Newborn & Infant Nursing Reviews 16 (2016) 230–244

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Newborn & Infant Nursing Reviews

journal homepage: www.nainr.com

The Neonatal Integrative Developmental Care Model: Advanced Clinical

Applications of the Seven Core Measures for Neuroprotective
Family-centered Developmental Care
Leslie Altimier, DNP, RN, MSN, NE-BC a,⁎, Raylene Phillips, MD, FAAP, FABM, IBCLC b,1
a
Philips Healthcare, 35 Warren St., Newburyport, MA 01950
b
Loma Linda University Children's Hospital, Department of Pediatrics, Division of Neonatology, 11175 Campus Street, CP 11121, Loma Linda, CA 92354

a r t i c l e i n f o a b s t r a c t

Keywords: The Neonatal Integrative Developmental Care Model, which outlines seven core measures for neuroprotective
Core measures family-centered developmental care of premature infants, is a framework that guides clinical practice in many
Integrative neonatal intensive care units (NICUs) around the globe. The seven neuroprotective core measures are depicted
Neuroprotection as overlapping petals of a lotus as the 1) healing environment, 2) partnering with families, 3) positioning &
Developmental handling, 4) safeguarding sleep, 5) minimizing stress and pain, 6) protecting skin, and 7) optimizing nutrition.
Family-centered
Skin to Skin Contact (SSC) is considered the foundation for care of infants in the NICU and its importance as
Infant
Premature
the “normal environment” and the ideal place of care is described. The mother/child dyad is the center of the
NICU lotus surrounded closely by symbols representing various aspects of the healing environment, highlighting the
physical, extra-uterine environment in which the infant now lives, the significance of the developing infant's
sensory system, and the influence of people (patient, family, and staff) who help to create a healing environment
for hospitalized infants and their families. The Neonatal Integrative Developmental Care Model utilizes neuro-
protective interventions as strategies to support optimal synaptic neural connections, promote normal neuro-
logical, physical, and emotional development and prevent disabilities.
© 2016 The Authors. Published by Elsevier Inc. This is an open access article under the CC BY-NC-ND license
(http://creativecommons.org/licenses/by-nc-nd/4.0/).

In the United States, approximately 500,000 babies each year are born
prematurely at less than 37 weeks' gestational age (GA) or low birth
weight (less than 2500 grams), and as many as 10 to 15% of these babies
require treatment in the neonatal intensive care unit (NICU).1,2 The man-
agement of premature infants has advanced over the past decades to the
point that infants born as early as 23 weeks' gestation now have a chance
of survival due to a multitude of technologic advances. This progress comes
with great costs as premature infants are in the NICU for many weeks or
months, and many have impaired short and long-term outcomes.3–7
Although physical and motor disorders may be more noticeable,
preterm and medically fragile infants are also at greater risk for cogni-
tive, social–emotional, mental health, behavioral, speech-language,
and regulatory difficulties well into school age and beyond. 8–18
Educational attainment of young adults that began as a very low birth
weight (VLBW) infant, is also poorer than term-born adults with
fewer completing higher education and a greater proportion opting to
undertake vocational education or training.19 There is also evidence of
an increased risk for psychiatric disorders in adulthood, including ASD,
ADHD, and mood disorders.20–28
⁎ Corresponding author. Tel.: +1 513 706 8813.
E-mail addresses: LAltimier@gmail.com (L. Altimier), rphillips@llu.edu (R. Phillips).
1
Tel.: +1 909 226 3748 (Mobile).
Neurodevelopment
To better understand the developmental problems associated with
prematurity and other high-risk events, it is essential to understand
the basics of neurosensory development of the neonate, paying particu-
lar attention to the stage of development that occurs in the third trimes-
ter of gestation, the period of time in which preterm infant brains are
developing in the NICU, in an environment entirely different than the
protective environment of the womb.
The neurologic and sensory systems do not exist as separate entities, but
are interdependent and comprise the neurobehavioral and neurosensory de-
velopment of the infant. Every sensory experience is recorded in the brain,
leading to a behavioral response, thereby leading to yet another sensory ex-
perience. This cyclic interdependent action and reaction is the basis for neu-
robehavioral and neurosensory development. When premature infants have
sensory experiences that are inappropriate for their stage of development
(as often occurs in the NICU), their neurodevelopment occurs differently
than it would have in the protective environment of the womb. It is not sur-
prising, then, to see different neurosensory and neurobehavioral outcomes
in babies born prematurely compared to those born at term.
Recent evidence suggests that early preterm birth (b32 weeks GA) is
a risk factor for autism spectrum disorders (ASD). ASD is a group of
complex neurodevelopmental syndromes of the central nervous system

http://dx.doi.org/10.1053/j.nainr.2016.09.030
1527-3369/© 2016 The Authors. Published by Elsevier Inc. This is an open access article under the CC BY-NC-ND license (http://creativecommons.org/licenses/by-nc-nd/4.0/).
 L. Altimier, R. Phillips / Newborn & Infant Nursing Reviews 16 (2016) 230–244
characterized by impaired communication, social interaction chal-
lenges, and restricted behaviors. Although neuropathology of ASD is
not fully understood, the most consistent pathology includes curtail-
ment of normal development of the limbic system and abnormal devel-
opment of the cerebellum and associated nuclei in children with a
genetic susceptibility who experience abnormal stressors during a crit-
ical period of brain development. 20–29 The prevalence of ASD has in-
creased over the past two decades and is estimated to affect one in 88
children in the United States, according to the Centers for Disease Con-
trol & Prevention (CDC).22 Estimated prevalence of ASD in all preterm
infants ranges from 12%–41%.22–29
The fetal neurologic system is in a highly active stage of develop-
ment during the third trimester of gestation. With volumes of research
documenting long-term disabilities in prematurely-born children, un-
derstanding how we can better support the preterm infant's fragile neu-
rologic system can pave the way to decreasing the negative effects of
fetal development occurring outside the protective womb, in the
extra-uterine environment of the NICU.30–33
Both the structural and functional development of the brain are shaped
by the influence and interaction of several major factors. These include ge-
netic endowment, internal, endogenous, or hormonal stimulation, and ex-
ternal experiences from the environment that stimulate the sensory
organs. Outside stimulation from the environment can influence or alter
the expression or effects of genes through a process called epigenetics.
Although initial stimulation of each sensory system is internal or en-
dogenous, at a critical or sensitive point in development, external stim-
ulation and experiences are needed for further development.
Experiences that influence fetal, infant, and child development can
come from their physical, sensory, chemical, nutritional, social, and/or
emotional environments. Events and stimuli from any of these compo-
nents of environment are capable of altering the course and outcome
of developmental processes producing changes in brain development
that can be either positive or negative. 34
Neuroprotection in the NICU
Neuroprotection has been defined as strategies capable of preventing
neuronal cell death.35 Neuroprotective strategies are interventions used
to support the developing brain or to facilitate the brain after a neuronal
Fig. 1. Neonatal Integrative Developmental Care Model.
231
injury in a way that decreases neuronal cell death and allows it to heal
through developing new connections and pathways for functionality.36
The earlier in gestation a baby is born, the more vulnerable is its fragile
brain and the more critical it is to provide effective and consistent neuro-
protective care from the moment of birth in order to protect and support
optimal brain development. As we strive to continue to improve our mor-
bidity and mortality rates, we are challenged to enhance the neuroprotec-
tive strategies for these infants, thus demonstrating the need for a
developmentally supportive environment that focuses on the interper-
sonal experiences of the preterm infant and family in the NICU. Every
baby, regardless of gestational age, deserves neuroprotective care
throughout their hospitalization due to rapid brain growth and neurologic
development occurring during the early neonatal period.
Family-integrated, neuroprotective, developmentally supportive care
includes creating a healing environment that manages stress and pain
while offering a calming and soothing approach that keeps the whole
family involved in the infant's care and development.37–39 Neuropro-
tective developmental care is grounded in support by research from a
number of disciplines including nursing, medicine, neuroscience, and
psychology.38,40–44 Improvements in health outcomes, lengths of stays,
as well as hospital costs have been documented when neuroprotective ed-
ucation and subsequent change of care practices were implemented.45–48
The Neonatal Integrative Developmental Care Model:
Clinical Applications
The Neonatal Integrative Developmental Care Model (IDC) (Philips
Healthcare Andover, MA. USA) identifies seven distinct core measures
that provide clinical guidance for NICU staff in delivering neuroprotective
family-centered developmental care to preterm infants and their families
in the NICU (See Fig. 1).37,38,39 Each core measure has a standard(s) with a
policy or protocol that guides care of the infant/family as it relates to that
specific core measure. Corresponding infant characteristics, which are
measurable reflections of the desired core measure outcomes, are identi-
fied, and specific goals target the improvements/outcomes desired. Clini-
cal applications include neuroprotective Interventions that define and
specify the actions required to meet the goal(s). 38 These must be
evidence-based, reliably applied and scientifically valid.
To effectively implement many neuroprotective interventions, a cul-
tural shift within the NICU must occur in order to adopt new evidence-
based practices. Changes in care practices are usually not easy and success
is dependent on introducing change in a systematic fashion. Quality im-
provement (QI) methods such Plan/Do/Study/Act (PDSA) have proven ef-
fective in initiating and sustaining changes that can result in improved
outcomes.49 One such program is the Wee Care Neuroprotective care pro-
gram. The Wee Care neuroprotective NICU Program (Wee Care; Philips
Healthcare) is a multiday multidisciplinary structured program in
neuroprotective family-centered developmental care, which provides
eLearning, didactic education, hands-on interactive workshops, physician
sessions, and in-unit consultation to all individuals who care for prema-
ture infants in a NICU. This training and consultative program is an evi-
dence - based quality improvement program designed to optimize the
NICU environment and caregiving practices in order to facilitate the best
outcomes for premature infants and their families. This unique program
combines evidence-based practices with the seven neuroprotective core
measures for family-centered developmentally supportive care aimed at
standardizing neuroprotective care practices in the NICU. This is achieved
and sustained by incorporating transformational change methodology
into the training program. The Wee Care neuroprotective NICU Program,
which trains all NICU staff has been shown to improve noise and light
levels in the NICU, improve infant medical outcomes, improve staff satis-
faction, improve family satisfaction, decrease length of stay (LOS), and de-
crease hospital costs.43–46 Examples of neuroprotective interventions and
sample QI projects will be further explained below and consolidated in
Appendices A and B.
232 L. Altimier, R. Phillips / Newborn & Infant Nursing Reviews 16 (2016) 230–244

Foundation for Infant Care in the NICU: Skin-to-Skin Contact (SSC)

Skin-to-skin contact (SSC) is the optimal environment for any new-

born, but particularly for the premature infant in the NICU. The defining
feature of SSC is direct contact between parental skin and infant skin, by
holding a diaper-clad infant on a parent's bare chest in an upright prone
position. Essentially, this is a place of care, the "normal environment for
newborns." Skin-to-skin contact provides the right environment for
DNA, epigenes, neural circuits and physiological regulation to function
most optimally. A mother and her baby are inextricably linked and to
separate the two is highly stressful to both. Incubator care, while neces-
sary if mother is unavailable, is actually abnormal to the developing
brain of an infant. Skin-to-skin contact (sometimes called kangaroo
care) is a fundamental, essential component of neuroprotective and pa-
tient–family oriented care for hospitalized preterm infants.50,51 Being
skin to skin with mother protects the newborn from the well-
documented negative effects of separation, supports optimal brain de-
velopment and facilitates attachment, which promotes the infant's
self-regulation over time. 52 SSC became codified through the World
Health Organization (WHO) into what is called “kangaroo mother
care” (KMC), a full-care strategy. 51 While SSC in most NICUs in the
United States is often not as comprehensive as KMC, any amount of
SSC should be encouraged and facilitated.
Skin-to-skin contact with mother (or father) is directly neuroprotec-
tive and supports brain plasticity. 53 When practiced only six hours a
week for 8 weeks, it has been shown to accelerate brain maturation in
electroencephalogram (EEG) tracings of infant brain activity.54 Both ma-
ternal and paternal oxytocin levels have been shown to significantly in-
crease during SSC, reducing stress and anxiety responses in mothers
and fathers of preterm infants.55 With this single activity, each of the 7
neuroprotective core measures are supported. Skin-to-skin contact with
mother (or father) is the ultimate healing environment for newborn in-
fants (Core Measure #1),51 provides an opportunity to partner with fam-
ilies by giving parents an active role in their infant's care and healing
(Core Measure #2), facilitates supportive positioning and handling
(Core Measure #3). provides proximity to maternal odors, which contrib-
utes to sleep cycling, thus safeguarding sleep56 (Core Measure #4). SSC
has been shown to foster optimal autonomic and physiologic stability
and to reduce indices of pain, helping to minimize stress and pain
(Core Measure #5). It protects skin by providing humidity and supporting
thermoregulation (Core Measure #6). It increases mother's milk supply
and facilitates breastfeeding, optimizing nutrition (Core Measure #7). In
all these ways, SSC promotes optimal brain development, supports
healing and growth, improves parental–infant bonding, reduces infection
rates, and decreases length of hospital stay. 50 For these reasons, SSC is
seen as the foundation of all neuroprotective care.51
Core Measure #1: Healing Environment
The healing environment, Core Measure #1, addresses the physical
environment of the NICU, including space, privacy and safety, the sensory
environment of temperature, touch, proprioception, smell, taste, sound,
and light, as well as people (families and staff) and their interactions.39
Premature infants have demonstrated markedly improved outcomes
when the stress of environmental sensory overstimulation is re-
duced. This can be accomplished by incorporating neuroprotective
strategies into the care of infants and also by aspects of NICU design
(Fig. 2). 57
NICUs should be designed to encourage family reunification and
presence, facilitate psychosocial support, address/minimize sensory im-
pact, offer social connection, and enable positive parental experiences.
NICUs should also be designed to facilitate staff work and self-care, in-
cluding quiet rooms for respite and debriefings after stressful events.
Nurses working in single family room NICU's are less likely to experi-
ence burnout and more likely to rank quality of care higher.
Fig. 2. Core measure #1 of The Neonatal Integrative Developmental Care model: The
healing environment
Single family room (SFR) designs continue to gain broad acceptance
as a way to improve the physical environment for the infant and im-
prove family accommodations for parents. Enhanced ability to control
light and noise can result in improved infant sleep. SFR can also lead
to reduced infection rates. 58 In January 2017, a new prototype room
(“extended family room/EFR”) will open at Memorial Children's Hospi-
tal in South Bend IN, which is modeled after Sweden's University Hospi-
tal of Karolinska. The goal is to, not only, keep mothers and infants
together, but to accommodate the entire family unit in this new room.
A second headwall for the mother, and space for an adult patient bed,
including the required code clearances around the bed will increased
the size of the new EFR to 430 SF. Each room will have a dedicated kan-
garoo care chair to support both mothers and fathers in providing SSC.58
While the ideal scenario is to have families intimately involved in care of
their babies, when families cannot be present, rather than isolating those in-
fants in SFRs, which can cause developmental language delays,59 infants
placed together in a pod arrangement can be better supported develop-
mentally through appropriate sensory stimulation, such as hearing the
soft sounds of the human voices of staff.58 Communicating with infants in
a developmentally supportive fashion remains the responsibility of the pri-
mary caregiver, which when the family is not present, is the bedside nurse;
and this appropriate age-based communication is a neuroprotective inter-
vention for language development. When an adult patient is hospitalized
and does not have the opportunity for family or visitors, the nurse takes
time to talk to them, which is a practice that should be replicated with
the infant.
Core Measure # 2: Partnering with Families
Partnering with families, Core Measure #2, is essential in order to
optimize developmental outcomes of infants in the NICU. Prematurely
born infants have “premature” parents who are usually unprepared
for the crisis of having their newborn in the NICU. Preterm deliveries
are usually unexpected, families are often separated from their support
systems when their newly born infant is admitted to the NICU, a place
many parents did not even know existed before this event. For most
parents, the NICU is an alien environment and their first experience in
the NICU is usually a profound shock and very traumatic.60 Their infant
is attached to wires, cables, and equipment in a place that is far different
 L. Altimier, R. Phillips / Newborn & Infant Nursing Reviews 16 (2016) 230–244
from what they had planned. Parents of these NICU babies are likely to
experience greater emotional stress, depression and anxiety, uncertain-
ty about their baby's future, financial stress and even post-traumatic
stress disorder (PTSD) than do parents of term infants. 61–63 Parents
and families worry constantly while trying to maintain optimism and
hope. It is important to recognize that the intensive care experience is
not uniform and that family responses differ. Mental health providers
should be integrated into the NICU caregiving team to provide psycho-
social support at the level required for each individual family.64
With every NICU admission, normal parent–infant bonding is forever
altered. The experience of having an infant in an intensive care unit im-
pacts not only the vulnerable infant and the parents' physical and emotion-
al health, but also affects the developing bond between the newborn and
his or her parents.65,66 The NICU experience impacts all family dynamics,
not just during the intensive care unit stay, but also in the months and
years afterwards. For each family, the first experiences with their baby,
whether in the home or the intensive care unit, can set the trajectory for
the long-term parent–child relationship and the parent's perspective of
their parent roles.67 Many NICU parents leave the NICU with mental health
issues either caused or exacerbated by what happens to them there.68
The emerging concept of “trauma-informed care” is a transformative
one.69 The NICU is a place of trauma and the integration of trauma-
informed care into all aspects of care for infants and their families in the
NICU can alleviate or transform some of the trauma they have experienced
in a more positive way.64,69–73 In recent years, health care organizations
have become increasingly aware of the importance of providing psychoso-
cial support for parents of hospitalized infants and to recognize the emo-
tionally traumatic impacts of having an infant with medical illness. Many
parents will learn their first lessons about being a parent inside of the
NICU, and while many of these lessons will be useful in the future, an
equal number will not only be unhelpful but potentially damaging.74 In-
fants who are hospitalized in intensive care experience a number of threats
to the establishment of secure and nurturing relationships. They are at the
mercy of their hospital environment and often experience medical proce-
dures and practices that result in altered social interactions and emotional
resilience.75 Maternal distress early in a child's life can have long-term ef-
fects on child behavior.76
Attachment theory's key concept is the necessity of the formation of an
emotional bond between an infant and primary caregiver and how the
bond affects the child's behavioral and emotional development into
adulthood.77 Grounded in attachment theory, infant mental health involves
giving shared attention to the infant, the parent, and the early developing
attachment relationship.73,78 There is increasing awareness in psychology
and obstetrics of the effect that maternal mental health has on fetal brain
development and the psychological transition that occurs during
pregnancy.79 With this increased awareness, there is an accompanying un-
derstanding that pregnancy marks the beginning of the parent–child rela-
tionship that is vital for the infant's wellbeing. Even early fetal
environment can alter mechanisms within the fetus that persist into
adulthood.80 The importance of experiencing early relationships as warm,
caring, and stable is clear, as it results in the infant's ability to develop ap-
propriate social–emotional development and long-term mental health.81
Because families are the constant in the infant's environment, help-
ing families achieve a positive outcome from their NICU experience
should be a priority for staff.82 Equilateral respect among all members
involved in the partnership will promote optimal patient care, enhance
family satisfaction, and engage the healthcare team in ways that in-
crease job satisfaction and a sense of fulfillment.
Zero separation from parents should be the ultimate goal to ensure
neurodevelopment is supported to normal standards (as in optimal devel-
opment assumed for term infants), not merely protected from effects
of toxic stress.83 Early bonding with both physical and psychological
components, leads to emotional connections and secure attachment.84 A
baby's interaction with mother makes a significant difference in brain de-
velopment, including brain structure and function. Reciprocal tactile stim-
ulation between mother and infant contributes to increased maternal
233
responsiveness and infant attachment.85 SSC helps fathers in attachment,
confidence, caregiving, and interactions with their premature infants.
When the quality and/or quantity of parental care toward infants is limit-
ed, such as with preterm infants in the traditional NICU setting, these ad-
verse experiences can lead to negative changes in brain structure and
function.86
The NICU environment, although initially strange and even frighten-
ing to parents, can become comforting and inviting with attentive and
compassionate caregivers who enable parents to be at the bedside of
their infant, coach them on how to understand their baby's behavioral
cues and how to provide appropriate caregiving. Sensitive NICU staff
can provide active listening as parents process their shock, anger, and
grief over the loss of a normal pregnancy and/or normal healthy term in-
fant, and empower them to be active participants on the caregiving team.
The family is integral to developmental care, and normal development
cannot occur without the family. An example of this type of NICU care is
seen in the Family Integrative Model (FIC), a model of care focusing on
partnering with families where, the nurses support the parents through
education, coaching and mentoring, to become primary caregivers in
their infant's journey through neonatal care.87 The practice of Family Inte-
grated Care has been successful in Estonia and in Canada, and is being in-
troduced in the United States.88,89
All families, even those who are struggling with difficulties, bring
important strengths to their infant's experiences in the NICU. Parents
must be viewed as vital and essential members of the caregiving team
and active partners in the care of their infant, rather than visitors to
the NICU, and should be given 24-hour access to their infant. Individual-
ized family-centered developmental care is a framework for providing
care that enhances the neurodevelopment of the infant through inter-
ventions that support both the infant and family unit.
Creating an effective partnership between professionals and families
has shown benefits such as decreased length of stay, increased satisfac-
tion for both staff and parents, and enhanced neurodevelopmental out-
comes for infants.90 Having parents provide much of their infant's care
in the NICU also improves short- and long-term outcomes among in-
fants and reduces stress among parents.89 A comprehensive approach
to discharge/transition planning that includes psycho-social support
and a focus on the caregiver-infant relationship offers families the sup-
port they need and deserve at a critical time in their lives. 91 Establishing
family-professional partnerships in the NICU environment can be chal-
lenging; however, family-centered care is recognized as a best practice
which includes mutual respect, information sharing, collaboration,
confidence-building, and joint decision-making. 92
The concept of partnering with families in the NICU includes a
philosophy of care, which acknowledges that over time, the family
has the greatest influence over an infant's health and wellbeing.
Compassionately delivered family-integrated care, with zero-
separation, where skin-to-skin contact is the norm, is the ideal
model of care to encourage normal development, attachment and
bonding, and empower parents to be equal partners on the caregiv-
ing team. 38,39,51,89
Core Measure #3: Positioning & Handling
Position and handling, Core Measure #3 has the inherent goal of
supporting the premature infant's body as closely as possible to the po-
sition the baby would have been in the womb. In utero, the infant is
contained in a circumferential enclosed space with 360 degrees of
well-defined boundaries. Providing developmentally supportive posi-
tioning in the NICU is essential for optimal musculoskeletal develop-
ment, which influences not only neuromotor and musculoskeletal
development, but also physiologic function and stability, thermal
regulation, bone density, neurobehavioral organization and sleep fa-
cilitation, calmness and comfort, skin integrity, optimal growth, and
brain development. 93 Developmentally supportive positioning is an
intervention that has been proven to improve postural and musculoskeletal
234 L. Altimier, R. Phillips / Newborn & Infant Nursing Reviews 16 (2016) 230–244
outcomes as well as improve physiologic outcomes and sleep states; how-
ever, developmental positioning has not yet become a standardized
intervention.94–97 There remains a gap between what is known in the evi-
dence and what is practiced in some NICUs, and although it is clear that de-
velopmental positioning is effective in improving outcomes, less is known
about how to improve the developmental positioning proficiency of the
nurses providing the care. Incorporating a standardized Infant Positioning
Assessment Tool (IPAT), along with education, is effective in improving de-
velopmental positioning proficiency of NICU nurses, as well as improving
consistency in positioning.95,96
Supporting body containment of the infant in the NICU environment
increases the infant's feelings of security, decreases stress, and reduces
excessive energy expenditure. Forming a “nest” with soft boundaries,
as well as a padded foot-roll for foot-bracing, provides postural, behav-
ioral, and physiological stability to the newborn. Infants who are
contained within soft boundaries are usually more calm, require less
medication, sleep longer and gain weight more rapidly. Ensuring secure
containment with firm bendable positioning aids [such as with the
Bendy Bumper, (Philips)] promotes a reflex stimulus for extremity ex-
tension and subsequent flexion recoil, furthering the ability of the
baby to remain in a midline, flexed and contained position. Therapeutic
supportive positioning devices must allow spontaneous movement,
provide tactile and proprioceptive containment, and displace infant
body weight when placed in alternative positions, such as prone. Pro-
viding ventral support [such as with the Prone Plus (Philips, Boston,
MA)] utilizes the natural force of gravity to assist in proper prone posi-
tioning and ventral support of premature infants, by making it possible
to keep their shoulders rounded and hips flexed, as they would have
been inside the womb. The unique memory foam elevates the infant's
upper body to promote flexion without placing excessive pressure on
the knees and elbows.
Handling of infants should be done with slow, gentle, modulated
movements, with the infant's extremities flexed and contained, which
may require a four-handed technique in very fragile infants. A preterm
infant, when handled for reasons such as diaper changes, feeding, bath-
ing, diagnostic or therapeutic procedures can react negatively for sever-
al minutes during and after the procedure until becoming exhausted.
This results in an unnecessary expenditure of energy that can, even
well after the procedure has ended, result in signs of distress, pain
and/or instability that may be manifested physiologically (bradycardia,
tachycardia, drop in oxygen saturation and apnea) or behaviorally (flac-
cidity, fatigue and difficulty sleeping).
Frequent handling and touching can disturb sleep leading to de-
creased weight gain, decreased state regulation, and more impor-
tantly, detrimental effects on brain development. Attention to
appropriate timing of caregiving according to the infant's sleep and
arousal is important, as better sleep organization has been correlat-
ed with improved outcomes. 98 Because infants do not always toler-
ate all of the handling and care that is being clustered into one
caregiving period, the practice of clustering care should be based
on infant's behavioral cues. Cues provide communication about an
infant's physiological status and needs at any given time. Caregiving
based on infant cues involves a relationship where behavioral mes-
sages that the infant communicates may guide the timing for inter-
ventions or opportunities for sensory input and interaction. These
cues also indicate how the infant tolerates stimuli and stimulation
and when they need a break or individualized support.
Caregiving behaviors must be adapted to alleviate as much aver-
sive or negative sensory input from caregiving activities as possible.
Collaborative interprofessional care should be coordinated to negoti-
ate timing, intensity, and appropriateness of interventions, tests, and
procedures. Altering care practices by responding to the individual
infant cues requires a paradigm shift from task-oriented and sched-
uled care toward infant-responsive care, which is needed to promote
optimal developmental outcomes. Educating, coaching, and
mentoring parents in developmentally appropriate positioning and
handling will not only be beneficial to parents and babies, but can
save nurses time by involving parents in caregiving tasks they can
competently accomplish.
Core Measure #4: Safeguarding Sleep
Safeguarding sleep, Core Measure #4 emphasizes the multi-faceted
importance of sleep for the infant in the NICU. Sleep patterns of preterm
infants undergo age-dependent maturational changes, and sleep pres-
ervation is essential for the normal neurodevelopment and adequate
growth and healing of these infants. 99,100 Quiet sleep (QS) is necessary
for energy restoration and the maintenance of bodily homeostasis. Ac-
tive sleep (AS) is important for sensory input processing, memory
encoding, and consolidation and learning. Sensory inputs, especially
during critical periods of development, may influence normal sleep–
wake cycling.101
At approximately 28 weeks' gestation, individual sleep patterns
begin to emerge characterized by rapid eye movement (REM) and
non-rapid eye movement (NREM) sleep periods. REM and NREM
sleep cycling are essential for early neurosensory development, learning
and memory, and preservation of brain plasticity for the life of the
individual. 99 Preservation of “brain plasticity,” the ability of the brain
to constantly change its structure and function in response to environ-
mental changes, is an essential process throughout childhood and
adult life. Sleep deprivation (both REM and NREM) results in a loss of
brain plasticity which is manifested by smaller brains, altered subse-
quent learning, and long-term effects on behavior and brain function.
Facilitation and protection of sleep and sleep cycles are essential to
long-term learning and continuing brain development through the
preservation of brain plasticity.102 Safeguarding sleep is also essential
to promote healing and growth.
Consideration to positioning should be given in order to promote
quality sleep and decrease arousals from sleep. Preterm infants are
more likely to remain in a sleeping state when they are in the prone
position. 103 The number of arousals per hour from sleep is highest in
the supine position and least in the prone position. 104 Documentation
of the infant's state, utilizing validated scales, promotes consistency in
the assessment of infants' sleep states and cues, leading to more stan-
dardized practices when incorporating infant cues into caregiving
schedules.
The design of SFR's, where every patient room has a window can
help maintain circadian rhythms for the baby, parents, and staff. NICU
babies and their parents may have long stays in the hospital, and day-
light supports a sense of normalcy by providing connection to the
daily cycles of light.58
Core Measure #5: Minimizing Stress & Pain
Minimizing stress and pain, Core Measure #5 is especially important
in the developmentally unexpected, and often harsh, environment of
the NICU where even routine cares can be stressful, and often painful,
to premature infants. From the first moments after birth, the premature
infant is subjected to noxious sounds, bright lights, and a multitude of
stressful and painful procedures along with repetitive, non-nurturing
handling and usually, separation from mother. Seemingly typical han-
dling and caregiving by the NICU staff such as bathing, weighing, and di-
aper changes are perceived as stress to the prematurely born
infant.44,105 This altered sensory experience is inherently stressful and
has negative effects on the infant's brain development.
Infants who spend their first weeks or months of life in the NICU may
demonstrate a developmentally unexpected sensory stress response.
Exposed to painful, repeated, and unpredictable medical procedures,
and possibly to physical pain or discomfort related to illness, these in-
fants may not have consistent support from a parent or professional
caregiver to provide a buffer to help them stay regulated and recover
from these stresses. Toxic stress has been linked to changes in the
 L. Altimier, R. Phillips / Newborn & Infant Nursing Reviews 16 (2016) 230–244
developing brain, negatively impacting the creation of neural connec-
tions, and this impact is likely to be more pronounced in preterm infants
and particularly those without a supportive caregiver present. 106
NICU stressors and painful interventions can raise cortisol levels,
limiting neuroplastic reorganization and therefore, learning and memo-
ry of motor skills. Infants who are exposed to repeated painful experi-
ences can have negative short- and long-term consequences for brain
organization during sensitive periods of development. 107,108 Adverse
neurodevelopmental outcomes following neonatal intensive care are
well documented. Increased exposure to procedural pain has been asso-
ciated with poorer cognitive and motor scores, impairments of growth,
reduced white matter and subcortical gray matter maturation, and al-
tered corticospinal tract structure.109–112
Minimizing stress in preterm infants has many neurologic benefits
such as reducing the likelihood of programming abnormal stress re-
sponsiveness which will help preserve existing neuroplastic capacity. 113
Effective prevention and management of procedural and postoperative
pain in neonates are required to minimize acute physiological and
behavioral distress and may also improve acute and long-term
outcomes.114
To consistently manage stress and pain in neonates, accurate moni-
toring of pain, as the “fifth” vital sign needs to be assessed utilizing a
standardized pain assessment tool. With the assessment of pain,
comes management through pharmacologic and non-pharmacologic
measures. For common painful procedures, such as heelsticks,
venipunctures, orogastric tube (OG) insertions, non-pharmacological
interventions should be the first choice in non-compromised infants.115
Non-pharmacological interventions that have demonstrated efficacy
are: maternal presence, breastfeeding, breastmilk, SSC, sucrose, non-
nutritive sucking, facilitated tucking, swaddling, and developmentally
supportive positioning. 115–117 Maternal-related olfactory stimuli
(mother's milk) has been associated with comfort and diminished
pain response in both term and preterm infants. 118 These findings sup-
port the hypothesis that infants remember, recognize, and prefer smell
that is associated with their prenatal environment including maternal-
related olfactory stimuli (mother's milk), auditory recognition
(mother's voice, heartbeat, and music).119–121
Core Measure # 6: Protecting Skin
Protecting skin, Core Measure # 6 is multifaceted. Functions of
the skin include thermoregulation, fat storage and insulation, fluid
and electrolyte balance, barrier protection against penetration and
absorption of bacteria and toxins, sensation of touch, pressure, and
pain, and conduit of sensory information to the brain. Each of these
functions may impact neurodevelopment. Immature skin structures
of premature infants are very different than the skin of full-term in-
fants. The premature infant has an underdeveloped skin barrier,
which puts the infant at risk for high water loss, electrolyte imbal-
ance, thermal instability, increased permeability, additional skin
damage, delayed barrier maturation, and infection. 122 Infants in the
neonatal intensive unit are at risk for skin compromise due to imma-
ture skin, compromised perfusion, fluid retention, being immuno-
compromised, medical diagnosis, etc., as well as the presence of
dressings, tapes, adhesives and various medical devices, such as
IVs, and CPAP or nasal prongs, that are essential to their care. 123
Skin care practices outlining bathing protocols, emollient usage, hu-
midity practices, and use of adhesives for babies in each stage of devel-
opment should be incorporated into unit practices and policies.
Improved skin outcomes can be realized by utilizing the most
evidence-based skin care guidelines available along with careful moni-
toring and gentle, consistent handling, positioning and cares, The key
to achieving optimum skin condition is through the utilization of vali-
dated skin assessment tools to assess the skin condition and evaluate at-
tributes that indicate skin compromise.124
235
Core Measure # 7: Optimizing Nutrition
Optimizing nutrition, Core Measure # 7 has well-documented ef-
fects on infant brain development. Scientific evidence overwhelm-
ingly indicates that breastfeeding is the optimal method of infant
feeding and should be promoted and supported to ensure optimal
nutrition in for all infants whenever possible. Breastfeeding is the
single most powerful preventive modality available to health care
providers to reduce the risk of common causes of infant morbidity
and mortality. Because breast milk is the most well-tolerated sub-
strate for enteral feedings in the premature infant, full enteral feed-
ings are reached sooner when breast milk is used, thereby
decreasing the total days of total parental nutrition (TPN) needed
and the potential for TPN-induced side effects. 125
The protective properties of breast milk cannot be duplicated. Signif-
icantly decreased risks of necrotizing enterocolitis (NEC), sepsis, and
retinopathy of prematurity (ROP) have been demonstrated when breast
milk is used for enteral feedings.126 Additionally, deeper nuclear gray
matter brain volume and better IQ, improved academic achievement,
working memory, and neurodevelopmental outcomes have also been
found in preterm infants fed breast milk. 127,128 Because of the many
documented benefits of human milk for the preterm infant, supporting
mothers in the initiation and maintenance of adequate breast milk
supply should be a major focus in the NICU.
When mother's own milk is not available or is contraindicated,
donor human milk is strongly recommended for this vulnerable pop-
ulation. Even when adequate breast milk is available, most prema-
ture neonates in the NICU learn to eat via nipple (bottle) feeding.
Immature feeding is a common reason for prolonged hospital stays
for premature infants and persistent poor feeding can result in hos-
pital readmissions. Maturational and developmental issues in pre-
mature infants affect oral feeding success because only 53% of brain
cortical volume is present at 34-week gestation when an infant is
just beginning oral feeds.
Oral feeding is a complex task for premature infants and requires a
skilled caregiver in assisting the infant in achieving a safe, effective,
and pleasurable feeding experience. Infant-driven feeding scales that
addresses feeding readiness, quality of feeding, as well as developmen-
tally supportive caregiver interventions are beneficial when initiating
oral feedings in the premature neonate. Goals for successful infant-
driven feedings are that oral feedings be safe, functional, nurturing,
and individually and developmentally appropriate.47 State organization
and ingestive behaviors are regulated by the same autonomic nervous
system. The autonomic control of the stomach includes a cephalic
phase that prepares the stomach for food, followed by a gastric phase.
The cues for these phases are primarily olfactory, but also linked to
state organization; therefore, consideration should be given to matching
the neonate's feeding schedule to his own sleep cycle, rather than the
clock.129
Educating staff and parents about infant cues and specialized
feeding techniques for breastfeeding and bottle feeding are essential
as they are the foundation for continued success and prevention
of future oral aversions. 130 As with the previous core measures, a val-
idated tool (feeding readiness, quality of feeding, and caregiver tech-
niques) should be utilized to promote consistency in assessing
readiness, evaluating quality, as well as caregiver efforts and
techniques. 131
Breastfeeding difficulties can impact the fragile mother–infant
relationship; therefore, providing support for breastfeeding mothers in
learning to feed their preterm infants at the breast, as well as learning
to feed with a bottle (with expressed breast milk or preterm formula)
is important and should not be left for the day of discharge. 132 Daily
skin-to-skin contact/holding can facilitate early “practice” breastfeeding
sessions for mothers and babies. Assuring that breastfeeding infants are
competent and mothers are comfortable with breastfeeding well before
discharge should be a priority.
236 L. Altimier, R. Phillips / Newborn & Infant Nursing Reviews 16 (2016) 230–244
Neuroprotection for NICU Staff
Working in the NICU is, by nature, a highly stressful job and rates
of burnout and compassion fatigue are high among NICU staff.
Protecting the mental health of NICU staff is not only important for
their personal wellbeing, but ultimately protects the quality and in-
tegrity of their work in caring for babies and families. When efforts
are made to support staff, job satisfaction increases and employee
turnover decreases.
Because of the highly technical nature of medical care in the NICU,
much attention is paid to clinical training, but relatively little training
is provided on optimizing interpersonal relationships, communication
and teambuilding and almost no training is given on how to educate,
coach and mentor parents and families of babies in the NICU. In the in-
tegrative, family-centered developmental care model, NICU staff mem-
bers are asked to educate, coach and mentor parents to become active
participants in their infant's care and are also expected to provide active
listening and psychosocial support to parents as they negotiate the crisis
of having a baby in the NICU. This is a monumental task with short- and
long-term implications for the quality of life during the NICU admission
for both parents and NICU staff, which can ultimately influence the
baby's health and well-being. NICU staff cannot be expected to pro-
vide this quality of care without specific and ongoing education and
training. Equipping NICU staff with the skills necessary to educate,
coach, mentor and support parents to provide NICU staff with the
support they need, is critical to the success of family-centered de-
velopmental care.
Mental health professions should be an integral part of the NICU
team and not only support parents, but can also enhance support for
staff. Comprehensive psychosocial support requires interdisciplinary
collaboration. 133 Providing psychosocial support to parents whose in-
fants are hospitalized in the NICU can provide parents' functioning as
well as their relationships with their babies. 134
Staff members who develop burnout may have further reduced abil-
ity to provide effective support to parents and babies. 134 Education
about self-care and recognizing signs of burnout and compassion fa-
tigue can be provided by mental health professions. Staff should be sup-
ported in ethical decision making and coached in sorting out personal
and NICU family moral values that may differ. Debriefings and “pauses”
after stressful events can provide peer support for NICU staff.
To support the entire interdisciplinary team from a psychosocial per-
spective, a multidisciplinary workgroup of professional organizations
and NICU parents was convened by the National Perinatal Association,
which included six interdisciplinary committees (family-centered de-
velopmental care, peer-to-peer support, mental health professionals in
the NICU, palliative and bereavement care, follow-up support and staff
education and support). Each committee developed recommendations
for program standards related to each of the above stated topics to pro-
mote the psychosocial support of parents with babies in the neonatal in-
tensive care unit.63,64,133–138
Perhaps the most important aspect of “neuroprotection” for NICU
staff is frequent, regular, and sincere appreciation for their dedication
and the quality of care they provide in the NCIU. Both private and public
acknowledgements of ongoing and extraordinary efforts can boost mo-
rale and motivate staff to continue to improve the care they provide to
babies and families in the NICU.
Transforming Practices through Quality Improvement
Creating an organizational structure that promotes patient safety
and achieves quality outcomes requires shared accountability and
teamwork within organizations. Applying a systematic approach to im-
proving key processes is the most effective strategy for reliably identify-
ing the source of problems and testing changes designed to improve and
sustain change. It is always challenging to find ways to translate ideas
into actionable change at the frontline where patient care can be
impacted. Utilizing Edward Deming's PDSA cycle is an effective model
for learning and change management. This model incorporates the ap-
plication of Plan, Do, Study, Act (PDSA) in order to help teams improve
the quality of care. Improving quality is about making healthcare safer,
more efficient, patient-centered, timely, effective and equitable. The
PDSA cycle can help identify, describe, and provide structure for a natu-
ral process whereby groups/teams initiate change within their system.
Using this explicit framework for managing a change program ensures
the team does not drift from the initial objectives, and also ensures ac-
tual achievable and valid measurements are identified. Clinically ad-
vanced neuroprotective interventions related to SSC, each of the 7
core measures, as well as to promote teamwork, are further outlined
in Appendix A.39,139,140
This model of quality improvement emphasizing change manage-
ment principles related to neuroprotective practices has been utilized
worldwide via the Wee Care Neuroprotective NICU Program (Wee
Care; Philips).141 The Wee Care training and consultative program com-
bines evidence-based practices with seven core measures for neuropro-
tective family-centered developmental care aimed at standardizing
neuroprotective care practices in the NICU. The Wee Care program,
which trains all NICU staff, has been shown to improve noise and light
levels in the NICU, improve infant medical outcomes, improve staff sat-
isfaction/engagement, improve family satisfaction, decrease length of
hospital stay, and decrease hospital costs. 40,44,45,47,142 Facilitating the
best outcomes for premature infants and their families has been
achieved by optimizing the NICU environment, caregiving practices,
caring for staff, as well as families. 39,40 The identification of overarching
goals with defined aim statements for each core measure has assisted
many NICUs across the globe in providing a structured approach to
changing and maintaining their neuroprotective family-centered devel-
opmental care practices. An example of a PDSA action plan is outlined in
Appendix B.
Summary
High-risk infants are both dependent on and vulnerable to the NICU
environment. While dependent on the NICU for the maintenance of
their physiologic functions during recovery from the insult of being
born too soon, they are also vulnerable to all the stressors inherent in
having fetal development occur outside the womb in the artificial envi-
ronment of the NICU. As the preterm infant matures, the quality of the
environment in which the infant resides plays a critical role in the tra-
jectory of recovery, growth and development.
Learning the principles of neurodevelopment and understanding the
meaning of preterm behavioral cues make it possible for NICU care-
givers and parents to provide individualized developmentally appropri-
ate, neuroprotective care to each infant. Partnering with families and
restoring parent–infant attachment supports both physiologic and
emotional stability of infants and their parents. Providing gentle con-
tainment, supportive boundaries, and flexed positions, all help to simu-
late the womb that was lost prematurely. By minimizing stress and pain,
safeguarding sleep, protecting skin and optimizing nutrition, NICU care-
givers can enhance the daily experience of the infants in their care and
increase the chances of achieving optimal physical, cognitive, and emo-
tional outcomes. NICU staff do not learn these skills during their clinical
training and require specific education in neuroprotective, family-
centered, developmental caregiving theory and practice. They also
need education on how to provide psychosocial support and effectively
communicate with families who are experiencing the crisis of having a
baby in the NICU. It is important to “care for the caregiver” by providing
NICU staff with the support they need due to the stressful nature of
working in the intensive care setting.
Changes in developmental care can often begin with a few moti-
vated caregivers altering the way they care for premature infants.
Role modeling, mentoring, and collaboration are key in the promo-
tion of optimal developmental care. An overarching goal is to achieve
 L. Altimier, R. Phillips / Newborn & Infant Nursing Reviews 16 (2016) 230–244 237

Appendix A. Advanced clinical applications of neuroprotective interventions related to the seven core measures of neuroprotective family-centered
developmental care.

Core measure #1: Healing environment34,37,38,51,57,133,135,139

Standard: A policy/procedure/guideline on the healing environment including physical space and privacy as well as the protection of the infant's sensory system exists and is
followed throughout the infant's stay.

Infant characteristics Goals Neuroprotective interventions

Stability of the infant's autonomic,
sensory, motoric, and state regulation
systems
An environment will be maintained that
promotes healing by minimizing the
impact of the artificial extrauterine NICU
environment on the developing infant's
brain
General:
• Educate, coach, and mentor parents on the importance of creating a
healing environment that protects the developing sensory system of the
preterm infant. Emphasize the central role of parents in the healing
environment.
Skin-to-skin contact:
• Facilitate early, frequent, and prolonged skin-to-skin contact (SSC)
• Encourage zero-separation between parents and infant
• Provide comfortable and safe reclining chair or adult bed for early, frequent,
and prolonged SSC
Space:
• Maintain a private and safe environment for the infant and family that consists
of a minimum of 120 sq. ft. per patient
• Provide organized, non-cluttered space for the family to support
comfortable and private caregiving
• When renovations are planned, advocate for single family rooms (SFR) and
promote utilization of the latest standards from the “Recommended Standards
for Newborn ICU Design” at http://www3.nd.edu/~nicudes
Tactile:
• Provide a neutral thermal environment for the infant incorporating the
following factors:
• Facilitate early, frequent, and prolonged skin-to-skin contact.
• If ELBW, provide humidity during the first one - two weeks after birth
• Provide care in incubator or SSC until infant can maintain own temperature
Vestibular:
• Change infant's position gently and slowly without sudden movements
• Eliminate moving infants to different bed-spaces to accommodate
staffing patterns
Olfactory:
• Maintain a scent-free & fragrance-free unit
• Minimize exposure to noxious odors
• Expose infant to mother's scent when possible via breast pad, or soft cloth,
Gustatory:
• Position infant with hands near face
• Provide colostrum or expressed breast milk (EBM) oral care per protocol
• Provide positive oral feeding experiences as outlined in “Optimizing Nutri-
tion” section
Auditory:
• Support infants with consistently calm, relaxing environment with muted
sounds during caregiving interactions
• Be mindful of own voice and other sounds produced in the NICU
• Monitor sounds levels to maintain average sound levels of 45 dB
• Silence alarms as quickly as possible and avoid unnecessary alarms
• Comfort crying infants as quickly as possible
• Expose infant to audible maternal/paternal voice
Visual:
• Provide adjustable light levels up to a maximum of 60 fc
• Gently shield infant's eyes during cares if overhead light is needed
• Be mindful of structuring an infant's visual field to support alert wakefulness
as appropriate, transition to sleep, or quiet, restful sleep
• Minimize purposeful visual stimulation until 37 weeks gestation
Overall healing environment:
• Consider all sources of light, sound, movement, smell and taste
confronting an infant during care, and eliminate all inappropriate or
unnecessary sources of stimulation
• Create and implement an individualized developmental care plan for each
infant
• Provide guidance to parents on how to create and sustain a healing
environment with respect to sensory exposures and experiences
• When renovating the NICU environment, advocate for optimal family support spaces
and resources

Core measure #2: Partnering with families36,49,61,81,133–135,137,141

Standard 1: A policy/procedure/guideline on partnering with families to include unlimited access to ensure around-the-clock information and access to their baby exists and is
followed throughout the NICU.
Standard 2: There is a specific mission statement addressing partnering with families.
Standard 3: NICU staff are competent in educating, coaching and mentoring parents in infant caregiving skills and in providing psychosocial support to NICU families.

Infant characteristics Goals Neuroprotective interventions

Infant's response to • Family-centered care is supported • Facilitate early, frequent, and prolonged skin-to-skin contact
parental interactions from birth or as soon as a NICU stay is • Encourage zero-separation between parents and infant
anticipated (antenatally if possible) • Educate, coach, and mentor parents in becoming active participants
in their baby's care in supporting their infant's developmental goals

(continued on next page)

(continued on next page)
238 L. Altimier, R. Phillips / Newborn & Infant Nursing Reviews 16 (2016) 230–244
(continued)
Appendix A. (continued)
Core measure #1: Healing environment34,37,38,51,57,133,135,139
• Parents will NOT be viewed as “visitors”
but as equal & vital members of the
caregiving team with zero-separation
supported and encouraged (24hr/d)
• Parents will be supported & encouraged
as the primary and most important
caregivers for their infant, incorporating
them as full participatory, essential
healing partners
within the NICU caregiving team
• Infant will develop emotional connection
& secure attachment with parents
• Parents who lose a baby before, during,
or shortly after birth, or later in the NICU
will be supported at all points of care
Core measure #3: Positioning & handling:36,37,92,133,137
Standard: A policy/procedure/guideline on positioning & handling exists and is followed throughout the infant's stay that includes educating, coaching and mentoring parents
on how to position and handle their infant.
Infant characteristics Goals
• Autonomic stability • Autonomic stability will be maintained
during handling throughout positioning changes and
• Ability to maintain handling activities as well as during
tone and flexed periods of rest and sleep.
postures with and • Parents will be educated, coached, and
without supports mentored in how to position and handle
their infant
• Preventable positional deformities will
be eliminated or minimized by main-
taining infants in a midline, flexed,
contained, and comfortable position
throughout their NICU stay
• Support families with a warm, respectful, and welcoming manner
• Acknowledge where the family is in regards to stages of grief and loss and
provide individualized and appropriate resources as needed
• Actively listen to families' feelings and concerns (both verbal and
non-verbal)
• Incorporate parents as full participants in parenting their baby in the NICU
• Encourage families to personalize their infant's bed space and make
the NICU environment more home-like
• Encourage participation in medical rounds and nursing hand-offs
• Share information with families in a tone of voice that preserves
confidentiality
• Honor both Health Insurance Portability and Accountability Act (HIPPA) and
safety concerns while in the NICU
• Provide parents with full access and input to both written and electronic
medical records
• Accommodate the presence of families in the NICU and seek ways to endure
their comfort
• Include and support sibling and extended family participation as
desired by parents
• Communicate the infant's medical, nursing, and developmental needs in a
culturally appropriate and understandable way, avoiding acronyms and
medical jargon
• Educate parents on infant attachment, language development, developmental
and safety issues and infant behavioral cues (appropriate for their infant's ges-
tational age)
• Support breastmilk expression and breastfeeding
• Provide social networking opportunities for parents of infants in the NICU
• Provide peer-to-peer support with parents who have gone through similar
NICU experiences
• Encourage and empower parents as they develop confidence in their own
abilities to continue caring for their baby when going home
• Provide anticipatory guidance regarding grieving and risks/symptoms of
postpartum depression and PTST to mothers and fathers, and other
family members, recognizing they all may process the NICU experience
differently
• Provide psychosocial support for all members of the family, including
grandparents and the baby's siblings
• Provide staff education related to principles of family-centered care and how
to support parents' caregiving roles
Neuroprotective interventions
• Facilitate early, frequent, and prolonged skin-to-skin contact
• Educate, coach, and mentor parents in how to position, contain
and handle their infant in a developmentally appropriate manner.
• Provide infants with positioning supports needed to maintain
optimal tone and position and to remain either in a quiet,
restful sleep or a relaxed, comfortable wakefulness.
• Utilize a validated & reliable positioning assessment tool [i.e. Infant
Positioning Assessment Tool (IPAT)] routinely to ensure appropriate
positioning and encourage accountability.
• Maintain a midline, flexed, contained, and comfortable position at
all times utilizing appropriate positioning aids and boundaries
• Provide appropriate ventral support to ensure flexed shoulders/hips
• Provide swaddling when bathing and weighing.
• Avoid doing procedures with infant in a prone position where
he/she is unable to use self-comforting abilities
• Anticipate, prioritize, and support the infant's individualized
needs during each care-giving interaction to minimize stressors
known to interfere with normal development.
• Engage with infant and let behavior of infant guide care.
Do cares “with the infant, rather than “to” the infant.
• Assess infant sleep–wake cycle to evaluate appropriate timing
of positioning and care.
• Reposition infant with cares and minimally every 4 hours
• Provide 4-handed support during positioning and caring activities
• Promote hand to mouth/face contact
• When providing caregiving activities:
• Collect all supplies prior to approaching infant so infant is not
left unattended or unsupported once hands-on care has begun
• Seek another person to support infant care during a potentially
stressful experience, including bathing and weighing.
• Include parents in providing support when available and willing.
 L. Altimier, R. Phillips / Newborn & Infant Nursing Reviews 16 (2016) 230–244 239

(continued)
Appendix A. (continued)
Core measure #1: Healing environment34,37,38,51,57,133,135,139

• The caregiver sees her or himself in partnership "with" the baby so that
caregiving procedures are performed “with” the infant rather than “to” the
infant.
• Infants will be provided developmentally appropriate stimulation/play as
they mature (i.e. mobiles, swings, etc.)

Core measure #4: Safeguarding sleep36,96,97,133,137

Standard 1: A policy/procedure/guideline on safeguarding sleep exists and is followed throughout the infant's stay.
Standard 2: A policy/procedure/guideline on back-to-sleep practices exists and is followed prior to discharge.

Infant characteristics Goals Neuroprotective interventions

• Infant sleep–wake states, cycles, and
transitions
• Infant's maturity and readiness for
back-to-sleep protocol
• Infant sleep–wake states will be
assessed before initiating all
caregiving activities
• Prolonged periods of uninterrupted
sleep will be protected
• Infants will be transitioned to
back-to-sleep when
developmentally appropriate
• Facilitate early, frequent, and prolonged skin-to-skin contact
• Educate, coach, and mentor parents on sleep-wake states and how to
safeguard their baby’s sleep, recognizing the importance
of sleep for healing, growth and brain development
• Utilize a validated & reliable scale to assess sleep-wake states to promote sleep
• Recognize and protect sleep cycles, especially REM sleep
• Promote a quiet environment to ensure uninterrupted sleep.
• Avoid sleep interruptions from bright lights, loud noises,
and unnecessary disturbing activities.
• Protect quiet sleep states by providing flexibility in timings of care
• Engage with infant and let behavior of infant guide care
• Individualize all caregiving activities by clustering cares based on infant sleep–wake
states. Take care not to over-stress infant with too many clustered cares at once.
• If necessary to arouse a sleeping infant, approach using a soft
voice/whisper followed by gentle touch
• Support smooth transitions back to restful sleep before stepping away from
bedside
• Protect infant's eyes from direct light exposure and maintain low levels of
ambient light
• Use incubator covers to protect the infant from direct light
• When developmentally appropriate, provide some daily exposure to light, pref-
erably including shorter wavelengths, for entrainment of the circadian rhythm
• Avoid (when possible) high doses of sedative and depressing
drugs which can depress the endogenous firing of cells thus,
thus interfering with visual development, REM, and NREM
sleep cycles, and thus optimal brain development.
• Provide developmental care appropriate for the age and maturation of the
infant including supportive positioning to promote restful sleep
• Assure infant is able to maintain normal sleep pattern during back-to-
sleep well before discharge and role model this behavior in the NICU
• Provide tummy-time/prone-to-play time routinely for infants that are
Back-to-Sleep
• Coach, educate, and mentor parents about the importance
and rationale for back-to-sleep and tummy-time

Core measure #5: Minimizing stress & pain36,115,133,137,142-145

Standard: A policy/procedure/guideline on the assessment and management of pain exists and is followed throughout the infant's stay.

Infant characteristics Goals Neuroprotective interventions

Behavioral cues indicating
stress or self-regulation
• Promote self-regulation and
neurodevelopmental organization
• Reduce excessive stress and
pain in the NICU
• Facilitate early, frequent, and prolonged skin-to-skin contact
• Educate, coach, and mentor parents on infant cues related to stress and
pain and how to provide their infant with nonpharmacological support
during stressful or painful procedures
• Provide individualized care in a manner that anticipates, prioritizes, and
supports the needs of infants to minimize stress and pain
• Utilize a validated & reliable pain assessment tool to
evaluate the need for pharmacologic support
• Regularly evaluate the clinical need for frequent labs and procedures, and reduce
the excessive number of stressful/painful procedures whenever possible.
• Provide non-pharmacologic support (breastfeeding, skin-to-skin contact,
sucrose, pacifier) prior to/ with all minor invasive interventions
• Provide midline, flexion, and containment with all positioning (whenever
possible) to promote comfort
• Provide therapeutic positioning aids to maintain supportive positioning
• Provide guidance to parents on how to collaborate with NICU
staff to minimize their baby's stress and pain
• Invite parents to help support their baby during painful
procedures if they are available and willing to participate
• Reserve parenting activities for parents (feeding, diapering, etc.)

Core measure #6: Protecting skin36,120,121,133,137

Standard: A policy/procedure/guideline on skin care exists and is followed throughout the infant's stay.

Infant characteristics Goals Neuroprotective interventions

Maturity and integrity • Reduce trans-epidermal water loss • Facilitate early, frequent, and prolonged skin-to-skin contact
of infant skin of ELBW infants

(continued on next page)

240 L. Altimier, R. Phillips / Newborn & Infant Nursing Reviews 16 (2016) 230–244

(continued)
Appendix A. (continued)
Core measure #1: Healing environment34,37,38,51,57,133,135,139

• Maintain skin integrity of the
infant from birth to discharge
• Provide developmentally appropriate
infant massage
• Educate, coach, and mentor parents on skin care, swaddled
bathing, and delivery of developmentally appropriate infant massage
• Utilize a validated & reliable skin assessment tool
on admission and routinely according to hospital protocol
• Provide humidity for ELBW infants during the first one - two weeks
after birth (50% humidity is provided when infant is in skin-to-skin contact)
• Provide appropriate positioning support utilizing gel products and other
positioning aids to prevent skin breakdown
• Examine position of nasal prongs per protocol to protect
against breakdown of nasal septum
• Minimize use of adhesives and use caution when removing
adhesives to prevent epidermal stripping
• Avoid soaps and routine use of emollients
• Use only water for bathing b1000 gram infants
• Use pH neutral cleansers for bathing N1000 gram infants
• When bathing, do swaddled bathing in bed or tub
(to reduce stress and promote relaxation) with overhead
warmer (to prevent risk of hypothermia).
• Provide bathing no more than every 72 to 96 hours
• Priority should be given to parents to bathe their own
infant whenever possible
• Provide parents guidance on how to protect their baby's
skin and its many functions, including its role as a conduit
of neurosensory information to the brain
• Teach parents how to give developmentally appropriate infant
massage to promote relaxation, bonding and attachment

Core measure #7: Optimizing nutrition36,61,131,133,137

Standard 1: A policy/procedure/guideline on optimizing nutrition using cue-based/infant-driven breast or bottle feeding (which includes infant readiness, quality of feeding and
caregiver techniques) is followed throughout the infant's stay.
Standard 2: A policy/procedure/guideline on skin-to-skin contact (kangaroo care) exists and is followed throughout the infant's stay.

Infant characteristics Goals Neuroprotective interventions

• Physiologic stability with
feeding & handling
• Feeding readiness cues
• Coordinated suck/swallow/
breathing (SSB) throughout
breast or bottle feeding
• Endurance to maintain
nutritional intake and
support growth
• Feeding will be safe, functional,
nurturing, and developmentally
appropriate
• Optimized nutrition will be enhanced
by individualizing all feeding care
practices
• Oral aversions will be prevented by
assuring feeding is a positive experi-
ence for infant
• First oral feeds will be at the breast
for babies whose mothers are
pumping their milk
• Infants of breastfeeding mothers will
be competent at breastfeeding
prior to discharge
• Facilitate early, frequent, and prolonged skin-to-skin contact
• Educate, coach, and mentor parents about positive oral
stimulation, infant feeding cues, and feeding techniques
• Promote positive oral/olfactory stimulation during early
skin-to-skin contact by letting infant lick, nuzzle and
smell the nipple if interested
• Minimize negative perioral stimulation (adhesives, suctioning, etc.)
• Utilize indwelling gavage tubes rather than intermittent tubes.
• Promote Non-Nutritive Sucking (NNS) at mother’s pumped
breast during gavage feeds
• Hold infant and use NNS with appropriate sized pacifier
during gavage feeds when mother is not available.
• Provide taste and smell of breast milk, if available,
with gavage feedings
• Utilize validated & reliable Feeding-Readiness and
Infant-Driven Feeding tools, and involve parents in assessments
of feeding readiness and quality of feeds.
• Ensure every feeding experience is a positive, pleasant,
and nurturing experience
• Educate parents about the medical importance of breast
milk for most infants, especially for ELBW infants.
• Support and encourage mother’s expressed breast
milk (EBM) supply
• Provide donor human milk for ELBW infants (whenever possible) if mother's
milk is not available or is contraindication.
• Ensure first oral feeding is at the breast for baby’s whose
mothers have been pumping their breast milk
• Support and encourage competent breastfeeding well
before discharge
• Promote side-lying position close to parent/caregiver
when bottle-feeding
• Provide guidance to parents on how to provide supportive
oral feeding experiences for their infant, including
positioning and pacing

Teamwork & collaboration131–134,137,139

Standard 1: An interdisciplinary team of caregivers works together collaboratively to support the medical, developmental and psychosocial needs of infants and families.
Standard 2: Hospital leadership facilitates staff education and training related to Neuroprotective Family-Centered Developmental Care principles and practices, including how
to educate, coach and mentor parents in the care of their infants during NICU hospitalization.
Standard 3: A policy/procedure/guideline on roles and responsibilities of team members and collaboration thereof exists and is followed.

Infant characteristics Goals Neuroprotective interventions

Infant and family are central • An individualized developmentally • Support parents as the primary caregivers by educating,
to each team member's appropriate environment is coaching, and mentoring them in parenting their
plans, decisions and caregiving provided for every infant and family babies in the NICU
 L. Altimier, R. Phillips / Newborn & Infant Nursing Reviews 16 (2016) 230–244 241

(continued)
Appendix A. (continued)
Core measure #1: Healing environment34,37,38,51,57,133,135,139

• Each parents is viewed as an active
member of the caregiving team
• All staff members are equipped with
the knowledge and skills they need to
care for babies and support parents
and families
• All staff members are supported in self-
care to
prevent burn-out and compassion fatigue
• Support parents in being active members of the caregiving team
• Include parents in all medical decision making
• Provide as much space and comfort as possible for family caregiving,
keeping charts and equipment well organized and avoiding clutter
• Consistently share information about infant’s behavioral
competencies, vulnerabilities, thresholds and parental
involvement when communicating with colleagues during
medical rounds or staff shift change
• Prior to performing a procedure, care, or exam on an infant
under the care of another team member (or parent), discuss the needs
of that team member to mutually agree on the timing
• Respect and support the roles of other individuals and
disciplines when caring for infants – support each other
through mentoring relationships
• Willingly and proactively assist colleagues to provide support
for infants in their care during potentially stressful procedures
• Ensure all infants and families are treated consistently
with support, dignity, and respect by all team members, and
constructively confront team members if discrepancies are noted
• Educate and train staff in all disciplines on neuroprotective
family-centered developmental care principles and practices
• Educate staff about methods for improving and expanding
family-centered developmental care in the NICU
• Educate staff on the differences and value of cultural
practices other than their own
• Educate staff on active listening skills and other optimal
methods of communication with parents in distress
• Educate staff about stages of grief and risks of postpartum
depression and PTSD in NICU parents and staff
• Educate and support staff on elements of self-care to
proactively prevent and minimize burn-out and compassion fatigue
• Have a program to regularly acknowledge and appreciate
the NICU staff and the work they do for babies and families

Appendix B. PDSA for Core Measure #3: Positioning and handling.

Goals Aim Plan Do: (actions) Do (contact) Timeline Comments Rewards

updates consequences

Goal CM #3: 1. 100% of infants 1. Positioning of each 1. Educate staff on: 1. Educator/DC 1. Jan. 10–Mar. Measurement: Rewards: Staff will
Positioning & will be positioned infant will be assessed a. Principles of positioning champion #1 10 1. Scoring on receive a "Shout-Out"
handling in a midline, flexed and scored utilizing b. use of positioning aids (Beth/Jane) IPAT will be note from the DC team
and contained the Infant Positioning c. IPAT tool 2. Jan. 5 10–12 on for scoring 100% on IPAT
position with an Assessment Tool Use 2. Educator (Beth) 100% of audit scores of 10 - 12
IPAT score between (IPAT) every shift and 2. Document staff 3. Jan. 5 infants during designated audit
10 and 12. twice a week by competencies on 3. DC champion #2 period.
audit team or Positioning and (Joe) 4. Jan. 10
Developmental Care handling Consequences: Staff will
(DC) champion 4. DC champion #3 5. Feb. 1 be coached on any
3. Create NICU /supply tech IPAT scores of b 10
guideline on 6. Mar. 1 during the designated
positioning 5. EMR rep/IS audit period.
support 7. Mar. 1 If Behavior continues,
4. Create par level manager will counsel
of positioning supplies 6. DC champion #4 staff and manage
with appropriate (with QI support) performance.
supply and access
7. DC champion #4
5. Incorportate IPAT (with QI support)
into NICU documentation
8. DC lead/educator/
6. Create audit tool for manager
measuring positioning
of infants

7. Prepare dashboard for

reporting IPAT audit scores
to enable trend analysis

8. Create communication
plan for all staff/families)
Status update/communication
Date Update

(continued on next page)

242 L. Altimier, R. Phillips / Newborn & Infant Nursing Reviews 16 (2016) 230–244
Appendix C. Quick Tips for all NICU Staff.
Core Measure 1: Healing Environment
A healing environment protects the developing sensory system of preterm infants
a) Protect auditory system by minimizing noise
• Talk in a “library voice” when near bedsides
• Keep pagers and phones on vibrate
b) Protect visual system by minimizing direct light
• Cover baby’s eyes during exams and procedures
• Be sure isolette covers and blankets protect from direct light
c) Protect olfactory system by minimizing odors
• Let hand sanitizers dry before putting hands inside isolette
• Leave perfumes and colognes at home to maintain a fragrance-free NICU
d) Protect vestibular and tactile system
• Use slow gentle movements during handling
e) Skin-to-skin contact (SSC) provides the most healing environment
• Facilitate early, frequent, and prolonged skin-to-skin contact
Core Measure 2: Partnering with Families
Parents are the most important caregivers in a baby’s life
a) Go out of your way to make parents feel welcome in the NICU
• Always greet parents and introducing yourself with name and role
• Having a baby in the NICU is usually an unexpected crisis for families
• Expect the need to repeat conversations and explanations more than once
• Use lay language free from acronyms when talking with parents
b) Involve parents as active members of the caregiving team
• Educate, coach and mentor parents in caring for their baby in the NICU
• Include parents in medical rounds and nursing shift change discussions
• Ask parents how they think their baby is doing – then listen
c) Skin-to-skin contact helps to heal the wounds of interrupted bonding and attachment
• Recognize importance of parent-infant attachment on brain development,
frequent, and prolonged skin-to-skin contact
Core Measure 3: Positioning and Handling
Positioning should mimic the fetal position in the womb
a) Maintain head in a midline position
• Be extra vigilant with ventilated ELBW infants
• Ask RT to help reposition ETT and/or reposition infant if needed
b) Maintain limbs and trunk in flexed, tucked position
• Gently reposition infant after extending limbs during exams/procedures
• Reposition infant in positioning aid after exams/procedures
c) Handle preterm and sick infants with slow, gentle movements
• Ask for help with procedures or complicated handling
• Ask staff or parent to provide 4-handed support if needed
d) Skin-to-skin contact is the “natural habitat” for all newborns
• Skin-to-skin contact is the closest to being back inside the womb
• Facilitate early, frequent, and prolonged skin-to-skin contact
Core Measure 4: Safeguarding Sleep
Sleep is essential for healing, growth, and optimal brain development
a) Never waken a sleeping baby unless absolutely necessary
• Support long periods of restful, uninterrupted sleep whenever possible
• Time routine cares/exams to coincide with baby’s sleep/wake cycles
b) Protect sleep states by minimizing noise and light
• Talk in a “library voice” when near bedsides
• Be sure direct light is not shining on sleeping babies
c) Skin-to-skin contact promotes the most optimal sleep cycles
• Remember - newborns sleep best when in skin-to-skin contact
• Facilitate early, frequent, and prolonged skin-to-skin contact
Core Measure 5: Minimizing Stress and Pain
Stress and pain are part of NICU life – but both can be minimized
a) Supporting a healing environment helps to minimize stress
• Protect babies from excess noise and light
• Talk in a “library voice” and cover baby’s eyes during exams
• Watch for signs of stress during exams and pause when possible
- Extended digits and limbs indicates stress
- Excessive tone or absence of tone indicates stress
b) Use positioning and boundaries to provide containment
• Be sure baby is well-contained during exams and procedures
• Be sure baby is repositioned properly after exams and procedures
Appendix C. (continued)
c) Use extra supports during painful procedures
• Ask staff or parent to provide 4-handed support when needed
• Many parents are willing and eager to help support their baby
• Give them a chance to participate if they are available and willing
d) Be sure Sweet-Ease is given 2 minutes prior to painful procedures
• Understand mechanism of action (activation of endogenous opioid receptors.
• Understand absorption (via buchal mucosa - not via digestion).
e) Be sure adequate analgesics are given for painful procedures if needed
• Be proactive with post-op pain management
f) Skin-to-skin contact reduces stress and pain – Mother’s presence is analgesic
• Encourage early, frequent, and prolonged skin-to-skin contact
Core Measure 6: Protecting Skin
Skin is a conduit for nerve cells to send sensory messages to the brain
a) Monitor humidity level inside incubator during first week for ELBW infants
• Be sure humidity is provided until skin is keratinized - about 5-10 days
- Being skin to skin on mother’s chest provides about 50% humidity
b) Monitor nasal septum for skin breakdown if nasal prongs are used
• Check prongs frequently – there should be no pressure on septum
• Check septum each shift for erythema or breakdown
c) Monitor other susceptible skin areas
• Check mouth for oral thrush and diaper area for rash
• Check trunk/limbs for pressure ulcers and IV sites for erythema/infiltrates
d) SSC sends impulses to the brain to support maturation of the amygdala/limbic
system
• Encourage early, frequent, and prolonged skin-to-skin contact
Core Measure 7: Optimizing Nutrition
Human milk is the optimal diet for most human infants.
a) Discuss the medical need for breastmilk with parents whenever the opportunity
arises
• Explain how breastmilk is a medicine, especially for preterm infants
• Explain need for early/frequent pumping if baby is unable to breastfeed
b) Support mother’s early and continued milk supply
• Provide enthusiastic support for any breastmilk mother provides
• Explain the importance of ongoing pumping to maintain milk supply
c) Provide ongoing breastfeeding education and support
• Explain how important breastmilk is for healing and nutrition
• Explain how important breastmilk is for brain development and vision
• Explain how important breastmilk is to decrease risk of NEC and sepsis
d) Skin-to-skin contact increases breastfeeding initiation and duration
• SSC increases prolactin and oxytocin – both needed for lactation
• Facilitate early, frequent, and prolonged skin-to-skin contact
e) Cue-based, infant-driven feeding prevents later oral aversions
• Oral feedings should be safe, developmentally appropriate and nurturing
• Provide cue-based rather than volume feedings
- Monitor feeding readiness and signs of stress during feeds
f) Support breastfeeding well before discharge
• Babies can practice suckling when skin to skin whenever interested
• The first oral feeding should be at the breast if mother has been
pumping
• If term baby has excessive difficulty latching, get lactation support
- Check mouth for anomalies, e.g. cleft such as cleft palate or ankyloglossia (tongue-tie)
- If present, alert physician to get appropriate treatment
Guiding Principles
a) All infants are in a critical period of brain growth and organization
• Everything that happens in the NICU impacts brain development
• Providing excellent, evidence-based medical care is always our goal
• The manner in which we give it influences developmental outcomes
b) Neuroprotective developmental care is relational
• Treat every baby as a little human being who has their own unique
identity
• Do exams and procedures “with” the baby, not “to” the baby
• Notice individual differences and preferences in each baby
c) Emotional connection with parents is essential for optimal outcomes
• Parents are the most important caregivers for their baby in the long run
• Support parent-infant attachment in every way possible in the NICU
• Provide psychosocial support for NICU parents as needed
d) Skin-to-skin contact is the most fundamental form of neuroprotective care
• Skin-to-skin contact with mother is the “natural habitat” for all newborns
• Skin-to-skin contact supports all 7 of the Neuroprotective Core Measures
• Encourage and facilitate skin-to-skin contact whenever possible
 L. Altimier, R. Phillips / Newborn & Infant Nursing Reviews 16 (2016) 230–244
an effectively healing, peaceful, and satisfying environment for NICU
staff, families and the infants entrusted to our care.
Developmentally supportive care is sometimes perceived as
“nice,” yet optional. It is sometimes thought of as “fluff” in a primarily
technologically-driven environment. Ignorance of or dismissal of the
growing body of evidence about the importance of providing neuro-
protective care for preterm infants is no longer acceptable. Consis-
tent acceptance, practice, and accountability must be established to
provide the high-quality care every infant and family deserves. Use
of established guidelines, policies, and procedures to guide neonatal
practice is essential. Healthcare professionals must be cognizant
of the growing body of research regarding the impact of the NICU
environment on neurodevelopmental outcomes of premature and
sick infants.
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