Revisión sistemática: Mínima
manipulación en prematuros
Systematic review: Minimal manipulation
in preterm infants
Tania Karina Tenesaca Tenesaca
Maestría en Gestión del Cuidado de Posgrados
de la Universidad Católica de Cuenca, Ecuador
https://orcid.org/0000-0002-6241-0967
tania.tenesaca.47@est.ucacue.edu.ec
Isabel Cristina Mesa-Cano
Maestría en Gestión del Cuidado del Posgrados
de la Universidad Católica de Cuenca, Ecuador.
Carrera de Enfermería de la Universidad Católica
de Cuenca, Ecuador.
https://orcid.org/0000-0003-3263-6145.
imesac@ucacue.edu.ec
Andrés Alexis Ramírez-Coronel
Maestría en Gestión del Cuidado del Posgrados
de la Universidad Católica de Cuenca, Ecuador.
Carrera de Enfermería de la Universidad Católica
de Cuenca, Ecuador.
Laboratorio de Psicometría, Psicología
Comparada y Etología (LABPPCE) del Centro de
Investigación, Innovación y Transferencia de
Tecnología (CIITT) de la Universidad Católica de
Cuenca, Ecuador.
Health and Behavior Research Group (HBR).
https://orcid.org/0000-0002-6996-0443
andres.ramirez@ucacue.edu.ec.
Guayaquil - Ecuador
http://www.jah-journal.com/index.php/jah
Journal of American health
E-1
Esta obra est bajo una Licencia Creative Commons
Atribucin-NoComercial-CompartirIgual 4.0 Internacional.
RESUMEN
Se considera prematuro a un nacido vivo de
menos de 37 semanas. Cada año nacen 15
millones de prematuros, alrededor de 1
millón de ellos fallecen anualmente,
muchos de los sobrevivientes padecen de
alteraciones neurológicas. Objetivo: Revisar
en la literatura científica sobre la mínima
manipulación en prematuros. Metodología:
Se realizará una revisión sistemática de la
literatura. La investigación se llevó a cabo a
través de los siguientes buscadores: SciELO,
PubMed, Scopus, Redalyc, Lilacs y Google
Scholar. Resultados: Se presenta las
principales complicaciones relacionadas al
manejo de los pacientes prematuros, y se
resalta la importancia del rol de la
enfermera en el cuidado de dichos
pacientes. Conclusión: Es primordial que los
profesionales a cargo del cuidado de recién
nacidos prematuros tengan conciencia y
conocimiento de que alguien tan indefenso
requiere cuidados especiales, y deben ser
capaces de interpretar y conocer las
necesidades de su paciente.
PALABRAS CLAVE: Prematuro, mínima
manipulación, neurodesarrollo, cuidados
de enfermería.
ABSTRACT
A live birth of less than 37 weeks is
considered premature. Every year 15
million preterm infants are born, about 1
million of them die annually, and many of
the survivors suffer from neurological
alterations. Objective: To review the
scientific literature on minimal
manipulation in preterm infants.
Methodology: A systematic review of the
literature will be carried out. The research
was carried out through the following
search engines: SciELO, PubMed, Scopus,
Redalyc, Lilacs and Google Scholar. Results:
The main complications related to the
management of premature patients are
presented, and the importance of the
nurse's role in the care of these patients is
highlighted. Conclusions: It´s essential that
the professionals in charge of the care of
premature newborns have awareness and
knowledge that someone so helpless
requires special care, and they must be able
to interpret and know the needs of their
patient.
KEYWORDS: Prematurity, minimal
manipulation, neurodevelopment, nursing
care.
INTRODUCCTION
A live birth of less than 37 weeks is
considered premature (1). Every year 15
million premature babies are born, about 1
million of them die annually, many of the
survivors suffer from neurological
alterations (2). The Neonatal Intensive Care
Unit exposes them to events of different
levels of stress (3) where they receive
luminous stimuli (4), noise and excessive
manipulation (5), causing alterations in the
correct cerebral and sensorial development
(6); being neurologically immature, they
present difficulties to adapt to this invasive
environment (7).
Neonates are exposed to many painful and
often unavoidable procedures (8);
Excessive handling, pain and constant stress
(9) can cause profound deterioration (7),
negatively influencing brain and
neurobehavioral development in the short
or long term (10), and they may also suffer
from morphological and functional changes
in the brain associated with prematurity
(10,11), changes in vital signs and even
vomiting, lack of appetite, regurgitations
and motility and sleep disorders (12), so the
nurse should adopt competencies that
favor the reduction of pain through music,
skin-to-skin contact with the mother and
using non-pharmacological methods (10)
In a premature infant, neurological
development and maturation is a critical
period (11), so it is essential to provide care
focused on neurodevelopment (13,14).
Nurses spend the most time caring for the
neonate (15), so the theoretical
contribution of this study is to contribute to
improving knowledge of the subject in
order to provide comprehensive and more
humanized care, since prematurity involves
crucial neurological and physical processes
for development (16), in which the
premature infant requires minimal
manipulation techniques and non-
pharmacological treatments to minimize
pain and reduce stress (17), reducing the
impact of hospitalization and reducing
sequelae in later stages (18).
The World Health Organization has
guidelines that indicate that premature
infants, due to their health conditions,
should receive care based on techniques,
approaches and methods (19). The clinical
practice guide of the Ministry of Public
Health of Ecuador states that pain
management is justified on ethical and
physiological grounds. It is worth
mentioning that pain causes general
discomfort (20), persistent physiological,
neurological and behavioral alterations
(21); as well as a greater probability of
presenting disorders, mainly sensory and
neurodevelopmental disorders during
childhood (19,20).
In the following systematic review, the
following research questions are
formulated: What are the main nursing
interventions in minimal manipulation in
preterm infants? And what are the nursing
care focused on neurodevelopment in
preterm infants?
In an article by Zurita et al. in Ecuador, pain
management by nursing personnel in a
neonatology service of a general hospital in
the city of Quito was evaluated, concluding
that after a painful procedure, 89.4%
presented oxygen desaturation, followed
by 26% with hypoglycemia (26%).
Regarding pain management, it was
determined that 100% of the nursing staff
did not use pharmacological or non-
pharmacological measures for pain
management and prevention (8).
Thus, to understand the importance of
minimal manipulation in premature infants
to preserve their neurodevelopment, it is
necessary to understand the philosophy of
the Newborn Individualized Developmental
Care and Assessment Program "NIDCAP"
(10), which is based on observing the
neonate's responses to care interventions,
providing individualized maneuvers that
contribute to physiological and behavioral
stability, focusing on neurodevelopment
(19).
The general objective is to review the
scientific literature on minimal
manipulation in premature infants, having
as specific objectives: to describe the main
nursing interventions in minimal
manipulation in premature infants and to
identify the nursing care focused on
neurodevelopment in premature infants.
METHODOLOGY
TYPE OF RESEARCH
A systematic review of the literature was
carried out. For this process, the
recommendations of the PRISMA
statement were followed.
SEARCH STRATEGIES
The research was carried out through the
following search engines: SciELO, PubMed,
Scopus, Redalyc, Lilacs and Google Scholar.
For the search, the following keywords
related to the objectives were used
according to the terms Mesh and DeCs:
"premature" AND "minimal manipulation"
OR "neurodevelopment" OR "nursing care"
and in English: "premature" AND "minimal
manipulation" OR "neurodevelopment" OR
"nursing care". The intersection between
these descriptors, using Boolean AND and
OR connections. Associated with this,
observational reports, cross-sectional,
retrospective and prospective studies and
cross-sectional studies in neonates were
considered.
Inclusion and exclusion criteria
For the selection of the sample, the
inclusion criteria were used: systematic
reviews, scientific articles, publications of
health institutions and research related to
minimal manipulation in prematurity,
available in their entirety, in Spanish and
English language, during the period 2017 to
2021. Reviews, articles and publications
that were duplicated or from repositories,
and that did not have the expected
scientific quality were excluded.
PROCEDURE
The following steps were followed for the
procedure. In the first stage, the topic was
identified by formulating the research
question in the PICO (Population,
Intervention, Control, and Disposal) format:
Why describe the main nursing
interventions in minimal manipulation in
premature infants? And why identify
nursing care focused on neurodevelopment
in premature infants?
In the second stage, the inclusion criteria
were established as follows: systematic
reviews, scientific articles, publications of
health institutions and research related to
minimal manipulation in prematurity,
available in their entirety, in Spanish and
English, during the period 2017 to 2021.
Reviews, articles and publications that were
duplicated or from repositories, and that
did not have the expected scientific quality
were excluded.
I n the fourth and fifth stages, the
evaluation of the studies was carried out
with more criteria (according to the
objectives set), and the interpretation of
the results obtained, in order to reach the
sixth stage where the discussion and
synthesis of knowledge was formed. The
aim was to provide a systematic review
with rigorous and exhaustive scientific
information with studies with more and
better pertinent information that
contributes to the scientific community.
RESULTS
Twelve scientific articles related to
manipulation in preterm infants were
analyzed. The selection process, using the
PRISMA statement, is detailed in Figure 1,
and the main characteristics of the selected
articles are presented in Table 1.
Table 1. Selection of articles by systematic review
N°
Base
Journal
Language
Title
Author and year
Objective
1
Redalyc
Pediatric Act of
Mexico
Spanish
Neurological risk in
the neonatal
medium-risk infant.
Neurological risk in
the neonatal
medium-risk infant
Vericat et al. (22)
2017
With this qualitative
review of the
specialized literature
we intend to describe
the characteristics of a
group of neonates
collectively called
medium neonatal risk
newborns and who, at
birth, do not present
evident
neurodevelopmental
compromise. We also
inquired about the
etiological factors
associated with this
condition.
2
Elsevier
Perinatology
and Human
Reproduction.
Spanish
Comparative
measurement
Delaware the
intensity Delaware
Delaware noise
inside and outside
Delaware closed
incubators
Valdes de la Torre et
al. (6) 2018
Measuring and
comparing noise
intensity outside and
inside closed
incubators.
3
Scielo
Latin American
Journal of
Nursing
Portuguese
Sizing of painful
procedures and
interventions for
acute relief of acute
pain in preterm
infants.
Petean et al (5).
2017
To dimension the
exposure of
premature infants to
painful procedures,
relating the
distribution of
exposure to
contextual factors,
and as well as to
describe the
pharmacological, non-
pharmacological
interventions, used by
health professionals
during the first two
weeks of
hospitalization of the
premature infant in
two neonatal units.
4
Scielo
Medical
Horizont
Spanish
Neurodevelopmental
sequelae of
extremely low birth
weight and very low
birth weight preterm
infants at two years
of age discharged
from the Neonatal
Intensive Care Unit of
the Edgardo
Rebagliati Martins
National Hospital.
2009-2014
Fernández et al. (9)
2017
To describe the
neurodevelopmental
sequelae of extremely
low birth weight and
very low birth weight
preterm infants at two
years of age,
discharged from the
Neonatal Intensive
Care Unit of the
Edgardo Rebagliati
Martins National
Hospital.
5
Scopus
Quarterly
electronic
journal of
nursing
English
Spanish
The philosophy of
developmentally
focused care of the
preterm infant
(NIDCAP): a review
of the literature
Harillo et al. (10).
2017
Harillo et al (10).
2017
To know the
interventions of the
philosophy of
developmentally
centered care of the
preterm newborn
(NIDCAP) aimed at
optimizing the
macroenvironment
and
microenvironment,
together with family-
oriented actions in
order to favor the
stability and
organization of the
development and
behavior of the
preterm newborn;
and from here, to
evaluate the
effectiveness of its
application.
6
Scielo
Brazilian
Journal of
Intensive Care
English
Temporal
assessment of
neonatal pain after
airway suctioning
Gimenez et al. (23).
2020
Temporal assessment
of a painful stimulus in
premature infants
using 3 neonatal pain
scales.
7
Redalyc
Archives of
Medicine
English
Evaluation of pain as
an indicator of
neonatal health
status.
Zurita J (8). 2020
To evaluate the
management of pain
by the nursing staff of
a neonatology service
of a general hospital in
the city of Quito
(Ecuador).
8
Scopus
Quarterly
Journal of
Nursing.
Spanish
Pain in newborns
exposed to nursing
procedures in the
neonatology unit of
a Chilean clinical
hospital.
San Martín et al 2017
(24)
To assess the intensity
of pain in newborns in
the face of nursing
procedures, which
were performed on
them on the occasion
of care and treatment.
It was based on Jean
Watson's humanistic
vision of care.
9
Scielo
Audiology
Communication
Research.
Portuguese
Analysis of pragmatic
skills in premature
infants.
Filgueira de Souza et
al (13). 2020
To characterize the
pragmatic skills of
preterm infants and to
investigate whether it
correlates with
gestational age, sex,
and age group.
10
Scielo
Cuban Journal
of Public Health
Spanish
Nutritional status
and
neurodevelopment
in early childhood
Luna et al (17). 2018
Luna et al. (16) 2018
To unveil the existing
relationship between
nutritional status and
neurodevelopment in
this phase of the
child's life, a stage
between birth and 5
years of age.
11
PubMed
Medical
Colombia.
.
Spanish
Professional
performance of the
occupational
therapist in the
Neonatal Intensive
Care Unit
Rubio(19). 2019
To determine the
realities and
knowledge about the
practice of OT in the
Neonatal Intensive
Care Unit (NICU) of
the occupational
therapist in the
interaction between
the infant,
occupation,
caregivers and the
NICU environment.
12
Scielo
Medical
scientific mail.
Spanish
Early care protocol
for neonates with
high-risk
neurodevelopmental
Hechavarría et al.
(25) 2018
To boost the
development of early
care (ECI), through the
follow-up of children
with developmental
alterations, and
intervention in those
at high risk. 2018 To
boost the
development of early
care (ECI), through the
follow-up of children
with developmental
alterations, and
intervention in those
at high risk.
DISCUSSION
A review of 12 articles selected from the
scientific literature was carried out with the
aim of describing the main nursing
interventions in minimal manipulation in
preterm infants and identifying nursing
care focused on neurodevelopment in
preterm infants.
According to Vericat (22), the increase of
prenatal controls, the reduction of
premature births and cesarean delivery are
relevant factors for optimal
neurodevelopment. For the author, after
delivery, it is necessary to take extreme
care of the neonate in the Neonatal
Intensive Care Units (NICU), controlling
conditions such as hyperbilirubinemia,
neonatal sepsis and respiratory distress,
associated with developmental alterations
in medium-risk neonates. In this sense,
Fernandez (9) exposes multiple factors that
interfere in the development of the infant;
which include the severity of neonatal
morbidity, the degree of physiological
immaturity, medical complications and the
environmental conditions experienced in
the NICU, therefore, this environment must
be modified in order to reduce the potential
damage in high-risk premature newborns.
Furthermore, Petean et al. (5) argue that
the newborn population requiring the NICU
usually has multiple pathologies that can
significantly increase the number of painful
procedures, and that the more immature
the classification of the newborn, the
greater the exposure to pain. Thus, extreme
preterm infants, in addition to the
biological risk inherent to maturity, are
subject to the detrimental consequences of
repeated exposure to painful procedures.
In the study developed by Gimenez et al.
(23) it is confirmed that newborns took at
least 3 minutes to recover from a painful
stimulus and return to their initial state.
They point out that verification of the time
required for neonates to recover after a
painful stimulus is relevant and urgent
because it allows objective management of
non-pharmacological and/or
pharmacological strategies for neonatal
pain relief after various procedures used in
the Neonatal Intensive Care Unit.
On the other hand, San Martín et al. (24)
argue that the fact that neonates are
subjected to frequent and prolonged pain is
detrimental to the nervous system and can
cause physiological instability, increase the
vulnerability of the premature infant to
neurological lesions such as intracranial
hemorrhage, and in the long term cause
problems related to neurological deficit,
cognitive alterations and learning
difficulties. This can be evidenced in Zurita's
study (8) in which after a painful procedure
89.4% presented oxygen desaturation,
followed by 26% with hypoglycemia. Zurita
evidenced that 100% of the nursing staff did
not use pharmacological or non-
pharmacological measures for pain
management and prevention, highlighting
that pain management in neonatal patients
was not given priority.
Regarding the development of preterm
infants, Rubio (19) argues that if individual
needs are not stimulated in the long term,
damage will be evident, which could be:
praxis, imitation, sequencing and
construction abilities; motor skills;
cognitive abilities such as perception;
processing skills (ability to organize actions
in a timely and safe manner) and emotional
regulation abilities that could affect the
ability to respond efficiently; in contrast to
the above, Hechavarría (25) concludes that
plasticity phenomena affect not only
specific aspects of sensory or motor
systems, but also complex behaviors, which
is called "behavioral plasticity"; In addition,
Filgueira and Casais (13) mention that
there is a marked need for early
intervention and logopedic follow-up of
premature newborns, hence the
importance of conducting longitudinal
studies to investigate the prevalence and
persistence of language alterations, both in
the short and long term.
In this context, Luna et al. (16) emphasize
the importance of nutritional status,
indicating that it is one of the
environmental factors involved in the
neurodevelopment of the child, since
nutrition during the first year of life is a
decisive factor in its development.
Harillo and Rico (10) indicate that there is
currently a trend in the care of preterm
newborns called Developmental and Family
Centered Care (DCC). This is based on a
philosophy that embraces the concepts of
dynamic interaction between the newborn,
family and environment to optimize both
the macroenvironment (noise, lights) and
the microenvironment (posture,
manipulations, pain) in which the child
develops. They also stress the need to
approach it as a common project for all
neonatal care professionals such as
neonatologists, nurses, nursing assistants,
specialists, technicians and administrative
staff in order to provide continuity between
care for the family before birth and care for
the child and family after birth.
CONCLUSIONS
Prematurity is the first cause of neonatal
and infant morbidity and mortality, and
constitutes one of the most frequent health
problems. For this reason, health personnel
in Neonatal Intensive Care Units should
work to maintain a comfortable
environment, with humanized care,
applying minimal manipulation in the
premature infant, in order to reduce
complications and sequelae in
neurodevelopment, considering that
constant exposure to painful procedures
and stressful situations increase the risk of
these.
Therefore, it is paramount that
professionals caring for preterm infants
have awareness and knowledge that the
preterm infant is physiologically immature
and requires special care focused on the
prevention of future complications leading
to short and long term
neurodevelopmental sequelae. They must
be able to interpret and know their
patient's needs. Under this premise, it is
important for nurses in neonatal units to be
trained in the care they should provide to
newborns, especially extreme preterm
infants who are more likely to present
complications. It is proposed that future
research focused on neurodevelopment
and focused on patients who were born
premature and suffer from disabilities.
References:
1. Mesa A, Gómez A. The imaginary
dialogue of mothers with their
premature babies. Latin American
Journal of Social Sciences, Childhood
and Youth. [Internet]. 2019;18(1):1–
18. Available from:
http://www.scielo.org.co/pdf/rlcs/v
18n1/2027-7679-rlcs-18-01-
00135.pdf
2. Gerónimo N. Preterm delivery from
live birth registries in Colombia,
period 2008 - 2017. Rev Médica
Risaralda [Internet]..
2020;26(2):138–47. Available from:
http://www.scielo.org.co/pdf/rmri/
v26n2/0122-0667-rmri-26-02-
138.pdf
3. Linhares M, Gaspardo C. Non-
pharmacological management of
neonatal pain: Research and clinical
practice in the neonatal intensive
care unit. Estud Psicol [Internet].
2017;34(3):345–54. Available from:
https://www.scielo.br/j/estpsi/a/Rw
gjYrZHGRChnKmGGscrMCL/?lang=e
n
4. Córdoba D. Recovery of the low birth
weight neonate: relevance of open
door NICUs. Colombian Journal of
Nursing [Internet]. 2020;19(3):1–12.
Available from:
https://revistacolombianadeenferm
eria.unbosque.edu.co/index.php/RC
E/article/view/3092/2868
5. Petean, D. Firmino, M. Correa, T.
Moraes A, Vici-Maia J. Silvan C.
Scaling of painful procedures and
interventions for acute pain relief in
premature infants. Rev Lat Am
Nursing [Internet]. 2017;25:1–9.
Available from:
https://www.scielo.br/pdf/rlae/v25/
0104-1169-rlae-25-e2917.pdf
6. Valdés-de la Torre G, Martina L,
Braverman A, Iglesias J, Bernárdez I.
Comparative measurement of noise
intensity inside and outside closed
incubators. Perinatology and Human
Reproduction [Internet].
2018;32(2):65–9. Available from:
https://doi.org/10.1016/j.rprh.2018.
06.002
7. Romero A, Rodríguez M. Knowledge
and non-pharmacological
interventions to reduce neonatal
pain and stress. Memoirs of the
Health Sciences Research Institute.
[Internet]. 2019;17(3):34–40.
Available from:
https://scielo.conicyt.cl/scielo.php?
pid=S0717-
95532019000100214&script=sci_art
text&tlng=n
8. Zurita J, Paredes K, Rueda D, Méndez
D. Assessment of pain as an indicator
of neonatal health status. Medical
Archives [Internet]. 2019;20(1):156–
63. Available from:
https://www.redalyc.org/journal/27
38/273862538016/
9. Fernández C, Matzumura J, Gutiérrez
H, Zamudio L, Melgarejo G.
Neurodevelopmental sequelae of
extremely low birth weight and very
low birth weight preterm infants at
two years of age, discharged from
the Neonatal Intensive Care Unit of
the Edgardo Rebagliati Martins
National Hospital 2009-2014.
Medical Horizon [Internet].
2017;17(2):6–13. Available from:
http://www.scielo.org.pe/pdf/hm/v
17n2/a02v17n2.pdf
10. Harillo D, Rico J, López A. The
philosophy of the developmental
centred care of the premature infant
(NIDCAP): A literature review.
Enfermería Glob [Internet].
2017;16(4):577–602. Available from:
https://scielo.isciii.es/pdf/eg/v16n4
8/1695-6141-eg-16-48-00577.pdf
11. Alcalá M, Gibello A, Casallo M,
Ortega L. Early care in prematurity: a
case report. Int J Dev Educ Psychol
[Internet]. 2019;2(1):23–31.
Available from:
https://www.redalyc.org/journal/34
98/349860126002/349860126002.p
df
12. Gómez M. Experience in two
hospitals on the observation of pain
responses in hospitalized premature
infants. Journal of the Spanish Pain
Society [Internet]. 2018;25(5):271–7.
Available from:
http://www.scielo.org.pe/pdf/hm/v
17n2/a02v17n2.pdf
13. Filgueira A, Casais L, Pondé E.
Analysis of the pragmatic skills in
preterm children Análise das
habilidades pragmáticas de crianças
nascidas pré-termo. Audiol Commun
Res [Internet]. 2020;25:2263–4.
Available from:
https://doi.org/10.1590/2317-6431-
2019-2263
14. Ota A. Neonatal management of
prematurity: advances in Peru.
Journal Peru Gynecology and
Obstetrics. 2018;64(3)415- 422 DOI
https//doi.org/1031403/rpgo
v64i2106 [Internet].
2018;64(3):415–22. Available from:
http://www.scielo.org.pe/pdf/rgo/v
64n3/a15v64n3.pdf
15. Soto J, Veramendi N. Knowledge and
application of neonatal pain care.
Opcion [Internet]. 2017;33(84):536–
56. Available from:
http://www.redalyc.org/pdf/310/31
054991019.pdf
16. Luna J, Hernández I, Rojas A, Cadena
M. Nutritional status and
neurodevelopment in early
childhood Nutritional Status and
Neurodevelopment in Early
Childhood. Rev Cuba Salud Pública
[Internet]. 2018;44(4):169–85.
Available from:
https://www.scielosp.org/article/rcs
p/2018.v44n4/169-185/
17. Torres E, Lugo G, Matos J, Puch E.
Massage versus music therapy to
reduce stress in preterm infants in a
neonatal critical care unit, a
systematic review. Nursing journal
Mexican Institute of Social Security
[Internet]. 2020;28(1):49–57.
Available from:
http://revistaenfermeria.imss.gob.m
x/editorial/index.php/revista_enfer
meria/article/view/1095/1053
18. Guzmán V, Nicolini D, Domínguez B,
Guzmán J. Psychotherapeutic
management of pain : through music
and touch in neonates: the "Sentire
Method." Study on Contemporary
Cultures [Internet].
2018;XXIV(47):9–40. Available from:
https://www.redalyc.org/journal/31
6/31655797002/31655797002.pdf
19. Rubio M. Performance of an
occupational therapist in a neonatal
intensive care unit. Colomb Med
[Internet]. 2019;50(1):40–5.
Available from:
http://www.scielo.org.co/pdf/cm/v
50n1/es_1657-9534-cm-50-01-
00030.pdf
20. Fernandes M, Gomes A, Carreiro A.
Prognosis of Newborns in Neonatal
Intensive Care Units: An Integrative
Review / Prognosis of Newborns
Admitted to Neonatal Intensive Care
Units: An Integrative Review.
Research Journal Care is
Fundamental Online [Internet].
2020;11(3):748–55. Available from:
http://www.seer.unirio.br/index.ph
p/cuidadofundamental/article/view
/6806/pdf
21. MSP. Preterm newborn. Clinical
practice guideline [Internet].
National Directorate of
Standardization. Quito- Ecuador;
2015. 1–130 p. Available from:
https://www.salud.gob.ec/wp-
content/uploads/2016/09/GPC-
Recén-nacido-prematuro.pdf
22. Vericat A OA. Neurological risk in
children of moderate neonatal risk.
Acta Pediatr Mex [Internet].
2017;38(4):255–66. Available from:
http://www.scielo.org.mx/pdf/apm/
v38n4/2395-8235-apm-38-04-
0255.pdf
23. Gimenez I, Rodrigues R, De Faria M,
Rezende B, Da Silva V, Silva R, et al.
Temporal assessment of neonatal
pain after airway aspiration. Rev Bras
Ter Intensiva [Internet].
2020;32(1):66–71. Available from:
https://scielo.isciii.es/scielo.php?scr
ipt=sci_arttext&pid=S1695-
61412017000400001
24. San Martín D, Valenzuela S,
Huaiquian J, Luengo L. Pain in the
newborn in a neonatology unit of a
clinical Chilean hospital TT - Pain in
the newborn exposed to nursing
procedures in the neonatology unit
of a Chilean clinical hospital. Global
Nursing [Internet]. 2017;16(4):13–
23. Available from:
https://bd.univalle.edu.co/scholarly-
journals/pain-newborn-
neonatology-unit-clinical-
chilean/docview/1967317081/se-
2?accountid=174776
25. Hechavarría, L, Cruz, U. Hernández
M, López M. Protocol for early care
of high-risk neurodevelopmental
neonates. Medical Scientific Mail
[Internet]. 2018;22(1):137–54.
Available from:
http://scielo.sld.cu/pdf/ccm/v22n1/
ccm12118.pdf
