Non-invasive respiratory support in newborn - nursing care

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1 JOURNAL OF PUBLIC HEALTH, NURSING AND MEDICAL RECUE 2013 (2) 7 JOURNAL OF OF PUBLIC HEALTH, NURSING AND MEDICAL RESCUE No.2/2013 (7-13) Non-invasive respiratory support in newborn - nursing care (Nieinwazyjne wspomaganie oddechu u noworodka opieka pielęgniarska) M Lewicka 1, A,E,F, M Sulima 1, B, E Taras 2,C, B Stawarz 3,D Abstract Neonates are prone to respiratory problems, which can potentially lead to life-threatening conditions. The most common clinical syndromes that lead to acute respiratory failure in the newborn include: respiratory distress syndrome, meconium aspiration syndrome, congenital heart disease, pneumonia, pneumothorax, apnoea, extreme immaturity and persistent pulmonary hypertension. Respiratory distress syndrome (RDS) is the most common cause of neonatal treatment in intensive care units. The introduction of the non-invasive method of ventilatory support by continuous positive airway pressure in the 70's helped reduce the use of intubation and mechanical ventilation significantly. Technological progress has led to the emergence of the Infant Flow device in Previous clinical reports indicate that the Infant Flow method is promising, efficient and its high efficiency reduces the incidence of pulmonary complications. In the process of newborn care that employs the Infant Flow system, the following must be observed: providing appropriate ambient temperature, pulmonary hygiene, newborn body care, proper feeding, prevention of damage to the nasal apertures, protection against infection, handling the anxiety of the child. Caring for neonates with respiratory failure treated in neonatal intensive care units requires extensive knowledge of nursing theory and practical skills. Proper nursing allows one to identify problems quickly and take appropriate measures to eliminate them. In the care of newborns treated with the Infant Flow method, the child's parents should be taken into account. Research shows that parents expect educational activities on the part of nurses and midwives as well as the opportunity to participate in a support group. Helping parents go through the difficult time of their child being in hospital is important as it has a great influence on the way they will care for the child themselves later on. Key words - newborn, neonates, respiratory support, care, intensive care. Streszczenie W okresie noworodkowym występuje skłonność do zaburzeń oddychania, w wyniku których może dojść do stanów zagrożenia życia. Do najczęstszych zespołów klinicznych prowadzących do ostrej niewydolności oddechowej u noworodka zalicza się: zespół zaburzeń oddychania, zespół aspiracji smółki, wady sercowonaczyniowe, zapalenie płuc, odmę opłucnową, bezdech, skrajną niedojrzałość oraz przetrwałe nadciśnienie płucne. Zespół zaburzeń oddychania (ZZO) jest najczęstszą przyczyną leczenia noworodków w oddziałach intensywnej terapii. Wprowadzenie w latach 70-tych do terapii oddechowej noworodków nieinwazyjnego sposobu wspomagania wentylacji metodą ciągłego dodatniego ciśnienia w drogach oddechowych pozwoliło w znacznym stopniu ograniczyć intubację i wentylację mechaniczną. Postęp techniczny doprowadził do pojawienia się w 2001 roku urządzenia Infant Flow. Dotychczasowe doniesienia kliniczne wskazują, że metoda Infant Flow jest obiecująca i efektywna a jej wysoka skuteczność zmniejsza występowanie powikłań płucnych. W procesie pielęgnacji noworodka podłączonego do zestawu Infant Flow należy zwrócić uwagę na następujące elementy: zapewnienie odpowiedniej temperatury otoczenia, toaleta dróg oddechowych, pielęgnacja ciała noworodka, karmienie noworodka, zapobieganie uszkodzeniom otworów nosowych, ochrona przed zakażeniem i infekcją, postępowanie przy znacznym niepokoju dziecka. Opieka nad noworodkiem z niewydolnością oddechową, leczonym w oddziale intensywnej terapii neonatologicznej, wymaga od personelu pielęgniarskiego dużej wiedzy teoretycznej i umiejętności praktycznych. Prawidłowo sprawowana opieka pielęgniarska pozwala na szybkie rozpoznanie problemów i podjęcie adekwatnych działań celem ich eliminacji. W sprawowaniu opieki nad noworodkiem leczonym metodą Infant Flow należy uwzględnić rodziców dziecka. Badania naukowe wskazują, że rodzice oczekują działań edukacyjnych ze strony pielęgniarek i położnych oraz możliwości uczestniczenia w grupie wsparcia. Pomoc rodzicom w przejściu przez trudny czas pobytu ich dziecka w szpitalu ma istotne znaczenie dla podjęcia samoopieki w warunkach domowych. Słowa kluczowe noworodek, wspomaganie oddechu, opieka, intensywna terapia.

2 JOURNAL OF PUBLIC HEALTH, NURSING AND MEDICAL RECUE 2013 (2) 8 Author Affiliations: 1. Department of Midwifery, Gynaecology and Gynaecological Nursing; Faculty of Nursing and Health Sciences, Medical University of Lublin, 2. Midwifery and Perinatology Clinic, Department of Neonatology, Independent Public Teaching Hospital #4 in Lublin, 3. Institute of Health Protection, The Bronisław Markiewicz State Higher School of Technology and Economics in Jarosław Authors contributions to the article: A. The idea and the planning of the study B. Gathering and listing data C. The data analysis and interpretation D. Writing the article E. Critical review of the article F. Final approval of the article Correspondence to: Dr Magdalena Lewicka Department of Midwifery, Gynaecology and Gynaecological Nursing; Faculty of Nursing and Health Sciences, Medical University of Lublin, Chodźki 6 Str., PL Lublin, Poland, m.lewicka@umlub.pl R I. INTRODUCTION espiratory problems are often the case in the neonatal period. Their consequence might even be life-threatening conditions. The cause is usually improper adaptation to retrouterine life. Over the last few decades, the fields of midwifery and neonatology have made a great progress. Thanks to the development of knowledge on and diagnostic methods of assessing the condition and maturity of the foetus, one can more and more often anticipate life-threatening conditions of a neonate even before the child is actually born. Timely diagnosis, treatment and prophylaxis can decrease the perinatal mortality rate [1]. The frequency of neonatal respiratory failure is inversely proportional to the gestational age and the maturity of the systems participating in gas exchange. Respiratory distress is the most frequent cause of treatment among neonates in intensive care units. It occurs in around 1% of all newborns, 90% of those born before 25 th week of pregnancy and 70% born between 28 th and 32 nd week of pregnancy [2,3,4]. As the non-invasive respiratory support in the form of continuous positive airway pressure method had been introduced to respiratory therapy in the 70s, intubation and mechanical ventilation could be reduced significantly. Technological development made it possible to introduce innovations and in 2001, the Infant Flow device emerged. This method is a modification of CPAP (Continuous Positive Airway Pressure) and allows to stimulate a neonate s respiration and broaden the monitoring of breathing. So far, the clinical achievements have indicated that Infant Flow is a promising and effective method decreasing the frequency of pulmonary complications. The introduction of the Infant Flow method marks the beginning of a new era in Polish neonatology [2,5]. The purpose of this paper is to present the possibilities of respiratory assistance in cases of neonatal respiratory disorders as well as nursing a child treated with Infant Flow. II. THE ADAPTATION OF A NEONATAL RESPIRATORY SYSTEM TO RETROUTERINE LIFE The switch from foetal to retrouterine life requires numerous adaptive changes. Newborns, used to aquatic environment and dependence on their mothers, have to adapt quickly to independent functioning. The adaptation of a premature baby is extremely difficult, as numerous systems and organs are not yet fully developed [6,7]. The commencement of breathing is the first and most crucial vital function of a newborn. During the first inhalation, alveoli get filled with air and the resorption of the lung fluid takes place. The first breath of a neonate is stimulated by different stimuli: sensory (touch, cold, pain), chemical (drop in oxygen pressure, increase in carbon dioxide, higher concentration of hydrogen ions) and mechanical ones (receptors located in the chest and lungs) [3,4,7]. Initially, a neonate s breathing is irregular and rapid; it is accompanied by diaphragm and intercostal muscle tension. Then respiration stabilizes; the standard breathing rate for a healthy and not premature newborn is 40 to 60 breaths per minute. Newborns intercostal muscles are weak and they do not take part in respiration, their main task being stabilizing the chest structure. While in the cases of ordinary neonates it is enough, a premature newborn s chest may collapse during stronger inhalations (both ribs and intercostal spaces can be sucked in easily and are not strong enough to support the diaphragm). Premature neonates have small and scarce alveoli, most of them still being developed and therefore unable to participate in gas exchange. The respiratory tract is shorter and narrower than in comparison with non-premature newborns, which makes it easier for microorganisms and foreign bodies to be aspired into alveoli [3,4,8]. The most common clinical syndromes that lead to acute respiratory failure in the newborn include: respiratory distress syndrome, meconium aspiration syndrome, congenital heart

3 JOURNAL OF PUBLIC HEALTH, NURSING AND MEDICAL RECUE 2013 (2) 9 disease, pneumonia, pneumothorax, apnoea, extreme immaturity and persistent pulmonary hypertension. [3]. Respiratory distress syndrome (RDS) is the most common cause of neonatal respiratory failure. The primary cause of RDS is the shortage of surfactant a substance that stabilizes alveoli which leads to a collapse of alveoli and their exclusion from ventilation, development of atelectasis, hypoxemia, hypoxia and metabolic acidosis. Respiratory distress system is also connected with morphological underdevelopment of lungs, capillary endothelial cells and chest as well as insufficient blood flow through the lungs [3,4,9]. The RDS risk factors include perinatal asphyxia, premature birth, twin pregnancy, the mother s hypertension or diabetes and various genetic conditions. The clinical symptoms of RDS are disorders in the first breath, difficulties with the continuous respiration, tachypnea, groaning during exhalation, shortness of breath, retraction of intercostal spaces with increased oxygen demand in the initial hours of life, bronchial respiratory sound and cyanosis (when no oxygen is provided) as well as tachycardia [2,3,9]. III. NON-INVASIVE RESPIRATORY SUPPORT IN NEWBORN - NURSING CARE Non-invasive ventilation is a way of implementing positive air pressure to the lungs without the use of an endotracheal tube. The advantages of non-invasive ventilation include: the maintenance of a physiological respiratory tract through the nose, natural mechanisms of air-heating and humidification, natural protection against infections (the function of ciliated epithelium), no need for intubation (hence the absence of intubation-related complications), the possibility of feeding the neonate though oral cavity, the possibility of direct motherchild contact through kangaroo care and the similarity with the physiological processes in the organism of a neonate [10,11]. The optimal method of neonatal respiratory assistance is the CPAP technique. CPAP is a method of supporting spontaneous ventilation by providing constant positive air pressure in the respiratory tract. This method may be used in order to treat or prevent the development of atelectasis in newborns. Thanks to it, the pressure in the respiratory tract is increased and thanks to that it also has wider diameter. CPAP regulates and decreases the respiration rate, stabilizes the chest, makes the functioning of the diaphragm more effective and improves the oxidization of arterial blood PaO 2 [3,11,12]. A newborn s respiratory work is imposed by the device and depends on the product of the pressure and the volume of respiration gases. The increased respiratory work during inhalation is necessary to overcome the higher exhalation resistance during exhaling [3,11]. In 1988, G. Moa and K. Nilson developed a generator that can provide newborns with respiratory assistance in a noninvasive way. It introduces a stable pressure to the respiratory tract that can be maintained during the whole breathing cycle and recognizes the phases of inhalation and exhalation. While exhaling, the air heading out of a newborn s respiratory tract changes the direction of the gas flow and there is no obstruction between the inhaled and exhaled gases. Thanks to that, exhalation resistance does not increase. The change of the gas flow direction is called a fluidic flip, which signifies the switch in the gas motion. All in all, this generator is a basic element of bi-level CPAP Infant Flow, in which positive pressure is created in the vicinity of the infant s nasal apertures [5,10,11,13]. The Infant Flow generator is fixed with two respiratory channels, both of which are equipped with a nozzle. Inside the nozzles, the respiratory gases flowing from a pressurized driving system accelerate. These gases are directed to the nasal cavity through a nose-inserted tube or a mask. The ingoing flow provides pressurised gas, the particles of which go through a nozzle and expand in the nasal cavity, creating positive air pressure. During spontaneous exhalations, the flow or air going out of the infant s airways switches the direction of the flow going into the exhalation channel. These changes are possible thanks to the so-called Coandă effect. Switches in the gas flow into the inhalation and exhalation routes occur in accordance to the infant s needs [5,11,13]. In the Infant Flow system, changes in the positive air pressure are minor and occur along with the rhythm of the child s spontaneous breathing, thanks to which less respiratory work has to be put into breathing. The respiratory workload of an infant connected to a CPAP system device with continuous flow is seven times as large as that using the Infant Flow system [11,13,14]. In 2001, Bingall et al. first used a new kind of newborn respiratory assistance system based on an Infant Flow method called SiPAP (Synchronous Intermittent Positive Airway Pressure). This method provides a newborn breathing in a ncpap system with synchronous intermittent sighs. It consists in creating interchangeably two separate levels of pressure (BiPhasic), whose values are independent and adjustable. Sighing can be stimulated by the infant or performed in a time cycle. The sigh consists in a gradual increase of the CPAP level from the basic to the elevated one (SiPAP). The duration of the elevated pressure (Ti) may be adjusted within the range of seconds. Such a sigh is defined as pressure support All the respiratory work during sighing is done by the device. Thanks to the sighing process, a neonate is provided with an extra tidal

4 JOURNAL OF PUBLIC HEALTH, NURSING AND MEDICAL RECUE 2013 (2) 10 volume while no respiratory work has to be done by the patient. This system is a complementation of the standard Infant Flow. It increases lung capacity, it changes alveoli which are unstable during exhalation for more stable ones and stimulates breathing [11,13,14,15]. The breathing modes in the Infant Flow SiPAP system: ncpap nasal continuous positive pressure in the respiratory tract using an Infant Flow generator, ncpap + apnoea continuous positive respiratory pressure with an option of monitoring spontaneous breaths and activating an apnoea alert, BiPhasic two levels of positive pressure in the respiratory tract stimulated interchangeably; the values of those levels are adjusted interchangeably and the change of the pressure is introduced on the basis of a time cycle, BiPhasic + apnoea the BiPhasic mode extended by monitoring breaths and detecting apnoea, BiPhasic triggered a two-level, nasal CPAP application fixed with a inhalation-exhalation flow change triggered by the infant, with monitoring breaths and detecting apnoea, Mechanical breath used to stimulate the infant in the ncpap mode [11,14,15]. The application of Infant Flow is recommended in the cases of: respiratory distress, meconium aspiration syndrome, apnoea and bradycardia in premature babies, upper respiratory tract defects e.g. floppy larynx, excessive lung fluid (transient tachypnea, pulmonary oedema), diseases causing airway obturation (bronchiolitis, bronchopulmonary dysplasia) as well as weaning from mechanical ventilation. On the other hand, the contraindications to the use of Infant-Flow include: heart defects with limited pulmonary flow (tetralogy of Fallot), haemorrhagic diathesis, shock as well as congenital choanal atresia. The advantages of Infant Flow consist in its being non-invasive (the method does not require intubation and decreases the risk of a newborn s lung damage or post-intubation complications), keeping the lungs open with stable ncpap (which prevents alveoli from closing) and requiring only insignificant respiratory work (neonates with very weak respiratory drive can be treated using this method) [11,13]. Connecting a child s respiratory system to an Infant Flow device is performed directly prior to the equipment is used. One has to make sure all the elements are connected properly and the system works in an airtight manner. Before a neonate is connected, oxygen needs to be calibrated and both flow and pressure must be tested. The ambient temperature needs to be set in accordance with the guidelines of the humidifier manual. The adjustment of humidity should be performed in such a manner that evaporation takes place in the inhalation system. Proper humidification and heating of the gases provided to a neonate are crucial as far as preventing from mucus thickening and nasal aperture obstruction is concerned [3,11,14]. A newborn in this method is to wear a small cap, which is fixed with a generator using two tapes. The cap has some fastenings to fix the tube system with. It is very important to select the cap that fits the baby s head. Its eyes should not be covered and the tapes must not be pressed tightly against its cheeks. The generator is provided with a silicone nose attachment or a mask used to connect the patient to the system. The generator should be secured in a stable and safe way. The size of the attachment or mask should be adjusted to the current weight of the neonate; their location is also crucial there should be no pressure on the nose. The most popular type of connection used in the cases of newborns and premature babies are double nose attachments made of soft, high-quality silicone. Such attachments are unlikely to damage the nose and easy to use. In the cases of neonates who do not weigh much and have very sensitive skin, the interchangeable use of nose attachment and mask is recommended. In the course of the Infant Flow method, one must ensure the child has confortable body position and proper ambient temperature. Neonates can undergo the process in both open and closed incubators [11,14]. IV. NURSING NEONATES PROVIDED WITH THE INFANT FLOW RESPIRATORY ASSISTANCE Neonates in intensive care units require special care and attention from the medical staff. Proper treatment and nursing of those little patients depend upon the technological equipment of the unit, the qualifications of nursing staff and adherence to medical procedures [8]. Connecting a neonate to an Infant Flow device requires monitoring the vital signs, i.e. respiratory rate, blood pressure, heart rate and blood oxygen saturation. The respiratory rate can be measured by means of chest observation or by auscultation with the stethoscope pressed against the sides of the chest. If the Infant Flow system is SiPAP, respiration is monitored by a Graseby capsule, which records the movements of the diaphragm that take place before pressure changes in the respiratory tract [11,16]. In order to assess the heart rate and haemoglobin oxygen saturation, a cardiac monitor or a pulse oximeter is used. The sensor of the device is attached to the arm or leg of the child, after which digital and graphic readings indicate of the child s blood and tissue oxidization, which enables a timely intervention should the saturation level decrease. The sensors should be of disposable type and their placement changed every 4 to 6

5 JOURNAL OF PUBLIC HEALTH, NURSING AND MEDICAL RECUE 2013 (2) 11 hours. The neonatal blood pressure is dependent upon each child s birth weight, gestational age and the day after the birth. The blood pressure measurement requires the use of a properly sized cuff connected to the cardiac monitor. Physiological blood pressure depends on the stroke volume of the left ventricle as well as vascular resistance. In the cases of immature newborns, vascular resistance is of greatest significance as it can be too little because of a patent ductus arteriosus [11,14, 16]. Neonates with RDS treated with Infant Flow may have problems with water and electrolyte balance because of excessive or insufficient water and electrolyte supply (also excessive water and electrolyte loss or retention). Therefore, patients should have their fluid and electrolyte levels carefully checked. Laboratory tests are performed according to a patient s needs as well as his or her general condition. Blood count, gasometry, glycaemia, electrolytes and serum bilirubin concentration are monitored [16]. The following elements must be observed in the nursing care of neonates treated with Infant Flow: proper ambient temperature, pulmonary hygiene, body care, proper nourishment, preventing from nasal apertures, preventing from infections, handling the child s anxiety [7,8]. Neonates with RDS have problems maintaining right body temperature. Cold causes vasospasms, limits blood perfusion in tissues, intensifies metabolic acidosis, hypoxemia and hypoxia, which inhibits the surfactant production in the lungs and negatively affects the functioning of some systems including the central nervous system. In order to provide appropriate ambient temperature, a neonate should be placed in an incubator. The air temperature and humidification in a closed incubator depend on the newborn s body weight, general condition as well as how many days old he or she is. Modern incubators have the function of adjusting the ambient temperature to the temperature of the infant s body. Anything that makes contact with the a child s skin should be warmed up; that includes the hands of medical personnel and parents as well [6,7,8]. Nursing provided in the incubator should be organized in such a manner so as not to disturb the neonate. Maintaining the right body temperature of the newborn baby is the most crucial factor on which its survival depends. The most frequent nursing task performed on newborns who are intubated and treated with mechanical ventilation is the removal of mucus from the respiratory tract. During the Infant Flow treatment no routine mucus suction is required. In case the accumulation of it is considerable, a catheter should be inserted into the stomach in order to dispose of it. Proper heating and humidification of respiratory gases causes the respiratory tract to be relieved of mucus. Using a cotton pad, mucus can be removed from the mouth area [6,17,18]. Suction should be performed if the mucus is thick and hard to get rid of, if blood saturation is decreased, if heart rate is affected by the mucus in respiratory tract and if the child is anxious. Airway mucus suction is painful and unpleasant for the baby. The observable effects of the pain are disturbances in the cardiovascular system, decreased oxygen pressure in blood and the risk of tissue hypoxia. Premature babies may experience apnoea during suctions. As nursing interventions may be unpleasant for babies, they are performed in an incubator and kept to a minimum [6,17]. The sensitive skin of a newborn may be tended using olive oil, baby wipers and cotton pads. Infants comfort is attended to thanks to the use of baby support pillows and changing the position of their body and head. Babies can be bathed when they are stable, the Infant Flow therapy is over and they are ready to leave the incubator. Until that time, their hygiene is tended to inside incubators. Since a newborn s skin is treated with a thin layer of olive oil which protects it from going dry or irritations, bathing is not a necessity. Also, baby backside hygiene needs to be attended to diapers must be changed when needed, protective ointment used and backside provided with ventilation. The cord stump care involves only dry methods, as new guidelines have it. The stump is wiped with a dry cotton pad, with no disinfectant used. It should be uncovered, with air access [8,19]. A problem with RDS neonates is the probability of swelling on the whole body, especially arms and legs. The cause of that is fluid retention. The swelling developing on the limbs should be rubbed with warm olive oil. Moreover, legs should be placed upon a special pillow. A record of fluid input and output should be kept [3,9]. Yet another element of newborn care connected to the use of Infant Flow is nutrition. Premature babies often find it hard to eat as a result of the absence or underdevelopment of sucking reflex. Newborns have difficulties coordinating sucking reflex with swallowing and breathing. In order to provide an infant with all the nutrients, intravenous or oral feeding is employed [20,21]. Infants are fed with fresh mother s milk. Initially, when patients are still immature, with no sucking and swallowing reflexes, gastric tube is used. After the tube is fixed, its location is checked and it is fixed by an adhesive plaster. A measured amount of milk is poured into the syringe connected to the gastric tube and the milk flows to the child s stomach thanks to gravity. The next step is feeding the mother s milk to a child

6 JOURNAL OF PUBLIC HEALTH, NURSING AND MEDICAL RECUE 2013 (2) 12 using a pipette or a small glass. The number of feedings per day is increased and the newborn eat bigger portions. Also, sucking and swallowing reflexes are stimulated. If the child is stable after the Infant Flow system is disconnected (no desaturation takes place, skin is pink and vital signs are normal), an attempt to breastfeed is made. At first, some difficulties with getting hold of the nipple and coordinating sucking, swallowing and breathing reflexes may occur. Learning proper breastfeeding requires a lot of patience and persistence, both on part of the mother and the child. Most newborn infants master the skill of sucking mother s breast rather quickly [6,22,23]. Another crucial element of newborn baby care in the Infant Flow method is nose hygiene. The elementary question here is to select a proper size of nose attachment or mask. The exhalation tube going out of the generator is fixed using a ball joint. When the infant moves his or her head, the turning point is located on the joint rather than inside the nose. The attachment is fixed to the nose, which makes it impossible it to move inside the nose. The fixing system is not expected to cause the infant s anxiety or immobilize him. Every 2 or 3 hours, the skin around nasal apertures should be checked it is supposed to be clean and dry. No oiling or disinfecting ointments should be applied around the nose. During the Infant Flow treatment it is important to use nose attachment and mask interchangeably. It bears crucial significance as far as the prevention of nasal damage to the baby is concerned. Damage to the nasal mucosa is more often than not caused by improper nasal attachment fixing or unskilful degumming [11,13,14]. There are many internal factors facilitating the development of infections. The infection risk in relation to newborns treated at intensive care units amounts to 20% [8,24]. Newborns are subjected to numerous hygienic, diagnostic and therapeutic activities at intensive care units. Their immaturity as well as clinical condition make them exposed to infections. Therefore, the equipment used in the course of the treatment must be sterile and all the invasive procedures should be performed in fully aseptic conditions. The staff should wash their hands as well as put on gloves and protective clothing prior to and after each contact with a child All equipment used in the newborn nursing care should be washed frequently and sterilized as long as it possible. In order to guard newborns against infection, venous catheters should be properly maintained [8,24]. What is more, in the Infant Flow method the child s parents should be taken into consideration. Studies show that parents expect educational activities on the part of nurses and midwives as well as the opportunity to participate in a support group. Helping parents go through the difficult time of their child being in hospital is important as it has a great influence on the way they will care for the child themselves later on. [25,26] V. CONCLUSIONS Nursing newborn babies with respiratory failure treated in the neonatal intensive care units requires extensive knowledge of nursing theory and practical skills. Proper nursing allows one to identify problems quickly and take appropriate measures to eliminate them. Medical staff should encourage parents to participate in the nursing of their child, provided that they express their will to do so. The cooperation of the staff and parents should be based on educating and giving instructions on feeding, nursing and establishing emotional contact with the child. VI. REFERENCES [1] Szczapa J, Wojsyk-Banaszak I. Ocena stanu ogólnego oraz dojrzałości noworodka. W: Pediatria. Dobrzańska A, Ryżko J. (red.). Wrocław; Urban&Partner 2005: [2] Gajewska E, Czyżewska M, Paluszyńska D. 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