Growing Preterm 33 to 36 Weeks

 

Assessment

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

Handling and Interventions

Behavioral Development 

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

Nursing Implications

  • Interventions or opportunities for sensory experiences should take place with consideration of infant cues and ideally when an infant is in an awake state. 
  • Slow controlled and gentle handling during caregiving. Gently prepare infants for handling with a soft voice or gentle touch to help infant minimize stress and remain stable.
  • Contain (head and hands in the midline, shoulders forward, lower limbs in neutral towards the midline) or swaddle infant during uncomfortable or noxious procedures.
  • Patting or stroking may be better tolerated at this age.  Monitor infant’s cues.
  • Hold infants during feeding if awake - this includes during tube feeding.  Offer pacifier for pre-feeding skill development.
  • Where clinically possible consider day/night patterns for interventions.  For example, weigh infant, take blood pressure and change bedding in the daytime as able.
  • Introduce kangaroo care when medically stable.  Nuzzling at the empty breast as appropriate in preparation for breastfeeding.

Positioning

Motor Development

  • Smoother and more controlled movements are present at this gestational age.
  • Stronger flexion of knees and hips during rest and development of tone in the lower extremities occurs at this age.
  • Infant can turn own head from side to side.
  • Infant has improved capability to use posture and movement to self regulate (calm themselves).

Nursing Implications

  • Use supportive positioning techniques to enhance flexion and promote comfort.
  • Opportunities for movement should always be possible.  Provide boundaries using nested bedding, blanket rolls and/or Snuggle-up for infants in isolettes to enhance flexion, promote midline and improve symmetrical development.
  • Continue swaddling at this age to help control over body movements to develop. 
  • Swaddle infant for bathes to minimize infant stress.
  • Infants in cribs should be positioned on their backs (SIDS recommendation unless a special medical order) in a position allowing hand to mouth contact.
  • For infants in cribs who display limited flexion continue to provide a nest of bedding. No nests or blankets around face. 
  • Vary the position of the crib or the infant’s head for proper development.

Light and Vision

Development

  • Increased ability to maintain lid tightening in response to bright light.
  • Eye opening and alert state are improved with low lighting.
  • Infant may have difficulty breaking gaze on a highly stimulating object. 

Nursing Implications

  • Protect infant from bright lights during care giving and procedures. Reduce exposure from light in isolettes by using a cover.  Provide eye protection for infants receiving phototherapy and shield light from infants in adjacent isolettes or cribs.
  • Support emerging need for eye contact.  Generally infant shows preference for human faces at this age. 
  • Research does not support the use of black and white visual stimuli. 
  • Dim the lights at night if safe to do so, whereby promoting development of circadian rhythms. 

Sound and Hearing

Development

  • Sensory and transmission portions of the auditory system are functional.
  • At this age there is increasing responsiveness to voices with a preference for a soft human voice.
  • Responses to noise and auditory environments begin to organize.
  • Startle response with loud noise still evident 

 

Nursing Implications

  • Minimize 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 music in room.
  • Discourage the use of the top of the isolette as a writing surface or a storage area.
  • Ensure CPAP and Ventilator tubing is regularly cleared of H2O
  • Talk softly to your baby as cues allow.
  • Music and audiotapes are not recommended for this gestational age group. 

Non-Nutritive Sucking

Development

  • Suck, swallow and breathe coordination is maturing.  Developing rhythm with sucking but coordination can be inconsistent.
  • Rooting reflex emerges. 
  • Nipple feeding usually tolerated. Refer to Feeding Readiness Scale and consider infant readiness cues prior to oral feeding.

Nursing Implications

  • Encourage hand to mouth contact. 
  • Offer standard small pacifier to encourage wider jaw excursion 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. 

Smell and Taste

Development

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

Nursing Implications

  • Encourage parents to hold infant during NG/OG feedings. Continue to offer pacifier as tolerated.
  • Protect from noxious odors. Open alcohol wipes and antiseptic preparations away from the incubator and infant.
  • Avoid use of scented perfume.
  • Dip pacifier or cotton swab in milk to offer tastes to infant.