Assessment

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

Handling and Interventions

Behavioural Development

• Behavioural states are poorly differentiated. ³
• Response to handling results in physiologic instability.
• Indicators of physiologic instability can be diffuse-ranging from typical stress signs to exhausted collapse .³

Nursing Implications

• Provide opportunities for undisturbed rest. Cluster cares but avoid completing a number of potentially distressing interventions at the same time. If an infant indicates signs of stress during handling - stop and provide ‘time out’ for the infant to recoup from that intervention. ⁴
• Interventions should ideally take place with consideration of infant cues.
  Slow controlled gentle handling.
  Abrupt/fast changes in position are poorly tolerated. ^{2, 4}

  Click here to see a video of a baby being gently turned and then contained

• Gently prepare infant for handling with a soft voice or gentle touch to help promote physiological stability and state organization. ⁵
• Vary infant head and body position-mindful of infant physiological status and response to handling.
• To soothe infant during uncomfortable procedures contain infant-head and hands in midline, shoulders forward, lower limbs flexed and adducted towards the midline. ²  Elicit help from a parent or another nurse. Avoid stimulating the infant with stroking or patting. ³

  Click here to see a video of a baby being contained

• Where clinically possible consider day/night patterns for interventions. ⁴ For example weigh infant and change bedding in the daytime.
• Introduce Kangaroo Care when medically stable.

Positioning

Motor Development

• Movements are mainly jerks, twitches and startles that can increase with stressful input.
• Weak muscle tone. Decreased flexion in limbs, truck and pelvis.
• Unable to control posture, movement and tone. ³

Nursing Implications

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

Light and Vision

Development

• Eyelids may be fused at 23-25 weeks.
• Cornea hazy until 27 weeks. Pupil reflex is absent.
• Limited ability to maintain lid tightening in response to light.
• Eyes may open but do not focus.
• Infant typically responds to light / visual stimuli with behavioral and physiological signs of stress. ³

Nursing Implications

• Minimise light levels where appropriate. Protect infant’s eyes from bright light during care giving procedures. Reduce exposure to light in incubators by using a cover. Provide eye protection for infants receiving phototherapy and shield light from infants in adjacent incubators/cots.
• Visual toys and pictures are not appropriate for this gestational group. Ensure toys and pictures are not placed within direct visual space. ⁹
• Dim lights in room at night if safe to do so, to enhance development of circadian rhythms. ¹⁰

Sound and Hearing

Development

• Inner ear has attained full adult size and function.
• Infant may respond to soft voice and sound and may show preference for mother’s voice.
• Infant may demonstrate physiological instability to noise/auditory activity. ^{3, 11}

Nursing Implications

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

Non-Nutritive Sucking

Development

• Immature gastrointestinal system.
• Gag reflex present at 26 weeks gestation.  Sucking may appear but not synchronized with swallow. ^13-15

Nursing Implications

• Encourage hand to mouth contact.
• No pacifier unless sucking cues evident.
• Suction orally only when clinically necessary. ^13-15

Smell and Taste

Development

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

Nursing Implications

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

Parents

• Promote early and continued parental involvement.
• Encourage parents to observe their infants behavior /cues. Emphasize infant’s low tolerance for stimulation. Encourage parents to assist with cares where they can (in particular, gentle touch and containment).
• Offer information and education on preterm developmental care. ^{3, 5}

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