Assessment

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

Handling and Interventions

Behavioural Development

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

Nursing Implications

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

Positioning

Motor Development

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

Nursing Implications

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

Light and Vision

Development

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

Nursing Implications

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

Sound and Hearing

Development

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

Nursing Implications

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

Non-Nutritive Sucking

Development

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

Nursing Implications

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

Smell and Taste

Development

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

Nursing Implications

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

Parents

• Promote parental independence and enjoyment of maturing infant.
• Offer opportunity for education on deep-water bathing, massage techniques and infant development. ^{3, 5}

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