NICU Program

Know your premmie

While your preterm baby is in the NICU you may experience a lot of emotions from loss, guilt, self-blame, anger, anxiety, depression and many more. These are all normal, since the birth of a preterm baby is similar to the loss of a baby. Remember, you've lost the opportunity of experience a normal pregnancy and birth, but most of all to take a healthy, full term baby home. However, the following information intends to support you on this roller-coaster ride and aims to help you experience the wonders of a preterm baby by Adjusting your Dream.

In the fetal development section we've discussed the preterm baby behaviour depending on her gestational age. Keep this in mind when you get to know your little one.

Before even touching or interacting with your baby it is important to observe her and read the cues she is giving. Your baby has different behavioural stages and behavioural cues that will help you give her the appropriate care at the right time. A behavioural stage (turning-in, coming out or reciprocity) will tell you whether your baby is ready for interaction or whether you should rather not handle her at the time, since she is already experiencing stress.

A baby needs to cope on five different levels, known as subsystems.

1. Autonomic system that ensures the functioning of all the automatic activities, such as heart rate, blood pressure, breathing and oxygen levels in the blood.

2. The motor system (muscle movements) includes the flexed posture and limb-and-trunk movements.

3. The state organisational system is the states of consciousness (sleep and wake states)

4. The attention-interaction system is the different awake states that are associated with the ability to interact.

5. The fifth system is the self-regulatory system.

For more detail on the different subsystems, you can read Chapter four of Prematurity - Adjusting your Dream.

Sleep and awake stages

Babies have two sleep stages, namely quiet sleep and active (rapid eye movement or REM) sleep. They also experience awake stages that can be categorised in quite alert, drowsiness, active alert and then crying.

Quiet Sleep

Quiet Sleep is when your baby's eyes are tightly shut and still; breathing regular and almost no activity is seen except for startles or mouthing.

Active sleep is when the eyes are closed with slow rolling movements or REM (rapid eye movement); she may briefly open her eyes, has irregular breathing and make sucking movements. She may have movement of the limbs from minor twitches to stretching movements and your baby may respond to voices and other noises.

Active sleep

Drowsy

Drowsy is when your baby's eyes open and close, but with a glazed appearance and dull eyes with droopy eyelids when the eyes are open. Her breathing is faster and shallower than in quiet sleep and she has increased movement with mild startles. Response to voices and other noises may be delayed.

Quiet alert babies have wide-open eyes with a bright and shining look. They can focus attention on face or objects, little or no body movement or facial movements and regular breathing. This is a good time to feed, talk, look at or hold your baby. Premature babies may spend time in quiet alert normally only after 32 weeks gestation, and before this time only be awake for a maximum of two minutes a day.

Quiet alert

Active Alert

Active alert is the stage when the eyes are generally open. Generalised movements are often accompanied by grimacing and / or brief vocalizations and the baby has regular breathing. It may be difficult to get the baby to interact, since she is struggling to cope with her environment.

Fussing/Crying is a stage that any parent or caregiver wants to avoid, since it is so stressful to the parent and the baby. During crying or fussing the baby shows generalised movement with agitated vocalization, which ranges from mild fussing to continuous crying. She also has irregular breathing and colour changes (red or pale).

Fussing or Crying

Since your baby cannot talk to you her only way of communication is through non-verbal (body) language. When someone, either you or the nurse, is handling your baby, your little one will tell you through her body language whether she is ready for the activity or not. Your baby may show either readiness or avoidance (or stress) cues.

Readiness cues, also known as self-regulatory behaviour is the techniques a baby use to interact with her environment and if the environment is unsupportive, these techniques help her to cope. Some of this self-regulatory behaviour includes non-nutritive sucking, foot bracing, hands to chin, grasping and hands to face. You can help your premmie to reach self-regulation by supporting her with lots of skin-to-skin contact, positive touch techniques, positioning and protection from the harsh NICU environment.

Swaddling

Hands-to-Mouth

Nesting

Stress Cues

Frequent handling and even routine procedures disturbs sleep, which leads to decreased weight gain, decreased state regulation and low oxygen levels in the blood. Even noise and bright light can cause stress in the preterm infant. The premmie will show her inability to cope with her environment through stress cues. Some stress cues you may see in your premmie are:

Physiologic/ autonomic (Automatic Functions)

Colour changes - pallor or flushing
Changes in vital signs (e.g. Heart rate, breathing)
Hiccups
Spitting up
Sneezing
Yawning

Yawning	State subsystem (States of consciousness) Irritability Diffuse sleep states - grimacing, twitching Glassy eyes Gaze aversion Staring Panicked look	Gaze Version
Frowning	Looking Away	Crying

Motor subsystem (Muscle Movements)

Hyperextension of extremities - saluting, arching, airplane, sitting on air, "stop" sign
Frantic movements
Finger splaying
Generalised hypotonia - low muscle tone

Extension of Extremities	Arching	Toe Splaying
Finger Splaying	Fatigue	Sitting on Air

Attention/interaction (Awake stages, ability to interact)

Yawning Yawning

Avoid interaction Looking Away

"Stop sign"

A baby that is tired or over stimulated will send out a signal that says, "I need a break!" These time-out signals tell us to stop what we are doing and give the baby a rest. You saw examples of these time-out signals or stress cues. Look for these signals whenever you do an activity with your baby. Ask your baby's nurse to help you identify these signals. Remember that it takes practice to learn to identify them.

Read more on stress cues in Chapter 4 of Prematurity - Adjusting your Dream.

Calming the premmie

Handling of the preterm baby must be based on two critical components: individualisation of care and timing. Stress can be minimised for your baby if the caregiver is able to identify individual stress signals and respond appropriately, time interventions to allow for undisturbed rest periods, and provide "time-out" for your baby to re-organise during stressful procedures. Your baby can be helped to re-organise by following the steps of positive touch, such as still touch, containment hold and skin-to-skin care.

Stroking is a natural and instinctive action for parents, but for a fragile baby it might be too much to tolerate, since the premature baby may experience stroking as painful. Instead of stroking you can rest a hand on your baby. This is known as still touch.

Containment hold is when you cup the premmie's head and one other body area with a steady hand giving positive gentle pressure. Movement should always be gentle, firm and rhythmical started on a body part the baby seems to like being touched. E.g. hold your baby firmly against your chest and rock her body slowly. Only start if baby is physiological stable and seems to tolerate the touch.

Massage As for movement, stroking can begin in a formal sequence. Massage in premature babies should be done with extreme care, since it may have negative effects. This should only be done in babies that are stable and seems to tolerate touch well. Massage should preferably not be started before the baby is in the reciprocity stage.

You can also implement the following to prevent:

Avoid more than one stimuli at a time - only talk or touch.
Prevent visual over-stimulation by using busy toys, eye contact, bright lights and colours.
Handle your premmie slow and gentle and keep her in flexion, midline and contained.
Provide time-out when she seems stress while you are caring for her.
Stop and do still touch or containment hold till she calms down and then continue with nappy change, or what you were busy with.

More ways to help calm your baby

Hold your baby firmly but gently in a curled position. Place your hand on your baby's feet and on head or shoulders to help your baby curl up and relax.
Swaddle your baby in a blanket. Bend the legs up and bring the arms to the middle of the body. Leave your baby's hands free to find the mouth.
Help your baby bring one hand up to the mouth. Let your baby suck on a fist, thumb, or fingers. Try a pacifier, too.
Give your baby your finger or a small washcloth roll to hold.
Place your baby on the side and surround with blanket rolls. These blanket boundaries will keep your baby in a curled position and provide a feeling of security. This is called "nesting".
Check with the nurse looking after your baby before trying these suggestions and ask her to show you how to best perform these calming activities with your baby.

Imitate Fetal position Flex hands and feet onto the body	Imitate pressure and closeness of womb	Use still touch and resting hands
Support hands in midline - close to face & mouth	Provide sucking & grasping opportunities	Avoid light stroking - over-stimulating
Hold hands cupped around head and back / feet	Provide one stimulation at a time (talk / touch)	Relax and Enjoy your Baby

Chapter five of Prematurity - Adjusting your Dream is full of ideas on how to interact with you baby depending on her developmental stage.