Developmentally Appropriate/Supportive Interventions in the NICU

Many thanks to the multi-disciplinary Sunnybrook Team

Objectives
To understand the various interventions that can be implemented in the macro and microenvironment within the NICU To appreciate the importance of these various interventions

Interventions
Environmental changes- macro and micro Cluster of care Non-nutritive sucking Positioning Skin to Skin Care Pain Management Family Centered Care

 Promote stability and reduce stress in the infant Respond to the infants cues Protect the family

Macro environment
The NICU design of the unit needs to be developmentally friendly The staff needs to function as a team and be supportive of developmentally appropriate care the staff needs also are taken into consideration Lights Sounds

Lighting
Photometers to measure lighting <32wks GA minimize ambient light exposure use covers over isolettes Provide task lighting for staff and family Provide Night time staff exposure to adequate lighting Protect infants eyes from direct light exposure at: Admission Eye exams Under phototherapy lights Other procedures

In our unit fully covered isolettes until approximately 32 weeks or while critically ill

Cycled Lighting
> 32 wks GA cycled lighting: 210-270 lux from 7 AM to 7 PM blankets are not permitted on top of the isolettes infants are allowed 2 naps in dimness in this 12-hour period lighting is lower than 25 lux from7 PM to 7 AM. After 37 weeks GA provide more complex visual stimulation

Circadian rhythm
In utero circadian rhythm of the fetus is set by mother by her activity level, eating, temperature, heart rate, blood pressure,melotonin and her cortisol levels Preterm infants in the NICU lack the maternal entrainment and are exposed to unpredictable lighting in the unit Cycled lighting may assist the preterm infant achieve some circadian rhythm in an appropriate timeline

Sound Levels

average NICU is 70 - 80 dB recommended level is 50 dB well maintained and sealed empty isolette should be 50 dB perceived loudness of sound doubles with every 6 - 10 dB opening isolette doors gives perception of sound 8 times louder

Sound
Sound measurements to be done of the unit and in the isolette and at the open bed space Sound reducing materials on surfaces in the unit ie walls and floor Respond to monitors, equipment, pagers Attention to other noise producing equipment Traffic patterns in the unit where high traffic, keep babies away ( or at least the sickest)

 Reduce bedside conversations, other noises around bedside/isolette Want infant to hear mothers voice above background sounds Reduce lights people talk quieter

Reduce stress and crying of infants

Naptime or quiet time Staff conversations

Noise Reduction
What doesnt work

isolette covers

infant foam ear covers

curtains between baby areas noise police might work

Micro Environment
Surrounding the infant: Cluster of Care Positioning Touch- procedural / non-procedural Pain management Use of expressed colostrum ( oral immune therapy) and breastmilk Oral feeding = breastfeeding , bottle feeding

Cluster of Non-Emergent Care

Should be according to infants cues Should not be interrupting sleep Bedside nurse the guardian: others to make an appointment as to when to handle ( other than a hand-hug by parent) Clustering of care is believed to support infant development by decreasing infant energy expenditure and promoting sleep.

clustering

of care with recovery time scheduled assessment times gentle, slow repositioning hand containment or nesting

Non-Nutritive Sucking (NNS)

A reflex that is elicited when an infant sucks on a pacifier, hand or any object that does not deliver liquid NNS is important for infants state regulation assists in calming the infant it is seen in utero as early as 11 - 13 weeks GA Use when there is maternal infant separation

separation of mom & abnormal scenario

baby creates an

size appropriate, use during tube feeds

Cochrane Review (Pinelli and Symington,2010

NNS was found to decrease significantly the length of hospital stay in preterm infants. The review did not reveal a consistent benefit of NNS with respect to other major clinical variables (weight gain, energy intake, heart rate, oxygen saturation, intestinal transit time, age at full oral feeds and behavioral state). The review identified other positive clinical outcomes of NNS: transition from tube to bottle feeds and better bottle feeding performance.

 These infants showed less defensive behaviors during tube feedings, spent less time in fussy and active states during and after tube feedings, and settled more quickly into sleep.

Positioning the Preterm Infant

 Positioning is defined as a bodily posture assumed by the patient or in which the patient is placed to achieve comfort The particular disposition of the body and extremities to facilitate the performance of certain diagnostic or therapeutic postures

Historical Perspective
In the past, supine was the position of choice for infants, It allowed easy observation and easy access by caregivers The practice of supine positioning was challenged based on studies of respiratory function in adults. Attinger et al. (1956) studied preterm infants to determine the optimal position for care. Prone position was found to offer more benefits than supine or side lying positions. The findings of their hallmark study altered care in NICUs, wherein all infants were positioned prone.

 A 2001 review of 180 papers examined neuromotor development and the physiological effects of positioning and interventions in order to minimize or prevent short and long tem negative outcomes Emerging results indicated that: the development of posture and mobility in newborn infants requires an optimal balance between active and passive muscle tone prone position is physiologically more beneficial for the preterm infant than supine and lateral positions prone position can lead to short and long term postural and associated developmental problems

Why is Developmentally Appropriate Positioning Important?

Overall hypotonia (low muscle tone) Imbalance of active and passive muscle power Affects of gravity Lack of uterine containment Caudocephalic direction of neuromotor development

Muscle Tone
what is it ?

Muscle tone
The state of slight contraction usually present in muscles that contributes to posture and coordination Resistance of muscles to passive elongation or stretch Power and adaptability of the muscles during spontaneous movements Affected by state Factors affecting Muscle Tone in the Preterm population

Postural control
Provides a basis for stability during movement Passive muscle power- slight, sustained contraction in anti-gravity muscles Supine posture provides an overall impression of passive muscle tone

Active muscle power- degree of vigour in spontaneous movements, fluent alterations in flex/ext symmetrical, goal directed movements

Passive muscle tone

Best observed when infant at rest quiet alert state State of slight muscle contraction that contributes to postural control and coordination of the extremity movements Begins approx 28 weeks gestation age Develops in a caudocephalic direction

28 week Gestational Age

Dubowitz et al, 1999

32 week Gestational Age

Dubowitz et al 1999

Posture: 36 - 37 weeks Gestational Age

Dubowitz et al 1999

36 weeks gestational age

Posture: Full Term

Dubowitz et al 1999

40 weeks

Active Muscle Power

Is observed when an infant makes a movement in reaction to a situation As preterm infants have low muscle tone, they appear to develop exagerrated active muscle power Therefore increased extension with movements

Passive Muscle tone and active muscle tone need to work in harmony to provide stable postures and fluent movements The preterm infants have low muscle tone and exagerrated active muscle power, therefore very difficult to maintain a posture or position without assistance

 Need to determine a position that is medically effective and developmentally supportive moving target No long lasting perfect position

Positioning Goals

Goals of Positioning
Head Goals

prevent head & neck hyperextension put neck in elongated position chin in neutral position or slightly flexed downward

Nose Goals

maintain normal nare shape prevent nasal notching and keep the septum intact good alignment of tubing in the nostrils

Plastic surgery cant fix notches

please, spare the nares !

Eroded Caudal Septum

Columellar Transection

Columellar Notching

Upper Extremity Goals

forward flexion of shoulders to prevent shoulder retraction hands to midline hands to mouth grasp opportunities

Trunk & Lower Extremity Goals

maintain a straight, aligned trunk hip and knee flexion to approx. 90 degrees prevent excessive abduction and external rotation maintain knees in a midline (neutral) position feet - allow bracing, maintain a symmetrical position

Principles of Positioning
Flexion Midline Symmetry Alignment Weight bearing Containment Comfort and sleep Learning opportunities for the intimate caregiver

 Flexion: the act of bending or is the condition of being bent In utero, the fetus is maintained in a flexed position by the uterine wall In the NICU, the preterm infant should be positioned in a flexed posture in order to imitate the intrauterine posture and to enhance the development of flexor muscle tone

 Midline :the line through the middle of the body ie from the nose to the umbilicus. With positioning it is imperative to bring both the upper and lower extremities towards the midline so that the hands have easy access to the mouth,and the hips and knees are towards the midline so promote good alignment of the hips. As infant moves towards the midline, they are moving into a position of flexion and as they move away from the midline, they are moving into an extended position which will increase stress and disorganization.

 Symmetry is defined as the correspondence in size, form and arrangement of parts on opposite sides of a plane, line or point In positioning of the preterm infant in the NICU this would involve the placement of the extremities in a similar position and direction

P R O N E

S U P I N E

 Weight Bearing:It is important to be cognizant of the body surfaces on which the infant is lying hereby bearing their body weight. These weight bearing surfaces are also the pressure points from which the infant is in contact with the surface of the external support. Too much pressure or prolonged weight bearing on one point can be a source of pain and/ or discomfort. Movement occurs in the body parts that are not bearing weight.

most of my weight is on my head ! & thats not good arm

weight bearing

knees

new weight bearing surfaces

side of face shoulder hip

 Alignment is the state of being in arranged in a line. Good postural alignment would mean that the ear is in line with the shoulder, in line with the hip, in line with the ankle. Good alignment in the infant will promote better quality movements ie the ability to move towards the midline into flexion, will enhance the development of age appropriate muscle tone and will decrease the likelihood to move away from the midline towards extension and therefore increasing the stress of the infant.

 Containment is defined as positioning the infant with the use of equipment to maintain the flexed midline position of the infant, giving the infant a sense of stability and security. The gentle pressure of the equipment will inhibit the big amplitude movements yet allow small movements which are normal in a fetus therefore a preterm infant.

 Promote comfort and sleep A multitude of learning opportunities for the intimate caregiver

Good positioning is a positive oral experience - hands to mouth, to midline - gentle forward flexion - Non- nutritive sucking - reducing stress, allowing the infant to achieve state regulation - feeding readiness cannot feed until achieve systems stability in bed with handling and then with holding

Passive and active positioning

Containment is defined as assisting the infant to achieve and maintain a flexed, midline position by using blankets or equipment to provide boundaries Blankets or positioning equipment provide support and gentle inhibition of the large amplitude movements of the extremities. Containment does not restrain the infant.

Facilitated tuck: the tucked position is described as the infant being placed in side lying, with the trunk being curled forward gently, with the hips and knees flexed past 90 degrees and brought towards the midline along with the shoulders and elbows flexed past 90 degrees thereby allowing the hands near the mouth or the face (Ward-Larson et al, 2004) the gentle positioning of an infants arms and legs in a flexed midline position close to the infants body while the infant is in either a side-lying, supine or prone position (Hill et al, 2005) involves a caregiver providing the postural support with their hands preferably on the head and feet while a second person performs a procedure or routine care. These two studies demonstrated that the technique of facilitated tucking during routine care and/or a painful procedure may be an effective measure to reduce stress and/or pain for the infant.

Benefits: Positioning in Prone

Gas exchange Chest wall synchrony with respirations Fewer episodes of apnea Sleep state improved Decreased energy expenditure Increased gastric emptying Decreased reflux episodes

Benefits: Positioning in Supine

Visualize chest movement Chest movement with Oscillation or Jet ventilation Umbilical lines, chest drain placement Less nare pressure when on Hudson Prong CPAP Allows extremity movement Back to Sleep

Benefits: Positioning on Right and Left Side!

Head is in midline Hands to midline, mouth Sucking and grasping opportunities Left side decreases reflux episodes Pneumothorax treatment Post op reasons

Equipment

blanket rolls headhuggers frogs isolette covers butterflies prone pillow creative equipment

Long and short term implications of positioning

Skull shaping Preference to face one way Increased trunk extension and shoulder retraction Hips and other lower extremity postures

frequent right facing can lead to

preferred right facing which can lead to

weeks or months of therapy to return to midline

Skull Shapes

 Skull deformations occur after embrogenesis

Result from nondisruptive mechanical forces ie postnatal positioning in the NICU

Skull weight bearing on the hard surface

Definitions
Dolichocephaly having a cephalic index <75% common in premature infants usually caused by prone/ side lying positioning in the NICU Scaphocephaly abnormal length and narrowness of skull, as a result of premature closure of the sagittal suture, usually accompanied by mental retardation They will appear the same initially

 Central Occipital flattening Brachycephaly ( a Cranial Index >81% , indicates a shortened anterior-posterior dimension and widening of the bilateral eminences)

CI = 54%

 Plagiocephaly asymmetric head known as Positional Plagiocephaly ( without synostosis) deformation of the skull(occiput) produced by extrinsic forces acting on an intrinsically normal skull from supine lying Right* ( most common)and Left occipital flattening

Features of disorganized,organized and self regulating behaviours

Disorganized tend to be jerky, frantic, flailing, involve extension, repetitive movements that tend to increase disorganization Self-regulating start to calm, involve active flexion, coming to the midline, jerkiness starts to become more smooth,sucking Organized smooth, flexion, hands and feet together

Infant Activities

Deep Sleep

REM sleep

Indeterminate sleep

Quiet awake

Active awake

Crying

Exhaustion

Heart rate

Stable / steady

Slight irregularity

Irregular

Irregular

Irregular

Irregular

Bradycardia

Respiratory

Regular /smooth

Disruption of regular breathing pattern

Chaotic breathing pattern

Regular / smooth pattern

Irregular

Irregular

Apnea

Colour

Pink

Pink

Pink

Pink

Pink / red

Red, dusky, circumoral cyanoses

Pale, mottled dusky

Visceral

none

none

none

none

Spit up

Spit up

Emesis, BM

Eyes

Closed & no movement

lids closed or just slightly parted, eye moves under lids in phasic patterns

heavy lids fluttery lids Dull eyes

Bright focused

Lids open, more eye movement, less focus

Eyes tightly closed with grimace

Dull, unfocused

Face

No movement

Small twitch, sucking motion

Twitches, brow raise, smile,

Minimal movement

Frequent movements, sucking, rooting, grimace, hyperalert

Grimace,

Gape face

Head & Trunk

No movement

Minimal to slow rotation or lifting, maintains tucked flexed position

Larger smooth trunk movement, diffuse stretch

Minimal movement

Mild arching, extension,

Arching, hyperextension,

Arching, extension and flaccid

 Red is stop, dont disturb, state is good: Green is good to go (i.e. capable of feeding, interacting) Yellow is a state that needs assistance to move into the red or green state

scent free in the NICU and in the isolette

Odours
Cloth dolls huggies Perfume free zone Reduce exposure to noxious odours ( alcohol hand wash) Protect from exposure to odour of cigarette smoke Use of colostrum and breast milk

Maternal Scent Skin to Skin

Skin to Skin Care (Kangaroo Care)

Skin To Skin Care

Stable Infant placed upright with only a diaper on mother or fathers bare chest Willing caregivers staff and mother/father Transfer often the most difficult Length of time a sleep cycle

Flexion Midline Symmetry Alignment Weight bearing Containment Comfort and sleep Learning opportunities & experiences

Infant Benefits of Skin to Skin

Improves state organization, Increases the length of quiet sleep state (NREM) shorter periods of REM sleep Assists thermal regulation, Stabilizes respiratory patterns, oxygen saturation, reduces apnea, reduces bradycardia Increases rate of weight gain Functions as an analgesic during painful procedures Shortens hospital stay Positive impact on physiological and behavioral organization and later for mental health outcomes Positive impact on perceptual, cognitive and motor development

Maternal Benefits to Skin to Skin

Increase mothers milk production Positive impact on breastfeeding outcomes Improves maternal adaptation to infant cues Positive impact on mother infant attachment Positive impact on maternal sense of competence, during hospitalization and after discharge Positive impact on paternal feelings

Infant Massage
Numerous studies : claim many short and long term benefits for infant and mother Can be a simple as a hand hug to infant massage Need to watch the infants cues and reactions Probably best to teach the mother and closer to term age for the infant

Massage
Massage has been found to soften scar tissue by freeing restrictive fibrous bands and increasing circulation Release the underlying adhesions Reasons: cosmetic promote full lengthening of the affected structures with growth

Scars
Surgical - PDA Ligation - Abdominal Procedural - Central lines - Chest tubes - IV infitration - tape removal

Pain Assessment & Management: Pharmacological and Non-Pharmacological Interventions in the NICU

Sharyn Gibbins, RN, PhD May 15, 2006

Pain
Pain is an unpleasant sensory and emotional experience associated with actual or potential tissue damage or described in terms of such damage IASP
Pain has been defined further as a subjective experience that is best understood through selfreports Verbal communication and self-report are considered the gold standard for pain assessment

Challenges to the Pain Definition

In the absence of verbal communication, other indicators such as physiological, hormonal, biochemical and behavioral responses to painful stimuli should be considered forms of self-report that are surrogate markers to infer the existence of pain in high-risk populations (Warnock & Lander 2004)

Efforts should be directed towards increasing recognition of pain and developing broader sources of information to infer the subjective experience of pain in nonverbal neonates

Summary of Pain Responses

PHYSIOLOGICAL INDICATORS
Increased Heart Rate Changes in Respiratory rate

BEHAVIOURAL INDICATORS
Increased Facial Actions Cry

BIOCHEMICAL/HORMONAL INDICATORS
Increased Cortisol Increased Epinephrine

Increased Intracranial Pressure

Fluctuations in Blood Pressure Decreased Oxygen Saturation Changes in Heart Rate Variability Dilated Pupils Palmar Sweating

Increased Body Movements

Changes in State Fussiness/Sleeplessness Flexor withdrawal reflex Consolability/sleep patterns

Increased norepinepherine
Increased Growth Hormones Decreased Prolactin Decreased Insulin Protein Catabolism Decreased Immune Responses

Difficulties with Interpretation of Individual Pain Responses

Behavioral but not physiological indicators are predominant during painful procedures in preterm infants
Repeated pain affects pain response
preterm infants who were born at 28 weeks gestation and hospitalized in a NICU for 4 weeks (early preterm group) had significantly higher heart rates and lower oxygen saturation levels during heel lances than preterm infants born at 32 weeks (late preterm group) the more recently a preterm infant had experienced a painful procedure, the less likely he/she would demonstrate behavioral pain responses to subsequent painful procedures

Responses are influenced by gestational age, behavioral state and severity of illness

Biological Factors
gender differences

Myths of Pain in Infants

Infants Lack Myelination
The neural pathways for pain perception are present in newborn neonates (Anand, 1993; Fitzgerald, 2000;Humphrey, 1964 ) The density of nociceptive nerve endings in the skin of neonates is similar to or greater than that in adult skin
(Anand 1993)

Nociceptive pathways to the brainstem and thalamus are myelinated by 30 weeks gestation (Anand & Carr, 1989;
Anand et al.,1989; Fitzgerald, 1993; Rakic & Goldman-Rakic, 1982)

Myths of Pain in Infants

Capacity for fetal pain is limited
Fetal awareness of pain requires functional thalamocortical connections (Lee et al, 2005 ) EEG patterns denoting wakefulness is present around 30 weeks
Lack of surrogate markers Neuroanatomical evidence reports developmental ranges (21-30 weeks) Purpose was termination NOT preterm infant management

Pain in Infants
Approximately 8.2% of the contacts in the NICU are comforting Stevens et al (1999) found that infants born between 27 to 31 weeks gestation received a mean of 134 painful procedures within the first two weeks of life and approximately 10% of the youngest and/or sickest infants received over 300 painful procedures Porter (1999) found that preterm infants experienced, on average, over 700 painful procedures during their hospitalization Gibbins et al. (2002;2005) found the mean number of painful procedures per day was greater than 5 (range 0 to 10) and 12/day if non-tissue damaging procedures were included Stevens et al. (2005) found the mean number of painful procedures per day was greater than 10

Measurement & Assessment of Infant Pain

Assessment
Assessment involves subjective judgment about the quality and significance of pain for a particular infant Assessment may include measurement but also involves clinical judgment based on observation

Measurement
Measurement is used to (a) quantify pain (b) evaluate the effectiveness of pain relieving interventions and/or (c) compare pain responses across situations with the same infant and between infants

Limitations in Infant Pain Measures

Plethora of infant pain measures
Limited psychometric analyses of existing pain measures

Certain high-risk populations excluded

ELBW (<1000g) (Grunau et al., 2000; Morison et al., 2003) Cognitively impaired (i.e. Drug influence) (Stevens et al)

Certain situations excluded

Chronic vs. Procedural vs. Disease related

ELBW
Flexing and extending extremities, finger splaying, fisting and mouthing (Grunau et al 2000, Holsti et al. 2004) Startles, twitches, jitters and tremors were not associated with pain Decreased salivary cortisol in ELBW infants Pain responses in ELBW infants (Gibbins et al)

Neurologically impaired
Stevens et al. 2005

Infants at highest risk for NI demonstrated less physiological and behavioral responses to pain
significant within-subject effect of phase was found with:
- facial activity (F(3,239) = 45.58, p <.0001) - maximum HR (F(3,302) = 5.80 , p =.0007) - minimum HR (F(3,302) = 6.81, p =.0002) - minimum 02 (F(3,297) = 5.72 , p =.0008)

Compared to cohorts B and C, significant betweensubject effect with cohort A exhibiting:

less facial activity (F(2,233) = 12.17, p=<.0001) lower maximum HR (F(2,302) = 14.4, p <.0001) lower minimum HR (F(2,302) = 5.52, p<.004) lower mean cry fundamental frequency (F(2,33)= 3.57, p<.039)

Procedural Pain
Procedural pain in neonates still not treated consistently Measures to manage neonatal pain can be both pharmacological or non-pharmacological OR a combination of both

Painful Procedures or Conditions

Heelsticks (more painful than venipuncture (Shah,2002) Venipuncture/arterial puncture Skin lesions, abrasions, IV burns Rib,clavicle and extremity fractures Chest drain insertion Picc lines IM injections Surgical procedures Removal of adhesive tape/bandaids may be the most frequent painful procedure (Franck,2006) Intubation Eye exams

Approaches to Pain Management

Pharmacological alleviate pain with drugs that are safe and effective
Non-Pharmacological therapies, such as environmental or behavioral interventions, that do not include pharmacological agents One does not preclude the other For the NICU infant, there should always be environmental and behavioural strategies in place

Developmentally Sensitive Strategies

Environmental strategies can help by: Indirectly by reducing total amount of noxious stimuli
Behavioural strategies may: Block nociceptive input along ascending fibers Activate descending endogenous opioid and non-opioid pathways-decrease nociceptive transmission Interventions-activate attention and arousal systems that help modulate pain Standard of Care for all painful procedures

Stevens, Gibbins, & Frank, 2000

NICU Environment
Reduce noxious stimuli Multiple painful procedures, frequent handling plus environmental factors increase the infants stress responses Promote calm environment ( macro & micro) Promote physiologic stability Individualize care according to infants cues Handle slowly promote self regulatory behaviours Provide adequate preparation and support esp prior, during and following a painful procedure

Developmental Interventions Comfort Measures

Research examining multiple developmentally sensitive measures to reduce pain is limited
positioning facilitated tucking ( using hands) containment ( using equipment) non-nutritive sucking

Non-nutritive sucking
Mechanism unknowntheory is that the release of serotonin (only when sucking) may modulate, directly or indirectly the transmission and processing of nociceptive stimuli (Blass,
1995)

Studies-preterm and term Meta-analysis 3 studies significant reduction in heart rate after heel prick (1997) Heelstick decreased crying time (Field & Goldston, 1984)

Sucrose
The most studied non-pharmacological pain relief treatment in newborns Sucrose-disaccharide consisting of fructose and glucose Hypothesis/Mechanism of action-sweet taste promotes analgesia through activation of the endogenous opioid release that attenuates nociceptive information

Reduces heart rate and behavioural indicators of pain

Initial data supported that sucrose was effective in reducing pain that led to studies evaluating the efficacy and safety of sucrose, as well as the most effective dose in reducing pain

Sucrose for management of neonatal procedural pain

Evidence has been available for several years that sucrose is effective in managing pain in newborns 30 RCTs, meta-analysis (Stevens et al, 1997) and systematic reviews (Stevens et al., 2002) CPS and AAP have recommended its use for treatment of procedural pain in neonates (AAP, Pediatrics,
2000)

Consensus statement (Anand et al. 2001) that advocate for sucrose as frontline or adjunct therapy for most painful procedures

Dosage and Administration

Dose dependent on Gestational Age Dose of 0.5mls used for preterm and up to 2 mls for term infants Must be administered on the anterior aspect of the tongue Most effective if administered 2 minutes prior to painful procedure; Lasts up to 5 minutes

Dose can be divided to allow for re-administration for longer procedures

Most effective in conjunction with pacifier-synergistic/additive effect No data on maximum dose

Conclusions
Infants have a capacity for pain by mid gestation Pain has immediate and long term consequences Physiological, behavioral and biochemical indicators are proxies for pain in infants Pain measures must be population/ and context specific and have established psychometric properties Certain high-risk populations excluded
ELBW (<1000g) (Grunau et al., 2000; Morison et al., 2003) Cognitively impaired (i.e. Drug influence) (Stevens et al)

Certain situations excluded

Chronic vs. Procedural vs. Disease related

Conclusions
We need to use developmental strategies and non pharmacological methods as much as possible We need to be judicious in our management of post operative pain and procedural pain.
When we chose pharmacological measures
Chose the right drug Start low Use objective measures to evaluate and titrate to each babys needs

We need to develop guidelines for pain assessment and management

Infant Massage
Numerous studies : claim many short and long term benefits for infant and mother Can be a simple as a hand hug to infant massage Need to watch the infants cues and reactions Probably best to teach the mother and closer to term age for the infant

Massage
Massage has been found to soften scar tissue by freeing restrictive fibrous bands and increasing circulation Release the underlying adhesions Reasons: cosmetic promote full lengthening of the affected structures with growth

Scars
Surgical - PDA Ligation - Abdominal Procedural - Central lines - Chest tubes - IV infitration - tape removal

Nothing about my babies, without me

Parents are not visitors Part of the team Involved in making decisions Participate in Rounds Participate in care

 Controlling infection in the unit is of utmost importance but it does not mean excluding parents from caring for their infants
( Venkatesh et al, 2011)

Many units now have a parent support position as part of the team ( former NICU parent)