Neonatology Medical Staff
Other Awards and Accolades

  • Autonomic Subsystem more

  • Motor Subsystem more
  • State Subsystem more
  • Attention/Interaction Subsystem more


  • Self Regulation Subsystem more


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Neurobehavioral Development

Autonomic Subsystem

Basic vital functions that are essential for survival are controlled here:

  • Heart rate
  • Respiratory rate
  • Temperature

 

  • With maturity of the autonomic nervous system (ANS) and resolution of illness the high-risk baby will resolve episodes of apnea and bradycardia
  • Maturation of the hypothalamus and the ANS will facilitate temperature stability and regulation of body temperature.
  • Stress cues (Disorganization) include (Holditch-Davis D and Blackburn ST, 2007; Gardner SL and Goldson E, 2011; Carrier CT, 2010):
    • Tachycardia
    • Tachypnea/pauses, gasping
    • Colour changes: (cyanosis, mottled, flushed, periorbital duskiness)
    • Visceral: hiccups, spitting up, gagging
  • Nursing Intervention:
    • Decrease external stimuli
    • Provide containment using hands to calm. Practice containment by gently placing your warm hands on the baby’s head and lower back/buttocks with legs tucked under him/her, and applying supportive pressure for approximately 10-15 minutes.4 If 10 minutes is not practical, contain the neonate using your hands until the neonate is calm, then replace your hands with one or a pair of Zakys to continue containment.
    • Once calm, if not medically contraindicated, kangaroo care or skin-to-skin holding may be offered to calm and support the neonate. The baby, clothed only in a diaper, is held prone or semi-upright skin-to-skin against the bare chest of the mother or father. Kangaroo care provides a variety of low-intensity stimuli generated by the mother and/or father. The baby receives vestibular stimulation due to the rise and fall of the warm chest as the parent breathes. Olfactory senses are stimulated by the mother’s breasts and the unique smells of the parents. Auditory stimulation is generated by the parents’ heart beats and respirations, as well as their vocalizations.Gardner SL and Goldson E, 2011; Carrier CT, 2010
    • The use of the Kangaroo Zak will provide containment against the mother and permits free movement of the mother’s hand such that she will be able to kangaroo her baby for long periods of time.
    • If kangaroo care is not an option, reposition the neonate using The Zaky to provide support and comfort.
  • Parent Development:
    • Parents are anxious due to their baby’s hospitalization.
    • Teach them how to recognize signs of overstimulation.
    • Explain the benefits of kangaroo care and how to use the Kangaroo Zak
    • Demonstrate ways to provide containment using their hands and The Zakys. Parents will soon become proficient in positioning their child using The Zakys.
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Neurobehavioral Development

Motor Subsystem

 

  • Refers to the baby’s ability to control posture, muscle tone and movement.
  • An organized baby will have good tone in the trunk and all extremities, display sucking, hand to mouth and grasping behaviors
  • As the preterm baby matures, movements become more organized, smooth and less jerky, and are closely tied to the development of the state subsystem.
  • Flexion is the normal position, with the degree of flexion dependent on post-menstrual age.
  • Stress cues (Disorganization)2,3,4:
    • Resting position deteriorates from flexion to hypotonicity to flaccidity
    • Leg extensions
    • Finger splays
    • Fisting
    • Arching
    • Sitting on air
    • Tongue extensions
    • Frantic, agitated activity
  • Nursing Intervention:
    • Slow, gentle handling
    • Provide containment using hands to calm
    • If not medically contraindicated, kangaroo care using the Kangaroo-Zak will provide containment against the parent.
    • If kangaroo care is not an option, reposition the neonate using The Zaky to provide support and comfort. A nest may be used for containment by using 1 or 2 Zakys.
  • Parent Development:
    • Teach parents the stress signs of overstimulation and disorganization.
    • Signs of “Hospitalitis”3:
      • Touch aversion (due to the multitude of touch/events that become associated with pain)
        • Hypertonicity or hypotonicity
        • Resists being held
        • Fights and flails during caregiving activities
Demonstrate ways to provide containment using their hands and The Zaky, or using skin-to-skin using the Kangaroo Zak.
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Neurobehavioral Development

State Subsystem

  • Behavioral states, or states of consciousness, are groups of characteristic behaviors and physiologic changes that present together in a regular pattern.
  • Behavioral states influence the way the neonate will respond to stimuli. For example, a sleepy baby will respond very differently to an alert baby when presenting with the same stimulus.
  • Observe how the baby transitions through the states from sleeping to drowsy, awake to alert, and crying. Also note the transitions between the states as well as the quality of the organization of the behavioral state.2,4 A healthy full-term baby may move smoothly from sleeping to drowsy to awake, while a chronically ill infant may move quickly from sleeping to hard crying, with no transitions in between. A fragile neonate, especially a very preterm baby, may be incapable of displaying clearly defined behavioral states.
  • With handling or sensory stimulation, the preterm or high-risk neonate may have sudden changes in the autonomic, motor and state subsystems.2,4 
  • Stress cues (Disorganization)2,3,4
    • Color changes
    • Bradycardia
    • Apnea
    • Flaccidity
    • Abrupt state changes
    • Gaze aversion
    • Irritability
    • Panicked, worried look
  • Nursing Interventions4
    • Cluster care according to the individual’s tolerance level
    • Stabilize the autonomic and motor subsystems
    • Decrease external stimuli
    • Use of primary nurse to consistently interpret baby’s behavior and for bonding behaviours
    • Provide containment using hands to calm
    • If not medically contraindicated, kangaroo care using the Kangaroo-Zak will provide containment against the parent.
    • If kangaroo care is not an option, reposition the neonate using The Zaky to provide support and comfort. A nest may be used for containment by using 1 or 2 Zakys.
    • Reposition using The Zaky to provide support and comfort.
  • Parent Development
    • Familiarize them with stress cues that their infant typically displays.
    • Signs of Hospitalitis3:
      • Sudden state changes because of the inability to modulate sleep states
      • More active states that quiet states
    • Teach them positioning techniques they may use to calm the neonate or use to help keep the baby organized.
    • If the parents are available, using the Kangeroo-Zak to position the baby skin-to-skin may be very soothing for the baby and the parents.
    • Their baby may find it comforting to be nested by Zakys that have their mother’s scent on it.
The Zaky that has been warmed in the blanket warmer may be very soothing and relaxing to the distressed neonate.

 

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Neurobehavioral Development

Attention / Interaction Subsystem

Attention/Interaction Subsystem

  • The baby must be in an alert state
  • Is an indication that the baby is ready to interact and is ready to receive auditory and visual stimuli
  • With increasing postmenstrual age and maturation, the neonate will be able to orient and focus on sensory stimuli, and becomes especially interested in focusing on the face.
  • With increasing postmenstrual age and maturation, the neonate will transition out of the state of alertness better and the length of time spent in the alert quiet state will increase.
  • In order to respond socially to healthcare personnel and parents, the neonate must develop control over the awake and alert states.2,4
  • Developing control over the awake and alert states is essential for the neonate to become integrated into the family
  • With maturation the baby will demonstrate good self-quieting and consolability, along with robust crying.2
  • Stress cues (Disorganization)2,3,4
    • Increasing stress when more than one stimuli is introduced
    • Respirations become irregular
    • Coughing, sneezing, yawning, sighing
    • Staring, gaze aversion, panicked/worried look
    • Irritability, frantic agitated movements
    • Any signs of stress from any of the other subsystems
  • Nursing Interventions
    • Modify the stimulation based on the neonate’s responses.
    • Use hand containment to calm the neonate.
    • Be a role model for the parents in teaching them how to relate and interact with their neonate.
    • Teach signs of stress (above), how to recognize them and how to intervene.
    • Teach signs of behaviours that show the baby is ready to interact:3
      • Sucking that becomes slower or stops
      • Turns toward the stimuli, especially auditory
      • Opens mouth and extends the tongue
      • Vocalizes
  • Parent Development
    • The very premature neonate may glassy-eyed or have a dull look when in an alert quiet state. Typically the state will only last a brief time, and then become longer as the preterm baby matures.
    • Until the preterm baby matures and/or the high-risk neonate recovers from illness, the baby will be unable to process multiple sensory stimuli and will become overstimulated easily.
    • Teach parents that there will be times when their baby will be able to tolerate touch and auditory stimuli (the parent talking or singing to the baby), and other times that he/she will only be able to one form of stimuli.
    •  If not medically contraindicated, kangaroo care using the Kangaroo-Zak will provide containment against the parent.
    • If kangaroo-care is not an option, teach parents positioning techniques they may use to calm the neonate or use to help keep the baby organized. Their baby may find it comforting to be nested by Zakys that have their mother’s scent on it. A nest may be used for containment by using 1 or 2 Zakys.
    • A Zaky that has been warmed in the blanket warmer may be very soothing and relaxing to the distressed neonate. Reposition using The Zaky to provide support and comfort.
    • Signs of Hospitalitis3
      • Disorganized sucking such that it can’t be used to self-quiet.
      • Gaze aversion
      • Social unresponsiveness: doesn’t fix and follow; flat affect; no smiling
      • Crying is the only “awake” state, and may be out of control
      • Minimal to absent quiet alert state.
          • Baby is described as either awake and crying or sleeping

 

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Neurobehavioral Development

Self-Regulation Subsystem

 

  • This subsystem is at the top of the hierarchy, and cannot be achieved if the other subsystems are not stable or are displaying disorganization.
  • As the neonate matures and/or recovers, he/she develops the ability to regulate temperature, sleep-wake cycles and calm himself/herself once basic needs have been met.1
  • The subsystem also assists in the integration of all the other subsystems and allows for smooth transition between behavioural states2.4
    • Autonomic: sucking, grasping
    • Motor: tucks arms/legs in close to the body, braces feet against blanket nest or side of incubator, grasps blanket/endotracheal tube, etc.,
    • Behavioural state: sucking, fixing and following with eyes, robust rhythmic crying, focused attention
    • Attention/Interaction: hand to mouth; hand holding
  • Stress cues (Disorganization):2,4
    • Changes from alert quiet state to sleep state
    • Postural changes: becomes less flexed or “limp-noodle” like
    • Gaze aversion
    • Any stress cues from the other subsystems
  • Nursing Intervention
    • Develop a plan of care individualized to the neonate that assesses and evaluates external stimuli and the resultant neonate’s response to optimally support neurodevelopmental organization and positive growth.
    • Modify the environment to decrease the stimuli
    • Use of hand containment to calm the neonate and help him/her to re-integrate the other subsystems to achieve a balanced, stable and relaxed behavioural state.
    • If not medically contraindicated, kangaroo care using the Kangaroo-Zak will provide containment against the parent.
    • If kangaroo care is not an option, reposition the neonate using The Zaky to provide support and comfort. A nest may be used for containment by using 1 or 2 Zakys.
    • Reposition using The Zaky to provide support and comfort.
  • Parent Development
    • Until the preterm baby matures and/or the high-risk neonate recovers from illness, the baby will be unable to process multiple sensory stimuli and will become overstimulated easily.
    • Teach parents that there will be times when their baby will be able to tolerate touch and auditory stimuli (the parent talking or singing to the baby), and other times that he/she will only be able to one form of stimuli.
    • Teach parents positioning techniques they may use to calm the neonate or use to help keep the baby organized. Their baby may find it comforting to be nested by Zakys that have their mother’s scent on it. A Zaky that has been warmed in the blanket warmer may be very soothing and relaxing to the distressed neonates
    • The Zaky decreases or may virtually eliminate several signs of "Hospitalitis" which include:
      • Asocial behavior such as gaze aversion, unresponsiveness, persistent sleep state
      • Touch aversion
      • Oral aversion, refusal of oral feeds, back arching, out of control crying, unable/difficult to be consoled
      • Failure to thrive despite adequate or enhanced caloric intake
      • Developmental delays in motor, social, emotional and language development