Respiratory status and behavioral response of premature infant with nesting model care approach in neonatal intensive care unit

ABSTRACT


Introduction
Premature birth is a problem that often occurs in newborns. World Health Organization (WHO) defines premature birth as a baby born before 37 weeks of pregnancy or less than 259 days counted from the first day of the last menstrual period. Most babies admitted to neonatal care had a gestational age between 34 and 36 weeks (AlJohani, Qaraqei, & Al-Matary, 2020). Premature births occur associated with several factors such as socio-demographic, obstetrical, maternal, and environmental factors (Altimier & Phillips, 2016).
Premature birth is a global problem that occurs in several countries worldwide. The estimated global data shows that in 2014, approximately 10.6% of all live births globally were

Research methods
This study is a quasi-experimental design with a pre-post-test group design. In this study, subjects were divided into two groups. The intervention group was given treatment using modern nesting, and the control group received the usual simple nesting treatment applied in the hospital, or this study is called conventional nesting. The population in this study were all patients with premature infants admitted to the Neonatal Intensive Care Unit (NICU) Hospital Dr. Wahidin Sudirohusodo. The sampling technique is purposive sampling. The inclusion criteria were premature babies treated on the first day and cared for in an incubator. At the same time, exclusion criteria were premature babies using a mechanical ventilator.
The number of samples were determined based on a previous study conducted by Zen (2017) where the average behavior of infants in the non-nesting phase was 6.22 with a standard Please cite this article as: Seniwati, Nurmaulid, Kadir, and Irmayanti (2022)  deviation of 2.92. In the nesting phase, the average behavior of the babies was 3.61 with a standard deviation of 2.27. To anticipate the possibility of respondents dropping out, 10% of the total sample was added to 20, so the total sample of the control and treatment groups was 40. Instruments used to measure the respiratory status of the respondent, the researcher used score down as an indicator (Kosim, Yunanto, Dewi, Irawan, & Usman, 2014) and for behavioral responses using the Anderson Behavior State Scale (ABSS) (Yang, Yang, & Chang, 2014), (Duran et al., 2012). Data were analyzed using the Mann-Whitney test to determine the differences between the two groups and the Wilcoxon test to determine the effect before and after the intervention. This

Characteristics of respondents
The total sample of this study was 40 premature infants admitted in the Neonatal Intensive Care Unit (NICU) and consisted of two groups: Modern Nesting and Conventional Nesting. Girls dominated the Characteristics of respondents as many as 55%, birth weight of respondents in importance between 1500-2499, for the gestational age, more than 80% of the respondents in the range 33-37 weeks gestation, and approximately 80% of an infant suffering respiratory distress (Table 1). 3.2 Respiratory Status of modern nesting group and conventional nesting group Respiratory status was measured using a score down. Figure 1 below shows a decrease in score down before the intervention and after the intervention of the first day until the seventh Please cite this article as: Seniwati, Nurmaulid, Kadir, and Irmayanti (2022)  day. The decrease scores down in the modern nesting group of 3.6 into a 1.95 or a decrease of 1.65. As for the conventional nesting group also experienced a decline in scores is from 2.4 down into 1.45 or deterioration of 0.95.

Figure 1. Respiratory status before and after nesting by two groups during 7 days
Based on the result of this study, a respiratory status measured by score down in two of the groups shown that there was a gradual decrease of score down in the first day to the seventh day and there was no significant value the differences score of two groups. This was due to the two groups of this study using nesting devices as intervention even though it was only a differentiating model both of them. The use of nesting with fixation has an impact on the pulse rate and the client's breathing. Pulse frequency and the baby's breathing is more stable by using a nesting device during NICU (Noor, Hasanah, & Ginting, 2016).
The differences in the respiratory status of two groups using score down with the Mann Whitney test showed that there was not significant of this study with P-value = 0.292. (Table 2). On the other hand, with using the Wilcoxon test to identify the effect of nesting model care from two groups, the result shown that there is significant value on respiratory status in the modern nesting group before and after intervention where P value = 0.001 whereas conventional nesting has no significant effect (table 3). The effect of nesting model cares for respiratory status using score down shown that group of Modern Nesting has a significant value compared with Conventional Nesting. This contrast with the research conducted by Zen (2017) that there was not significant in breathing frequency pre-and post-intervention. Meanwhile, Gill, Kumar, & Sharin (2015) reported that the respiratory rate of an infant after nesting intervention was the lower value of mean than before the intervention. In this study, the materials of Modern Nesting made from cotton with dacron as a cushion and completely with 2 fixations on the top of infant body's so that makes covered it and baby feel more comfortable during putting on the nest. Nevertheless, nesting traditional using rolls of blankets and towels to form a nest. During the observation, the size of conventional nesting sometimes not suitable for infant bodies and not to be fully covered. The use of nest with the standard procedure and giving the right position to the baby can provide a sense of calm and comfort to the baby even though wearing respiratory devices during in NICU (Efendi et al., 2019). Supportive positions through applying nesting techniques have useful for better oxygenation in premature infants (Yildizdas, Barutcu, Gulcu, Ozlu, & Leventeli, 2021).

Behavioral responses of modern nesting group and conventional nesting group
In terms of behavioral responses, it can be seen in the group of modern nesting, especially on day 1 which dramatically decreased from 5.5 to 3 or a decrease of 2.5. Meanwhile, conventional nesting plummets from 3.8 to 2.3 or went down to 1.5 (Figure 2). The differences in behavioral responses in the two groups illustrate that there is significant value with P = 0.027 (table 4). More details about behavioral responses, there is an effect nesting model care with two models of nesting before and after the intervention to behavioral responses where each value respectively P = 0.009 and P = 0.025 (table 5). The score of Anderson Behavior State Scale (ABSS) in two groups of nesting showed a dramatic declined in the first-day intervention and steadily go down until the seventh day. The  (2016) that there were statistically significant differences concerning behavioral response as regards infants 'sleep/awake state where the premature infant having deep sleep during applying positioning in nesting. Nesting as a developmental care application in premature infants reduces crying times of infants during the invasive procedure due to prone position increased the respiratory function and oxygenation (Kahraman, Basbakkal, Yalaz, & Sozmen, 2018). Moreover, nest posture increased the deep sleep hours of premature infants as the most imperative state of brain development (Reyhani, Ramezani, Boskabadi, & Mazlom, 2016).

Limitation
The limitation in this study is the frequency of down score observation of each respondent is carried out differently. In addition, confounding factors such as the use of breathing support were not identified in relation to the downs score in both intervention and control groups.

Conclusion and recommendation
Based on the results, it can be concluded that there were no significant differences between respiratory status between modern nesting and conventional nesting of this study. While behavioral response has a significant value. Besides, Modern nesting has a significant effect on the respiratory status and behavioral responses. Whereas conventional nesting only significant in behavioral responses. It can be recommended that the use of modern nesting can be beneficial in premature infants, especially in improving down scores and behavioral responses.