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Developmental Care - the Older Preterm Infant

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Assessment of the Older Preterm Infant (37 plus weeks corrected gestation)

  • Respond to infant cues for feeding, physical contact and social interaction.1,3
  • Continue to assess for exhaustion and overload in infants with respiratory compromise.

Handling and interventions

Behavioural Development

  • Tolerance of handling and interventions usually increases.
  • States well defined with clear transitions.2
  • Periods of alertness for socialization with development of longer attention spans.3

Nursing implications

  • Provide rhythmic care patterns (nappy change, feeding, socialization,) to enhance sleep/wake organization.4 Incorporate day/night patterns into interventions. 
  • Swaddle or contain (head and hands in the midline, shoulders forward, lower limbs flexed and adducted towards the midline) during uncomfortable or noxious procedures.2,7 Patting and stroking may be tolerated.3 
  • Hold infants for feeding-this includes tube feeding. 
  • Breastfeeding during or after painful procedures- individual assessment required. 
  • Continue Kangaroo Care opportunities for infants transitioning to oral feeding.21
  • Sucrose for painful and uncomfortable procedures.

Positioning

Motor development

  • Infant demonstrates a wide range of movements. 
  • Controlled movements increase. 
  • Trunk and extremities usually flexed at rest. 
  • Infant can self - regulate behaviour with movement and posture.3

Nursing implications

  • Infants in cots should be positioned on their backs (SIDS recommendation unless a special medical order) unswaddled allowing hand to mouth contact. 
  • For infants in cots who display limited flexion consider a nest or a swaddle below shoulder level. No nests or blankets around face.2,7
  • Vary the position of the infant head for sleep and approach infant from a different side of the cot to avoid right sided head preference.20
  • Continue Kangaroo Care opportunities for infants transitioning to oral feeding 
  • Supervised by parent, 'tummy' time either over parent's knees or on a floor matt. Also supervised side-lying position to promote hands to midline posture.20 
  • Swaddle infants that display signs of stress during bathing.

Light and Vision

Development

  • Generally shows preference for human face. 
  • Sees best at a distance of 20-25cm. 
  • Sight is still immature with much development to follow at 0-6 months.9,22

Nursing implications

  • Use low lighting levels and continue to protect from bright lights and direct sun light. 
  • Dim lights at night thereby promoting development of circadian rhythms.16,17
  • Offer opportunities for visual stimulation if infant is displaying longer attention spans. 9

Sound and Hearing

Development

  • Response to noise is more consistent and organised. 
  • Can localize and discriminate sounds. 
  • Stress behaviours may still be displayed to certain loud sounds. 
  • Gradual onset of auditory stimuli preferred.3,11

Nursing Implications

  • Avoid loud noise and multiple sound sources. Be aware of sound/noise levels in NICU. 
  • Ensure CPAP and Ventilator tubing is regularly cleared of H2O. 
  • Auditory stimulation as per baby's cues. Start with soft voice leading on to normal conversation volume/tone. 
  • Music audiotapes for infants in cots if parents wish - not to be set on continuous play.

Non-Nutritive Sucking

Development

  • Suck, swallow and breathe co-ordination becomes more consistent and organized. 
  • Endurance for oral feeding increases.13-15

Nursing Implications

  • Encourage hand to mouth contact. 
  • Encourage non-nutritive sucking during NG/OG feeds and for comfort. 
  • Offer standard small pacifier to encourage wider jaw excursion and therefore breast feeding and nutritive sucking patterns. 
  • Do not offer pacifier prior to painful procedure. 
  • Oral suction, only when clinically necessary.15,19,23

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 prior to use after being soaked in Milton solution.

Parents

  • Promote parental independence and enjoyment of maturing infant. 
  • Offer opportunity for education on deep-water bathing, massage techniques and infant development.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