Perinatal Intensive Care Neonatal Developmental Care

Nursing

Learning Outcomes
Upon completion of this section, the student will:
1. Describe the neonatal intensive care unit
environment and its impact on families and
neonates.
2. Identify the principles for of individualized
neonatal development care.
3. Describe intervention strategies to enhance the
environment of the NICU.
Study Questions
Journal References
Aita, M. et al (2013) Intervention Minimizing Preterm
Infants’ Exposure to NICU Light and Noise. CLIN NURS
RES, 22 (3): 337-58
Allen, K. (2012) Promoting and Protecting Infant Sleep.
Advances in Neonatal Care, 12(5): 288-291
Altimier, L. et al (2016) The Neonatal Integrative
Developmental Care Model: Advanced Clinical
Applications of the Seven Core Measures for
Neuroprotective Family-centered Developmental Care
Newborn and Infant Nursing Reviews, 16 (4): 230-245

1. Ashra is finally able to hold her 6 day old
premature infant, born at 28 weeks. She asks you
what signs they should watch for to determine
when her baby is uncomfortable.
Required Text Readings
Bader, L. (2014) Brain-Oriented Care in the NICU: A Case
Study. Neonatal Network, 33(5):263-267
Brady, K. et al (2014) An Interprofessional Quality
Improvement Project to Implement Maternal/Infant
Skin-to-Skin Contact During Cesarean Delivery. JOGNN),
43(4): 488-496

Merenstein, G. (2016) Chapter 13 Brelsford, G. et al (2016) Sacred Spaces: Religious and

Secular Coping and Family Relationships in the Neonatal
Intensive Care Unit. Advances in Neonatal Care, 16(4):
Websites 315-322

1. Age Appropriate Care of the Premature and Cooper, L. et al (2014) Close to Me. Advances in Neonatal
Critically Ill Hospitalized Infant: Guideline for Care, 14 (6):410-423
Practice, 2011
http://www.nann.org Craig J. et al (2015) Recommendations for Involving the
Family in Developmental Care of the NICU Baby. J
2. Developmental Care in the NICU Perinatol, 35 (1):S5-8
http://www.aboutkidshealth.ca
D'Agata, A. et al (2016) Infant Medical Trauma in the
3. Developmental Care and Early skin-to-skin Neonatal Intensive Care Unit (IMTN): A Proposed
contact for mothers and their healthy newborn Concept for Science and Practice. Advances in Neonatal
infants, 2017 Care, 16(4): 289-297
http://www.cochrane.org
Diniz M. et al (2014) Socio-demographic Profiles and
4. Kangaroo Care for the Preterm Infant and Qualifications of Neonatal Nurses in Developmental Care:
Family, Reaffirmed 2017 a Descriptive Study. ONLINE BRAZ J NURS, 13(3): 292-301
http://www.cps.ca
Doerhoff, R. et al (2015) Human Factors in the NICU.
5. Zero to Three J PERINAT NEONAT NURS, 29(2): 162-169
http://zerotothree.org
Feely, N. et al (2013) The Father at the Bedside: Patterns
of Involvement in the NICU. JPerNeoNursing, 27 (1):8-9
George Brown College, R. N. Perinatal Intensive Care Nursing
©Heather Urquhart 2017-2018 NURS 4048
 Perinatal Intensive Care Neonatal Developmental Care
Nursing
Graci, A. (2013) A Rounding System to Enhance Patient,
Parent, and Neonatal Nurse Interactions and Promote
Patient Safety. JOGNN, 42 (2): 239-42
Hardy, W. (2011) Integration of Kangaroo Care. Into
Routine Caregiving in the NICU. Advances In Neonatal
Care, 11 (2): 119-121
Head, L. (2014) The Effect of Kangaroo Care on
Neurodevelopmental Outcomes in Preterm Infants.
J PERINAT NEONAT NURS, 28 (4): 290-9
Hubbard, J. et al (2017) Parent-Infant Skin-to-Skin
Contact Following Birth: History, Benefits, and
Challenges. Neonatal Network, 36 (1):89-97
Jefferies, A. et al (2012) Kangaroo Care for the Preterm
Infant and Family. Paediatr Child Health, 17 (3):141-143
Karl, D, et al (2011) Use of the Behavioral Observation of
the Newborn Educational Trainer for Teaching Newborn
Behavior. JOGNN, 40 (1): 75-83.
Lacina, L. et al (2015) Behavioral Observation
Differentiates the Effects of an Intervention to Promote
Sleep in Premature Infants. Advances in Neonatal Care,
15(1):70-78
Lubbe, W. et al (2012) NICU Environment -- What Should
It Be Like? JNEONAT NURS, 18(3): 90-93
Ludington-Hoe, S. et al (2013) Kangaroo Care as a
Neonatal Therapy. ACTA PAUL ENFERMAGEM, 26 (1): 1-7
Moody, C. et al (2017) Early Initiation of Newborn
Individualized Developmental Care and Assessment
Program (NIDCAP) Reduces Length of Stay: A Quality
Improvement Project. Journal of Pediatric Nursing, 32:
59-64
Morag, I, et al (2011) Cycled Light in the Intensive Care
Unit for Preterm and Low Birth Weight Infants. Cochrane
Database of Systematic Reviews, Issue 1.
Neal, D. et al (2008) Music as a Nursing Intervention for
Preterm Infants in the NICU. Neonatal Network, 27 (5):
319 -322.
George Brown College, R. N. Perinatal Intensive Care Nursing
Neu, M. (2013) Influence of Holding Practice on Preterm
Infant Development. MCN, 38(3):136-143
Penda, R. et al (2013) Alterations in Brain Structure and
Neurodevelopmental Outcomes in Preterm Infants
Hospitalized in Different Neonatal Intensive Care Unit
Environments. The Journal of Pediatrics, (in press): 1-9
Pineda, R. et al (2014) Alterations in Brain Structure and
Neurodevelopmental Outcome in Preterm Infants
Hospitalized in Different Neonatal Intensive Care Unit
Environments. J PEDIATR, 164 (1): 52-60
Rhoads, S. et al (2012) Challenges of Implementation of a
Web-Camera System in the NICU. Neonatal Network, 31
(4): 223-228
Shoemark H. et al (2016) Characterising the Ambient
Sound Environment for Infants in Intensive Care Wards.
J Paediatr Child Health, 52 (4): 436-40
Spittle, A. et al (2015) Early Developmental Intervention
Programmes Provided Post Hospital Discharge to Prevent
Motor and Cognitive Impairment in Preterm Infants.
Cochrane Neonatal Group: 10.1002/14651858.CD005495
Stalnaker, K. et al (2015) Osteopenia of Prematurity:
Does Physical Activity Improve Bone Mineralization in
Preterm Infants? Neonatal Network, 35, (2): 95-104
Stevens, D. et al (2014) A Comparison of the Direct Cost
of Care in an Open-bay and Single-family Room NICU.
J PERINATOL, 34(11): 830-835
Valizdeh, L. et al (2013) Nurses' Viewpoint About the
Impact of Kangaroo Mother Care on the Mother--infant
Attachment. J NEONAT NURS, 19 (1): 38-43
Zarem, C. et al (2013) Neonatal Nurses' and Therapists'
Perceptions of Positioning for Preterm Infants in the
Neonatal Intensive Care Unit. NEONAT NETW), 32 (2):
110-6
Zwedberg, S. et al (2015) Midwives' Experiences with
Mother-infant Skin-to-skin Contact After a Caesarean
Section: 'Fighting an Uphill Battle'. MIDWIFERY, 31(1):
215-220
©Heather Urquhart 2017-2018 NURS 4048
 Perinatal Intensive Care Neonatal Developmental Care
Nursing
Neonatal Developmental Care
In utero fetal tactile-kinesthetic and vestibular
stimulation occurs throughout gestation. The
development, organization, and function of the fetus's
sensory systems are influenced by the mother's physical,
psychosocial and emotional characteristics. The fetus and
mother create environments that influence and develop
each other. The maternal environment is particularly
influential on fetal brain development and future health
and well-being (Merenstein, 2016).
At birth the fetus transitions to the extrauterine
environment with significant physiologic changes.
Through their sensory capabilities they are enabled to
communicate and adapt within this new environment
through many complex behaviours. A warm, dimly lit
environment with skin-to-skin contact promotes a non-
stressed adjustment immediately at birth. In the days to
follow, the environment continues to change and further
adaptation is required. The infant’s personality and
behavioural development are affected by stimuli and
relationships, whether at home or in the NICU
environment (Merenstein, 2016). The environment in the
NICU is characterized by sensory deprivation of normal
stimuli that a premature infant would have experienced
in utero, and that a term infant would experience at
home with their families.
The usual caregiving, such as feeding, holding,
playing and singing, promotes interaction between the
infant and others. This interaction assists with
development and a sense of self in the newborn. Lack of
appropriate interaction and stimulus deprivation leads to
long term negative consequences, such as
developmental and physical delays. Infants develop trust
through their ability to communicate their needs and the
reliability of their environment (Merenstein, 2016).
Infants have highly developed sensory
capabilities, with touch being the major form of
communication. Fetuses are able to hear by 22 weeks
gestation and become familiarized with voices of their
mother and significant others. As neonates they
recognize and have preference to these same voices. Full
term infants have the ability to habituate to repeated
George Brown College, R. N. Perinatal Intensive Care Nursing
sounds. Newborns quickly recognize their mother and
prefer to black and white and the human face. They are
sensitive to bright lights. Infants are able to distinguish
smells and tastes and provide clues as to their likes
(breast milk) and dislikes (turning their head to
unpleasant odours).
Crying is considered the language of newborns
(Merenstein, 2016) and communicates their response to
hunger, pain, overstimulation, discomfort, and need for
affection and attention. Infants learn to self soothe
themselves through non-nutritive sucking, hand to
mouth movements, to attend to stimuli in the
environment. Smiling occurs by 4 weeks of age.
Synchrony is achieved between the parent and infant
through these essential responses to behavior.
Postnatal NICU Environment
Infants within the NICU environment are challenged by:
 confinement (incubator, ventilator, restraints)
 noise (caregivers, equipment, environmental)
 light
 tactile stimulation (care, touch)
 unpredictable routines
 painful, intrusive procedures
 disruption of sleep - wake cycles
 multiple caretakers
 parental separation
 lack of parental interaction
Newborns in the NICU have a limited ability to shape
their environment, communicate to others, create
attachments and develop their sensory capabilities. An
infants’ ability to elicit a response with a behavior, is
impacted by their gestational age and physical well-
being. A preterm infants‟ immature central nervous
system may not allow them to make a response, they
may develop an intolerance of stimuli or they may
withdraw from the interaction. Characteristics of
behavioural organization are unique to the preterm
infant (Merenstein, 2016) and may be evaluated with an
assessment scale.
Interventions
©Heather Urquhart 2017-2018 NURS 4048
 Perinatal Intensive Care Neonatal Developmental Care
Nursing
An infant’s sensory response to normal stimuli is
lacking in the NICU and the response to inappropriate
stimuli is overly abundant. Individualized
developmentally supportive care was introduced in the
1980’s to address these environmental concerns. A
systemic review indicated that developmental care
interventions demonstrated some benefit to preterm
infants (Symington, 2002). These were:
 increased short-term growth outcomes
 decreased respiratory support
 decreased incidence of chronic lung disease
 decreased length and cost of hospital stay
 improved neurodevelopmental outcomes
The ultimate goal of intervention strategies in
the NICU is to facilitate and promote infant growth and
development, while at the same time lowering their
stress. By altering the environment to be more
developmentally appropriate for infants, maladaptive
behaviour is diminished. Principles for designing
developmental care interventions in the NICU
environment include:
 recognition of each infant's unique temperament
and individual stage of development
 sensitive observation of the infant's behaviours
in determining both the nature and timing of
interventions
 assessment of the stimulation to which the
individual infant is exposed
 the necessity of parent participation
Altering and eliminating the environmental stressors
are important strategies to developmentally appropriate
care. Specific times may be designated for performing
non-emergent procedures (physical assessment, diaper
changing) and the allowance for rest periods. Efforts
should be made to reduce the amount of adverse
auditory stimulation (radios, phones, intercoms) and light
exposure, by covering the incubator. Promoting the
parent infant interaction, providing caregiving education
and unlimited parental contact are all essential goals to
success. Consistency of caregivers, organizing care,
clustering care, limiting the stimuli and assessing the
infant for tolerance contribute to this plan.
Providing early, consistent opportunities for the
parents to touch, talk, hold and care for their infant is
essential. Skin-to-skin contact, also known as kangaroo
George Brown College, R. N. Perinatal Intensive Care Nursing
care, assists with parents feeling closer to their babies.
(Merenstein, 2016). It was introduced more than 25
years ago in Columbia as an approach to low birth weight
infants in response to overcrowded nurseries, costly
resources and high infection/mortality rates. It was
adopted by other countries and is now considered to be
an important intervention to decrease mortality and
morbidity for low birth weight infants in developing
countries. Kangaroo care is a means to involve parents in
their infants care and to humanize the NICU experience
(CPS, 2017).
The naked infant (with a diaper) is placed on their
parents’ bare chest in an upright prone position and
provides advantages for both. They are covered with a
blanket and closely monitored for 1 to 3 hours. It can be
offered to infants on ventilator support and to those of
extremely low birth weight. Exclusion criteria includes
unstable infants, those receiving neuromuscular blocking
agents, newly post op, those with arterial lines/chest
tubes, those receiving inhaled nitric oxide, those being
cooled, fractures, those receiving high frequency
ventilation and those with a compromised airway. In
addition discussion with the health care team is essential.
Benefits include improved oxygenation, enhanced
temperature regulation, decreased episodes of apnea
and bradycardia, decreased infection rates, increased
periods of quiet sleep, less crying, stabilization of vital
signs, reduction of pain, enhancement of parental
attachment, longer duration of breast feeding, increased
growth and early discharge. Parents report feelings of
being needed, increased confidence, touching their
infants more and being more adaptive to their infant
signals. Similar advantages in neurobehaviour have been
noted after discharge and may have an effect on long-
term behaviour (CPS, 2017).
Limitations include staff uneasiness in moving an
infant attached to extensive equipment, inadequate
education, inadequate time (Olds, 2012), lack of privacy
and parental reluctance. Guidelines for skin-to-skin
contact are recommended for all NICU’s, including
gestational age, weight criteria, readiness, tolerance,
physiological monitoring (stability and stress) and a safe
stable transfer (Ludington-Hoe, 2008). An individualized
inter-professional team approach to determine infant
and parental readiness is suggested.
©Heather Urquhart 2017-2018 NURS 4048
 Perinatal Intensive Care Neonatal Developmental Care
Nursing
Strategies
Intervention strategies to promote
developmental care must be individualized according to
the infant's State, physiologic status and stress clues.
(Merenstein, 2016)
Circadian Rhythms: Sleep-wake cycles are interrupted in
the NICU. To minimize this, infants should not be
awakened when asleep. If awakening is necessary, a soft
gentle approach, such as stroking is best. Day-night
cycles can be facilitated with dimming the lights and
quieting the NICU, at preset intervals.
Tactile/Kinesthetic: Human touch is the most important
tactile stimulation. Gentle but firm handling quiets
babies. During painful procedures body containment,
comfort measures (such as a pacifier) and adequate pain
relief is essential. Social non painful contact should be
provided by parents and professionals when the infant is
awake, alert, and receptive. Proper positioning of infants
also promotes appropriate normal development and
organizes the sensory system. Skin to skin contact should
be promoted as tolerated, including those infants who
are ventilated. Bringing the hands to the mouth
encourages self-consoling behaviours. Occasional body
containment maneuvers, such as bunnying, swaddling,
bean bags, and cradling in nests assists with decreasing
stress. The acutely ill infant requires minimal handling.
Massage therapy may improve circulation and promote
weight gain.
Auditory: The NICU is a place of noises. Common sources
include equipment, alarms, and people, with talking
being the greatest contributor. Increased environmental
noise can lead to startles, fussiness, apnea, bradycardia,
hypoxic episodes and sleep disturbances in neonates.
Strategies to minimize noise include quieting alarms,
avoiding placing items on top of or tapping an incubator,
avoiding loud music or intercom devices, and emptying
moving water in nebulizer tubing. The human voice is the
most preferred sound, particularly that of an infant’s
parents. Music therapy may also be advantageous.
Visual: The NICU is often well lit for many hours of the
day. Decreased light levels in day-night cycles and
avoidance of bright lights are recommended. Those
receiving phototherapy are devoid of light and require
regular breaks from the eye pads.
George Brown College, R. N. Perinatal Intensive Care Nursing
Smell/Taste: The infant in the NICU is able to respond to
olfactory stimuli, including noxious smells, such as
aseptic solutions. The smell of breast milk is very
pleasant, and placing a drop on the lips, allows the baby
to recognize the mother's own smell and taste of her
milk. Aromatherapy is utilized by placing an article of
clothing or a cloth that belonged to or was held by the
mother. Non-nutritive sucking satisfies an infant's
sucking needs. Babies may undergo an aversion to stimuli
around the mouth, such as with suctioning or vomiting,
leading to feeding difficulties.
Crying/Smiling: Crying is a signal that the infant needs
attention. Immediate response decreases the infant's
physiologic stress, increases the infant's trust in the
environment and enhances the sense of self and control.
Babies who are unable to cry, such as those who are
intubated, signal their needs by agitation, bradycardia
and decreased oxygenation.
Infants in the NICU have much of their early life
encompassed with procedural stimuli, rather than the
essential appropriate social stimuli they require. The
ability of the parent and infant to create a relationship is
disrupted by illness and hospitalization. The NICU must
be an environment conducive to optimal growth and
development, and promote positive parent-infant
interactions.
Review Questions
1. State three means by which infants are isolated
from normal stimuli in the NICU.
2. Give three strategies to diminish the noise in an
NICU.
©Heather Urquhart 2017-2018 NURS 4048