In The: Evidence For
In The: Evidence For
In The: Evidence For
in the Neonatal
Period
T
over the past 20 years have significantly altered the short-term outcomes for infants who received developmen-
nursing care delivered to infants in the neonatal period. tal care, while the findings of studies exploring outcomes
Nowhere else is this more evident than in the neonatal for older children are not yet conclusive. Symington and
intensive care unit (NICU), where some of the most Pinelli (2002) confirmed these findings and reported that
noteworthy contributions have drastically improved the developmental care interventions demonstrated short-term
outcomes of even the smallest of the very low birthweight benefits of increased growth, decreased pulmonary sup-
infants born today. In the past 5 to 10 years, neonatal nurs- port, decreased incidence of respiratory disease, decreased
es and nurse researchers have recognized the need to refo- length and cost of hospitalization, and improved neurode-
cus their attention toward how to best support the prema- velopmental outcomes.
ture infant and parent during this period (Bakewell-Sachs Developmentally sensitive nursing interventions focused
& Blackburn, 2003). This article provides a review of cur- on purposefully decreasing stimulation and minimizing
rent nursing research published from January 2000 stress were found to be related to improved oxygenation
through October 2004 that supports best practices during saturation, decreases in need for exogenous surfactant and
the newborn period. total parenteral nutrition, and less documented feeding in-
The author conducted a comprehensive review of all tolerance (Prentice & Stainton, 2003; White-Traut et al.,
peer-reviewed nursing research articles published between 2004). While several studies reported evidence of develop-
January 2000 and October 2004 using the Cochrane Li- mental care, others studies documented nurses’ lack of
brary database as well as CINAHL and MEDLINE. Key knowledge of the principles of developmental care, specifi-
words used in the searches included neonatal nursing, cally assessment of infant behavioral cues (Aita & Goulet,
neonate, infant, newborn, premature infant, preterm infant, 2003; Liaw, 2003; Turrill, 2003). Holditch-Davis and
low birthweight, and neonatal intensive care. To be includ- Black (2003) conducted a review of current programs of
ed the article must have been published within the past 4 research published since 1990 on the care of the preterm
years in a peer-reviewed journal by a nurse(s), translated infants and concluded that of the 17 nurse researchers with
into English, and reported research findings on nursing well-established programs of research, only three used a de-
care issues during the immediate neonatal period or first velopmental perspective to frame their work. Long-term
month of life. outcomes of developmental care during the neonatal period
have also been studied with inconclusive results.
Review of the Literature White-Traut and her colleagues have made significant
Content analysis of the nursing research articles that met contributions to the research on developmental issues of
the inclusion criteria revealed the following predominant high-risk neonates, focusing primarily on the physiologic
five categories of studies: (1) developmental issues, (2) responses of premature infants to stimulation in the form
neonatal skin care, (3) feeding, (4) skin-to-skin care, and of intervention. Her most recent work has shown that with
(5) pain management. While nursing research on different 37 premature infants born at 23 to 26 weeks with periven-
topics related to the care of the premature infant has been tricular leukomalacia and/or intraventricular hemorrhage,
published, these categories of studies were most prevalent those who received auditory, tactile, visual, and vestibular
and provided the best evidence for nursing practice to date. multisensory intervention twice a day from 33 weeks post-
conceptual age until discharge showed increases in heart
1. Developmental Issues rates even at rest (White-Traut et al., 2004). With this same
The majority of studies reviewed addressed the importance sample of infants, White-Traut and colleagues also demon-
of developmentally focused nursing interventions for the strated that those infants who received the multisensory in-
newborn. Byers (2003), in her summary of the research to tervention demonstrated increased alertness, faster transi-
date on developmental care, discussed the underlying tion to nipple feeding, and decreased lengths of hospital
framework of the Neonatal Individualized Developmental stay (White-Traut, Nelson, et al., 2002). Those infants also
Care and Assessment Program developed by Als (1986), tended to exhibit better motor and mental performance at
stating that “caregiving for the newborn is based on the in- 1 year (Nelson et al., 2001). In another study of cocaine-
fant’s behavioral and psychological cues as well as the exposed newborns who received this multisensory interven-
nurse’s knowledge of normal developmental and functional tion, White-Traut, Studer, Meleedy-Rey, Labovsky, and
maturity” (Byers, 2003, p. 174). Developmental care in the Kahn (2002) concluded that the stimulation promoted nor-
NICU should include management of the environment, mal physiologic and behavioral function in a sample of 72
flexed positioning, clustering of care, promotion of nonnu- nonexposed and 45 drug-exposed infants. The research is
tritive sucking, kangaroo care, cobedding of multiples, ac- conclusive that nursing care delivered to newborns should
tivities to promote self-regulation and state regulation, and be within a developmental framework.
collaboration with parents to promote bonding (National Certain environmental factors of the NICU have been
Association of Neonatal Nurses [NANN], 2000). These shown to have deleterious effects on infant outcomes. Re-
well-known and often studied aspects of developmental search has been published that documents efficacy of nurs-
care should be a part of each NICU nurse’s practice while ing interventions to decrease noise and stress (Bremmer, By-
providing care to all newborns in the NICU. ers, & Kiehl, 2003; Johnson, 2003; Morrison, Haas,
2. Neonatal Skin Care plementation of the AWHONN newborn skin care guide-
Nurse researchers have also studied newborn bathing: lines was successful and that changed skin care practices re-
Medves and O’Brien (2004) reported the results of their sulted in improved skin condition in premature and full-
randomized clinical trial with 111 full-term infants and term newborns. Barriers to the utilization of these guide-
found evidence of neonatal heat loss during bathing, not lines were explored by Johnson and Maikler (2001), who
related to who bathes or the location of the bath; in anoth- found that in a sample of 136 nurses from 26 hospitals,
er study, Behring, Vezeau, and Fink (2003) found that the some nurses perceived preexisting practice as superior to
timing of the bath (within 1 hour of birth compared with 4 some protocols. Other nurses reported difficulty in reading
to 6 hours after birth) did not significantly impact infant and understanding research, lack of authority to implement
temperature. the protocols, and lack of physician support
Infant massage has been studied and found to assist
mothers in better understanding their infant’s behavior and 3. Feeding
in decreasing parental stress (Beyer & Strauss, 2002; Ram- Studies exploring breastfeeding and studies on maternal ex-
sey, 2001). While these studies were qualitative in design, periences of infant feeding were most often reported in the
results seem to indicate that teaching parents infant mas- literature. DiGirolamo and Grummer-Strawn (2003) fol-
sage techniques is a noninvasive approach to assisting par- lowed 1620 women from their prenatal visits through 12
ents to better understand infant development, the parenting months postpartum. They found that when staff had
role, and how to interact with their babies. Harrison recorded “no stated preference for feeding method” on the
(2001) conducted an integrative review of the literature on medical record, there was a significant relationship to dis-
comfort touch in the NICU and reported that when infants continuance of breastfeeding after 6 weeks, with the major-
are physiologically fragile, they respond well to gentle ity of subjects reporting that they did not receive positive
stroking and massage, specifically with decreased motor breastfeeding messages from hospital caregivers. Hong,
variability and distress. Modrcin-Talbott, Harrison, Groer, Callister, and Schwartz (2003) further confirmed the criti-
and Younger (2003) confirmed these findings, specifically cal role nurses play in supporting breastfeeding with new
concluding that gentle human touch nursing intervention is mothers. Mothers reported that emotional support in terms
neither aversive nor stressful to premature infants. of offering reassurance, being concerned, remaining pre-
sent, offering proactive help, providing specific teaching, 4. Skin-to-Skin (Kangaroo) Care
and offering tangible support (ointment for sore nipples, A significant amount of nursing research has been pub-
videos, pamphlets, and phone numbers) was viewed as lished during the last few years on the efficacy of skin-to-
most supportive. The finding that nurses who do not sup- skin or kangaroo care (KC) for premature infants and their
port breastfeeding may send conflicting messages to moth- parents. McGrath and Brock (2002) reviewed the research
ers was further supported by Kaewsarn, Moyle, and to date and concluded that KC is safe and therapeutic for
Creedy (2003). premature infants and parents in terms of enhancing
Successful breastfeeding has also been found to be re- growth, decreasing mortality, facilitating attachment, de-
lated to maternal confidence. Hall, Shearer, Mogan, and creasing maternal stress, and increasing maternal self-confi-
Berkowitz (2002) found that mothers whose infants were dence in parenting. Other research has shown that KC is
weighed before and after breastfeeding had no significant effective in increasing the quality and amount of contact
increase in confidence and feelings of competence early on between infants and their parents (Anderson et al., 2003),
in the postpartum period, but that over time this practice decreasing energy expenditure during transfer (Neu,
did significantly increase the mothers’ competence and Browne, & Vojir, 2000), and decreasing episodes of apnea,
confidence in their breastfeeding skills. Dennis (2003) bradycardia, and periodic breathing (Luddington-Hoe, An-
conducted a study testing the psychometric properties of derson, Swinth, Thompson, & Hadeed, 2004). Chwo and
the revised Breastfeeding Self-Efficacy Scale (BSES) and colleagues (2002), in a randomized clinical trial of 34
found it to be an effective measure of breastfeeding self- mother-baby dyads, found that preterm infants who re-
efficacy, concluding that this scale is ready for clinical use ceived KC were more likely to have higher mean tympanic
to identify mothers at risk and to identify behaviors that temperatures, more quiet sleep, and less crying than con-
could then guide practitioners in confidence-building in- trol-group infants who did not receive KC.
terventions. The results of the effects of KC on successful breastfeed-
Successful transition to oral feeding has been studied in ing remain mixed (Carfoot, Williamson, & Dickson,
terms of development of early oral feeding skills (Ross & 2003). Results of studies examining effectiveness of KC
Browne, 2002; Thoyre, 2003; Thoyre & Carlson, 2003), with ventilated infants and infants less than 28 weeks post-
how feeding opportunities and challenges are discussed by conceptual age are also less conclusive. Smith (2001) found
providers with parents (Pickler & Reyna, 2003; Pridham, that very low birthweight infants showed instability in tem-
Saxe, & Limbo, 2004), maternal perceptions (Wooldridge perature and oxygen saturation during KC. In a case study
& Hall, 2003), indicators of oxygen decline during oral of a ventilated infant, Swinth, Anderson, and Hadeed
feeding (Thoyre & Carlson, 2003), and the effects of mu- (2003) found that KC may accelerate recovery from respi-
sic-reinforced nonnutritive sucking on feeding rates (Stand- ratory distress while enhancing maternal relaxation and de-
ley, 2003). The comprehensive literature reviews conducted creasing stress. Future research is needed in this area.
by Thoyre (2003) and Ross and Browne (2002), while not In spite of well-documented positive outcomes of this
original research, have stressed the importance of viewing technique for most premature infants, many NICUs and
feeding through a developmental lens and reiterate the im- nurses are still resistant to the practice of KC (Engler et al.,
portance of the nurse’ role in recognizing infant readiness 2002). Franck, Bernal, and Gale (2002) found that in 215
to begin and advance oral feeding. Nurses also must help NICUs across the country, practice of KC was much less
mothers deal with their perceptions and misconceptions than expected, especially for intubated infants. Anderson
around adequacy of milk supply, which has been found to and colleagues further supported this in 2003 when they
be a key factor in the transition from hospital to home found that holding times of infants receiving KC were
(Wooldridge & Hall, 2003). Providing increased bottle- more than double that of controls. Many infants do not
feeding opportunities (Pickler & Reyna, 2003) and con- experience KC because of fears by nurses that KC with
sciously being aware of how nurses label feeding issues mothers will put them at greater risk for heat loss than if
(Pridham, Saxe, & Limbo, 2004) will positively influence they were either in an incubator or under warming lights.
feeding success in preterm infants. Other barriers to KC include concerns for safety, unavail-
The NICU environment • By limiting door closings, portable x-rays, high-volume nonessential personnel, visitors, and unat-
tended alarms, nurses can effectively decrease noise and infant stress.
Skin-to-skin • KC is safe and effective for premature nonventilated infants 28+ weeks and their parents.
Pain management • Most nurses do not document or evaluate pain and do not use well-validated pain assessment
tools.
• The PAIN and NIPS scales have strong validity and are ready for clinical use.
• Nonpharmacologic interventions are effective (especially oral sucrose) in relieving pain during
invasive procedures.
• Oral sucrose is more effective than EMLA cream during venipuncture.
• Nonpharmacologic measures in conjunction with procedural anesthesia should be used during
circumcision.
• Swaddling and facilitated tucking is effective during heel sticks and suctioning.
Sleep position • Nurses should put infants to sleep on their backs and advise parents to do so as well.
ability of staff and mothers, and staff interruptions (Ander- nursing assessment of infant pain. Reyes (2003), in a de-
son et al., 2003). Ludington-Hoe, Nguyen, Swinth, and scriptive survey of 24 nurses and an audit of 107 records,
Satyshur (2000) reported that in a small sample of prema- found that while nurses believed that neonatal pain assess-
ture infants, there was no change in abdominal tempera- ment was important, and that they were capable of doing
ture and actually an increase in toe and maternal breast it, evidence that they either documented pain or evaluated
temperature in the KC group. Further research about KC is pain management interventions was lacking from the ma-
needed with all newborns as well as with premature in- jority of patient records. Dodds’ study (2003) confirmed
fants, with adoptive parents, with ventilator-supported in- these findings that pain assessment tools were used by less
fants, and with mothers who are depressed. Nurses need than half of the 21 nurses surveyed. Further results showed
additional education to overcome barriers to practice. that the majority used nonnutritive sucking to relieve pain
and rarely used medications or other nonpharmacologic in-
5. Pain Management terventions. While the validity of the Pain Assessment in
It is well documented that infants experience pain. Much Neonates (PAIN) Scale and the Neonatal Infant Pain Scale
of the research during the last decade has focused on the (NIPS) (Hudson-Barr et al., 2002) has been reported, Boyd
development of infant pain measurement tools (Bakewell- (2003) concluded that they are rarely used by nurses. Duhn
Sachs & Blackburn, 2003; Franck, 1987). Research pub- and Medves in 2004 evaluated 35 infant pain assessment
lished during the past few years has focused on nonphar- tools and concluded that several were not published or val-
macologic interventions as well as continued interest in idated. They cautioned nurses to use only validated multi-