The premature child's stay in the neonatal unit leads to unwanted effects in both the newborn and its family. The exposure of children to a hostile environment, like that of an intensive care unit, hinders the brain’s development. In addition, there is an emotional impact on the parents, which changes the process of child raising 1. Research has shown that care programmes centred on development have a favourable effect on the child's development. The medium- and long-term development of very premature babies show that changes in behaviour and learning, plus emotional and social difficulties, may possibly prevented by the establishment of such care.

Both the modifications made in the environment of the NICU, as well as those carried out in the care of premature babies, have produced benefits for children, showing a significant improvement in infant development. To improve patient care, it is essential to take into account factors affecting this development:

3. Care-centred development. The situation in neonatology units in Spain, J Perapoch et al.

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Environmental Light and the Premature Child

The NICU is typically illuminated for 24 hours a day by a mixture of variable daylight and fluorescent tubes. The child is subjected to 10,000 lux of light, while the baby's retinas can tolerate only 200 lux.

According to clinical studies investigating the impact on the visual system of premature babies, there can be consequences on visual acuity, colour vision, with squinting, and so-called "premature myopia". Reducing light in the neonatal unit has been shown to maintain more stable breathing in children, decrease the heart rate, blood pressure, respiratory rate and motor activity. (See Enviroment Light and the Preterm Infant,  Alistair et all).

• Measure and document the lighting in the unit.
• Use natural light, with a smooth transition between periods of light and darkness.
• Cover the incubators.
• Use individual lights, for better observation and more rigorous procedures.
• Use lights with dimmers or similar to allow for a gradual change from darkness to light, to reduce potential stress on the child caused by the sudden change in the lighting.
• Use curtains or blinds to reduce exposure to direct sunlight.
• Use screens to separate children from phototherapy treatment.
• Do not cover children’s eyes more than is necessary. More about environmental ligth…

Noise and the Premature Child

Premature babies are extremely sensitive to noise. The NICU is frequently a noisy environment, with frenetic activity from staff on occasions and little distinction between day and night. Moreover, the premature child can stay for days, weeks or months within this environment. Excessive or loud, piercing noises can damage the delicate structures of the premature baby’s hearing, with a risk of sensorineural hearing loss.
There is evidence of adverse effects for children in relation to noise, like interference with sleep, or increased intracranial pressure in very unstable children. .

It is therefore recommended that the following practices to reduce noise emission at all levels are adopted:

• Change tone of voice. Reduce the volume of alarms.
• Repair noisy equipment.
• Open and close the incubator hatches gently.
• Remove radios, telephones, printers.
• Cover incubators with blankets.
• Do not hit the incubator or support objects on it.
• Put up silence posters or signs to educate staff and families. More about noise…

Postural Care for the Premature Child

The premature infant has not had the opportunity to develop the physiological flexibility that occurs in the last 3 months of pregnancy. This can lead to postural deformities that may affect its psychomotor development, its attachment to and relationship with its parents and its own self-esteem when mature.

Postural care objectives for the premature baby are:

1. Encourage active flexing of the trunk and limbs (facilitate hand-mouth activity).
2. Achieve a more rounded head and an active rotation (rotation with an elliptical head is harder).
3. Encourage more symmetrical postures.
4. Help babies in their movements against gravity.
5. Encourage visual exploration of their environment (head-midline).
6. Maintain a necessary degree of flexibility, which allows for greater self-adjustment in the child and a capacity to calm itself, which in turn helps in controlling its behaviour.
7. The supine position should be maintained with the greatest amount of bending, using aids such as playpens or mats, for moving the hips and supporting the feet.

Kangaroo Care

The technique of kangaroo care, recommended by the World Health Organization, was described about 15 years ago in Bogota, and was initially suggested as a minimal neonatal care alternative in hospitals with limited resources. Kangaroo care must have three components:

1. Skin-to-skin contact: placing the child, naked except for the nappy, on the chest of the mother, as soon and as often as possible.
2. Breastfeeding (recommended by WHO, UNICEF and the Spanish Association of Paediatricians), regarded as the best food for the first six months of life for all children, as it improves the immune system and reduces the risk of transferring illnesses, both acute and chronic, from mother to child.
   
3. Early discharge with strict follow-up.
   

Studies carried out on this practice consider that the skin-to-skin component of this programme is of great value in counteracting the negative effects of prolonged separation of children from their parents. It also offers the first intimate encounter between mother and child, even in intensive care. Close, tender and prolonged contact (as long as the child shows it is stable on the chest of the mother), helps parents to get to know their child, and helps build up the parental bond. More about kangaroo care …