Steps

Rationale/Points of Emphasis 1

1 Use measures to decrease the intensity of light exposure to the neonate, to include

• Dim lighting with no direct view of the electric light source or sun in the neonate space

• Cycled lighting

• Use of eye patches

• Covers over the isolette

• Minimal use of procedural lights

• Use of window shades

Isolettes should never be covered if the neonate is unstable. This practice would obstruct ongoing assessment of the neonate.

Primarily implemented to promote comfort, enhance preterm neonates’ rest and recovery, and assist in the development of rest-activity patterns. One source of natural daylight visible from the neonate space is recommended. Findings from studies of the relationship between light exposure and retinopathy of prematurity are inconclusive. The use of continuous dim lighting, cycled lighting, eye patches, and covers over incubators has been implemented in many NICUs, with little research to support the effectiveness of these measures to prevent retinal injury. However, no adverse effect has been noted from using these measures.

Cycled lighting has been found to be conducive to the development of rest-activity patterns that are in phase with the solar light-dark cycle. The retinal effects of short-term, high-intensity lighting from procedure lights and neighboring phototherapy lights has not been investigated.

2 Use measures to minimize extraneous environmental noise:

• Eliminate bedside rounds, unless patient contact is needed

• Minimize staff conversation near neonates

• Lower volume level on equipment alarms

• Discourage loud talking and laughter in the unit

• Avoid placing equipment on top of the isolette

• Use electronic monitors to assess noise levels and make modifications to ambient noise levels as needed

Sudden and loud noise leads to physiologic and behavioral disturbances for the preterm and sick newborn. Adverse effects include sleep disturbances, motor arousals (e.g., startles and crying), hypoxemia, tachycardia, and increased intracranial pressure. In addition, careful attention to building design can control some transient sound. Careful placement of travel paths, size and location of bed spaces, and selection of equipment and communication systems result in decreasing the NICU background noises. “In infant rooms and adult sleep areas, the combination of continuous background sound and operational sound shall not exceed an hourly L_eq of 45 dB and an hourly L₁₀ of 50 dB, both A-weighted slow response. Transient sounds or Lmax shall not exceed 65 dB, A-weighted, slow response in these rooms/areas” (Committee to Establish Recommended Standards for Newborn ICU Design, 2012, p. 32 ).

3 Use heated humidifiers instead of nebulizers in the NICU. When hoods are used, use those manufactured with noise-reduction features.

Heated humidifiers produce lower sound intensities and frequencies than nebulizers used with hoods.

4 Air temperatures within the NICU should be 72°-78°F (22°-26°C) with a relative humidity of 30-60%. Provide an environment with up to 95% relative humidity for all neonates younger than 30 weeks’ gestation, less than 1 kg birth-weight, and during the first week of life. This can be done either by raising the level of ambient humidity inside the incubator or by creating a moist microenvironment using a waterproof covering over the neonate.

Premature neonates lose large amounts of heat by evaporation. Factors contributing to this condition include age (younger than 30 weeks’ gestation), decreased amounts of subcutaneous fat, poorly developed epidermis, a relatively large body surface area, and frequently exposed body posture. By 2 weeks of age, the premature neonate’s epidermal barrier has matured in structure and functions similar to that of a term neonate.

Steps

Rationale/Points of Emphasis

1 Examine routine nursing procedures to evaluate what is essential and nonessential handling. When possible, eliminate unnecessary activities such that care is provided on an individualized basis to minimize stress to the newborn.

Handling of preterm neonates leads to physiologic changes: decreased levels of oxygen in arterial blood (Pao₂) or TCPO₂, increased intracranial pressure, heat loss, tachycardia, tachypnea, and bradycardia. Many handling episodes are for nonessential care activities lasting less than 30 seconds. Whether the handling episode is a medical intervention or a soothing measure, handling, when poorly timed, stresses the vulnerable preterm newborn.

2 Structure the neonate’s 24-hour day such that care activities are clustered to allow for extended periods of uninterrupted sleep. Cover the isolette of the stable neonate during scheduled naps while observing and monitoring the neonate’s status on a regular basis. Do not implement care and interventions during rest unless the neonate requires emergency interventions or soothing activities to sleep.

Sleep-wake cycles of the preterm neonate are affected by activities such as handling, routine nursing care, painful procedures, and interactions with family members. Inadequate periods of rest can slow weight gain, growth, and increase apneic episodes. Caregiving activities should be clustered, structured, and paced to promote adequate periods of rest; to avoid sudden disruptions in sleep or movement; and to ensure that maladaptive behaviors are not elicited during care and handling. Perform several procedures during a single contact with the neonate if response is well tolerated, approach or arouse the neonate in a soothing and calming manner, remain at the neonate’s bedside after interventions to ensure no maladaptive responses are present, and provide calming measures when maladaptive behaviors are demonstrated during or after-care activities.

3 Gently prepare the neonate for handing using a soft voice or a gentle touch.

Promotes physiologic stability and state organization.

4a Position the neonate to enhance neurobehavioral states and to promote good body alignment.

Research supports the supine position as the optimal sleeping position for healthy term neonates.

4b For symptomatic premature neonates, the best position in an isolette is lying prone with the neonate’s pelvis slightly elevated, the lower limbs weight bearing through the anterior knee, and the hips not flexed greater than 90 degrees.

In premature neonates, especially those experiencing respiratory distress, gastroesophageal reflux, or airway anomalies, the prone position is the position of choice. Improper neonate positioning can contribute to longterm physical deformities such as bilateral head flattening, shoulder retraction, lateral flexion of the arms, and abnormal abduction of the hips, legs, and knees (“frog-leg” position).

caREminder

The supine sleeping position (“Safe to Sleep”) is recommended for all healthy and term infants for sleep throughout the first year of life.

caREminder

If positioning is difficult due to medical condition, consultation with a physical therapist may be helpful.

4c Of the indirect positioning methods, gel pillows are the method of choice.

Research supports the use of indirect positioning methods (e.g., mattresses, supports) to promote vestibular stimulation, enhance neurobehavioral states, promote growth, prevent bilateral head flattening, and decrease episodes of apnea.

5a Contain the neonate to minimize extraneous movements. Maintain contained position with use of blanket rolls or other developmentally supportive items alongside the neonate.

Random movements by the neonate may lead to inconsolability, alterations in vital signs, and increased consumption of oxygen and glucose. Containing the infant can lead to increased consoling behaviors and decreased extraneous movements of the extremities.

5b Containment is achieved by placing the neonate’s arms and legs in a flexed midline position close to the neonate’s trunk with the neonate in a supine position.

Stress responses in the newborn elicited by turning, moving, or painful procedures can be decreased by containing the neonate’s movements.

6 Per institutional guidelines, offer opportunity for cobedding of twins. During cobedding, use positioning and physical support of the newborns to enhance their ability to touch and hold each other while maintaining neonates in supine position. Monitor the neonates’ temperatures and environmental temperature to avoid overheating the neonates.

Cobedding twins enhances extrauterine adaptation by allowing continued physical contact with the other twin and by supporting synchrony in caregiving and feeding of twins that may facilitate mutuality in their circadian rhythms and sleep-wake patterns. Cobedding twins affects the environmental temperature requirements of the newborns when placed together or separated. Teaching with family members must convey that when neonates go home, they may cobed together; however, they may not cobed with other children or adults because this places the newborns at risk for suffocation. Some institutions may not allow cobedding due to the unsubstantiated basis for this intervention.

7 Initiate nonnutritive sucking (NNS) with the neonate before the onset of feedings. Introduction of the intervention 2, 5, and 10 minutes before feeding has proven to be beneficial to the neonate. Although the optimal length of time of the intervention requires further investigation, careful monitoring of neonate behavioral state assists the nurse in determining when the neonate has achieved a quiet alert state and oral feedings may begin.

Do not use sucrose water as part of the NNS regimen as it is considered a medication and must have an order; sucrose-coated pacifiers are most commonly used as a comfort measure during procedures.

Medically stable neonates provided with an NNS stimulus before feeding were more likely to be in transitional or alert states after the intervention and at the start of feeding. Neonates who received NNS also had higher oxygen saturation rates during the intervention, faster first-suck onset during feeding, a significantly longer first-suck duration, and fewer behavioral state changes during feedings. They are also more likely to initiate nutritive sucking earlier. NNS does not have an overall effect on feeding time or on amount of formula consumed.