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Developmental Care - the Growing Preterm Infant

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Assessment of the Growing Preterm Infant (33 to 36 weeks gestation)

  • Assess the infant's response and ability to tolerate activities.1
  • Monitor for signs of stress. Infants may display increased tolerance for handling, but watch for signs of exhaustion in individuals with residual respiratory compromise.2

Handling and interventions

Behavioural Development

  • Behavioural states become more distinct.2
  • Smoother transition between states
  • Quiet/ deep sleep continues to increase.
  • Infant may arouse for feeding.
  • Stress response to noxious stimuli may vary but physiologic instability still evident. 3

Nursing implications

  • Interventions or opportunities for sensory experiences should take place with consideration of infant cues and ideally when an infant is in an aroused state. 4
  • Slow controlled gentle handling. Gently prepare infants for handling with a soft voice or gentle touch to help facilitate physiological stability and state organization. 5
  • Contain (head and hands in the midline, shoulders forward, lower limbs flexed and adducted towards the midline) or swaddle infant during uncomfortable or noxious procedures.2,7 Patting or stroking may be tolerated.2
  • Hold infants during feeding if awake - this includes tube feeding.
  • Sucrose for painful and uncomfortable procedures.
  • Where clinically possible consider day/night patterns for interventions. 2 For example weigh infant, take B/P and change bedding in the daytime.
  • Introduce Kangaroo Care when medically stable. 

Positioning

Motor development

  • Smoother and more controlled movements. 
  • Stronger flexion of knees and hips during rest and development of tone in the lower extremities. 
  • Can turn own head from side to side. 
  • Infant has improved capability to use posture and movement to self regulate.3

Nursing implications

  • Use supportive positioning techniques to enhance flexion and promote comfort.2 Opportunities for movement should always be possible. Provide boundaries using a nest for infants in incubators to enhance flexion - with napkin or blanket roll or Snuggle up.6, 7
  • Consider swaddling for unsettled but physiologically stable infants in incubators.7
  • Swaddle infant for initial baths if signs of stress occur. 
  • Infants in cots should be positioned on their backs (SIDS recommendation unless a special medical order) allowing hand to mouth contact. 
  • Infants in cots who display limited flexion, consider a nest or a swaddle below shoulder level. No nests or blankets around face.2
  • Vary the position of the infant head for sleep.20

Light and Vision

Development

  • Increased ability to maintain lid tightening in response to bright light. 
  • Eye opening and alert state are facilitated by low lighting. 
  • Infant may have difficulty breaking gaze on a highly stimulating object.3,22

Nursing implications

  • Protect infant from bright lights during care giving and procedures. Reduce exposure from light in incubators by using a cover. Provide eye protection for infants in receiving phototherapy and shield light from infants in adjacent incubators/cots. 
  • Support emerging need for eye contact - generally infant shows preference for human faces. 9
  • Research does not support the use of black and white visual stimuli.3,18
  • Dim lights at night if safe to do so, whereby promoting development of circadian rhythms. 16,17

Sound and Hearing

Development

  • Sensory and transmission portions of the auditory system are functional. 
  • Increasing responsiveness to voice stimuli with a preference for soft human voice. 
  • Responses to noise and auditory environments begin to organize. 
  • Startle response with loud noise still evident3,11

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.
  • 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.
  • Audiotapes are not recommended for this gestational age group.12

Non-Nutritive Sucking

Development

  • Suck, swallow and breathe co-ordination maturing - some rhythmicity but co-ordination can be inconsistent. 
  • Rooting reflex emerges. 
  • Nipple feeding usually tolerated.15,19,23

Nursing Implications

  • Encourage hand to mouth contact.
  • Offer standard small pacifier to encourage wider jaw excursion and therefore breast feeding and nutritive sucking patterns.
  • 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

  • Encourage parents to hold infant during NG/OG feedings.
  • Protect from noxious odours.
  • Open alcohol wipes and antiseptic preparations away from the incubator and infant.
  • Avoid use of strongly scented perfume.
  • Dip pacifier or teat in milk after being soaked in Milton solution.

Parents

  • Promote early and continued parental involvement.
  • Encourage parents to observe their infants behavior /cues.
  • Promote independence by encouraging parents with feeding and cares, in particular containment during and after handling, top and tail wash or bath and Kangaroo care.
  • 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