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CHAPTER 13 The Neonate and the Environment Impact on Development
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389
color; (4) quiet, alert state, focuses on feeding;
and (5) coordinates suck-swallow-breathe.
379,410
Coordination of feeding is facilitated by (1) imposing
breaks/pacing (e.g., removing the nipple from the
mouth; tipping the bottle so that the nipple is empty
but remains in the infant’s mouth), (2) limiting bolus
size (limiting the number of sucks before a swallow
results in smaller bolus size) by limiting the number
of successive sucks before the infant becomes stressed,
and (3) slowing the flow rate (e.g., using lowflow-rate nipples,
hydrostatic pressure and gravitational flow).
267
upright positioning to decrease
379
Signs of stress during nipple feeding, their sig-
nificance, and appropriate interventions are listed
in the Critical Findings in Table 13.13. Stress can
be avoided and oral feeding efficiency enhanced
by ensuring that the preterm infant is awake and
alert for feeding.
165
Even preterm infants who
are near discharge still have oxygen desaturations when fed by their mothers; the incidence
is decreased in infants receiving supplemental
oxygen, beginning a feeding with a higher baseline oxygen saturation, and in those of an older
postconceptual age.
406,410
Parents must be taught
how to interpret their infant’s cues of stability and
stress so that they can modify their behavior and
learn to intervene to help their infant safely and
successfully feed.
380,408
Skills parents need for effective feeding include (1) following the infant’s lead
about readiness to feed—preterms are able to root
and open their mouths to the stimulus of a nipple; (2)
assessing breathing cues, providing adequate rest (see
Table 13.13), and not interrupting by “jiggling” or
moving the nipple to stimulate sucking; and (3) recognizing that noisy swallowing and drooling indicate
dysfunction
380,408
(see Table 13.13). Strategies that
parents consider helpful in mastery of these skills are
(1) being included in decision making about feeding
and its success, (2) observing a nurse feed their baby,
and (3) having a nurse spend time with them while
they are feeding their baby to give them feedback,
ideas, and tips about feeding.
380,408
For parents, learning to feed their infant is viewed as a significant symbol of parenting, as an opportunity to read and react
to infant cues, and as a coregulator of feeding.
380,408
Recent research shows that maternal psycholog-
ical well-being influences feeding of their premature infant. Maternal depression, worry, and role stress
were highest one week prior to the onset of the first
oral feeding. Maternal depression and role stress
were associated with less use of developmentally
supportive feeding behaviors such as minimizing
tactile stimulation, providing steady tactile containment and stabilization, and regulating milk flow in
response to neonatal cues.
325
Additionally, maternal
psychological functioning influences maternal presence in the NICU (distress associated with decreased
maternal presence) and the length of stay.
82,163
A feeding plan, developed with parents,
must be individualized for each infant and posted
at the bedside (see Box 13.15 and the Case Study).
All care providers must adhere to the plan for consistency and continuity of stimuli and to promote
infant learning.
380
Evidence-based approaches to
nipple feeding (for NICU preterms and sick term
infants) have been developed that integrate contingent, developmental principles with more nurse
autonomy and multidisciplinary collaboration and
support. The Early Feeding Skills (EFS) Assessment
checklist has been developed to assess a preterm
infant’s readiness for oral feeding, oral feeding skill,
and ability to maintain physiologic stability and
tolerance of oral feeding.
410
The Premature Infant
Oral Motor Intervention (PIOMI) is an evidencebased, validated intervention that facilitates the development of oral feeding skills, improves oral feeding,
shortens length of stay, and lowers costs.
Preterm Oral Feeding Readiness Scale (POFRAS)
evaluates aspects of physiology, behavior, and nonnutritive sucking and is moderately accurate in determining oral feeding readiness.48 The Supporting Oral
Feeding in Fragile Infants (SOFFI) method contains
an algorithm to assist nurses in decision making, using
specific evidence-based strategies and interpreting
behavioral cues for bottle feeding preterm, sick,
and fragile infants.
364
SOFFI is recommended to be
used in conjunction with the National Association
of Neonatal Nurses Guideline for Practice: Infant
directed oral feeding for premature and critically ill hospitalized infants.
365
The Infant Driven Scale assesses feeding readiness in preterm infants and identifies infants
at risk for delayed full oral feedings.
151
The Neonatal
Eating Assessment Tool (NeoEAT) Bottle Feeding
is a valid and reliable parent-report assessment of
bottle feeding in infants younger than 7 months of
319
age.
NeoEAT Bottle Feeding can be used in clinical practice to identify infants who need assessment
and/or intervention and to measure their response
to intervention. Three versions of the NeoEAT tool
(NeoEAT Breastfeeding, NeoEAT Bottle Feeding,
and NeoEAT Breastfeeding and Bottle Feeding)
have been developed and tested for validity.
365,380,408
229
The
318
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TABLE
13.13
CRITICAL FINDINGS
STRESS* DURING NIPPLE FEEDINGS
SIGN SIGNIFICANCE INTERVENTION
Color change
Pallor, dusky, gray, central
cyanosis—perioral/
periorbital
Oxygen desaturation
Feeding too rapidly with brief, shallow breaths
Low hematocrit level
Breath-holding
406,407
Assess baseline color before feeding
Assess bottle-feeding delivery system: soft-walled
system significantly improves oxygen saturation,
coordination of suck/swallow/breathe, and more
like breast feeding compared with rigid-walled
feeding bottle
Periodic removal of nipple to facilitate deep breathing
Monitor changes in color during feeding
Use pulse oximeter during feeding to maintain
saturation ≥92%
Changes in state of alertness Quiet alert state optimal for successful feeding
Increased infant focus on feeding
Offer preterm opportunity to suck on pacifier before
feeding—encourages awake/alert behavior
Increased organization of oropharyngeal muscle
movements
Increasing drowsiness, falls asleep:
Respiratory fatigue resulting from rapid feeding,
desaturation, increased respiratory rate, and/or
work of breathing
Pulse oximeter monitoring during feeding—give
and/or adjust oxygen to maintain saturations
≥92% during nippling efforts
Unwrap if sleepy
Fatigue resulting from behavior/energy expenditure
(e.g., crying; bathing) before feeding
Breathing
1. Respiratory fatigue:
Falls asleep, ceases feeding before adequate volume obtained
Fussiness/restlessness—resulting from oxygen
desaturation (e.g., hypoxia) because of the work of breath-
ing (WOB) and nippling; disorganized behavioral state
Increased respiratory effort resulting from work/exercise
BPD
97,272
266,406
especially in the infant with CLD/
of feeding,
WOB before feeding is increased further with effort of
feeding
Infants with poor endurance may be unable to feed or
may demonstrate poor weight gain despite accept-
able intake
Periodic rest periods and pace energy expenditure
with nipple feeding
Swaddle/rock if fussy
PMA >32 weeks who are ready to initiate oral
feedings: delay of start by 1 week reduces physio-
logic distress (oxygen desaturations) with feeding
Pulse oximeter monitoring with feeding to ensure
adequate oxygenation; give oxygen PRN to keep
saturation ≥92%
Provide chin/cheek support (see Box 13.7)
that decreases energy expenditure, enhances
state organization and sucking activity
2. Tachypnea
Respiratory rate >60/min
WOB increases with feeding; respiratory rate increased
with work of feeding
Increased incoordination of suck-swallow-breathe with
Brief and/or frequent breaks in feeding to enable
deep breaths and reorganize breathing
patterns
feeding; predisposes to aspiration
Increased risk for aspiration if gasping for breath
3. Nasal flaring Attempts to increase oxygen intake because of hypoxia
or increased WOB
Pulse oximeter; supply adequate oxygenBrief breaks
to reorganize breathing
4. Nasal blanching Distress of breathing/hypoxia
Incoordination of suck-swallow-breathe with possible
aspiration if flaring/blanching occur
5. Chin tugging/head bob-
bing/“catch-up” breathing/
grunting
Attempting to increase air entry because of “air
hunger”/hypoxia/WOB/decreased tidal volume
Incoordination of suck-swallow-breathe; increased risk
As for signs 1 through 3
for aspiration
153,267,364,365
406,407
407
440
407
Continued
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391
TABLE
13.13
CRITICAL FINDINGS—CONT’D
STRESS* DURING NIPPLE FEEDINGS
SIGN SIGNIFICANCE INTERVENTION
6. Crowing sounds—
high-pitched stridorous
Incoordination of opening/closing of vocal cords that
increases the risk for aspiration into the trachea
454
As for signs 1 through 3
noise on inspiration
7. Swallowing Primary swallow dysfunction predisposes to aspiration,
380
swallowing may be evaluated by videofluoroscopy
A. Drooling Loss of bolus control because of:
Inability of tongue to collect and hold fluid that is flowing
too fast
Give fewer sucks in a row, followed by brief break
(pacing) so that bolus is smaller and easier to
completely swallow
Rapid respiratory rate, excessive WOB that shortens
time for swallowing to occur, so that only part of
bolus is swallowed
B. Gulping Use of prolonged sucking pattern or long sucking bursts
(especially at the beginning of feeding) without deep
Give brief breaks (pacing) to assist the infant in
slowing down the feeding
breathing at the appropriate intervals
Results in oxygen desaturation, bradycardia, apnea
resulting from suppression of respiration
Increases incoordination of suck-swallow-breathe and
stimulates pharyngeal stretch receptors, resulting in
vagally stimulated apnea
C. Gurgling sounds in the
pharynx (breathing
sounds are wet/noisy)
Fluid collecting in the throat, pharynx, or supraglottic
space above vocal cords
380
Noisy respirations caused by breathing through fluid in
Brief break from feeding to enable extra swallow/
dry swallow to clear fluid from throat
hypopharynx because bolus is too large or flow is
too fast
D. Swallowing (several
times) in succession
Deliberate swallows in succession to clear bolus
(that is too large/flow is too fast) from pharynx
Break from feeding to clear throat and regain control
of respiration
Breathing is delayed with successive swallowing and
268
266
Usually can be prevented by close attention and
intervention to previous signs of feeding difficulty
Breaks from feeding to clear airway, regain control of
respiration and state organization
Ability to cough enables infant to clear airway
Inability to cough, color change, hypotonia,
E. Coughing, choking,
gagging, spitting up
may result in apnea/ bradycardia
Fluid has entered (or nearly entered) the airway
Changes in color, heart rate, respiratory rate suggest
swallowing problems
Occurrence toward end of feeding suggests
gastroesophageal reflux; frequent or intense spitting
up also may indicate reflux
bradycardia, and apnea are symptoms of
airway obstruction that may require suction and
cardiopulmonary resuscitation
Change nipple and/or bottle system
223
223
*Stress signals delay the transition to full oral feedings.
BPD, Bronchopulmonary dysplasia; CLD, chronic lung disease; PMA, post menstrual age; PRN, as needed; WOB, work of breathing.
Modified from Shaker C. Nipple feeding preterm infants: an individualized, developmentally supportive approach. Neonatal Netw. 1999;18:15.
458
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The latest Cochrane review found no RCT or quasi-RCT of instruments for assessing readiness to
commence oral feedings in preterm infants.
95
A case report has been published of the progress
of one preterm infant’s nutritive sucking and development of effective feeding skills using the nfant®
Feeding Solution system.70 The noninvasive assessment system measures tongue movements against a
bottle nipple and streams the data to a tablet as the
infant sucks. The real-time data is then used to evaluate
not only sucking ability and progression but also the
efficacy of interventions with a goal of providing safe,
cue-based feedings that progress to full oral feedings
quickly, resulting in earlier discharge and cost savings.
CASE STUDY
Tommy was a 28-week preterm infant with severe RDS, prolonged
ventilation, and now BPD. He is now 38 weeks’ postconceptual age,
receiving hood and nasal cannula oxygen and trying to learn to nipple
feed. In the morning report, the night nurse says that Tommy “has
bradycardia with tube passage so that 24 hours ago he had a cardiorespiratory arrest that required resuscitation. He also has bradycardia and
tachypnea with bottle feeding.”
Tommy’s nurse evaluated his initial attempts to bottle feed (after
waiting for him to demand) and wrote the care plan (see Box 13.18)
after feeding him 45 mL in 20 minutes without tachypnea, cyanosis,
or bradycardia.
BPD, Bronchopulmonary dysplasia; RDS, respiratory distress syndrome.
CRYING OR SMILING INTERVENTION
Crying is the infant’s innate care-eliciting behavior, a signal that he or she needs attention. The
energy expenditure of a crying infant is increased
by 7.5% compared with the resting state.
Immediate response decreases the infant’s physiologic stress, increases the infant’s trust in the
environment, and enhances the sense of self and
of control over the world.
249
The infant’s need
to escalate to “out-of-control” crying is decreased
with immediate response so that infants are easier
to soothe. Consoling the crying infant also helps the
infant change states so he or she is able to attend to
and interact with the environment.
Term infants vocalize, cry, and look at their
caregiver more than do preterm and ill infants.
Although preterm infants are more irritable than
351
158
BOX
13.18
1. Sit upright. This decreases the flow of formula from the bottle and
a. His gag reflex, which causes the bradycardia
b. His anxiety, which is caused by a bolus of formula in his mouth
2. Use a blue nipple. This is the shortest nipple and decreases stimula-
3. Gently push up under his chin when he gets a mouthful of formula.
4. Talk to him. Softly and gently, tell him he can swallow, and praise
5. Nipple. Have him do this as much as possible (he will only get better
TOMMY’S FEEDING PLAN
thus decreases:
tion of his hypersensitive gag reflex, which causes his bradycardia.
(All other nipples stimulated him to gag.)
This pushes his tongue upward against his palate, the same way the
tongue moves during swallowing. (reader: Swallow and note your
tongue motion.) He becomes frightened (i.e., eyes wide open and
fearful; increased respiratory rate; arching and struggling) when he
has a mouthful of formula, because he is used to sucking only on a
dry pacifier and having nothing to swallow. His fear raises his heart
rate, respiratory rate, and gag reflex, which causes bradycardia.
him when he does.
with practice) and supplement feeding with the indwelling nasogastric tube (no more intermittent tube passage).
full-term infants, preterm infants cry less throughout
the day than do full-term infants. NICU infants
exhibit fewer care-eliciting behaviors (some
preterm infants in one study never cried, vocalized, or looked at their caregiver).
158
Preterm
infants thus are less responsive to the caregivers
(both parents and professionals), who receive less
positive feedback from the infant and hence are less
rewarded. In one study, those NICU infants who
were able to cue the care provider (cry, look, vocalize) were consistently responded to 80% to 100% of
the time.
158
Intubated infants who cannot produce an audi-
ble cry signal their needs by agitation, heart rate
changes, and changes in oxygenation. Preterm
infants (<32 weeks’ gestation) may recover better
from agitation when left alone, because active consolation is overstimulating. How caregivers attempt
to soothe a crying infant while giving NICU care
includes (1) no response to cries (58.1% of the
time), (2) response by talking (29.2% of the time),
(3) response by social touching (5.5% of the time),
and (4) response by talk and social touching (7.2%
of the time).
158
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393
Parents and staff should use graduated interventions in quieting a crying infant by the
following:
• Soothing with gentle, high-pitched talking (loud
enough that the infant can hear it above his or
her crying)
• Placing the palm of the hand across the infant’s
chest or holding arms on chest with the palm of
the care provider’s hand
• Swaddling with blankets to decrease self-upsetting
startles
• Picking up infant, holding (upright is the most
soothing position), and rocking
• Placing the infant skin-to-skin on the parent’s
chest
• Offering a pacifier
Most stimulation in the NICU is procedural.
The lack of social stimulation in the NICU not
only affects the infant but also teaches parents
that their infant is too weak for, too fragile for,
uninterested in, or incapable of social interaction.
Again, social stimulation must be paced according to the stage of development and stability of
the infant
115
(see the Critical Findings in Box 13.2).
Enhancing the infant’s social environment includes
presenting the smiling, moving, talking care provider’s
face to the alert infant; touching and stroking; and
soothing and consoling the distressed infant.
In many busy NICUs, parents and a foster grandparent program provide this sensory integrated social
experience. If the infant has been transported to a
referral center, parents may live some distance away
and be unable to visit daily. A chronically ill 4- to
5-month-old infant who begins to recognize the foster grandmother may smile, relax, and feed better for
her and is often fussier and more irritable on her day
off. A foster grandparent program benefits both infants
and seniors—the infant receives love and socialization,
and the senior “has a reason to get up in the morning.”
If possible, parents should be encouraged to
perform the “firsts” with their infant (e.g., first
nipple feeding, first bath, first time out of the
incubator). Because parents are not always present,
they will miss some important milestones for their
infant (e.g., extubation). Many NICUs have developed baby diaries (or calendars) and/or use videotaping in which the nurses, physicians, and foster
grandparents write or record important information
about the infant’s day (as if the infant were the author).
The text is accompanied by self-developing pictures
with humorous captions (e.g., “Look at me. I’ve got
BOX
13.19
ADVANTAGES OF SINGLE-FAMILY ROOM
NICU CARE
230,231,350,434,453
Increased developmental and family-centered care
Increased parental participation in their infant’s care:
• More skin-to-skin care
• More visits; more time in NICU
• Ability to stay overnight in the NICU
• Received more breastmilk
• Lower gestational age at full oral feedings
• Growth: faster weight gain; higher weight at discharge mediated by
increased developmental support
• Increased parental satisfaction, reduced stress, more privacy, and
fewer interruptions
Cost-effective:
• Shorter length of stay
• Less sepsis
• Fewer medical procedures due to enhanced maternal involvement
Improved neonatal outcomes:
• Better attention due to increased developmental support
• Less stress, hypertonicity, and lethargy due to developmental care
• Less pain and physiologic stress due to enhanced maternal/parental
involvement
• Higher language and cognitive scores at 18 to 24 months of age
my tube out!”). Staff members are very creative in
relating what’s been happening so that the parents
have not only a verbal report (that may be forgotten
over time) but also a keepsake of NICU progress.
The pursuit of “humane,”
10,11
based
developmental care continues with
redesign of NICU environments,
204
relationship-
448
including single-room care and changing the attitudes and care
practices among health care providers. Advantages
of single-family room care are listed in Box 13.19.
A comparison study of single-family NICU rooms
versus open-ward NICU was conducted in an urban
NICU with low levels of parental visiting and holding
and found poorer outcomes at 2 years—rather than
the room configuration, the presence and careby-parents influences improved outcomes.
337
More
recent follow-up studies comparing the outcomes of
preterm infants cared for in single-family rooms to
open-bay NICUs also found improved outcomes
in those infants cared for in single-family rooms
because of enhanced maternal involvement and
better developmental support.
230,231
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Creating an integrated, relationship-based, family-centered, developmental care philosophy requires
the following:
• A commitment by individual care providers to
alter practice for the benefit of neonates and
families and to integrate family-centered devel-
opmental care into their individual practice
• Relationship building with neonates, families,
and colleagues
• The use of effective change strategies within the
institution’s organizational climate
• Implementing the guidelines of national profes-
sional organizations
16,448
to satisfy ethical, legal,
and professional standards of care
• Changing health care providers’ knowledge
base, which requires multidisciplinary educa-
tional opportunities (e.g., orientation, in-service,
continuing education, consultation) and written
resource materials
6
Developmental care can no longer be considered “nice, but optional,” especially with the
evidence that not only brain function but also
actual brain structure are positively affected by
the early experiences of family-centered developmental care in the NICU.* A study evaluating the
effect of developmental care on the neurodevelopmental outcomes of preterm infants found less
psychomotor delay (16.1%) at 2 years of age in
those toddlers who received developmental care
in the NICU than those toddlers cared for without developmental care (27.4%).
205
Another recent
study of toddlers who were born prematurely (75%
very preterm; 25% moderate/late preterm) found
those with a longer stay in the NICU had the
highest risk for behavioral problems.74 The level of
prematurity or the presence of BPD/CLD and ROP
did not affect temperament, whereas a longer stay in
the NICU was associated with more pervasive developmental and emotionally reactive problems. Based
on these findings, these researchers emphasize the
need for developmental care in NICUs to reduce
stressful and painful experiences for premature
babies and to provide protection from overwhelming stimuli in the NICU during the premature infant’s initial development. Developmentally
appropriate care in the NICU must also be accompanied by “proactive developmental monitoring and
implementation of timely therapeutic and educational
early intervention services … to continue to support
optimal outcomes for preterm infants.”
* References 7–9, 270, 271, 289–291.
238
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