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Developmental Care - the Developing Preterm Infant

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Assessment of the Developing Preterm Infant (28 to 32 weeks gestation)

  • Observe infant's cues and behaviour.1
  • Assess the infant's response and ability to tolerate activities. Monitor for signs of stress and exhaustion.2

Handling and interventions

Behavioural Development

  • Behavioural states gradually become more distinct by 32 weeks. 
  • Quiet/ deep sleep increases around 30 weeks. 
  • Response to handling results in physiologic instability. 
  • Infant displays more typical signs of stress.2

Nursing implications

  • Provide opportunities for undisturbed rest. Cluster cares but avoid completing a number of potentially distressing interventions at the same time. If an infant indicates signs of stress during handling - stop and provide 'time out' for the infant to recoup from that intervention. 4
  • Interventions should ideally take place when an infant is in a gently aroused state and with consideration of infants cues.
    Slow controlled gentle handling.
    Abrupt/fast changes in position are poorly tolerated.2,4
  • Gently prepare infant for handling with a soft voice or gentle touch to help promote physiological stability and state organization.5
  • Vary infant head and body position-mindful of infant physiological status and response to handling.
  • To soothe infant during uncomfortable procedures contain infant-head and hands in midline, shoulders forward, lower limbs flexed and adducted towards the midline.2 Elicit help from a parent or another nurse. Avoid stimulating the infant with stroking or patting.3
  • Where clinically possible consider day/night patterns for interventions.4 For example weigh infant and change bedding in the daytime.
  • Introduce Kangaroo Care when medically stable.
  • Consider sucrose for infants >31 weeks gestation

Positioning

Motor development

  • Twitches and startles common at 28/40 weeks leading to more controlled movements by 32 weeks. 
  • Muscle tone weak but develops slowly over this gestational period. 
  • Leg movements increase with beginning flexion of hips and legs.3

Nursing implications

  • Use supportive positioning techniques to enhance flexion and promote comfort.6 Opportunities for movement should always be possible.
  • Provide boundaries using a nest-with a napkin/ blanket roll or Snuggle-up.5,6
  • Always swaddle infant when transferred to and from incubator.7

Light and Vision

Development

  • Sluggish pupil response to light. 
  • Able to maintain lid tightening in response to bright light. 
  • Eye opening increases in dim light. 
  • May focus briefly on visual stimuli. 
  • Rapid uncoordinated eye movements.3

Nursing implications

  • Minimise light levels where appropriate. Protect infant's eyes from bright light during care giving procedures. Reduce exposure to light in incubators by using a cover. Provide eye protection for infants receiving phototherapy and shield light from infants in adjacent incubators/cots.
  • Minimise visual stimuli. Toys and pictures should not be placed within direct visual space.9 
  • Dim lights in room at night if safe to do so to enhance development of circadian rhythms. 16,17
  • Shading from light gives appropriate opportunities for spontaneous eye opening. 
  • Research does not support the use of black and white pictures for this gestational group. 3,18

Sound and Hearing

Development

  • Middle ear and transmission section of auditory system is complete.
  • Orientation to soft sound develops during this period.
  • Infant can quickly fatigue to auditory stimulation.
  • Infant is sensitive to loud noise and can demonstrate physiological instability to noise/auditory activity. 3, 11

Nursing Implications

  • Minimise environmental noise. Be aware of sound/noise levels in NICU. Talk softly at the bedside.
  • Attend to alarms promptly and set alarm volume as low as is clinically safe. Decrease volume/tone of telephone ring and no radios in rooms.
  • Close incubator doors quietly. Do not tap or bang on incubator. Discourage the use of the top of the incubator as a writing surface and or storage area.
  • Ensure CPAP and ventilator tubing is regularly cleared of H2O.
  • Encourage parents to talk softly to their baby as cues allow.
  • Music audiotapes are not recommended for this gestational age group.12

Non-Nutritive Sucking

Development

  • Rooting reflex present but a delayed response can occur.
  • Poor suck, swallow and breathe co-ordination that matures over this period.13,14,15,19

Nursing Implications

  • Encourage hand to mouth contact.
  • Nipple feedings are generally unsafe at 28-30 weeks gestation. Infants > 30 weeks gestation may nuzzle at breast during KC with close assessment.
  • Offer preemie pacifier to support non-nutritive sucking.
  • Encourage non-nutritive sucking during NG/OG feeds and for comfort.
  • Do not offer pacifier prior to painful procedure.
  • Oral suction only when clinically necessary.13,14,15,19

Smell and Taste

Development

  • Taste and smell receptors are thought to be functional.
  • Physiologic responses to unpleasant olfactory stimuli have been documented by research. 3

Nursing Implications

  • Parents may familiarize their infant with the smell of breast milk by using milk soaked gauze prior to and during a feed. Discard immediately after use.
  • Protect from noxious odours.
  • Open alcohol wipes and antiseptic preparations away from the incubator and infant.
  • Avoid use of strongly scented perfume.
  • Dip pacifier in milk after being soaked in Milton solution.

Parents

  • Promote early and continued parental involvement.
  • Encourage parents to observe their infants behavior /cues.
  • Teach parents to identify infant's readiness for touch and handling and emphasise the infants potential low tolerance for stimulation.
  • Encourage parents to assist with cares where they can- in particular gentle touch, containment during and after handling, top and tail wash and Kangaroo care where appropriate.
  • Offer information and education on preterm developmental care.3,5

References

  1. Als, H.(1986). A synactive model of neonatal behavioural development: a framework for assessment of neurobehavioral development in the premature infant and for support of infants and parents in the neonatal intensive care environment. Physical and occupational therapy in pediatrics,6,(3-4),3-53
  2. Taquino, L.T. & Lockeridge, T.(1999).Caring for Critically Ill Infants: Strategies to Promote Physiologic Stability and Improve Developmental Outcomes
  3. Turner, A., & Santangelo, S. Developmental and Behavioral Characteristics of the preterm infants. Santa Rosa: NICU INK.
  4. Peters, K.L.(1999). Infant Handling in the NICU: Does Developmental Care Make a Difference? An Evaluative Review of the Literature. Journal of Perinatal Nursing,13(3) 83-109
  5. Hinkler, P.K. & Moreno, L. A. Developmentally Supportive Care. Theory Application - A self study guide module. Childrens Medical Venture.
  6. Reid, T & Freer, Y. (2001). Developmentally Focused Nursing Care. In G. Boxwell. Neonatal Intensive Care Nursing (pp.14-44).London: Routledge.
  7. Short, M.A., Brooks-Brunn, J. A., Reeves, D. S., Yeager, J. & Thorpe, J. A. (1996). The Effects of Swaddling Versus Standard Positioning on Neuromuscular Development in Very Low Birth Weight Infants. Neonatal Network, 15,(4) 25-31.
  8. Ludington-Hoe, S., Ferreira, C., Swinth, J & Ceccardi, J.(2003). Safe criteria and procedure for kangaroo care with intubated infants. JOGNN, 32, 579-588.
  9. Oehler, J.M.(1993) Developmental Care of the Low Birth Weight Infants. Nursing Clinics of North America, 28, (2), 289-301.
  10. Fielder, A.R., & Moseley, M. J. (2000). Environmental Light and the Preterm Infant Seminars in Perinatology, 24 (4), 291-298.
  11. Moore K.L. & Persuad, T.V. N. (1998) The Developing Human. Philadelphia: Saunders.
  12. Kenner, C. & Wright Lott, J. (2003). Comprehensive Neonatal Nursing (3rd ed.). Philadelphia: Saunders.
  13. Gewolb, I., Vice, H., Frank L., Schweitzer-Kenney, E. L., Taciak, V. L, Bosma L.& James F.( 2001). Developmental patterns of rhythmic suck and swallow in preterm infants. Developmental Medicine & Child Neurology 43:22-27.
  14. Wolf, L. S.& Glass, R.(1992). Feeding and Swallowing Disorders in Infancy. Therapy Skill Builders:San Antonio
  15. Oetter, P., Richter E. W., Frick, & Sheila, M.(1995). M.O.R.E. Integrating the Mouth with Sensory and Postural Functions. (2nd ed.)Hugo, Minnesota: PDP Press.
  16. Brandon, D. H., Holditch-Davis, D. & Belyea, M. (2002). Preterm infants born at less than 31 weeks gestation have improved growth in cycled light compared with continuous near darkness. Journal of Pediatrics, Feb, 192-199.
  17. Mirmiran, M., & Ariagno, R. L. (2000). Influence of Light in NICU on the 'Development of Circadian Rhythms in Preterm Infants. Seminars in Perinatology, 24, (4), 247-257.
  18. Glass, P. (1999). The Vulnerable Neonate and the Neonatal Intensive Care Environment. In G. Avery, M. A. Fletcher & M. MacDonald (5th ed.). Neonatology Pathophysiology and Management of the Newborn (pp.91-108). Philadephia: Lippincott Williams & Wilkins.
  19. Pinelli, J. & Symington A.(2002). Non-nutritive sucking for promoting physiologic stability and nutrition in preterm infants. The Cochrane Library 4:54.
  20. Duber, K. & Flake, M. (2003). Occipital flattening of positional origin. Canadian Nurse, 99, (1) 16-21.
  21. World Health Organisation (2003). Kangaroo mother care: a practical guide.
  22. Altimer, L. B. (2003). Management of the NICU Environment. In C. Kenner & J Wright Lott (3rd ed.). Comprehensive Neonatal Nursing, (pp.229-237). Philadelphia: Saunders.
  23. Pinelli, J. & Symington, A.( 2000). How Rewarding Can a Pacifier Be? A Systematic Review of Nonnutritive Sucking in Preterm Infants. Neonatal Network, 19,(8):41-48
  24. American Academy of Paediatrics. (1997). Noise: A Hazard for the Fetus and Newborn.-Policy Statement. Pediatrics,. 100, (4),1-9
  25. Cattaneo,A., Davanzo,R., Uxa, F., & Tamburlini,G. (1998) Recommendations for the implementation of Kangaroo Care for low birth weight infants. Acta Paediatr, 87, (4),440-445.
  26. Monterosso, L., Kristjanson, L., & Cole, J. (2002).Neurodevelopment and the Physiologic Effects of Positioning in Very Low Birth Weight Infants. JOGNN, 31 ,(2), 138-146.

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Document Control

  • Date last published: 31 December 2004
  • Document type: Clinical Guideline
  • Services responsible: Neonatology
  • Owner: Newborn Services Clinical Practice Committee
  • Editor: Sarah Bellhouse
  • Review frequency: 2 years