Providing Comfort and Developmentally Supportive Care for Your Premature Baby

How you can comfort your premature baby in the NICU by minimizing noise, providing positioning support, and reading your baby's clues.

By Susan L. Madden, author of The Preemie Parents' Companion

Although your baby needs to be in the hospital nursery, it is not always a very comfortable or restful place to be. Lights are on 24 hours a a day; machinery, alarms, people, telephones, and radios can create a lot of noise; and necessary medical procedures are often painful. Even routine caretaking activities can be tiring and disruptive.

In the last ten years, Boston psychologist Heidelise Als and others have researched and developed ways of making nurseries and neonatal care more "baby friendly." They have recommended changes in the ways nurseries operate to help lesson the negative effects hospital care and minimize the stress babies experience. In addition, they recommend that the care each baby receives be adjusted to best fit that child's needs and coping abilities. This approach, known as individualized developmental care (or formally, NIDCAP - Neonatal Individualized Developmental care and Assessment Program), is designed to provide an environment in which a preemie's development can continue as normally as possible despite his early birth. Research into its effects has shown that babies who are cared for using the individualized developmental care approach have fewer medical complications, shorter stays in the hospital, better weight gain, and fewer days on respirators. There may be long-term effects of this approach, as well. Some of the early research has indicated that babies cared for with the NIDCAP approach may show more organized behavior and better development in their first year of life.

As a result of this work, many nurseries have made modifications o the nursery environment and to the way in which they provide care. For example, medical and caregiving procedures are often clustered so that babies can sleep undisturbed for several ours at a time. In addition, during invasive or uncomfortable procedures, various comforting methods may be used to help babies stay calm. These include holding a baby in a curled position with hands or swaddling, giving the baby something to grasp, or a pacifier to such on. Our nursery may have a staff member - usually a nurse - who has been rained in the NIDCAP method. She will observe your baby, help plan his care, and advise you and the staff on the best ways of handling him.

As a parent, you can provide comfort and support to your growing baby in a a number of ways. These may include making modifications to your baby's surrounding to minimize stress from noise and lights, as well as learning how best to hold and interact with your baby as he grows and matures.

Observe your baby's environment and try to minimize unnecessary noise and light. There are a number of simple adjustments you can make in your baby's surroundings to help reduce the amount of disruptive stimulation that he receives.

• Make sure your baby is shielded from light either by adjusting the amount of light shining directly on him or by putting a baby blanket or other covering over his incubator or bassinet. If your baby is on a warming table, see if there is some way to shield his eyes from light.
• Always close the doors to his incubator quietly instead of snapping them shut. Try not to set anything down on top of the incubator, or do it quietly.
• If the nursery seems particularly noisy because of a radio playing or phones ringing, talk to the staff about your concerns. They may be able to make adjustments to lessen the noise or move your baby to a quieter location. One mother was concerned because the receiver of a wall phone hanging near her baby's incubator was constantly falling off and startling him. She finally got the nursery to replace it with a desk phone which cause much less disturbance.
• Keep voices low around your baby, particularly when he is sleeping, or move away form his bedside for conversations.
• If your baby's bed is located in an area of the nursery where there is a great deal of activity or foot traffic, ask that he be relocated to a quieter spot.
• If your baby is on a respirator, make sure that the water that accumulates in the tubing is emptied regularly.

Hold your baby in a flexed position and provide boundaries around him while he sleeps. Preemies, like all newborn babies, feel more secure when they are swaddled securely in a blanket with their legs tucked up, arms bent, and hands brought together in front of them. When they sleep, they prefer to be touching or lying up against something, and will often move in the incubator until they are up against the wall or the bottom of the enclosure. By positioning your baby in a a curled position and providing boundaries for him when he sleeps, you not only help him feel calm and comfortable , but you also encourage the development of the curled position known as flexion that babies naturally assume in the womb. Preemies, with their lack of muscle strength, have a hard time maintaining this position by themselves, and, if left alone, will lie spread-eagled with straight arms and legs on the relatively hard, flat surfaces of their nursery beds.

• To provide comfort to your baby and support his physical development, try the following measures.
• Swaddle your baby in a blanket with his arms and legs bent and hands brought together in front of him or to his face.
• When you hold your baby, keep him in a slightly curled position, with his legs tucked up and his hands brought forward in front of him.
• Create a nest for your baby to sleep in. Wool Blankets or cloth diapers and place them around your baby to help keep his legs tucked or put them against his back and around the top of his head.
• A folded cloth diaper placed under your baby's chest when he is on his stomach can help him to feel secure and be in a flexed position.
• If your baby must sleep on his back, provide rolls along his sides to keep his arms bent and hands brought together in front of him, and another roll under his knees to keep his legs tucked up.
• In the hospital, babies sometimes sleep on artificial lambskins or water beds to soften the surface of the bed. Artificial lamb skins and water beds are recommended for use only in the hospital where your baby is continuously monitored. They shouldn't be used at home as they are associate with a higher risk of Sudden Infant Death Syndrome (SIDS).

Learn to read your baby's cues and pace your activities with him accordingly. As discussed earlier in this chapter, premature babies tend to express themselves through physical changes and behavior. As you spend more time with your baby and as he matures, you will begin to recognize how he signals that he is getting tired or upset, and the things he does to calm himself. The following technique may help your child stay calm or regain his equilibrium if he has become upset.

• Provide one form of stimulation at a time: if you rock him, don't talk; if you are feeding him, try not to look him in the eye; while you are holding him, shield his eyes from strong light. Add more types of stimulation slowly, watching your baby for signs of stress.
• When your baby signals that he is getting tired and needs some time out, give him a rest period by cutting back on some of the stimulation he is receiving. For example, if you are rocking and looking at him, look away and just hold him quietly, perhaps shading his eyes from light until he relaxes again. Or decrease the intensity of the stimulation by talking more softly, or rocking more slowly. If these approaches don't work, your baby may simply need to be paced back in his incubator or bassinet to rest and sleep.
• Help your child bring his hands to his face or mouth, or offer him your little finger or a pacifier to suck on.
• Handle and move him slowly and gently.
• If your baby must be unwrapped from his blankets during certain procedures, use your hands to keep his arms and legs tucked and to create boundaries around him. This will comfort him and help him feel more secure.
• Apply gentle but firm pressure on your baby's back or chest with your open hand. This helps him to block out other stimulus, calm down, and organize himself.

Susan L. Madden is the author of The Preemie Parents' Companion : The Essential Guide to Caring for Your Premature Baby in the Hospital, at Home, and Through the First Years. The parent of a child born 12 weeks premature, Susan Madden has written about health and health care policy for many years. In her informative book, Susan L. Madden guides you from your earliest meeting with your child in the NICU through the transition of your child's first year at home. © Susan L. Madden Reprinted by permission of the publisher, The Harvard Common Press. All rights reserved.