Special Considerations for Premature Infants

Premature infants must fight to survive in a world that they are not yet scheduled to enter for weeks or months. Inside the mother, the infant is shielded from the full intensity of stimulation such as sights, sounds and movements. The premature infant's central nervous system is not yet equipped to handle the environment, and easily becomes overstimulated. This can cause the infant to feel stressed. The Developmental Care Model seeks to minimize environmental stress in the Neonatal Intensive Care Unit (NICU), and improve developmental outcomes. 

What is Overstimulation?

Have you ever felt hopped up from too much caffeine? Or had a cold medicine that didn't agree with you? Remember that jittery feeling, like you could crawl out of your skin? Maybe you've felt overstimulated by sounds, and could not tune out routine noises, like the sound of machinery or air conditioning. Perhaps you became more aware of the clothes on your body. You may have wished you didn't have to talk to anyone, and that no one would talk to you. Maybe you wished you could escape to a quiet place. Do you get the idea of what it feels like to be overstimulated?

How Will I Know If My Baby Is Overstimulated?

Premature babies tell us they are overstimulated in many ways. Signs and signals of stress are grouped into three areas: autonomic, state-related, and motor stress signals. I have indeed seen virtually all of these stress signals exhibited by premies while working with infants and families in the NICU.

Autonomic or Visceral Stress Signals

Significant increase or decrease in breathing rate

Pauses in respiration

Changes in breathing patterns

Decrease in blood oxygen level

Changes in skin color, such as turning red, pale blue, ashy gray or mottled

Startling, tremoring or twitching

Gagging, gasping, spitting up, straining with or without a bowel movement

Coughing, sneezing, hiccuping

Yawning, sighing

State-Related Stress Signals

Whimpering sounds, facial twitches, or appearance of smiling

Eyes staring or floating, avoiding gaze, panicked look, glassy eyed

Irritability, fussing, crying

Fluctuations of state systems, such as drowsy to sleep state, and back to drowsy

Increased motor activity while asleep

When awake and alert, the infant may not be able to handle focusing, and may look away (gaze avert)

Motor Stress Signals

Limpness of body, arms, legs or face

Tenseness of body, arms or legs

Splaying (spreading) of fingers

Grimacing

Hands in front of face, with hands open or fisted

Frantic flailing of arms and legs

Identifying Stress Signals

Your baby communicates in many ways. The fact that s/he becomes easily overstimulated is not anyone's fault. S/he becomes easily overstimulated due to her/his premature birth.

Ask members of your infant's team to help you identify stress signals. Don't be too timid to ask. Don't think that you should already know, or that if you don't that you are a bad parent. Stress signals indicating overstimulation have been identified and researched through years of study by healthcare professionals who take care of premature infants. This information has to be learned. It does not come automatically to anyone!

But how can I interact with my baby without causing overstimulation?

You can learn to interact with your infant in a way that is comforting to the infant. You can also learn to help comfort your infant when s/he is stressed by noises and activity in the NICU.

I like the sound of that! Tell me more about what I can do to comfort my baby.

To avoid overstimulation, try offering only one input at a time:

Offer a pinky finger to grasp.

Place your hand gently but firmly on her/his back or bottom.

Speak slowly in a soft, soothing voice.

Use your hand to tuck your infant's feet and legs near her/his bottom.

Gently swaddle, reposition “snuggly” or “bendy bumper”, or place rolled blankets to help your infant feel contained.

Anything Else?

Most NICUs routinely do things to insure the comfort of premature infants. You could review your child's NICU environment with her/his team for changes and improvements.

Does your child have a “snuggly” and “bendy bumper” or other containment?

Is the lighting low in the NICU, with additional protection to block out the light to your infant's isolette or crib?

Are there additional measures the NICU staff can pursue to reduce stimulation for your infant?

Is noise minimal? No radio? Quiet voices? Doors, hamper lids, drawers closed quietly, or padded to minimize noise?

Are more sensitive babies placed in low traffic, low noise areas?

How does my infant show s/he is not overstimulated?

Signals of an optimal state, indicating low stress, are the opposite of the stress signals.

Autonomic or Visceral Signals

Smooth breathing at a good rate

Good color

Good digestion

Motor Signals

Smooth movement and good muscle tone

Hand and foot clasping, grasping, hand to mouth movement, and sucking

State-Related Signals

Good sleep state

Good self quieting

Relatively easy to calm

Robust and rhythmic crying

Focused, alert attention to face of caregiver

Animated expressions

A Word About Feeding

Most babies are unable to feed by sucking on a bottle before 34 weeks gestation. Readiness for nipple feeding of course varies from baby to baby. If I observed 3 to 4 stress signals in the infant, I would gently attempt to feed. If I observed 8 to 12 or more stress signals, I would defer bottle feeding and recommend the infant be continued on tube feeds. Feeding readiness also depends on medical conditions, if any, such as motor or breathing problems.

Your infant's team feeding specialist could be a Speech Therapist (Speech Language Pathologist) or Occupational Therapist. Occupational Therapists often assist in individualizing your infant's needs for feeding readiness. Strategies suggested by Occupational Therapists for feeding your infant might include:

Swaddling to contain your child, holding firmly

Minimizing movement during feeding

Placing the nipple in the baby's mouth and holding it still

Stroking the cheek once or twice gently if needed to encourage sucking

Maintaining a quiet environment with minimal talking to your infant during the feeding

SUMMARY

Developmental Care Model provides a framework for examining and responding to stress in premature infants. By minimizing stress, the infant's chances to thrive are enhanced. This model has been studied with good evidence in terms of measures such as decreased duration of NICU stays and improved developmental outcomes.