DEVELOPING PRETERM INFANT

(28 to 32 Weeks Gestation)

Assessment

·  Observe infant’s cues and behavior.

·  Assess the infant’s response and ability to tolerate activities. Monitor for signs of stress and exhaustion. 

·  Identify infant’s readiness for touch and handling.  Infants this gestational age generally have a low tolerance for stimulation.

Handling and Interventions

Behavioral Development 

·         Quiet/ deep sleep increases around 30 weeks.

·         Behavioral states gradually become more distinct by 32 weeks.

·         Response to handling results in physiologic instability.

·         Infant displays more typical signs of stress. 

Supportive Interventions

·         Provide opportunities for undisturbed rest. Cluster cares and 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.

·         Interventions should ideally take place when an infant is in a gently aroused state and with consideration of infant’s cues. Use slow controlled and gentle handling techniques. Abrupt/fast changes in position are likely to be poorly tolerated.

·         Gently prepare infant for handling with a soft voice or gentle touch to help infant maintain stability and minimize stress response. 

·         Vary infant’s position being mindful of physiological status and response to handling. This will help facilitate normal development.

·         To soothe infant during uncomfortable procedures contain infant.  Help infant maintain head and hands in midline, shoulders forward, lower limbs flexed and adducted towards the midline.   Elicit the help of others if necessary.  Avoid stimulating the infant with patting and stroking.  Use continuous touch principles.

·         Where clinically possible consider day/night patterns for interventions.  For example weigh infant and change bedding in the daytime.

·         Introduce Kangaroo Care when medically stable.

·         Consider sucrose for infants >31 weeks gestation for support during invasive or uncomfortable procedures.

Positioning

Motor Development

·         Twitches and startles are common at 28 weeks leading to more controlled movements by 32 weeks.

·         Muscle tone is weak but develops slowly over this gestational period.

·         Leg movements increase with beginning flexion of hips and legs.

Supportive Interventions

·         Use supportive positioning techniques to enhance flexion and promote comfort. Opportunities for movement should always be possible but supported.

·         Provide boundaries using nested bedding/blanket rolls, or Snuggle–up.

·         Always contain infant when being transferred to and from the incubator.

Light and Vision

Development

·         Sluggish pupil response to light is typical at this gestational age.

·         Infants are able to maintain lid tightening in response to bright light.

·         Eye opening increases in dim light.

·         Infant may focus briefly on visual stimuli.

·         Rapid uncoordinated eye movements are present

Supportive Interventions

·         Minimize light levels where possible. Protect infant’s eyes from bright light during caregiving and procedures. Reduce exposure to light in the isolette by using a cover. Provide eye protection for infants receiving phototherapy and shield light from infants in adjacent isolette/cribs.

·         Minimize visual stimuli. Toys and pictures should not be placed within direct visual space. 

·         Dim the lights in the room at night if safe to do so in an effort to enhance development of circadian rhythms.

·         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. 

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.

Supportive Interventions

·         Minimize environmental noise. Be aware of sounds/noise levels in NICU.

·         Attend to alarms promptly and set alarm volume as low as is clinically safe. Decrease telephone ring volume and no radios in rooms or music in rooms.

·         Close isolette doors quietly. Do not tap or bang on isolette. Discourage the use of the top of the isolette as a writing surface or storage area.

·         Ensure CPAP and ventilator tubing is regularly cleared of H₂O.

·         Talk softly to your baby as cues allow.

·         Music is not recommended for this gestational age group.

Non-Nutritive Sucking

Development

·         Rooting reflex is present but a delayed response can occur.

·         Poor suck, swallow and breathe co-ordination that matures over this period. 

Supportive Interventions

·         Keep oral experiences pleasurable.

·         Encourage hand to mouth contact.

·         Nipple feedings are generally unsafe at 28-33 weeks gestation. Infants > 32 weeks gestation may nuzzle at the breast during Kangaroo Care with close assessment. 

·         Offer pacifier to support non–nutritive sucking.

·         Encourage non-nutritive sucking during NG/OG feeds for feeding association and for comfort. 

·         Oral suction only when clinically necessary.  

Smell and Taste

Development

·         Taste and smell receptors are functional.

·         Physiologic responses to unpleasant olfactory stimuli have been documented by research. 

Supportive Interventions

·         Familiarize infant with the smell of breast milk by using milk soaked swab prior to and during a feed. Discard immediately after use.

·         Use expressed breast milk soaked swab for oral care.

·         Protect from noxious odors.

·         Open alcohol wipes and antiseptic preparations away from the isolette and infant.

·         Avoid use of scented perfume.