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Developmentally Appropriate/Supportive Interventions in the NICU

Many thanks to the multi-disciplinary Sunnybrook Team

• 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

• • • • • • • 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 infant‟s 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 .

eating. 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 . temperature.Circadian rhythm • In utero circadian rhythm of the fetus is set by mother by her activity level.

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 Levels • • • • • average NICU is 70 .

pagers • Attention to other noise producing equipment • Traffic patterns in the unit – where high traffic.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. keep babies away ( or at least the sickest) .

• Reduce bedside conversations. other noises around bedside/isolette • Want infant to hear mother‟s voice above background sounds • Reduce lights – people talk quieter • Reduce stress and crying of infants • Naptime or quiet time • Staff conversations .

Noise Reduction What doesn‟t work • isolette covers • • • infant foam ear covers curtains between baby areas “noise police” might work .

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

Cluster of Non-Emergent Care • Should be according to infant‟s 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. .

slow repositioning •hand containment or nesting .•clustering of care with recovery time •scheduled assessment times •gentle.

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 infant‟s 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 .

oxygen saturation. . age at full oral feeds and behavioral state). energy intake. • The review identified other positive clinical outcomes of NNS: transition from tube to bottle feeds and better bottle feeding performance. • The review did not reveal a consistent benefit of NNS with respect to other major clinical variables (weight gain.2010 • NNS was found to decrease significantly the length of hospital stay in preterm infants.Cochrane Review (Pinelli and Symington. heart rate. intestinal transit time.

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


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” .

• 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. wherein all infants were positioned prone. • Prone position was found to offer more benefits than supine or side lying positions. (1956) studied preterm infants to determine the optimal position for care. . supine was the position of choice for infants.Historical Perspective • In the past. The findings of their hallmark study altered care in NICUs.

• 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

degree of vigour in spontaneous movements.slight. fluent alterations in flex/ext – symmetrical. sustained contraction in anti-gravity muscles • Supine posture – provides an overall impression of passive muscle tone • Active muscle power. goal directed movements .Postural control • Provides a basis for stability during movement • Passive muscle power.

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 .

1999 .28 week Gestational Age Dubowitz et al.

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 .

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

therefore very difficult to maintain a posture or position without assistance .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.

• 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 can‟t fix notches .

spare the nares ! .please.

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

• As infant moves towards the midline. . they are moving into an extended position which will increase stress and disorganization.and the hips and knees are towards the midline so promote good alignment of the hips.• Midline :the line through the middle of the body ie from the nose to the umbilicus. they are moving into a position of flexion and as they move away from the midline. • 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.


• 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 .


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

most of my weight is on my head ! & that‟s not good arm weight bearing knees .

new weight bearing surfaces side of face shoulder hip .

• Good postural alignment would mean that the ear is in line with the shoulder. 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.• Alignment is the state of being in arranged in a line. 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.


. 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.• Containment is defined as positioning the infant with the use of equipment to maintain the flexed midline position of the infant.


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


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


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.


supine or prone position (Hill et al. 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. with the trunk being curled forward gently. . 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. 2004) the gentle positioning of an infant‟s arms and legs in a flexed midline position close to the infant‟s body while the infant is in either a side-lying.• • • • Facilitated tuck: the tucked position is described as the infant being placed in side lying.


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 .


usually accompanied by mental retardation They will appear the same initially • . as a result of premature closure of the sagittal suture.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.

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


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 .






coming to the midline.Features of disorganized. flailing. hands and feet together . involve active flexion.organized and self regulating behaviours • Disorganized – tend to be jerky. jerkiness starts to become more smooth. flexion. involve extension. frantic. repetitive movements that tend to increase disorganization • Self-regulating – start to calm.sucking • Organized – smooth.

extension and flaccid . rooting. dusky. extension. circumoral cyanoses Pale. diffuse stretch Minimal movement Mild arching. sucking motion Twitches.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. brow raise. Gape face Head & Trunk No movement Minimal to slow rotation or lifting. Minimal movement Frequent movements. sucking. smile. unfocused Face No movement Small twitch. hyperextension. grimace. BM Eyes Closed & no movement lids closed or just slightly parted. Arching. hyperalert Grimace. eye moves under lids in phasic patterns ‘heavy lids’ ‘fluttery lids’ ‘Dull’ eyes ‘Bright’ focused Lids open. less focus Eyes tightly closed with grimace Dull. mottled dusky Visceral none none none none Spit up Spit up Emesis. more eye movement. Arching. maintains tucked flexed position Larger smooth trunk movement.

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

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 father‟s 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 .



cognitive and motor development . 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. • Stabilizes respiratory patterns. reduces apnea. oxygen saturation. Increases the length of quiet sleep state (NREM) shorter periods of REM sleep • Assists thermal regulation.Infant Benefits of Skin to Skin • Improves state organization.


during hospitalization and after discharge • Positive impact on paternal feelings .Maternal Benefits to Skin to Skin • • • • • Increase mother‟s 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.


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 infant‟s 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 .tape removal .PDA Ligation .Abdominal • Procedural .IV infitration .Chest tubes .Central lines .


RN. PhD May 15. 2006 .Pain Assessment & Management: Pharmacological and Non-Pharmacological Interventions in the NICU Sharyn Gibbins.

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 .

other indicators such as physiological. 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 .Challenges to the Pain Definition In the absence of verbal communication. hormonal.

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 .

behavioral state and severity of illness • Biological Factors – gender differences .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.

. Rakic & Goldman-Rakic. 2000.Humphrey.1989. Fitzgerald.Myths of Pain in Infants “Infants Lack Myelination” • The neural pathways for pain perception are present in newborn neonates (Anand. 1989. Fitzgerald. 1993. 1993. 1982) . 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. Anand 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 .Myths of Pain in Infants “Capacity for fetal pain is limited” • Fetal awareness of pain requires functional thalamocortical connections (Lee et al.

over 700 painful procedures during their hospitalization • Gibbins et al. (2005) found the mean number of painful procedures per day was greater than 10 . (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. on average.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.

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 .

2003) – Cognitively impaired (i.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. Procedural vs. 2000.. Morison et al. Disease related . Drug influence) (Stevens et al) • Certain situations excluded – Chronic vs..e.

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

0008) • Compared to cohorts B and C. p<. significant betweensubject effect with cohort A exhibiting: less facial activity (F(2.17.302) = 14.minimum HR (F(3.80 .0007) .4. p =.33)= 3.52.Neurologically impaired Stevens et al. facial activity (F(3.233) = 12. p=<. p =.302) = 5.302) = 6.039) .0002) .72 .239) = 45.302) = 5. p =.0001) .57. 2005 • Infants at highest risk for NI demonstrated less physiological and behavioral responses to pain significant within-subject effect of phase was found with: . p <.0001) lower minimum HR (F(2. p <.0001) lower maximum HR (F(2.58.004) lower mean cry fundamental frequency (F(2.81.maximum HR (F(3. p<.minimum 02 (F(3.297) = 5.

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. 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.2002) • Venipuncture/arterial puncture • Skin lesions.2006) • Intubation • Eye exams . abrasions.

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 • .

Gibbins. & Frank. 2000 .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.

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

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. 1995) • Studies-preterm and term – Meta-analysis 3 studies significant reduction in heart rate after heel prick (1997) – Heelstick –decreased crying time (Field & Goldston. directly or indirectly the transmission and processing of nociceptive stimuli (Blass. 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 • .

Pediatrics. 2001) that advocate for sucrose as frontline or adjunct therapy for most painful procedures .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. 2000) • Consensus statement (Anand et al. 2002) • CPS and AAP have recommended its use for treatment of procedural pain in neonates (AAP.. 1997) and systematic reviews (Stevens et al. meta-analysis (Stevens et al.

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.Dosage and Administration • Dose dependent on Gestational Age • Dose of 0. 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 .

. Drug influence) (Stevens et al) • Certain situations excluded – Chronic vs. Disease related . 2003) – Cognitively impaired (i. 2000. Morison et al.. Procedural vs. 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.Conclusions • Infants have a capacity for pain by mid gestation • Pain has immediate and long term consequences • Physiological.e.

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 baby‟s 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 infant‟s 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 .


• 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 .

2011) • Many units now have a parent support position as part of the team ( former NICU parent) .• Controlling infection in the unit is of utmost importance but it does not mean excluding parents from caring for their infants ( Venkatesh et al.