Review
Developmental care: does it make a difference?
Correspondence to:
Dr P C Bustani, Jessop Wing,
Sheffield Teaching Hospitals,
Sheffield S10 2SF, UK; Porus.
bustani@sth.nhs.uk
Accepted 25 February 2008
Published Online First
11 March 2008
Arch Dis Child Fetal Neonatal Ed 2008;93:F317–F321. doi:10.1136/adc.2006.113407
P C Bustani
ABSTRACT
The term ‘‘Developmental Care’’ has been applied to a
wide range of interventions. These may be centred on the
nursing management of the infant, their environment or
family-based interventions. The short-term targets of
reducing infant stress and promoting stability have led to
hopes that long-term neurodevelopmental outcomes may
be improved by some or all of these practices. Thus far
the paucity of large clinical trials consistently demon-
strating positive outcomes has resulted in cynicism
among many clinicians. However, the generally positive
experiences of those units which have adopted many of
these practices have contributed to the spread of these
interventions in neonatal units. The emergence of large
well-conducted clinical trials may provide the evidence to
support or refute the outcome-based assumptions of
developmental care.
Developmental Care has generated both interest
and controversy amongst neonatologists. In con-
sidering whether developmental care can make a
difference, we first need to define what we mean
by it, and then consider which outcomes we deem
important.
WHAT IS DEVELOPMENTAL CARE?
There is no single definition of ‘‘Developmental
Care’’ and the phrase means different things to
different people. Definitions may include value-
based statements, such as ‘‘a philosophy and a way
of thinking that incorporates the infant and the
family’’; practice-based statements, such as ‘‘a
range of strategies designed to reduce the stresses
of the neonatal intensive care unit (NICU)’’1; or
outcome-based statements such as ‘‘in-hospital
care that aims to improve quality of life out-
comes’’.2 By stating an outcome-based definition,
however, there is an expectation that there should
be measurable evidence of success.
For some, the strategies proposed involve a series
of active interventions such as swaddling, kan-
garoo care, non-nutritive suckling or infant mas-
sage. Others place the emphasis on avoidance of
interventions or potentially noxious environmental
factors, such as excessive noise, bright lighting,
frequent handling and pain. The emphasis on
parent–patient relationships is another theme that
is often invoked as an example of good develop-
mental care. These individual factors can be
combined into a model of care, and a number of
units have adopted these measures as a package
either as part of developmental care guidelines, or
by investing in commercially available packages to
alter unit philosophy. Recently, the most common
interpretation of developmental care has been the
provision of all the above management strands
within an overall framework that is individualised
to the patient. This is exemplified by the Neonatal
Individualised Developmental Care and
Assessment Program (NIDCAP).
BIOLOGICAL BASIS FOR IMPROVED LONG-TERM
OUTCOMES
With increasing survival of premature infants,
greater emphasis is now being placed on improve-
ment of neurodevelopmental outcomes. Even in
the absence of disability, there are high reported
rates of difficulties in attention, behaviour and
cognition.3 Between 30 weeks’ gestation and term,
there is a massive expansion of the cortical grey
matter and rapid formation of synapses, and this
neuronal wiring can be influenced by external
factors.4 5 Paucity of stimulation, on the one hand,
or excessive stimulation, on the other, may be
deleterious.6 Additionally, frequent episodes of
transient hypoxia can result in neuronal apoptosis
and thus influence brain development.7 It has been
estimated that 75% of hypoxic episodes in preterm
infants are associated with the provision of care
giving.8 9
INTERVENTIONS AND EVIDENCE BASE
A recent Cochrane review analysed the range of
developmental care interventions available and
concluded that ‘‘before a clear direction for practice
can be supported, evidence demonstrating more
consistent effects of developmental care interven-
tions on important short-term and long-term
clinical outcomes is needed’’.1 The review covered
evidence both for specific interventions and care
programmes.
Positive interventions
Table 1 summarises the improved outcomes
achieved with the use of specific developmental
care interventions.
Positioning
Positioning, the practice of swaddling in preterm
infants, showed an improved Morgan Behavioural
Score at 34 weeks in the intervention group. No
other benefits were demonstrated.10
Massage
Six small randomised controlled trials (RCTs) of
the effects of massage involving a total of 274
patients of low birth weight demonstrated an
improved weight gain in the neonatal unit of 5 g/
kg/day. Length of stay was shortened by 4 days on
average11; however, concerns were raised about the
validity of the studies.
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Table 1 Improved outcomes associated with the use of specific developmental care interventions
Intervention Outcome
Swaddling Morgan newborn
neurobehavioural examination
Massage Weight gain
Length of stay
Kangaroo care Severe illness at 6 months
Not breast feeding exclusively 12
at discharge
Daily weight gain
Non-nutritive sucking Length of stay
Results as weighted mean difference (WMD) unless specified relative risk (RR). (Statistics computed with Comprehensive Meta-
analysis software, Biostat.)
Kangaroo care
Kangaroo care is common in the developing world, where
access to incubators is scarce. Theoretical benefits are heat
conservation and improved breastfeeding rates. Reported
benefits from studies include reduced infection rates by
41 weeks’ gestation and improved weight gain.12 This suggests
that these benefits may be secondary to improved breastfeeding
rates in the intervention groups. It is not apparent whether
there is benefit in the developed world, although its use is
becoming more widespread in the belief that it facilitates the
establishment of successful breast feeding and assists parental
bonding.
Non-nutritive sucking
Although the use of a pacifier during the establishment of oral
feeds is counterintuitive for some, the weight of evidence
supports this simple intervention. Length of hospital stay is
reduced by an average of 7 days, and there appears to be
improved transition to bottle feeds.13 As a practice, this has
gained widespread popularity among many UK units.
Avoidance of negative factors
For noxious events, it is much more difficult to prove an
improved outcome in a group of infants than it is to
demonstrate physiological instability in response to the factor
of interest. There are, however, recommendations based on
accepted best practice.
Noise
Loud noises are associated with desaturations in preterm
infants,8 while reduction in background noise by the use of
ear muffs has been shown to increase periods of quiet
sleep time.14 The American Academy of Pediatrics re-
commends avoidance of noise levels above 45 dB on an
NICU.15 Our own experience is that background noise levels
of above 50 dB and intermittent loud noises of up to 70 dB are
not uncommon.
Light
Guidelines on US NICU design recommend adjustable ambient
lighting, separate procedural lighting and at least one source of
daylight.16 Some experts suggest exposing infants to 200 lux
during the day and reducing to near zero at night to assist
development of circadian rhythms.17
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Patients Effect size
References (n) WMD Confidence interval
10 46 6.2 2.6 to 9.8
11 274 5 g/day 3.5 to 6.7
11 176 4.5 days 2.4 to 6.5
12 283 RR = 0.3 0.14 to 0.67
279 RR = 0.44 0.25 to 0.68
12 285 3.6 g/day 0.8 to 6.42
13 87 7 days 1.7 to 12
Procedural pain
Numerous studies have been carried out demonstrating
physiological stability associated with the use of local anaes-
thetic creams, use of spring loaded lances and administration of
breast milk or sucrose orally at the time of painful proce-
dures.18 19 Pain relief is now considered best practice.20
Combined approaches
A variety of developmental care approaches/interventions can
be combined and implemented on a neonatal unit. Although
little evidence is available from RCTs to support this, the
assumption is that if each individual component is beneficial,
then the sum of these parts may be greater than the whole.
Many North American units have adopted the ‘‘Wee-Care’’
programme where the company provides education on devel-
opmentally aware practices to every staff member on the unit,
including doctors, nurses, phlebotomists and cleaning staff.21
Some service evaluation has been published suggesting that
implementation of the programme was temporally associated
with a reduced incidence of retinopathy of prematurity,
bronchopulmonary dysplasia and in-hospital costs, primarily
through reduced time to discharge home.22 23 These packages are
relatively expensive when considered in the UK ‘‘market’’ and
have yet to make significant inroads into NHS trusts.
Parenting interventions have been studied with the premise
that developmental care can be delivered by parents in the
NICU and continued through to home with the aim of
improving neurodevelopmental outcomes by promoting more
sensitive and responsive parenting. The Parent–Baby Interaction
Program was studied within a multicentre randomised crossover
trial, but failed to demonstrate any measurable effects on infant
outcomes, parenting stress or mother–child interventions.24
NIDCAP
For many, NIDCAP has become synonymous with ‘‘develop-
mental care’’. Devised by Heideliese Als in 1986, the programme
was formulated around her observations of preterm infants’
responses to environmental factors and medical procedures.25
Rather than prescribing a standard series of environmental and
nursing measures, these were adapted according to the
responses of the infant to these interventions. The tool used
for these ‘‘prescriptions’’ is based on a prolonged period of
observation by a trained assessor watching for changes in status,
including physiology, motor patterns and state regulation. A
formal record of 91 related behavioural indicators are recorded in
Arch Dis Child Fetal Neonatal Ed 2008;93:F317–F321. doi:10.1136/adc.2006.113407

2-minute epochs before, during and after nursing care or
procedures. These cues are used to put together reports every
1–2 weeks providing a summary of each infant’s strengths and
weaknesses with recommendations detailing how to provide
maximum support to each infant without placing undue stress
on them. The underlying philosophy is that avoidance of
stresses in the environment provides physiological stability and
minimises interference with normal brain development while
providing adequate stimulation, thereby providing a basis for
improved long-term neurodevelopmental outcome.
Short-term physiological studies are the easiest to perform as
they enable infants to be used as their own controls in crossover
trials. Evidence has been provided in studies to demonstrate that
developmental care conditions result in improved sleep
patterns.26 Provision of developmental care by NIDCAP-trained
nurses during nursing procedures, such as weighing, reduced
neonatal discomfort or pain and heart rate variation while
maintaining cerebral oxygenation.27 There were fewer hypoxic
episodes associated with handling and mean saturations were
higher.28
Studies of NIDCAP throughout the course of a neonatal
admission have generally been of two types: the RCT that is
considered the ‘‘gold standard’’ for most doctors, and phase-lag
studies where two comparable cohorts are compared before and
after the introduction of a new practice to the neonatal unit. A
number of such studies looking at the effect of NIDCAP have
been performed, each with relatively small numbers of patients.
Two meta-analyses have been performed to look at these
outcomes. As these have been used by doctors primarily to help
decide whether to support the use of NIDCAP or not, it is
worth looking at these in some detail.
The meta-analysis by Jacobs et al in 20022 examined the two
types of outcome-based studies used for NIDCAP, the RCT29–33
and phase-lag study.25 34 35 Meta-analysis of both types of study
showed fewer days of supplemental oxygen required, earlier
establishment of oral feeds and improved neurodevelopmental
outcome at 9 months of age using Bayley scores. The RCTs
demonstrated improved outcomes in the incidence of severe
intraventricular haemorrhage and in weight gain, head growth
and number of days requiring intermittent positive pressure
ventilation (IPPV); however, these were not replicated in phase-
lag studies. Conversely, phase-lag studies suggested that
NIDCAP resulted in reduced incidence of chronic lung disease
(CLD) at 28 days, increased rate of retinopathy of prematurity
and poorer weight gain. Jacobs stated, based on these results,
that ‘‘there is insufficient evidence to support NIDCAP to
improve medical and neurodevelopmental outcomes of preterm
infants’’.
The Cochrane meta-analysis published in 2006 included the
earliest Als phase-lag study and recent RCT.25 36 They chose to
Table 2 Improved outcomes derived from meta-analysis of NIDCAP-based RCTs
Outcome References
IPPV days 26, 30, 32, 34, 38, 39
Length of stay 26, 30, 32, 37–39
9 Months–1 year Bayley PDI 30, 33, 34, 37
9 Months–1 year Bayley MDI 30, 33, 34, 37
Moderate/severe CLD 30, 34, 37
Results as weighted mean difference (WMD) unless specified relative risk (RR). (Statistics computed with Comprehensive Meta-
analysis software, Biostat.)
CLD, chronic lung disease; IPPV, intermittent positive pressure ventilation; MDI, mental development index; NIDCAP, Neonatal
Individualised Developmental Care and Assessment Program; PDI, psychomotor development index; RCT, randomised controlled
trial.
Arch Dis Child Fetal Neonatal Ed 2008;93:F317–F321. doi:10.1136/adc.2006.113407
Review
remove the study performed by Fleisher et al and placed it into
the category of ‘‘other individualised interventions’’; however,
the methods were based on NIDCAP.31 The results demon-
strated fewer ventilation days and reduction in moderate to
severe CLD. Neurodevelopment was improved as shown by
APIB scores (scoring system based on assessment at term
corrected),5 36 mental and psychomotor Bayley scores at
9 months corrected age and mental scores at 12 months of
age. The reporting of APIB as an outcome was in contrast to the
review by Jacob et al,2 which questioned the use of this measure
as an outcome proxy as correlation with long-term outcome had
not been sufficiently validated. Indeed, beyond 12 months of
age, few studies have had sufficient patient numbers or used the
same outcome measures as each other to be able to make valid
inferences. A three-centre RCT study by Als et al was excluded
owing to site differences; however, the results of each of the
sites were reported individually and, if included in the meta-
analysis, could contribute to the overall results.37
Recent abstract data from Edmonton in the largest RCTs to
date have shown significant improvements in short-term
outcomes (length of stay, IPPV days, CLD).38 Re-analysis
combining all appropriate studies together with some of the
Edmonton short-term data provides a summary of the positive
effects of NIDCAP-based interventions—namely, shorter dura-
tion of IPPV, earlier discharge, reduced incidence of moderate or
severe CLD and improved neurodevelopmental outcomes at 9–
12 months of age (table 2). Data from Edmonton suggesting
significant improvement in 18-month neurodevelopmental
outcome is eagerly awaited in a final publication.39
Both meta-analyses observed that studies were limited by the
small numbers of patients in each, the methods of recruitment
(RCT vs phase lag), the lack of blinding and concerns about spill
over of care from one group to the other. Some of these
problems will remain difficult to deal with in the future. For
units that adopt the RCT approach to research in this area, a
subgroup of nurses will have been trained in developmental care
and are likely to have a significant effect on the practices of their
colleagues. Additionally, the nature of the group of nurses who
undergo training for NIDCAP provision may in itself provide
another source of bias to studies. It is interesting to note that
one study was terminated in part because nursing staff became
convinced of the benefits of NIDCAP and subsequent difficul-
ties in continuing with provision of control practices.33 The
spillover effect was further potentiated as much of the
intervention was not directly applied to the baby, but to the
general environment, thus leading to progressive adoption of
practices during the course of studies such as reduced lighting,
noise and the clustering of medical interventions. This concept
of increasing spillover may explain why some of the medical
outcome differences noted in the earlier studies were reduced in
Patients Effect size
(n) WMD Confidence interval
322 28.2 days 24 to 212
331 29.7 days 23.9 to 215.5
102 +13.7 7 to 20
102 +15.6 10.6 to 20.6
89 RR = 0.42 0.19 to 0.93
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more recent studies conducted in the same centres (Als 1986-
2004).25 29 36 With time, the control group receives care that is
more in keeping with the ethos of developmental care and only
differs from the NIDCAP group in that formal individualised
behavioural reports are not produced. The only way to truly
avoid this effect is by the use of phase-lag studies; however,
there is then potential effect from other changes in practice that
may occur longitudinally. Glazebrook et al employed a multi-
centre crossover RCT approach to minimise longitudinal effects,
although it is again difficult to guarantee against certain nursing
practices being maintained in centres where the intervention
precedes the control arm.24
It is unclear how much of the benefit from NIDCAP results
from the formalised observations and resulting individual care
plans as opposed to the general practices of developmental care
encouraged by the programme. Certainly, repeated observations
have an additional role in that they encourage direct observation
by the NIDCAP specialist of the care giving itself, with close
involvement of the parents. This provides a powerful method
for ensuring sustained adherence to developmental care
practices. In support of this, Westrup et al reported an
‘‘impression that there is a clear decrease in the quality of
developmentally supportive care during periods without obser-
vations and care plans’’.40 This provides an alternative approach
to conducting an RCT whereby infants can be randomised to
development care practices as part of a multicentre cluster
crossover trial, similar to that carried out by Glazebrook et al.24
By specifically removing the direct observations involved in
NIDCAP, one can quantify how important these and the
associated reports are in contrast to the more general develop-
mental care practices.
The effects of NIDCAP are not restricted to the neonate.
Parents are encouraged to participate actively with care, are
present during the scheduled observations and are given a report
with the details of their infant’s strengths, weaknesses and with
the specific care plans to be provided thereafter. Methods used
to promote parental involvement vary between units. In one
example, each intensive care infant is in their own room with
their parents cohabiting for most of the day, nurses enter for
care giving only or in response to alarms, which are monitored
from a central monitoring system elsewhere on the unit.
Parents’ perceptions of NIDCAP has been shown to be positive
when compared with traditional nursing models41 with an
increase in closeness reported by parents, although there is also
a suggestion that anxiety levels may be increased.42 The authors
suggest this anxiety may reflect increased bonding by the
parents.
The greatest challenges with implementation of NIDCAP
may be with nursing attitudes. As described earlier, the
traditional role of nurse as one-to-one care giver during most
interventions is replaced by care being provided either together
with another nurse, or with a parent. These should be provided
in accordance with a care-giving report of which the parent is
aware, and intermittently will be directly observed by a
NIDCAP assessor. In addition, what might have taken a few
minutes with traditional nursing provision may now take 20–
30 minutes to carry out. Although surveys of neonatal units
have suggested that nurse staff perceptions may provide the
greatest obstacle to implementation,43 studies of staff opinion
where NIDCAP has been adopted show that nurses felt working
conditions, job satisfaction and delivery of care had
improved.40 44
The contrasting results from NIDCAP based studies provide
ammunition for both protagonists and antagonists of this
F320
intervention. Certainly the quality of studies either in design,
patient numbers or consistency of outcome is less than would
be expected for contrasting medical interventions such as use of
prophylactic indometacin, high-frequency oscillation or post-
natal steroids. However, a counter to this argument is that
while these are active interventions that expose an infant to
potentially toxic products or injurious modalities, developmen-
tal care practice is considered less invasive than normal nursing
practices and therefore should only need to demonstrate that
infants are more stable with its use with no demonstrable long-
term consequences. One may consider that this argument has
been reasonably satisfied by the data thus far amassed.
What has not been demonstrated in whether this represents
value for money? Implementation of developmental care
practices such as installation of dimmer lighting, covers for
incubators, training staff in positioning techniques and reducing
noise on the unit are relatively low cost. However, costs in
excess of £3000 are required to prepare a NIDCAP trainer to
perform the formalised observations and provide teaching to the
unit staff in implementation of practices. As performance of
observations is time-consuming, it is estimated that two full-
time positions are required to effectively support an NICU of
40–50 beds. These costs may potentially be recouped from
reduction in days on the neonatal unit, although while this may
provide savings for American hospital finance models, in the UK
it would be primary care trusts who would reap the benefits
rather than the hospitals that would probably have to make the
outlay.
Developmental care, judged by reviewing published reports,
may have suffered by the emphasis on reducing long-term
morbidity rather than as a process that promotes a better way
of providing nursing care to infants. Very few interventions
have been able to conclusively demonstrate improved neurode-
velopmental outcome, and whether NIDCAP or any other
developmental care model can achieve this with the constraints
in study design or recruitment is difficult to predict. The results
of the Edmonton study with reported improved 18-month
outcomes may prove sufficiently compelling. Benchmarking
exercises have recognised the role of developmental care as best
practice despite the level of evidence and many units are turning
to NIDCAP or Wee-Care as a favoured approach. It may be that
these are the most effective ways of implementing develop-
mental-centred nursing techniques, or simply because first-hand
witnessing of care provision in units that use these methods can
be quite compelling.
CONCLUSIONS
Developmental care practices range from individual interven-
tions, to manipulations of the environment, to standardised
packages of care provision and, finally, to individualised care
programmes. These are designed to reduce the stresses of the
neonatal environment and promote infant stability, and
evidence has amassed to support this claim. It is proposed that
this stability and the provision of non-stressful stimulation as
provided by individualised programmes such as NIDCAP can
lead to improvements in longer-term outcome. Reasonable
evidence has been produced to suggest a benefit in reducing
duration of respiratory support and potentially CLD. There is
supportive evidence of improved outcome at 12 months of age;
however, longer-term improvements have not yet been suffi-
ciently proved. Although it has not yet been conclusively shown
that formal and expensive programmes such as NIDCAP or
Wee-Care are sufficiently better than simply combining baby
friendly practices to justify widespread adoption, they may
Arch Dis Child Fetal Neonatal Ed 2008;93:F317–F321. doi:10.1136/adc.2006.113407

provide the best way of implementing these practices. In the
absence of these long-term benefits large collaborative studies
need to be conducted. In the meantime, the choice has to be
made as to whether these improvements in nursing care can
justify the costs of implementing such changes in the neonatal
unit.
Acknowledgements: I am grateful to Alan Gibson for his helpful comments on the
manuscript and to Caryl Skene for starting developmental care promotion locally. Also
to Inga Warren for demonstrating the techniques of NIDCAP, Jacques Sizun for
permitting me to see NIDCAP in action in his NICU and Juzer Tyebkhan for providing
data from his recent studies.
Competing interests: None.
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