Nature is supreme the way it looks after all the needs of the baby in the womb. The baby is gently rocked in the warm amniotic fluid and is well protected from infections and effectively shielded against light and sound(1). The baby is comfortably "nested" in a flexed posture with hands in the midline close to his mouth. The uterine blood flow provides a soothing music akin to a waterfall while tick-tack of the maternal heart beats provides him constant soothing beats of a cuckoo clock. The physiological needs of oxygenation, nutrition and excretion are admirably met by the utero-placental unit(Table 1). Despite several attempts, scientists have failed to fabricate an incubator with all the qualities and characteristics of the womb.

Birthing is a traumatic experience both for the mother and her baby. Apart from the discomfort and trauma associated with the process of delivery, the baby is suddenly thrust into a world of bright lights, loud sounds and cold environment. Healthy term babies are neurologically mature to withstand these environmental onslaughts and they rapidly adjust to the extrauterine environment with minimal assistance without any serious difficulties or hazards. But preterm babies are neurologically immature and physiologically unstable. They cannot tolerate environmental insults and stresses, which may adversely affect their neuromotor development. Due to advances in technology, the survival of perterm babies has improved but the quality of life among the survivors has not significantly improved. It is believed that differences in cognition, behaviour and neuropsychological parameters between preterm and term babies may be explained on the basis of striking dissimilarities between their environments before achieving full maturity(2).

Table 1 –The Virtues  of the Womb

•

Cushioned and comfortable aquatic abode

•

Thermal comfort

•

Zero insensible water losses

•

Shielded from light

•

Protected from sound.

•

Effective and safe ECMO-like oxygenation

•

Optimal excretion of waste of products

•

Isolation and asepsis

•

Parenteral nutrition

During the last three to four decades technology has revolutionized the care of preterm babies. The earlier relatively humanized approaches in the care of preterm babies by gentle handling and "masterly inactivity" has been replaced by the use of aggressive and invasive hi-tech modalities to provide life support to tiny babies to improve their survival. The art of newborn care has been sacrificed at the altar of technology(3). The babies are being handled as "objects" without any concern either for their comfort or for their stimulation. The intensive care of the newborn babies has become mechanical or "robotic" and stereotyped instead of being flexible and individualized. We are caring our babies entirely with our brains with total disregard for providing them care with our hearts. It is a pity that technological advances have dehumanized the care of preterm babies.

We have now realized that there is a need to have synthesis of "art and science" of neonatal care in order to provide holistic care to preterm babies. Hi-tech care should be provided but comfort of the baby should not be ignored. Babies must be given appropriate analgesics and sedatives to relieve pain and discomfort of procedures. They should be reared in the neonatal intensive care unit (NICU), which should simulate the ecology of the womb to ensure maximum comfort to the baby. The babies should be handled with gentle touch, love and compassion and the nurses should feel "connected" and "tuned" to the babies under their care(4,5).

We should create a baby-friendly womb-like ambience and ecology in the NICU to simulate in-utero environment. Depending upon the degree of immaturity, graded rhythmic and soothing stimulation should be introduced when baby has achieved physiologic stability(6). The nurses should be trained to provide individualized developmentally supportive care to preterm babies by adopting a "flexible" approach. All the health care professionals in the NICU should be gentle, considerate and compassionate in providing care to preterm babies(7-9). Early and intensive participation by family members in the care of preterm babies should be encouraged to promote bonding, facilitate physical growth and neuromotor development(10).

It is a common observation that very low birth weight (VLBW) babies are being looked after in an unpleasant, noisy, too bright and aggressive-invasive environment without any concern regarding their physiological needs, comfort and periods of rest of the individual baby(11-13).

In the uterus infant is exposed to sound level of about 40-60 decibels. The NICU environment usually provides sound levels between 70-80 db. It has been shown that when sound level exceeds 77 db it causes discomfort to the baby (14). The main sources of noise in NICU include telephone rings, equipment alarms, paging bleeps, air compressor, carting of equipment, loud talking during the rounds etc. Chang et al(15) recorded 4994 peak noises during 48 hours observation period in the NICU and found that around 90% of loud noises were related to the personnel. The physiological consequences of loud sound include startle response, apneic attacks, bradycardia or tachycardia and oxygen desaturation. At times, sudden elevation of blood pressure is a risk factor for development of intraventricular hemorrhage. The baby is unable to sleep and rest and may remain irritable or cranky. This may lead to depletion of energy reserves with poor weight gain due to constant state of arousal. High noise level may cause damage to the cochlea and even the adverse effects of ototoxic drugs may be enhanced. Preterm babies have 5 times greater risk of development of hearing loss compared to term babies.

The harmful effects of the noise can be minimized by designing an acoustic-friendly nursery(13). The doors and drawers should be padded and ceilings and walls can be provided with noise-absorbing material. The health personnel should learn the art of speaking softly and walking gracefully in the nursery. Telephone rings should be replaced by blinking lights. Instead of air compressors, centralized sources of compressed air, oxygen and suction should be used. The nurses should anticipate activation of alarms and respond to them promptly or preemptively. The incubator can be covered with a blanket or specially made cover to dampen the noise and light reaching the baby. The doors and port holes of incubator should be opened gently. The incubator top should never be used as a writing surface. Decibel meters should be installed to monitor sound levels in the NICU.

Most NICU’s maintain high intensity of day and night illumination ranging between 50-150 foot candles for ease of observation. Procedure lights and phototherapy units may provide light intensity between 200-400 foot candles resulting in several adverse consequences. Bright light may adversely affect the development of central visual system and may lead to development of squint, "shutting out" behaviour with reduced socialization(12). The duration of rapid eye movements (REM) sleep is increased which may be associated with physiologic lability manifested by bradycardia and apnea. There is some evidence to suggest that exposure to bright light may predispose the baby to develop retinopathy of prematurity(16). When nursery illumination is maintained uniformly bright during the day and night, it may adversely affect the circadian biologic rhythm leading to reduced release of growth hormone and poor weight gain (17).

The illumination in the nursery should be kept dim without compromising ease of observation. The light should be further dimmed off and on to create periods of "quiet time" during each shift and baby should not be disturbed for a procedure unless it is unavoidable. Dim lighting has been shown to improve duration of sleep, decrease motor activity, reduce heart rate, improve tolerance of feeds and increase weight gain of medically stable preterm babies. The windows of the NICU should be covered with screens and blinds. The light should be dimmed at night to simulate day- night pattern to promote hormonal surge and physical growth. Bed side lights with dimmer switches should be provided to create specialized microenvironment for each baby. The incubator should be covered with a blanket or specially-designed cover. When incubator is covered, the baby should be attached to a vital sign monitor. Eyes should be covered and protected against exposure to bright light when incubator lid is opened or baby is picked up. The eyes should be shielded or covered while using procedure light or during phototherapy. The lux meter can be used to monitor light intensity in the NICU.

All efforts should be made to provide babies with as comfortable a positioning as possible although it is impossible to achieve in-utero comfort levels and cushioning. The preemies have poor muscle tone and they lie with their arms and legs straight or extended. The extended posture for a long period of time may lead to abnormal tone with consequent delay in motor development. It has been shown that preterm babies maintain better oxygenation, temperature control and sleep pattern when they are nursed in a prone or lateral position(18). Body position also affects gastric emptying and neurobehavioral development. When a baby is handled roughly, he feels uncomfortable by squirming, crying and recoiling his arms and legs. There is evidence to suggest that rough handling may lead to hypoxemia and sudden elevation of blood pressure with risk of development of intraventricular hemorrhage(19).

The infant should be positioned prone or on the side with flexed extremities by providing a "nest" with a rolled blanket. Swaddling simulates in-utero feeling of lack of space and it makes the baby less jittery or prone to startle. Babies love to be nursed on a sheepskin, water bed or gloves filled with water. Nursing the baby on a water bed rekindles his memories of in-utero environment.

Infant should be provided with midline orientation to facilitate hand-to-mouth activities which are self-soothing. The hands of the baby should be left free so that he can get them to his face to suck his fingers or just touch his face. Putting on a small diaper or placing soft material between the legs provides comfort to the baby. The baby must be handled minimally and gently with clean and warm hands and warm heart(20). Sudden changes in the position must be avoided. During positioning and moving the infant or while doing procedures such as suctioning, "containment" should be provided. It can be accomplished by holding the arms and legs of the infant close to the midline of the body or by supporting his head and buttocks. When hands of the caretaker are busy in doing the procedure, the flexed legs of the infant can be enclosed in a blanket to provide containment.

Nothing is more humanized and natural for a baby than providing feeding with human milk to all babies(1). The milk of a mother, should be given to her baby because milk is not only species specific, it is indeed baby-specific! Extremely preterm babies cannot self feed and they are given expressed breast milk (EBM) through a nasogastric tube. Even when nutritional feeds cannot be provided due to physiologic instability, the baby should be provided with minimal enteral feeds to harness its trophic effects on the GI tract. Trophic feeds are credited to enhance maturation and growth of intestinal mucosa and gut musculature. The oxygen uptake and intestinal blood flow are increased. There is early elaboration of a large number of gut endocrines like gastrin, cholecystokinin, motilin and inhibitory peptides. The colonization of the gut with friendly lactobacilli and bifido bacteria prevents entry of pathogenic bacteria(1).

The hi-tech care to VLBW babies should be provided with gentleness and due concern for their comfort and physiologic stability. The major goal of reducing noise, bright light and rough handling is to ensure that babies in the NICU attain physiologic stability(21). The process of healing and velocity of physical growth and neuromotor development are enhanced when babies become stable.

The stable babies are awake, alert and responsive. They have stable vital signs without undue fluctuations. The baby is pink with satisfactory arterial oxygen saturation and good tissue perfusion as evidenced by capillary refill time of less than 2 seconds. The muscle tone is in accordance with gestational maturity and there are no apneic attacks or subtle seizures. The baby should have satisfactory GI functions and should be able to tolerate enteral feeds.

The preemies should be provided with developmentally supportive care to meet their neuro behavioral and physiologic needs in order to foster their normal physical growth and neuropsychological development. It is desirable to assign one or two babies to a nurse and they should follow individualized and flexible approach in their care. Simulation should be provided when "baby is physiologically stable and alert or receptive. The well-organized state of the baby is characterized by well defined awake and sleep states, robust crying, successful self consoling and self-quieting. The babies should preferably be left undisturbed during periods of deep sleep. The care in the NICU should not be merely task-oriented but the nurses should feel "connected" or "tuned" with the babies under their care and provide individualized care to promote emotional and neuropsychological development of the babies(22-26).

It must be remembered, however, that both lack of stimulation and over stimulation are equally bad for optimal development of preterm babies. Only one stimulus should be introduced at a time while observing infant’s physiological and behavioral responses. When baby shows signs of disorganization or hyper-alertness, the stimulus should be withdrawn and baby should be provided hand- on-containment and given time for recovery before continuing. The evidences of hyper-alertness include wide-open eyes, a look of fear or panic or the appearance of being "hooked" to the stimulus and baby having difficulty in breaking away. The stimulatory messages to the CNS are transmitted through specially modulated tactile, vestibulo-kinesthetic, auditory, visual and olfactory sensations.

The tactile stimulation should be provided by gently touching the head or back of the baby while speaking softly in a soothing voice. The baby should be positioned in such a way so that he is able to suck his fingers or hand or is able to touch his face. The baby should be encouraged to grasp the finger of the caretaker or edge of the blanket or a small rolled up cloth. The baby should be provided with opportunities for rooting and non-nutritive sucking.

The mother should be encouraged to provide intermittent skin-to- skin contact to her premature baby admitted in the NICU (27-30). It provides comfort, warmth and "special" smell of the mother to the baby. It improves mother-infant bonding and promotes breast- feeding. When baby is held against mother’s heart, he is reminded of the in-utero soothing music produced by uterine blood flow and maternal heart beats in the womb. During skin-to-skin contact most babies feel comfortable, stop crying and achieve physiological stability. At times intractable apneic attacks may be relieved by skin-to-skin contact. During skin-to-skin contact there is a possibility of transfer of tremendous electro-magnetic energy from a compassionate mother to her tiny baby producing calmness, comfort, autonomic stability, promotion of physical growth and augmentation of forces of healing. These virtues of skin-to-skin contact needs to be further studied and exploited.

Music is credited to have numerous qualities and capabilities and it has been shown even to enhance the growth of plants. Studies have shown that soft and soothing music to individual babies enhances their physiologic stability and improves weight gain velocity(31). Babies like and enjoy classical or gentle instrumental music. The baby can be made to listen to the taped voice of parents and family members on and off. This enhances parent-infant bonding and gives family members the sense of involvement in the care of their baby.

Babies should be picked up and encouraged to develop an eye-to-eye contact. Babies often turn to the source of diffuse light. Visual stimuli can be provided with the help of bright toys and pictures. A picture with distinct facial pattern can be placed on the incubator or crib wall in line with the gaze of the baby. Dim-light encourages babies to open their eyes and look around.

The baby should not be exposed to unpleasant or noxious odors. Alcohol, betadine, or other skin scrub bottles should be opened away from the baby. The medicated swabs should be removed from the incubator immediately after their use. The baby should not be dabbed with hair spray or cologne. Skin-to-skin contact provides pleasant and "special" smell of the mother to the baby. Babies are sensitive and attracted to the smell of the mother’s milk, which is used for rooting the nipple during breast-feeding. The gauze pads or cotton balls soaked in mother’s milk can be kept inside the incubator to stimulate olfactory system.

Humanized care is not an alternative to hi-tech care but is complementary in order to provide best or holistic care to preterm babies. We should strive to provide a good mix and balance between technology-based care and humane care to preterm babies. The NICU should have womb-like ambience and ecology. The lighting should be kept dimmed with a day-night pattern. The sound level should be low and light kept dimmed to have "quiet periods" during each shift. The baby should be provided with a comfortable "nest" and kept on the side or prone with flexion of limbs. The nurses should be trained to provide an individualized and developmentally supportive care. The nurses should feel connected and tuned with babies under their care. Apart from analgesics and sedatives, caressing; cuddling and containment are useful to provide comfort to the baby during painful procedures (32). Nothing is more humanized than feeding the baby with milk of her mother because milk is not only species specific; it is baby-specific.

Early and intensive family participation in the care of preterm babies is important for their organization; growth and development(33). We should demystify NICU and actively involve and inform the parents about the care and condition of their baby. Mother should be encouraged to provide the benefits of skin-to-skin contact to her baby. She should be asked to touch talk, feed and take care of her baby and provide necessary tactile visual and auditory stimuli(34). Mothers are more likely to look after their babies with devotion and compassion and this is likely to augment the forces of healing and promote the process of recovery of high-risk and sick preterm babies. All efforts should be made to enhance the survival of preterm babies but our goa1 should be to improve the quality of life among those who survive.

Contributors: AKD provided the concept and reviewed the literature. MS drafted the manuscript and would act as a guarantor.

Funding: None

Competing interests: None

Meharban Singh,
Consultant Pediatrician, 
Child Care and Dental Health Center,
6625, Sector- 37, NOIDA
E-mail: [email protected]

Ashok K. Deorari,
Additional Professor of Pediatrics,
WHO Collaborating Center for Training and Research in Newborn Care,
All India Institute of Medical Sciences, New Delhi 110029.
E-mail: [email protected]

 

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