Assessment

• Assess infants response/ability to tolerate activities. ¹
• Monitor for signs of stress Infants may display increased tolerance for handling but watch for signs of exhaustion in infants with residual respiratory compromise. ²

Handling and Interventions

Behavioural Development 

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

Nursing Implications

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

Positioning

Motor Development

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

Nursing Implications

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

Light and Vision

Development

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

Nursing Implications

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

Sound and Hearing

Development

• Sensory and transmission portions of the auditory system are functional.
• Increasing responsiveness to voice stimuli with a preference for soft human voice.
• Responses to noise and auditory environments begin to organize.
• Startle response with loud noise still evident  ^{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.
• Discourage the use of the top of the incubator as a writing surface or a storage area.
• Ensure CPAP and Ventilator tubing is regularly cleared of H₂O
• Encourage parents to talk softly to their baby as cues allow.
• Audiotapes are not recommended for this gestational age group.  ¹²

Non-Nutritive Sucking

Development

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

Nursing Implications

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

Smell and Taste

Development

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

Nursing Implications

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

Parents

• Promote early and continued parental involvement.
• Encourage parents to observe their infants behaviour /cues.
• Promote independence by encouraging parents with feeding and cares, in particular containment during and after handling, top and tail wash or bath and Kangaroo care. 
• Offer information and opportunities for education on preterm developmental care. ^{3, 5}

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