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

Nursing Implications

• Provide opportunities for undisturbed rest. Cluster cares but avoid completing a number of potentially distressing interventions at the same time. If an infant indicates signs of stress during handling- stop and provide ‘time out’ for the infant to recoup after that intervention. ⁴
• Interventions should ideally take place when an infant is in a gently aroused state and with consideration of infants cues. Slow controlled gentle handling. Abrupt/fast changes in position are likely to be 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 facilitate physiological stability and state organization. ⁵
• Vary infant head and body position- mindful of 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 the help of a parent or another nurse. Avoid stimulating the infant with patting and stroking. 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.
• Consider sucrose for infants >31 weeks gestation.

Positioning

Motor Development

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

Nursing Implications

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

Light and Vision

Development

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

Nursing Implications

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

Sound and Hearing

Development

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

Nursing Implications

• Minimise environmental noise. Be aware of sound/noise levels in NICU. Talk softly at the bedside.
• Attend to alarms promptly and set alarm volume as low as is clinically safe. Decrease telephone ring volume 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 or storage area.
• Ensure CPAP and ventilator tubing is regularly cleared of H₂O.
• Encourage parents to talk softly to their baby as cues allow.
• Music audiotapes are not recommended for this gestational age group. ¹²

Non-Nutritive Sucking

Development

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

Nursing Implications

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

Smell and Taste

Development

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

Nursing Implications

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

Parents

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

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