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CHAPTER 13 The Neonate and the Environment Impact on Development
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349
home with their families. However, the NICU
is also an environment of sensory bombardment—constant noise, light, and tactile stimulation;
intrusive, invasive procedures; upset of sleep-wake
cycles; and multiple caregivers. Rather than too
much or too little stimulation, infants in the
NICU receive an inappropriate pattern of stimulation (e.g., noncontingent, nonreciprocal,
painful [rather than pleasant], and multiple
stimuli).
7,156,158
Because the immature CNS of the
premature infant cannot tolerate these stimuli, the
easily overstimulated preterm infant protects himself
or herself by physiologic and interactional defensive
maneuvers that are maladaptive.
Inappropriate patterns of stimuli that stress
the preterm infant in the NICU environment
influence brain structure and function during
a critical period of brain development.
96,260,397
The first study to examine a relationship between
stressors in the NICU and alterations in brain development was published in 2011. This prospective
cohort study used the Neonatal Infant Stressor Scale
304
(NISS)
to measure daily exposure to stressors of
preterms (<30 weeks’ gestation) for the first 14 and
28 days of life and from admission to the NICU
until term equivalent postmenstrual age (PMA) or
discharge.
386
Magnetic resonance imaging (MRI)
examinations were performed at term equivalent
age (about 36–44 weeks’ PMA) and the association between exposure to stressors and abnormal
brain development was then calculated. The most
immature, sickest preterms were exposed to
the highest number of stressors and procedures, particularly in the first 14 days of life.
Higher exposure to stressors was associated with
decreased brain size in the frontal and parietal
sections.
386
Increased stress was also associated
with altered microstructure in the temporal
lobes, especially the right lobe, that resulted in less
mature, poorly developed connections between the
temporal lobes.
386
A combination of destructive
and developmental mechanisms contribute to
the encephalopathy of prematurity.
433
White
matter injury to the developing brain is recognized
as the cause of common motor, behavioral, and
cognitive problems in surviving premature infants
117
(see Chapter 31).
A study by the same investigators found altered
neurobehaviors at term equivalent in a prospective study of preterm infants (<30 weeks’
estimated gestational age).
338
Using the NNNS,
BOX
13.3
ALTERED NEUROBEHAVIOR IN PRETERM
INFANTS IN NICU
Preterms (at Term Equivalent) Compared with Full-Term
Infants
• Poorer orientation
• Lower ability to tolerate handling
• Lower ability to self-regulate
• Poorer reflexes
• Increased stress
• More excitability
• Altered muscle tone—hypotonic or hypertonic
Preterm Infants From 34 Weeks’ Premenstrual Age
Compared to Term Equivalent
• Changes in motor function:
• Declining quality of movement
• Increasing hypertonia
• Decreasing hypotonia
• Changes in behavior:
• Increasing arousal
• Increasing excitability
• Decreasing lethargy
Adapted from Pineda RG, Tjoung TH, Vavasseur C, et al. Patterns of altered neurobehavior
in preterm infants within the neonatal intensive care unit. J Pediatr. 2013;162:470.
differences in neurobehavior were examined
between preterm infants at term and full-term
controls, between 34 weeks’ PMA and full-term
equivalent, and relationship of neurobehavior to
perinatal exposures (such as days of intubation, postnatal steroids, oxygen use after 36 weeks’ corrected
338
age).
At term equivalent, preterm infants
exhibited a broad range of altered behaviors
(Box 13.3). Studied preterms between 34 weeks’
PMA and term equivalent also exhibited behavioral
and motor changes that were not influenced by any
of the measured perinatal exposures. At 34 weeks’
PMA, preterms with significant cerebral injury had
increased excitability compared with non–brain-injured preterms.
338
The researchers concluded that
the neurobehavioral changes occurring before
term may present a rich opportunity in the
NICU for interventions to ameliorate developmental disadvantages evident in the studied
preterms by term equivalent age.
Altered neurodevelopmental outcomes and
resulting altered neurobehavior may also affect
the infant’s ability to attach to parents. A study
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BOX
13.4
Physiologic Benefits Developmental Benefits Cost Savings
Decrease in:
Increase in:
Daily weight gain; head growth/length
* References 7–9, 11, 205, 208, 226, 256, 270, 271, 289–292, 301, 311, 335, 371.
BPD, Bronchopulmonary dysplasia; CPAP, continuous positive airway pressure; IQ, intelligence quotient; IV, intravenous; IVH, intraventricular hemorrhage; NEC, necrotizing enterocolitis;
NICU, neonatal intensive care unit; ROP, retinopathy of prematurity.
OUTCOMES OF INDIVIDUALIZED DEVELOPMENTAL INTERVENTION IN THE NICU*
Improvement in:
Incidence of IVH or pneumothorax and
severity of BPD, ROP, NEC
Ventilator/CPAP use
Need for supplemental oxygen
Need for gavage feedings/IV nutrition
Number of apneic episodes
Need for sedation/analgesia
Stability of cardiorespiratory function
Sleep states/sleep duration
Significant electrophysiologic differences
in frontal, temporal, central, occipital,
and parietal lobes of the brain
Behavioral organization of autonomic, motor, attention modulation,
and self-regulatory abilities
Interactive capability of infant with staff and parents
Quality of parent-infant interaction (perception of preterm as better
regulated, more autonomous, and more gratifying; enhanced com-
petence in parental role)
Less parental personal stress
Feelings of closeness with preterm
Cognitive function/IQ
Development of feeding skills (earlier full oral feedings)
Fewer behavioral problems and attentional difficulties
Continuation of maternal ability to read and respond to infant behav-
ioral cues/appreciation of the infant
Better psychomotor outcome at 2 years of age
Increase in maternal conflict and anxiety when care is not consistent
Better sentence comprehension at 36 months
Shorter length of stay
Earlier discharge at younger
age
Decrease in hospital charges
involving very preterm/VLBW infants, full-term
infants, and their mothers examined the security of
the infant’s attachment to the mother at 18 months
455
of age.
A majority of the full-term (72%) and the
very preterm infants (61%) were securely attached.
However, more very preterm infants (32%) had
disorganized attachment than the full-term infants
(17%). Researchers concluded that neurodevel-
opmental problems in the very preterm infants
altered their ability in social relationship with
their mothers.
Research has shown medical, developmental,
and cost benefits to low-birth-weight (LBW)
infants from individualized behavioral and environmental care in the NICU (Box 13.4). The
most effective interventions (1) follow the
Newborn Individualized Developmental Care
and Assessment Program (NIDCAP),*; (2)
are contingent on the infant’s responses, thus
are interactive and individualized; (3) create
* References 8, 9, 11, 270, 271, 335.
an environment that balances protection from
sensory overload with provision of enough
stimulation to promote emerging capabilities;
and (4) collaborates with the parents in planning, providing, and evaluating developmental
7,11,255
care.
The first randomized controlled trial (RCT) of
individualized developmental care (NIDCAP)11
for VLBW (inborn and transported) infants conducted in three diverse NICUs showed improvement in medical well-being and neurobehavioral
and family function.11 Neurobehavioral benefits
included better autonomic or motor system
regulation and self-regulation and reduced need
for facilitation.11 Given the diversity of the NICU
settings and populations, the biggest differences in
beneficial outcomes were appreciated in the most
challenged settings (e.g., NICUs initially using the
least developmental care, families with multiple social
and cultural vulnerabilities, the sickest infants).
11
Another RCT studied the effectiveness of
NIDCAP initiated within 72 hours of NICU
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351
admission in 30 preterms (28–33 weeks’ gestational
age [GA]) on brain structure and function.7 The
group of preterms receiving NIDCAP showed
significantly better neurobehavioral functioning
at 2 weeks’ and 9 months’ corrected age on
mental and psychomotor development than that
of the control group. Changes in the brain on
MRI included a more mature brain fiber structure
between brain regions (e.g., frontal to occipital;
frontal to parietal) than is consistent with enhanced
neurobehavioral functioning. The study’s con-
clusion is that the quality of early experiences
(e.g., before term) significantly alters brain
structure and function.7 Several more recent
RCTs of NIDCAP show improved health and
neurodevelopmental outcomes, shorter length
of stay, and less chronic lung disease (CLD) for
VLBW preterms and severe intrauterine growth
restricted (IUGR) preterm infants at 2 weeks’
corrected age, 9 months corrected age, and at
8 years. Higher quality of developmental care
in the NICU is associated with better neurobehavioral performance (i.e., better attention
and self-regulation, less excitability and hypotonicity, lower stress scores, and better language
skills at 36 months).
289-291
Preterm infants are not the only infants at risk
from the stress of overstimulation in the NICU.
Acutely ill infants and chronically ill infants
with prolonged hospitalization also experience
stress. A term infant with persistent pulmonary
hypertension (see Chapter 23) is particularly vulnerable to repeated handling, procedures, and
interventions that decrease Pao2. Thus, these infants
are managed on a minimal intervention regimen:
Care is organized, coordinated, and individualized
to decrease noxious stimuli and physical manipulations. The chronically ill infant with bronchopulmonary dysplasia (BPD) has been shown
to improve when behavioral or environmental
changes were initiated.
The ultimate goal of intervention strategies
in the NICU is to facilitate and promote infant
growth and development and thus task mas-
334
tery.
During rapid stages of brain development,
neuroprotection of the preterm and sick term
infant’s brain in the NICU by providing an environment that nurtures brain growth and minimizes
brain injury is essential.
50,247
In the NICU, these
goals are achieved by the following:
• Altering the environmental and caregiving stressors that interfere with physiologic stability
• Promoting individual neurobehavioral organization and maturation by identifying and facilitating stable behaviors and reducing stressful
behaviors
• Conserving energy
• Teaching parents to interpret infant behavior
• Promoting infant-parent interaction and
caregiving
Core measures for evidence-based developmen-
tal care have been identified: (1) protected sleep;
(2) pain and stress assessment and management;
(3) developmental activities of daily living, such
as positioning, feeding, and nonnutritive sucking
(NNS); (4) family-centered care; and (5) a healing
environment.
93
Establishing biorhythmic balance and physio-
logic homeostasis is necessary for survival and is
enhanced by a sensitive, responsive NICU environment. An unresponsive environment may so
stress the preterm infant that apnea, bradycardia,
and other physiologic instabilities severely compromise and prolong recovery.
156,227,334,413
For
the hospitalized infant, development of the sense
of self and trust is undermined by noncontingent
stimulation that prevents establishing a sense of
competence and control of the environment.
158
When the ventilated infant experiences hunger or is
wet, he or she cannot signal the care provider with
a cry because of the tube. Thus, the infant experiences a need but cannot signal and bring care and
relief. The infant soon learns that he or she is not in
control of the situation. Similarly, another intubated
infant may be quietly asleep and not experiencing a
need, but it is “care time,” so the nurse moves, wakes,
changes, and generally disturbs the infant. This
infant also soon learns about not being in control
of the situation.
Hospitalized infants, especially those with
prolonged stays, may exhibit the classic signs
of institutionalized infants or infants suffering
from maternal deprivation (Box 13.5).
the goal of “environmental neonatology”
392
158
It is
to
prevent this maladaptive behavior by altering the
NICU to be more developmentally appropriate and responsive to infants. Normalizing the
environment begins with an assessment of the
stimulation to which the individual infant is
exposed. The type (i.e., noxious versus pleasant;
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BOX
13.5
CRITICAL FINDINGS
CLASSIC SIGNS OF
“HOSPITALITIS”
Asocial Behavior
• Gaze aversion—fleeting glances at caregiver with inability to maintain eye contact
• Flat affect—social unresponsiveness (little fixing and following;
little smiling) to caregiver
• Little or no quiet alert state—infant abruptly changes state and
often is described as “either asleep or awake and crying” (crying is
only “awake” state); out-of-control crying
Touch Aversion*
• Becomes hypotonic or hypertonic with caregiving or attempts at
socialization
• Fights, flails, and resists being cared for or held
• Aversive responses (see Table 13.4) to caregiving or holding
Feeding Difficulties
• Have multiple origins, including delayed onset of oral feedings, touch
aversion around mouth secondary to invasive procedures, multiple
caregivers, feeding on schedule rather than demand
• Rumination syndrome—voluntary regurgitation, a form of self-comfort and gratification when environment is not nurturing or gratifying
Failure to Thrive
• Poor or no weight gain despite adequate caloric intake
• Develops mental delays (language, motor, social, emotional)
* Infant associates human touch with pain.
contingent versus noncontingent), amount, and
timing of stimulation should be noted. To decrease
noxious stimuli, no infant should have “routine”
care (e.g., all infants are suctioned every 2 hours;
all infants have a glucose test every 4 hours).
156
Care should be individualized by asking these
questions: “Why are we doing this procedure?” and “Is this procedure necessary for
this infant’s care?” Overstimulation in the NICU
occurs when 81% to 94% of all contacts are medical or nursing procedures, an average of 40 to 132
of which are performed per day.
124
The frequency,
pattern, and trends of caregiver encounters and
disturbance have not changed over the past 20
19,68,334
years,
although caregivers grossly underestimate the amount of handling to which NICU
infants are exposed. Nurses, who are best able to
control overstimulation, provide the majority of
handling, sleep disruption, excessive disturbance,
and noncontingent interaction to these fragile
infants (number of contacts ranging from 79 to
164 times, evenly distributed over a 24-hour
period).19 Painful, invasive procedures that are not
vital to the individual infant are stress-producing
events that should be eliminated (see Chapter 12).
Rest may be the most important environ-
mental change.
181,334
Sleep disruption is stressful
to preterm and sick term neonates in the NICU
and alters weight gain, visual development, state
regulation, cortical growth, and physiologic sta-
66,160
bility.
Disturbing preterm infants for care
every 3 to 4 hours during the night and exposure to light for less than 15 minutes does not
prevent preterm infants from developing circadian rest-awake/active patterns or appropriate
weight gain as long as they are exposed to regular light-dark cycles.
199
In a study of ventilated
extremely LBW (ELBW) infants, the relationship
between hypoxemia and state revealed that sleep
disruption with its accompanying motor activity
was associated with hypoxemia more often than
when these infants were in active/quiet sleep.
Recommendations of this study include (1) using
strategies (e.g., clustering care, kangaroo care [KC])
to promote sleep in ventilated infants and (2)
sleep cycling analogous to in utero patterns (e.g.,
more quiet sleep) to improve ventilatory stability,
decrease hypoxemia, and improve oxygenation.
Quiet sleep for preterm infants is enhanced by
(1) no caregiving; (2) social interaction, especially with the parents in skin-to-skin care; (3)
NNS; and (4) lateral positioning.
236
A recent
study showed that rapid sleep onset in premature
infants in the NICU is facilitated by distal skin
vasodilation.28 Quiet sleep is disrupted with routine and intrusive care.
mental care promotes sleep.
184
Individualized develop-
5
Although rest periods are necessary for normal
growth and development and optimal immune func-
361
tion,
care continues to be evenly distributed
over 24 hours without adequate periods of undisturbed rest.
5,334
Rest periods of less than 60 min-
utes are ineffective and insufficient for the preterm
to complete a normal sleep cycle.
334
The length of
rest periods in most NICUs has not changed (Table
13.5), and institution of a rest period (even only 1
hour in length) does not necessarily decrease the
amount of disturbance.
185
A recent study of “hands
227
227
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353
TABLE
13.4
ORGANIZATION DISORGANIZATION
CRITICAL FINDINGS
Self-Regulatory Versus Stress Behaviors
Physiologic
Cardiorespiratory: stable heart and/or respiratory rate; regular, slow
respirations
Color: pink, stable Color: mottling, duskiness; cyanosis—central or generalized; pallor or plethora
Gastrointestinal: tolerates feedings Gastrointestinal: abdominal distention; spitting up; vomiting; gagging; stooling
Cardiorespiratory: increase or decrease in respiratory rate; irregular respirations;
apnea; gasping; bradycardia; blood pressure instability; sneezing, hiccoughs,
coughing, sighing
Behavioral
Body movements smooth and synchronous: consistent tone of all
body parts; arms and legs flexed with smooth movements
States: well-defined sleep-wake Unable to modulate states: sudden state changes; more active than quiet sleep;
Self-quieting behaviors: hand-to-mouth, hand or foot clasping, finger
folding or grasping, sucking, foot or leg bracing
Attentive behaviors: alert gaze; fixes and follows visual stimuli;
ceases to suck or slows suck rate, turns toward auditory stimuli,
smiles; imitates; opens mouth, extends tongue; vocalizes: coos,
babbles, habituates to stimuli
Tremors, jittery and jerking movements; hypotonia or hypertonia (flaccid trunk,
extremities; movements arching, flailing, extended extremities; finger splays,
fisting)
awake states with gaze aversion, frowning, grimacing, staring, irritability, wideeyed “help me” look
Limited use of self-quieting behaviors (may need assistance from caregiver)
May demonstrate any of the foregoing stress signals when attempting to interact
with one or more modes of stimuli (e.g., rocking, talking) simultaneously in
environment (either animate or inanimate)
Data from Als H, Brazelton TB. A new model of assessing the behavioral organization in preterm and full-term infants: two case studies. J Am Acad Child Psychiatry 1981;20:239; and
Gorski PA. Stages of behavioral organization in the high-risk neonate: theoretical and clinical considerations. Semin Perinatol 1979;3:61.
TABLE
13.5
AUTHOR, YEAR LENGTH OF REST PERIOD
Korones, 1976
Duxbury, 1984
Evans, 1994
Appleton, 1997
Levy, 2017
NICU, Neonatal intensive care unit.
on” care evaluated 25 term and near-term infants in
the NICU and found that the maximum duration
for rest between handling sessions was 50.9 minutes (+26.2 minutes) with a median of 2.3 minutes between handling contacts.
REST PERIODS FOR NICU INFANTS: RESEARCH BASIS
211
113
124
19
233
233
Regardless of
Range of mean rest periods 5.6–19.2 min
Average time of 30.2 min
Time between handling:
1–38.45 min in first nursery
1–60 min in second nursery
2–59 min
50.9 min (+26.2 min); median 2.3 min
behavioral state, the infant was disturbed: (1) 29.5% in
active sleep, (2) 23.1% in quiet sleep, (3) 29.9% when
awake, and (4) 17.4% in an indeterminate state. With
sleeping neonates, awakenings and arousals occurred
57% of the time. With “hands on” care, shallow
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breathing—primarily when the infants were in active
sleep—occurred between 16% and 28% of the time,
apnea occurred 8% of the time, and oxygen desaturations occurred 19.5% of the time.
233
Nurses have
a low level of knowledge about neonatal sleep
and should be prime advocates for guarding sleep
and knowing that adequate sleep is necessary to
protect the development of the neonate’s brain
while in the NICU.
257
A fetus in utero and a term infant at home relate
to a minimum of caregivers and thus need to learn
one or only a few sets of cues. Consistency of care-
givers is essential for an infant’s developmental
agenda. Multiple caregivers in the NICU confuse
the infant by providing many care-related cues
for the infant to learn—many techniques of handling and many emotional, nonverbal messages
to decode. Primary nursing minimizes the number of care providers, because the primary nurse
and one or two associates always (or as much
as possible) care for the infant; assess, revise,
and write the care plan; and coordinate care.
247
Primary nursing also adds consistency and continuity for parents and satisfaction for nurses.
247
The infant’s state or level of arousal provides an
appropriate context for caregiving. Some infants
exhibit a low threshold for stimuli; they are easily
overwhelmed and fatigued. Others with a higher
threshold are quieter, more difficult to arouse,
initiate less, and thus receive less interaction.12
Organizing care to be reciprocal to the infant’s
state reinforces the infant’s competence in signaling a need (sense of self) and having it met
(sense of trust and mastery). As the infant matures,
feeding on demand rather than on a schedule not
only teaches this valuable lesson but also increases
absorption and use of caloric intake.
156,384
If the
infant is asleep, ask: “Should we do this now? Would
another time be better?” In some centers, physicians
make an appointment with the nurse to examine
the infant at a time that is optimal for the infant.
Because preterm infants exhibit short duration
of state cycles until around 38 weeks, they have
decreased tolerance for stimuli. The smaller, sicker,
and less mature the infant, the less he or she is
able to handle stimuli. Some preterm infants tol-
erate all care done at once and long periods of rest;
others do not and need care spread out to decrease
overstimulation and decompensation. Clustering
of care—performance of several procedures
together in a short period—may result in more
physiologic alterations (changes in cardiorespiratory
stability, changes in blood pressure, increased cortisol
levels, and heightened pain responses) than a single
care-taking event or the actual length of the handling
episode.
183
Studies show increased and prolonged
behavioral motor responses and increased cortisol levels indicative of stress during clustered
care; clustered care is especially stressful for
preterms less than 28 weeks’ gestational age.
182
Clustering care may not ensure long rest periods,
because 50% of all rest periods in several NICUs
were shorter than 10 minutes (see Table 13.5).
124
If the practice of clustering care—with its prolonged disturbance of the preterm infant—results
in alterations of vital signs, oxygen saturation,
and infant stress and fatigue, then care should be
individualized and provided to minimize physiologic and behavioral disturbances.
171,183,227,334
A
study of medically stable preterms found that after
nursing interventions, these infants generally sleep,
either from satiety or from the significant energy
expenditure associated with caregiving.
399
Even “preterm growers” may be unable to
tolerate more than one stimulus at a time. They
feed best if visual, auditory, and social stimuli
are not provided until after the feeding. As the
infant matures and is able to tolerate integrated
experience, multimodal stimuli are provided.
449
Studies of multimodal stimuli (e.g., auditory, tactile,
vestibular, visual) provided to preterms demonstrate
(1) increased alertness, (2) earlier discharge, (3) faster
progression to full oral feedings, (4) improved organization of behavioral states, (5) stable respiratory
rate and oxygen saturation, and (6) a significant
decrease in resting heart rate.
449,450
Alterations in the individual infant’s daily
schedule are made to accommodate a more flexible or structured schedule—whichever is better
for the infant.
158
Assessing the infant before,
during, and after an interaction or intervention
guides the care provider in adapting care and the
environment to the individual infant (Table 13.6).
An organized infant is able to interact with the
environment without disrupting his or her physiologic and behavioral functioning.12 When a disor-
ganized preterm interacts with the environment,
signs of physiologic and behavioral stress may
occur (see Table 13.4), in which case the interaction should cease.
171,210
The potential effects of
stress and trauma to fragile preterm infants have not
only short-term but also long-term impacts on their
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TABLE
13.6
TIME FRAME ASSESSMENT
PARAMETERS FOR ASSESSING INTERACTION AND INTERVENTION WITH NEONATES
Before
Gather baseline data before touching the infant
Gestational age and postconceptual age
Diagnosis
Level of physiologic homeostasis:
Previous vital signs
Oxygenation state—continuous pulse oximetry or transcutaneous monitor
Neonatal state:
Sleep—deep, light, drowsy
Awake—quiet, active alert, crying
Self-regulatory versus stress behaviors (see the Critical Findings in Table 13.4)
During
Gently and as unobtrusively as possible assess
physiologic and behavioral signs during intervention
Level of (current) physiologic homeostasis—vital signs and changes:
Observation (without touching infant)—color, posture, general appearance, respiratory rate,
temperature (skin, incubator), blood pressure (transducer), oxygenation (from continuous monitor)
Quiet (with minimal disturbance)—auscultate heart, lungs, and abdomen; axillary
temperature, blood pressure (cuff); head-to-toe assessment; oxygenation (saturation
Neonatal state change:
Sleep—deep, light, drowsy
Awake—quiet alert, active alert, crying
Self-regulatory versus stress behaviors (see Table 13.4)
355
decreases with distressful, disturbing stimuli)
After
Assess physiologic and behavioral signs after
intervention (delayed reactions may occur minutes
after care)
outcomes.
337,386
An intubated preterm infant cared
for in a NICU with a strict suction “routine” every
2 hours responds with profound cyanosis, lowered
TcPo2 and pulse oxygenation, and bradycardia
and requires bagging after every suction (with no
secretions obtained), an obviously unnecessary and
stressful intervention. In a less rigid, more individualized care setting, that same infant may signal the
need for suction by becoming restless, by a decrease
in oxygenation, or by heart rate changes (tachycardia or bradycardia). Suctioning improves the infant’s
condition—the infant lies quietly and has improved
oxygenation, and the heart pattern stabilizes. This
infant has signaled his or her need, and the care
providers have read the cues and responded with
Level of physiologic homeostasis
Vital signs—Returned to baseline values? More stable or less stable than baseline values?
Neonatal state change—Return to baseline state? To a higher state? Unable to be consoled? More
consolable left alone?
a stabilizing intervention—the infant has not been
stressed by an unnecessary procedure.
Knowledgeable professionals are able to role
model for and teach parents how to relate to
their premature infant.
208
Parents are taught
to recognize and use infant states to maximize
appropriate interaction.
208
The drowsy premature
infant may be unable to engage in eye-to-eye contact with their parents or be able to sustain it for too
short (for the parents) a period. Waiting until the
infant is more awake to initiate eye contact is more
rewarding for the parent and less stressful for the
infant. Role model for parents that their infant is
an individual and, although premature, can signal for more or less stimulation (see Table 13.4).
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A preterm infant who is lightly touched may
startle, jerk, or withdraw from parental touch. In
response, the parent suddenly and sadly pulls his or
her hand away and is reticent to touch the infant
again. Intervention includes helping parents read cues
and learn appropriate responses to their infant. Teach
parents how to recognize a stressed infant and how to
intervene. At the same time, be sure to acknowl-
edge the parents’ knowledge of the infant and
support them. Above all, do not patronize.
Professionals have much to learn from parents,
who are “professionals” in their own right. The
prime rule of relating to infants is this: The infant
leads; the adult follows.
Feeding a premature infant may be difficult
because the infant “goes to sleep” during feedings.
The usual parental ministrations of talking to the
infant, soothing with touch, or holding upright on
the shoulder may not work with a fussy, irritable
preterm infant.
The preterm infant’s behavior may be so disorganized, unpredictable, or misunderstood by the
parents that an appropriate response is not pos-
6,156
sible.
Thus, parents often become exhausted,
bewildered, and frustrated in their encounters with
their preterm infant’s behavioral response to their
care as rejecting and unloving: “My baby doesn’t
like me.” Teach parents that their infant’s disor-
ganization with stimuli is related to prematurity
(i.e., an immature CNS) and not to parent
ministrations. Reassure them that as the premature infant grows and displays maturational
changes, he or she will be able to tolerate more
stimulation and will be more responsive to their
care.
Just as parent-infant interaction is responsible for
normal development of the term infant, parent-infant interaction is crucial in the development of
at-risk infants. Many parents of premature infants
have been observed making heroic efforts over long
periods to interact with their less alert, active, and
responsive infants.
156,275
Parenting the preterm has
been described as “more work and less fun.” Setting
parents up to succeed involves placing parents
in situations in which they will experience
positive feedback from their infants. Suggesting
and role-modeling intervention strategies show parents what and how to play and interact with their
infants. Parent participation in intervention strategies is ensured by stressing how important it is to
infant development, that professionals are too busy
to provide all the necessary interventions, and that
parents are in a unique position to provide developmental care in the hospital and at home after
discharge. Parents, with help from professionals,
are the ideal planners and providers of developmentally appropriate intervention strategies
380
(see Table 13.1).
A rooming-in setting for parents and their at-risk
newborns is the best environment for cues to be
learned and care given according to these cues.
Unlimited and unrestricted contact of parents
and newborns should be the policy in every
normal, medium-risk, and high-risk nursery
(see Box 29.2). Providing a single-room NICU, a
family room, bonding room, or apartment in which
parents and their soon-to-be-discharged newborn
can room-in helps the transition from hospital to
home care. Rooming-in before discharge gives
mothers and fathers an opportunity to assume full
responsibility for their infant’s care, tests the reality
of caregiving, helps them learn caregiving activities
and their infant’s behavior patterns, and confirms
their readiness for independent parenting and the
infant’s readiness for discharge.
Intervention Strategies
Because infants experience their environment through sensory processes, intervention strategies are
based on tactile/kinesthetic, auditory, visual, olfactory/
gustatory, and communication skills. Interventions
must be individualized according to the infant’s
state, sensory threshold, physiologic homeostasis,
and stability or stress cues.
CIRCADIAN RHYTHMS
In utero, the states of the fetus are regulated by the
sleep-wake cycles of the mother. In the NICU, multiple intrusions disrupt regulation.
affects an infant is not fully known, although limited
energy may be drained, the infant may be subjected
to further stress,
6,158
neurodevelopment altered, and
outcomes of therapeutic interventions may not be
optimized. To minimize interruptions and excessive
handling, infants should not be awakened when
asleep; if they must be awakened for care, it should
be during active sleep by talking softly and stroking
5,110
gently.
Appointments for examinations should
be made before feeding to decrease unnecessary
disturbance of sleep but with enough rest time (if
needed) before actual feeding.
124,183,227
358-360
How this
CHAPTER 13 The Neonate and the Environment Impact on Development
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357
Adequate numbers of caregiving encounters—
physical assessment, vital signs, diaper or linen
change, and procedures—must be balanced against
constant manipulations.
123,156
Because essentially
all NICU (levels II and III) infants are continuously monitored, “laying on of hands” every
1 to 2 hours is often unnecessary. Thorough
physical assessment and vital sign recording
every 4 hours is easily alternated with recordings from the monitors every 4 hours. Thus,
the infant is evaluated every 2 hours but not
disturbed that often. An acutely ill infant may
need closer observation, but alternating “hands-on”
with monitor readings accomplishes the goal without overwhelming an infant with few reserves. One
systematic review recommends regulating elective care (i.e., routine laboratory draws, x-rays,
and cardiac assessments) so that it is not being
done during sleep.
422
Sleep-wake patterns are influenced by feeding
method
404
and schedule,
60,61
temperature, position,
CNS maturation, birth weight, caregiving practices,
and environmental effects (e.g., ambient light, noise,
day/night).
221,358-360,415
In the NICU, activity/
rest patterns are evident as early as 35 weeks’
post-conceptual age and cycle at 3-hour intervals, related to feeding schedules.60 During the
first week at home, the 3-hour sleep-wake cycle
established in the NICU is replaced by a circadian
rhythmicity.61 Sleep-wake patterns in breastfed and
bottle-fed infants differ. During the first month of
life, full-term breastfed infants awaken more and
sleep less during the night.
149
Day-night cycles are facilitated by afternoon
naptime and nighttime in which the dimming of
lights or covering of incubators and cribs with
blankets and quieting of NICU noise enable
infants to sleep. Deep, quiet sleep is facilitated
by quiet and dark, soft music or nature sounds,
gentle stroking of the head, and self-regulated
tasks (self-sought proximity of infant to “breathing
403
bear”).
Maintaining daily naptime and nighttime
hours helps infants reset their diurnal rhythms and
become accustomed to sleeping in dim light and
a quiet environment. Percentage of sleep time
and duration of sleep for preterm infants in the
NICU is longer at night than during the day,
and better sleep patterns were associated with being
male, younger PMA and chronological age, smaller
in body weight, and less illness severity.
221
Among
convalescing preterm infants (<34 weeks’ gestational
age), four standard rest periods per day resulted in
(1) increased daily weight gain, (2) increased sleep,
(3) less-active states during nap time, (4) decreased
occurrences of apnea, and (5) by 3 weeks, less
quiet waking time and longer uninterrupted sleep
episodes.
181,411
Uninterrupted sleep and diurnal
rhythmicity also are associated with improved
state organization in VLBW infants and with
less fussing and crying.
TACTILE AND KINESTHETIC
INTERVENTION
359,360
Because the sense of touch is highly developed
in utero, even a very immature preterm has acute
tactile sensitivity. For newborns, human touch
is the most important tactile stimulation. Not
all touch is equal, however, nor is it responded to
equally by term or preterm infants who are well,
critically ill, or recovering from illness. One study
has shown the effect of the vulnerability of LBW
infants in their response to the nurturing touch of
their mothers. Nurturing maternal touch was associated with a secure attachment in robust infants;
in highly vulnerable, sick LBW infants, this same
nurturing touch was associated with a less secure
attachment.
444
Any type of tactile stimulation is
composed of six factors: duration, location, action,
intensity, frequency, and sensation. Tactile sensa-
tion both arouses and quiets. Gentle but firm
handling quiets infants because they feel more
secure; light, uncertain touch often results in
agitation and withdrawal. Handling for routine
care (e.g., vital signs, changing the diaper or
position, venipuncture for blood draws or placement of IV lines, feeding, heelsticks, suction,
and physical or neurologic examinations) can
result in hypoxia, increased intracranial pressure,
episodes of apnea/bradycardia, agitation, elevated pain and stress scores for VLBW preterms,
and increased or decreased heart rate and blood
pressure.* Applying developmentally supportive
care to “routine” procedures such as diapering
decreases the physiologic stress response in fragile
preterm infants and offers them repeated opportunities to enhance their neurodevelopment.
Handling. How a neonate is handled during care
123
affects his or her physiologic and behavioral
response. Use of body containment during
* References 68, 98, 99, 123, 125, 241, 332, 399, 462.
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suction decreases the physiologic and behavioral responses to this stressful procedure.
402
Comparing preterm responses to swaddled and
unswaddled weighing, unswaddled infants exhibit
more physiologic distress, more motor disorganization, poorer self-regulation, and more need for caregiver facilitation than when they were swaddled for
weighing.
302
Transferring preterm infants from
the incubator to the parent for holding or KC
is stressful. One study evaluated physiologic disor-
ganization in preterms according to the method of
transfer from the incubator for KC (nurse picking
up the baby and transferring to the parent versus
the parent picking the baby up directly from the
incubator).
307
Both transfer methods resulted in
increased physiologic and motor disorganization
(i.e., oxygen desaturation, tachycardia, cyanosis/
pallor, hypotonia, decreased self-regulation, and
increased need for caregiver facilitation to maintain physiologic stability during transfer). In both
methods of transfer (which lasted 6–9 minutes), the
ventilator was disconnected (for 5 seconds). Both
the infant’s desaturation readings and tachycardia recovered to baseline levels faster with the
parent transfer.
307
Excessive handling of preterm, VLBW, or
sick neonates results in significant physiologic
consequences, such as blood pressure changes,
alterations in cerebral blood flow, hypoxia, and
other stress behaviors.
241
One study of ventilated
VLBW infants found an average of 53 handling
episodes, for an average length of 3 minutes over a
24-hour period.68 These infants had pain scores significantly higher after than before handling regardless of the reason for the handling (i.e., invasive/
noninvasive or social/nonsocial).68 A recent study
compared the frequency and severity of hypoxemia
episodes (SpO2 <75%; SpO2 <85%) in 24 mechanically ventilated premature infants during daytime
(0900-1700) and nighttime (2100-0500) hours.
193
Nighttime hours had fewer and less severe
hypoxemia episodes when compared to daytime hours. The researchers concluded that the
babies were handled less frequently and had less
sensory stimulation during the nighttime hours.
A particularly vulnerable group of preterm infants,
those with periventricular leukomalacia (PVL),
react to handling and multisensory stimulation (e.g.,
auditory, tactile, visual, vestibular) with an increase
in heart rate above their already higher resting heart
377
rate.
These CNS-injured preterms require close
observation and monitoring during handling, stressful procedures, and interventions.
450
A total body position change is not considered a painful procedure, but in LBW preterm
infants with endotracheal tubes and umbilical
artery catheters, the handling necessary to change
the infant’s position elicits pain behaviors.
Nonpainful tactile stimulation (e.g., routine nursery handling) of preterm infants has been shown
to produce equal or higher levels of physiologic
stress activation than does a painful stimulus
(e.g., heelstick).68 In the same study, the relatively
low behavioral activation during “routine handling”
led the researchers to conclude that this tactile stimulus was not unpleasant to the infants, even though it
produced a high level of physiologic stress response.
In the NICU, infants who are repeatedly subjected to painful, intrusive procedures develop
touch aversion—the association of human touch
with pain. Tactile vulnerability has also been found
in infants who require multiple postnatal medical
interventions, who are exposed to illicit drugs in
utero, and whose mothers had their own predisposition regarding being touched (a genetic compo-
443
nent?).
These infants cry uncontrollably, squirm
away, flail arms and legs, and recoil when touched,
knowing that pain will soon follow. An infant who
has received ventilatory therapy may have touch
aversion around the mouth: The infant is averse to
facial stroking and rooting, has a hypersensitive gag
reflex, and refuses to nipple feed. Painful procedures
should be minimized to those absolutely (medically) indicated—no infant should be subjected to
“routine” painful procedures. During those necessary procedures, it is essential to provide body
containment, comfort measures (e.g., a pacifier), and
adequate pain relief (see Chapter 12).
Touch. Touch that is not related to caregiving
(i.e., social contact) should be provided by
parents and professionals when the preterm
infant is aware, alert, and receptive. When
parents touch their babies, the amount and types
of touch vary widely—most frequently, holding, stroking, rubbing, or placing a finger in the
infant’s hand. Preterm infants respond individually and physiologically to their parents’ touch;
there is more variation in heart rate and oxygen
saturation levels compared with baseline values.
These variations depend on gestational age, infant
state, and the amount of handling before parent
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