DSC Book

a
Developmentally Supportive Care (DSC)

of the Preterm, Fragile and/or Critically ill
Infant in the NICU
Chief Scientifc Editor
Dr Amitava Sengupta
National Neonatology Forum of India
803, 8th Floor, Northex Tower, Pitampura, New Delhi - 110 034
Tel.:011-27353535 E-mail: secnnf@nnf.org
b
DSC of the Preterm, Fragile and/or Critically Ill Infant in the NICU
i
Developmentally Supportive Care (DSC)
of the Preterm, Fragile and/or Critically ill
Infant in the NICU
Chief Scientic Editor
Dr Amitava Sengupta
Tel.:011-27353535 E-mail: secnnf@nn.org
www.nn .org
ii
Contributors Contributors
Amitava Sengupta, Fellowship Neonatology (Neth)
Director, Mother & Child Unit
Head, Department of Neonatology & Pediatrics
Paras Hospitals, Gurgaon (NCR), India
Chief Advisor: 49
th
Annual National Conference of IAP (Pedicon 2012)
Chairperson: Neonatal Neurocon 2013, Gurgaon (NCR)
National Faculty: NNF-IAP Advanced NRP 2010
Email: amit19762000@yahoo.com
Ms Amy Carroll, OT Doctorate
Thomas Jefferson University, Philadelphia, PA, USA
Consultant, Occupational Therapy
Division of Neonatology-Department of Pediatrics
Mother & Child Unit
Email: carroll.amyp@gmail.com
Aditya Dixit, MD
Consultant, Department of Neonatology & Pediatrics
Mother & Child Unit
Email: dr.adityadixit@gmail.com
Rakesh Tiwari, MD
Consultant, Department of Neonatology & Pediatrics
Mother & Child Unit
Email: drrakeshtiwari@gmail.com
Sanjay Wazir, DM Neonatology (PGI Chandigarh)
Chief, Division of Neonatology
The Apollo Cradle, Gurgaon (NCR), India
Email:swazir21@gmail.com
S. P. Senthil Kumar, M.D.(PAED), Fellowship Pediatric Critical Care
Consultant Pediatric Intensivist
Email: drsenthilsp@yahoo.co.in
Vikram Datta, MD, DNB
Secretary NNF & Professor
Department of Neonatology
Lady Hardinge Medical College
New Delhi, India
WHO Fellow in Epidemiology
Email: drvikramdatta@gmail.com
iii
Contents Contents
Chapter 1
1
Overview, Evidence base and Core Measures of DSC
Amitava Sengupta
Chapter 2
6
Development of Various Neonatal Sensory Systems and their Implications for Interventions of
Developmentally Supportive Care
Aditya Dixit, Rakesh Tiwari
Chapter 3
11
Neuromotor maturation and Stages of neurobehavioral organization of the Preterm and High
Risk Infant
Amitava Sengupta, S. P. Senthil Kumar
Chapter 4
14
Principles and Practices of Developmentally Supportive Care
Amy Carroll
Chapter 5
23
Feeding in High- Risk Infants and Neurodevelopmental assessment of feeding abilities
Amitava Sengupta
Chapter 6
26
Assessment and Management of Pain in Neonates
Vikram Datta

Chapter 7
30
Family Centred Care
Amy Carroll
Chapter 8
32
Environmental Considerations for Reduction of Stress & Energy Conservation
Amitava Sengupta
Chapter 9
36
Kangaroo Mother Care and Developmentally Supportive Care
Sanjay Wazir
Appendix 38
iv
What began as an opportunity for an NICU posting for Amy Carroll two years back, led to an extraordinary
interdisciplinary collaboration with the Paras Hospital NICU team.
The Neonatal group at Paras Hospitals, Gurgaon (NCR), India, delivers state of art and quality care to Preterm, Fragile
and/or critically ill infants in their NICU.
There was consideration of the developmental needs of the preterm /fragile or critically ill infants and eventually, an
extended role for Amy Carroll as a facilitator of an inter-professional Developmentally Supportive Care (DSC) team
evolved. The team embarked on a DSC knowledge translation journey which initially included review of volumes
of current DSC literature and related evidence based best practices in the NICUs across the globe. The effort was
supported academically by the Occupational Therapy Doctoral Program at Thomas Jefferson University, Philadelphia,
USA, as Amy Carroll was completing her Doctorate in the same program.
The two years of dedicated research and clinical work by the DSC team culminated in the creation of a 5 week program
for the nursing staff through knowledge translation methods.
The knowledge translation consisted of: weekly training sessions, integrated practice of techniques, and strength-
based strategic planning sessions tailored to the Paras Hospital setting. The Paras DSC vision was, and still is, to create
a Culture of Developmentally Supportive Care that is relevant and useful for all families and NICUs across the
NCR and India. We are ever closer to realizing that vision due to the amazing efforts of all NICU staff including the
Consultants, Resident Specialists, the NICU Nursing Staff and the DSC team. We are most appreciative of National
Neonatology Forum (NNF) India for allowing us the opportunity to share our experience with our readers. We hope
that this information will be a useful catalyst for DSC in other NICUs across our country and abroad!
We would like to thank the Secretary NNF India, Dr. Vikram Datta for his intense and unconditional support and
encouragement, which has made our endeavor possible.
Dr. Amitava Sengupta
Director: Mother & Child Unit
Head: Department of Neonatology & Pediatrics
Chief Advisor: 49th Annual National Conference of IAP (Pedicon 2012)
Chairperson: Neonatal Neurocon 2013, Gurgaon (NCR)
National Faculty: NNF-IAP Advanced NRP 2010
An Initiative An Initiative
v
The field of Neonatology has experienced some remarkable progress over the last four decades in care of the
newborn. This has reflected with dramatic reductions in both neonatal and infant mortality and has enabled
the neonatal team to save more babies of lower gestational age and extremely low birth weight (ELBW). In the
present times, the incidence of prematurity is high in both western and eastern worlds However; morbidity rate of
neurodevelopmental impairment has not decreased for this population.
The preterm infant experiences a hostile environment in the intensive care (NICU) setting as compared to the
womb. This altered sensory experience can have a negative impact on an infants brain development
The in-utero environment of a developing fetus is characterized by generalized extremity flexion and containment,
limited light and noise exposure, sleep cycle preservation, and unrestricted access to mother via somatosensory,
auditory, and chemosensory pathways. This environment is favorable for positive sensory input which is crucial for
normal fetal brain development.
A newborn preterm infant is deprived of these basic developmental needs upon transition from the womb to the
environment of the newborn intensive care unit. This environment is typically characterized by painful procedures,
excessive light and noise exposure, interrupted and inadequate sleep, and separation from mother. Negative
replaces positive sensory input into the developing fetal brain which, as research shows, can permanently alter
normal brain development.
Developmental Care in the NICU is defined by efforts in unit design, equipment selection, policies, care protocols,
and staff training to maintain the basic physical, sensory, and interpersonal needs of the preterm infant while
minimizing exposure to noxious and painful stimuli. These can positively impact preterm infant brain development
and long-term outcome.
A successful developmental care program is the product of a multidisciplinary team of parents, nurses, nurse
practitioners, neonatologists, occupational/physical therapists, administrators, architects, engineers, and social
workers. It requires a shift of attitudes regarding ownership of an infants care and the personhood of the preterm
patient.
As care providers to preterm neonates it is our responsibility to aim for improving functional outcomes and achieve
Positive Neuro developmental outcomes with an intact survival. This comprehensive manual aims to contribute to
this goal.
It has culminated from the untiring and collective efforts of an array of knowledgeable and experienced neonatal
care givers and has been designed to sensitize and provide an overview of the various facets of Developmentally
Supportive Care (DSC).
Dr Amitava Sengupta
Fellowship Neonatology (Neth)
Director, Mother & Child Unit
Head, Department of Neonatology & Pediatrics
Chief Advisor, 49
th
Annual National Conference of IAP (Pedicon 2012)
Chairperson, Neonatal Neurocon 2013, Gurgaon (NCR)
National Faculty, NNF-IAP Advanced NRP 2010
Foreword Foreword
vi
Message President Message
Greetings from NNF
It is indeed a great pleasure to know of the workshop on DSC at Paras Hospital. The topic has been in focus for
quite some time now. During the presidency of Dr Armida Fernandes (2003-2004) the term Humanized Care
was used and was the theme of the year. What was an art has developed a lot of science behind it and is well
established now.
The importance of the subject can be realized from the fact that a chapter has been devoted to this topic in
the updated FBNC module made for district SNCUs. Still a lot of work needs to be done nationwide. The workshop
will help develop awareness further and also expert manpower in this field.
The proposed manual will surely serve a very useful purpose for health workers. If selective portions of it can put
on NNF website it will reach to much wider and interested audience.
A chapter for parents will also be welcome. As you are aware parents section has been started on NNF website for
dissemination of knowledge to community.
Finally I wish best of learning to participants and much greater implementation of the principles for benefit for our
tiny beneficiaries.
Dr Shikhar Jain
President NNF 2013-14
vii
Jai Ho !! Greetings from NNF
I am happy to know that Paras hospital has taken an initiative to conduct a Workshop on Developmentally
Supportive Care (DSC). It will be a feather in the cap of NNF to organize such a prestigious meet. The issue of
intact survival is being highlighted at all levels. Neonatologists & Pediatricians who are in touch with the community
are best suited for nurturing the physical & mental health of the new born.. Use of appropriate technology and
training is the need of the hour and this workshop will be giving hands on experience. There is need for follow up
& assessment of these discharged infants.
Training, teaching & partnership is required to fill the gaps. I hope recommendation of this workshop will help in
the NNF Goal of availability, affordability, accessibility & my personal & national agenda of quality.
Best of Luck and my wishes for all success.
Dr. Ajay Gambhir
President Elect NNF 2015-16
Message President Elect Message
viii
Friends,
With the advent of new technology and knowledge, more and more tiny neonates are surviving in our NICUs.
But is survival the only marker of our success? This is a question we all need to answer as neonatologists and
researchers. Survival is only meaningful if it is an intact survival with intact neurodevelopmental outcome.
The concept of NICU stress caused by multiple physical and noxious processes affecting the final outcome
including neurodevelopmental outcome is well known. But are we geared or prepared to tackle it in our ICUs?. We
all know that NICU should be developmentally friendly but how to achieve it in our NICU remains a challenge. I
was personally sensitized to this concept nearly 6-7 years back when during the course of my research on the topic
of neonatal pain I was exposed to the fact that neonatal pain can adversely affect the developing neonatal brain
.Subsequently ,during the development of NNFs accreditation guidelines the concept of developmentally supportive
care was incorporated in the assessment process to ensure that our Indian NICUs are more developmentally
supportive to the needs of the neonate.
Over the years it was realized by all that the need of the hour in India was to formulate and conduct trainings for
our colleagues in this fascinating subject. As no background study material was available which suited Indian needs
Dr Amitava Sengupta with his friends at Paras Hospital, Gurgaon took the lead in developing the study package
and finalizing the workshop schedule for this first ever DSC Workshop in India. As you will feel at the end of this
workshop that one day is not enough to learn DSC, but it will surely sensitize you to the concept and take you
on a path where you will lead the formation of developmentally friendly NICUs in your region. This workshop
will not only make you more knowledgeable but also more compassionate and empathetic to the needs of the
tiny neonate. If this is achieved I will be happy that you have taken the first step in creating a developmentally
supportive unit.
I thank my seniors especially President Dr Shikhar Jain and President Elect Dr Ajay Gambhir for supporting me in
planning and execution of this workshop. We plan to spread the message of DSC across India by holding similar
workshops at various places in the near future. The study material will be made available for free download at our
website www.nnfi.org.
With best wishes and regards
Prof. Vikram Datta
MD,DNB,FNNF
Secretary General NNF
Department of Neonatology
Lady Hardinge Medical College
New Delhi ,India
drvikramdatta@gmail.com,secnnf@nnfi.org
Message Secretary Message
1
Background
The field of Neonatology has experienced some
remarkable progress over the last four decades
in care of the newborn. This has reflected with
dramatic reductions in both neonatal and
infant mortality.
A variety of progresses have been responsible
for this improvement, including better obstetric
care, improved pharmacologic agents, research
and development of newer respiratory support
devices, micro methods for measuring a variety of
parameters in the neonate, and use of surfactant.
Along with this, the expansion of knowledge in
cellular biology, genetics and infectious diseases,
has enabled the neonatal team to save more
babies of lower gestational age and extremely
low birth weight (ELBW).
1
In the present times, the incidence of prematurity is high
in both western and eastern worlds and it is worthwhile
to be acquainted with some facts and figures regarding
preterm birth.
Preterm birth
Preterm is defined as babies born alive before 37 weeks
of pregnancy are completed. There are sub-categories
of preterm birth, based on gestational age:
a) Extremely preterm (<28 weeks)
b) Very preterm (28 to <32 weeks)
c) Moderate preterm (32 to 34 weeks).
d) Late-preterm infants (34
0
7
to 36
6
7
weeks)
In May 2012, WHO and partners The Partnership for
Maternal, Newborn & Child Health, Save the Children
and the March of Dimes Foundation (USA) published
a report Born too soon: the global action report on
preterm birth that included the first-ever estimates of
preterm birth globally.
An estimated 15 million babies are born preterm every
year. That is more than one in 10 babies. Around one
million children die each year due to complications
of preterm birth. Many survivors face a lifetime of
disability, including learning disabilities and visual and
hearing problems. In almost all countries with reliable
data, preterm birth rates are increasing.
2
Over 60% of preterm births occur in sub-Saharan Africa
and south Asia, but preterm birth is truly a global problem.
Countries with the highest numbers include India, China,
Nigeria, United States of America, Brazil, and many others.
2
India has the maximum number of preterm births with
3,519,100 of them, almost 24% of the total number.
Comparative figures are China: 1,172,300, Nigeria:
773,600 The United States of America: 517,400.
2
Born too soon is the latest contribution to the UN
Secretary Generals Global Strategy for Womens and
Childrens Health, which aims to save 16 million, lives
by 2015.
With the strong evidence of increase in incidence of
preterm births, there is also increased survival rate of
preterm infants as a result of huge medical advances.
However, morbidity rate of neurodevelopmental
impairment has not decreased for this population. The
quality of care giving experiences that preterm infants
receive in a neonatal care unit has had a significant
impact on this population.
3

To reduce developmental dysfunctions in preterm
infants, neonatal care giving needs to be modified
to support infants brain, social, and emotional
development during hospitalization.
4
In fact, our goal should be to improve functional
outcome, have positive neuro developmental
outcome and achieve intact survival of the fragile,
preterm and/or critically ill infant.
Developmental care for high-risk infants has been a
recognized practice strategy in neonatal intensive care
units for over two decades. Developmental care has
been linked to a variety of favorable clinical outcomes.
It is a professional practice, education and research
opportunity that neonatal caregivers should explore,
evaluate and refine continuously within the rapidly
changing technological environment of the NICU.
Overview, Evidence Base
and Core Measures of DSC
Amitava Sengupta Fellowship Neonatology (Neth)
1
Chapter
Medical Advances
Survival of Extremely Low Birth weight Premies
Nutrition
Cellular Biology
Genetics
Pharmacologic
agents
Surfactant
Understanding
of Pulmonary
Function
Respiratory
Support
devices
Micro methods
for Parameters
in Neonates
2
Concern for high-risk infants
Als and colleagues described the complex relationship
between the developing brain of preterm infants and
the increasingly technological NICU environment.
5

In 3rd trimester fetal development and even in early
infancy the brain is drastically changing with new brain
cell production and migration, synaptic pruning and
brain organization.
6

Children born preterm are at greater risk for: LD, low IQs,
ADHD, and neuropsychological deficits. They also display
deficits in visual motor integration, executive function,
temperament, language and emotional regulation.
6

Definitions
Traditional Care: This involves a medical model which is
task oriented; without regard to individuals need. Care
giving is homogenous and families are regarded as visitors.
What is Developmentally Supportive Care
(DSC)?
This is a holistic module which incorporates care that
supports: brain architecture and development, motor
development and normalizing movement patterns,
sensory system and state system development, oral/
feeding development along with family development.
It involves a broad category of interventions designed
to minimize the stress of the NICU environment. These
interventions include elements such as control of
external stimuli (auditory, visual, tactile, vestibular),
clustering of nursing care activities to avoid disrupting
sleep, positioning or swaddling of the preterm infant
and calming techniques.
7

The goal is to provide a structured care environment which
supports, encourages and guides the developmental
organization of the premature and/or critically ill infant.
Why is DSC important?
When in the NICU neonates are under severe and often
life threatening stress. They have immature and or
fragile autonomic and nervous systems. DSC can give
them more reserve to heal, minimize affects of trauma,
and promote normal development of nervous system.
Benefits of DSC
Developmental Supportive Care supports autonomic
stability, normal motor, sensory, neurological development
and promotes behavioral state organization.
8
It also decreases length of hospital stay, improves weight
gain and shortens the time to full enteral feeding. The
neuro-developmental scores at 9-12 months age were
seen to be improved.
9

NIDCAP with pre-term infants with IUGR showed
improved neuro-behavior, electrophysiology and brain
structure. Neurobehavior measures at 42 wks correlated
with EEG and MRI at 42 weeks and neurobehavior at 9
months (RCT: Newborn Individualized Developmentally
Supportive Care and Assessment Program (NIDCAP) Als
et al, 2012 out of Harvard Medical School, Childrens
Hospital Boston, Brigham and Womens Hospital,
University of Rochester medical center)
Core measures for DSC
Core measures for developmental care are focused on
neonatal caregiver actions which are disease independent
but nonetheless essential to promote healthy growth and
development of the infant and family. The proposed five
core measures represent the first step in operationalizing
evidence-based developmental care.
The core measures
10
are as given below
1) Protected sleep
2) Pain and stress assessment and management
3) Activities of daily living (positioning, feeding and
skin care),
4) Family-centred care
5) The healing environment.
Each core measure set represents an organized group of
caring activities that relate to the holistic needs of the
infant-family dyad with context to the hospital experience.
Presenting care strategies in this format creates an
opportunity for neonatal care providers, to take the focus
off the care task and placing it on the care experience.
Core measure 1: Protected sleep
Protected sleep is the most important core measure
because it highlights the importance of behavioral
state; which is the foundation for all human activities.
It involves a totally undisturbed sleep state/phase,
in which the infant conserves energy, experiences
weight gain and has optimal brain growth.
The protocol should include specific interventions
that promote sleep
11
and educate families about the
importance of sleep in the hospital as well as post-
discharge at home.
12
Protected sleep core measures
Infant sleep-wake states will be assessed, documented,
and guide all infant care delivery and interactions.
13

All non-emergent care giving is provided during
wakeful states. Care strategies that support sleep are
individualized for each infant and documented.
14
Care giving activities that promote sleep (i.e. facilitative
tuck, swaddled bathing and skin-to-skin care) are
3
incorporated into the patients daily care plan. Light and
sound levels are maintained within the recommended
range. Cycled lighting is used to support nocturnal sleep.
Families are educated on the importance of sleep
safety in the hospital and the home. This education is
documented.
15
Core measure 2: Pain and stress assessment
and management
Working format and care giving practices specific to
pain and/or stress assessment and management include:
1) Routine assessment and documentation of pain
and stress with an established pain/stress tool.
16

Each infant is assessed for pain and/or stress at a
minimum of 4 to 6 hours interval.
2) Management of pain and stress before, during, and
following all painful procedures with subsequent
documentation of interventions and a return of the
infants pain scores to pre-procedural baseline.
17
Non-pharmacologic and / or pharmacologic
measures are utilized prior to all stressful and/or
painful procedures.
3) There should be sharing of the pain and stress
management care plan with parents.
18

Pain instrument (Scoring System) Age Range
CRIES (a)
Crying
Requires increased oxygen
Increased vital signs
Expression
Sleeplessness
Neonates from
32-60 weeks
Premature infant pain profile (PIPP)- (b) Tested in infants 27
Weeks to term
Neonatal infant pain scale (NIPS) - (c ) 28-38 weeks
a) Krechel SW, Bildner J. CRIES: A new neonatal postoperative pain
measurement score. Initial testing of validity and reliability.
Peddiatric Anaesthesia 1995; 5:53-61.
b) Stevens B, Johnston C, Petryshen P, Taddio A. Premature infant
pain profile: development and initial validation. The Clinical
Journal of Pain 1996;12:13-22.
c) Lawrence J, Alcock D, McGrath P, Kay J, MacMurray SB, Dulberg
V. The development of a tool to assess neonatal pain, Neonata;
Network. 1993:12:59-66
Core measure 3: Developmental activities of
daily living: positioning, feeding and skin care
Working format and care giving practices for positioning
include a dedication to ensure proper postural support
throughout the infants hospital stay, documentation
and role modelling of appropriate positioning practices
to parents and colleagues. Positioning: Infant positioning
is documented to provide comfort, safety, physiologic
stability and optimal neuromotor development.
19
Each
infant is positioned and handled in flexion, containment
and alignment during all care giving activities.
Distinct guidelines for feeding focus on the appropriate
use of non-nutritive sucking, employing infant feeding
cues as a measure of infant feeding readiness and
parental education and support of breastfeeding and
the use of breast milk.
20
Finally, care giving practices specific to skin care
highlight the importance of accurate assessment and
documentation of skin integrity and practices which
protect the vulnerable skin surface.
21
Skin integrity is
assessed using a reliable assessment tool at least once
per shift and documented. (Braden Q Scale or similar
tool). The skin surface is protected during application,
utilization and removal of adhesive products.
Assessment of Skin Integrity
Neonatal/Infant Braden Q Scale
Intensity and Duration of Pressure Score
General Physical
Condition
1. Gestational Age
28 weeks
2. Gestational Age >
28 weeks and 33
weeks
3. Gestational Age >33
weeks and 38 weeks
4. Gestational Age > 38
weeks
Mobility
The ability to
change and control
body position
1. Completely immobile:
Does not make even
slight changes in body
or extremity position due
to sedation or paralytic
medication.
2. Very Limited:
Makes occasional
slight changes in body
or extremity position.
3. Slightly Limited:
Makes frequent changes
in body or extremity
position, turns head,
limited extension/flexion
of extremities.
4. No Limitations: Makes
major and frequent changes
in position, moving all
extremities, turning head,
positive reflexes (reaching,
grasping, startle, etc.).
Activity
The degree of
physical activity
1. Bedfast: Confined to
bed, minimal shifting of
position. Limited position
choices due to condition
or equipment
2. Very Limited:
Tolerates position
changes, may be lifted
to reposition but is not
out of bed.
Tolerates frequent
position changes, can be
held and/or out of bed,
skin to skin care.
4. No Limitations:
Can be repositioned or held
freely.
Sensory Perception
The ability to
respond in a
developmentally
appropriate way to
pressure -related
discomfort
1. Completely
Limited: Unresponsive
to environmental or
tactile stimuli, due
to diminished level
of consciousness, or
sedation/ medication.
2. Very Limited:
Not tolerant of
environmental stimuli,
oversensitive to noise,
lights, & touch, easily
agitated, difficult to
calm.
Easily agitated but calms
with comfort measures.
Few self-calming
behaviors, occasionally
successful at self-
calming
4. No Impairment:
Age appropriate responses
to aversive stimuli, alert,
perceptive with successful
self-calming behaviors.
Overview, Evidence Base and Core Measures of DSC Chapter 1
4
Core measure 4: Family-centered care
The family-centered care core measure recognizes that
families must have
1) Access to their infant.
22
2) Assessment of their emotional and physical well-
being and their evolving competence and confidence
in parenting their infant.
23
Family is supported in
parenting activities to include skin-to-skin care,
holding, feeding activities, dressing, bathing,
diapering, singing and all infant care interactions.
Tolerance of the Skin and Supporting Structure Score
Moisture
Degree to which
skin is exposed to
moisture
1. Constantly Moist:
Skin is kept moist almost
constantly.
Dampness is detected
every time patient is
moved or turned.
1. 2. Very Moist:
Skin is often, but not
always moist. Linen
must be changed at
least every 8 hours.
Increased frequency
of output (stools or
urine).
2. 3. Occasionally Moist:
Skin is occasionally
moist, requiring linen
change every 12 hours.
3. 4. Rarely Moist:
Skin is usually dry, routine
diaper changes; linen only
requires changing every 24
hours.
Friction - Shear
Friction: occurs
when skin moves
against support
surfaces Shear:
occurs when skin
and adjacent bony
surface slide across
one another
1. Significant Problem:
Agitation leads to
almost constant friction
and vigorous rubbing
of head, knees or
extremities against bed
surfaces.
2. Problem:
Complete lifting
without sliding against
sheets is impossible,
fragile skin. Frequently
slides down in bed,
requiring frequent
repositioning.
3. Potential Problem:
During a move skin may
slide to some extent
against sheets but easily
repositioned. Maintains
relatively good position
in bed most of the time
but occasionally slides
down.
4. No Apparent Problem:
Able to completely lift patient
during a position change.
Maintains good position in
bed or chair at all times.
Nutrition
Usual food intake
pattern
1. Very Poor:
NPO and/or maintained
on clear liquids, or IVs
for more
than 5 days OR
Albumin <2.0 mg/dl
Never tolerate a
complete feeding and
losing weight.
2. Inadequate:
Is on tube feedings
or TPN which provide
inadequate calories
and nutrients for age
or
Trophic feeds
Tolerates partial feeds,
some emesis,
No weight gain or
losing weight.
3. Adequate:
Is on tube feedings
or TPN which provide
adequate calories and
nutrients for age
or
Tolerates P.O. feeds,
stable weight or weight
gain. 20gm/Kg/day.
4. Excellent:
Is on a normal diet providing
adequate calories for age.
All feeds taken orally,
consistent weight gain.
20gm/Kg/day < 2 kg weight
or 20 gm/day 2 kg
Tissue Perfusion
and Oxygenation
2. 1. Extremely
Compromised:
Hypotensive
(MAP <50mmHg; <40
in a newborn) When
position changed,
generalized edema.
High frequency/high
ventilatory requirements.
3. Compromised:
Normotensive but
compensated
4. extremities cool,
cardiac defects.
Oxygen saturation
may be <95 %; or
Hemoglobin maybe <
10 gm/dl; or
Capillary refill may be
> 3 seconds.
Serum pH is < 7.40.
Unstable body
temperature oxygen
requirement
4. 3. Adequate:
Normotensive by self or
compensated.
Oxygen saturation
may be <95 %; or
Hemoglobin maybe < 10
mg/dl; or
Capillary refill may be >
3 seconds.
Serum pH is normal,
stable body temperature,
possible oxygen
requirement.
4. Excellent:
Normotensive by self.
Oxygen saturation >95%;
Normal Hb; Capillary refill <
3 seconds,
Capillary refill < 3 seconds.
Stable body temperature and
no oxygen requirement.
Total Score: If < 20 : At significant Risk for Skin Breakdown
Minimum Score 8 Maximum Score 32
Scoring Pattern: Score <16 = High Risk 17-20 = Moderate Risk 21-24 = Mild Risk
1. Adapted The Neonatal Skin Risk Assessment Scale for Predicting Skin Breakdown in Neonates Huffines, B. & Logsdon, M. C., 1997 and
Predicting Pressure Ulcer Risk in Pediatric Patients The Braden Q Scale Curley MAQ, Razmus IS, Roberts KE, & Wypij D., 2003.
2. LAKEWOOD HEALTH SYSTEM; Barbara Braden and Nancy Bergstrom, 1988
3) Access to resources and supports that assist them in
their short and long term parenting needs
23.

Families are invited to participate in a neonatal intensive
care unit family support group. Culturally sensitive
family education on infant safety and infant care is
available in various formats. Resources for the social,
spiritual and financial needs of families are provided.
Core measure 5: The healing environment
The working format specific to the healing environment
5
include the physical, human and organizational elements
essential for a safe and healing hospital experience.
The care giving practices include
1) Measurement and maintenance of recommended
light and sound levels and assurance of physical and
auditory privacy with a quiet, dimly lit environment.
24

Continuous background sound and transient sound
in the neonatal intensive care unit shall not exceed
an hourly continuous noise level of 45 to 50 decibels
(dB). Transient sounds or Lmax (the single highest
sound level) shall not exceed 65 dB.
Ambient light levels ranging between 10600 lux and
160 foot candles shall be adjustable and measured
at each infant bed space
2) Promotion of effective communication, collaboration,
and caring behaviors among the healthcare team.
25
Direct care providers demonstrate caring behaviors
which include adherence to hand hygiene protocols,
cultural sensitivity, open listening skills and a
sensitive relationship orientation. Nurse-physician
collaboration is defined, practiced, and reinforced
on a daily basis
3) Documentation of evidence-based policies, procedures
and resources to sustain the healing environment over
time.
26
A system for staff accountability in the practice
of developmental care as outlined by the core
measures is operational. Resources to support the
implementation of developmental care as defined by
the core measures should always available.
References
1. Assisted Ventilation of the NEONATE 5th Edition; year 2011;
Jay P. Goldsmith, MD; Edward H. Karotkin, MD; Chapter
1- Introduction to Assisted Ventilation, Jay P. Goldsmith;
Edward H. Karotkin; page 1.
2. May 2012, WHO and partners The Partnership for
Maternal, Newborn & Child Health, Save the Children
and the March of Dimes Foundation (USA) published
a report Born too soon: the global action report on
estimates of preterm birth globally.
3. Liaw, Yang, Yuh, & Yin, 2006; Peters, 1998.
4. Als, 1999; Holditch-Davis, Blackburn, & Vandenberg, 2003.
5. Als 1982, Als et al. 1988a, 1988b.
6. Vanderberg, 2007; Volpe, 1995 as cited by Legendre,
Burtner, Martinez, & Crowe, 2011.
7. Symington & Pinelli, 2009, Cochrane Collaborative.
8. Manual of Neonatal Care; Cloherty, Eichenwald, & Hansen,
2012
9. Systematic Review of DSC; Symington & Pinelli, 2009,
aspects of DSC
10. Coughlin, Gibbins, & Hoath, 2009
11. Feldman et al. 2002, Schmidt 2004, Ludington-Hoe et al.
2006
12. Task Force on Sudden Infant Death Syndrome 2005,
Ludington-Hoe et al. 2006
13. Holditch-Davis et al. 2003, Grigg-Damberger et al. 2007
14. Feldman et al. 2002, Schmidt 2004, Ludington-Hoe et al.
2006, White 2007
15. Task Force on Sudden Infant Death Syndrome 2005,
Ludington-Hoe et al. 2006
16. Stevens & Gibbins 2002, Anand et al. 2006
17. Anand et al. 2006, Sharek et al. 2006
18. Franck et al. 2001, 2004
19. Sweeney & Gutierrez 2002, Vaivre-Douret et al. 2004,
Chizawsky & Scott-Findlay 2005
20. McCain 2003, Pinelli & Symington 2005, Ludwig &
Waitzman 2007
21. Lund et al. 2001, Curley et al. 2003
22. Johnson et al. 2004, Nibert & Ondrejka 2005
23. Doucette & Pinelli 2004, Kaaresen et al. 2006
24. Brown et al. 2003, Ohlinger et al. 2003, Schmidt 2004
25.
.
Johnson et al. 2004, White 2007
26. Lafferty 2004, Schmidt 2004
Overview, Evidence Base and Core Measures of DSC Chapter 1
6
Development of Various Neonatal Sensory
Systems and their Implications for Interventions of
Developmentally Supportive Care
Aditya Dixit MD, Rakesh Tiwari MD
Maturation of all the sensory systems begins during
the latter part of embryogenesis. However, this process
is not fixed and to some extent, sensory inputs drive
the maturation. Furthermore, the rate of maturation of
various sensory modalities varies. The usual sequence
is as follows: tactile, vestibular, gustatory-olfactory,
auditory and then visual. Hence while carrying out
developmental interventions in the NICU, stimulation of
the senses should begin with the most mature.
Tactile system
Neuroanatomy
Receptors in the skin respond to pressure and then
transmit impulses to the spinal cord through the dorsal
root, ascending in the posterior tract and terminating
in the gray matter of the cord. At this point, connecting
fibres decussate and continue in the ventral spinothalamic
tract to the medulla and thalamus, terminating in the
post-central gyrus.
Development
Receptor cells are present in the perioral region by 8
weeks of gestation and spread to all skin and mucosal
surfaces by 20 weeks. Cortical pathway is intact by 20 24
weeks. Tactile threshold is very low in preterm infants. It
has been demonstrated that preterm infants less than 30
weeks respond with leg withdrawal to a plantar pressure
stimulus at pressures almost one-third as compared to
same response in a term infant. At about 32 weeks PCA,
a qualitative shift in response occurs. Infants less than
32 weeks respond to repeated stimulation with a diffuse
behavioural response. In contrast, infants > 32 weeks
show habituation to the same stimuli.
Disturbances
Tactile hypersensitivity is commonly encountered in
children born preterm. It is said to be a manifestation
of sensory integration deficit during the prenatal and
perinatal period. It appears as infants overreaction to
touch, generally the hands or oro-facial regions. The
infant may withdraw, retch or gag in response to touch
stimulus around the oral area. Some infants may show
intolerance of food with texture and resist transition from
liquids. Infants may also be hypersensitive to touch on
their extremities, with prolonged palmar-mental reflex,
exaggerated hand and toe grasp, or leg withdrawal.
Intrauterine experiences
Intrauterine fetal movements provide tactile self
stimulation. As term approaches and intrauterine space
becomes more constraining, the normal posture of
flexion evokes hand to mouth, skin to skin, and body
on body tactile feedback. The effect is progressive
throughout gestation.
Touch and handling in NICU
After a premature birth, tactile input is radically
altered. The type and frequency of tactile stimulation
imposed on a preterm neonate in the NICU may be
overwhelming. During a 2 week period, a sick neonate
may be handled by more than 10 nurses, in addition
to physicians, occupational therapists, x-ray technicians
and finally the parents.
Handling occurs more often among the sickest infants,
typically is related to procedures, generally is disturbing
and is often painful. On an average, sick preterm
neonates are handled more than 50 times a day with
less than 20 minutes of consecutive uninterrupted rest.
Disturbance of sleep has biologic and immunologic
consequences. Secretion of cortisol and adrenaline
normally is inhibited during sleep. Growth hormone,
which is released during quiet sleep, increases protein
synthesis and mobilization of free fatty acids for energy
use. Thus sleep facilitates healing.
Excess handling can lead to blood pressure changes
and alterations in cerebral blood flow leading to
desaturation episodes and in extreme cases, even
intracranial haemorrhages in unstable preterm neonate.
Even more benign manipulations, such as those that
occur during neurodevelopmental assessment, also may
adversely affect the preterm infant. Decreased plasma
Growth hormone levels have been reported after
administration of the Brazelton Neonatal Behavioural
Assessment Scale to preterm infants at 36 weeks
PCA. Thus, handling could be stressful even for stable
preterm infants.
Tactile interventions in the NICU
Two general approaches are used Reduction in general
handling and Provision of planned tactile experiences.
The general order of tactile intervention might be:
If acutely ill minimal handling, containment (e.g.
Swaddling), and gentle touch without stroking
When medically stable and near term holding, rocking
gently, stroking, continue to swaddle
Non-nutritive sucking
Non-nutritive sucking is an important oral-tactile
intervention that supports both feeding and early
2
Chapter
7
behavioural regulation. It represents an early endogenous
rhythm and a manifestation of sensorimotor integration.
Non-nutritive sucking facilitates important physiologic
and behavioural mechanisms and potentially reduce
cost of care. Infants provided with non-nutritive sucking
during gavage feeding showed significantly improved
gastrointestinal transit time, greater suck pressure, more
sucks per burst and fewer sporadic sucks. Non-nutritive
sucking has been shown to decrease motor activity and
increase quiet states in stable preterm infants. Also,
it dampens an infants behavioural response after a
painful stimulus.
Vestibular system
The vestibular system is situated in the non-auditory
labyrinth of the inner ear. It responds to movements
as well as directional changes in gravity. The three
fluid-filled semicircular canals, one for each major
plane of the body, lie at right angles to each other. The
ampulla, located at the end of each canal, contains hair
fibres in a sac, or cupula. Motion of the body or head
causes pressure changes that move the cupula, which
stimulates the hair cells and transmits an impulse along
the vestibular portion of the eighth cranial nerve to
the vestibular nuclei of the medulla and cerebellum.
From there, information is transmitted to motor fibres
going to the neck, eye, trunk and limb muscles. There
are no connections to the cortex. Vestibular stimulation
affects levels of alertness. Slow, rhythmic, continuous
movement induces sleep. Periodic or higher amplitude
swings increase arousal.
Development
The three semicircular canals begin to form before 8
weeks of gestation, reaching morphological maturity
by 14 weeks, and full size by 20 weeks. Response to
vestibular stimulation has been observed by 25 weeks
of gestation. The traditional vertex presentation of the
fetus at term gestation is thought to occur from fetal
activity in response to vestibular input.
Disturbances
Lack of normal vestibular stimulation in the developing
organism is thought to affect general neurobehavioral
organization. Children who were born preterm are
reported to have deficits in balance at preschool age.
Intrauterine experience
The fetus experiences both contingent and
noncontingent vestibular stimulation that varies during
gestation.From the beginning of embryonic life, the fluid
environment of the womb provides periodic oscillations
and movements that emanate from normal movements
of the mother as well as activity of the fetus itself.
Reports by mothers of fetal movement occur around 16
weeks. After 28 weeks of gestation, there is a decrease
in the relative amount of amniotic fluid, and, thus, the
movement of the fetus becomes partially constrained by
the more limited physical space. Vestibular experience is
then less contingent on self-activation and more related
to normal maternal activity and position change, which
often occurs in response to fetal activity. In general,
maternal activity level slows as parturition approaches.
After birth, the infant is held normally. Movement is
slow from maternal breathing and shifting. Change
of position is gradual, even by experienced parents.
Vestibular stimulation is used to affect statemoving to
upright or laying down increases arousal; monotonous
side-to-side rocking and walking in the form of parental
pacing reduce the level of arousal.
Vestibular experience in the eeonatal intensive
Care unit
Vestibular stimulation after preterm birth is limited to
efficient manipulation or turning of the neonate by the
caregiver. It clearly lacks any of the temporal qualities
or contingencies that the maternal environment may
have provided. Spontaneous limb movement generally
is diffuse, often unrestricted, and typically disorganizing
in its effect.
Intervention in the neonatal intensive care unit
Like the tactile sense, the early development of the
vestibular system provides a theoretical basis for
primary intervention with preterm neonates. More
than 3 decades ago, Neal demonstrated that daily
rocking facilitated the development of preterm infants.
Subsequent research simulated the intrauterine
environment and provided compensatory vestibular
stimulation. An oscillating waterbed was devised, which
moved with the rhythm of maternal respirations but
with an amplitude of less than 2.5 mm at the surface of
the unoccupied waterbed. The safety of this paradigm,
as well as efficacy in reduction in apnea of prematurity,
has been well demonstrated. In addition, the infants on
waterbeds demonstrated more organized sleep state
and motor behavior, decreased irritability, enhanced
visual alertness, and improved somatic growth. Other
sources of vestibular stimulation, such as rocking chairs,
swings, and hammocks, have not been investigated
formally. Rocking chairs probably belong in any nursery.
Swings are questionable, given the excessive upright
position of the baby and the standard rate of oscillation
(i.e., too fast).
Positioning
The physical position of an infant is part of the NICU
tactile-vestibular experience. Nursing sick preterm
infants routinely has been with the infant in the supine
position and exposed, which may simplify management
but may not be advantageous for the infant. Prone
positioning in the NICU has been strongly supported
physiologically. The current NICU dilemma is that the
prone sleep position is contrary to the recommendation
by the American Academy of Pediatrics (AAP), which now
supports supine positioning because epidemiologic data
associate supine positioning with a lower rate of sudden
infant death syndrome.. It has been demonstrated that
Development of Various Neonatal Sensory Systems and their Implications for Interventions of Developmentally Supportive Care Chapter 2
8
gastric emptying was facilitated in either the prone or
right lateral position compared to the supine or left
lateral position. This was particularly significant for
the sick preterm who already showed a delay in gastric
emptying. The prone position, compared to supine, is
associated with more quiet sleep and less active sleep or
crying. Quiet sleep, in turn, is associated with improved
lung volume, more stable respiration, less apnea, and
improved PAO2 . Finally, the prone position compared
to supine is associated with a higher PAO2 among
healthy preterm infants and, even more significantly, in
those with respiratory distress syndrome. The evidence
suggests that, when possible, the sick infant should be
nursed in a prone or right lateral position. In the prone
position, placing the infant on a small folded strip from
shoulder to hip, could allow more physiologic flexion and
adduction. In side lying, it may be easier to position the
infant in soft flexion. Gentle containment of the limbs
usually can be managed with strips of soft cloth across
the upper arm and thigh. Some movement should be
allowed within a controlled range. Each posture should
facilitate the infant bringing hands to mouth
Kangaroo care
Kangaroo care is a technique that evolved primarily in
South America . Traditionally, the infant is clad only in a
diaper and placed under the mothers clothing between
her breasts, remaining there according to the mothers
comfort, and feeding on demand. The technique
provides fairly sustained multimodal stimulation: tactile,
vestibular, proprioceptive, olfactory, and auditory. It
appears to be safe for larger preterm infants or those
who are medically stable. Temperature regulation in the
infant does not appear to be a problem, but needs to
be carefully monitored on an individual basis. It seems
to have the greatest benefit in terms of facilitating and
maintaining lactation and enhancing maternal sense of
competency for these infants. More data are needed
among medically stable infants before kangaroo care
should be attempted prior to 32 weeks conceptional
age or with infants requiring mechanical ventilation.
Suggested readings
1. Kuhn CM, Schanberg SM, Field T, et al. Tactile-
kinesthetic stimulation effects on sympathetic and
adrenocortical function in preterm infants. J Pediatr
1991;119:434.
2. Als H, Lawhon G, Brown E, et al. Individualized
behavioral and environmental care for the very-
low-birthweight preterm infant at high risk for
bronchopulmonary dysplasia: neonatal intensive
care unit and developmental outcome. Pediatrics
1986;78:1123.
3. Jay S. The effects of gentle human touch on
mechanically ventilated very short gestation infants.
Ph.D.Thesis, University of Pittsburgh, Pittsburgh, PA,
1982.
4. Field TM, Schanberg SM, Scafidi F, et al. Tactile/
kinesthetic stimulation effects on preterm neonates.
Pediatrics 1986;77:654.
5. Harrison LL, Leeper JD, Yoon M. Effects of early parent
touch on preterm infants heart rates and arterial
oxygen saturation levels. J Adv Nurs 1990;15:877.
6. Hack M, Estabecek M, Robertson S. Development of
sucking rhythm in preterm infants. Early Hum Dev
1985;11:133.
7. Bernbaum JC, Pereira GR, Watkins JB, et al.
Nonnutritive sucking during gavage feeding
enhances growth and maturation in premature
infants. Pediatrics 1983;71:41.
8. Field T, Ignatoff E, Stringer S, et al. Nonnutritive
sucking during tube feedings: effects on preterm
neonates in an intensive care unit. Pediatrics
1982;70:381.
9. Woodson R, Hamilton C. Effects of nonnutritive
sucking on heart rate in pre-term infants. Dev
Psychobiol 1988;21(3):207213.
10. Field T, Goldson E. Pacifying effects of nonnutritive
sucking on term and preterm neonates during
heelstick procedures. Pediatrics 1984;74:1012.
11. Cordero L, Clark DL, Schott L. Effects of vestibular
stimulation on sleep states in premature infants. Am
J Perinatol 1986;3:319.
12. Anderson GC. Current knowledge about skin-skin
(kangaroo) care for preterm infants. J Perinatol
1991;11:216.
Gustatory olfactory
Neuro anatomy
The sensation of taste is through the taste receptors
found in the taste buds located in the papillae of
the tongue, soft palate and epiglottis. Brain stem,
hypothalamus and cerebral cortex play a role in
discerning taste stimuli.
Olfactory receptors are present in the posterior part
of nasal epithelium. Limbic system is responsible for
discerning olfactory stimuli.
Gustatory experiences are related to olfaction. Olfaction
also plays important role in infant attachment to care giver.
Development: The taste buds appear around 8 to 9
weeks and the taste receptors are present by 16 weeks.
Morphological changes continue in 2ndtrimester.
Preterm infants (30 to 36 weeks) show stronger sucking
response to glucose. Stimulation of taste receptors has
important implication for early feeding and behavioural
regulation.
The olfactory system differentiates very early in
gestation. Information about the functional onset of
human olfaction is scant but 1 week old infant will
reliably turn their heads away from noxious smell and
they prefer the odour of their mothers breast pad. It
has been observed that by 28 to 32 weeks gestation
majority of new-borns show response to olfactory input.
Disturbance: Due to frequent stressful procedures and
poor coordination of suck and swallow, infant respond
9
negatively to the introduction of food in the mouth.
Moreover in preterm infants there is marked alteration
of the oro-gustatory environment.
Intrauterine experience: The amniotic fluid is a complex
solution of suspended particulate and dissolved
odorants that keep changing in response to maternal
hormonal changes and diet.
Experience in NICU: The chemical composition of
breast milk is different from the amniotic fluid. Further
variability is brought out by changes in formula
composition, concentration and temperature. Moreover
addition of oral medications and supplements may
lead to averse conditioning associated with negative
experiences.
Intervention in NICU: Familiarising the neonate with
the odour of breast milk can facilitate the feeding.
Placing mothers breast pad nearby or putting a small
drop of breast milk on the tongue tip or lips helps. This
also ensures that the gut priming does not bypass the
mouth entirely.
The oro-gastric stimulation also leads to activation of
endogenous opioid system, raising the threshold to
noxious tactile stimuli. On the contrary repeated use
of this pathway may have negative repercussions on
feeding behaviour of some neonates.
Auditory
Neuroanatomy: Peripheral component consist of
auditory canal, tympanic membrane, ossicles, oval
window, cochlea with its fluid and hair cells. The sound
waves travel from the auditory canal to hair cells which
generate neural impulse to the auditory cortex in the
temporal region.
The absence of auditory stimulation would cause
cortical neuronal degeneration.
Development: The development of the auditory system
begins around 3 to 6 weeks of gestation. By 25 weeks of
gestation the major structures of ear are in place.
Both cortical auditory evoked responses and brain stem
auditory evoked responses can be elicited by 25 to 28
weeks. The wave morphology is different from the full
term infants and the latency is prolonged.
The maturation of the foetal auditory system is marked
by an increase in spectral sensitivity, in both lower and
higher frequencies and a decrease in auditory threshold.
Research shows that 2 to 4 days old neonates prefer
their mothers voice.
Disturbance: Preterm infants are at increased risk for
sensori-neural hearing loss and developmental language
disorders. Language disorder may be receptive or
expressive dysfunction. Receptive language disorders
are referred to as auditory processing deficits.
Intrauterine experience: The foetus is exposed to
sound predominantly from the mother in form of
respiration, borborygmi, placental and heart rhythms,
maternal speech. The intensity of sounds in amniotic
fluid is 70 to 85 dB with predominance of low frequency.
The available frequencies in utero also parallel cochlear
development.
Experience in NICU: Acoustic environment in NICU
differs in peak intensity, spectral characteristics and
pattern. Ambient noise is generated by motors, fans,
ventilators equipment, personnel, telephones, alarms,
carts etc. The intensity of background is around 50 to
60 dB. The auditory environment varies in incubators
as compared to open beds. These aberrant noise
levels cause sensory neural damage, induce stress and
contribute to language or auditory processing disorders.
More severely ill neonates are exposed to increased noise
and ototoxic drugs. Loud noise also leads to alteration
in corticosteroid levels, autonomic changes and sleep
disruption.
Intervention in NICU: Strive to reduce ambient noise
and also induce patterned auditory input. Quiet times,
occluding the infants ears for short term only might be
beneficial during acute phase of illness.
Visual
Neuroanatomy: Light is transmitted through the
cornea, pupil, lens and optic media to the retina. The
photoreceptors i.e. rods and cones absorb the light and
convert it to an electric impulse. This impulse travels
to the ganglion cells, the optic nerve and through
the lateral geniculate nucleus to the occipital cortex.
Information from either the left or right visual field will
fall on the contralateral portion of each retina and be
transmitted to the same hemisphere of the brain.
Development: By 24 weeks of gestation gross
anatomic structures are in place and the visual pathway
is complete. Between 24 to 40 weeks the visual system
undergoes extensive maturation and differentiation. As
early as 24 weeks to 28 weeks, a visual evoked response
to bright light can be obtained and there is lid tightening
behavioural response.
Around 32 weeks, visual evoked response becomes
more complex and the pupillary reflex is more efficient.
A bright light will cause immediate lid closure and
the response is sustained. There is beginning of
attention and the neonate briefly fixates. New-born are
photophobic, visual attention is facilitated under low
illumination. Neonates can fixate on a high contrast
form i.e. 1/16 inch line at a distance of 1 foot; they have
preference for human face.
Disturbance: Visual system of the preterm infant
is susceptible to retinopathy of prematurity (ROP),
thicker lenses, poorer visual acuity, higher incidence of
astigmatism, high myopia, strabismus, anisometropia
and colour deficits. Risk for visual disorders is increasingly
related to gestational age. In addition the preterm
Chapter 2 Development of Various Neonatal Sensory Systems and their Implications for Interventions of Developmentally Supportive Care
10
infant also has difficulty processing visual information
at a more cognitive level.
Intrauterine experience: The womb generally is dark
but small amounts of red or long wavelength light can
be transmitted to the foetus. Aspects of light dark cycle
that reach the foetus are mediated more by maternal
sources such as rest activity cycles and hormones of the
mother than by light directly.
Experience in NICU: After birth ambient light increases
markedly as modern NICU are brightly lit environments.
The intensity is dependent upon location of crib, the
number of overhead light units, windows, season of the
year. The light exposure is greater for most vulnerable
to visual problems and may be even for 24 hours a day.
Supplementary source such as phototherapy, heat lamps
and indirect ophthalmoscope add to the exposure.
Bright light in an infants face is a source of stress. Lower
ambient light is associated with significantly less active
rapid eye movement and quiet sleep state. New-born
also have increased eye opening and awake periods in
lower ambient light.
Intervention in NICU: Limit the ambient light to
necessary levels and shield the eyes from supplementary
sources. Prolonged patching beyond what is necessary
may be detrimental, both in terms of stimulus deprivation
and effects on corneal growth. Opportunities for
spontaneous eye opening under dim oe dark conditions
should be provided. Animal studies suggest that dim
dark cycling may be beneficial for regeneration after
retinal damage. A day night cycling regimen in the
intermediate care nursery before hospital discharge
affects behaviour and improves sleep pattern.
Suggested reading
1. White RD. Recommended standards for the newborn
ICU.J Perinatol 2007; 27 (Suppl.2),S4-S19
2. Chermont AG,Falco L F, de Souza Silva EH, et al.
Skin to skin contact and/or oral 25% dextrose for
procedural pain relief for term newborn infants.
Pediatrics2009; 124: e1101-e1107.
3. GrayL, Philbin MK. Effects of the neonatal intensive
care unit on auditory attention and distraction.
ClinPerinatol2004;31: 243-260.
4. LongJ,Lucey J, Philip A. Sound level in NICU. Pediatrics
1980; 65:143-145.
5. Bradley RM, Mistretta CM. Fetal sensory receptors.
Physiol Rev 1975;55:352.
6. Mistretta CM, Bradley RM. Development of the sense
of taste. In: Blass EM, ed. Handbook of behavioural
neurobiology. Vol. 8: Developmental psychobiology
and developmentalneurobiology. New York:
PlenumPress, 1986:205.
7. Porter RH, Balogh RD, Makin JW. Olfactory influences
on mother-infant interaction. In: Rovee-Collier C,
Lipsitt LP, eds. Advances in infancy research. Camden,
NJ: Ablex, 1988:39.
8. Smotherman WP, Robinson SR. Milk as the proximal
mechanism for behavioral change in the newborn.
ActaPaediatrSuppl1994;397:64.
9. Blass EM, HoffmeyerLB. Sucrose as an analgesic for
newborn infants. Pediatrics1991;87:215.
10.Barr RG, Quek VS, Cousineau D, et al. Effects of intra-
oral sucrose on crying, mouthing and hand-mouth
contact in newborn and six-week-old infants. Dev
Med Child Neurol1994;36:608.
11.Aslin RN, Pisoni DB, Jusczyk PW. Auditory
development and speech perception in infancy. In:
MussenPH,ed. Handbook of child psychology, vol. II,
2nd ed. New York: John Wiley and Sons, 1983:573.
12.Birnholz JC, Benacerraf BR. The development of
human fetal hearing. Science1983; 222:516.
13.Dubowitz LM, Dubowitz V, Morante A, et al. Visual
function in the preterm and fulltermnewborn infant.
Dev Med Child Neurol1980;22:465.
14.Miranda SB. Visual abilities and pattern preferences
of premature infants and full-term neonates. J
ExpChild Psychol1970; 10: 189.
15.Mann NP, Haddow R, Stokes L, et al. Effect of night
and day on preterm infants in a newborn nursery:
randomised trial. BMJ 1986; 293:1265.
11
Neuromotor Maturation and Stages of
Neurobehavioral Organization of the Preterm and
High Risk Infant
Amitava Sengupta

Fellowship Neonatology (Neth)
S P Senthil Kumar

M D (PAED), Fellowship Pediatric Critical Care
AUTONOMIC Stage1: Turning-In
(<28weeks Gestational Age)
Stage 2: Coming-Out (29-
34weeks Gestational Age)
Stage 3:Interacting (reciprocity)
(35-40 weeks Gestational Age)
FLUCTUATIONS in
HR, RR, and O2
requirements with
any stimuli
MORE LESS STABLE
light touch, noise,
bright light
over stimulates over stimulates over stimulates
beginning of spontaneous
arousal
beginning of spontaneous arousal
stress signs autonomic instability,
decreased feed tolerance, color
changes
change in color, spitting up,
hiccoughs
gas/bowel movement, sneeze/
cough
Neuromotor maturation process of the preterm, fragile
or sick infant covers the infants active movement,
resting posture, muscle tone, reflexes and/or behavioral
responses. There are certain known variables that can
affect the above mentioned factors of the infant. These
include:
1) Infants gestational age (G.A.) at birth
2) Infants current gestational age
3) Timing of evaluation
4) Events prior to or leading up to assessment
5) Current and any significant past medical issues
6) Current medications
The sick newborn, the premature infant and the fragile
infant move very differently than the healthy, full-
term infant. All infants who are born prematurely will
miss an important inter-uterine motor milestone: the
development of flexor tone. This critical component
of muscle development occurs throughout the third
trimester of pregnancy.
26 to 28 weeks Gestational Age- Extension
34 to 36 Weeks Gestational Age - Flexion
During the first two trimesters, extensor tone becomes
well established as an infant develops his extensor
muscles along the back of his body. As the fetus grows
larger and more cramped during months 7, 8, and 9,
the muscles used for flexion, (muscles along the front
of the body) develop. When born with the disadvantage
of missing this crucial milestone, a premature infant will
have differences in both their muscle tone and posture
once born.
Normal motor development occurs in a sequential
pattern. Prior to 40 weeks gestation, whether in
utero or outside the womb, an infants muscle tone
development progresses in a caudo-cephalic (toe to
head) and centripetal (distal to proximal) direction.
At 40 weeks Post- Conceptual Age (PCA), the infants
actual due date, an infants motor development reverses
and begins to progress in the opposite direction in a
cephalo-caudal (head to toe) and proximal to distal
(from the middle of the body out) direction. The same
development pattern found in a normal term infant.
Stages of behavioral organization in
Preterm infants
Stage 1 is known as the In-Turning Stage. It is typically
seen under 28 weeks gestational age or at any age of a
very sick infant and is characterized by autonomic and
physiologic instability.
Stage 2 is known as the Coming-Out stage. It is
typically seen in 29 to 34 weeks gestational age or at
any age of a very sick infant and is characterized by the
beginning of response.
Stage 3 is known as the Interacting (reciprocity) stage
with It is typically seen in 35-40 weeks gestational age
and is characterized by mature responses.
3
Chapter
12
MOTOR Completely hypotonic
Movements are mostly jerky
and twitches
Needs help to keep in flexed
position
Beginning control of
movements of arms and legs,
Hips and knees begin to show
some flexion, arms extended
Needs NESTING to keep limbs
in FLEXION
Beginning control of movements of
arms and legs,
Resting position strong flexor tone
if healthy and full term
STRESS signs Change in muscle tone.
Flaccidity to increased tone
with stiff extension, flailing,
jerky movements
Stiff arms and legs, arching,
finger or toe splaying, turns
head away, flailing, tremors
SLEEP 20-22 Hrs/day
Needs quiet and low lights to
protect from overstimulation
Beginning to come to a calm
awake state for short periods
Needs quiet and low lights
during day and lights off at
night

Sleep 17-20 hrs/day
Awakens and maintain an alert
state for 10-20 min. several times
Can stay alert during activities such
as feeding
Needs quiet and low lights during
day and lights off at night
Do not disturb sleep! Brain and body grows during deep sleep
TOUCH Minimal handling to prevent
overstimulation
Can begin NESTING possibly
just with nest to help flex
Any touch should be steady
and firm, not light
To KMC-responds well
Provide blanket supports and
nest for proper positioning
Any touch should be steady and
firm, not light
To KMC-responds well
Provide blanket supports and nest
for proper positioning
Swaddle in crib/home
SENSES Stage1: Turning-In
(<28weeks Gestational Age)
Stage 2: Coming-Out (29-
34weeks Gestational Age)
Stage 3:Interacting (reciprocity)
(35-40 weeks Gestational Age)
Opens eyes but eyes are very
sensitive
AVOID ANY BRIGHT LIGHT
Vulnerable to sensori-neural
hearing loss
Keep NICU quiet
Can have a cloth from mother
s skin to familiarize with her
scent
Opens eyes when lights are low
AVOID ANY BRIGHT LIGHT
Baby can see 6-8 inches away,
not ready for visual stimulation
Noise may cause baby to shut
down
Keep NICU quiet
Begins to recognize mother
Can have a cloth from mothers
skin to familiarize with her
scent
Shield eyes from bright light
Baby can see 6-8 inches away,
Visual gaze: initially looks away
then fixates for about 15 sec
Keep NICU quiet, speak softly to
baby
Recognizes mother
FEEDING Not ready
No pacifier/dextrose
NNS,
NG feeding
NOT READY FOR ORAL
FEEDING
Feed orally
Breastfeed/palada feeds
Co-ordination of suck, swallow and breathing comes at around 34 weeks
SOCIAL/
EMOTIONAL
Knows when someone is close
Always touch or speak softly
prior to beginning care or
procedure
Knows when someone is close
Always touch or speak softly
prior to beginning care or
procedure
Learning to self calm by
bringing hands to mouth and
to face
Ready to be held and spoken
to when awake Self calming
behaviors: Brings hands to mouth
and to face, grasps your finger,
holds feet together, sucks fingers
or a pacifier Enjoys looking at
peoples face Always touch or
speak softly prior to beginning care
or procedure
REFLEXES no reflexes or cry as yet Begins at 32 weeks Reflexes mature
Organized and Presented by Dr. Senthil Kumar, 2013 Evidence Base: Fern, 2011; Gorski, Davison, & Brazelton, 1979; Staff of The Childrens
Hospital Denver, Colorado, 1989
13
Neuromotor
Development
Stage1: Turning-In
(<28weeks GA)
Stage 2: Coming-Out
(29- 34weeks GA)
Stage 3: Interacting with
(35-40 weeks GA)
Tone
&
Movement
-Completely hypotonic
-Movements are mostly
jerky and twitches
-More whole limb
movements
**Needs support for flexed
position
-Beginning control of
movements of legs first
and then arms.
-Hips and knees begin to
show some flexion
-Arms still extended
**Needs support to keep
in flexion position
-Beginning control of movements
of arms and legs
-Resting position strong flexor
tone if healthy and full term
**Needs Support to keep limbs
in flexion position
Motor Stress
Behaviors
- Change in muscle tone
- Flaccidity to increased
tone with stiff extension,
- Flailing, jerky movements
- Stiff arms and legs -
Arching
- Finger /toe splaying
- Turns head away -
Flailing, tremors
- Stiff arms and legs, - Arching
- Finger /toe splaying
- Turns head away
- Flailing, tremors
Positioning an infant with appropriate support of his
motor system is one of the easiest ways to have an
immediate motor development.
Supportive positioning is a simple, unobtrusive
intervention strategy easily used in conjunction with
the state of the art medical equipment found in our
NICU. It can be used effectively even in most medically
fragile infants. If kept with inadequate or inappropriate
positional support, the premature, convalescing and/or
sick infants typical resting posture, inherent low muscle
tone and abnormal movement patterns may lead to a
variety of developmental disadvantages.
Neuromotor Maturation and Stages of Neurobehavioral Organization of the Preterm and High Risk Infant Chapter 3
14
Principles and Practices of Developmentally
Supportive Care
Amy Carroll OTD
Introduction
This chapter provides a brief background about the
foundations and key concepts related to DSC, as well
as, an introduction to DSC practices and principles:
Identification of preterm stress and self-regulatory
behaviors
basic practices to manage stress and pain
developmentally supportive care and handling
guidelines
positioning principles
**Discussion of customized sensory stimulation and
specific developmental sensory interventions beyond
what occurs through more typical care giving of medical
staff and parents (as appropriate- i.e. Kangaroo Care)
are beyond the scope of this workshop and require
further study on the part of a provider.
Background
Developmentally supportive care (DSC) practices are
evidence-based interventions that promote newborn
brain and neurobehavioral development
1,2,3
In the 1970s
and early 1980s researchers (Als, Lester, & Brazelton,
1982; and Gorski, Davison, & Brazelton, 1979)helped
establish a knowledge base about the development of
behavioral states, also called sleep states or state of
arousal, in preterm and newborn infants. The authors
also identified stress and self-regulatory (self-calming)
behaviors of the infants.States, stress behaviors, and
self-regulatory behaviors are neuro-behaviors described
by several more contemporary authors. Many of the
behaviors are included in the Manual of Neonatal Care
(Cloherty)
4
as well.
Theoretical foundations
Based on this knowledge base, several theoretical
frameworks have been created.
5
The Synactive Theory
is one such model that is a commonly cited theoretical
base for DSC. Synactive theory was first applied to the
population of preterm infants by Als, Lester, & Brazelton
in 1979
5
. A central feature of synactive theory is the
focus on the neurobehavioral capacity of the infant as
the baby develops. The babys neurobehavioral capacity
develops through interactions with caregivers and the
environment [i.e. sensory, medical, and care giving
experiences in the NICU]
5
Neurobehavioral capacity
Neurobehavioral capacity is evidenced through
observation of the infant. Specific behaviors reflect
neurobehavioral organization (i.e. calm state) or
disorganization (stress with reduced capacity to self-
calm).
5
The neuro-behaviors are classified across five
subsystems:
autonomic/physiologic
motor
attention/interaction
state (of arousal)
self-regulatory
Preterm, and often sick or fragile term, infants are in
a developmental process of differentiation of these
subsystems
5
. Early preterm babies display diffuse states
of arousal that are not so easy to isolate from each other.
As they mature, the babies demonstrate more defined
arousal states, and more defined stress responses. They
also increase their ability to self-regulate (self-calm).
Without caregiver support, these infants may display
overactive, prolonged, or absent stress responses to
experiences. This would be reflective of their limited
ability to self-regulate their behavior and return to a
stable, calm state.
Developing the neurobehavioral capacity for self-regulation
is a very important skill that allows infants to engage in
the developmental and daily activities that support growth
and development.
5.
Some of these activities
5
:
feeding and making nourishment needs known
seeking comfort
family bonding
early social interaction
seeking opportunities to explore
beginning attention skills.
***note: Preterm infants are also in a process of physical
and sensory development which were discussed in
Chapter 2 and 3.
Developmentally supportive care
Developmental care interventions support newborn brain
and neurobehavioral development
1,2,3.
Individualized,
developmental care begins with caregiver observation
and response to the infants individual stress cues
and self-regulatory (calming) behaviors
4
. Caregivers
respond to the behaviors in ways that help reduce
stress and promote behavioral/state regulation.
4
In this
manner caregivers support the babys neurobehavioral
organization and development.
Definitions
State: also described as state of arousal, sleep state, or
behavioral state; referring to a state of responsiveness
to sensory stimulation or excitability.
6
States associated
4
Chapter
15
with neurobehavior in infants include: deep sleep, light
sleep, drowsy, quiet alert, active alert, & crying
5

Neurobehavioral organization: is the ability to maintain
balance among the 5 subsystems of neurobehavioral
development (autonomic, motor, state, attention/
interaction, self-regulatory) thus allowing the infant to
manage sensory and postural experiences or demands
that support their development. This can be noted by a
calm quiet alert state or sleep state
7
.
Stress: An organisms total response to environmental
demands or pressures. Stress in humans results from
interactions between persons and their environment
that are perceived as training or exceeding their adaptive
capacities and threatening their well-being
6
.
Self-Regulation: (self-calming) 1) Neurobehavioral
stability and control of four underlying subsystems-
physiologic/autonomic, motor, state of arousal, and
attention/interactional. These first four subsystems
undergo progressive intrauterine refinement and lead
to self-regulation (the fifth subsystem).
8
2) the ability
to actively cope with environmental demands and
to interact with the environment
5
. Self-regulatory
behaviors are used by the infant to maintain or regain a
balanced or organized state. Primary examples include
when a baby draws into a fetal position and/or sucks on
a pacifier to calm.
A. Assessment/ observation of stress and
self-regulatory behaviors.
7,9
As noted briefly above, when applying DSC, caregivers
first assess and observe the infants behavior and then
respond as needed with appropriate DSC interventions
or activities
1. Stress behaviors as organized by subsystems:
Behavioral state, autonomic/ physiologic
responses, motor behaviors, and attention/
interaction behaviors
2. Self- Regulatory behaviors
Ways infants attempt to soothe themselves (i.e.
hand to mouth)
Assessment and observation
Maturational assessment
Each baby is assessed for gestational age and
maturation within 24-48 hours of birth. The neonatal
Physicians at Paras Hospitals use the Maturational
Assessment of Gestational Age as per the guidelines for
this assessment.
Stress and self-regulatory assessment
There are a number of tools that can be used to guide
the assessment and observation of preterm stress, pain,
and/or neurobehavior development. For the purpose of
introducing DSC in their NICU, the Paras Hospitals DSC
team created 3 documents.
A Stress and Self-Regulatory Behavior Assessment
based on the stress signs established in the
literature
4,8,9,10,
and an assessment used in
another NICU setting-(Adapted from the Pediatric
Rehabilitation Assessment at Holy Reedmer Hospital
and Medical Center, Pediatric Rehabilitation Dept.,
Meadowbrook USA).
A Stress and Self-Regulatory Behavior Worksheet for
use during observations.
An adapted worksheet used for team members
during DSC training.
*Samples provided at the conference
Once the babys GA, medical history and status/
presentation and postural position are recorded the
baby will be observed for stress and self-regulatory
behaviors. Below please see examples of the common
behaviors noted on assessment and observation of
stress and self-regulation.
Stress behaviors
I. Behavioral States (also referred to as sleep states
or states of arousal).
In 1973 Brazelton developed a state classification
for full term infants, and in 1982 Als and associates
adapted the classification to more clearly describe
the undifferentiated states of arousal in preterm
babies
5
. Each of the below states can be further
classified in terms of:
A: for Als (associated more with preterm behavior)
B: for Brazelton (associated with more mature
neonate behavior).
A general state description is provided below:
5
-
description cited (Als, Lester, & Brazelton, 1982)-See
cited source for further details.
Note: Infants develop from pre-term baby behavior
states, described by Als, toward the more differentiated
behavior states of mature neonates, described by
Brazelton
5
.
1. Deep sleep:
1A: (more preterms) - eyes closed, regular breathing,
relaxed face, no eye movement under lids,
no spontaneous movement but fairly rapid
oscillating movement with isolated startles and
jerky movements or tremors
1B: (more toward term)- eyes closed, no eye
movements, regular breathing, relaxed facial
expression, no spontaneous activity except
isolated startles
2. Light sleep:
2A: Sleeping with eyes closed or partly closed, rapid
eye movement under lid, irregular respirations,
low activity level with diffuse disorganized
movement, sucking movements, whimpers,
grimaces and twitches
Principles and Practices of Developmentally Supportive Care Chapter 4
16
2B: Sleeping with eyes closed and rapid eye
movement under lids, low activity level with
movements and dampened startles. Respirations
can be more irregular in response to certain
stimuli. Mild sucking or mouthing movements
off and on movements, possibly one or two
whimpers, a smile, or sigh.
3. Drowsy (Dozing):
3A. dozing with eyelids fluttering or longish blinks,
or open but glassy eyes, variable activity level,
may have mild startles, fussing, vocalizations,
whimpers, grimaces etc.
3B. As above but with less vocalizations, whimpers,
and fussiness.
4. Quiet Alert
4A. Quiet alert
4AL (Als, low alert): Awake with minimal
activity. Eyes half open or open. Eyes dull,
distant, little focus or clearly awake and
reactive but eyes only open intermittently.
4AH (Als, high alert): Eyes wide, seems
hyper-alert or panicky, may be unable to
break the intensity of fixation
4B. Quiet alert
4B (Brazelton): Eyes bright, seems to focus,
attentive (most mature and defined).
Minimal motor activity
5. Active awake:
5A: Vigorous movement or increased muscle tonus
and somewhat distressed in facial expression or
other stress signs
5B: Eyes can be open or closed, but infant clearly
awake, well-defined movements, fussiness, but
not crying
6. Crying
6A: Grimacing, crying face but sound is strained,
weak, or absent
6B: Rhythmic, intense, robust crying
Observations of an infants state also include the
following qualitative parameters:
irritability or lethargy, quality of each state (diffuse
or clear), ease of transition, energy cost
II. Autonomic stress (signs) behaviors
5
:
Changes in HR, RR, SaO2, BP
Color change
Gag
Hiccup
Stooling
Sneeze
Yawn
III. Motor Stress Behaviors
5,7
Back Arching
Finger Splay
Startle, Twitch, Tremor
Flailing
Limb Extension
Tongue Extension
17
Sitting on Air
Salute
Additional motor stress signs: facial grimace and gaping
(open) mouth
IV. Attention/Interaction Stress Behaviors
5
Gaze Aversion
Covering Eyes
Hyper Alert
Additional attention stress sign: frowning
V. Self-Regulatory Behaviors
5
Flexion Posture
Hands to Mouth
Hands to Face
Sucking
Foot Bracing
18
Grasping
B. Caregiver responses to infant stress & self-
regulatory cues
5
(non-pharmacologic)
Caregivers attend to and respond to the observable
stress and self-regulatory cues in the following ways:
1) Pain and stress management- supportive practices
2) Provide routine activities of daily living (i.e. feeding,
nappy change)
3) Adjust environmental stimuli (sound, light,
temperature, movement, smells)
4) Use developmentally supportive handling and
positioning
1. Pain and Stress Management- Supportive Practices
There is an exceedingly high number of painful
experiences associated with the life-saving and highly
sophisticated care provided to infants in the NICU
11
General guidelines:
Prior to DSC interventions:
Physicians: Deem if baby is age appropriate and
medically stable enough for the particular DSC
intervention. NICU can set up guidelines, and
providers can seek physicians approval (i.e. to
initiate nesting, NNS etc.)
DSC provider (i.e. physician, nurse, or therapist) must
watch the babys response during each care and
procedure, as well as, the babys response to a DSC
intervention to determine if it is indeed supportive.
For care:
As you would with any person before starting care-
Softly greet/talk to the baby before touching- at the
onset of any handling or procedure
12
Minimize handling for very young preterm babies.
Use gentle but still, firm touch rather than light
touches or tapping when touching a preterm. For
close to term sick neonates- observe their response
to light touch and if they display a stress response try
the still firm touch.
Sometimes when a young preterm baby is stressed by
an experience just taking a brief break from the care
to allow time without stimulation can help the baby to
regain a calmer state.
DSC interventions for stress and pain (non-pharmacological)
*Use interventions when baby is considered medically
able to tolerate and age appropriate:
Facilitated tuck (also called containment):
Facilitated Tuck: Involves firmly containing the infant
using a care-givers hands on both head and lower
limbs to maintain a folded-in (flexion) position. Infant
may or may not be wearing clothes
13
,

can be done
prior to and during care and procedures that are known
or observed to be stressful to the baby. This is done with
our hands as noted below.
Ex. Facilitated (helping to) Tuck or Containment with ones hands:
to babys legs, arms, or both legs and arm
Swaddling (sometimes called bundling):
Swaddling is when an infant is securely wrapped in
a blanket to prevent the childs limbs from moving
around excessively.
13
Swaddling helps a baby achieve
the folded in or flexion posture achieved through
facilitated tuck. Swaddling has been found effective for
stable preterm infants for reactivity (stress responses)
and immediate regulation of pain.
13
Swaddling evidence:
Swaddling into a flexion position is one evidence-
based strategy to help manage a [stable] preterm or
term babys pain and stress
13
.
Swaddling must be used with great caution for sick
or very preterm babies because it also restricts access
in emergency situations.
5
Medically stable preterm babies weighing 1600

grms can be transferred to cot care without adverse
affects on temperature stability or weight gain.
14
Practical points for swaddling

9
swaddle babies in a flexed and midline position, hips
with a posterior tilt
have elbows flexed to allow hands to touch mouth
and face
legs also flexed and tucked up close to the body
swaddle should be secure so that the swaddle stays
in place, but also so that the infant can have some
movement into extension and back to flexion
For tiny infants (2kg) use a small thin cloth vs. a large
hot and bulky blanket.
19
Kangaroo Care (KC) (also known as skin-to-skin contact):
Infants are placed and held against a caregivers (usually
parent) bare chest during KC. (See Kangaroo care
chapter). For preterm babies, KC is effective to manage
pain reactivity and to support immediate pain-related
regulation during stressful or routine painful procedures
(i.e. heel sticks or draws).
13
Non-Nutritive Sucking (NNS)
For NNS: a pacifier or non-lactating nipple- (after breast
milk is expressed) is placed into an infants mouth to
stimulate sucking behaviors
13
. NNS has been determined
to be effective for preterm babies for pain reactivity and
to support immediate pain-related regulation
13
. NNS
is also considered effective for immediate pain-related
regulation in neonates
13
.
Use for soothing the stressed infant
Use prior to and during a painful event
Swaddling
Non-nutritive sucking
Kangaroo Mother Care
Oral sucrose:
Sucrose for analgesia: 0.012 g to 0.12 (0.05 ml to 0.5
ml) of 24% solution given orally 2 minutes prior and
just prior to painful procedures is suggested for infants
on the NICU, especially in combination with other non-
pharmacological pain management techniques (i.e.
facilitated tuck, NNS)
15
Sucrose procedures has been
found to attenuate moderate pain in preterm babies.
11,13
Also tending to proper care and handling practices as
per gestational age- also is important to manage stress
and pain.
Breast feeding (age appropriately)
As appropriate for the circumstance, breast feeding is as
effective as oral sucrose for managing pain in preterm
babies
15
2. Basic care and handling
8
during activities of daily
living
Activities of daily living include routine care activities
such as feeding, [nappy changes, bathing], positioning
and maintaining skin integrity.
16
Greet with soft talk to the baby before touching, at
the onset to any handling or procedure.
During care of babies in the coming out or
reciprocal stage of development, monitor babys
response to soft talking during routine care- when
baby pays attention and does not display stress,
then this can be a good (brief) time for this bonding
or social interactive activity. It is important to stop
the interaction when the baby demonstrates stress-
gaze aversion or other.
Cluster cares, allow times for undisturbed rest
(protected sleep).
16
But not too many stressful interventions together.
If baby is stressed - stop and provide time out
During care use slow controlled gentle handling/
movement. Avoid abrupt changes in position
Avoid temperature and postural stress- i.e. swaddle
in a blanket for weighing and subtract the weight of
the blanket from the total on the scale for the babys
weight
As much as possible seek to maintain a facilitated
tuck (flexion posture).
Changes in cerebral oxygenation and blood volume,
measured with near-infrared spectroscopy (NIRS)
during diaper change with elevation of legs and
buttocks, during suctioning and during routine
repositioning and movement have been assoicated
with early parenchymal brain abnormalities
4
Still, gentle, but firm touch for younger preterm
babies (i.e. those in the turning-in or coming out
stage) or older sick babies if they demonstrate stress
with stroking or patting.
Offer one kind of stimulation at a time (soft talk,
touch, or visual (i.e. a parents face to observe) with
young preterm babies
9,5
See Feeding chapter for more detail on this activity
3. Management of the NICU environment
5
to
minimize infant stress
4
Adjust to promote rest and sleep, establish healthy
sleep rhythym
Lighting: Minimize light where able
Protect eyes from bright light
Dim lights at night if safe
Cover incubators or try shields without contacting
baby
Visual stimulation before 30-32 wks GA illicits
stress response
Sound: Range -40-45 dB in NICU
Infants get physiologically disorganized with
20
louder noise
Talk softly at the bedside
Set alarms and phone rings as low as is safe,
silence promptly
Neonate may prefer mothers voice
Infants respond best to soft voice
Other Sensory: Mentioned but outside todayscope
Touch (infant massage)
Music and Sound: recommend caregiver, and
especially, maternal vocals
Vestibular (movement): recommend KMC and
proper care related movement- but other outside
the scope
**Caution for use of other sound or vestibular without
training and fuller knowledge base
**Find more senory information in chapter 2
4. Practical points of positioning
Premature infants (and many sick term infants) lack
the physiologic flexion pattern that is characteristic of
the healthy full-term infant. Postural hypotonia causes
the infant to rest in a flattened position on the resting
surface if they are unsupported. The flexion posture
is not only important for motor development it is
immediately important for the self-soothing behaviors
that supports the babys neuro-behavioral development
during this critical time.
Sick or early preterm infants benefit from positioning
that promotes the flexion posture. It is also
recommended that these infants have experience in
varied positions (prone, supine, side lying) with proper
supports.
5,9
However, when deciding how and which
positions should be included in an infants care, it is
important for health professionals to consider the risk
of SIDs
5
(discussed below) and the individual needs of
each baby (i.e. medical status and stability, structural
concerns, individual tolerances to different positions,
degree of monitering available).
Positioning cautions:
Every babys medical status and individual situation
needs be considered when providing supportive
positioning.
Babies with significant hypertonus or spasticity
are at risk for muscle shortening and contractures
and should be seen by a physical or occupational
therapist as early as possible
Babies with noted skeletal or muscular anomalies
will require management and positioning
recommendations by a medical specialist.
Cautions about SIDS-the Back to sleep program
17
To decrease the risk of Sudden Infant Death Syndrome
(SIDS) the Back to Sleep Program offers the following
guidelines for at home or if a baby is not closely
monitored while in the hospital:
Always put baby to sleep on their back
Mattress should be firm with mattress protector,
mattress pad and sheet only
No extra padding- no pillow
No stuffed toys or blankets near baby for sleep
Avoid overheating during sleep
Avoid alterations in head shape by encouraging
awake (and supervised) tummy-time and upright in
arms cuddle-time
There was an approximate 50% reduction in SIDS in
U.S.A. since instituting these American Academy of
Pediatrics Guidelines.
18
NICU staff must provide adequate family education
re: SIDS as preterm babies and babies that have spent
time on the NICU have a much higher incidence of
SIDS following hospitalization. Staff should also be
aware that they are models of practices to parents.
All positioning supports and non-supine positioning
should be discontinued when approaching discharge of
the baby
18
.
Why position high-risk infants?
5,9
Proper positioning of preterm and sick infants
Promotes the flexion posture that is characteristic of
normal full-term development
Helps the baby develop self-calming skills:
hands to midline, hands to mouth or face, the
flexion position itself
Promotes deep sleep and thus protects the babys
developing nervous system and brain
Promotes autonomic stability
Saves energy and calories for growth and development
Gives a sense of security
Provides the proprioceptive feedback that supports
motor development
Prevents or minimizes deformity
Helps maintain skin integrity
Helps muscle tone
Positioning supports development
9
:
Early preterm babies are initially hypotonic
Muscle tone develops in legs first
Physiologic flexion is under-developed in preterm
infants
General developmental progression
<28 wks: hypotonic
32 wks: hips and knees show some flexion,
arms extended
34 wksflexor tone in legs but cannot hold
over time, still tends to abduct at hips
Full term sick: needs support for flexion over
time
Full term healthy: strong flexor tone
Positioning and stress management
Grenier, Bigsby, & Vergara (2003)
19
conducted a study of
preterm infants on an NICU. They observerd thestress
21
behaviors when babies were in various nested and un-
nested positions. Results suggested that preterm babies
have less stress when positioned in prone nested,
pronesupported, side lying nested, and in supine
nested. Infants had the most stress when in sidelying
unsupported.
Implications: Consider providing opportunities for
infants to be in nested or supported prone, nested
sidelying, and nested supine if infants are deemed
medically appropriate and as per the facilities back to
sleep protocol. (i.e. always on back, or only vary positions
when well supervised and monitored in the NICU).
Practical points for positioning:
Provide nesting, swaddling, or other support for the
infant to maintain a flexion posture, but
Position according to medical status and stability
Allow for alteration for medical equipment,
positional constraints etc.
i.e. nest if not tolerating a full nest, if on
oxygen in a manner that may interfere, if IVs
or surgical site indicates a certain position etc.
Nest size, shape and height can be according to
the babys size and need. No one size or shape
fits all- focus on what is needed for the desired
position. For example we provide a very shallow
small nest for very young newborn premature
babies.
Do not totally restrict movement
9
As the baby gets improved postural tone allow
more freedom of movement
9
Provide exposure to varied positions: prone,
sidelying, supine (all supported)
9
Babies may have varying tolerances to different
positions that need to be considered and respected.
A trained occupational or physical therapist should
be consulted when a baby presents with unique
positional needs or constraints.
Key points for head and neck positioning
9
:
Support head in midline and neck in neutral position
and slight chin tuck
How?
Small soft cotton cushioning, cloth rolls, or gel
pillow
Attend to the need for the baby to vary their head
position
Primarily according to babys tolerance or
need
Generally can consider with each scheduled
routine care (i.e. vitals, diaper changes)
Why support and change head position
9
? It helps
prevent:
Brachycephaly: flat in back, wide across
Scaphocephaly: flat on sides, long front to back
Torticollis
Poor visual development for learning skills
Brachycephalic
Head Shape
Scaphocephalic
Head Shape
Why support neutral neck positioning/chin tuck:
Unobstructed airway
Better swallowing
Avoids postural imbalances and weaknesses
Key points for shoulder and arm positioning
9
:
Promote protraction and neutral elevation of the
shoulder
Shoulders round and forward
Arms flexed close and towards midline of the
body
How: Small blanket roll or cotton under shoulders in
supine, provide a ventral support to trunk in prone
to encourage curve of shoulders around it. Bring
arms forward in sidelying and encourage shoulder
protraction (forward).
Why:
Encourages hands and head in midline which is
important for development
Hands can explore face, mouth, each other
Can use hands to perform calming behaviors
(hand to mouth, face, or together)
Easier to breathe
Learns normal movement patterns
**Tonic flexion of wrists or fisted hands may require
therapeutic intervention from an occupational therapist
Key points for trunk positioning
9
:
Promote slight flexion (decrease extension),
symmetrical position (not flexed to a side)
How? Provide nest or rolls to support the limbs in
flexion and also support trunk toward flexion
Why?
Hypotonia promotes extended body position at
rest:
Motor stress behaviors tend to be extension
positions
Flexion posture helps baby manage stress
Key points for hips
9
:
Promote hips (and knees) in flexion and neutral ab/
adduction and rotation
How? Avoid M position *(Frog legs)
In supine: Position side of knees off the supporting
surface so knees are up
22
In prone: Provide support under the pelvis (and
trunk) to allow more adduction of legs
In side-lying: Legs naturally adduct if diaper does
not prevent
Use small nappy or adapt to allow baby to be in a
position with legs neutrally ab/adducted
Why? Promotes flexion posture, avoids stress to hip
joint
*If baby has hip dislocations must position in M
Key points for feet
9
:
Promote neutral supported foot positions
Avoid: Turning out of foot- can be due to M
position in legs
Avoid foot drop - can be if unsupported feet
hanging over nest
How?
Support against base of nest or provide a
boundary
In prone, may provide dorsal ankle support
Why?
Can lead to deformity that causes challenges with
proper weight bearing for standing and walking
Skin Integrity: Details of assessments given in chapter 1
References
1. Montirosso, R., Del Prete, A., Bellu, R., Tronick, E.,
Borgatti, R., & Group, a. t. (2012). Level of NICU quality of
developmental care and neurobehavioral performance in
very preterm infants.Pediatrics, 129, e1129-e1137.
2. Goldstein, R. F. (2012). Developmental care of premature
infants: A state of mind. Pediatrics, 129, e1322-e1323.
3. Liu, W., Laudert, S., Perkins, B., MacMillan-York, E., Martin,
S., & Graven, S. (2007). The development of potentially
better practices to support the neurodevelopment of
infants on the NICU.Journal of Perinatology, 27, S48-S74.
4. Spruill-Turnage, C. & Papile, L.A. (2012). Developmentally
supportive care. In J. P. Cloherty, E. C. Eichenwald, A. R.
Hansen, & A. R. Stark, Manual of neonatal care (pp. Loc.
4964-5151). Philadelphia: Lippincott Williams & Wilkins, a
Wolters Kluwer business.
5. Vergara, E. R., & Bigsby, R. (2004). Developmental
&therapeutic interventions in the NICU. Baltimore: Paul H.
Brookes Publishing Co.
6. Farlex, Inc. (2012). Medical Dictionary: Stress. from The
Free Dictionary: http://medical-dictionary.thefreedictionary.
com/stress
7. Staff of The Childrens Hospital Denver, Colorado. (1989).
Developmental Intervention for Preterm and High-Risk
Infants. (P. Creger, Ed.) Denver: Therapy Skill Builders.
8. Als, H. (1986). A synactive model of neonatal behavioral
organization: Framework for the assessment and support
of neurobehavioral development of the preterm infant and
his parents in the environment of the neonatal intensive
care unit. In. Sweeney, JK, Ed. The High-Risk Neonate:
Developmentally Therapy Perspectives. New York, NY:
Haworth. Physical and Occupational Therapy in Pediatrics,
6, 3-55
9. Fern, D. (2011). A neurodevelopmental care guide to
positioning and handling the premature, fragile, or sick
infant. New York: DF Publishing.
10. Liaw, J.-J., Yang, L., Chang, L.-H., Chou, H.-L., & Chao, S.-C.
(2009). Improving neonatal care through a developmentally
supportive care training program. Applied Nursing
Research, 22, 86-93.
11. Cignaccio, E. L., Sellam, G., Stoffel, L., Gerull, R., Nelle, M.,
Kanwaljeet, J., & Engberg, A. a. (2012). Oral sucrose and
facilitated tucking for repeated pain relief in preterms:
A randomized control trial. Pediatrics, DOI: 10.1452/
peds.2011-1879.
12. National Womens Newborn Services. (2004, Dec.). Clinical
guidelines index: Developmental care. Retrieved March 15,
2012, from National Womens Newborn Services: http://
www.adhb.govt.nz/newborn/Guidelines.htm
13. Riddell, P., Racine, N., & Turcotte, K. e. (2012). Non-
Pharmacological management of infant and young child
procedural pain. Cochrane Database of Systematic Reviews,
10:CD006275.
14. New, K., Flenady, V., & Davies, M. W. (2011). Transfer of
preterm infants from incubator to open cot at lower versus
higher body weight. Cochrane Database of Systematic
Reviews(9), Art. No.: CD004214. doi:10.1002/14651858.
CD004214.pub4.
15. Spruill, C., & LaBrecque, M. A. (2012). Chapter 67:
Preventing and treating pain and stress among infants
in the newborn intensive care unit. In J. P. Cloherty, E. C.
Eichenwald, A. R. Hansen, & A. R. Stark, Manual of neonatal
care, seventh edition (7th ed., pp. 870-885). Philadelphia:
Lippincott Williams and Wilkins, a Wolters Kluwer business.
16. Coughlin, M., Gibbins, S., & Hoath, S. (2009). Core
measures for developmentally supportive care in neonatal
intensive care units: Theory, precedence, and practice.
Journal of Advanced Nursing, 2239-2248.
17. Bigsby, R. (2012). Intervention for the high risk infant:
Providing services in the NICU and during the transition
home [PowerPoint slides, bound]. Bayside, MA: Education
Resources, Inc.
18. Aris, C., Stevens, T. P., Lamura, C., Lipke, B., McMullen, S.,
Cote-Arsenault, D., &Consenstein, L. (2006). NICU nurses
knowledge and discharge teaching related to infant sleep
position and risk of SIDS. Advances in neonatal care, 6(5),
281-294.
19. Grenier, I. R., Bigsby, R., & Vergara, E. R. (2003, May/June).
Comparison of motor self-regulatory and stress behaviors
of preterm infants across body positions. The American
Journal of Occupational Therapy, 289-296.
23
Introduction
The neonatal caregiver is responsible to facilitate
successful oral feeding experiences for the high risk
infant.
For this, they must be knowledgeable about
(1) Neurodevelopmental progression of the sucking
response
(2) Common feeding problems encountered in high
risk infants
(3) Factors in the NICU infantss experience which
interfere with the acquisition of healthy oral
feedings.
(4) Criteria which must be assessed prior to initiating
nutritive sucking activity.
(5) Developmentally supportive interventions to
promote a successful feeding experience for an
individual infant.
The first postnatal year is a critical time for brain
development. Therefore, these infants must be
nourished in the best way possible for optimal growth,
development, and physical well-being
The infants ability to suck and the provision of non-
nutritive sucking opportunities assists the baby in
behavioral state modulation. The psychological
advantages of a pleasurable feeding experience are
important in establishing a positive mother-infant
relationship. Many NICU graduates are difficult
feeders and are consequently at risk for stressful and
negative feedings interactions.
The health care team has a direct impact on the
promotion of successful feeding experiences for difficult
feeders and their parents. The professional caregiver
not only serves as a role model for parents, but also
must provide them with anticipatory guidance based
on observation and analysis of their infants unique
feeding behavior
The sucking response
Sucking is a simple and rhythmical motor reflex and is
present in all healthy full term infants (Wolff, 1968). It is
comprised of a pattern of bursts and pauses (Brazelton,
1987)
Neonatal sucking combines the use of positive pressure
(expression) with negative pressure (suction). Expression
is a function of the tongue as it applies pressure to the
nipple, moves up against the hard palate and moves
backwards. The pattern combining the use of positive
and negative pressure may be termed as suckling. This
specific pattern differentiates it from a more mature
sucking action which is almost entirely a function of the
abilities to generate negative pressure or suction. An
example of mature sucking is the use of straw, in which
negative intra-oral pressure is produced by lowering the
floor of the mouth.
The fixed pattern of sequencing of suck, swallow and
breathe is controlled by the medulla. The reflex and
co-ordination of sucking, swallowing and breathing
is mature and usually well developed by 34 weeks
gestational age. The above patterns are immature and
frequently not functional in the premature infant.
Neurodevelopmental progression of the
sucking response
10 weeks post-connectional age (PCA)
Perioral stimulation produced opening of mouth.
Lips do not protrude as in sucking reflex.
14 weeks (PCA)
Basic taste bud morphology and its nerve supply are
established.
24 weeks (PCA)
Ganglion cells innervate the entire gastrointestinal
system initiating motility.
28 weeks (PCA)
Routing, sucking and swallowing reflexes are
established, but the response may be slow and
inadequate
32 weeks (PCA)
Gag reflex is present.
34 weeks (PCA)
Co-ordination of sucking, swallowing and breathing
is established with the myelinization of the medulla.
The promotion of positive feeding experiences
Successful oral feeding experiences are dependent on
many variables which include
Gestational age and weight
Physiologic stability and overall medical status
Muscle tone, energy level and endurance
Previous oral experiences of the infant
Attitude and experience of the caregiver and overall
environmental atmosphere
Behavioral organization is the ability to maintain a
balance among the physiologic, motor, state attentional/
interactional, and self-regulatory subsystem of
behavioral maturation while dealing with environmental
demands
Feeding in High- Risk Infants and Neurodevelopmental
Assessment of Feeding Abilities
5
Chapter
24
Prior to the initiation of nutritive sucking activity in
the high-risk newborn, special attention to care giving
routines may support behavioral organization, provide
positive oral experiences, and minimize the potential for
future aversive feeding behaviors.
The high risk infants capacity for behavioral organization
can be enhanced by the following environmental,
positioning and non nutritive sucking considerations
when incorporated into the Developmental Care.
Environmental considerations
Consider type of lighting (prefer cycled lighting)
Keep monitor alarms at low volume and silence them
as soon as located.
Close incubator portholes gently
Keep ventilator tubing free of bubbling water
Keep medical and nursing rounds away from the
bedside
Attempts to simulate diurnal patterns of both light
and sound
Minimize the use of noxious stimuli around the
infants face and/or mouth suction orally only as
necessary; be as gentle as possible with tape removal
when re-taping the ETT
Positioning and handling considerations
Encouraging flexion posture, hand to mouth activity,
and smooth state transition will promote feeding
readiness.
Swaddling the infants may help promote soft flexion
and use slow gentle movements when repositioning.
Avoid the spine W configuration (frog-like position).
Never discourage parents from touching their baby.
Encourage parents to gently place a finger in the babys
palm and thus stimulating the grasp reflex which is a self
regulatory behavior and unlikely to disorganize the infant
Allow the infant being gavage fed to arouse
spontaneously for a feeding. Avoid abrupt awakening.
A review of the literature reveals numerous potential
benefits to be derived from providing an infant with
Non Nutritive Sucking (NNS) opportunities prior to
the initiation of enteral feeding.
Help the infant remain calm and behaviorally organized
when offering NNS opportunity during a gavage
feeding. Encouraging the infant to continue the NNS
activity 5-10 minutes post feeding, as individual
tolerance permits. This may result in better oxygenation
(Bernbaum, Pererira and Peckham 1982)
Note: every infant must be evaluated individually and
on a continual basis.
Preparation for and Introduction to
Nutritive Sucking (NS)
The demands for NS are different from those of NNS.
NS requires greater coordination between sucking,
swallowing and breathing.
Nutritive Sucking Patterns are essentially four as given
below
Mature Nutritive Suck: Long sucking bursts of 10 or
more with breathing interspersed with suck/swallow
Immature Nutritive Suck: Short sucking bursts of
less than five with swallowing occurring before or
after the sucks
Disorganized Nutritive Suck: Reflects a lack
of rhythm in total sucking activity rather than
incoordination of a specific response (Braun and
Palmer, 1985)
Dysfunctional Nutritive Suck: Reflects problem
nippling due to abnormal movements of the tongue
and jaw (Braun and Palmer, 1985)
Criteria which must be assessed prior to
initiation of the nutritive feeding process:
Does the infants exhibit an ability to organize his
physiologic, motor and state system?
Is the infant receptive to NNS opportunities?
Is the infant rooting reflex easily elicited?
Is the infant able to coordinate suck and swallow during
NNS activity?
Observe the presence or absence of hungry behaviors
(crying spontaneous, rooting, mouth opening and hand
to mouth activity)
What are the physical demands of the infants daily
routine? Does he have any energy reserves?
Is the infant able to maintain a normal body temperature
if swaddled when taken out of the incubator/ open care
system?
If the infant is on gavage feeding. Is there consistent weight
gain over time and what is the general muscle tone?
What is the infants oxygen requirement? Will
supplemental oxygen or increased liter flow make the
difference between success and failure with the infant
who works very hard to suck, swallow and breathe?
Setting the scene for the NS experience
Coordinate with other members of the NICU team to
plan stressful treatments and /or procedures at times
not associated with feeding.
Assess the infants color, HR RR and effort, muscle
tone, and state during the feeding. Periods of apnea
or bradycardia during a feeding may indicate that the
infant is not ready for nutritive sucking
Environmental factors like extraneous sounds, excessive
lighting and movement may distract or disorganize the
infant while trying to organize his physiologic, motor
and state systems.
Feed the infant on a demand schedule when possible,
by observing for hungry behaviors; i.e. near feeding
times. Avoid initiating NS activity when the infant is very
agitated or in a deep sleep state.
25
Chapter 5 Feeding in High- Risk Infants and Neurodevelopmental Assessment of Feeding Abilities
Consider swaddling the infant to minimize extraneous
movements and provide him with external stability.
Optimal positioning is with the infants head in midline
and very slightly flexed with arms cuddled forward.
Exaggerated neck flexion may compromise the infants
ability to breathe. Extension of the neck opens the
airway and can result in aspiration. Swaddling provides
the external support needed by an individual infant to
maintain a soft flexion position, promoting capacity
for behavioral organization and control. Excessive
environmental stimuli may need to be reduced.
Common feeding problems and therapeutic
oral motor interventions
A successful Oral Feeding Experience should be: safe,
functional and pleasurable
Safe: The caregiver should feel confident that the
infants risk of aspiration is minimal
Functional: the infants should consume enough
formula in a reasonable amount of time to assure an
adequate daily caloric intake and growth.
Pleasurable: The feeding interaction should be
pleasurable and provide positive reinforcement to bpth
the infants and the caregiver.
Common feeding problem
1) Poor coordination of suck/ swallow/ breathing,
resulting in choking and aspiration
2) Fatigue
3) State Disorganization
4) Weak/arrhythmical suck (K. VandenBerg (1987)
Fatigue
The feeding process can be very tiring for the preterm or
disorganized infant. Monitor the neonates physiologic
parameters and/or clinical indicators to prevent fatigue.
The possible need for supplemental oxygen during the
feeding process should be consider. Swaddling the
infant to provide external support of his extremities may
help reduce fatigue.
Carefully assess and monitor the babys feeding
regimen. Consider various options
More frequently with smaller volumes?
Less frequently with larger volumes?
Less frequently with smaller volumes and increased
caloric density of the feed?
State disorganization
Feeding behavior is affected by infant state or level
of arousal (Meier and Pugh, 1985). Infants feed more
eagerly and show a more organized NS pattern if awake
and active.
Infants with significant feeding difficulties are at risk for
speech and language abnormalities (Illingworth). Same
muscles necessary for good NS activities are used in
speech production.
Stop signs
1) Increased biting
2) Lack of jaw closure
3) Tongue thrusting
4) Gagging/hiccoughing repeatedly
5) Inability to suck
6) Infant sucks eagerly on pacifier or finger but has
weak or arrhythmical nutritive suck
7) If the nurse finds herself doing more of the feeding
than the infant
The above behaviors are STOP SIGNS which should be
viewed with concern. Short rest periods are usually
adequate to prevent the above behaviors. However, if
they continue, consultation with a neonatal occupational
therapist should be taken.
26
Introduction
Neonates for decades were considered not capable of
either experiencing pain or mounting a measurable
response to pain. Neonatal Pain not only has an
acute impact on the physiological parameters of the
neonate but also has got the potential to cause long
term neurodevelopmental disabilities. This has led
to significant research in the area of neonatal pain
perception, its mechanism, pathways and modalities to
reduce pain. This short review will sensitise the readers
to the fascinating but sensitive topic of neonatal pain. I
am sure it will leave you more empathetic to the needs
to the neonates in NICU who experience multiple painful
procedures during their stay in the hospital. Evidence
based management of pain in neonates forms one
of the important components of the developmentally
supportive care package.
the possibility that an individual is having pain and is
in need of appropriate pain relieving treatment. The
effect of pain on the neurobehavioural status of the
infant later in life is a subject of intense interest as it has
medical and ethical implications.
The number of painful procedures experienced by
neonates in NICUs varies from a low of 5 to a high of 15.
Clearly, infants in the NICU undergo numerous tissue-
damaging procedures, with at least half not being
treated. With increasingly high number of neonates
being delivered prematurely, these fragile preemies
with prolonged NICU stay and frequent complications
experience multiple painful procedures.
Why should we treat pain in neonates?
Current medical evidence concludes that there are long-
term deleterious effects of repeated pain experienced
by preterm neonates in the NICU. Several studies
have reported that repetitive painful procedures lead
to dampened bio-behavioural responses to pain, an
indicator of interrupted development, of heightened
peripheral sensitivity to pain and altered Hypothalamic-
Pituitary-Adrenal (HPA) axis reactivity.
Physiological responses to painful stimuli are manifested
as acute increase in heart rate, blood pressure, heart
rate variability, intracranial pressure and decreased
arterial oxygen saturations. These physiological
changes are of significant magnitude and rapidity to
produce reperfusion injury and venous congestion
leading to Intraventricular Hemorrhage (IVH) and/
or Periventricular Leukomalacia (PVL). Behavioral
and physiological responses to repetitive pain may
lead to an extension of early IVH caused by perinatal
factors, or directly contribute to hypoxia, hypercarbia,
acidosis, hyperglycemia, ventilator dys-synchrony, and
pneumothoraces, all of which have been associated
with late IVH or the extension of early IVH.
Thus untreated pain has the potential to lead to
significant neurodevelopmental derangements in the
neonate directly as well as indirectly.
How to assess neonatal pain?
Tools for neonatal pain assessment: A number of scales
for measuring neonatal pain have been designed and
validated to varying degrees.
Suggested management approaches for neonatal pain
Heel Lance
Consider use of venepuncture instead of heel lance
in full-term neonates and more mature preterm
Assessment and Management of Pain in Neonates
Vikram Datta MD DNB FNNF, WHO Fellow in Epidemiology
6
Chapter
Procedures causing neonatal pain
Table 1: Painful procedures performed in neonatal intensive
care unit
Diagnostic Therapeutic Surgical
Arterial Bladder catheterization Other surgical
procedures
Heel lancing Central line insertion/
removal
e.g. peritoneal
drain, cut
down
Lumbar
puncture
Chest tube insertion/
removal
Retinopathy of
prematurity
examination
Chest physiotherapy
Suprapubic
bladder tap
Dressing change
Venipuncture Gavage tube insertion
Eye examination Intramuscular injections
Laser therapy for
retinopathy
Peripheral venous
Catheterization
Mechanical ventilation
Postural drainage
Removal of adhesive tape
Suture removal
Ventricular tap
Definition of Pain
An unpleasant sensory and emotional experience with
actual or potential damage or described in terms of
such damage (IASP 1979). A recent note has been
added to the International Association for the Study
of Pain(IASP) definition that states that the inability to
communicate verbally or non verbally does not negate
27
neonates (because it is less painful, more efficient
and requires less re-sampling). This approach may
not apply to the care of extremely preterm infants.
Use a pacifier with sucrose (concentration 12%-24%)
given 2 minutes before the procedure.
Use swaddling, containment, or facilitated tucking.
Consider skin-to-skin contact with the mother.
Use a mechanical spring-loaded lance, eg: Autolance.
EMLA (a eutectic mixture of local anesthetics: Lidocaine
and Prilocaine Hydrochloride in an emulsion base),
Acetaminophen, and warming the heel are ineffective
for heel lancing; squeezing for blood collection is the
most painful part of the procedure.
Percutaneous Venous Catheter Insertion
Use a pacifier with sucrose.
Apply EMLA to the proposed site (when non urgent).
Consider opioid dose(s), if intravenous access is
available.
Consider a similar approach for venepuncture.
Percutaneous Arterial Catheter Insertion
Apply EMLA to the proposed site.
Consider subcutaneous infiltration of Lidocaine.
Table 2: Tools for neonatal pain assessment
Variable PIPP (Premature
Infant
Pain Profile)
NFCS (Neonatal
Facial
Coding Scale)
NIPS
(Neonatal
Infant
Pain Scale)
CRIES (Cry,
Requires
Oxygen,
Increased
Vital Signs,
Expression,
Sleeplessness)
N-PASS (Neonatal
Pain Agitation and
Sedation Scale)
Echelle
Douleur
inconfort
nouveau-ne
Indicators
asessed
GA, Behavioral
state, Heart rate,
Oxygen saturation,
Brow bulge, Eye
squeeze,
Nasolabial furrow
Brow bulge,
Eye squeeze,
Nasolabial
furrow, Open lips,
Stretched mouth,
Pursed lips, Taut
tongue, Chin
quiver, Tongue
protrusion,
Facial
expression,
Cry,
Breathing
patterns,
Arm and Leg
movement,
Arousal
Crying, Requires
increased
oxygen,
Increased
vital signs,
Expression,
Sleeplessness
GA, Heart rate,
Resp rate, Blood
Pressure, Oxygen
saturation,
Crying, Irritability,
Behavioralstate,
Tone of
extremities,
Facial
expression,
Body
movements,
Sleep,
Consolability
Age level Term and preterm
neonates
25wks GA to term
neonates
Term and
preterm
neonates
Neonates 32-60
wk GA
23-40wk GA 26-26 wk GA
Pain
stimulus
Procedural Procedural Procedural Prolonged (post
operative)
Ongoing and
acute pain
and sedation
(post-operative
ventilated)
Prolonged
(post
operative)
Reliability
data
Inter and Intra-
rater reliability
>0.93
Inter and Intra-
rater reliability
>0.85
Inter-rater
reliability
>0.92
Inter-rater
reliability >0.72
Inter rater
reliability >0.85
Inter rater
reliability
>0.59
Clinical
utility
Feasibility and
utility established
at bedside
Feasibility
established at
bedside
Not
Established
Nurses prefer
CRIES over
another scale
Feasibility and
utility established
at bedside
Feasibility
and utility
established at
bedside
Consider a similar approach for arterial puncture.
Peripheral Arterial or Venous Cutdown
Consider subcutaneous infiltration of Lidocaine;
avoid intravascular injection.
available.
Central Venous Line Placement
Use swaddling, containment, or facilitated tucking
Apply EMLA to the proposed site, if non urgent.
Consider slow intravenous opioid infusion (Morphine
Sulfate or Fentanyl Citrate).
Consider using general anesthesia for the procedure.
Umbilical Catheter Insertion (Umbilical Arterial/Umbilical
Venous)
Consider the use of a pacifier with sucrose.
Avoid the placement of sutures or hemostat clamps
on the skin around the umbilicus.
Peripherally Inserted Central Catheter Placement
Chapter 6 Assessment and Management of Pain in Neonates
28
Apply EMLA to the proposed site (when non-urgent).
available.
Lumbar Puncture
Because containment is not possible, careful physical
handling is advised.
Subcutaneous or Intramuscular Injection
Avoid subcutaneous and intramuscular injections;
give drugs intravenously whenever possible.
If necessary:
Apply EMLA to the proposed site (evidence for this
approach is available from studies in children, but
not from studies in neonates).
Endotracheal Intubation
Many variations in clinical approach have been noted;
the superior efficacy of any one technique is not
supported by current evidence.
Use combination of Atropine Sulfate and Ketamine
Hydrochloride
Use combination of Atropine, Thiopental Sodium,
and Succinylcholine Chloride.
Use combination of Atropine, Morphine, or Fentanyl,
and nondepolarizing muscle relaxant (Pancuronium,
Vercuronium, Rorcuronium).
Consider using a topical Lidocaine spray, if available.
Other drug combinations are frequently used.
Tracheal intubation without the use of analgesia or
sedation should be performed only for resuscitation in
the delivery room or for other life-threatening situations
associated with the unavailability of intravenous access.
Endotracheal Suctioning
This is considered a stressful procedure and may be
associated with the same physiological responses that
accompany other painful procedures.
Use a pacifier; may consider giving sucrose.
Consider continuous intravenous infusion of opioids
(Morphine) or slow injection of intermittent opioid
doses (Fentanyl, Meperidine, or Alfentanil).
Nasogastric or Orogastric Tube Insertion
Use a gentle technique and appropriate lubrication.
Chest Tube Insertion
Anticipate the need for intubation and ventilation in
neonates breathing spontaneously.
Consider slow intravenous opioid infusion (morphine
or fentanyl; see table 4 for dosages).
Other approaches may include the use of short
acting anaesthetic agents.
The use of intravenous Midazolam is not recommended.
Circumcision
If deemed necessary
Use an appropriate clamp (Mogen clamp preferred
over Gomco).
Place a dorsal penile nerve block, ring block, or
caudal block, using plain or buffered Lidocaine.
Consider Acetaminophen for postoperative pain.
Analgesics can be combined for maximum efficacy,
although the addition of Sodium Bicarbonate to
Lidocaine does not alter the neonatal responses to
Lidocaine injection.
Ongoing analgesia for routine NICU care and procedures
Use a pacifier; may consider giving sucrose.
Low-dose continuous infusion of Morphine or
Fentanyl if patient is ventilated.
There is no evidence to show that neonates can be
safely sedated for several weeks or months and the use
of Midazolam is not recommended.
Consider acetaminophen therapy.
The efficacy and safety of repeated Acetaminophen
doses is unknown, rectal absorption is variable, and
intravenous Propacetamol is not available in the United
States.
Reduce acoustic, thermal, and other environmental
stresses.
Effect of repeated procedural pain on developing brain
and neurobehaviour:
Learning and memory have been demonstrated in
preterm infants as young as 32 weeks of gestation.
Preterm infants are often exposed to repetitive invasive
procedures causing acute pain during the neonatal
intensive care. These experiences occur during a critical
window of increased plasticity of the developing brain.
Lengthy hospitalisation of the extremely preterm neonate
occurs during a period when the brain is undergoing
major development, including the establishment
and differentiation of sub-plate neurons, alignment,
orientation and layering of cortical neurons, elaboration
of dendrites and axons, formation of synapses, selective
pruning of neuronal processes and synapses, as well as
proliferation and differentiation of glial cells.
Repetitive untreated pain thus has a potential of
causing altered neurobehaviour in the preterm neonate.
29
To conclude, it is evident with current evidence that
the sick preterm neonates who undergo a multitude
of procedures in neonatal ICU are vulnerable to long
term deleterious effects of untreated neonatal pain.
Clinicians therefore should be sensitive to the concept
of pain relief in NICU and maintain a well structured
pain relief protocol with a good follow up for early
identification of neurodevelopmental delays.
Management of pain by Pharmacological and non
pharmacological means will go a long way in making
the NICU more developmentally supportive.
Suggested Readings:
1. KJS Anand. Clinical importance of pain and stress in
preterm neonates. Biol of Neonate 1998; 73:1-9
2. RE Grunau et al .Long term consequences of pain in human
neonates. Seminars in Fetal and Neonatal Medicine. 2006;
11: 268-75.
3. Cignacco E, Denhaerynck K, Nelle M, Bhrer C, Engberg
S. Variability in pain response to a non-pharmacological
intervention across repeated routine pain exposure in
preterm infants: a feasibility study. Acta Paediatr. 2009;
98(5): 842 846
4. Denise Harrison et al. Analgesic Effects of sweet tasting
solutions for Infants: Current State of Equipoise. Ped 2010;
126: 894-902
5. K. J. S. Anand and the international evidence based group
for neonatal pain. Consensus statement for the prevention
of pain in the newborn. Arch Pediatr Adolesc Med 2000;
155: 173-80.
6. Slater R, Cornelissen L, Fabrizi L, et al. Oral sucrose as an
analgesic drug for procedural pain in newborn infants: a
randomised controlled trial. Lancet 2010; 376: 1225-32
Chapter 6 Assessment and Management of Pain in Neonates
30
Family centered care (FCC) is a core component
of developmentally supportive care
1
that is rooted
in collaborative partnerships between health care
providers, patients, and families.
2
Providers of family-
centered care understand the important role family
plays in the health and wellbeing of a child
2
. They
also appreciate developmental, social, and emotional
support as an aspect of health care.
2
Concepts of family-centered care originated largely
in the U.S. with the seminal work of Shelton et al.
1987.
3, 4
It is expected that family centered care will be
implemented in any variety of ways according to the
health care setting, the age of the child, the nature of
the childs illness (i.e. chronic or acute), and the families
and communities served. With this reality the outcomes
of family centered care will also vary.
4
9
Elements of family centered Care:
Of the nine elements described as part of family-
centered care, Shelton, et al., 1987
3
specified eight and
Johnson (1990)
5
added one more
4
.
recognizing the family as a constant in the childs life
facilitating parent-professional collaboration at all
levels of health care
honoring the racial, ethnic, cultural, and socio-
economic diversity of families
recognizing family strengths and individuality and
respecting different methods of coping
sharing complete and unbiased information with
families on a continuous basis
encouraging and facilitating family-to-family support
and networking
responding to child and family developmental needs
as part of healthcare practices
adopting policies and practices that provide families
with emotional and financial support
designing health care that is flexible, culturally
competent, and responsive to family need.
4
Categories of family supportive care
interventions
A recent Cochrane
4
review delineated 4 kinds of
interventions that promote family centered care.
While some specific interventions may not be useful or
practical in all settings and cultures; it may be helpful to
consider ways that the spirit of the intervention can be
incorporated. The interventions include:
Environmental interventions: primarily to provide
more privacy for families, more closeness of parents
to their baby and as able, more parental involvement
in their babys care.
Communication Interventions: such as 1)to
include(and involving) parents at interdisciplinary
rounds and/or family conferences to plan future care
2)to seek ways to allow continuity of care-giver (i.e.
primary nursing) 3) to have local hospital based
interpreters 4)developing collaborative care pathways
where both parent and health care providers
document issues and progress. 5) Additional to
these mentioned in the review, it may be helpful to
provide supportive communication training for staff
to help alleviate some of the stress felt by parents.
Education Interventions: could include family
education series or protocols as well as staff
continuing education opportunities related to FCC.
Family Centered Interventions could be referrals
to other hospitals or community services (such as,
social workers, religious advisors, mental health
professionals, home health care, and rehabilitation
services), facilitating parent-to-parent support, or
creating flexible charging schemes for poor families.
Policy intervention: such as visit policies that aim
to increase the closeness or bonding for families,
communication policies for improving the quality of
communication between staff and parents, policies
for support of families etc.
Additional literature review related to FCC
Though family centered care emerged from the U.S. it
is commonly practiced, to varying extents,in pediatric
settings throughout the world. Below is an additional
sample of recent literature that pertains to aspects of
family-centered care:
Importance of Early Bonding
(Mehler, et al., 2011)
6
Authors in Germany- Post
Hoc Analysis, quantitative study-The study supports
the hypothesis that the first hours after birth are a
sensitive period for the development of attachment
behavior in VLBW infants. Enabling a mother to see
her baby shortly after birth, during this sensitive
period, may be helpful for forming an important
basis for the secure attachment of the preterm infant
and their mother.
(Flacking, et al., 2012)
7
- Authors in Sweden, Finland,
U.S.-Literature Review- There is increasing evidence
supporting the benefits of early parentinfant
closeness during hospital care of preterm infants.
Both physical and emotional parentinfant closeness
should be facilitated in neonatal units taking into
account the socio-economic, political and cultural
variations in different countries.
Family Centred Care
Amy Carroll OTD
7
Chapter
31
(Guillaume, et al., 2013)
8
Authors in France-
Prospective, qualitative Study: At birth and during
the first weeks in the NICU, the creation of a bond
between mothers and fathers and their premature
baby is rooted in their relationship with the caregivers.
Nurses caring attitude and regular communication
adapted to specific needs are perceived by parents as
necessary preconditions for parents interaction and
development of a bond with their baby. These results
might allow NICU staff to provide better support to
parents and facilitate the emergence of a feeling of
parenthood.
Stress of parents: Importance of parent
participation and support
(Chourasia, Surianarayanan, Adhisvan, & Bhat,
2012)
9
- Authors in India- descriptive study-mothers
were found to experience stress associated with
having their baby on the NICU. They perceived the
stress to be associated with the alteration of their
parenting role (as far as breastfeeding and how to
help comfort their baby) and also related to the looks
and behavior of their baby.
(Obeidat, Bond, & Callister, 2009)
10
: Authors in
Jordan- Systematic Review: A predominant stressor
for parents with a baby in the NICU is their inability
to fulfill a normal parenting role by protecting their
infant from sources of pain. Parents also experience
feelings of helplessness, fear, insecurity, and worry
about their babys outcomes.
(Lasiuk, Comeau, & Newburn-Cook, 2013)
11
-
Authors in Canada- Interpretive descriptive study-
preterm birth was associated with prolonged
uncertainty, lack of agency, alterations in parental role
expectations and associated trauma. This emphasized
the importance of breast feeding, kangaroo care
and family centered practices so meaningful to
the parents.
References
1. Coughlin, M., Gibbins, S., & Hoath, S. (2009). Core
measures for developmentally supportive care in neonatal
intensive care units: Theory, precedence, and practice.
Journal of Advanced Nursing, 2239-2248.
2. Institute for Patient and Family-Centered Care. (n.d.).
Frequently Asked Questions. Retrieved from Institute for
Patient and Family-Centered Care: http://www.ipfcc.org/
faq.html
3. Shelton, T., & Jepson, E. a. (1987). Family-centered care for
children with special healthcare needs. District of Columbia,
Washington: Association For the Care of Childrens Health.
4. Shields, L., Zhou, H., Jan, P., Taylor, M., Hunter, J., & Pascoe, E.
(2012). Family-Centered care for hospitalized children aged
0-12 years. Cochrane Database of Systematic Reviews(10),
1-58. doi: 10.1002/14651858.CD004811.pub3.
5. Johnson, B. (1990). The changing role of families in health
care. Childrens Health Care, 234-241.
6. Mehler, K., Wendrich, D., R, K., Roth, B., A, O., Pillekamp,
F., & Kribs, A. (2011). Mothers seeing their VLBW infants
within 3hrs after birth are more likely to establish a secure
attachment bond: evidence of a senstive period with
peterm infants? Journal of Perinatalogy, 31, 404- 410.
7. Flacking, R., Lethonen, L., Thomson, G., Axelin, A., Ahlqvist,
S., Moran, V. H.,... Group, T. S. (2012). Closeness and
seperation in neonatal care. ACTA Peadiatrica, 132-137.
8. Guillaume, S., Michelin, N., Amrani, E., Benier, B., Xavier, D.,
Lescure, S., . . . Jarreau, P.-H. (2013). Parents expectations
of staff in the early bonding process with their premature
babies in the intensive care setting: A multicenter study
with 60 parents. BMC Pediatrics, 13, 1-9. Retrieved from
http://www.biomedcentral.com/1471-2431/13/18
9. Chourasia, N., Surianarayanan, P., Adhisvan, B., & Bhat, B. V.
(2012). NICU admissions and maternal stress levels. Indian
Journal of Pediatrics, DOI 10.1007/s12098-012-0921-7.
10. Obeidat, H. M., Bond, E. A., & Callister, L. C. (2009). The parental
experience of having an infant in the neonatal intensive care
unit. The Journal of Perinatal Education, 18, 23-29.
11. Lasiuk, G. C., Comeau, T., & Newburn-Cook, C. (2013).
Unexpected: An interpretive description of parental
traumasassociated with preterm birth. BMC: Pregnancy
and childbirth, 13(Suppl 1), 1-10. Retrieved from http://
www.biomedcentral.com/1471-2393/13/S1/S13
Chapter 7 Family Centred Care
32
Sound and Acoustics in the Neonatal
Intensive Care Unit
Background
Noise is omnipresent in our environment and is termed
as undesirable sound. Sound is vibration in a medium,
usually air. It has intensity (loudness), frequency (pitch),
periodicity, and duration. The loudness of sound is
measured in decibels (dB), a logarithmic scale. The
ability to hear sounds at certain frequencies is more
readily lost in response to noise; therefore, the intensity
is adjusted for frequency to give the A-weight (dBA).
In non-occupational settings, environmental noise is
expressed as a day-night average sound level (DNL). For
the protection of the public health, the US Environmental
Protection Agency has proposed a DNL of 55 dB during
waking hours and 45 dB during sleeping hours in
neighborhoods, and 45 dB in daytime and 35 dB at night
in hospitals.
NICU setting
There has been growing awareness of the potentially
deleterious impact of the environment upon the rapidly
developing and vulnerable preterm brain Presence of
noise in the neonatal intensive care unit (NICU) has been in
focus as a special concern. The preterm infant transitions
from an acoustically subdued and predominantly lower
frequency in utero environment, to the NICU environment
with measured sounds levels that may be excessive
and potentially hazardous. Loud noises in the NICU
significantly change the behavioral and physiological
responses of infants. Studies have also demonstrated
that hypoxemia occurred in infants in conjunction with
sudden loud noise (of approximately 80dB).
Development of hearing
The human cochlea and peripheral sensory end organs
complete their normal development by 24 to 25 weeks of
gestation. Ultrasonographic observations of blink-startle
responses to vibroacoustic stimulation are first elicited at
24 to 25 weeks of gestation, and are consistently present
after 28 weeks, indicating maturation of the auditory
pathways of the central nervous system. The hearing
threshold (the intensity at which one perceives sound) at
27 to 29 weeks of gestation is approximately 40 dB and
decreases to a nearly adult level of 13.5 dB by 42 weeks
of gestation, indicating continuing postnatal maturation
of these pathways. Thus, exposure of the fetus and
newborn to noise occurs during the normal development
and maturation of the sense of hearing. Sound is well
transmitted into the uterine environment.
Recommendations for sound levels
Infant rooms/areas
Combination of continuous background sound and
operational sound should not exceed 45 dB to 50 dB
and transient sound has an upper limit of 65 dB. (RD
White; Journal of Perinatology; 2007 27, s4-s19)
Staff work/family areas
Combination of continuous background sound and
operational sound should not exceed 50 dB to 55 dB
and transient sound has an upper limit of 70dB. (RD
White; Journal of Perinatology; 2007 27, s4-s19)
Fluctuations
Peak mean sound levels in NICU can reach up to 118 dB
(Kent et al, 2002)
Mean 77.4 dB, Range 69-118 dB, Impulsive noises (closing
ports and cabinets) can produce peak levels of over 100dB
Factors influencing the neonatal sound dose
Virtually all high amplitude noise is associated with the
following:
Ventilator Noise and alarms
Staff activities like closing drawers, doors, trash cans,
incubator ports
Voices (across the room conversation)
Avoidable unit activities
These include
Snapping a plastic porthole closed or closing an
incubator cabinet door
Setting a plastic bottle on top of incubator, Finger
tapping on an incubator
Moisture bubbling in ventilator tubing
An IV pump placed on top of incubator
A bradycardia alarm
Staff Voice Levels in the NICU are a function of
background sound levels. Raised voice is required for
face to face conversation when background sound
levels exceed 59dB. SHOUTING requires over 71 dB (Not
uncommon levels in the NICU; Lasky 1995)
Potential effects of excessive sound levels
on hearing
A single impulsive sound can induce hearing loss
Impulsive noise > 140 dB can rupture the tympanic
membrane and break continuity of the ossicular chain
Prolonged exposure to NICU levels > 70 dB resulted
in higher incidence of hearing loss among preterm
infants (Liu, et al., 2010)
Environmental Considerations for Reduction of
Stress & Energy Conservation
8
Chapter
33
An NICU Noise Control Protocol essentially
consists of 3 main activities
1. Noise monitoring activities
Use portable digital sound pressure level meter
2. Noise reduction activities
a. Activity modification
b. Equipment noise reduction
i. Alarm volumes should be adjusted till the
sound level is 50 dB SP
ii. Visual alarms are ideal to reduce noise but the
method is labor intensive
c. Control of noise reverberations within the NICU.
Any noise generated in the NICU gets reflected
and re- reflected till it losses its energy which
is called reverberation. This phenomenon adds
to the already existing noise level. Acoustic
tiles on the roof and veneer flooring reduced
reverberations
d. Control of air borne and structure borne noise
transmitted into the NICU from outside.
3. Hearing screening
All neonates in the NICU should be screened for
hearing impairment before discharge from hospital
or latest by the first follow up visit.
We help calm
Products for Sound Attenuation include Mini-Muffs
and Sensory comforts. However, these products are not
recommended for long term use on preemies.
Lighting design and recommendations in
the neonatal intensive care unit
Lighting in the neonatal intensive care unit (NICU) has
a fascinating history that reflects the perspectives of
NICU design in general. In the premature nurseries of
the 1970s, lighting levels were dictated by the needs
of the staff while giving care, with little known about
the impact of direct lighting on the development of
the infant or on circadian rhythms of either infants or
caregivers. NICUs were considered models of clinical
and technological excellence in their time, and their
typically bright, uniform lighting continued the practice
of lighting levels determined by caregiver needs. The
physical environment of the NICU, and in particular its
lighting, has important effects on both infants and their
caregivers (Rivkees and Rea).
With ongoing research findings evolving, the newer
strategies in NICU planning used dim lighting in entire
patient care areas. Dim lighting experienced in utero
was the best guide to appropriate lighting levels for
premature infants in the NICU.
In the 1980s, there was some indication that cycled
lighting might be better than a continuous level of
lighting [1], and by 2003, the importance of diurnally
cycled lighting to infants was established [2,3]
Meeting the needs of infants
Before 28 weeks gestation, continuous dim lighting
(less than 20 lux) is probably the most suitable infant
environment (article by Graven). After 28 weeks post
conceptional age (PCA), maintaining this dim lighting
level at night is appropriate, but daytime levels should
be increased to 250500 lux (article by Rivkees).
Appropriate daytime lighting levels for infants can be
achieved with either electric light or sunlight
Neonatal vulnerability to light
Amount of light reaching the retina is greater for infants
Sound Levels
Quality
Peak
Intensity, dBA
Example Inside Incubator Effect
Just audible 10 Heartbeat
Very quiet 20-30 Whisper <35 dBA desired for sleep
Quiet
40 Average home
50 Light traffic background <50 dBA desired for work
Moderately
loud
60 Normal conversation Motor on and off
70 Vacuum cleaner Bubbling in ventilator tubing Annoyance
Loud
80 Heavy traffic Telephone ringing Tapping incubator with fingers
90 Pneumatic drill
Closing the metal cabinet
doors under the incubator
Hearing loss with
persistent exposure
Very loud 100 Power mower Closing solid plastic porthole
Uncomfortably
loud
120 Boom box in car
Dropping the head of the
mattress
Pain and distress
140 Jet plane 30 m overhead
(Noise: A Hazard for the Fetus and Newborn, Committee on Environmental Health, Pediatrics 1997;100;724 )
Environmental Considerations for Reduction of Stress & Energy Conservation Chapter 8
34
of lower gestational age. Irradiance received (in mean
W/cm
2
nm) is as given below
530 @ 24 wks
350 @ 28 wks
240 @ 32 wks
Pupil reactivity is decreased in infants < 30 weeks
gestational age and thus> exposure (Osorio, et al 2009,
Robinson & Fielder, 1990)
Light levels in NICU and implications
The most immature infants are at greatest risk for
potentially adverse effects from NICU lights. These
include the critically ill under procedure lamps and
those with immature motor organization who are least
able to protect themselves through position change.
Prolonged NICU stay in continuous lighting can cause
considerable stress.
Recommended Light Levels
Ambient lighting in infant-care areas
Ambient lighting levels in infant spaces shall be
adjustable through a range of at least 10 to no more
than 600 lux (approximately 1 to 60 foot candles),
as measured at each bedside. Both natural and
electric light sources shall have controls that allow
immediate darkening of any bed position sufficient
for trans illumination when necessary (Recommended
standards for newborn ICU design: Journal of
Perinatology (2006). Perception of skin tones is critical
in the NICU;
Procedure lighting in infant care areas
Separate procedure lighting shall be available to each
infant bed. The luminaire shall be capable of providing
no less than 2000 lux at the plane of the infant bed, and
must be framed so that no more than 2% of the light
output of the luminaire extends beyond its illumination
field. Temporary increases in illumination necessary to
evaluate a baby or to perform a procedure should be
possible without increasing lighting levels for other
babies in the same room.
Avoid direct exposure to intense direct light and
ensure consistent eye protection for infants receiving
phototherapy and infants adjacent to phototherapy.
Modify intensity of lighting to mimic natural day/night
cycles.
Cycled Light vs. Near Darkness
Randomized controlled trials compared low intensity
cycled vs near darkness from birth in infants <32 wks g.a.
Infants in cycled light gained weight faster (Brandon,
Holditch-Davis, et al, 2002), had more activity during
the day, and rest at night (Rivkees, Mayes, et al. 2004).
It is most important to cycle lighting during 2 weeks
before discharge
(Cochrane Database Review 2011: Morag & Ohisson:)
Common light levels outdoor at day and night
Condition
Illumination
(ftcd) (lux)
Sunlight 10,000 107,527
Full Daylight 1,000 10,752
Overcast Day 100 1,075
Very Dark Day 10 107
Twilight 1 10.8
Deep Twilight .1 1.08
Full Moon .01 .108
Quarter Moon .001 .0108
Starlight .0001 .0011
Overcast Night .00001 .0001
(http://www.engineeringtoolbox.com/light-level-rooms-d_708.html
Common Light Levels Outdoor)
Recommended Light Level in Different Work Spaces
Activity
Illumination
(lux, lumen/m
2
)
Public areas with dark surroundings 20 - 50
Simple orientation for short visits 50 - 100
Working areas where visual tasks are
only occasionally performed
100 - 150
Easy Office Work, Classes 250
Normal Office Work, PC Work, Study
Library, Groceries, Show Rooms,
Laboratories
500
Supermarkets, Mechanical Workshops,
Office Landscapes
750
Normal Drawing Work, Detailed
Mechanical Workshops, Operation
Theatres
1,000
Quiet Periods where environmental light and sound
were significantly reduced, showed reduced median
diastolic blood pressure and mean arterial pressure with
reduced infant movements. (Rosemarie Bigsby 2012)
Contribution to Positive Outcomes
The environment should not have more sensory
stimulation than the infants individual stress threshold.
A proper balance should be maintained between the
infant & the care giving environment. The goal is
to promote a stable, well organized infant who can
conserve energy for growth and development.
Avoid Contribution to Negative Outcomes
STRESS
Physiologic instability
Poorly regulated states of arousal
Disorganized behavior
35
Greater vulnerability to pain may lead to alteration in
brain development (Anand et al 2000)
Our final goal should be to improve functional outcomes
with positive neuro developmental outcomes and intact
survival.
Suggested reading
1. Environmental Protection Agency, Office of Noise
Abatement and Control. Information on Levels of
Environmental Noise Requisite to Protect Public Health
and Welfare with an Adequate Margin of Safety (Report
No. 550974-004). Washington, DC: Government Printing
Office; 1974
2. Gottfried AW. Environment of newborn infants in special
care units. Infant stress under intensive care: Environmental
Neonatology 1985
3. Richards DS, Frentzen B et al Sound levels in the human
uterus. Obstet Gynecol 1992.
4. Long JG, Lucey JF, Philip AG. Noise and hypoxemia in the
intensive care nursery. Pediatrics.
5. Birnholz JC, Benacerraf BR. The development of human
fetal hearing. Science. 1983; 222:516 518
6. Gerhardt KJ, Abrams RM, Oliver CC. Sound environment of
the fetal sheep. Am J Obstet Gynecol. 1990; 162:282287
7. RD White, Recommended standards for newborn ICU
designJournal of Perinatology (2006) 26, S2S18 r 2006
Nature Publishing Group
8. Robert D. White, MD; Lighting design in the neonatal
intensive care unit: practical applications of scientific
principles; Clin Perinatol 31 (2004) 323 330.
9. Scott A. Rivkees, Linda Mayes; Rest- Activity Patterns
of Premature Infants are regulated by cycled lighting
Pediatrics 2004; 113;833
Environmental Considerations for Reduction of Stress & Energy Conservation Chapter 8
36
Introduction
Being born at a weight less than 2500 gm is a major
problem across the world and one that is associated
with high neonatal infant mortality and morbidity
rates. Babies born at less than 2500 grams are 20 times
more likely to die than the heavier babies. More than
20 million babies across the world representing 15.5%
of all live births are born with a low birth weight with
more than 95% being born in developing countries.
In developing countries, LBW accounts for 50% of all
neonatal deaths. However, besides the increasing death
rates in such children one of the major concerns is the
concern about the long term cognitive and other health
related disorders. Approximately 40% of very low birth
baby survivors have long term sequelae.
A clear delineation of modifiable factors affecting
outcomes might offer opportunities to improve prognosis
after discharge and positive long-term outcome. Recent
interventions aimed at providing a more appropriate
environment and humane care in the neonatal intensive
care unit (NICU) have demonstrated positive effects.
These interventions are guided by a neurodevelopmental
framework based on animal models that provide evidence
for a fine-tuned environmental input for normal cortical
development. They have been designed to reduce the
stress in the newborn period. Newborn Individualized
Developmental Care and Assessment Program (NIDCAP)
is a convincing examples of this new tradition of
interventions focused on developmental supportive
care as compared to specialized medicaltechnical care.
This program encompasses all care procedure as well as
social and physical aspects in the NICU, and supports
the parents involvement as the first infants primary co
regulator.
Kangaroo mother care
Kangaroo Care originated in Bogota, Columbia in
1983 by Neos Edgar Rey and Hector Martinez when
they developed the Kangaroo Mother Care program
to decrease the high mortality rate among preemies.
Mothers carried their preemies in slings all day, every
day and the mortality rate fell from 70% to 30%.
The two components of KMC are:
Skin-to-skin contact: Early, continuous and prolonged
skin-to-skin contact between the mother and her baby
is the basic component of KMC. The infant is placed on
her mothers chest between the breasts.
Exclusive breastfeeding: The baby on KMC is
breastfed exclusively. Skin-to-skin contact promotes
lactation and facilitates the feeding interaction. Various
randomized controlled trials and other observational
studies have shown that KMC has distinct advantages
in reducing neonatal mortality, promoting early
discharge, improving breast feeding, thermal control
and improving the bonding amongst the mother baby
dyad. The reader is suggested to visit www.kmcindia.
org for detailed information on the subject and the
technique to do the same.
Kangaroo mother care as part of
Developmentally supportive care
Kangaroo Mother Care can be associated to
developmental care intervention and part of it (skin-
to-skin contact) has been introduced by Als as a
component of the NIDCAP. Bogots KMC program is
scheduled during the routine post neonatal intensive
care period, when infants usually remain in hospital until
they reach a satisfactory medical status. This period is
generally viewed as hampering the normal parentchild
interaction process, as it forms an obstacle to caring for
and touching the infant. KMC shortens this suboptimal
period and like developmental care programs it allows
the parents to play an active role.
KMC major basic components in relation to
DSC
The first is the intervention timing which starts early
in hospital, as soon as infants physiological state
is stabilized. NICU environment is very hostile and
leads to sensory input overload which can disrupt the
developing brain. Developmentally supportive care
focuses on reducing the noxious stimuli which promots
environment based on observable physiological and
behavioural cues. Underlying rationale for early start of
KMC is that infants require qualitative compensation for
lost intrauterine experience as well as avoidance of input
overload. As pointed out by Als and others developmental
care during the last weeks of (extrauterine) gestation
positively influences neurodevelopmental functioning,
and it appears to prevent frontal lobe and attentional
difficulties in the newborn period.
Another major component of the KMC is the kangaroo
position (see www.kmcindia.org for details) that
induces combinations of sensory modalities: auditory
stimulations through the mothers voice, olfactive
stimulations by the mothers body proximity, vestibular-
kinesthetic stimulations with the infants location on
the adults chest and carried during 24 hr a day for days
or weeks, tactile stimulations by permanent skin-to-skin
contacts, and visual stimulation as the infant is placed
Kangaroo Mother Care and Developmentally
Supportive Care
Sanjay Wazir MD, DM Neonatology (PGI Chandigarh)
9
Chapter
37
in an upright position (60
o
) which allows him to see the
mothers face and body and the contextual elements
as the mother moves in her routine activities. All these
multimodal sensory stimulations programs have been
reported to have short term impact on physical and
mental maturation as has been detailed elsewhere in
the book.
The third major component is the parent involvement.
KMC strengthens the connection between the infant
and the carrier (prominently the mother or the father
and members of the extended family) both becoming
more sensitive to each other. This can be particularly
challenging if the infant is perceived as fragile by
the parent. Clinical observations of the carrier/infant
transactions are suggestive of a bonding phenomenon
whereby infants behaviours reinforce and elicit the
parenting skills focused at fostering development. This
close relationship adds a fulfilling dimension to their
role as primary caregiver and enhances their feelings
of responsibility and competence. This component
is highly recommended in preventive developmental
interventions aimed at optimizing cognitive outcomes.
A fourth component of the Bogotas kangaroo program
is the breastfeeding. Breast milk is the main source of
nutrition although infants may receive preterm formula
and vitamin supplements when necessary. Based on
studies and various meta analysis it has been shown that
breast milk fed babies have a 2-3 IQ points advantage
over the formula fed babies and the advantage is
higher in the low birth weight category. By promoting
the use of breast milk, not only does the KMC result
in more breast feeding rates but also lesser infections,
both of them independently associated with the poor
neurodevelopmental outcome.
Finally, Bogotas KMC program reduces length of exposure
to typical NICU environment that is well recognized as
stressful, and programs aimed at reducing the stress
in this environment have been successful in favoring
weight gain and mental development. As infants leave
hospital earlier, carried on the mothers womb, proximal
noise might be reduced and mostly absorbed by the
mothers skin and dress etc. From the time of the early
hospital discharge, parents become totally in charge of
their infant and responsible for his health and survival.
This high parent involvement procedure is viewed as an
effective part of the intervention and appears to change
their attitude and developmental expectations and their
interactive behaviors with their infant.
Summary
The theoretical framework behind the family centred,
developmentally supportive NIDCAP is supported by
various research studies across various disciplines of
human brain studies and must certainly be promoted
as part of NICU care of fragile babies. However,
NIDCAP requires considerable investment in terms of
money, physical changes in current NICU infrastructure
and substantial education effort in change in care
practices amongst the health care providers. Embracing
KMC on the other hand does not involve either the
change in infrastructure or money and is directly
dependent on the mother rather than the health care
provider. Although the long term data is not available,
short term (one year) data does suggest improved
neurodevelopmental benefit of KMC. Further research
should focus on determining the long term impact on
neurodevelopment of KMC
Suggested reading
1. Lawn JE, Mwansa-Kambafwile J, Horta BL, Barros
FC, Cousens S Kangaroo mother care to prevent
neonatal deaths due to preterm birth complications Int J
Epidemiol. 2010 Apr;39 Suppl 1:i144-54.
2. Ruiz-Pelez JG, Charpak N, Cuervo LG Kangaroo Mother Care,
an example to follow from developing countries. BMJ. 2004
Nov 13; 329(7475):1179-81.
3. Venancio SI, de Almeida H. Kangaroo-Mother Care:
scientific evidence and impact on breastfeeding. J Pediatr
(Rio J). 2004 Nov;80(5 Suppl):S173-80
4. Westrup B. Newborn Individualized Developmental
Care and Assessment Program (NIDCAP) - family-
centered developmentally supportive care. Early Hum
Dev. 2007 Jul; 83(7): 443-9. Epub 2007 Apr 25.
5. Coughlin M, Gibbins S, Hoath S. Core measures
for developmentally supportive care in neonatal intensive
care units: theory, precedence and practice. J Adv Nurs.
2009 Oct; 65(10):2239-48.
Kangaroo Mother Care and Developmentally Supportive Care Chapter 9
38
Pre During Post Date: Task: GA:
Observer:
Checklist of NICU Caregiver Behaviors
*MO
*1/2
Developmentally Supportive Care Non- Developmentally Supportive Care
1 Talking to infant:
: softly greets baby prior to infant interaction
: talks to baby in soft voice during cares
: sings
Talking or chatting with other people
: no greeting
: chats with other during care (not the baby)
: talks loudly with baby or others
2. Handling techniques: as medically able
: supports & encourages tuck during handling
: moves baby slowly and gently
: avoids pressure on upper spine/neck
: puts baby in a different position after cares
Handling techniques:
: unsupported or un-tucked movement
: fast or rough movements
: lifts legs & trunk putting pressure toward neck
: leaves baby in same position
3. Positioning / body support:
: found nested or supported toward flexion
: supports head: midline or to avoid misshape
: provides nest/rolls/swaddle to support flex.
: nappy fits or is adapted to fit
Positioning / body support:
: no positioning support
: nest around baby but not supporting to flexion
: unsupported head: for midline or head shaping
: nappy too big/not adapted
4. Stress Management:
: anticipates and prevents stress/pain
: prompt response to babys stress related
need (offers care, calms, etc.)
: pauses care for distress (auto. or other)
As per GA or medical status:
: swaddles, contains, holds the baby
: pacifier, facilitates grasps, reassures
Stress Management:
: does not anticipate and attempt to prevent stress
(I.e. give pacifier, swaddle, talk to baby etc.)
: does not address babys distress/pain

: inappropriate technique for medical status or GA
5. Gentle touch:
: still or slow, firm yet gentle touch
: if older caresses or touches the baby
affectionately; slowly, softly)
Over-stimulating touch:
: light quick strokes
: abruptly starts
: taps, pinches (affectionately)
Environmental Factors
6 Adheres to sound protocol
: quiet NICU
: speaks softly
: informs others to speak softly
: promptly silences alarms; cell phones quiet
Loud noise
: speaks loudly in the NICU
: allows others to speak loudly
: makes or does not address noise
7.
Adheres to lighting protocol
: dim NICU during day, darker at night
: when bright light needed, babys eyes are
protected
: eyes and genitals covered under billi-lights
Inappropriate lighting
: not dim NICU during day, or darker at night
: bright lights with no eye protection
: eyes and genitals covered under billi-lights
8. Maintains thermal stability:
: monitors temperature regularly or as part of
a response to unknown stressor
: wraps baby before holding out of cot
: partly wraps or covers the baby for
protection from the cold during the bath
Decreased thermal stability:
: temperature issue is left unaddressed even if
baby is stressed for unknown reason

Family Centered Family Centered
9 Communicates warmly with parents
: greets parents when they enter
: answers their questions in a kind manner
: displays caring and affection for their baby
: explains the NICU equipment when asked
: encourages mom to speak/sing softly to baby
Poor communication with parents
: parents not greeted when they enter
: answers their questions in a kind manner
: displays caring and affection for their baby
: explains the NICU equipment when asked
: encourages mom to speak/sing softly to baby
*MO: Missed Opportunity * : Less Quality
APPENDIX I
By: Amy Carroll, OTD (2014) Modified from (Liaw, Yang, Chang, Chou & Chao, 2009)
39
Division of Neonatology- NICU
Assessment of Infants Stress and
Self-Regulation Responses
(Adapted fromthe Pediatric Rehabilitation Assessment at Holy Reedmer Hospital and Medical Center, Pediatric Rehabilitation Dept.,
Meadowbrook USA).

Behavioral Organization
Vital Signs At rest: HR_______ RR_______ SaO
2
_______
With activity: HR_______ RR_______ SaO
2
_______
Sleep States on Assessment:
a. Deep sleep (no movement, regular breathing) b. Light sleep (eyes shut, some movement) c. Dozing (eyes opening and closing)
d. Awake (eyes open, minimal movement) e.Wide awake (vigorous movement) f. Crying

Stress States: a.Lethargic b.Irritable c.Abrupt Changes d. Slow Transition e. Smooth
Transition
Stress Signs
Autonomic Motor Attention
a. HR b. RR a. Back Arch a. Gaze Avert
c. SaO2 b. Finger/Toe Splay b. Covers eyes
d. Yawn c. Limb Extension c. Panic
e. Hiccough d. Grimace d. Hyper-Alert
f. Sneeze e. Tongue Extension e. Frown
g. Gag f. Gaping Mouth
h. Color Change g. Twitch/Tremor
h. Sit on Air
i. Salute j. Flail
k. Other: ______________________________________
Signs of Self-Regulation (calming)
a.Flexed Posture f.Foot Bracing
b.Finger Grasping g.Seeking Boundaries
c.Hand to mouth h.Sucking
d. Hand to face i.Hands together
e.Requires external support
j. Other:____________________________________
___________________________________________
___________________________________________
___________________________________________
___________________________________________
___________________________________________
Patient Name: _______________________________DOB: ____________________Date:____________________
Gestational Age: ______________________________ Chronological Age: ______________________________
Apgar: _____ @1min _____@5min Present Weight: ________________________________
Medical History: ________________________________________________________________________________
____________________________________________________________________________________________
Comments/Observations: Rest/Routine Care/Procedures:
Recommendations:
Current Medical Status and Presentation
Environment: a. Radiantb.Open Crib c.Bili Lights d.Other_____________________
Oxygenation: a. Room Air b. Nasal Cannula c. CPAP d. NIPPV e. Ventilator
Feedings: a.NPO b.IV c. N/GT d. OG e.Pallada f. Breast
Comments: ___________________________________________________________________________________
Position: a.Side-lying: RL b. Supine c. Head: L C R d. Prone e. Swaddled f. Nested
Resting Posture: a.UE/LE flexed b.only LE flexed c.extended flaccid d.extended stiff e.excessive hip abd/ER
Muscle Tone: a.Normal b.Hypotonic c. Hypertonic d.Opisthotonus
Comments:____________________________________________________________________________________
Patient ID Sticker
APPENDIX II
40
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:
APPENDIX III
41
42
Tel.:011-27353535 E-mail: secnnf@nnf.org

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