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Introduction

Progress in medical technology and the Neonatal Intensive Care Unit (NICU) have made the survival of smaller and smaller infants possible. As a result, we now have a new kind of human being: The Preterm Infant.

Of course, preemies are in many ways small versions of the full term infant. But preemies also are very different from full term infants, and they live in a world that is very different from that of either the fetus in the womb or the full-term infant at home. Therefore, it is unfair to think of the preemie as either a fetus or a mini full-term baby: preemies are unique, and deserve unique and special treatment.

The preemie of 24 weeks gestational age would normally expect about 16 more weeks in the womb, where:

• oxygen and food are provided by the placenta, thus there is no need to breathe or digest.
• temperature is comfortable and stable.
• there is protection from injury.
• the effects of gravity are not felt, and the baby moves easily and stays comfortably curled-up (flexed).
• there is constant motion, thus the baby is rocked gently much of the time.
• the baby feels the rhythms of the mother's changing day-night activity.
• the baby's nervous system does not have to respond to lots of different kinds of things (sights, sounds, touches).
• there are no intense lights, sounds and touches, although the baby does hear his/her mother's rhythmic heart and bowel sounds, can hear speech, and feels gentle touch from his/her own limbs and the fluid and sides of the womb.

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Understanding Preemie Development

Why does my baby not act like a full-term baby?

To learn about what infant's do, it is helpful to think about five areas of development. These areas are parts of the whole system, the whole baby. These areas of development are controlled by the brain and develop in cooperation with each other.

The five areas of development are:

Physiological

things that happen automatically, such as breathing, heart rate, color changes, digestion, bowel-movements

Motor

posture, movements, muscle tone

States of Consciousness

levels of sleep and being awake, and changes from one to the other

Attention

The ability to focus on a message, such as to turn to sounds and look at faces and other objects; this leads eventually to being able to respond socially - to interact with - people.

Self-Regulation

The ability to keep the other areas in balance, for example, the ability to calm down (reduce motor activity and change from a state of crying to being quietly awake) when upset, by tucking limbs close to body, bracing self against side of crib, or sucking on hands.

Because the nervous systems (brains) of preemies are not as mature as those of full-term babies, development in these five areas is not as far along as in a full-term baby.

For example, you may find your preemie has:

• Immature physiologic development, as seen when:
  • the baby changes color often
  • breathing or heart rate is uneven
  • the baby gags easily.
• Immature motor development, as seen when the baby:
  • twitches, is tense or stiff, trembles
  • is limp
  • can't stay curled up.
• Immature control over states of consciousness, as seen when the baby:
  • can't become alert, or stay alert for long
  • is generally fussy.
• Immature development of attention, as seen when the baby:
  • can't focus on you
  • becomes worn out trying to respond to you.
• Immature self regulation, as seen when the baby:
  • has a hard time calming down after being disturbed
  • has trouble handling several kinds of things going on at the same time, e.g. having you talk to and look him/her in the eyes at the same time, or talk while also feeding.

What Can My Baby Do?

Hearing - The Auditory System

Hearing is fairly well developed by 20 weeks gestational age (GA).

By 25 to 28 weeks GA, the preemie responds in different ways to different sounds. For example:

• Attends more to - shows more interest in - voices than other sounds.
• Shows dislike (by frowning or startling) of loud noises, such as a machine alarm or loud voice.
• Can pick out the mother's voice (which he/she has heard in the womb) and prefers it over other voices.

What sounds do preemies hear?

• By 28 weeks GA, sounds of about 40 decibels (dB) loudness (between normal speech at 50 dB and whispers at 30 dB).
• At full term, sounds as soft as 20 dB loudness, equal to what an adult with good hearing can hear.
• Sounds with low and medium pitches better than high-pitched sounds.

Seeing - The Visual System

Seeing takes longer to mature than hearing and touch, but progress occurs rapidly between 22 and 34 weeks of gestational age (GA).

• At first, preemies spend only very brief periods of time with their eyes open, and do not focus on anything.
• By 30 weeks GA, preemies will respond in different ways to different sights.
  • They respond to bright light by blinking or shutting their eyes, but in softer light will open their eyes and focus on objects.
  • They can scan an object with their eyes, even though they can't yet control the movement of their heads.

Infants don't see as well as adults.

• They are nearsighted (can only see things up close). They see best when objects are about 8 to 10 inches away from their faces.
• Preemies take longer to focus on an object than do full term infants, and their vision is not as clear as either full-term infants or adults.

Sleeping and Waking - The Behavioral State System

What a baby does and how he/she reacts to what is going on depends a lot on the state of sleep or wakefulness the baby is in. For example:

• A baby who is in a deep sleep is hard to wake up and will try hard to go back to sleep; a baby in light or dream sleep can be waked quite easily and is more likely to stay awake.
• A baby cannot focus on your face when in the drowsy wake state, no matter how hard you try to get his/her attention, but can if in an alert state.

Babies have two sleep states, an in-between sleep-wake state, and three wake states. At first the states are hard to tell apart, but they become more clear as the baby grows. The amount of time a baby spends in each state also changes as the baby grows. Both of these patterns of change reflect the gradual maturing of the brain and nervous system.

Sleep States

• Deep sleep (also called Non-REM or quiet sleep) - The baby is very still. Every now and then there is a sigh or startle. Breathing is quite even. Deep sleep is thought to be the more restful stage of sleep, and important for growth. Young preemies have very little deep sleep, and there may be more little movements and less even breathing.
• Light sleep (REM or active sleep) - The baby may move quite a bit and make little noises; breathing is uneven; eyelids often flutter (Rapid Eye Movements [REM]), and eyes may open briefly or be kept slightly open for long periods of time.

  Young preemies spend most of their time in light sleep. Very young preemies don't move as much or have as much REM as older preemies.

• Sleep/wake Transition - It is hard to tell whether the baby is asleep or awake, as when the baby is beginning to wake up. The baby moves quite a bit, may grunt and open eyes briefly, but may go back into light sleep several times before really waking up.

  Young preemies may be in this state quite a bit.

The Pattern of Sleep States

A full term baby spends about 15-20 minutes at a time in deep sleep and 65-70 minutes in light sleep. A young preemie may spend only 2-5 minutes in deep sleep before going back into light sleep. All infants (preemies, too) go to sleep into light sleep, and if not disturbed, wake up from light sleep.

The pattern of more light than deep sleep changes slowly over the first year to the adult pattern of spending more time in deep than light sleep. Thus a gradual increase in the amount of deep sleep shows that the brain is growing as it should.

At term age (40 weeks), preemies still do not have as much deep sleep as the full term. However, if light levels are lower at night than during the day during their "growing" period in the NICU, they may progress faster.

During each sleep period, infants go through two or three light-deep-light sleep cycles. It is important that they be able to go through this cycling. That is a big reason for trying not to disturb infants during their sleep periods.

Wake States

Just as there are levels of sleep, babies also have several levels of being awake:

• Drowsy - The baby's eyes open and close, looking like he or she can hardly stay awake or is having trouble waking up. Sometimes the eyes are open, but the baby is "dazed out", not looking at anything. There is usually not much movement.
• Active awake - The baby is awake, but is not really looking at anything. Eyes may be open or closed, and the baby is usually quite active. This is often the state the baby is in when fussing or crying.
• Alert - The baby is awake with eyes open and is looking around (scanning). Preemies often have a "not very alert" state, in which they seem to be trying to focus but don't have the wide open, shiney eyes of a fully alert baby.

Fussing/Crying

Some experts describe fussing or crying as a separate behavioral state, others describe it as a behavior that can occur in many states.

• Fussing/crying - This is a pattern we recognize in any aged infant. It usually happens during active wakefulness. But fussing can occur in light sleep, and as they get older, infants may be able to cry and stay alert, although this is hard for them to do. The very young preemie may but not have the strength to make any noise when fussing or crying.

The Pattern of Wake States

Before 26-27 weeks, it may be hard to tell whether the preemie really wakes up. There is no alert state.

Between 27 and 30 weeks the preemie usually can become alert only for a very short time. When awake, the preemie is either drowsy or active awake. The time spent alert gradually goes up as the baby grows, and the amount of active awake goes down. Thus increasing alertness is another sign that the brain is growing well.

The baby needs to be alert to attend to (think about) what he/she sees. This is a very important form of learning. Alertness is also very important for interacting with people, and therefore is related to social development.

At full term age (39-40 weeks), preemies still are not spending as much time alert as a full term baby does. However, many of the things now being done in NICUs to help preemies grow well (see section on Developmental Care) may help them be more alert earlier.

Communicating

Your baby talks to you through his/her behavior and you can learn to understand or "read" your baby's behavior. You can learn who your baby is, what his/her behaviors mean, what he/she likes and doesn't like.
For example, there are cues, or signs, a preemie gives when stressed and others when stable:

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How to Help Preemies Develop Well

How can I parent my preemie?

There are many things that you can do to help your baby progress in each of the five areas of development described under Understanding Preemie Development:

• Learn to read your baby's behaviors - You will come to know when your baby is stressed and needs some rest time, and when he or she is relaxed, can be handled, and is ready to respond to you.
• Learn how to interact with your baby - What are the things he or she likes, doesn't like; what are the best times during the day; how long at a time does he/she have the strength to respond to you?
• Make the environment as comfortable for the baby as you can:
  • keep light and noise levels moderate.
  • keep the baby's position flexed.
  • allow undisturbed periods of sleep.
  • provide opportunities to interact when he/she is awake.
• Accept that each baby is different and may be a challenge to understand, and that progress will take time.
• Give yourself permission to feel disappointed, helpless, or incompetent when you can't figure out what the baby wants or needs; your baby may not know, either. Feel happy and proud when you can read your baby. The important thing is that you are trying to understand what your baby is telling you.
• Trust your instincts - You have known you baby longer than anyone.

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Giving "Developmental Care"

Many nurseries are finding ways to help preemies develop as normally as possible during their stay in the hospital. This is called giving the preemie "developmental care".

Developmental care is designed to:

• prevent the brain from being injured by intense or painful stimulation, and
• provide the kinds of every day experiences that, to the best of what we know now, will help the baby to develop normally in all of the 5 areas.

A major goal of developmental care is to protect the preemie's brain and central nervous system, which control the five areas of development discussed in the Introduction. Those areas (physiological, motor, sleep/wakefulness, attention, and self-regulation) are the base for the baby's motor, mental and social development.

Why is Developmental Care important?

A number of researchers have studied preemies up through school age, and have found that they are more likely than children born full term to have problems with learning, coordination, language, and behavior (for example, paying attention, sitting still). Because there is a lot of research that shows that what happens to animal and human infants on a day-to-day basis affects the way that the brain develops, we think that some of these problems may be due to the fact that the preemie's early months were spent in a world that is very different from and more stressful than that of most human babies.

Studies of developmental care have shown that by making the NICU world more "baby friendly", some of these problems can be prevented.

What happens with Developmental Care?

Developmental care gives attention to the preemie's:

• Physical Environment
• Social Environment
• Individuality - Understanding Your Preemie as a Person

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The Physical Environment

In the physical environment of the NICU, there is a lot of equipment being used in and around the baby; a lot of people and machines that make noise; lighting that is often kept very bright so that the doctors and nurses can see well as they care for the baby; a place to stay (an isolette or radiant warmer) that does not make it easy for the baby to stay in a relaxed, curled up position; and many treatments that may be stressful or painful for the baby (e.g., suctioning, heel sticks for blood tests, having IVs placed, having X-rays or ultrasound, etc.). These treatments may mean that the baby is disturbed many times over the course of the day, disrupting sleep. For the very small preemies, just being handled for daily care (diapering, feeding) can be stressful.

The physical environment can be changed to:

• reduce the amount of sound
• reduce the amount of light
• provide rhythms in light levels
• provide some support for the baby's position
• make treatments less stressful
• reduce the number of times that the baby is disturbed.

Sound

Why are loud sounds a concern?

Loud sound is a concern because:

• it may damage the baby's ears and lead to loss of hearing,
• the baby feels it as stressful.

The sound of the isolette motor is at a level (55-60 decibels) that is comfortable for adults. If the baby has respiratory equipment (mechanical ventilation, CPAP), this makes it noisier. Other sounds then raise levels to what an adult would find uncomfortable (75-85 db). Loud, sharp sounds can raise levels to 100-200 db, which may damage cells in the ear. This is more likely to happen when the baby is on certain medicines that make the ear sensitive.

Loud or sharp sounds can cause physiological changes (high heart rate, fast breathing, apnea, a drop in blood oxygen levels). They also may startle the baby and disturb sleep.

How can the level of sound be reduced?

Sound levels can be reduced by talking quietly, closing doors and portholes gently, not dropping things on top of the incubator, turning down machine alarms and phone ring levels, and turning off radios.

Are some sounds helpful?

The sound that seems to impress preemies the most is the sound of your own voice. Providing a tape recording of you talking and reading to your infant may be one way to provide sound that will calm your baby.

Keep in mind, however, that for the very small preemie, extra sound when other things are going on may be disturbing. It is important, therefore, to watch your baby when you turn on the tape to be sure that he or she likes it.

Light

Why is light a concern?

Light is a concern because:

• bright light may cause injury to the eye;
• constant light may disturb body rhythms;
• bright light may keep your baby from opening his/her eyes and looking around.

Studies done with animals show that bright light can damage the cells in the eye. Preemies are at risk for getting Retinopathy of Prematurity (ROP), changes in the eye that can lead to loss of vision, if severe. Although not yet proven, constant bright lighting may increase this risk.

Constant levels of light may slow the normal development of sleep-wake cycles. Preemies that have been in nurseries where the lighting is dimmed at night advance more quickly in their sleep-wake patterns. This means that they begin to spend more time during each sleep period in deep sleep and less time in light sleep sooner than babies kept in constant light.

Light can affect the level of arousal of your baby. In bright light the baby is less apt to open his or her eyes when awake, thus misses chances to explore the world and to interact with you and others.

How can the amount of light be reduced for my baby?

Isolettes can be covered to block the amount of light reaching your baby. Laying a blanket over the top of the isolette is the easiest thing to do. Letting the blanket drape over the sides, or using a specially fitted cover (now available commercially), can block light from the sides as well as the top of the isolette. With current monitors displaying heart rate, breathing, and oxygen levels, the staff know how your baby is doing even with the isolette covered.

When lights are dimmed, procedures requiring the use of extra light can be done with an additional light at your baby's bedside (e.g., a lamp or ceiling spot light). The staff also will try to be as quick as possible when the use of bright light is necessary.

If overhead phototherapy lights are being used, a special mask will be used to cover your baby's eyes. Staff also will try to reduce the amount of light other babies are exposed to during the treatment.

In many nurseries, a "quiet time" is held during the day, when lights are dimmed for several hours and your baby is not disturbed unless a procedure is really needed.

In some nurseries, lights are dimmed at night. This helps in starting a day/night sleep schedule and supports daily changes in hormone and temperature levels. The dimmed light also gives some extra protection from the higher light levels needed for daytime activities.

Positioning

Why is positioning a concern?

Positioning is important because:

• The preemie cannot get into a comfortable position on his/her own.
• Over time, positioning affects your baby's motor development.

What is important to know about positioning?

The preemie does not have the muscle strength to control movements of arms, legs or head that full term infants have. It is hard for them to move against the force of gravity. Therefore they tend to lie with their arms and legs straight, or "extended", rather than tucked in, or "flexed".

Being in an extended position for long periods of time can lead to stiffness - "abnormal tone" - in the shoulders and hips, and this can delay the baby's motor development.

It probably is not very comfortable for the preemie to be on its back out straight, or extended. If left this way, some preemies may try hard to get into a more relaxed, curled up position, using up energy that could be used for growing.

Small preemies maintain better oxygen levels and temperature, and sleep better, when on their tummies or sides than when on their backs. (However, when the baby goes home, he/she should be put on the tummy only when awake, not for sleep.)

How can the baby be kept in positions that are comfortable and help motor development?

Sometimes it is hard to place the preemie in a curled up, flexed position because of necessary equipment, such as IVs, CPAP, or mechanical ventilation. But usually it can be done.

Guidelines for positioning include:

• Place the baby on tummy (when in the NICU and on monitors) or side, with arms and legs flexed.
• Cover, clothe, wrap or swaddle the baby, to help keep the flexed position. This also gives him/her the feeling of being cuddled.
• Make a 'nest' around the baby to hold him/her in a flexed position. Nurseries use different ways to do this. Some use blanket rolls. The inserts made for car seats make good nests - the baby lies on the insert, therefore it stays in place better than blanket rolls.

  There also are products for sale to keep the baby in a flexed position, such as the "Snuggle Up", Children's Medical Ventures, Boston MA.

• Leave the baby's hands free so that he/she can get them to the face. Sucking on fingers or hand, and even just touching the face, is one way babies calm themselves.
• As a part of the nest, give the baby something to push against with his/her feet. This allows the baby to feel more stable.
• Encourage the baby to hold on to - grasp - something, like your finger, the edge of the blanket, or a small rolled-up cloth. This helps the baby feel more stable.

Handling

Why is handling preemies a concern?

How preemies are handled is a concern because:

• It may lead to physiologic stress
• It may lead to behavioral stress.

When handled for medical care, preemies often show that this is physiologically stressful by a rising heart rate or dips in heart rate (bradycardia); rising respiration rates or periods of holding the breath (apnea); falling levels of blood oxygen (desaturations); color changes to dusky or flushed; and other responses such as hiccups or yawning. Even pulling adhesive tape off can cause these responses.

During daily care, such as diapering and feeding, preemies may react in the same ways.

When handled, preemies also may show in their behavior that this is stressful, for example, by more moving, more jerks, startles and tremors, and fussing/crying.

What is important to know about the effects of handling?

When a baby's blood oxygen level drops (desaturations), this can directly affect the brain. Therefore, it is important to prevent this during activities that happen over and over again, such as taking temperature and blood pressure, diapering or feeding, as well as during treatments that are especially stressful or painful.

Preemies learn. They learn that certain things are not comfortable or not pleasant. When this happens over and over, they may learn to dislike being touched.

How can the baby be handled to make it less stressful?

Handling can be made less stressful to the preemie by using a "developmental approach". This means:

• Position the baby comfortably and securely, and provide special supports to hold the baby in a flexed position during the handling. This includes "containing" or holding in the baby's arms and legs to keep him/her flexed and to prevent jerky movements.
• Pace the care according to how the baby reacts. For example, stop (give the baby a break) and gently contain the baby when he/she starts to get upset, and don't start again until the baby has settled down.
• Give the baby ways to keep him/herself calm. This would include a pacifier, something to hold onto, something against which to brace his/her feet, and helping him/her to keep hands up near the face to allow sucking on fingers.
• Keep other stimulation at a minimum. This would include not talking or trying to make eye contact if the baby shows signs of stress, and keeping general noise levels low.
• Most of all, adjust to the preemie's behavior as much as possible, letting him/her tell you what feels OK and what doesn't, and when to keep going, when to stop, and when to start up again. See the section below on How Do I Interact with My Baby?

Touch

Handling is touching. The sense of touch develops very early in fetal life. For very small preemies, the skin is so fragile that touching has to be done with great care. For preemies younger than about 30 weeks gestational age (GA), studies show that touch may be more stressful than soothing. For older preemies, however, gentle touching can be helpful.

Preemies react in different ways to different kinds of touch. A light, feathery touch may be upsetting. A firm, steady touch is more likely to calm the baby. Giving the stable preemie gentle human touch or massage for a short period every day has been shown to be helpful, for example, it may help babies gain weight faster. As with everything, how and how often the preemie is touched needs to be based on his/her responses.

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The Social Environment

The NICU is your preemie's home away from home. It is where he/she begins to learn about people, how they respond to him/her, and how it feels to be talked to, held, soothed - or left alone. You are the most important part of that social home, even if you cannot be there much of the time.

Why might the preemie's social environment be a concern?

There are many reasons to be concerned about the preemie's early social environment:

• You as parent(s) are the baby's most important social partner(s), but you are not able to be with your preemie as much as you would were he/she at home.
• There are many people with whom your preemie must interact, therefore he/she has to learn about many more people than does a full term infant and there is more chance that those people won't understand him/her.
• The isolette provides support for your preemie, but it also cuts him/her off from people. For example, it can make it hard for the preemie to know that voices are attached to people, or that people are more than hands.

What is important to know about interacting with my preemie?

An infant interacts with those around him/her in many ways: by looking (attending), listening, and touching/feeling. When the baby attends, he/she focuses on and follows things (tracks), and makes eye contact.

There are other ways in which preemies attend: listening, feeling your touch, turning the head towards you. Being aware of these is important, especially for those preemies who are slow in being able to be alert, or those who have problems with seeing.

Guiding all forms of attention are our feelings or emotions. It is what we feel that makes us want to go towards something or to pull away, to interact with someone or turn inward.Your preemie does have feelings. This may not be very clear other than when he/she cries or is cranky; then we are sure that the baby does not feel good about things. But how do we know when the baby does feel good?

Feeling comfortable, feeling a gentle touch, hearing a familiar voice, all give the baby positive feelings, and he/she lets us know these feelings in several ways. These include not showing signs of stress, looking relaxed, having a relaxed expression, and as he/she grows, attending visually.

It is important that the baby know, through the way that people respond, that his/her feelings are important and have been recognized. If the way people respond has nothing to do with the way the baby is feeling, he/she may soon learn that what he/she feels is not important and that trying to interact with people does not work. Some babies may even give up trying and come to dislike interacting with people.

Interacting through touch and holding

In most NICUs, parents are encouraged to touch their babies right away. NICUs have different policies about when it is all right to hold the baby, either inside or outside of the isolette.

Kangaroo Care

A form of holding encouraged in many NICUs is known as Kangaroo Care. This is holding your infant inside your shirt/blouse, against your skin. It also is known as "skin-to-skin contact". This form of holding was adopted from countries where isolettes to keep preemies warm are scarce. Holding the baby against the parent's skin was found to be very effective in keeping temperature normal. Studies show that the mother's body temperature adjusts to keep the baby's temperature at the right level. The baby's breathing also becomes more even, and heart rate and blood oxygen levels stay steady.

Early kangaroo care is holding the baby as soon as he/she is stable after birth, and may not be possible for many preemies. Intermediate kangaroo care is holding after the infant has become relatively stable, although extra oxygen and monitoring for apnea and heart rate dips may still be necessary. Late kangaroo care is holding after the baby is stable and breathing room air.

Both parents can give kangaroo care. You will be asked to wear a loose top or wear a scrub gown open in the front. The baby is dressed with only a diaper (and maybe a hat), and is placed on your chest between your breasts. The blouse or gown is closed over the baby to maintain warmth. The baby's temperature, heart rate and respiration will be checked by the nurse, or the monitors may be left on during kangaroo care.

Parents report that kangaroo care is a wonderful way to feel close to their preemie. Studies show that the babies do well during kangaroo care, and that if repeated often, it may be helpful for the baby's development.

Additional information about Kangaroo Care

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Understanding Your Preemie as a Person

Above all, developmental care means respecting who your preemie is as a person.

Your baby is unique.

• Although all infants grow in similar ways, your preemie is as unlike other preemies as you are unlike other adults.
• Your preemie interacts with people and responds to things differently than other preemies. Also, his/her medical condition is not exactly the same as that of other preemies.
• Your preemie is changing every day and most likely will need different ways of being cared for next week than this week.

Therefore, the care your preemie receives needs to fit his/her own personality. It is important not to do the same thing for all preemies, but to care for each preemie according to the messages he/she sends.

How do you find out about your baby's unique behaviors?

The best way is to observe your baby when you or the nursery staff are taking care of him/her.

There are special exams that look at a preemie's behavior to get a picture of how he/she acts and reacts, what he/she likes and doesn't like. What is learned from the exam can be used to make the baby's world fit his/her own special needs.

The exams look at such things as if and how quickly the baby gets to be awake and alert; how he/she soothes him/herself when upset and how easy it is for an adult to soothe him/her; movement patterns; and how much handling the baby can stand without becoming upset.

You can find out more about these exams by asking the nursing staff, occupational therapist, or developmental specialist in your NICU.

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