System

Signs of Stress

Signs of Stability

Interventions

Autonomic

Respiratory

Tachypnea, pauses, irregular breathing pattern, slow respirations, sighing, or gasping

Smooth, unlabored breathing; regular rate and pattern

Reduce light, noise, and activity at bedside (place pagers/phone on vibrate, lower conversation levels at bedside).

Color

Pale, mottled, red, dusky, or cyanotic

Stable, overall pink color

Use hand containment and pacifier during exams, procedures, or care.

Slowly awaken with soft voice before touch including all procedures, exams, and care unless hearing impaired; use slow movement transitions.

Visceral

Several coughs, sneezes, yawns, hiccups, gagging, grunting and straining associated with defecation, spitting up

Visceral stability, smooth digestion, tolerates feeding

Pace feedings by infant’s ability and cues in appropriately modified environment.

Autonomic-related motor patterns

Tremors, startles, twitches of face and/or body, extremities

Tremors, startles, twitching not observed

Gently reposition while containing extremities close to body if premature.

Avoid sleep disruption.

Position appropriately for neuromotor development and comfort; use nesting/boundaries or swaddling as needed to reduce tremors, startles.

Manage pain appropriately.

Motor

Tone

Either hypertonia or hypotonia; limp/flaccid body, extremities, and/or face; hyperflexion

Consistent, reliable tone for postmenstrual age (PMA); controlled or more control of movement, activity, and posture

Support rest periods/reduce sleep disruption, minimize stress, contain or swaddle.

Posture

Unable to maintain flexed, aligned, comfortable posture

Improved or well-maintained posture, with maturation posture sustainable without supportive aids

Provide boundaries, positioning aids, or swaddling for flexion, containment, alignment, and comfort as appropriate.

Level of activity

Frequent squirming, frantic flailing activity, or little to no movement

Activity consistent with environment, situation, and PMA

Intervene as needed for pain management, environmental modification, less stimulation; encourage skin-to-skin holding; containment.

State

Sleep

Restless, facial twitching, movement, irregular respirations, fussing, grimacing, whimpers, or makes sounds; responsive to environment

Quiet, restful sleep periods; less body/facial movement; little response to environment

Comfortable and age-appropriate positioning for sleep with a quiet, dim environment and no interruptions except medical necessity Position with hands to face or mouth or so they can learn to achieve this on their own.

Awake

Low-level arousal with unfocused eyes; hyperalert expression of worry/panic; cry face or crying; actively avoids eye contact by averting gaze or closing eyes; irritability, prolonged awake periods; difficult to console or inconsolable

Alert, bright, shiny eyes with focused attention on an object or person; robust crying; calms quickly with intervention, consolable in 2-5 minutes

Encourage parent holding as desired either traditional or skin-to-skin.

May be ready for brief eye contact around 30-32 weeks without displaying stress cues

Support awake moments with PMA-appropriate activity based on stress and stability data for individual infant.

Self-regulation

Motor

Little attempt to flex or tuck body, few attempts to push feet against boundaries, unable to maintain hands to face or mouth, sucking a pacifier may be more stressful than soothing

Strategies for self-regulation include foot bracing against boundaries or own feet/leg; hands grasped together; hand to mouth or face, grasping blanket or tubes, tucking body/truck; sucking; position changes

Examine using blanket swaddle or nest to support infant regulation by removing only a small part of the body at a time while keeping most of body contained during exam.

Ask a parent or nurse to provide support during exams, tests, or procedures; swaddle or contain as needed to keep limbs close to body during care or exams and to provide boundaries for grasping or foot bracing.

Position for sleep with hands to face or mouth.

Provide pacifier intermittently when awake and at times other than exams, care, or procedures.

Give older infants something to hold (maybe a finger or blanket).

Encourage parent to support parenting skill; teach parents communication cues and behaviors; model appropriate responses to cues.

State

Rapid state transitions, unable to move to drowsy or sleep state when stressed, states are not clear to observers

Transitions smoothly from high arousal states to quiet alert or sleep state; focused attention on an object or person; maintains quiet alert state without stress or with some facilitation

Consistently avoid rapid disruption of state behavior (e.g., starting an exam without preparing the baby for the intrusion) by awakening slowly with soft speech or touch; use indirect lighting or shield eyes depending on PMA during exams or care.

Assist return to sleep or quiet alert state after handling.

Provide auditory and facial visual stimulation for quietly alert infants based on cues; premature infants may need to start with only one mode of stimulation initially, adding others based on cues.

Swaddling or containment to facilitate state control or maintenance

Source: Modified from Als H. Toward a synactive theory of development: promise for the assessment and support of infant individuality. Infant Ment Health J 1982;3:229-243; Als H. A synactive model of neonatal behavioral organization: framework for the assessment of neurobehavioral development of the premature infant and his parents in the environment of the neonatal intensive care unit. Phys Occup Ther Pediatr 1986;6:3-55; Hunter JG. The neonatal intensive care unit. In: Case-Smith J, Allen AS, Pratt PN, eds. Occupational Therapy for Children. St. Louis, MO: Mosby; 2001:593; Carrier CT, Walden M, Wilson D. The high-risk newborn and family. In: Hockenberry MJ, ed. Wong’s Nursing Care of Infants and Children. 7th ed. St. Louis, MO: Mosby; 2003.