MULTISENSORY STIMULATION PROTOCOL FOR PRETERM BABIES

VISUAL
Why?
In a preterm birth, the neonate is exposed to excessive negative stimulus causing over stimulation in contrast to near dark environment
of the mother’s womb.
The visual cortex is one of the last to be myelinated.
Prior to 8th month, there is no way for a preterm to control the amount of light into the retinal field.
So any bright light can damage the retina, leading to long term visual deficits.
Any stimulation of the sensory organs done before their development will lead to negative and harmful effect on growing preemie.
Hence a sequenced visual stimulation is required.

VISUAL STIMULATION GUIDELINES

Population • Preterm 28-32 Weeks
When to start • 30 weeks, Haemodynamically stable.

Intervention: Remember to carry out the following slowly, gently & rhythmically
• Aim to protect baby’s sleep
<30 weeks • Encourage rem sleep
• Eyes have to be protected from bright light as it disrupts the growth hormone.
• Opens eyes when lights are low, can see up to 6-8 inches.
30-36 weeks • Encourage mother to talk to the baby, sing and make eye contact while handling the baby.
• No purposeful visual stimulation should be given.
• Can see up to 8-10 inches, fixates for 15 seconds.
• Contrast patterns exposure for 5 minutes.
36-40 weeks • Caregiver needs to sing, change facial expressions, make the baby touch his or her face along with
eye contact.
• Vibrant coloured toys-red, orange and green may be used, same toy to be used.
• To help stimulate your infant’s vision, decorate the room with bright, cheerful colours. Include artwork
and furnishings with contrast colours and shapes.
>40 weeks
• Hang vibrant coloured mobile toys above or near their crib. Make sure they are surrounded with variety
of colours and shapes.

REFERENCES:
1. Effect of Multisensory Stimulation on Neuromotor Development in Preterm Infants.
https://www.researchgate.net/publication/234047818
2. Early Developmental Care Interventions of Preterm Very Low Birth Weight Infants.
https://www.indianpediatrics.net/aug2013/aug-765-770.htm
3. Developmentally supportive care in preemies and neuroprotection in NICU.
Dr Amitava Sengupta.

Fernandez Hospital (Regd. Office), 4-1-1229/1, Bogulkunta, Hyderabad – 500001. Telangana, India.
[email protected] | www.fernandez.foundation
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Off Abid Road, Opp. Old MLA Quarters, OUTPATIENT CLINIC Road No. 12, OUTPATIENT CLINIC DEVELOPMENT CENTRE
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Hyderabad – 500001 Hyderabad – 500029 Hyderguda, Hyderabad – 500029 Hyderabad – 500034 Miyapur, R.R. District – 500049 Madhapur, R.R. District – 500081
 SUPPORTIVE STIMULATION
Why?
In 3rd trimester of fetal development and even in infancy the brain is drastically changing with new brain cells production and migration,
synaptic pruning and brain organisation.
3rd trimester is the most crucial period during which the basic foundation for the neuromotor and neurobehavioral systems is being
laid in fetus.
Supportive stimulation is an effort to decrease the immediate adversities and developmental deficits associated with prematurity.
These interventions have been initiated to compensate for environmental deprivation or to accelerate the development of the
premature infant.
The different forms of stimulation have included vestibular, tactile, kinesthetic, auditory, oral, and various multimodal combinations.
Across studies, there is considerable evidence that supplemental stimulation produces positive effects on development which
include decreased apnea, more stable organization of state, increased weight gain, a decrease in abnormal reflexes, superior sensory
and motor performance on behavioural assessments, and earlier hospital discharge.
Increased Bayley scores on follow-up, accelerated social development, and higher infant intelligent scores were reported.

SUPPORTED STIMULATION IN PRETERM INFANTS

Population • Preterm infants born before 34 weeks of gestation.
• At corrected gestational age of 32 weeks.
When to start
• Hemodynamically stable preterm infants.
Frequency • 30 minutes session every day for 3 weeks. (32-35 weeks)

Intervention: Remember to carry out the following slowly, gently & rhythmically
• Massage.
Tactile and kinesthetic • Passive movements.
• Joint compressions.
• Frequent positional change.
• Swaddled rocking.
Vestibular
• Slow rhythmic movements of the baby up/down and side to side in caregivers arms with the baby
close to the body.
• Muted sounds with calm and relaxing environment.
• Exposure to parent’s voice.
Auditory
• Talking to the baby.
• Singing lullabies.
• Minimize exposure to noxious odours.
Olfactory
• Expose infant to mothers scent. e.g. kmc or cloth with mothers scent.
• Provide positive oral experience.
Gustatory • Position the baby insides with hands near the mouth.
• Provide colostrum or EBM oral coating.

REFERENCES:
1. Auditory brain development in premature infants The importance of early experience.
https://www.researchgate.net/publication/224823029
2. Effect of Multisensory Stimulation on Neuromotor Development in Preterm Infants.
https://www.researchgate.net/publication/234047818
3. Infant stimulation program. https://www.britannica.com/science/infant-stimulation-program
4. Volume XVIII, Number I 2004 Stimulation Programs for Preterm Infants (Tiffany Field, Maria Hernandez-Reif and Julia Freedman).
5. Supplemental Stimulation of Premature Infants: A Treatment Model
Journal of Pediatric Psychology, Vol. 22, No. 3, 1997, pp. 281-295
John N. I. Dieter and Eugene K. Emory.

Department of Physiotherapy
 POSITIONING PROTOCOL IN NICU

Aim:
To ensure preterm and sick neonates receive individualised positioning that optimises their musculo-skeletal development, supports
their neurodevelopment and minimises complications
Acronyms for Positions which are (A-Alignment B-Boundary C-Comfort F-Flexion M-Midline)

Nesting for babies less than 36 weeks

The containment of monitored babies in incubators is by the use of a ‘nest’. This provides a boundary for containment and promotes
a flexed posture. The nest is our way of replicating the position of a baby in utero.
• Create a ‘nest’ using rolled nappies or blankets (depending on the size of the baby) in a ‘U’ shape to provide boundaries to push
against and minimise the effects of gravity.
• Cover rolled nappy or blanket with a wrap, flattening the top of the ‘U’ shape and emphasising the curve by conforming the wrap
around the curve.
• Place baby wholly within nest or place baby’s bottom against curve with legs flexed over the end.
• Shoulders to be protracted & supported by the nest.
• Use a narrow sheet as a seat belt over hips to further contain baby in the nest, with legs flexed.
• Alternate and/or incorporate supine, lateral, prone and sitting positions at care times.

Guidelines for babies > 36 weeks

Supine Prone Side

A ‘nest’ is used around the baby to The baby is positioned with some pelvic This position is used once the babies
maintain the shoulders and hips in the elevation so that the legs are weight- are physiologically stable. Side-lying
mid position. The knees and elbows bearing through the anterior knee and encourages flexion and symmetry. The
supported off the cot surface to reduce lower legs and the hips are not flexed trunk should be supported perpendicular
hip and shoulder abduction. The nest more than 90. Arms are kept adducted to the mattress. A rolled nappy between
should provide postural stability yet not near the body with hands near the mouth the legs will maintain the position and
restrict the baby’s movement. to encourage hand-to-mouth orientation. maintain neutral lower leg position.
Hands should be brought together or to
the face/mouth.

General practice guidelines:

• Aim to give the baby a balance of position over a 24 hr period alternating between Prone, Supine and Lateral.
• Reposition infant with care and minimally every 4 hours.
• Baby shall not lie on any lines.
• Provide 4-handed support during positioning and caring activities. While turning a baby use Palmar grip as opposed to fingertip
as this reduces the risk of damage to fragile skin.
• Never flip the baby over 180 degrees.
• Record the baby position with the observations on the Chart
• Babies who are being discharged must be acclimatized to sleeping in Supine position without position aids & the head of the bed
in a flat position.
• Educate parents on the differences in position between the Neonatal unit and Home
• Provide swaddling when bathing and weighing • Promote hand to mouth contact Educate parents about the principles and
techniques of positioning, containment, and handling.

Department of Physiotherapy
 Methods in cots or incubators for babies of 36 weeks or more (corrected) gestation

Supine

Babies around 35 weeks corrected gestation may be placed in a cot or in an incubator.

Sleeping in supine to encouraged in accordance with SIDS and Kids guidelines. Babies
should be swaddled.

Stable babies in incubators will benefit from supported sitting for brief periods when
awake. Initially support the baby’s head and trunk as if burping the baby. Progress to
gentle rocking side to side and from back to front as this will provide vestibular input.

REFERENCES:
https://www.slhd.nsw.gov.au/RPA/neonatal%5Ccontent/pdf/Nursing%20Guidelines/Positioning.pdf
Downs JA, Edwards AD, McCormick DC, Roth SC & Stewart AL (1991). Effect of intervention on development of hip posture in very
preterm babies. Archives of Disease in Childhood.66. 797-801.
Newborn & Infant Nursing Reviews journal homepage: www.nainr.com
Hunter J. Therapeutic Positioning: Neuromotor, Physiologic, and Sleep Implications. In: McGrath CKJ, ed. Developmental Care of Newborns
and Infants. Glenview, IL: National Association of Neonatal Nurses; 2010:285–312.
Hobson J. The development of sleep. New York: Scientific American Library; 1995.
Demirel G, Oguz S, Celik I, Erdeve O, Dilmen U. Cerebral and mesenteric tissue oxygenation by positional changes in very low birth weight
premature infants. Early Human Development [serial online]. June 2012; 88(6): 409-411

Department of Physiotherapy