Overstimulation and A's & B's

[justjenny]

Hello! I am a new NI nurse and I am looking for information and opinions on any possible connection between stimulation and apnea & bradycardia.

Here's my experience with a couple of babies (all rather similar in their situation)

30 wks, isolette, some RA/some 1L NC, BM gavage feeds, all freq. A's and B's.

Day 1: the pod is super busy and since these babies are generally speaking more stable their hands on is quick: diaper, vitals, assessment at beginning and end of shift, gavage feed while in isolette. Freq. but mild A's and B's requiring slight up in FiO2, or mild stim only. On caffeine.

Day 2: the pod is "less busy" (if that's possible-LOL) So hands on is same as above but the baby is removed from isolette and held for each gavage feed, then parents visit and hold and maybe sibling or grandparents are visiting and hold, talk, etc. Freq. A's and B's and about half of them are more severe/last longer: blow by required and/or mod. stim required.

Clearly, in my experience the two seem to be related. I was "lectured" however, on the importance of holding during gavage feedings for brain development, etc. (which I totally agree with) but some nurses believe that they should be held for all feeds no matter what and always "find the time" to do so. (according to them)

I would like to read more on this topic. There clearly is a limit to the amount of stim. a baby can handle and the babies cues are one way. I just question whether the baby should be removed for EVERY feed, especially if we know in advance that the parents will be in, etc.

I have learned a lot from this group, I hope I haven't left out any important info, but can you share some opinions and experiences on this matter? I really want to find the appropriate mix that is benefitting the baby, without overwhelming them.

Thanks!

Jenny

[BittyBabyGrower, MSN, RN]

If kids are doing that, then, yes they are being handled way too much. When we have kids like that,they only come out for parents. It is more important for them to conserve energy and not be stressed. If the baby is doing that, even for the parents, then we put them back. Bonding is important, but not at the expense of baby's well being.

I can't think of any articles that promote holding for all feeds if they aren't tolerating stimulation. It isn't like it is going to make it go away and they will get used to it, KWIM?

[Gompers, BSN, RN]

I've never heard that babies should always be held for gavage feedings. Maybe a term or near-term baby, but a preemie? We do as little stimulation as possible. I usually handle all my preemies Q6H to allow them plenty of time for undisturbed rest. I'll do hands-on vitals and diaper with one feed, then the next one I'll do monitor vitals and hang the feeding. I don't disturb the baby at all. No diaper change (unless they have skin breakdown) or anything. I don't even touch the baby. The way I figure, if they're premature, they'd still be in utero and wouldn't be touched or held anyways.

As they get older (like 30+ weeks) I'll offer a pacifier with each gavage feeding to help associate sucking with a full stomach. But I'll still let them sleep undisturbed for 6 hours if possible.

Of course, if the baby is having lots of A's and B's, has a bad residual, has a history of feeding intolerance, etc. - then I'll do hands-on vitals every time and really assess the baby. But otherwise, I leave them alone.

Every unit is different though. I know that some units do a lot more handling than others. We tend to have a large amount of micropreemies (quite a few under 500 grams) at all times, plus a lot of sick PPHN kids. So we're big on decreasing stimulation and are encouraged to handle the babies as infrequently as possible. Other units want full hands-on assessments every hour or two. You gotta do what your unit does, I suppose.

[Gompers, BSN, RN]

If kids are doing that, then, yes they are being handled way too much. When we have kids like that,they only come out for parents. It is more important for them to conserve energy and not be stressed. If the baby is doing that, even for the parents, then we put them back. Bonding is important, but not at the expense of baby's well being.

We try to teach this to our families early on. They usually have no problem with this, because usually when you pull the baby out for them and the baby starts having A's and B's, they get all nervous anyways. We also offer a free class called "Infant Cues and Handling" taught by one of our nurses and we encourage preemie parents to attend. In the class, they learn how to handle their preemie, and how to recognize when the baby is getting overstimulated and needs to rest undisturbed. Very helpful when we're all on the same page.

[justjenny]

I've never heard that babies should always be held for gavage feedings. Maybe a term or near-term baby, but a preemie? We do as little stimulation as possible. I usually handle all my preemies Q6H to allow them plenty of time for undisturbed rest.....

Every unit is different though. I know that some units do a lot more handling than others.... You gotta do what your unit does, I suppose.

Thanks for the reply. We do seem to handle our babies a lot, but not if they are micro-preemies, unstable vent, etc. but a 1300 gram 30 wk'er would never go 6 hours without being handled in our unit. One baby was a Q2 hr feed...I only did a hands on Q4....couldn't justify bothering the kid anymore than that.

As far as development, my thoughts are similar to yours: they are not being "handled" and stimulated so much in utero...so why should we be doing it? Our unit is SUPER conservative, but is big on holding the kids. I feel that if I can find something to back up my thoughts of "hands off" when *I* feel it is appropriate then maybe someone will listen (remember, I'm new....)

I appreciate any/all comments and thoughts on this matter!

Jenny

[lovemyjob]

We are very similar to Gompers. As little handling as possible is our rule. Monitor VS q4, hands on q12. Plus, preemies experience pain differently than term kids do. While a touch for a term kid could be soothing, it could be painful for a preemie. Plus, they dont go home until they grow, and stressing them keeps them from growing (that is how I expalin it to parents who want to reach in and touch their kid for hours on end.) Also, what do you do when you are compressing feeds and the kids 20ml goes in over an hour and a half....I know those nurse dont want you to sit there for an hour and a half!!! Unless it is written into a policy, you are not required to do it...plus, when they bring it up you can educate them on the need for the kids to sleep, undisturbed!

[prmenrs, RN]

I don't think you can make a hard and fast rule, just guidelines, to be adjusted @ the nurses discretion.

It's absolutely imperative to respond to the baby's cues: If s/he is mottling, doing a hand salute, finger splay, losing tone, etc., they need to go back to bed. If you keep @ it, a's & b's will increase, and you run the risk of them getting septic. You're stressing them.

I like the q6h handling as a guideline. If you want to hold them more often, do it against your chest, no eye contact, protect them from noise and light. Sit quietly. Shushing sounds are supposed to sound like placental sounds, but if you do that, do it gently.

Ask for references about holding for feeding ("evidence based practice"). If they give you something, make sure the reference applies to premies

If they DO give a reference, share it w/us, OK?

[LilPeanut, MSN, RN, NP]

It seems to me though that much lip service is given to the benefits of kangaroo care, but it isn't actually done as often as some researchers suggest it can be (ie even with vlbw infants still on a vent) and that often by the time kangaroo care is started, the baby is at a feeder grower stage, which may not be the time they need it the most?

Maybe we're just approaching the guidance we give parents for stimulation the wrong way.

[justjenny]

Maybe we're just approaching the guidance we give parents for stimulation the wrong way.

Thanks for your reply. I actually asked this question for my own reference as a new RN, and not as much for educating the parents. If anyone is going to handle/hold the baby - it should be the parents certainly more than I!

My original reason was because I was told point blank: "To help with brain development the baby should be held during gavage feedings - and that IS A HINT" and then another RN stated "so-and-so ALWAYS finds time to hold her babies during feeds - you should try to model yourself after a nurse like that"

My feeling was that perhaps some babies of a certain gestation cannot tolerate as much handling as some would like - and my experience with a few babies seems to support that - but as a new RN I cannot simply make a statement like that without being given the idiot treatment. If I can justify myself with "evidence based practice shows that infants at 30 wks gestation should be handled no more than X amount of times and/or for x amount of minutes..." or whatever (you get the idea) then my argument/opinion may hold more weight with the NNPs/Neos. If I don't have any evidence to support myself - I feel that I will be dismissed or accused of trying to "get out" of doing my work.

(I couldn't imagine a Q12 hr hands on where I work....)

Jenny

PS - I absolutely LOVE my unit and the hospital that I work at - don't get me wrong. I am simply trying to "find my way" in my own practice but want my care to be developmentally appropriate and safe!

[LilPeanut, MSN, RN, NP]

So far as the studies I've read - for true kangaroo care, there haven't been any limits found after which it was shown to be too stressing. That overall, the more they are kangarooed, the better, and even best if cares can be done on mom while kangarooing.

[prmenrs, RN]

I think the nurse's handling needs to be mindful of the baby's tolerance--if the baby shows signs of not tolerating it, you then have a reason not to handle that patient as often.

IMO, they have to be physiologically stable enough to tolerate handling in order for it to be good for their brains.

[LilPeanut, MSN, RN, NP]

There's a fair amount of research that says it helps them physiologically, not just neurologically....so, how do we balance it?