Learn more about the 3 physiological signs of stress* and 8 behavioral signs of stress.

Check below physiological stress signals that may be reflected in respiration rate, heart rate, and oxygen saturation.([FOOTNOTE=Peng N-H, Bachman J, Jenkins R, et al. Relationships between environmental stressors and stress biobehavioral responses of preterm infants in NICU. J Perinat Neonatal Nurs. 2009;23(4):363-371.],[ANCHOR=],[LINK=])

Discover the signs of Neonatal Stress

The Stressful NICU

Stressful events – a byproduct of life for babies in the NICU – may increase their heart rate and blood pressure, while decreasing their oxygen levels.1 Even sensory and environmental stimuli we take for granted, such as a simple touch and noise and bright lights, can affect physiologic responses such as heart rate, respiration, and oxygen saturation.1,([FOOTNOTE=Smith JR. Comforting touch in the very preterm hospitalized infant: an integrative review. Adv Neonatal Care. 2012;12(6):349-365.],[ANCHOR=],[LINK=])

The additive impact of multiple stressors over time may have profound long-term consequences on the lives of NICU babies.([FOOTNOTE=Newnham CA, Inder TE, Milgrom J. Measuring preterm cumulative stressors within the NICU: the Neonatal Infant Stressor Scale. Early Hum Dev. 2009;85(9):549-555.],[ANCHOR=],[LINK=]) In the rapidly developing perinatal brain, repeated neonatal stress may have long-term effects on the central nervous system,3  including effects on neural structure, function, and development.3,([FOOTNOTE=Smith BA, Gutovich J, Smyser MD, et al. Neonatal intensive care unit stress is associated with brain development in preterm infants. Ann Neurol. 2011;70(4):541-549.],[ANCHOR=],[LINK=])

Raising Awareness of NICU Stress

Intubated infants can’t audibly cry([FOOTNOTE=Hand IL, Noble L, Geiss D, Wozniak L, Hall C. COVERS Neonatal pain scale: development and validation. Int J Pediatr. 2010;2010: 496719.],[ANCHOR=],[LINK=]) — air can’t flow across their vocal cords.([FOOTNOTE=Grossbach I, Stranberg S, Chlan L. Promoting effective communication for patients receiving mechanical ventilation. Crit Care Nurse. 2011;31:46-60.],[ANCHOR=],[LINK=]) But intubated infants can give voice to their distress through behavioral and physiological signs.1

By recognizing stressors, understanding their impact, and monitoring premature babies closely, clinicians can develop plans to help improve care for their fragile neonatal patients and may improve neurologic and behavioral outcomes.2,([FOOTNOTE=Anand KJ, International Evidence-Based Group for Neonatal Pain. Consensus statement for the prevention and management of pain in the newborn. Arch Pediatr Adolesc Med. 2001;155(2):173-180.],[ANCHOR=],[LINK=])


WORLDWIDE, MORE THAN 15 MILLION INFANTS ARE BORN PREMATURE EACH YEAR.([FOOTNOTE=Maxwell LG, Malavolta CP, Fraga MV. Assessment of pain in the neonate. Clin Perinatol. 2013;40:457-469.],[ANCHOR=],[LINK=])

Measuring NICU Stress

To minimize NICU stress, we first need tools that provide consistent measurements removing variability of individual clinician assessments.([FOOTNOTE=Newnham CA, Inder TE, Milgrom J. Measuring preterm cumulative stressors within the NICU: the Neonatal Infant Stressor Scale. Early Hum Dev. 2009;85(9):549-555.],[ANCHOR=],[LINK=]) The Neonatal Infant Stressor Scale (NISS) is a standardized instrument that allows clinicians to record every stressor experienced by a NICU infant and calculate a cumulative stress score.1

Based on a survey of clinician impressions of infant responses, the NISS assigns weighted values to specific NICU events (eg, heel lance) and chronic conditions such as systemic infection and interventions such as administration of intranasal oxygen.1 The NISS is suggested to be used in conjunction with standard observations of pain, "to help track, measure, and manage presumed accumulated stress in preterm neonates."1 This information can help clinicians in the NICU to make the most informed decisions when evaluating interventions to reduce stress in fragile preterm infants.

24 Hours

IN SOME NICUS, BABIES ARE EXPOSED TO CONTINUOUS BRIGHT LIGHT UP TO 24 HOURS A DAY.([FOOTNOTE=Morag I, Ohlsson A. Cycled light in the intensive care unit for preterm and low birth weight infants. Cochrane Database Syst Rev. 2013;8:CD006982.],[ANCHOR=],[LINK=])

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What you can do to reduce stress in the NICU

  • Ventilation - delivering synchronized breath, with both invasive and non-invasive ventilation, can have important benefits for neonates.([FOOTNOTE=Mahmoud RA, Proquitté H, Fawzy N, Bührer C, Schmalisch G. Tracheal tube airleak in clinical practice and impact on tidal volume measurement in ventilated neo¬nates. Pediatr Crit Care Med. 2011;12(2):197-202],[ANCHOR=],[LINK=])
  • Patient monitoring - providing continuous SpO2, pulse rate, and respiration rate monitoring, so clinicians may detect respiratory complications earlier and intervene sooner.([FOOTNOTE=Joint Commission Sentinel Event Alert: Issue #49, pp1-4, August 8, 2012. (Available at],[ANCHOR=],[LINK=]),([FOOTNOTE=ASA Standards for Basic Anesthetic Monitoring, Committee of Origin: Standards and Practice Parameters (Approved by the ASA House of Delegates on October 21, 1986, and last amended on October 20, 2010 with an effective date of July 1, 2011, excerpt from section 3.2.4.],[ANCHOR=],[LINK=]),([FOOTNOTE=Essential Monitoring Strategies to Detect Clinically Significant Drug-Induced Respira¬tory Depression in the Postoperative Period. Prepared by Stoelting, R. and Overdyk, F.],[ANCHOR=],[LINK=])
  • Procedural stress - reducing any associated pain, discomfort, or risk of infection may help.

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