVIEW OF LITERATURE:
A study was conducted on a modified newborn intensive care unit environment may shorten hospital stay. Premature infants with birth weights from 1121 to 2000 gm were placed on a microprocessor-controlled cradle that provided levels of motion and sound analogous to those of the third-trimester intrauterine environment. The mean length of hospital stay was significantly shorter for experimental group infants than for control group infants after controlling for gestational age and weight on entry to the study. Experimental group infants began nippling earlier and stopped requiring gavage feedings sooner and had a decreased incidence of apnea. Appropriate levels and kinds of stimulation may facilitate the maturation of preterm infants.22
A study was conducted on the impact of temporally patterned stimulation on the development of preterm infants. To test the efficacy of temporally patterned kinesthetic and auditory stimulation for promoting development of infants born prior to term. Assessments included measures of neurological functioning, sleep-wake activity, mother-infant interaction, and mental and motor development at 8 and 24 months. All experimental infants, compared to controls, showed decreased rates of activity while in the hospital, fewer abnormal reflexes, and better orienting responses. The results indicate that both temporal patterning and contingent responsiveness in the preterm infant's early environment contribute positively to some aspects of the development of such infants.23
A study was conducted on energy expenditure in growing preterm infants receiving massage therapy in Israel, with the objective that Massage therapy has been consistently shown to increase weight gain in preterm infants. Each infant was studied after a period of 5 days of massage therapy. Metabolic measurements were performed by indirect calorimetry, using the Deltatrac II Metabolic cart.Energy expenditure was significantly lower in infants after the 5 day massage therapy period (59.6 ± 3.6 Kcal/Kg/ 24 hours) than after the period without (63.1 ± 5.4 Kcal/Kg/ 24 hours) (p = 0.05).This decrease in energy expenditure may be in part responsible for the enhanced growth caused by massage therapy.24
A study was conducted on effect of oil massage on growth and neurobehavior in very low birth weight preterm neonates in India with an objective to study the effect of oil massage on growth and neurobehavior in preterm babies less than 1500g. Neonates were randomized to three groups (a) massage with oil (b) massage without oil and (c) no massage. Weight, length, head circumference and triceps skin fold thickness were measured in the three groups at regular intervals. Neurobehavior using Brazeltons Neonatal Behavior Assessment Scale (NBAS) was assessed at enrolment and after 10 days of intervention. Weight gain in the oil massage group (365.8 +/- 165.2g) was higher compared to the only massage group (290.0 +/- 150.2g) and no massage group (285.0 +/- 170.4g). Oil application have a potential to improve weight gain among preterm very low birth weight neonates.25
A study on effect of music by Mozart on energy expenditure in growing preterm infants was conducted with an objective to rate of weight gain in preterm infants who are exposed to music seems to improve. A potential mechanism could be increased metabolic efficiency. Infants were randomly assigned to be exposed to a 30-minute period of Mozart music. infants who were exposed to music had a significantly lower resting energy expenditure than when not exposed to music (P .028). On average, the effect size of music on resting energy expenditure is a reduction of 10% to 13% from baseline, an effect obtained within 10 to 30 minutes. The effect of music on resting energy expenditure might explain the improved weight gain that results from this Mozart effect.26
A study was conducted on posture and movement in healthy preterm infants in supine position in and outside the nest, Italy. With the objective to evaluate whether lying in a nest affects the posture and spontaneous movements of healthy preterm infants. In the nest, the infants more often displayed a flexed posture with shoulder adduction and elbow, and hip and knee flexion, and the head was frequently in the midline. The nest was also associated with an increase in elegant wrist movements and movements towards and across the midline and a reduction in abrupt movements and frozen postures of the limbs. The nest did not affect the occurrence of asymmetrical tonic neck posture. Thus a nest promotes a flexed posture of the limbs with adduction of shoulders, facilitates elegant wrist movements and movements towards and across the midline and reduces abrupt movements and frozen postures of the arms and legs.27
A study was conducted on individualized developmental care for the very low-birth-weight preterm infant. Medical and neurofunctional effects in Boston with the objective to investigate the effectiveness of individualized developmental care in reducing medical and neurodevelopmental sequel for very low-birth-weight infants. Care giving by nurses specifically trained in individualized developmental care; observation and documentation of the infants' behavior within 12 hours of admission, and subsequently every 10th day. The infants in the experimental group had a significantly shorter duration of mechanical ventilation and supplemental oxygen support; earlier oral feeding; reduced incidence of intraventricular hemorrhage, pneumothorax, and severe bronchopulmonary dysplasia; improved daily weight gain; shorter hospital stays; younger ages at hospital discharge; and reduced hospital charges compared with the infants in the control group. Very low-birth-weight preterm infants may benefit from individualized developmental care in the neonatal intensive care unit in terms of medical and neurodevelopmental outcome.28
A study was conducted regarding developmental care for promoting development and preventing morbidity in preterm infants . Developmental care interventions may help preterm infants cope better with the environment of the Neonatal Intensive Care Unit (NICU).Developmental care refers to a range of strategies designed to reduce the stresses of the NICU. These include reducing noise and light, minimal handling and giving longer rest periods. The review of trials suggests that these interventions may have some benefit to the outcomes of preterm infants. evidence demonstrating more consistent effects of developmental care interventions on important short- and long-term clinical outcomes is needed.17
A study was conducted at Chicago regarding effect of auditory, tactile, visual, and vestibular intervention on length of stay, alertness, and feeding progression in preterm infants. This study determined whether an auditory, tactile, visual, and vestibular intervention (ATVV) reduced the length of hospitalization preterm infants by increasing the proportion of alert behavioral states, thereby improving their feeding progression. The study group demonstrated increased alertness during the first 5 minutes of intervention, which was significantly correlated to length of stay (p<0.05). The proportion of nippled (teat) intake increased significantly faster for the study group (p=0.0001). Infants in the study group were discharged at a mean of 36.54 weeks, 1.6 weeks earlier than control infants (p<0.05). ATVV intervention facilitated increased alertness, faster transition to complete nipple feeding, and decreased length of hospitalization. 29
6.3.STATEMENT OF THE PROBLEM:
“Effectiveness of Developmental care on the physical and physiological parameters of the Preterm and Low birth weight babies in selected hospitals at Bangalore “
6.4. OBJECTIVES OF THE STUDY:
1 To assess the physical and physiological parameters of the preterm and low birth weight babies.
2 To determine the effectiveness of Developmental care on the physical and physiological parameters of the preterm and Low birth weight babies.
3 To find the association between pretest scores of parameters with the selected demographic variables of Preterm and Low birth weight babies.
6.5. HYPOTHESIS: