Understanding the Transition: Immediate Post-NICU (0-3 Months Adjusted Age)

Why We Adjust Age for Premature Babies

Adjusting age for premature babies is essential to accurately assess their growth and developmental touchpoints. Since premature babies are born before completing the full term of pregnancy, their development might not align with that of full-term babies of the same chronological age.

How to Calculate Adjusted Age

Adjusted age is determined by subtracting the number of weeks the baby was born prematurely from their actual chronological age. For example, if a baby was born at 32 weeks and is now 10 weeks old, their adjusted age would be 2 weeks (10 weeks - 8 weeks of prematurity).

Adjusting to Home Life

Both you and your baby will need time to adjust to the new environment at home. It’s normal to feel overwhelmed! Here are some key points to keep in mind:

Taking Care of Yourself

Rest whenever you can and accept help from family and friends.

Monitor your own mental health. It’s normal to feel a range of emotions after the NICU experience. Don’t hesitate to seek support if you’re feeling overwhelmed.
- Did you know up to 40% of parents leaving the NICU experience signs and symptoms of post-traumatic stress disorder (PTSD), anxiety, or depression. This is likely only the tip of the iceberg. If you experience flashbacks or your mood interferes with your ability to find joy in your baby, please consult with your OB or PCP.
- To help assess your mental health, you can fill out the Edinburgh Postnatal Depression Scale (EPDS) and show it to your provider if you’re worried.

Support Resources

Mass.gov: Postpartum depression support & resources

Jewish Family and Children’s Services (“JF&CS serves people of all cultures and faith traditions”): Postpartum Depression and Anxiety Support Group and Families with Premature or Fragile Newborns (telehealth, home visits, and support group)

BIDMC of Boston: Postpartum Care and Support

MCPAP For Moms: Resources for Pregnant and Postpartum Women

Remember: Children are healthier and more stable when they’re with their parents! But it's important to remember that parents need to be stable too. Just like on an airplane where you put on your own oxygen mask before helping others, you need to take care of yourself first so you can take care of your child effectively.

Coping with Crying

It’s OK to let your baby cry! In the NICU, reducing stress was crucial, but at home, some crying is normal and OK. It’s a way for your baby to communicate their needs.

Learn to recognize different types of cries (hunger, discomfort, tiredness) and respond appropriately. Sometimes, letting your baby cry briefly is OK while you determine what they need (which is sometimes nothing that you can figure out). Some parents may find it difficult to hear their baby cry, feeling that the baby has already been through so much; this can be hard, but it’s OK—you’re doing a great job as you learn your baby’s cues, and they learn your responses.

Remember, you cannot spoil your baby, nor can you hold them too much, particularly right after discharge. Your baby is incredibly smart and will learn from your interactions. If you’re holding your baby while they sleep, make sure that the sleep environment is healthy and safe. Be mindful that habits formed now can become learned behaviors, so consider how you want to establish routines that support healthy sleep patterns.

Feeding

Breast Milk and Formula

Breast milk is great, but sometimes it’s not feasible, and that’s OK! If formula is necessary, ensure you are using the right type for your baby’s needs.

Choosing the Right Formula and Understanding Sensitivities

Contrary to popular belief, babies are not very sensitive to the taste of their formula. Babies are more sensitive to the smell or texture of their formula. An unpleasant or unfamiliar smell can make feeding more challenging, especially with hypoallergenic and amino acid-based formulas (like Alimentum and Neocate), which have a stronger odor. The texture of the formula can also impact feeding. Some formulas might be thicker or thinner than others, affecting how easily your baby can suck and swallow.

When considering changes in consistency, it may be helpful to work with a feeding specialist to evaluate and possibly adjust the nipple to a faster flow rate.

Key Features Influencing Feeding Pace

Nipple Size: There is no need to increase nipple size if your baby is finishing a feeding in under 30 minutes. Faster is not always better and may lead to choking. Signs that the nipple flow is too fast include milk leaking from the corners of the baby’s mouth, choking, coughing, and appearing stressed with wide eyes and hands out. Some babies never need to use nipple size 3.
- When is a nipple the right size? A nipple is the right size if your baby can comfortably finish a feeding within 20-30 minutes without showing signs of distress.
- When is the nipple too small or too slow? A nipple is too small if your baby seems frustrated, takes too long to feed, or is not gaining weight appropriately. If the nipple collapses during feeding, it may be too small or the flow too slow.
Height of Bottle as a Pacing Strategy: You can adjust the height of the bottle to slow down or speed up the feeding, depending on your baby’s needs.

Feeding Position: In the NICU, we often start with an elevated side-lying position where your baby lies on their side facing outward. This method (shown in the picture below) allows milk to drain out of the mouth if it flows too quickly, making it the slowest and safest way for babies to learn bottle feeding. However, transitioning to a cradle hold may become more suitable as your baby grows and develops feeding skills.

What NOT to Do

Twisting the Bottle: Twisting the bottle to elicit the sucking reflex might have been observed in the NICU and seemed useful, but it’s not a sustainable or advisable method. Relying on bottle twisting means that when this reflex is gone, your baby may struggle to feed because they haven’t learned to suck without this prompt. Such techniques can also inadvertently push babies to take more milk than they need, potentially decreasing their interest in oral feeding over time.
- Understanding the Sucking Reflex: The sucking reflex is an instinctive behavior that babies are born with, enabling them to feed effectively. This reflex is crucial for newborns to obtain nutrition before they have the motor skills to eat solid food. When the roof of a baby’s mouth or the side of their face is touched, the sucking reflex will be elicited. Over time, babies learn to coordinate sucking with swallowing and breathing, making feeding more efficient.
Rigid Schedules: Your baby isn’t on a strict feeding schedule like in the NICU. At home, their feeding times might be irregular, and that’s perfectly normal. It’s important to feed your baby when they show signs of hunger rather than sticking to a strict timetable; this helps them regulate their own hunger cues and supports healthy growth and development.

Remember: Your baby isn’t wearing a watch and telling time like the NICU nurses!

Weight Gain Issues

If your baby is not gaining weight adequately, consider exploring recipes and nutritional guidelines provided by your healthcare provider. Gavage feeding may also be recommended, and you can find more information here.

Encouraging Rooting

To help your baby develop effective feeding techniques, it can be beneficial to practice rooting early on. One effective method is to practice rooting on an empty breast in a reclined position, which allows the baby to use natural reflexes to find and latch onto the breast without any spells.

Thickening

Some parents may consider thickening their baby’s formula, which involves adding a thickening agent to make the formula less runny. This may be recommended by a feeding specialist or pediatrician if your baby has gastroesophageal reflux disease (GERD) or feeding skill deficits. Thickening can help prevent milk from coming back up and make feeding easier for babies who struggle with thin liquids.

If thickening is recommended, you will need guidance on the appropriate nipple size to ensure your baby can feed comfortably. Some parents thicken by adding cereal to make their baby feel fuller after a bottle, thinking they might still be hungry. We strongly encourage using cereal from a spoon but acknowledge that different cultures have different practices. It’s important to work with your baby’s doctor to ensure your baby’s needs are met appropriately!

Thickening Agents

Rice Cereal: Often used for thickening, it can help with GERD and feeding difficulties but should be used under professional guidance.
Oat Cereal: Another option for thickening, oat cereal can be easier on a baby’s digestive system and is often recommended as a first food.

Important Note: Do not thicken your baby’s formula without input from a professional. It’s crucial to ensure the thickening agent is suitable for your baby’s needs and that you are using the appropriate nipple size to maintain a safe and comfortable feeding experience.

Formula Preparation

Formula preparation may seem overwhelming when you first get home! If your baby is on an increased-calorie formula, you should have the recipe for making it from the NICU, or you can access it here. Formula comes as a powder, liquid concentrate, or ready-to-feed. If you’re using powdered formula, you may find it easiest to prepare 1-2 days of formula and store it in the refrigerator, pouring what your baby needs into a bottle for each feeding. Powdered formula should be carefully prepared to prevent bacterial contamination, according to these guidelines by the CDC.

Remember...

Once the baby’s mouth has been on the bottle of formula, after an hour outside of the refrigerator, the bottle should be thrown away.
If you’re warming a bottle or have boiled water to prepare formula per the CDC’s instructions, please check the temperature carefully before feeding your baby. Tap a few drops of the formula on the inside of your wrist to ensure it’s not too hot.

Feeding Difficulties

Feeding difficulties in babies can be a challenging experience for both the child and the parents. If your baby is struggling with feeding, it’s essential to understand the possible reasons and seek appropriate solutions.

Oral Aversion or Pediatric Feeding Refusal is a significant concern that often goes untracked as an outcome. Shockingly, up to 30-40% of children leaving the NICU may refuse to feed.

It’s important to note that some babies may never feed from a bottle, and that’s okay! They may transition directly to using a cup. Observing your baby’s feeding behavior and consulting with healthcare professionals like pediatricians or lactation consultants can provide valuable insights and support. Addressing feeding struggles early can help ensure your baby receives the necessary nutrition for healthy growth and development, and can make mealtime a more positive experience for everyone involved.

Why Does Feeding Refusal Happen?

Feeding refusal is often related to prematurity and sensitivity to exposures to oral experiences that the baby wasn’t yet ready for. Even if breastfeeding is not the goal, it can be a nice way to start feeding and develop a healthy interest in feeding. If your baby refuses to feed, they can be supported with gavage (NG or G-tube) feeding. The work then becomes helping them to learn to be orally interested, using either a bottle or, after 3-4 months corrected, a cup or purees.

For more information and resources, visit Feeding Matters.

Coughing and Choking

If your baby experiences coughing and choking during feeds, consult with your pediatrician to rule out any underlying issues and receive guidance on safe feeding practices. It’s crucial to identify whether the issue stems from the flow rate of the nipple, the consistency of the feed, or a possible underlying medical condition such as dysphagia. The pediatrician might recommend a swallow study or refer you to a feeding specialist for further evaluation and tailored advice.

Miserable and Arching All the Time?

If your baby seems miserable and is arching all the time, this could be a sign of reflux or milk protein intolerance. Symptoms like frequent crying, back arching during or after feeds, and refusal to eat may indicate discomfort from acid reflux or a sensitivity to milk protein. Discuss these symptoms with your pediatrician, who may suggest dietary changes, such as switching to a hypoallergenic formula, or medication to manage reflux. Keeping a symptom diary can help your doctor in diagnosing and treating the problem effectively.

Introducing Tummy Time

Tummy time is an essential activity for babies aged 0-3 months, helping them develop crucial muscles and skills. Placing your baby on their tummy while they are awake and supervised strengthens their neck, back, and shoulder muscles, preparing them for touchpoints like lifting their head, rolling over, and eventually crawling. Start with short sessions several times a day, gradually increasing as your baby becomes more comfortable. Remember, tummy time should always be supervised and conducted on a firm, flat surface to ensure safety and support healthy development.

Addressing Side Preference

Rotate the orientation of your baby’s bed nightly to vary their head position. Rotating the bed orientation encourages your baby to turn their head to different sides. Using colorful crib items or a “stimulation blanket” can also help draw your baby’s attention to a specific side. Remember: In the NICU, your baby may have been approached primarily from one side (likely the right side, since around 85-90% of people are right-handed) due to medical needs or equipment placement, leading to uneven muscle development and potential postural asymmetries.

Motor Skills

Midline Positioning

Positioning your baby in midline as soon as possible is crucial for their motor development. Midline refers to keeping your baby’s head, neck, and spine aligned, which helps in developing strong core muscles and proper head control.

Strategies to Help Get Them in Midline

Blanket and Roll: Use a rolled-up blanket to create a donut shape. Place your baby in the center to help maintain the midline position.
Early Time in Midline: Encouraging early time in midline is essential work for your baby. This positioning helps them build the foundation for later motor skills.

Meet physiotherapist/physical therapist extraordinaire Maureen Luther! In the top left is a video of her explaining the importance of positioning your young babies. You can start positioning your baby in midline as soon as possible.

Learning Through Hands

Hands-On Learning: Babies learn a lot through their hands, so it’s important to let them explore. Using mittens to prevent scratching isn’t ideal because it can interfere with their ability to feel and learn about their surroundings, as well as desensitize their mouths!
Hands in Mouth and Infection Concerns: It’s common for babies to put their hands in their mouths as part of their natural exploration and self-soothing. While parents may worry about potential infections, it’s generally safe and an essential part of their development. It’s important to let go of those concerns and allow your baby to explore this way.

Kangaroo Care at Home

Kangaroo care doesn’t have to stop when you bring your baby home. You can continue doing kangaroo care at home, holding your baby skin-to-skin to bond with them. Make this a special time with your baby and sing a lullaby, read a book, or talk to your baby.

Benefits of Kangaroo Care

Milk Production: Kangaroo care can help increase milk production in breastfeeding mothers by stimulating the release of oxytocin.
Sleep Regulation: Skin-to-skin contact helps regulate your baby’s sleep patterns and can improve their overall sleep quality.
Healthy Microbiome Transfer: Holding your baby skin-to-skin facilitates the transfer of healthy microbiomes, which are beneficial for their immune system and overall health.

Caution

Avoid kangaroo care when either you or your baby are asleep to ensure safety.

Benefit of Voice to Hearing Development: Using your voice is crucial for your baby’s brain development and language skills. Hearing your voice helps them identify and understand language early on. Pay attention to signs of hearing differences, like quietness or lack of startling to noise. If you have any concerns about your baby’s hearing, don’t hesitate to bring them up with your healthcare provider. Early identification of hearing differences is crucial for your baby’s development. It allows for timely intervention and support, which can significantly impact their language acquisition and communication skills.

Music and Its Benefits: Music can engage your child in multiple ways. It can be soothing and playful, helping to build both language and motor skills. Start by singing to your baby; they will enjoy hearing your voice regardless of how you think you sound. As your baby grows, incorporate clapping to the beat and gesturing to songs. Share music from your culture with your baby to enrich their auditory experiences.

What Happens If Baby Has Hearing Differences?

If your baby shows signs of hearing differences, such as not responding to sounds or not showing startle reflexes to loud noises, it’s important to get their hearing tested promptly. Early intervention can make a big difference in their ability to develop communication and language skills. Your healthcare provider may recommend repeat testing within the first year to monitor hearing development closely.

All Babies Need Repeat Testing Within the First Year

Regardless of initial test results, all babies should undergo repeat testing for hearing within their first year of life. This helps ensure that any potential hearing issues are detected early and appropriate interventions are provided if necessary.

Early Communication

Before babies start to say – or even understand – real words, they’re learning to communicate through interactions. Touching you when your baby is skin-to-skin with you or when you are doing “kangaroo care” is the very beginning of communication. Learning to recognize your face, smell, and voice are other very early communication skills that your baby will learn in the first few months of life.

Help your baby enjoy interacting with you by:

Reacting when they cry, gesture, or make different sounds
Using words to describe what they’re trying to “say”
Getting face-to-face and talking about what you’re doing together

The bond between a baby and their caregiver(s) is the foundation on which social relationships are based, so...

Let your baby see your face:

Start with a calm and quiet face
Ensure your baby has full postural support so they can focus on looking at your face without having to work for it
Smile and make funny faces
Imitate your baby’s facial expressions
Add expression and variation to your voice

If your baby is drawn to lights, gently illuminate your face and dim lights around the room to help them focus better.

Talk to your baby:

Make silly noises
Use real words
Put lots of expression in your voice

Remember to pause after you say or do something so you can notice your baby’s reaction. If they make a sound or a facial expression, respond to them; this is the beginning of a conversation!

Sleep

Why do babies sleep? Sleep is crucial for learning and growth. Babies need adequate sleep to process their experiences, develop brain connections, and regulate their emotions.

Sleep Environment

Room-sharing: Keep babies under 6 months in the same room with you. Place a bassinet or crib next to your bed.

Safe Sleep Setup: Use a firm, thin mattress with a fitted sheet. Avoid loose bedding, bumper pads, pillows, stuffed animals, or propping anything between the crib mattress and frame. Dress your baby in a one-piece sleeper or a sleep sack, and place them on their back.

Things You May Have Seen in NICU

While in the NICU, you may have observed certain practices. However, it’s important to note that practices like propping or elevating cribs are specific to the hospital environment (when your baby was on monitors) and not recommended for home use.

Swaddling

Swaddling, often done in the NICU, can help soothe babies by suppressing their startle reflex. However, it’s important to gradually relax swaddling to allow babies to learn to sleep without being swaddled long-term. Different cultures have varying sleep practices that may differ from what you’re used to, possibly influenced by home environments like softer mattresses.

Sleep Position

Always place your baby on their back to sleep; this reduces the risk of Sudden Unexplained Infant Death (SUID), which is higher in preterm infants.

Parent Involvement

Hold your baby often; you can’t hold them too much! This contact helps with bonding and regulation.

Gradually teach your baby to fall asleep in their crib by placing them down when they’re drowsy but not fully asleep.

Amount of Sleep

Around discharge, your baby may be sleeping up to 18 hours per day, taking naps in stretches of 3 to 4 hours. Somewhere in the first few weeks at home, they may surprise you and start to sleep for one longer stretch, hopefully at night! If your baby is growing (even just a little bit) and hydrated (you will know this by wet diapers around 6 times per day), let them sleep! This is a lovely sign of development and growth.

Dream Feeding

It’s important to note that “dream feeding,” where you wake your baby to feed them while they’re still half asleep, can disrupt their natural sleep cycle and interfere with their ability to settle into longer stretches of sleep at night. Babies who are not fully conscious during dream feeds are at a higher risk of choking because they may not have the protective reflexes fully engaged. Feeding during sleep also doesn’t allow babies to actively participate in the feeding process, which is crucial for learning feeding cues and establishing a healthy feeding routine!

Sleep “Onion”

Think of your baby’s sleep habits as layers that you gradually peel back to help them learn to sleep independently. Start with comforting routines but aim to transition to sleep practices that allow your baby to settle on their own over time.