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It is widely recognised that the SCBU environment deprives the preterm infant of normal stimuli that would take place inside the womb, and the term infant of the usual experience that would take place at home with their families. The SCBU environment can be a complex one, one that often presents the infant with inappropriate stimuli from light, sound, touch, procedures and pain, as well as being a stressful and worrying place for parents. As a parent, the thought of spending a significant length of time within SCBU can be a daunting one. The following sections aim to help you to understand how you can help comfort and support your baby during his/her stay on SCBU, how you can bond with your baby and how you can recognise your baby’s cues.

 

Recognising your baby’s cues | Appropriate handling and positive touch | Positioning | Kangaroo care | Non-nutritive sucking | Pain and pain relief

 

 

Recognising your baby’s cues

 

Infants, whether born prematurely, or term but unwell, have very different ways of expressing themselves than well term infants. The team caring for your baby are specially trained to recognise the signs and symptoms that your baby may show to express him/herself, and will happily explain how your baby responds to stressful or painful situations, so that you can recognise your baby’s cues in future. Typically, the more premature an infant is, the more stressful the environment is.This is due to immaturity of the nervous system resulting in an inability to cope with external factors as well as keeping his/her vital signs, such as heart rate, breathing rate and temperature, stable. As the baby develops towards term, the ability to cope with external factors such as noise, light and pain improves. However, an unwell term baby may well illicit certain negative responses to light, sound and pain detailed below as they have a reduced ability to cope with stress.

 

If your baby is stressed he/she may illicit some of the following behaviours:

• tachypnoea (rapid breathing), apnoea (cessation of breathing), gasping, gagging or sighing
  
  
• colour changes
  
  
• coughing, hiccoughing, vomiting
  
  
• sneezing or yawning
  
  
• tense or flaccid arms and legs
  
  
• hand on face, ears or eyes depending on the type of negative stimuli encountered
  
  
• raised hand in the 'stop’ position
  
  
• high-pitched cry, irritability, 'vacant’ expression
  
  
• poor weight gain over a prolonged period of time

 

 

Your baby will also let you know when he/she is happy, by eliciting some of the following signs:

• stable heart rate, breathing rate and good temperature control
  
  
• tolerance of feeds
  
  
• relaxed posture and tone
  
  
• sucking and looking for hands/fists to suck
  
  
• relaxed facial expression and extremities
  
  
• clear, definitive sleep states
  
  
• alert but relaxed facial expression
  
  
• greater weight gain
  
  
• earlier readiness for oral feeding

 

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Appropriate handling and positive touch

 

Handling the preterm infant or the unwell term infant is evidently suggested to be the most direct source of stress for infants, but can also be the most effective source of comfort and pleasure. As a parent, knowing whether handling your baby is having a negative or a positive effect can be difficult to determine. Staff are specially trained to handle appropriately, based on a baby’s condition and will advise you throughout your stay within SCBU. Unfortunately, some handling episodes, such as blood taking, will be unpleasant for your baby, but staff will help to teach you how to comfort your baby throughout these procedures.

 

You will observe cares such as nappy changes and mouth care being provided at varying intervals throughout your stay within SCBU. Rest periods are essential for effective sleep cycles, as well as normal growth and development. Infants who are premature or unwell will be minimally handled to reduce the stress that performing cares can have upon their physiological state, thus making them more unstable. Whereas, a baby that is medically stable or nearing term will be handled more appropriately and at more regular intervals to prepare towards the care he/she would receive at home. Bathing a premature baby, or a term baby immediately following birth, has been shown to cause various stress factors and destabilisation of the infant and is consequently not recommended. The nurse caring for your baby will show you how to perform a 'top and tail’ wash until your baby is well enough for routine bathing to take place in preparation for discharge home. Care is tailored to each individual baby, depending upon their condition and their ability to cope with stress.

 

 

Parental contact can be stabilising and positive for a baby, provided that it is appropriate and the surrounding environment conducive. Parents are encouraged to provide positive handling experiences for their baby, at times when their baby is relaxed and responsive rather than stressed and in pain. Positive experiences may include talking, touching and cuddling your baby. Gentle but firm touch, keeping the hand still rather than stroking the premature infant, helps to settle because they feel more secure. Talking in a soft voice is also proven to settle as the baby will recognise your voice from his/her time within the womb. Cuddling and rocking the term infant will also help to settle and comfort. Infant massage and play therapy (see separate sections under 'Development Care’) can be undertaken at times when your baby is alert and responsive to help promote appropriate development as well as relaxation times for your baby. Positive touch by parents (firm, still hands encompassing your baby’s body, especially head and legs) during negative procedures such as blood taking, and cuddling and rocking following procedures, has been shown to reduce the physiological and behavioural responses to stressful procedures. The key is to use your baby as the lead, and respond to his/her behaviour appropriately. Use the signs above to help you determine whether your baby is tolerating the activity well, or speak to the nurse caring for your baby for more advice.

 

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Positioning

 

Due to decreased muscle tone, premature infants are at risk of developing postural problems following a prolonged stay on NICU/SCBU. Neonatal units worldwide have recognised that correct positioning of premature infants throughout their stay greatly reduces the long term effects of prematurity such as increased neck extension, inability to draw shoulders into the midline, 'frog-leg’ position resulting from lack of postural support under the hips and decreased hand-to-mouth coordination. Similarly, for all infants, supportive positioning results in enhanced comfort, reduced stress, improved head control, stimulates visual exploration of the external environment and enhances development of motor skills, reflexes and postural tone.

 

Consequently, you will see your baby nursed in many different positions in order to promote optimum outcome. If your baby is premature he/she may be contained within a boundary encompassing the whole body using rolled sheets, quilts or gel boundaries. Hips and shoulders will be supported to aid development and prevent hip problems and problems drawing the shoulders into the midline as your child grows. Your baby may have a soft head boundary , which helps to soothe and calm and prevent head moulding. Cushioned mattresses are used to provide a boundary to support flexion and containment as well as reduce gravity on delicate pressure areas. Your baby may be nursed on his/her back in a supported position, side-lying supported with quilts or blankets which helps to encourage hand-to-mouth comfort, as well as providing support for the hips and shoulders, or on his/her tummy (prone). This position is especially suitable for infants requiring breathing support as the mattress helps to support the chest wall thus aiding breathing. Prone positioning is suitable only while your baby is being closely monitored due to the increased risk of sudden infant death syndrome (SIDS), and it must be remembered that prone positioning is not recommended when your baby comes home. As your baby nears term, you will notice that supportive positioning is gradually reduced, as your baby will gain muscle tone and want to move independently.  This will also prepare you for the transition towards home, as nesting and using rolled blankets and quilts to support your baby are not recommended due to the risk of overheating. 

 

Speak to the nurse caring for your baby if you would like to bring in blankets or quilts to help position your baby, or if you would like further advice regarding positioning techniques used.

 

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Kangaroo care

 

'Kangaroo care’ or 'kangaroo cuddles’ is the term used for the skin-to-skin contact that is encouraged throughout your baby’s stay. The infant is placed in a vertical position upon the maternal or paternal chest and has been shown to have significant positive effects on both the infant and parent. No matter how small or premature your baby is, kangaroo care can usually be accomplished providing the infant is stable.  It is recommended to have kangaroo care for as long as is comfortable for you and your baby to optimise the benefits. Positive effects for your baby of having kangaroo care include:

 

• improved oxygenation, more medically stable
  
  
• increased temperature stability, as the parental body temperature warms or cools according to the baby’s requirements
  
  
• increased restful sleep and increased content activity
  
  
• improved weight gain
  
  
• increased successful period of breastfeeding, as well as earlier oral feeding
  

There are numerous benefits for you too, including:

• increases self confidence, bonding, attachment and confidence
  
  
• increased feeling of being able to help your baby while he/she is in SCBU
  
  
• encourages more frequent visiting
  
  
• increases breast milk supply and duration
  
  
• earlier discharge

 

As a parent, it is entirely normal to feel anxious when the possibility of kangaroo care is broached with you. Remember that staff would not be suggesting you have your baby out for cuddles if he/she wasn’t well enough.

 

Tubing and wires will remain attached to your baby, but staff will guide you through what to do and the best way to pick up your baby. Your first experience of kangaroo care may well be full of feelings of anxiety, but try to remember the positive effects it will be having on your baby, and soon you will be relaxed and enjoying kangaroo care frequently. As your baby prepares for home, you will be encouraged to get your baby out for cuddles independently, as you would at home. Do not feel afraid to cuddle your baby, especially if he/she is unsettled or if you are establishing feeding and he/she is ready for a feed.

 

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Non-nutritive sucking

 

Non-nutritive sucking is the term used for when a baby sucks on something like a soother (a dummy) or a finger for comfort. Images of babies sucking on their fingers in the womb have been seen from as early as 18 weeks, and evidence shows that this type of sucking has a stabilising effect on physiological responses resulting in decreased tension, more restful behaviour and improved oxygenation. The sucks are smaller and quicker than your baby would use for oral feeding but have been shown to improve readiness and coordination for oral feeding.

 

 

The use of soothers is often recommended for premature babies as evidence shows that non-nutritive sucking can help babies to settle, feel comfort during painful procedures, tolerate their feeds better and move on to oral feeding more quickly. Indeed, if your baby has been born at term and is not receiving any, or only small amounts, of milk, then the use of a soother can also help to settle as well as providing comfort during painful procedures. As a parent, you may feel worried because lots of information in the press and on the internet can discourage the use of soothers. However, this information is based on the long term use of soothers for older babies and toddlers, and does not apply to premature babies, or unwell term babies that are not receiving oral feeds.

 

Your baby will show you if he/she would like to suck when you gently encourage sucking on a finger at a time when he/she is relaxed and comfortable. Offering a soother at the same time as giving a feed via a naso- or oro-gastric tube will help to stimulate digestion and storage of nutrients and your baby will begin to associate the sucking technique with receiving milk. Your baby will also tell you if he/she does not want to suck. If he/she spits out the soother, pulls a grimacing face, gags, closes his/her lips or frowns then your baby is telling you that they do not want to suck at this time. Some babies prefer to suck on their own fists and fingers rather than a soother. Your baby will be positioned in a way that helps to aid this hand-to-mouth action, therefore encouraging comfort from an entirely natural source. 

 

As your baby nears term, feeding is established and you begin to prepare for home, it is entirely your preference whether you wish your baby to continue using a soother. Evidence may suggest that establishing breastfeeding can be harder when a baby is also using a soother due to nipple confusion, however if your baby is establishing bottle feeds then this is less of a problem. This is entirely your choice.

 

Speak to the nurse caring for your baby or the speech and language therapist if you would like to consider a soother, if you feel you baby may benefit from the use of a soother or if you have questions or concerns regarding the use of soothers on SCBU.

 

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Pain and pain relief

 

Neonatal pain is a highly researched topic. Until fairly recently, it was generally considered that neonates did not feel any pain, and hence did not require pain assessment or pain relief. However, research has now established that neonates do indeed perceive, experience and remember pain. Premature infants have sufficient development of the central nervous system, even at 20 weeks gestation, to respond to painful stimuli, resulting in physiologic, hormonal, metabolic and behavioural changes. Consequently care providers must possess an awareness regarding the effects and consequences of pain and care must be tailored to assess and manage pain in order to prevent any detrimental effects to therefore improve the well-being of both the infant and the parents.

 

Throughout your baby’s stay within the SCBU, he/she may have to undergo numerous painful procedures. Staff are specially trained to anticipate, assess and appropriately respond to painful stimuli, thus ensuring your baby is as comfortable as possible throughout his/her stay. If your baby is in pain, you may notice some of the following signs:

 

• increased or decreased heart rate, oxygenation, blood pressure and breathing rate
  
  
• increased blood sugar levels due to the release of hormones due to increased stress levels
  
  
• facial grimace
  
  
• high pitched, shrill cry
  
  
• kicking or withdrawing legs, rigidity to arms and legs
  
  
• limp and flaccid arms and legs
  
  
• vomiting
  
  
• colour changes, mottled colouring.

 

Assessment of pain will take place as your baby’s condition dictates, and will look at a number of factors, including those highlighted above, to recognise the presence and severity of pain and to ensure adequate measures are taken to provide optimal pain relief.

 

Pain relief aims to enhance your baby’s ability to cope and recover and provide the most effective solution, with the least risk of causing further detrimental side-effects.  It can be sought from many different interventions, including medicines and comforting measures.

 

 

Medicines

Medicines, called analgesics, can be given to your baby to provide pain relief.  However, the use of analgesics may cause detrimental side effects due to immaturity of many of the organs used in breaking down and eliminating many of the drugs used.

 

 

Comfort measures

Measures that do not necessitate the use of medicines have been widely researched, and many have proved to be effective in reducing agitation, thus decreasing the negative outcomes shown above following painful stimuli.  Such measures include:

 

• appropriate handling - rather than waking an infant up from a deep sleep, procedures will often be timed at a time that is appropriate for your baby, when nappy changes or other cares are to be performed for example, thus increasing comfort and improving sleep-wake cycles
  
  
• swaddling - swaddling your baby involves wrapping in a soft blanket or quilt, keeping the arms and legs tucked in, to provide security and containment. Research has shown that swaddling can effectively reduce pain, especially in infants who are premature or low birth weight
  
  
• non-nutritive sucking - the use of a dummy, or soother, to suck on when encountering a painful procedure has also been shown to reduce many of the behavioural responses to painful stimuli (see above)

• sucrose - oral sucrose can be given to your baby if he/she is receiving some milk orally or via a naso- or oro-gastric tube. Sucrose works by provoking the brain to increase the level of pain threshold, thus reducing the behavioural and physiological indicators of pain.

 

As a parent, the prospect of your new baby having to undergo multitudes of painful procedures can be difficult to bear. Whilst many of the procedures are vital whilst your baby is staying on SCBU, you can have peace of mind that the doctors and nurses caring for your baby are skilled to anticipate pain and respond to it appropriately, as well as showing you how to help comfort your baby during painful procedures. Positive touch, swaddling and holding your baby before, during and after painful procedures can all help to reduce the pain that your baby will feel. Speak to the nurse caring for your baby for more help and advice.

 

 

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