Why clustered care giving could be considered the equivalent of a marathon for a sick, vulnerable or premature baby

This weekend in Sydney Australia, our city had its annual City to Surf marathon. Where 80, 000 motivated individuals complete a 14km run/walk through the streets of Sydney to the pristine beaches of Bondi. The City to Surf is an annual fundraiser for charities including our own unit/hospital and for anyone who has completed the event, heartbreak hill is a test of endurance and for some the scene of undeniable chafing. We would like to take this opportunity to congratulate everyone who competed in the event and use the event to highlight how caregiving in the neonatal setting for the vulnerable infants can be the equivalent of a marathon.

To cluster or not cluster. It is not going to take you long to realise within this article that we are very much on team don’t exclusive cluster cares. So, what is the difference between clustered and cue-based cares? We have summarised the concepts in the table below:

Cue Based  Cluster Cares
  • Care giving and interaction based on the infant's behavioural cues, including the appropriate provision or modification of sensory stimulation.
  • Adapting caregiving interventions to suit each individual baby
  • There is a risk of not identifying appropriate cues
  • There is a risk of over handling
  • It can be selectively implemented/applied
  •  Clustering of cares focuses on a minimum handling approach to protect periods of deep sleep by minimising the number of times an infant needs to be woken up or disturbed.
  • Risk exists if the infant isn't able to cope with the cluster of cares
  • Can become routine i.e. 4 hourly, 6 hourly cares based on the caregiver not the infant

What does the evidence tell us?

Research published since 2005 has suggested that routine tactile procedures (i.e. nappy changes or cares) may be at least as stressful for preterm infants as painful procedures (Holsti et al 2005). With preterm infants demonstrating heightened states or arousal and variations in their heart rate when an invasive procedure (i.e. insertion of a tube or collection of blood) follows routing nursing care giving, meaning these babies find it hard to differentiate between painful and stressful procedures when they occur close together and will often respond with the same types of behaviour (Holsti et al 2006).

 A more recent study found preterm infants up to 35 weeks gestation demonstrated stress responses to weighing and bathing procedures. However, if the infants were provided with support at the conclusion of the interventions by using swaddling and nesting, 5 minutes after ending the procedure they demonstrated recovery (Çaka & Gözen 2018).  The conclusion of this research which aligns with the NIDCAP philosophy of care is although clustering care which common in NICUs provides infants with longer rest periods, even during well-paced care it can produce significant stress responses even in older preterm infants. Caregiving should allow for the timing of rest periods and responsiveness to the infants’ individualized cues. In this way, we can minimize potentially deleterious stress responses.

Recommendations 

One of the things that we advocate for in caregiving is that respiratory support stays in position during caregiving. Why? Well imagine you are competing in the City to Surf and are an asthmatic you take a few puffs of your inhaler before you start the race and ease yourself into the first few streets. At the bottom of a very big hill I swipe your inhaler from your hand and run ahead of you up the hill with it, meanwhile the person running behind you starts pushing you up the hill moving you from one side of the road to the other, getting in your way, making you work harder and not allowing you time to stop… Why? Well because they think it isn’t that big of a hill. You get to the top of the hill and are wheezing, sweating, cursing, and trying to catch your breath. We knew you needed your inhaler before you started the race and removing it when you needed it most during exertion didn’t help, it placed you in a more vulnerable position. So why do it? (Please note we are not suggesting babies in the NICU are asthmatics).

Removing a baby’s respiratory support during caregiving is the same thing as swiping someone’s inhaler during a marathon – they are more likely to need support during exertion, caregiving is exertion in the neonatal setting. Watch what happens to a baby’s respiratory rate, their colour, their oxygen saturations and their tone during and particularly after caregiving – they are telling you they need not only the respiratory support they also need your help.  By removing respiratory support, we are robbing them of something they have demonstrated they need and precious calories for growth. So please leave it in place.

 What about the risk of pressure areas? You have a number of options available to you:

  • Ideally, we are completing caregiving in partnership with the family. Place the baby on the parent’s chest for skin to skin after the completion of cares and remove the support in a place where we know the baby regulates better.
  • Babies move, and squirm regularly look for an opportunity when they are already moving, squirming or telling you they are awake/unsettled, provide them with some support (i.e. hand hugs) and if they have settled with good colour, tone and respiratory rate remove the mask/prongs then.
  • Socialising with the baby (talking, smiling, singing) when they are in a quiet alert state with a brief break from their respiratory support and encouraging families to do this is a win-win for the baby and the carer.
  • Ideally separate out pressure area care from other caregiving!

The baby is really unstable and doesn’t tolerate handling. Unwell and vulnerable babies will still generally tell you when something is upsetting them or if they are uncomfortable. If you observe them squirming, arching, extending their arms or legs in the air with or without bradycardia (decreased heart rate) and desaturations (decreased oxygen levels) – they need your help. Place your hands on their feet and belly to offer support, consider if they are telling you they need to be repositioned. Ensure they are receiving adequate support from the environment is the nest close enough, are their hands in the midline near their face, are there lights or excessive noise in the area. Try using maternal scent and voice to help calm the baby. Pace care giving and any type of interactions for these babies. Change baby’s nappies who are unwell or vulnerable in the side-lying position – they cope better, and it is less stressful. Wait until the baby is in a calmer state with less evidence of distress before you even consider removing their respiratory support.

Doesn’t not clustering care this mean we handle the baby more? Ideally not. What we are suggesting is that you let the baby lead your interactions. Look for signs that they are uncomfortable or need assistance and intervene at that point. When you offer support work out how much help they need, are they uncomfortable, do they need to be repositioned can I rewrap or swaddle them and at the same time change their oxygen probe? Do I need to do a lot or a little? Once they have settled work out can they cope with any additional stimulation or exertion – no – well its time to stop. Not sure what you are looking for head to our website and check out our factsheets that explain baby’s cues in more detail. Care giving interactions should not be a 4-6 hourly event that consists of a famine of touch and then a fast and furious event of every possible intervention available. My question to nurses is do most babies really need their eyes cleaned every 4-6 hours? Rationalise and individualise the care giving to each baby.

 We suggest a hybrid of cue based individualised developmental care outlined below:

Goal

Strategy

Promote long periods of sleep and rest (cue/cluster)

-       Initiate care based on behavioral state

-       Be flexible in delivery of care (not routine)

Individualised to the infant

(cue)

-       Recognise approach and stop cues

-       What support do they require? What support works?

-       Four handed care (i.e. use two caregivers)

Prevention of overstimulation & energy consumption

(cue)

-       Pacing

-       What is nice to do? What needs to be done?

-       Loss of tone, bradycardia and apnea = STOP provide support, do you have to continue?

-       Four handed care and positioning

To avoid over-handling (cue/cluster)

-       Before handling ask yourself does this really need to happen?

-       Take note of how many times you touch the infant – your goal is to reduce unnecessary care touch

-       Differentiate between care and therapeutic touch

 But this means more work! Sure, I am not saying it doesn’t. We are in the business of supporting families to care for their babies. They are present in the neonatal unit during a particularly sensitive period of brain development, which includes neuronal migration, forging of synaptic connections, cortical organization, and myelination (D’Agata et al 2017). If that means we take more time and are focussed on individualising our caregiving to each infant and their responses that supports them to achieve more as an adult can you really argue against that? 

 So next time you are supporting a family to complete caregiving or completing caregiving with another staff member can I ask you to think about the caregiving marathon analogy and modify your approach to caregiving in the neonatal setting.

This article was written by Nadine Griffiths Clinical Nurse Consultant and NIDCAP trainer she has an interest in supporting neurodevelopmental care parents and babies in the neonatal setting. Her views do not necessarily represent those of the Australasian NIDCAP Training Centre.