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According to world health organization “Preterm birth is defined as babies born alive before 37 weeks of pregnancy are completed”. Every year estimated 15 million babies are born premature i.e. 1 in 10 babies and this number is rising with risk of neurodevelopmental and behavioural disabilities high in children and in adults who were born preterm.
The advances in recent years in neonatology have resulted in a marked improvement in the mortality of premature infants. As more infants are surviving, the importance of finding ways to improve developmental outcomes and their quality of life becomes paramount. (celestie M Maguire, 2007). Today many of preterm infant discharged from hospital NICU continue to lack well organized central nervous system which results in less control of sleep, fussing, crying, irritability, arousal, feeding and fail to attend minimal degree of physiological homeostasis. Their limited energy reserve are directed towards attempting to protect themselves from the stimulation that may be inappropriate for their current level of neurophysiological functioning. Often it may not be until three to six months after homecoming that these infants’ neurobehavioral organizational abilities begin to stabilize (Als,1997;Gorski,1984) so they require an array of intensive services throughout their first two years of life.
Need of supportive and active parent-infant interaction :
Parent-child interaction is the only cornerstone for supporting and regulating preterm infant’s neurobehavioral organization after arriving home. To stay connected with external world infant’s communicate using their basic language called behavioral cues (distressing signs when overstimulated and soothing signs when relax).
- NEUROBEHAVIOURAL ORGANIZATION {by Blackburn 2005} is a mature multidimensional construct and includes an individual's ability to interact with the environment while maintaining internal stability.
- BEHAVIOURAL CUES: Behavioral cues are defined as non-verbal and special forms of communication that new-born and young infants use widely to express their needs and wants {wales neonatal network guideline}.
Transition from the well supported and resourceful NICU to the home setting is demanding time for families. Most new parents require extra help to learn how to give their premature baby the sensory nourishment needed for optimal development, while taking special care not to overload the baby’s delicate nervous system.
Post discharge care by parents can have nurturing or direct toxic effect on brain, Therefore, all treatment in neonatal care and all care modifications at home should be considered from the perspective of their impact on brain development and the long-term developmental outcome of the child. Therefore it is important that a new parent tune in quickly to what overwhelms her baby and learn to read the cues before he/she overloads, to protect the development of brain and avoid the long term neurodevelopmental deficits.
Thus it is important to educate caregiver towards understanding infant’s needs and improve parent-infant interaction by making them understand various behavioural cues of infant and immediate ways to respond to their cues and in term help in early intervention and prevention of future damages to their baby. Early Intervention is crucial and important to timely invest on care of premature newborns in order to save them from being functionally impaired. During the first 1,000 days, the brain grows more quickly than at any other time in a person’s life and a baby needs the right nutrients at the right time to feed her brain’s rapid development. There are three crucial stages in the first 1,000 days: pregnancy, infancy and toddlerhood.
First let us understand various infant's Behavioural Cues and their Regulatory competence :
A) The infant competence level can be noted using the Infant Behaviour Assessment tool (IBA). Infant's Behavioural cues can be divided into 4 subsystems namely
- Autonomic cues : it includes observation of color (pink, mottled, pale, rusk, dusty), respiration rate or pattern (stable, yawn, sigh, irregular, sneeze, cough, hiccough, gasp, pause), visceral cues (stable, burps, spit up, gag, elimination, vomit) and neurophysiology cues (stable, tremor, twitch, startle, seizure)
- Motor responses : it includes observations of head, trunk/extremities, arm, hand and leg movements. Evaluate for the tone of the body whether it is regulated tone with smooth movement or spastic tone or flaccid tone. Evaluate the influence of the primitive reflexes on the body whether it is present on time, abnormally present, delay to elicit reflex, persistent reflex with respect to age.
- Regulatory state : it includes state of deep sleep, light sleep, drowsy, diffuse alert, alert, interactive alert, active alert, hyper-alert, cry.
- Attention/interaction cue : it includes observation of the facial features of the infant. Observe for interaction cues like infant's eyes gaze (facing gaze, directed gaze, brow rasing, blink, clench, upward gaze), facial expression (smile, ooh face, sober, lip compression, cry face), oral function (neutral, sucking, mouthing, tongue showing, suck search, drooling, tongue extension, jaw extension), vocal response (pleasurable, undifferentiated, protest) to any environmental stimulus.
- AUTONOMIC: pink, stable respiration, visceral and neurophysiologic indicators.
- MOTOR: Well regulated tone, smooth movement
- STATE: predominately interactive state.
- ATTENTION/INTERACTION: maintains period of sustained attention to presented stimulus.
- AUTONOMIC: mild colour change, and/or yawn, sigh, burp or perhaps a fleeting tremor.
- MOTOR: increase movement or occasional Squirm, well regulated tone and smooth movement predominate. Attempt to self-regulate is most often successful.
- STATE: Interactive state, alert to competing stimulus.
- ATTENTION/ INTERACTION: Approach behaviours predominate.
- AUTONOMIC: Mild to moderate colour changes and/or fluctuation in colour; and/or irregular respiration. Occasional twitch or tremor observed.
- MOTOR: Some period of well-regulated tone and smooth movement interspersed with disorganized behaviour. Self-regulatory behaviour are occasionally successful.
- STATE: Attempts to maintain interactive or alert state. Often fluctuates between alert and/or active alert/diffuse alert state.
- ATTENTION/INTERACTION: Momentary period of directed gaze or facing gaze
- AUTONOMIC: moderate to considerable colour changes and/or fluctuation in colour; and/or moderate periods of irregular respiration. Twitches, tremors and startles may be observed as well.
- MOTOR: motor disorganization. Ineffective attempt to self-regulate commonly observed.
- STATE: Most often alert, active alert and/or cry. Attempts to move to drowsy or light sleep.
- ATTENTION/INTERACTION: Fleeting, disorganized behaviour observed.
- AUTONOMIC: Severe colour changes and /or fluctuation in colour; and/or of irregular respiration. Twitches, Tremors and Startles or seizures may be observed as well.
- MOTOR: Disorganized behaviour observed, few if any self -regulatory efforts observed.
- STATE: Active alert predominates, culminating in cry, or attempts to move to drowsy or light/deep sleep.
- ATTENTION/INTERACTION: unavailable, protest vocalization predominant.
- Caregiver's or mother's responsibilities which includes : to recognise and respond to infant's cues, soothe distressed infant, communicate with infant by showing positive feelings and warmth and enhance infant's physical and cognitive growth through positive touch, movements and by talking to them. Delay stimulating or responding until infant's shows signs of readiness while feeding or other activities.
- Infant's position while sleeping i.e. supine, prone, side-lying, cradled in arms etc.
- Infant's upper limb, trunk and lower limb position when sleeping, feeding, interacting. Extremities oriented towards midline.
- Handling techniques while feeding or interacting with infant.
- Cue matched facilitation related hunger cues, stress cues.
- Need of swaddling, containment touch and Kangaroo mother care (KMC)
- Environmental facilitation by bringing changes in visual input or auditory input or temperature input on the infant's body.
- Dr.Sheetal Tatar, Dr.Hemant Nandgaonkar. Effectiveness of parental education based on neurobehavioural cues and it's impact on preterm infant development: Indian Journal of applied research (2020).
- World Health Organization. (2018). Preterm birth.
- Celeste M. Maguire, Jeanet Bruil. Reading Preterm Infants Behavioral Cues: An Interventional Study With Parents Of Premature Infants Born<32 Wks.: Early Human Development (2007)83,419-424.
- Rodd.E.Hedlund. Infant Behavioral Assessment and Intervention Program. IBAIP: 1986.
- Barr S. Wales Neonatal Network Guideline Wales Neonatal Network Guideline.2016;(June 2013):2–4.
- KAREN KOLDEWIJN P. Low Birth Weight Infants at 6 Months Corrected Age. J Pediatr. 2009;154(33):8.
- Cronin catherine M. The impact of very low birth weight on the family is long lasting:A matched control study. Arch Pediatr Adolesc Med. 1995;149(2),151–8.
- Lopez GL. Transition of premature infants from hospital to home life. Neonatal Netw. 2012;4(31):207–14.
- Teresa M.L, Transforming Mother Infant Interaction Within Cultural and Caregiving Context: Home-Based Occupational Therapy for Preterm Infants: Hong Kong J Occup Ther (2012) 22, 17-24.
- Lindsey B, Parenting Your Preemie with Sensory Issues: S.I. Focus Magazine — Autumn, 2008
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