  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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