minutes with time divided more evenly between active and quiet sleep. Term infants begin and end their sleep cycle in active sleep and have longer periods of awake, alert time. Both REM and non-REM sleep are crucial during fetal and neonatal life for the development of neurosensory function within the central nervous system (CNS), which processes sensory information from the outside world. Neurosensory development depends upon appropriate stimuli from both internal and external sources. Endogenous stimulation occurs only during REM sleep, something that a fetus at 32 weeks would be engaged in for the vast majority of the time. Once these sensory systems are formed using endogenous input from the baby’s own CNS, they are ready for exogenous stimuli from the external world. Fetal development of the sensory system occurs in a specific sequence: tactile (touch), vestibular (proprioception), olfactory (smell), gustatory (taste), auditory (hearing), and visual (sight). Disrupting this predetermined sequence of sensory development can interfere with later function. Since the visual system matures towards the end of the normal gestation, preterm infants are not ready for light or any kind of visual experience prior to 36-40 weeks gestation. Protecting sleep cycles, especially REM sleep, is absolutely essential for optimal neurosensory and visual development. Understanding the various newborn states of consciousness helps to guide both professional caregivers and parents. NICU Brain Sensitive Care Committee/Terrie Lockridge/ 11-2015/Swedish Medical Center – used with permission 5 Newborn States and Caregiver Considerations State Baby’s Behavior Caregiver Considerations 1 Deep/Quiet or Non-REM Sleep •No movement, only occasional jerks •Eyes closed, no eye movements •Startles with delay, suppresses quickly •Regular breathing •Lowest oxygen consumption •Low resting HR in some term infants •Difficult or impossible to arouse •No interest in feeding at this time •Not receptive to social interaction 2 Light/Active or REM Sleep •Random movements and startles •Eyes closed, rapid eye movements •Irregular respirations •Higher oxygen consumption •Term infants start and finish sleep cycles in active sleep •Preterms react more to stimuli at this time than term infants •May fuss briefly, and be awakened before truly awake and ready to eat •Lower, more variable O2 saturations 3 Drowsiness •Eyes open (dazed) or closed •Respirations more rapid and shallow •Intermittent startles •Slow response to sensory stimulation •Smooth state change after stimulation •May awake further or may return to sleep (if left alone) •Talking quietly to infant may arouse infant to a quiet alert state 4 Quiet Alert •Eyes open wide, face is bright •Focused attention •Body is quiet with minimal movement •Best state for learning because infant focuses all attention on visual, auditory, tactile or sucking stimuli •Best for interaction with parents 5 Active Alert •Eyes open and alert •Actively moving extremities •Reactive to external stimuli •Irregular respirations •May or may not be fussy •Infant has increased sensitivity to internal (hungry, tired) and external (wet, handling, noise) stimuli •Unable to fully attend to caregiver or environment because of increased sensitivity and motor activity 6 Crying •Cries, possibly intense •May be difficult to console •Respirations rapid, shallow, irregular •Indicates that individual tolerance limits have been met or exceeded •Not receptive to learning Infants in the NICU often spend a lot of time trying to sleep in spite of bright lighting, noise, and unpredictable handling. Sleep allows infants to enter an unresponsive state of “protective apathy”, where they can maintain physiologic homeostasis, conserve energy, and grow. Infants hospitalized for extended periods may show classic signs of “hospitalitis” (asocial behavior, touch aversion and failure to thrive), as well as sleep and maternal deprivation. Since unrestricted maternal access in the womb is no longer an option for prematurely born infants, skin-to-skin care provides an unrivaled antidote. Extended parent contact, reduced stress, and adequate sleep can be promoted by skin-to-skin care, as soon as possible, often, and as long as the infant remains stable. When skin-to-skin is not an option, parents can provide gentle containment during sleep periods (“hand hugs”). Cuddlers can be used to hold swaddled infants whose parents are either uninvolved or unable to visit frequently. NICU Brain Sensitive Care Committee/Terrie Lockridge/ 11-2015/Swedish Medical Center – used with permission 6 What can we do in the NICU? Caregiving based upon an infant’s sleep-wake states rather than scheduled “care times” provides adequate rest and sleep for baby and is one of the most important contributions made towards positive long-term outcomes. To facilitate sleep and reduce unnecessary procedural handling, the “Brain-Sensitive Caregiving” Vital Signs Order has been developed. Vital Signs and Clustering of Care if Stable 24 Hours After Admission: · Vital signs should be done twice per shift minimum (approximately every 6 hours), preferably when infant is awake. A full assessment, vital signs, diaper change, repositioning, oximeter site change, CPAP/NAVA break, feeding, and any indicated interventions can be done at this time. · VS and assessment frequency is