When you have a baby born prematurely, you are faced with starting parenthood differently than if your baby was born full term. Rather than being able to hold, touch, comfort, and console your newborn you are faced with the reality of having those moments fade away as your baby is taken to the neonatal intensive care unit. Instead of feeling the joy, wonder, and excitement of birth, you are left with feelings of sadness, fear, and emptiness. You may grieve over the early loss of your pregnancy and a healthy full term baby. Just as it is a very hard way for your baby to start out life, it is also a very hard way for you to start out being a parent.
Beginning parenthood in the NICU is far different from the picture you expected and feelings of hopelessness and helplessness are very normal. As you begin this journey with your baby, remember you still have a very important role in helping your baby develop in the early days and weeks in the NICU. Even if all you can do in the beginning is offer a gentle touch and reassuring voice, your baby will find comfort and contentment in your presence. As your preemie grows, you will assume more and more of their care and by the time your baby is ready to go home you will be doing almost everything for your baby.
It is important to understand that developmentally a premature baby is not the same as a full term newborn. Their immature nervous system is still wired to amplify input and is extremely sensitive and even the simple things like sound, touch, sights, and movement can be very stressful. Preterm babies have trouble making sense of the outside the womb world as their immature brains do not yet have the ability to pay attention to some things and ignore others and therefore become overwhelmed easily by many forms of stimulation at one time. Normal activity levels that a full term baby would have no trouble with, such as rocking, talking, and feeding at the same time; is very stressful, overwhelming and even intolerable to the premature baby.
Premature babies communicate through physical reaction and will not communicate like full term newborns, by crying. Crying requires energy and muscle strength and therefore will not be seen typically in a preemie until they are closer in age to their due date. Instead premature babies show their stress through disorganized neurological activity such as a fast or slow heart rate, breathing or apnea spells. Other disorganized activity includes: Yawning, coughing, hiccups, sneezing, and spitting up. A stressed preemie may also have poor muscle tone, become limp or stiff, have twitching or even tremor. When they are content (or organized) they are flexed, with arms and legs tucked in, and the hands close to the face or midline. They will have fluid movements and their heart and breathing rates are steady.
Preterm babies develop differently from full term infants just as your baby’s behavior, responsiveness to stimulation and the environment will differ based on their gestational age. It is very important to be aware of your baby specific stage of development so you can be responsive and understanding of their specific needs as they relate to their newly corrected gestational age and stage. Remember that your baby wasn’t supposed to be born yet, so be patient and understanding and provide the best emotional and physical support you can, as you help your baby develop and grow towards their journey to home.
Micro preemies:(Babies born 22-25 weeks of age and/or weighing less than 800 grams) Preemies born less than 26 weeks gestation have extremely immature nervous systems and will not show much outward response to stimulation but internally they may respond negatively. Because their nervous system is very immature they will have fluctuations in their heart rate, blood pressure, temperature and oxygen levels when they are moved, touched, or overstimulated by lights, and loud sounds. You may have little physical interaction with your baby during these early days but your presence and the gentle sound of your voice will be reassuring to your baby.
Premature babies between 26-29 weeks gestation will have more spontaneous movements and reactions to stimulation. These babies do spend most of their time asleep but will wake up briefly and may even open their eyes with dim lights. Neurological development is rapid in these weeks and it is important for the preemie to sleep as much as possible. They will not wake for prolonged interaction and will not show distress with crying but rather changes in posture, breathing and heart rate, as well as color changes, twitches, and tremors. Babies 26-29 weeks may get overstimulated with rubbing of the skin or hair but a soft voice and firm gentle touch are reassuring and comforting. At this stage of development your interaction with your baby may be minimal, depending on how stable your baby is. Limiting interaction to organized time is very important. Promoting healthy sleep cycles by keeping the environment quiet and dark, and allowing for rest periods between cares is important for neurological development.
Premature babies between 30-33weeks gestation will have more spontaneous movements but will continue to be uncoordinated and not purposeful. At this stage a preemie will be awake more, with alert periods lasting several minutes. Premature babies between 30-33 weeks continue to need a lot of sleep and thrive in a dark and quiet environment. They will begin to develop their suck but will not be ready to feed from a bottle or breastfeed as they have not developed the coordination to suck, swallow and breathe at the same time. Pacifier use and kangaroo care while being fed will help develop the patterns necessary for future feedings. Clustering of care is still very important during these weeks as preemies tend to tire easily. Crying, hiccups, sneezing are all signs of stress and disorganization at this gestational age.
Preterm babies between 34-36 weeks will begin to look more like full term infants only smaller. These babies (sometimes called late preterm) are still very much learning. They will begin to wake more often and thrive from touch and familiar sounds. The 34-36 week preterm baby will often be in an open crib environment but keep in mind they still need rest and sleep between feeds. This stage is when the preemie will begin to feed via bottle of breastfeeding. Keep in mind, they are learning and it will be a time of patience on your part and endurance training for your baby.
Organized vs. Disorganized behavior cues: Full term babies naturally put their hands together in front of their body, in midline, to organize. Preemies that don’t have mature neural systems are disorganized. They cannot synthesize all the sensations and stimulation they are receiving and they need help to get organized. Promoting organized behavior for you baby is one of the most important things you can do to mold and develop the neurological system. Organized behavior includes swaddling- keeping the arms and legs tucked in or bringing hands to midline or the face. Allowing your baby to be tucked in with boundaries provides an environment similar to that within the womb. Remember rest periods between feeds and care is also very important for your baby’s growth and development.
Developmental Care is the concept of promoting the best environment for the developing premature baby’s nervous system, creating the neural pathways in the brain that will be the building blocks for later more complex activities, such as crawling, walking, and talking. Developmental care concepts have proven that organized babies do better, that changes in environment can help or hinder their organization and therefore their neurological development. Subtle behavior changes in the preemie can indicate stress and disorganization or relaxation or readiness to interact with the environment. All babies are unique and based on gestational age as well as their personality, will have different ways on how they react to their world and the outside environment. As you spend more time with your infant you will begin to learn their specific behavior cues and what your baby can and cannot handle. What makes them stressed and disorganized and what you, as a parent can do to help soothe, comfort, and organize your baby. Nurses and healthcare worker come and go. You will be the one constant in your preemies care and will begin to know what works best for your baby. Following some of these developmental care concepts, you can make a huge difference on how your baby thrives and develops while in the NICU, as well as help lay the building blocks that will shape their development in the first few years of life.