Добавил:
Sekretar
kiopkiopkiop18@yandex.ru
t.me/Prokururor I Вовсе не секретарь, но почту проверяю
Опубликованный материал нарушает ваши авторские права? Сообщите нам.
Вуз:
Предмет:
Файл:Ординатура / Хирургия / Библиотека им академика М.И. Перельмана / Книга_37_библиотеки_им_акад_М_И_Перельмана
.pdf
CHAPTER 13 The Neonate and the Environment Impact on Development
https://t.me/medicina_free
379
is decreased should be established in the NICU.
Institution of a quiet time or rest period—through
reduction of (1) noise from talking, equipment,
telephones, and so on; (2) light by dimming overhead light; and (3) procedures to only emergency
treatment—has resulted in enhanced infant sleep
(34%–85%), less crying (14%–2.4%), and less parental
and caregiver stress.
395
A more recent study found
low noise levels during quiet time, with total
sleep time highest during quiet time with longer
awake periods after quiet time, prompting the
researchers to recommend quiet time as a nursing
intervention in all NICUs.
347
At discharge, NICU
infants often will not sleep in a quiet room. Softly
playing a radio facilitates sleep, and the infant gradually is weaned from it. Signs such as “Quiet . . . baby
sleeping” or “Do not disturb, I’m asleep (talk to my
nurse)” ensure undisturbed sleep if they are heeded.
The “in-turning” premature infant (see Box 13.2)
of less than 34 weeks’ gestation probably receives
enough auditory input from the NICU. Auditory
enhancement at this stage is probably overstimulation. Just as high-frequency sounds arouse, low-frequency ones, such as the heartbeat, respiratory
sounds, and vacuum cleaners, quiet and facilitate
110
sleep.
One study showed less behavioral response
and less salivary cortisol release by infants who were
presented with a heartbeat sound or white noise
(both at 85 dB) during and after heelstick.
Although music has been shown to soothe
full-term babies, the use of music with preterm
infants has been studied with inconsistent results.
Two meta-analyses of music therapy show benefits
to preterm infants in: (1) physiologic parameters
(heart and respiratory rates, oxygen saturations, quiet
sleep, and behavioral state), (2) feeding behaviors and
length of stay, (3) pain management, and (4) reduction
of maternal anxiety and parental stress.
40,316
The most
recent analysis also found studies showing no significant differences between preterm infants exposed
to various types of music therapy and no harmful
effects, possibly due to the lack of measurement of
the ambient noise in the NICU during music ther-
316
a p y.
A literature review of music therapy (more
live music) and musical stimulation (more recorded
music) found more individualized care with music
therapists that resulted in more effects on premature
infants’ physiologic and behavioral responses.
321
Presentation of in utero sounds and a female voice
to agitated, intubated preterm infants has resulted in
improved oxygen saturation and behavioral states. An
RCT of the effects of live music replicating womb
sounds was conducted at multiple sites with preterm
infants (≥32 weeks’ gestation).
240
Music therapists
chose lullabies identified by parents as important
to their cultural heritage and that were within the
parents’ vocal range, and parents were taught to
entrain their singing to their infant’s respiratory rate
and activity. Outcomes included (1) lower heart
rates during lullabies and music with a rhythm,
(2) increased caloric intake and sucking behavior
with parent-selected lullabies, and (3) decreased
parental stress.
240
Using music by Mozart has been
shown to lower resting energy expenditure by 7.7%
in preterm infants.
203
Preterm infants have lower pain
scores and better behavioral states during heelstick
when they listen to the same music that their mothers listened to during pregnancy.
214
However another
recent article by board-certified musical therapists
who specialize in music in the NICU states that
classical music, pop/rock music, and instrumental or
nature sounds (preferred by nurses and parents) are all
contraindicated for premature infants in the NICU
(especially if music is meant for calming) because of
musical complexity.
105
Music therapists in the NICU concentrate on
neurologic enhancement for sensory integration,
pacifier-activated sound to enhance NNS and feeding
readiness, live music to enhance physiologic stability
and calming, and education and emotional support
for parents in the NICU.
105,393
Careful decision-
making and consultation with music therapists
is recommended prior to use of recorded music
for premature infants in the NICU.
105
Evidence-
based guidelines for the use of recorded music
for premature infants are listed in Box 13.13.
105
Music therapy should be individualized according to
infant tolerance and cues, decibel levels monitored and
maintained in appropriate ranges, and staff and parents
educated about benefits.
316
Exposure of 20 healthy
preterm infants to low-intensity recorded maternal
voice over a 3-day period resulted in an increase in
oxygen saturations and a decrease in heart and respiratory rates during the voice period that persisted into
the after-voice period.
367
Recorded maternal voice
enables premature infants 35 weeks’ and later gestation
to be awakened less frequently by noises in the NICU
and to exhibit a sleep-wake pattern that responds
increasingly with age to their mother’s recorded
382
voice.
However, premature infants less than 35
weeks’ gestation did not have better sleep and less
wakening in response to their mother’s recorded voice.
UNIT TWO Support of the Neonate380
https://t.me/medicina_free
BOX
13.13
EVIDENCE-BASED RECORDED MUSIC GUIDELINES FOR PREMATURE INFANTS IN THE NICU
Eligibility Criteria
• At least 28 postmenstrual weeks
• Daily nursing approval
15,162,341
Music Characteristics
• Initial use for very premature infants: music should be as simple and
nonalerting as possible
• Soothing, constant, stable and relatively unchanging
• Voice alone or voice with only one instrument
• Light rhythmic emphasis and slow tempo
• Constant rhythm and volume
• Melodies in a high vocal range, which infants hear best
• Female (mother preferred) or child vocalists
• In the native language of the family
• Least alerting music for premature infants include:
• Three chords or less
• Major chords
• Lullaby style (repetitious: no separate melody for chorus/bridge)
• Music played slowly and softly
393
393
305
When to Play
• State—awake or at beginning of sleep
• During skin-to-skin care
218
• Immediately after painful/stressful procedure
• Audio recordings should not be left unattended with the high-risk
161
infant
162
When to Stop
• If infant exhibits frequent/continuous signs of overstimulation (e.g.,
squirming, arched back, grimacing, increased heart/respiratory rates,
105
irregular breathing pattern, changes in skin color, crying, splayed fingers,
hiccoughing)
• During painful/ stressful procedures
393
Duration and Frequency
• Maximum of 4 hours/day, alternating between 30 minutes of music
and 30 minutes of no music
25,424
Volume
• 65–75 dB, scale C15 (measured at ear, not source)
• Music should be played with background noise not exceeding 50 dB
162
Presentation
• Place speakers on each side of the infant’s head or feet so sound stimuli
are received binaurally
• Music equipment must be tested to ensure it does not create electrical
interference with medical equipment such as cardiac monitors and ventilators and is resistant (if used in the incubator) against high temperatures (∼36°C) and humidity (∼75%) levels
393
277,323
Contraindications
• Musical toys and mobiles because of the highly repetitive nature of the
sole music selection usually available with these toys, the inability to
adjust sound levels, and the lack of research on their use
• Radio, white noise, or nature sounds
• Earmuffs
277
• Headphones on the infant
162
pregnant
393
161
or directly on the mother’s abdomen while
• Music played free field in an open bay because the volume is difficult to
manage for each infant and it may not be appropriate because of the
gestational age for those subjected
393
393
Adapted from Detmer MR, Whelan ML. Music in the NICU: the role of nurses in neuroprotection. Neonatal Network. 2017;36(4):213–216.
The human voice is the most preferred sound.
The preterm in an incubator may be isolated
from important exposure to his or her mother’s
voice that would have occurred over months in
utero. A systematic review of the effects of maternal
voice on preterm infant’s development found
that an infant’s mother’s voice is a non-noxious
intervention that is consistent with developmental
care and should be embedded in developmental
care strategies.
345
Parental talking to their preterm
infant in the NICU has been shown to be a strong
predictor of infant vocalizations at 32 weeks and
conversational turns (i.e., infant coos and parent gives
a vocal response) at 32 and 36 weeks.72 This study
found that preterms begin vocalizing at 32 weeks
and that the rate increases over time. When parents are present in the NICU, preterm vocalizations increased by as much as 129%, particularly
at 32 weeks.72 Another study of maternal talking
and singing found greater oxygen saturation
levels, fewer negative critical events, and a prevalence of calm alert state in the preterms who
were reconnected to their mother’s voice while
in the NICU.
137
An exploratory study of VLBW
preterms (16 exposed to biologic maternal sounds
[BMS] matched with 16 exposed to usual NICU
CHAPTER 13 The Neonate and the Environment Impact on Development
https://t.me/medicina_free
sounds) was conducted to measure weight gain.
464
VLBW infants exposed to BMS (maternal voice
and heartbeat) gained more weight and had a
higher growth velocity compared with the control group.
464
While in the NICU, parents reading to
their newborns resulted in parental feelings of closeness to their infants, developing a sense of control,
intimacy, and normalcy.
222,438
Follow up of preterm
infants who were read to by their parents shows
better cognitive development at 2 years of age.
54
Increasing preterm infant’s language exposure
(by parents talking to their infant) improves the
infant’s language development, enhances parentinfant attachment, and decreases parental stress.
258
In the NICU, verbalizations to their preterm infant
and positive affective involvement during feeding by
mothers is associated with the same parental behaviors at 24 months.
150
Teach parents the neonate’s
preference for high-pitched voices speaking in
typical speech patterns (not baby talk). While in
the NICU parents, can talk to the baby about
their day, essentially conversing with the baby,
and listening for responses. Parental talking to
the baby in the NICU is associated with higher
scores on language and cognition at 7 and 18
months corrected age.73 The degree of attenuation
of the higher frequency of mother’s voice by the
lower frequency of incubator noise, the incubator
walls, and the ambient noise of the NICU has not
been measured. Role model and teach parents to
gently talk to the infant while touching and giving care. Teach parents to talk to their infant while
presenting their faces in the infant’s range of vision.
Watch for infant tolerance, and increase or decrease
talk time to avoid overload. For older infants, imitate
the infant’s coos and babbles; this reinforces and
encourages vocalizations.
For a neonate, hearing is more important
than vision for attachment and bonding to the
parents. Within seconds after birth, newborns
are able to discriminate and prefer their mother’s face. They have connected her familiar
voice with her unfamiliar face. A high index of
suspicion about hearing loss is warranted if caregivers do not observe normal responses to sound stimulation. Hearing screening by high-risk factors
alone identifies only about 50% of newborns
with significant hearing loss; therefore, universal newborn hearing screening is the standard
of care.
17
VISUAL INTERVENTION
The NICU is lit with bright, cool-white fluo-
rescent lights 24 hours a day. Light levels vary
between and within various NICUs. Early studies
showed light levels in the low range, from 34 to
100 lux at night and 184 to 1000 lux during the
day; more recent studies report light levels ranging
from low levels of 1 to 25 foot-candles (ftc) to high
levels of 235 ftc.
385
The amount of light to which
the preterm infant is exposed is influenced by
(1) location in the NICU, (2) seasonal or climactic variations, (3) use of phototherapy, (4)
ophthalmoscopic examinations (e.g., at birth
and for retinopathy of prematurity [ROP]
follow-up), (5) use of procedure lights,
(6) infant-related factors (e.g., maturity and
amount of eye opening, head position, or eye
shielding). Ambient light levels in the NICU
should be adjustable through a range of 10 to 600
lux (approximately 1–60 ftc) at every bedside.
Other light recommendations for newly built
NICUs are outlined in Table 13.12.
Although decreased light levels and response
to bright light have not been shown to reduce
the incidence of ROP, ophthalmic sequelae of
preterm birth are common.
160
(See Chapter 31
for a discussion of ROP.) There are three broad
categories of ophthalmic sequelae: (1) decreased
visual function, (2) strabismus, and (3) decreased eye
size (arrested growth) and abnormal refractive state
(increased myopia). In addition, there is abundant
animal, child, and adult research documenting negative biochemical and physical effects (e.g., change
in endocrine function, increased hypocalcemia, cell
transformations, immature gonadal development,
chromosome breakage).
158
Very preterm infants
are able to detect and react to small variations
in light levels.
NICU is associated with the following
465
Exposure to bright lights in the
158,317,465
• Decreased oxygenation (on pulse oximetry);
decreased regional cerebral saturation
• Increased incidence of retinopathy
• Altered vital signs (increased heart and respira-
tory rates)
• Alteration in state organization (i.e., altered sleep
patterns, poorer circadian rhythms; more wakefulness/less sleep
314
)
• Skin changes (e.g., tanning, rashes)
• Alteration of nutrients in total parenteral nutri-
tion (TPN) solution, formula, and breast milk
317
381
and
448
:
UNIT TWO Support of the Neonate382
https://t.me/medicina_free
TABLE
13.12
ILLUMINATION LEVEL PURPOSE
High levels: 60 foot-candles (ftc) Evaluate and assess skin color and perfusion
Lower levels: 10–20 ftc Safe and adequate because of concerns over retinal/ocular damage from continuous exposure to high levels
Nighttime levels: 0–5 ftc Diurnal variation in light levels
Procedure light: 185 ftc Available at every bedside to temporarily increase lighting for infant assessment/procedure without increasing
Support areas
Daylight One source visible from care areas for its psychological benefit for staff and families
NICU, Neonatal intensive care unit.
LIGHT RECOMMENDATIONS IN THE NICU
(60 ftc)
light exposure to all other babies
Prevent light from reaching infant’s eyes
For charting, medication preparation, etc., should provide adequate and separate light to accommodate
sleeping babies and working health care providers
Lighting should be located to avoid any infant’s direct line of sight to the fixture
Rapid increase in the intensity of ambient light
causes a decrease in oxygen saturation in younger,
immature preterm infants; slower increasing of light
levels enables easier adaptation.
317
The first goal in visual intervention is to
assess the current level of light and decrease
it wherever possible. A very immature preterm
infant is accustomed to the muted light of the
uterus (light filtered through the abdominal and
uterine walls) and has fused eyelids (if the infant is
less than 26 weeks’ gestational age). Draping blankets on top of the incubator or using a handmade
or commercial incubator cover decreases the light
at the infant’s level during rest but allows immediate maximal illumination when the cover is pulled
back. Using adjustable lighting at each infant’s bedside enables every infant to have more or less light
depending on the care and rest circumstances of the
individual infant. Because infants are continuously
monitored, not all infants need to be subjected to
maximal illumination at all times.
158
Cycled light—dimming the lights in daynight cycles—is associated with positive effects
(Box 13.14). Randomized controlled studies show
that the circadian clock of the preterm infant
is entrained by cycled light.
160
Preterm infants
exposed to low-level cycled light for 2 weeks before
448
BOX
13.14
• Behavior:
• Decreases/no change in movement or motor activity
• Increases motor coordination
• Increases sleep time
• Decreases fussing and crying
• More eye opening
• Cardiorespiratory changes:
• Decreases heart rate
• Decreases respiratory rate
• Feeding behavior:
• Quicker progression to oral feedings
• Feeds more efficiently and in less time
• Increased weight gain and better growth
• Circadian rhythm development:
• Melatonin level
• Temperature
• Heart rate
• Rest and activity patterns
• Decreased cortisol levels
• Decreased incidence and severity of retinopathy of prematurity
• Decreased parental and/or care provider stress
• Decreased infant handling and noise levels
• Shortens length of stay
EFFECTS OF CYCLED LIGHT
a
discharge showed night/day rest-activity patterns
a
within the first week after discharge. Preterms
References 55, 56, 224, 295, 359, 360, 426.
CHAPTER 13 The Neonate and the Environment Impact on Development
https://t.me/medicina_free
exposed to low-level uncycled light were delayed
in their development of day-night differences in
activity and rest till 3 weeks after discharge.
358-360
A recent randomized controlled trial of early (28
weeks’ PMA) versus late (36 weeks’ PMA)
introduction of cycled light to extremely preterm
infants (<28 weeks’ gestation) found improved
weight gain and shortened hospital stay with
early introduction of cycled light.
56
Visual attentiveness is correlated with birth
weight and gestational age; the more mature
the infant, the more the infant is able to fix and
follow. An infant at 28 weeks’ gestation fixes and
follows but may become apneic, behaviorally disorganized, and stressed as a result. Visual stimulation is
very tiring and taxing (increases the heart rate) for
the immature infant. Those of less than 34 weeks’
gestation probably receive enough stimulation from
the NICU environment. Premature visual stimulation also may interfere with auditory neurosensory
development. When these infants reach the “coming-out stage” (see Box 13.2), they may signal their
readiness for visually enhancing activities.
Infants receiving phototherapy are deprived of
visual sensory stimuli because of their protective
eye pads. These should be removed during care
and feeding and interaction with parents and
professionals. Interesting visual stimuli include inan-
imate objects (e.g., toys, black-and-white faces and
patterns, pictures of family members, artwork from
siblings, mobiles) and animate objects (e.g., faces of
parents, siblings, professionals) (Fig. 13.8). Infants
prefer the human face as a visual stimulus, especially the talking face, which stimulates both
visual and auditory pathways. Parents often need
to be encouraged that their infant prefers to watch
and listen to their faces and voices rather than toys.
Teach parents the abilities of the infant and
appropriate methods of visual stimulation:
• Place mobiles, pictures, and faces of high contrast
(i.e., black and white) within the visual range of
the newborn: 8 to 12 inches for term infants, a
little closer for preterm infants.
• Quiet alert is the best state for visual encounters
after feedings, if awake; swaddle the infant to
quiet or unwrap the infant to arouse; hold infant
upright.
• Place the infant on the abdomen (called “tummy
time”) with objects of various sizes and shapes
within visual range.
383
FIGURE 13.8 Premature infant fixing the gaze on a black-and-white face.
• Change toys and visual stimuli. Infants become
bored with the same thing.
• When the preterm infant tolerates multiple stimuli,
hold him or her in en face position (see Chapter
29) to feed, talk to, and rock. Whether the infant
is nipple or gavage fed, alternate sides so the infant
sees both sides of the care provider’s face (especially
important if the preterm infant exhibits the common preference for right-sided head turning).
• Place the infant at varied heights (in a baby carrier, crib, swing, infant seat, on the floor) so the
infant sees the world from various angles.
• Place the infant so that he or she can bring the
hands to midline and see his or her hands and
fingers and eventually reach for toys.
Infants who exhibit gaze aversion should
not be “pursued” by the face of the parent or
professional, because this only potentiates the time
“spent away” with their gaze to protect themselves
from overload. Gaze aversion, flat facial affect, and
absence of a smile may cast doubt on the ability of
these infants to see because there is no eye “language” or caregiver feedback of preference, recognition, and delight. These infants do see, but they fix
only fleetingly. Minimizing the number of care
providers is crucial for these babies so that they
deal with as few caregiver cues, styles, and ways
of being handled as possible. Most important,
the caregiver must be sensitive and responsive
to the infant’s negative and positive cues.
BOX
https://t.me/medicina_free
13.15
UNIT TWO Support of the Neonate384
BENEFITS OF NONNUTRITIVE SUCKING (NNS) FOR PRETERM NEONATES
Physiologic
• Promotes physiologic stability
• Better oxygenation
• Decreased heart rate
• Pain relief (see Chapter 12)
• Alters cardiac control during supine sleep (increased blood pressure
during sleep from 2–3 months after term corrected age, which is peak
occurrence of SIDS)
• Increased insulin and gastrin secretion that may stimulate digestion and
storage of nutrients
• Better milk absorption and improved digestion related to better glucose
• Fewer gavage feedings, faster transition from gavage to oral
• Accelerated transition to full oral feedings (both breastfeeding and bottle
• Shorter time to full transition to breastfeeding and to discharge; lower
• No effect on acid/nonacid GER—safe to use in premature infants with
142,246
utilization
42,142
feedings
154
feeding)
weight at full breastfeeding and at discharge; better sucking skills.
symptoms of GER
92
142
:
184
246
200
SMELL AND TASTE INTERVENTION
Newborns, including preterms, can detect, discriminate, respond (e.g., facial expression, change in
respirations, apnea), learn, and remember olfactory
262,427
stimuli.
The neonate’s well-developed sense of
smell is not stimulated in the NICU with pleasant
odors. A high-risk infant is stimulated by the smell
of forgotten alcohol, skin prep, or povidone-iodine
(Betadine) pads inside the incubator and the unpleasant taste or smell of oral medications.
262
Because a
premature infant cannot respond by crying or moving away, the infant responds to noxious smells by
a decrease in respiratory rate, transient apnea, or
an increase in heart rate.
262
Removal of noxious
odors from the incubator is as critical as removal of
sharp instruments after a procedure. Alcohol vapors
from alcohol-based hand rubs that had not
completely dried before touching the preterm
was cited as the most common unpleasant smell
to which the infants were exposed.
213
Other
unpleasant odors included cleaning solutions, detergents, soaps and skin care products, and wipes such
as alcohol or adhesive removers.
• Better weight gain
• Earlier discharge
20,42,142
142,154,200
Behavioral
• Comfort, soothing, and self-consoling behavior
• Improved behavioral organization that decreases energy consumption
• Quieter, more restful behavior; more sleep
• Less stress and tension
• Improved self-consolation and soothing
• Improved state modulation
• Improved neurobehavioral organization and maturation
• Increased readiness for nipple feedings because of a more alert state
(see Chapter 18)
• No negative effect on breastfeeding
196
246
:
87
Neuromotor Development
• Acceleration of the sucking reflex
• Improved muscle tone and coordination
• Accelerated neurologic maturation
142,154,200
Enhancing the olfactory environment includes
having parents hold the infant or sit close if the
infant cannot yet be held. The smell of the
mother’s breast milk is especially pleasant
and elicits more suckling than the smell of
formula.
45,427
Olfactory stimulation of sucking
in preterm infants increases with increasing postnatal age. Placing a drop of human milk on the
infant’s lips with a cotton ball or gauze sponge
helps the infant recognize the mother’s smell
and associate that smell with food and feeding
when the infant is able to nipple feed.45 An
RCT of preterm infants under 28 weeks’ PMA
exposed to the smell and taste of their own
mother’s milk prior to feeding found that those
very preterm infants attained full oral feeding
2 days earlier and had better weight gain than
very preterm infants who did not smell or taste
their mother’s milk.
35
The benefits of nonnutritive sucking (NNS)
during gavage and between feedings are listed in
Box 13.15. Meta-analyses of NNS studies have
found a significant effect on the transition to
CHAPTER 13 The Neonate and the Environment Impact on Development
https://t.me/medicina_free
385
full oral feedings (from gavage feedings), transition from beginning to full oral feedings, and
length of hospital stay.
142
Sucking on a pacifier
satisfies the infant’s sucking needs and may facilitate
early learning that satiety and sucking are associated.
However, nutritive and nonnutritive suckling are
not alike (see Chapter 18). The fact that an infant
vigorously sucks on a pacifier does not mean the
infant will be able to suckle nutritively, because the
expressive and swallow phases have not been present
in nonnutritive suckling and coordination of suck,
swallow, and breathing has not been necessary. This
is confusing to most parents and many professionals
and should be clarified for them.
High-risk infants often undergo prolonged periods during which a nil per os (NPO) status has been
ordered, and during these times, their sensation of
hunger is not relieved. Although pacifiers are soothing, these infants may learn that sucking and satiety
are not related. NICU infants also experience
many aversive stimuli around and within the
mouth (e.g., oral intubation, oral and endotracheal
tube suction, intermittent gavage) that result in
touch aversion of the mouth and a hypersensitive gag reflex. Feeding difficulties may result from
the following:
• Severity of illness
272,364
• Neurologic damage (e.g., IVH)
• Structural abnormalities (e.g., cleft palate or sub-
mucous cleft, recessed chin)
• Prematurity: The infant is too neurologically
immature and tires easily with “work” of feeding
• Aversive feeder (acquired or developmental:
sucking defect; psychological: “hospitalitis,”
rumination) and aversive feeding experiences
that alter brain structure
386,389
380
• A combination of these types
Neural maturation (34–35 weeks’ gestation) is
the developmental guideline for initiation of oral
feedings (see Table 13.2),
154,384
although some
infants are ready at an earlier age (30–34 weeks’
gestation) (see Box 13.2). Maturation of feeding
skills occurs because of developmental changes
in the CNS, coupled with experiential learning.*
So intimately interrelated are these indicators that
maturity depends on experience and experience
depends on maturity; therefore, the more opportunities to nipple feed, the more improved the
preterm neonate’s feeding performance. However,
* References 59, 278, 380, 384, 410.
BOX
13.16
BENEFITS OF CUE-BASED/INFANTDRIVEN FEEDING
Physiologic
• Improved physiologic outcomes
• Increased intake of nutrients
• Increased weight gain
• Fewer adverse events
• Earlier discharge home
223,409
206,223,274
346
206,346
274,346,445,446
Behavioral
• Enhanced behavioral maturity
• Enhances the development of self regulation and reinforces sleepwake cycles
• Earlier achievement of full oral feedings
• Safe, pleasurable experience for the infant and parents
343
No additional workload
Adapted from Lubbe W. Clinicians guide for cue-based transition to oral feeding in preterm
infants: an easy-to-use clinical guide. J Eval Clin Pract. 2018;24(1):80.
206,223,409
206,380,445,446
408
206,274,346
preterm infants may exhibit periods of apnea and
tachypnea with bottle feeding, because consistent
coordination of breathing with sucking and swallowing does not occur until 37 weeks’ gestation
(see Table 13.2). In preterm infants with a PMA
greater than 32 weeks who are ready to initiate
oral feeding, delaying their start by 1 week has
been shown to reduce physiologic distress (i.e.,
oxygen desaturations) with feedings.
440
The research basis for determining readiness
for initiation of oral feedings is discussed in
Chapter 18 and in Box 13.2. Cue-based or infant-
driven feedings are individualized feedings initiated
and discontinued based on the infant’s cues of
readiness to feed and satiety, rather than on
time or volume of feeding.
206,207,380
Benefits of
cue-based or infant-driven feedings are listed in Box
13.16. However, the most recent Cochrane review of
responsive (i.e., related to infant’s cues) versus
scheduled feedings found weak evidence to support benefits and overall no strong or consistent
evidence that responsive feedings affect important
outcomes for preterm infants or their families.
Coregulated feeds—the ability of parents to
know their infant’s cues and read and respond
dynamically to changing needs of the infant—
focuses on the feeding relationship rather than
441
UNIT TWO Support of the Neonate386
https://t.me/medicina_free
the volume consumed.
408
Parents learn from professional care providers how to individualize every
feeding encounter by (1) respecting infant cues, (2)
seeing their infant as an active partner, (3) evaluating
readiness to feed, (4) adjusting feeding to be contingent with the infant’s breathing rhythm and other
physiologic cues, (5) using proper positioning, and
(6) decreasing physical and environmental stimuli
that interfere with feeding.
365,380,408
A coregulated
feeding intervention in which mothers of premature infants received five nursing intervention
sessions during their infant’s transition to oral
feeding identified the top five issues of concern for both mothers and nurses: (1) reading
cues, (2) coregulating breathing, (3) providing
motoric stability, (4) regulating milk flow and
(5) providing rest periods.
409
Both mother and
nurse worked together on joint attention to infant’s
feeding challenges, auditory assessment of breathing
BOX
13.17
1. Minimize noxious stimuli to the mouth.
a. Suction only as needed (not routinely).
b. Consider indwelling gastric tube rather than intermittent gavage
c. Pass intermittent gavage tube down mouth through hole in pacifier
d. Perioral and intraoral techniques*
i. These techniques are only more aversive, rather than therapeutic,
ii. When performing oral exercises, do so with care—do not stimu-
iii. Use of a new motorized pulsating pacifier results in faster emer-
2. Enhance pleasant stimuli to mouth (first experiences with suckling have
a. Have infant smell or taste breast milk; use colostrum/human milk
b. Provide nonnutritive suckling
c. Facilitate hand-to-mouth behaviors.
d. Use nipple with proper flow rate.
STRATEGIES TO FACILITATE ORAL FEEDING
(e.g., an infant fed every 2 hours would have a gavage tube passed
12 times a day).
nipple; if infant has hypersensitive gag, passing smaller tube down
nose stimulates gag reflex less than passing tube down mouth.
on babies with touch aversion at mouth area; individualizing therapy is important.
late aversion reflexes (e.g., gag reflex).
gence of NNS and increase in proportion of oral nutrition.
lasting neurobehavioral effects).
for oral care.
while tube feeding
increased flow stimulates anxiety and/or gag reflex and causes
35,45
365
20,165
365
(see Box 13.15).
and NNS with mother’s voice84
153,267,379
If flow rate is too fast,
30
and swallowing, review of feeding session by videotape, and planning for the next feeding session.
Another study of preterm infants using a coreg-
ulated approach to oral feeding found fewer
apneic episodes and higher respiratory rate when
compared to infants being fed by the standard
feeding method.
324
Although there were no differences in oxygen saturation, heart rate, or bradycardia
between the groups, the infants fed by the standard
method showed significantly higher SD12, a measure of heart rate variability indicative of randomness
of the heart rate, a potential marker of increased
320
stress.
These strategies enable a safe learning experience for both parents and their infant, provide a
pleasant feeding experience, and lay the foundation
for positive feeding outcomes and improved neurodevelopment.
380,408
There is no one approach
for feeding preterms; strategies in Box 13.17 are
individualized to each infant and parent.
bradycardia—promotes incoordination. If flow rate is too slow,
fatigue and frustration are increased and may result in inadequate
consumption/growth failure.
e. Perioral and intraoral stimulation—facilitates development of nor-
mal sucking behaviors.
f. Use Lact-Aid nursing supplementer (see Chapter 18):
i. Never frustrate infant with dry breast.
ii. Positive reinforcement for infant to nurse.
iii. Calorically and energy efficient method.
iv. Oral therapy—teaches infant proper nutritive suckle.
g. For infants with difficulty in coordination of respiration with suck or
swallow (prevents stress of apnea and hypoxia and enhances plea-
sure of feeding experience) (see Chapter 18)
i. Assess feeding pattern (e.g., continuous or intermittent suck),
pulse oximeter, muscle tone, breathing pattern, heart rate.
ii. Remove nipple from mouth to enable infant to breathe (pace
feeding).
iii. Begin breastfeeding before bottle feeding.
18 Critical Findings: Readiness for Initiation of Oral Feedings:
Research Basis in Table 18.5.)
iv. Use of orthodontic nipple results in physiologic stability and more
effective feeding behavior in some infants.
v. Use of soft-walled bottle system improves oxygenation and
coordination and is more like breastfeeding than rigid-walled
153
bottle
26,165,229,237
97,406,407
:
410
223
396
(See Chapter
Continued
BOX
https://t.me/medicina_free
13.17
CHAPTER 13 The Neonate and the Environment Impact on Development
STRATEGIES TO FACILITATE ORAL FEEDING—CONT’D
387
3. Positioning: Use proper position to facilitate swallow and improve suction—symmetric positioning with predominance of flexion.
410
a. Hold with feedings (even gavage) as much as possible.
b. Consistent caregivers—parents, primary nurses, foster grandparents.
c. Kangaroo care before feeding improves alertness; does not tire infant and
should not be avoided before feeding; promotes breastfeeding.
d. Swaddle
380,410,454
:
89,152,365
i. Decreases startles
ii. Optimizes postural stability and control
iii. Infant may become too warm and sleepy.
28
e. Facilitate swallowing:
i. Position with chin tucked.
ii. If breastfeeding, turn infant’s whole body toward mother so
head and trunk are in alignment (infant is not trying to swallow
with head turned to one side).
iii. Upright position with neck, shoulders, and back supported—
slows gravitational flow of formula from nipple (as when infant
is in semireclined position); restricted milk flow (e.g., milk flows
only with active sucking, not with gravity) beneficial (e.g., more
efficient; more volume obtained).
iv. Head-elevated, side-lying position results in more physiologic sta-
bility (fewer and less severe bradycardia; slower, more relaxed
breathing) for bottle feeding;
380
systematic review of side-lying
position found conflicting results in studies and a large RCT with
a diverse group of premature infants is recommended.
324
v. Cuddling, semireclined position increases flow of formula by
gravity—may be too fast, regardless of nipple chosen; results
in increased gags, choking, and bradycardia.
vi. Prone with neck extended (slightly): Keeps tongue forward and
airway unobstructed.
vii. Good for aversive feeder who chokes.
viii. Gentle, upward pressure under chin (chin support) or at base of
tongue facilitates swallowing, because it mimics upward thrust
of tongue with swallowing.
f. Improve formation of suction:
i. Semireclining (>45-degree angle) on lap of caregiver—frees
both hands to work with infant on oral control.
ii. Cupping both cheeks (check support) with fingers of free hand
(i.e., hand not holding bottle) improves lip closure, suction formation, minimizes fluid loss, stabilizes the jaw, and organizes
46,454
deglutition.
iii. Gentle tugging at nipple (as if to take it out of mouth) may
smooth and strengthen suck; avoid prodding infant to suck.
g. Improve sucking organization
279
380
Multimodal intervention:
Auditory (10 minutes of mother/female voice)
Tactile (moderate touch stroking or massage)
Visual (eye to eye) stimulation
Vestibular (5 minutes of horizontal rocking)
4. Timing
a. Do not allow infant to cry to exhaustion before feeding—infant will
be too tired to eat.
b. Keep external stimuli to a minimum in immature preterm infants
(<34 weeks) for optimal intake and weight gain.
379,408
c. If or when satiated, infant will not suck:
i. Feed by cue-based/infant-driven/coregulated feedings (see
Box 13.16)
ii. If feeding on schedule, note whether infant gives cue of hunger:
fussiness and crying, hand-to-mouth behaviors or rooting, hiccups.
Infants as young as 32 to 33 weeks can provide cues so that
feeding can be individualized.
364,365,380
iii. If feeding on schedule, space time and see whether infant exhibits
cues of hunger (as described earlier).
iv. First, nipple what infant is able to feed; then tube feed (presence
of an indwelling nasogastric tube may result in compromised
respirations, oxygen desaturation, and bradycardia in the VLBW
384
infant).
d. Try to nipple feed for no longer than 20 to 30 minutes (infant
becomes too tired and uses up energy and calories to feed instead of
364
to grow).
e. Infants of advanced age (around 6 months) may be unable to nipple
if they have never had the opportunity. It may be more developmentally appropriate to cup feed or spoon feed infant, because normal
infants begin cup drinking between 6 and 8 months of age.
* References 20, 24, 26, 46, 164, 165, 229.
NNS, Nonnutritive sucking; VLBW, very low birth weight.
Feeding difficulties at the beginning of life often
lead to eating problems in infancy and later in
365,380
life.
Severe behavioral eating difficulties are
associated with prematurity, low birth weight, CNS
injury, distress during feeding in the first 6 months
of life, neurodevelopmental problems (cognitive,
language, motor, socioemotional delays), and regular
or frequent vomiting. Feeding difficulties are stressful to all family members, complicate parenting, and
strain the parent-infant bond.
94,365,380
Because criteria for discharge include full oral feed-
ings with adequate weight gain, transition to full oral
UNIT TWO Support of the Neonate388
https://t.me/medicina_free
feedings is a topic of ongoing research. A recent multicenter retrospective analysis of the feeding behav-
iors of 6146 preterm infants born at 29 weeks’ to
33 weeks’ gestation found that the median PMA
at first oral feeding was 33.9 weeks.59 This study
also found that for every week earlier that oral
feeding was begun, full oral feedings occurred
4.5 days earlier and discharge occurred 3.4 days
earlier. Factors influencing earlier full oral feedings
and earlier discharge included higher birth weight
and black maternal race.59 Longer transition time
to full oral feedings is significantly influenced by
(1) apnea, (2) birth weight or gestational age, (3)
younger age at first oral feeding, (4) BPD/CLD,
(5) number of days being tube fed/receiving ventilatory therapy, (6) desaturations of oxygen with
feeding and (7) location of the NICU.* Shorter
transition time to complete oral feeding is associated with (1) earlier skin-to-skin care and oral
feeding by parents
before bottle feeding,
152
—first feeding at the breast
396
(2) greater weight, (3)
older postconceptual age at initiation of nipple
feeding,
63,278,336
(4) use of oral stimulation (e.g.,
stroking, NNS, NNS with lullabies, NNS with
mother’s voice),† (5) use of oral colostrum,
35,45
and (6) a cue-based/infant-driven/coregulated
feeding protocol (see Box 13.16).
A randomized study of early introduction of oral
(bottle) feeding (e.g., within 48 hours of full tube
feeding) found the following
384
:
• Transition time to all oral feedings was signifi-
cantly shorter.
• Oral feeding was introduced 2.6 weeks earlier.
• Total oral feeding was achieved at earlier post-
menstrual age (e.g., 54% of 33 weeks’ PMA
infants versus 12.5% of control group).
• Weight gain and discharge weights were similar
for both groups.
• Episodes of feeding-related bradycardia and
desaturations were similar for both groups.
• Discharge was 10 days earlier for the earlier fed
infants.
These researchers postulate that feeding opportunities in young infants provide them with practice
and experiential opportunities to develop their
oral motor skills and coordination of suck-swallow-breathe.
384
A more recent study found that
every 1% increase in the proportion of missed
* References 192, 278, 384, 458.
† References 84, 164, 237.
oral feeding opportunities extended the time to
full oral feedings by 1.45 days and the time to
discharge by 1.36 days.
417
For infants with BPD/CLD, the more days
receiving positive-pressure ventilation and supplemental oxygen, the older (in postconceptual age) the
infant when he or she is first fully nipple fed. For
these infants, transition time to full nipple feeding
may be lengthened because of the increased work
of breathing, the precedence of breathing (at an
increased rate) over feeding, and changes in heart
rate variability.
97,273
However, a randomized study
found that infants with BPD/CLD fed by an individualized, semi-demand method (using the infant’s
behavioral cues and cardiorespiratory state to determine frequency, length, and method) achieved nipple feeding earlier (5.9 days) compared with control
infants (12.3 days).
272
The goals of intervention include (1) a safe
feeding (i.e., diminished risk for aspiration),
(2) a functional feeding (i.e., adequate caloric
intake for optimal growth and with minimal
energy expenditure), and (3) a pleasant, social
interactive experience for the infant and parents
or caregivers.
165,342,380,410
The use of individualized developmental care
may assist VLBW and preterm infants with BPD/
CLD in obtaining and maintaining an optimal
condition for progression to oral feedings. Use of
skin-to-skin KC improves weight gain, supports
and promotes breastfeeding, and shortens length
of stay (see Box 13.6). Because KC improves
alertness and does not tire the infant, it can be
used as a strategy to facilitate oral feeding (see
Boxes 13.6 and 13.14). The use of developmental
care enables VLBW preterm infants to initiate the
first oral feeding and have the last gavage feeding
at an earlier age compared with VLBW infants not
receiving developmental care. Preterm infants successfully completing oral feeding spent significantly
more time in awake states than did preterm infants
who were unsuccessful in their feeding.
Using developmental principles, health care providers are able to facilitate both the preterm infant
and parents in effective feeding experiences.
self-regulating preterm infant shows these signs
of stability during feeding: (1) smooth, regular
respirations (no or minimal increase in respiratory
rate or effort); (2) consistent postural control—
flexed, hands near face, maintains muscle tone,
calm/organized behavior; (3) maintains optimal
364,380
A
Соседние файлы в папке Библиотека им академика М.И. Перельмана