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CHAPTER 13 The Neonate and the Environment Impact on Development
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359
handling.
170
Less touching by the nurse within
the 2 hours before parental holding results
in less mean decrease in heart rate during
parental holding.
170
Parents provide more
positive touch (kissing and stroking); preterm
infants are more likely to smile and sleep for
their parents compared with responses after a
nurse’s touch. In animal studies, increased parental
touching in infancy results in changes in brain
structure, decreased levels of stress hormones, and
better ability to survive a stressful environment.
437
Parental touch of preterm humans enables
them to withstand the stress of illness and
the NICU environment. Recent research on
somatosensory processing found that the degree
of prematurity at birth determines the extent
to which the immature brain responds to light
touch, so that supportive experiences (such as
breastfeeding and skin-to-skin contact) are
associated with stronger brain responses, and
painful stimuli are associated with a reduced
brain response to the same touch stimuli.
259
Nonpainful touch such as stroking (of the head,
trunk, or hands) during care may calm, soothe, and
prevent touch aversion. Stroking of physiologically
stable preterm infants has been associated with
increased activity and alertness, a faster regaining of birth weight, more rapid weight gain,
less crying and apnea, enhanced developmental
status, and better social scores.
169,171
In another
study, systematic stroking of ventilated preterms
resulted in no adverse effects on oxygenation
and respiratory or heart rates.
104
However, in
preterm infants (26–30 weeks’ gestation) who
are not physiologically stable, stroking results in
decreased oxygen saturation, signs of behavioral
stress (e.g., grasping, grunting, gaze aversion),
and more avoidance cues (e.g., grimacing,
yawning, fussing or crying, tongue protrusion).
Other behavioral and physiologic effects include
heart rate and blood pressure changes, changes in
respiratory rate and rhythm, increase in avoidance
signals (e.g., increased startle reflex, agitation, crying),
increase in activity and movement, and decreased
visual responsivity.
99,170,241,307
If the preterm infant becomes agitated with stroking, a hand firmly placed on the head and lower back,
buttocks, or abdomen often quiets.
91,169
Hand place-
ment without stroking does not decrease oxygen
saturation or alter heart rate and has a soothing
effect (i.e., decreases active sleep, increases
quiet sleep, decreases respiratory and heart rates,
decreases motor activity and behavioral distress)
on small preterm infants.
171,172,188,285
Handle gen-
tly to avoid stressful reactions (e.g., flailing, arching, oxygen desaturation) and enable the infant
to become calm and rest between caregiving.
Parents should be taught and encouraged to provide
their preterm with “gentle human touch”
169,285
in
the form of supportive containment with their hands,
use of gradual and rhythmic action, observation of
infant responses (see Table 13.4), and modification,
alteration, or cessation of touch when necessary.
169,171
Therapeutic touch (TT), a complementary
therapy of balancing and increasing energy
to promote healing, does not require physical
contact, as hands are suspended over the body.
A randomized double blind study of the use of
TT on 10 physiologically fragile, very preterm
infants showed no adverse effects (i.e., oxygen
desaturations or apnea).
is indicated.
Massage. The touching and stroking of massage
388
451
Clearly more research
stimulate nerve pathways and aid myelinization by increasing hypothalamic activity and
production of the growth hormone somatotro-
pin. In animal studies, touch deprivation decreases
growth hormone secretion, which results in
undergrowth of all organ systems; a return to
normal secretion occurs with tactile stimula-
374
tion.
Massage affects the maturation of the
brain’s electrical activity and simulates intrauterine development as observed in term infants.
166
A
growth gene that responds to tactile stimulation
has been discovered; this suggests a genetic origin
for the touch-growth relationship.
134
Because
touch stimulation of the inside of a neonate’s
mouth increases the release of gastrointestinal
food absorption hormones (i.e., gastrin, insulin),
it is postulated that the tactile stimulation of
massage leads to a similar hormone release. Assays
of glucose and insulin levels in heelstick samples
of preterm infants suggest that massaged infants
show increased levels of insulin.
134
Research on massage therapy with preterm
infants has been conducted on medically stable,
growing infants (i.e., preterm growers). A recent
systematic review found clear benefits of massage
in hospitalized preterm infants.14 Despite positive
outcomes of massage research in Table 13.7 and its
cost effectiveness in decreasing length of stay, only
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TABLE
13.7
BENEFITS OF MASSAGE WITH PRETERM INFANTS: RESEARCH BASIS
STUDY RESULTS
Three times/day massage of preterms with physiologic and
biochemical measurements
373
21% increase in daily weight gain
Discharged 5 days earlier
Superior performance on habituation
Fewer stress behaviors (mouthing, grimacing, clenched fists)
Increase in catecholamine secretion in neonatal period (analogous to the normal
developmental increase after birth)
Increase in vagal activity
10 healthy preterm “growers”: three times/day massage for
15 min in a randomized sequence of 5 days of massage and
5 days without massage
217
Massaged for 15 min three times/day for 5 days: 68
preterms (mean GA = 30 wk) with either light- or
moderate-pressure massage
135
80 preterms randomized to moderate-pressure massage or
standard care
72 preterms randomized to massage or control therapy
106
107
Energy expenditure significantly lower after 5 days of massage than after 5 days without
massage in metabolically and thermally stable preterms
Decreased energy expenditure may contribute to enhanced growth caused by massage
Fewer stress behaviors and less activity from first to last day of the study
Moderate-pressure group: significantly more daily weight gain; more relaxed, less
aroused than light-pressure group
Increase in vagal activity and gastric motility, which may contribute to greater weight
gain in massaged preterms
Greater increase in body temperature in massage versus control preterms (even though
incubator portholes were open for the massage but not for the control group)
Massaged or exercise for 10 min three times/day for 5 days
30 preterms randomized to moderate-pressure massage or
passive flexion and extension of limbs
21 preterm infants (8 males and 13 females)
108
:
Greater weight gain in both massage and exercise groups due to different mechanisms:
• Massage increased vagal tone
• Exercise increased calorie consumption
389
Massaged male infants had improved autonomic nervous system function during
caregiving and sleep compared with nonmassaged male preterms. There was no
difference in heart rate variability between massaged and nonmassaged female
preterm infants.
40 stable preterm infants randomized to 20 minutes of
massage twice daily for 4 days or no massage
33
Lower level of transcutaneous bilirubin and more defecation in massaged versus
non-massage group.
389
33
Mother Massage
104 VLBW infants (≥750 to ≤1500 g; ≤32 wk GA)
randomized to control or standard care with maternal
massage four times/day of face and limbs with passive limb
281
exercises
66 stable preterm infants (32 massaged by their mother; 34
control group)
1
Medically stable preterms (33–37 wk GA; BW 1500–
1999g) randomly assigned to massage group or massage
with sunflower oil by their mothers three times/day for 14
consecutive days
129
Eight minutes of mother massage of preterms within 24 hours
of discharge and repeated on day of discharge
Olive oil massage for 10 days, three times/day for 15
minutes versus massage without olive oil
BW, Birth weight; CA, corrected age; GA, gestational age; LOS, length of stay; NICU, neonatal intensive care unit; VLBW, very low birth weight.
Significantly lower incidence of late-onset sepsis
Discharged from the hospital 7 days earlier
Improved neurodevelopmental outcomes at 2 years CA with massage
343
Lower pain scores after massage with heelstick and at discharge; higher cognitive scores
at 12 months’ CA compared with control group. No difference in weight gain, LOS,
breastfeeding duration, and motor skills between two groups.
Oil massage group: mean weight at 1 month and 2 months of age significantly greater
than body massage alone group
Less maternal anxiety on the day of discharge when mothers massaged their preterm
3
infants
3
Daily average weight gain with olive oil massage (21 g) compared to weight gain of
191
7 g without olive oil
191
CHAPTER 13 The Neonate and the Environment Impact on Development
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361
38% of NICUs practice massage on their stable
preterm infants.
136,439
Massage therapy provides
social touch rather than painful touch, prevents or
treats touch aversion, and should be taught to and
provided by parents in the hospital and at home.
276
Confidence in parenting skills and tactile communication between parents and infant is encouraged
when parents massage their infant. Because mas-
sage has not been studied in acutely ill preterm
infants, its use should be confined to preterm
growers.
134,429
Chronically ill infants (e.g., babies
with BPD or congenital heart disease) may exhibit
physiologic and behavioral disorganization with
massage, so the risk-benefit ratio must be assessed
carefully. The M technique, used for fragile infants
who do not tolerate conventional massage, is a
gentle, structured stroking technique that reduces
stress and anxiety. Outcomes of those exposed to
the M technique included (1) lower heart rate, (2)
increased oxygen saturations, (3) increase in quiet
sleep, and (4) fewer behavioral distress cues.
388
Varying sensations and touch patterns keep
infants interested in stroking and massaging. As
a preterm infant matures and is able to tolerate
variety, he or she should be introduced to different
textures (e.g., lambskins, stuffed toys, cotton, satin).
Baby clothes provide various textures, decrease heat
loss (especially hats), and make the infant more
attractive. (“He looks like a real baby!”; “She looks
like a girl because her shaved head is covered!”)
Holding. When the infant is preterm or a sick
term baby, holding him or her—an essential
step of parent attachment—is disrupted. Some
NICUs promote parental holding as soon as possible, whereas others have specific protocols about
weight criteria and extubation before parents are
able to hold their infant.
143
A national survey on
holding policies found (1) written protocols for
conventional holding (26%) and for KC (40%),
(2) for extubated infants: 73% offered KC, 99%
conventional holding, and (3) for holders of
extubated babies: mothers 73% KC, fathers 68%
KC, and 99% conventional holding for both
parents.
143
Potential benefits of enhanced parent-infant interaction and attachment, closeness
of parents to their infant, increased lactation, and
improved parental self-esteem are factors that
influence staff to facilitate holding.
143
A prospective cohort study of parental presence and holding in the NICU found significant
neurobehavioral benefits for preterm infants less
than or equal to 30 weeks’ gestation.
354
parenting (i.e., holding) in the NICU resulted
in lower arousal and excitability, better quality
of movement, less stress, and less hypertonic
muscle tone, thus a developmental advan-
354
tage.
Another study conducted in an urban
NICU with low levels of parental presence
and holding compared the neurodevelopmental
outcomes of preterm infants (<30 weeks’ gestation) cared for in single-family rooms versus
open ward NICU rooms.
337
The study outcome
showed that at age 2 years, children cared for in
the private rooms had lower language acquisition,
more externalizing behaviors, and a trend toward
lower motor scores than those in open wards.
The researchers were surprised by their findings
and remarked on the relative sensory depriva-
tion of the preterms in private rooms whose
parents were not often present and handling
their infants. Long periods of sensory deprivation—lack of parental presence, holding, and
auditory stimuli—may be as detrimental as the
sensory overload of a noisy, open NICU.
A qualitative study of factors affecting parental
presence found that active involvement in the
care of their extremely preterm infants, including
skin-to-skin holding, increased their motivation
to be present and their feelings of control.
Factors discouraging parental presence included
excessive noise38 and light levels in the NICU
and dismissive staff attitudes.
176
A more recent
study of predictors of parental involvement in the
care of their premature infants (n=81; <32 weeks’
gestational age) found that being Caucasian, older,
married, employed, having fewer children, having
familial support, and providing breastmilk were all
associated with more parental presence.
339
holding of the infant was associated with fewer
medical interventions, an employed father, being
Caucasian, fewer children, and having family support. Outcomes of parental holding resulted
in better reflex development at term age, and
skin-to-skin holding resulted in better reflexes
and less asymmetry at term and better gross
motor development at 4 to 5 years of age.
Communicating to parents the importance of
their presence and their care for their baby, as
well as providing a welcoming, nurturing, and
comfortable place for parents is the responsibility of all the NICU staff, especially nurses.
KC (Fig. 13.1), skin-to-skin contact between
parents and infant by placing the infant in a
Early
337
176
More
339
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vertical position between the maternal or paternal
breasts, benefits both parents and neonates (Box
13.6). Another position, “supported diagonal flexion,”
for skin-to-skin care has been studied to facilitate
more face-to-face exchanges between mother and
infant in the NICU.62 Supported diagonal flexion
resulted in more eye contact between mothers
and their infants, more maternal vocalizations,
caressing, and decreased postpartum depression
scores without altering physiologic stability in the
premature infants. KC for the healthy preterm has
been used in the delivery room, in the transitional
period (see Chapter 5), for adoptive parents, and for
transport. National surveys of holding/KC have been
conducted and have found that KC is practiced more
commonly in subspecialty (level III) than in specialty
(level II) care NICUs.
120,143
KC is well tolerated in the first week of life
by preterm infants with current or resolving
neonatal illness. KC of preterm infants for even
1 hour has been shown to provide benefits: significant decrease in heart and respiratory rates
and increased temperature and oxygen saturations, especially in SGA and female preterms.47
An RCT of healthy preterms (33–35 weeks’ GA)
found that KC for 3 hours improved breathing
patterns and resulted in no apnea or bradycardia
or periodic breathing or temperature instability.
248
KC improves gas exchange in preterm infants
of less than 1800 g. The smallest infants (<1000
g) remained more clinically stable (i.e., smallest
increase in heart rate, highest decrease in respiratory
rate and increase in oxygen saturation, no hypothermia) compared with infants larger than 1000 g.
141
A randomized study of three holding methods
(i.e., KC, cuddled, and a no restrictions method)
in preterms between 32 to 35 weeks’ gestation
concluded that both KC and cuddled holding
by parents may provide equal developmental
FIGURE 13.1 Kangaroo care.
BOX
13.6
BENEFITS OF SKIN-TO-SKIN CONTACT/KANGAROO CARE
Parental
• Activates maternal/paternal processes of search for meaning and mastery of the experience of premature birth
• Increases maternal/paternal self-confidence, competence, and self-esteem; lower levels of stress related to “incompetence”
• Enhances parent-infant attachment
• Increases parental oxytocin levels
ing in decreased anxiety levels
• More stress in mothers of late-preterm infants related to more facilitated
progression of the mother-infant relationship
• Initiates and maintains maternal/paternal behavior
• Positively affects mother’s mood/behavior; less maternal depression;
calming (decrease in salivary cortisol levels)
• Favorable impact on maternal parasympathetic nervous system as measured by heart rate variability
• Lowers parental heart rate and blood pressure
• Positive and personally beneficial experience
139
83
432
and decreased cortisol levels result-
83,90
369
41,83,303
64
197
• Positively affects parental identity and knowledge of infant
affects the process of becoming a parent
• Increases confidence in meeting infant’s needs
• More frequent visiting
• Parental eagerness for infant’s discharge
• A restoring experience and an energy-draining experience
• Long term:
• More consistent/contingent maternal/paternal responses at 15
months of age
• More sensitive, less intrusive, more reciprocal interactions from 6
months to 2 years from both mothers and fathers
• More affectionate touch, more adaptive to infant signals, and infants
more alert during interactions at 3 to 6 months
• Less maternal/paternal separation anxiety at 6 months
• Improved family cohesiveness
• Fewer reports of difficulties with breastfeeding
• 20-year follow-up of original cohort: parents more protective and nurturing
18
363
; positively
18
79
Continued
BOX
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13.6
CHAPTER 13 The Neonate and the Environment Impact on Development
BENEFITS OF SKIN-TO-SKIN CONTACT/KANGAROO CARE—CONT’D
363
Neonatal
• Thermal synchrony: mother’s body temperature rises and falls to maintain infant in neutral state (see Chapter 6)
• Higher body temperature resulting from advanced maturation of
thermoregulation
• Distal skin vasodilation promoting rapid sleep onset
• Cardiopulmonary:
• Adequate or improved oxygenation; reduction in oxygen require-
197
ment
; minimal decrease in cerebral oxygenation while gavage
263
feeding
• Fewer/no episodes of periodic breathing, apnea, and bradycardia
• Lower diaphragm electrical activity while being ventilated by NARS
• Lower heart rate/stable respiratory rate
• Higher vagal tone: indicative of quicker maturation of the autonomic
nervous system (even in infants with complex congenital heart dis-
173
ease)
; favorable impact on premature infant parasympathetic
nervous system as measured by heart rate variability
• Stable vital signs, oxygen saturation, and temperature before, during,
and after cardiac surgery
174
• Breastfeeding:
• Increased milk supply
• Increased incidence and length (even in very-low-birth-weight
138,381
preterms)
• Increased exclusive breastfeeding
51
• Positive effect on growth in VLBW infants
• Distinct oral microbiologic pattern and an accelerated pace of micro-
bial repertoire maturity
178
• Attainment of full breastfeeding in the NICU at a median age of 35
weeks’ PMA
313
• Behavioral:
• Increased alert activity
• The longer the period of KC the more the preterm neonate made
physical contact attempts with mother during breastfeeding
• Increased deep, quiet sleep
34
• Improved self-regulation: sleep-wake cycles, arousal, sustained
exploration
• Better emotional regulation and arousal modulation for interaction
and rest
• Decreased stress response: decrease in beta-endorphin and cortisol
432
levels
; less stress response to diaper change
• Decreased or no crying
125,126
28
390
83
64
381
308
253
• Increased en face positioning
• Better orientation and habituation
• Less pain response to painful procedure in both preterm and term
infants (see Chapter 12)
• Accelerated brain maturation
• Earlier discharge/ lower cost:
• Increased weight gain
127,381
• No increased infection/fewer infections51; decreased severity of
infection and mortality; decolonization from resistant bacteria on the
infant’s skin
220
• Out of incubator earlier
• Decrease in mortality of infants with birth weight <2000 g
51
• Regulatory interaction:
• Behavioral
• Sucking
• Neurochemical (decline in plasma oxytocin levels)
209,442
• Metabolic
• Sleep-wake cycles/improved sleep organization
• Cardiovascular
• Endocrine
• Immune
• Circadian
• Long-term:
• Increased length and head circumference at 9 months and 1 year of
age
• Less crying at 6 months of age
• Higher psychomotor scales at 6 months and higher mental scales at
6 months to 2 years
• Enhanced mental and psychomotor development at 1 year
• Better self-regulation, less frustration, and better able to calm themselves at 1 year of age
• Improved cerebral motor pathways and synaptic efficacy at
adolescence
• Enhanced cognitive development and executive functioning from 6
months to 10 years; by 10 years of age: attenuated stress response,
improved autonomic functioning, organized sleep, and better cognitive and behavioral control
• 20-year follow-up of original cohort: fewer school absences, less
hyperactivity, aggressiveness, externalization, and socio-deviant
behavior in young adults. Larger volume of left caudate nucleus on
79
brain MRI
MRI, Magnetic resonance imaging; NARS, noninvasive neutrally adjusted respiratory system; NICU, neonatal intensive care unit; PMA, post menstrual age.
Data compiled from references 51, 65, 89, 131, 141, 155, 242, 243, 245, 248, 250, 306, 309, 310, 362, 363, 376, 377.
UNIT TWO Support of the Neonate364
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benefits in the form of early behavioral organization to preterm infants.
303
All infants being
held either conventionally or by KC should be
monitored continuously for vital signs and oxygen saturation.
248
Parental holding is often (17%–33%) limited
or not supported by nurses and physicians.
43,143
Parents identify both the hospital staff and the
environment of the NICU as barriers and supportive of KC.
43,228
A recent phenomenologic
study found that NICU nurses attempt to balance
the developmental needs of infants with parental
readiness to participate in skin-to-skin care.
215
A
second phenomenologic study found that information, communication, consistency, and support
from staff to parents along with knowledgeable staff
assisted in parents performing and having positive
experiences with KC.
228
Barriers to holding infants
include (1) infant safety concerns (e.g., accidental
extubation, loss of arterial/venous lines, vital sign
or oxygenation instability) and (2) reluctance of
professionals and families to initiate or participate
in KC (e.g., adding to RN workload and belief
of losing control because of limited access to the
infant, difficulty providing care, lack of experience,
used for babies who are not developmentally ready,
belief that technology is better than KC, belief by
professionals that mother would feel trapped and
stressed).
120,143,296
From the caregiver’s perspective
there are four themes in the process of facilitating
skin-to-skin care: (1) varying thresholds of getting
started, (2) defining adequate resources, (3) dealing
with the demands and complexities of the neonate,
and (4) balancing parental readiness for skin-to-skin
care with the neonate’s needs.
431
More than 60% of
NICUs responding to one survey stated that low
birth weight and gestational age were not contraindications for KC; many NICUs did not permit KC
for babies on high-frequency oscillator ventilation
(HFOV) or vasopressors.
120
“Risky populations” for KC include infants
who are intubated (Fig. 13.2), have arterial/
venous lines and chest tubes, are on pressors
to maintain blood pressure, and are on HFOV.
A prospective, nonrandomized study in a level III
NICU found a low risk of mechanical compli-
cations and no increased risk of infectious complications with skin-to-skin contact in neonates
with an indwelling umbilical venous catheter.75
One of the national surveys found that 64% of
NICUs offered conventional holding to parents of
FIGURE 13.2 Kangaroo care of awake, alert, intubated, and ventilated
premature infant.
intubated infants and 45% offered KC of intubated
infants. The second survey found that 60% of NICU
nurse managers thought that intubated infants should
not receive KC.
120,143
In one study, 43 intubated,
hemodynamically stable preterms less than 1500 g
were assessed for 90 minutes (15 minutes of transfer;
60 minutes of KC; 15 minutes of transfer) and found
to have stable heart rates, oxygen saturations, axillary
temperatures, and mean arterial blood pressures.23
The researchers concluded that KC was safe for these
ventilated preterms under their study conditions. A
more recent study of 40 preterm infants (27.6 to 28.9
weeks’ gestation) receiving invasive (endotracheal
tube ventilation) and noninvasive (continuous positive
airway pressure [CPAP] and high-flow nasal cannulae)
respiratory support found no difference in physiologic
parameters (i.e., regional cerebral oxygenation, heart
rate, pulse oximetry values, temperature, or FiO2)
while being held skin to skin for 90 minutes when
compared to incubator care.
242
On the basis of a 3-year study in five NICUs
of mechanically ventilated infants receiving KC,
selection criteria (Box 13.7) and a safe protocol
(Box 13.8) for KC in this population have been
developed.
250,251
During this study, no adverse
physiologic or behavioral events or accidental extubations occurred. None of these babies was agitated,
and all slept and tolerated KC well. Previously
CHAPTER 13 The Neonate and the Environment Impact on Development
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BOX
13.7
• Birth weight >600 g; ≥30 weeks’ GA
• Ventilator for at least 24 hr before first kangaroo care
• SIMV: <35 breaths/min; Fio2 <0.50 (50%)
• Stable vital signs (TPR, B/P) and oxygen saturation
• Stable blood gases, bilirubin level
• No signs/symptoms of sepsis
• Not receiving vasopressors; no chest tube
• Lines (Broviac, umbilical, arterial, IVs) well secured
B/P, Blood pressure; Fio2, fraction of inspired oxygen; GA, gestational age; IV, intrave-
nous; SIMV, synchronous intermittent mandatory ventilation; TPR, temperature, pulse,
respiration.
Modified from Ludington-Hoe S, Morgan K, Abouelfrettoh A. A clinical guideline for implementation of kangaroo care with premature infants of 30 or more weeks’ postmenstrual
age. Adv Neonatal Care. 2008;8:S3.
BOX
13.8
SELECTION CRITERIA FOR KANGAROO
CARE WITH VENTILATED INFANTS
PROTOCOL FOR KANGAROO CARE WITH VENTILATED INFANTS
In Preparation for Transfer
1. Record baseline vital signs, oxygen saturation, and ventilator settings.
Secure and maintain continuous monitoring of these parameters during
kangaroo care (KC) to determine infant’s tolerance of KC.
2. Place infant supine on a clean blanket (folded in fourths) with assistance
of second person, and note changes in vital signs, saturations, or ventilator settings.
3. Auscultate chest and evaluate breath sounds, suction endotracheal tube,
and change diaper.
4. Drain water from ventilator tubings to decrease resistance, maintain airflow, and prevent retrograde water flow toward infant when moved or
positioned lower than or at the level of the ventilator.
5. Assess infant’s responses: Wait 15 minutes to enable physiologic adaptation (e.g., return of baseline vital signs/oxygenation for 3 minutes). If
still unstable at 15 minutes, the infant is probably not stable enough for
KC at this time.
6. Position the reclining chair near the ventilator, making sure there is
ample tubing length.
7. Two or three staff members will assist the parent in transfer of the infant:
• One person gathers lines to one side of the infant.
• One person transfers and secures the ventilator tubing.
• One person assists the parent.
Transfer Procedure
1. After a staff member disconnects the endotracheal tube (ETT) from
the ventilator, the parent slides his or her hands under the blanket and
reported parental perceptions of KC with ventilated
babies include the following:
• Ambivalence toward KC: yearning to hold the
infant yet being apprehensive about it
• The necessity of a supportive environment
• The special quality of parent-infant interaction:
intense connectedness and active parenting
Perhaps these parental and staff concerns may be
overcome with careful selection of infants, education about KC, a consistent procedure for transfer,
increase in confidence of the staff assisting parents
in KC, and a clinical guideline for implementing
177,250,251,309,310
KC.
Parents and staff need education
about KC, and staff can offer KC to parents instead
of waiting for parents to request this intervention.*
Recommendations about KC include the following:
* References 120,177,228,248
infant, lifts both, and places the infant prone against his or her chest
in one movement. Reconnect the ventilator tubing and let the infant
stabilize. (If the infant was not placed on a clean blanket or it was soiled
before transfer, the parent can lift the baby and a clean blanket is placed
over the infant when he or she is prone on the parent’s chest.)
2. Disconnect ventilator tubing from ETT and move parent backward toward
recliner, having him or her sit down when he or she feels the edge of the
chair against the calves of the legs. Reconnect the ETT to the ventilator
tubing.
3. Assist the parent in being comfortable by raising the footrest, position
the infant in a flexed position with head and neck in a neutral position to
avoid ETT movement (e.g., downward into the bronchi with head flexion
or possible extubation with head extension) and/or obstructive apnea
with head flexion or extension if the infant is on nasal continuous positive
airway pressure.
4. Secure the ventilator tubing by draping it over the parent’s shoulder. Do
not tape the tubing to the blanket, parent clothing, etc.
5. If using ISC temperature control (on the radiant warmer/incubator), turn
to air control, set temperature at 33°C while the baby is receiving KC,
and monitor the infant’s skin temperature from the temperature gauge
on the radiant warmer/incubator. (There is then no need to uncover or
cold stress the infant to take a temperature.)
6. Maintain continuous electronic monitoring throughout KC; check both the
infant’s and/or parent’s condition every 10 minutes during KC.
7. If the infant’s condition remains stable, facilitate KC for a minimum of 1
hour.
BOX
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13.8
UNIT TWO Support of the Neonate366
PROTOCOL FOR KANGAROO CARE WITH VENTILATED INFANTS—CONT’D
Transfer after Kangaroo Care
1. Slowly place the recliner in an upright position and assist parent to move
forward to the front edge of the chair.
2. One staff member handles the lines and another disconnects the ETT
from the ventilator lines.
3. Assist the parent to stand, reconnect the ETT to the ventilator tubing, and
let the infant stabilize.
ISC, Infant servocontrol.
Modified from Ludington-Hoe S, Ferreira C, Swinth J. Safe criteria and procedure for kangaroo care with intubated preterm infants. J Obstet Gynecol Neonat Nurs. 2003;32:586; and LudingtonHoe S, Morgan K, Abouelfrettoh A. A clinical guideline for implementation of kangaroo care with premature infants of 30 or more weeks’ postmenstrual age. Adv Neonatal Care. 2008;8:S3.
• It is an important therapeutic intervention for
healthy preterms (gestational age ≥34 weeks)
and their mothers in a modern, well-equipped
248,447
NICU
Health Organization.
as recommended by the World
457
• It is a simple, safe, cost-effective intervention that
reduces severe infant morbidity without serious
side effects, and more well-designed randomized
controlled trials are needed.
89
• Parents need education, a trusting relationship,
individualized support, and consistent information and communication from health care providers to be comfortable with KC.
228
• Nursing staff members need education about the
benefits of KC and confidence and competence
in skills to transfer and evaluate families and
infants during KC.
177
• Well-written NICU protocols for KC should
contain criteria for initiation, positioning, transfer to/from KC, care practices while in KC
(including use of continuous cardiorespiratory
monitoring, proper positioning of head, endotracheal tube, stability of arterial and venous
devices, and all life support equipment), provision of privacy, parental role, and interventions
for neonatal instability.
27,228,309,310
• Written information for parents about the benefits of KC, expectations of parents during KC, and
preparing for KC (e.g., eat, go to the bathroom,
bring a drink) assist parents and provide consistent, complete information to all families.
228
One should note that fathers can also partici-
pate in KC without endangering the infant. Aside
from the positive effects on the baby, paternal
4. In one movement, disconnect the ventilator tubing and place the infant
in the radiant warmer/incubator.
5. Reconnect the ventilator tubing to the ETT, stabilize, and secure all lines
inside the radiant warmer/incubator.
6. Document KC, length of session, and how the infant and parent tolerated
KC.
KC enhances the engagement and attachment of
the father, helps fathers attain their paternal role,
adapt to the crisis of preterm birth, includes the
father in the infant’s care, and facilitates more
equal parenthood.
43,228,312
A recent study of the
effects of the first skin-to-skin contact of fathers
in the NICU with their preterm infants found a
decrease in paternal physiologic stress responses
(i.e., lowered blood pressure and cortisol levels).
425
The
HUG Your Baby program improves fathers’ understanding of their preterm infant behaviors, lowers
paternal stress, and improves paternal confidence.
Bathing. There is a lack of evidence of the safety and
efficacy of sponge bathing preterm babies in the
NICU on a daily or every-other-day schedule.
198
144
Sponge bathing critically ill infants (28–34 weeks’
gestational age) results in significant increases in
behavior state and activity levels (i.e., motor stress
behavior, stability, reorganization), increase in
stress cue frequency, increase or decrease in heart
rate, decrease in oxygen saturation preterm, and
need for enhanced temperature support.
234,332,401
These detrimental effects caused by handling were
exhibited most frequently by neonates of younger
gestational ages. Because sponge bathing of critically
ill preterm infants clearly increases physiologic risk and
provides no clear benefits, the procedure of routine
bathing of these infants is unnecessary and not recommended.
21,252,333
Frequency of sponge bathing
can be reduced to from every other day to 3 or
4 times weekly without increasing skin flora colony
counts or colonization with pathogens.
144,225,252,348
(See Chapter 19.)
CHAPTER 13 The Neonate and the Environment Impact on Development
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367
Waiting to bathe these infants until they are physiologically stable with introduction of the bath as a
“recovery milestone” for parents to complete is a
more developmentally and physiologically appropriate
practice.
333
In one study, late preterm infants (LPI)
who were tub bathed experienced less hypothermia
and were significantly warmer at 10 minutes and 30
minutes after bathing compared with LPIs who were
sponge bathed.
244
Parents may tub bathe the premature grower, and this may provide a soothing, relaxing,
tension-relieving experience of multiple textures (i.e.,
water, water temperature, soap, washcloth).
A study of the effects of tub bathing on preterm
infants (done by nurses) found disruption of sleep
and an increase in stress behaviors. The study recommended considering the effects of “routine” nursing
procedures and modifying handling of the preterm
to promote recovery, growth, and development and
to decrease stress.
234
It is evident that more sup-
portive behaviors by the nurse (i.e., position
support and containment) enhanced the preterm
infant’s self-regulation during bathing.
235
Swaddled bathing (i.e., swaddled in a flexed,
midline position in a blanket while bathing) provides containment and helps the infant self-regulate. Benefits of swaddled bathing are listed in Box
13.9. A protocol for swaddled bathing is available with
best results occurring with an initial water temperature
of 100° to 101° F and a bath length of 8 minutes.
Self-Consoling. Consoling hand-to-mouth behaviors
349
are observed more frequently during caregiving
(by nurses, rather than parents) and before and
after feeding (especially in gavage-fed infants).
Hand-to-midline behaviors are encouraged by
cradling the infant for feedings (for both bottle
and gavage feedings if the infant tolerates it)
with both arms in the midline. If a premature
infant needs an oxygen hood, using one large
enough so that the infant’s whole upper body will
fit inside encourages hand-to-mouth quieting (Fig.
13.3). VLBW preterm infants whose whole body
was not inside the oxygen hood have been videotaped expending energy in persistent attempts
(30–40 minutes) to self-console and reduce stress
by trying to get their hands to their mouths. In
a recent study, preterm infants who displayed
more stress behaviors also displayed more
self-consoling behaviors.
146
Use arm restraints only when necessary,
and immobilize the extremity in a physiologic
position. Release and exercise the restrained
BOX
13.9
• Decrease in physiologic and motor stress
• Better energy conservation
• Improvement in state control
• Less crying and agitation
• Fewer stress cues
• Less temperature instability
BENEFITS OF SWADDLED
BATHING
76,116,132,349
FIGURE 13.3 Preterm infant in oxygen hood that is large enough to accommodate upper body to facilitate hand-to-mouth behavior. Note
sling that helps maintain flexion without frog-leg position.
UNIT TWO Support of the Neonate368
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extremity with each caregiving encounter. Avoid
restraining both arms so that one is free for handto-mouth behaviors. If both must be restrained (e.g.,
the infant pulls out the orogastric tube), give the
infant a pacifier.
Positioning. Preterm infants display motor devel-
opment that is different from that of term
infants.
288,370
A continuous assessment of muscle tone, response to positioning and handling,
oral-motor function, and response to sensory stimuli provide data for individualizing intervention.
The goal of intervention is to provide opportunities for normal development and organization
of the sensory systems, detect early developmental
problems, and educate parents about stimulation,
handling, and positioning. Although some studies
have shown that specific positioning for premature
infants does not significantly affect development,
others have shown that a developmental approach
to care of VLBW infants greatly reduces the longterm negative effects of prematurity.
297
Preterm infants usually have less developed
physiologic flexion in the limbs, trunk, and pelvis compared with term newborns (Table 13.8).
Even at 40 weeks’ postconceptual age, preterm
infants have less flexion than their full-term counterparts have. For preterm infants, long periods of
immobilization without a positioning device on a
firm mattress with the influences of gravity result in
a number of abnormal characteristics: (1) increased
neck extension with a right-sided head preference,
(2) shoulder retraction and abduction (reduces
forward rotation and ability to reach midline), (3)
increased trunk extension with “arching” of the
neck and back, (4) frog-leg position: hips abducted
and externally rotated, and (5) ankle and feet eversion (Fig. 13.4).
288,413
These characteristics interfere
with development of eye-hand coordination, head
control in prone/sitting, crawling/walking, cognitive development, and equilibrium.
370
Box 13.10
lists the reasons for proper positioning in the
NICU.
The infant should be provided with a variety of positions to avoid overstretching of the
joints, facilitate development of flexor tone, and
prevent deformities. Goals of proper positioning
include (1) optimizing alignment (e.g., neutral
neck/trunk and foot positions), semiflexed, midline
extremity posture; (2) supporting posture and movement within containment boundaries (avoiding
producing a barrier of immobilization), (3) modifying positioning and handling to support behavioral
state regulation of sleep-wake states; and (4) providing positions that encourage controlled, individual
exposure to stimuli while monitoring for signs of
behavioral stress from overstimulation and adjust
stimuli accordingly. A physical therapist can be helpful in facilitating these positions. Systematic, targeted
education for nurses and residents as well as “position champions” significantly improved positioning
of infants in the NICU after 18 months.
78,265
A change in body position influences ventilation by alteration of lung function, but how
often should repositioning occur? Sixty preterm
infants receiving respiratory support (mechanical
TABLE
13.8
GESTATIONAL AGE (WK) DEVELOPMENT
28 Completely hypotonic and lacks all physiologic flexion
32 Hips and knees begin to show some flexion while arms remain extended
34 Flexor tone apparent in legs
36 Loose flexion of arms and legs evident and grasp reflex present
40 Develops tone in utero and develops flexed position in intrauterine space; after birth, reflex activity and central nervous
*Muscle tone develops in caudocephalic and centripetal (distal to proximal) directions and interacts with simultaneous cephalocaudal development of movement to help affect posture.
Although knowledge of normal development before term helps detect signs of abnormality, variability of ±2 weeks’ gestational age must be considered.
From Anderson J, Auster-Liebhaber J. Phys Occup Ther Pediatr. 1984;4(1):89; Dubowitz LM, Dubowitz V, Goldberg C. Clinical assessment of gestational age in the newborn infant. J Pediatr.
1970;77:1; Palisano R, Short M. Phys Occup Ther Pediatr. 1984;4(4):43.
DEVELOPMENT OF TONE*
system maturity help term infant unfold and extend; term infant holds all four limbs in flexed position
112
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