Caring for a preterm baby

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Developmental support consists of a variety of intervention strategies in addition to medical care, to protect and promote the growth and development of a baby.  Developmental care includes among others the control of external stimuli, specific supportive behavioural techniques such as the positioning of the baby, skin-to-skin care, or the integration of parents in care activities and in the decision-making regarding the baby’s treatment and care.

Developmental care creates a neonatal unit environment that minimises stress for the baby, the parents and healthcare professionals. It reduces pain and provides a developmentally appropriate sensory experience for the individual baby.

Individualised approaches to family-centred care, where every baby and every family is cared for according to the individual needs, may be more suitable for the child and the family and are based on observation.

Studies suggest that babies who receive developmentally supportive care may stay in hospital for less time and gain weight better. Parents can learn quickly how to recognise when their baby is upset or uncomfortable and how to react. They should be involved in the care for their baby from the early beginning.

Signs that suggest that the baby feels comfortable include among others:

  • Pink skin colour
  • Normal and regular heart rate
  • Gentle, regular breathing
  • Normal oxygen saturation
  • Digesting food without discomfort
  • Gentle movements
  • Firm muscle tone (but not too tight)
  • Arms and legs folded towards body
  • Hands resting on face or head
  • Hands and feet brought together
  • Relaxed face
  • Sucking
  • Shiny alert eyes or eyes closed

Signs that suggest that a baby may not feel comfortable include among others:

  • Changes in skin colour
  • Low or high heart rate
  • Rapid breathing; unregular breathing with pauses
  • Lower oxygen saturation
  • Vomiting (throwing up) or gagging
  • Hiccups
  • Sounds of regurgitation
  • Choking, burping,
  • Frantic movements, tremors
  • Low muscle tone; loss of energy
  • Appears sunk into the bedding
  • Fingers or toes stretched wide; tight fists
  • Arching
  • Stiffness
  • Straining
  • Grimacing
  • Yawning
  • Looking away
  • Crying

When a baby shows any of these signs, the caregiver needs to adjust the care of the baby. This can include diaper changes, comfortable positioning, feeding or regulation of temperature, noise, and light.

The healthcare team and the parents can promote and support the development of the baby in many different ways, for example by:

  • Practicing skin-to-skin care
  • Breastfeeding or providing mother’s milk
  • Placing the hands on the baby’s head and lower back or feet
  • Placing the baby in a nest (rolled-up sheets to form boundaries around the baby)
  • Comfortable positioning
  • Monitoring environmental noise and adapt sound levels
  • Avoiding direct light exposure
  • Maintaining low levels of ambient light
  • Adapting the medical and care procedures to the sleep-wake-cycles of the baby
  • Optimising the pain management

To go home the baby should correspond the following criteria:

  • the child should be capable to maintain body temperature without the warming devices;
  • the child should eat so that parents could feed him independently;
  • the child should gain normal weight;
  • parents should be informed on the child’s status;
  • parents should participate in treatment, understand features of the child and it is correct to perceive signals and needs of the child.

Before leaving the hospital:

  • get acquainted with your child and learn to feel comfortable
  • be involved for the aid to your child in hospital
  • learn methods to console or calm your child
  • learn to change diapers and clothes
  • feed the child as often as possible
  • learn to bathe the child
  • learn to give drugs which your child will receive at home
  • learn treatment methods
  • learn to position correctly the child in a car seat
  • define what doctors will look for the child after going home
  • learn about grafts
  • if the child is going home with the oxygen equipment, learn how to use it
  • take all necessary documents from hospital

Care of the prematurely born baby during the first days at home:

  1. Patronage. Primary patronage to the prematurely born child is executed by the local pediatrician and the patronage sister on the first day at home or on following day. Frequency of observation by the local pediatrician and nurse is set individually, depending on specific conditions.
  2. Care of an oral cavity. Baby’s mouth is very gentle, easily vulnerable and does not require any manipulations if there is no signs of illness.
  3. Feeding. Try to nurse the baby as long as possible: breast milk for prematurely born children is the best vivifying means! If it is impossible to nurse, it is necessary to transfer to special compounds for children weighing less than two and a half kilograms. Usually in the name of these compounds, there is a word “pre”, for example to “frisopre” “alpre”, “pre-nan”, etc.: these compounds contain more protein and fat, it is more than calories and they help baby to gain weight better. It is impossible to give to prematurely born children normal cow’s milk at all — their intestine is not able to process it.
  4.  Bathing. Daily hygienic hydrotherapeutic procedures reduce a nervous and muscular tension of prematurely born children. Air temperature in bathroom have to be not below 24-26 °C, water temperature – 1-2 degrees higher than body temperature. Duration of bathing should not exceed 5 minutes. Not to frighten the kid during the first bathing, it is possible to wrap it in cloth and slowly put it in water. The baby’s head at the same time has to be on a fold of an elbow or on a palm. After bathing wrap baby in a warm towel, dry it carefully applying a towel to a body, in order to avoid traumatization of skin it is not necessary to triturate it. Ears need to be dried with cotton; to clear a nose use twisted cotton.
  5. Outdoors. After coming home it is worth not to walk for 1,5 — 2 weeks. At a temperature minus 10 and lower, you should not walk, but when it is minus 10 and higher it is possible to walk with any baby at the term of a gestation 44-46 is not dependent on weight. The first walk has to be short — only 10-15 minutes. Then make your walks longer until it would be 1-1,5 hours on fresh air.
  6. Body temperature.Preterm born babies are not able to adapt to temperature change the same way as adults do. Compared to their weight, the surface of a preterm baby’s body is about three times greater than the surface of an adult’s. Additionally, preterm babies and babies with low-birthweight have only little body fat. When the body temperature of a preterm baby is too low, they need more energy and oxygen to keep their body temperature. Therefore, it is important to help control the baby’s temperature by providing the optimal temperature in the environment, neither too hot nor too cold. The skin of a preterm born baby should always be dry and warm. Immediate drying and warming after delivery or after bathing can be done with warm blankets and skin-to-skin contact with the mother/ father. Open beds with radiant warmers are often used in the delivery room for rapid warming, for initial treatment, and for ill or late preterm babies who need constant attention and care. Incubators usually have the form of a closed box with several windows. They provide heated air via a fan device and the possibility to add humidity to the air. The environmental temperature in an incubator can be regulated according to the needs of the child. Once a baby is stable, open childcare beds can be used. A baby can lose large amounts of heat through the head. Therefore, the nurses or midwives usually cover the head of a baby with a small hat. Parents can ask healthcare professionals for advice on how to dress their baby in the hospital and at home.
  7. Pain. Just like adults and older children, preterm born babies can experience pain and it can be harmful to their developing brain. Therefore, every possible effort should be made to keep preterm babies pain free. Usually, pain results as a response to an acute stimulus that is likely to lead to injury or tissue damage. With respect to this, pain is an important signal and a vital mechanism to protect humans from possible further damage. Every individual experiences pain in a different way and pain perception can change throughout life, for example because of different experiences during childhood. Feeling pain means that the brain creates the perception of pain by using a complex system of nerves and receptors in the skin, muscles, bones, and organs, and their connections to the spinal cord and the brain. The message of pain is transferred from the pain receptors in the skin and tissue of the body part to the brain and back again to trigger a reaction to the stimulus. Many other types of messages, such as touch or temperature, are also transferred in this way which is important in terms of pain relief because they actually compete with each other. Various procedures have been developed which can help relieve the pain in preterm babies. There are two general types of pain depending on how long pain lasts. Acute pain is short-term, whereas chronic pain lasts for a longer period of time. However, these types are not mutually exclusive. Acute pain, especially if not properly addressed and treated, can also become chronic pain. Given that pain is a mind and body experience, emotional and physical interventions can be considered for assessment and relief of pain. Many preterm or ill born babies in the neonatal intensive care unit undergo one or more painful diagnostic and therapeutic procedures, e.g., blood sampling or surgery. When preparing for certain procedures, healthcare professionals know in advance that pain is going to occur. This allows them to use pain relief measures before the painful procedure starts. There are different strategies available for healthcare professionals to manage pain and stress in newborns including observational tools, pharmacological and non-pharmacological approaches. Observational tools are mainly so called pain scales for the assessment of signs of stress and pain before, during and after an activity to react appropriately according to the stress or pain level of the baby. These tools are also used for education and training of pain or stress behaviour. If the pain or stress level is on a low or moderate level, healthcare professionals might use a non-pharmacological approach to comfort the baby. This may include the reduction of stressful environmental factors (e.g. light and noise), skin-to-skin care, breastfeeding, providing glucose (a form of sugar) to the baby, giving the baby a pacifier to suck, gently touching or holding the baby, and speaking to the baby. The presence of parents can be helpful and supporting for the baby during and after a painful procedure. If needed, the care team will decide to give pain-reducing drugs (analgesics) to the baby. These can be administered in different ways, e.g. via an intravenous line or a tube. Analgesics can be given long-term or as a single dose.
  8. Positioning. The muscle tone is defined as the strength or tension of the muscle. Due to their immaturity, preterm babies usually have a lower muscle tone compared to term born babies. Maintaining a position can be quite challenging for a preterm baby. Movements are sometimes jerky and disorganised. Comfortable, supportive positioning and handling of the baby are important for the development of the skeletal and muscle system. Optimised positioning also helps to minimise stress, to promote breathing, digestion, and circulation, to preserve energy, and to promote the development of crawling, standing and walking. So called nests can be built by folding rolled-up sheets or bedding into a wide, thick band long enough to surround the baby. A nest provides the baby with boundaries with a surface to touch and brace against. These boundaries are similar to the situation in the womb which makes the baby feel more secure. At the same time, the nest can help to keep legs and arms in a developmentally supportive position. There are different comfortable lying positions for the baby. The supine position (i.e. lying on the back) is often used, if babies are unstable and need to be observed regularly. It facilitates acces to the baby, for example to initiate procedures if necessary. This position is also recommended to use at home to ensure safe sleep. The caregivers usually support the baby’s head, shoulders and hips with additional pillows under the head and the shoulders. The lateral position (lying on one side) supports a flexed position with bended arms and legs and allows the baby to adjust his or her own position. Usually, shoulders are rounded and relaxed, legs are bent with boundaries and hands can reach the mouth and face more easily. This position is often used to reduce stress during caregiving activities (e.g. mouth care, nappy change, or tube feeding), medical procedures, and lifting). The prone position (lying on the tummy/breast) may improve oxygen saturation, respiratory function, digestion, and sleep. Babies may lose less heat and energy. However, this position should only be used when the baby is monitored continuously and should not be used at home due to the risk of Sudden Infant Death Syndrome (SIDS).
  9. Sleep. Prematurely born babies sleep more hours a day, than ordinary children. It depends on degree of their prematurity. At I and II degrees aged up to two months there have to be 4 day dreams for 2-2,5 hours each; from two to five months — 3 day dreams for 2 hours each; and from five months to one year — 3 day dreams for 1,5-2 hours. At III and IV degrees, kids up to three months have to have 4 day dreams for 2,5 hours; from three to six months — 3 day dreams for 2,5 hours; from six months to one year  — 3 day dreams for 2,5 hours. Awakening of the kid has to be soft and delicate. It is possible to stroke the kid, tenderly to talk to him, only after that it is possible to take him on arms. To lay baby on a stomach helps to strengthen muscles of a nape, extremities, a stomach. To lay baby on a stomach is recommended from 3 weeks. Babies have two sleep states: deep or quiet sleep and active or light sleep (also called rapid eye movement or REM). Additionally, they also experience other “behavioural states” raging from drowsiness, being quietly or actively awake, being fussy to crying. It is not always easy to know in which behavioural state a baby is in. However, understanding the different behavioural states can help parents to know when their baby will be ready for interaction and when it is time to support their baby to get some rest. 1. Deep/quiet sleep: In this state a baby moves very rarely apart from occasional startles or mouthing. The breathing is slower and more regular than in the other stages. After 32 weeks gestational age this sleep state becomes more noticeable. 2. Light/active sleep: In this sleep state the eyes of the baby are closed, but slowly rolling eye movements, also called rapid eye movements (REM) can be observed.  Breathing tends to be faster and more irregular and a baby may briefly open the eyes or make sucking movements. For adults, this stage is associated with dreaming. In this state, brain connections are also modified which is particularly important for the developing brains of babies. 3. Drowsy: In this stage a baby’s eyes may open and close, but have a shiny appearance. It is also called half-awake, as the baby may be in a stage of waking up or falling back to sleep again. In this stage the care givers can either support the baby to fall back to sleep again, e.g., by putting the hands gently on the head and feet of the baby, or start to gently wake up the baby for a care procedure, e.g., a nappy change. 4. Quietly awake: When babies grow and mature, they can achieve a stage where they have wide-open eyes with a bright look and a relaxed facial expression. Babies in this state can focus on a voice, face or object. It is a good time to have care procedures such as feeds, or skin-to-skin care. 5. Actively awake: At this state a baby’s eyes can be open or closed. The child may seem restless or troubled, making movements often accompanied by grimacing or sounds. In this stage, the baby needs help to settle again and to cope with the environment. 6. Crying: Crying is the most stressful state for the baby, the parents, and the health care team.  During crying the baby shows generalised movement with agitated sounds, grimacing, and crying expression of the face. Breathing may be irregular and skin colour can change. It is important: The involvement of parents can also improve the sleep of a preterm baby. Parents interact with their baby in a different way and can take more time to manage transitions and to settle their baby to sleep. Additionally, the skin-to-skin care and the parents’ voice can promote sleep.

This information is based on materials from www.efcni.org. Special thanks to EFCNI for their support and advice 

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