Evidence for Best Practices

in the Neonatal
Period

Judy A. Beal, DNSc, RN

ABSTRACT
The purpose of this article is to provide a review of current nursing research that
supports best practices during the newborn period. The literature review of peer-
reviewed research articles published between January 2000 and October 2004 was
conducted via keyword searches using the databases of the Cochrane Library,
CINAHL, and MEDLINE. Key words included neonatal nursing, newborn, neonate,
premature infant, preterm infant, and low birthweight. Content analysis revealed the
following primary categories of studies that provide solid evidence for nursing prac-
tice: developmentally focused nursing care, neonatal skin care, feeding, skin-to-skin
care, and pain management. Neonatal nurse researchers have made many important
contributions to the research literature. Future research should expand the findings
to date on the effective use of pain scales, the outcomes of skin-to-skin care and
infant massage as standard practice for all neonates, and the effectiveness of nurs-
ing interventions to support the developmental sequelae of prematurity. Neonatal
nurses should become familiar with and implement those findings from nursing
research that strongly support evidence-based nursing practice.
Key Words: Neonatal nursing; Newborn; Neonate; Premature infant; Preterm infant;
Low birthweight.

November/December 2005 MCN 397

 he advances in treatment and achievements in research
T
over the past 20 years have significantly altered the
nursing care delivered to infants in the neonatal period.
Nowhere else is this more evident than in the neonatal
intensive care unit (NICU), where some of the most
noteworthy contributions have drastically improved the
outcomes of even the smallest of the very low birthweight
infants born today. In the past 5 to 10 years, neonatal nurs-
es and nurse researchers have recognized the need to refo-
cus their attention toward how to best support the prema-
ture infant and parent during this period (Bakewell-Sachs
& Blackburn, 2003). This article provides a review of cur-
rent nursing research published from January 2000
through October 2004 that supports best practices during
the newborn period.
The author conducted a comprehensive review of all
peer-reviewed nursing research articles published between
January 2000 and October 2004 using the Cochrane Li-
brary database as well as CINAHL and MEDLINE. Key
words used in the searches included neonatal nursing,
neonate, infant, newborn, premature infant, preterm infant,
low birthweight, and neonatal intensive care. To be includ-
ed the article must have been published within the past 4
years in a peer-reviewed journal by a nurse(s), translated
into English, and reported research findings on nursing
care issues during the immediate neonatal period or first
month of life.
Review of the Literature
Content analysis of the nursing research articles that met
the inclusion criteria revealed the following predominant
five categories of studies: (1) developmental issues, (2)
neonatal skin care, (3) feeding, (4) skin-to-skin care, and
(5) pain management. While nursing research on different
topics related to the care of the premature infant has been
published, these categories of studies were most prevalent
and provided the best evidence for nursing practice to date.
1. Developmental Issues
The majority of studies reviewed addressed the importance
of developmentally focused nursing interventions for the
newborn. Byers (2003), in her summary of the research to
date on developmental care, discussed the underlying
framework of the Neonatal Individualized Developmental
Care and Assessment Program developed by Als (1986),
stating that “caregiving for the newborn is based on the in-
fant’s behavioral and psychological cues as well as the
nurse’s knowledge of normal developmental and functional
maturity” (Byers, 2003, p. 174). Developmental care in the
NICU should include management of the environment,
flexed positioning, clustering of care, promotion of nonnu-
tritive sucking, kangaroo care, cobedding of multiples, ac-
tivities to promote self-regulation and state regulation, and
collaboration with parents to promote bonding (National
Association of Neonatal Nurses [NANN], 2000). These
well-known and often studied aspects of developmental
care should be a part of each NICU nurse’s practice while
providing care to all newborns in the NICU.
398 VOLUME 30 | N UMB E R 6
Byers (2003) concluded that research supports improved
short-term outcomes for infants who received developmen-
tal care, while the findings of studies exploring outcomes
for older children are not yet conclusive. Symington and
Pinelli (2002) confirmed these findings and reported that
developmental care interventions demonstrated short-term
benefits of increased growth, decreased pulmonary sup-
port, decreased incidence of respiratory disease, decreased
length and cost of hospitalization, and improved neurode-
velopmental outcomes.
Developmentally sensitive nursing interventions focused
on purposefully decreasing stimulation and minimizing
stress were found to be related to improved oxygenation
saturation, decreases in need for exogenous surfactant and
total parenteral nutrition, and less documented feeding in-
tolerance (Prentice & Stainton, 2003; White-Traut et al.,
2004). While several studies reported evidence of develop-
mental care, others studies documented nurses’ lack of
knowledge of the principles of developmental care, specifi-
cally assessment of infant behavioral cues (Aita & Goulet,
2003; Liaw, 2003; Turrill, 2003). Holditch-Davis and
Black (2003) conducted a review of current programs of
research published since 1990 on the care of the preterm
infants and concluded that of the 17 nurse researchers with
well-established programs of research, only three used a de-
velopmental perspective to frame their work. Long-term
outcomes of developmental care during the neonatal period
have also been studied with inconclusive results.
White-Traut and her colleagues have made significant
contributions to the research on developmental issues of
high-risk neonates, focusing primarily on the physiologic
responses of premature infants to stimulation in the form
of intervention. Her most recent work has shown that with
37 premature infants born at 23 to 26 weeks with periven-
tricular leukomalacia and/or intraventricular hemorrhage,
those who received auditory, tactile, visual, and vestibular
multisensory intervention twice a day from 33 weeks post-
conceptual age until discharge showed increases in heart
rates even at rest (White-Traut et al., 2004). With this same
sample of infants, White-Traut and colleagues also demon-
strated that those infants who received the multisensory in-
tervention demonstrated increased alertness, faster transi-
tion to nipple feeding, and decreased lengths of hospital
stay (White-Traut, Nelson, et al., 2002). Those infants also
tended to exhibit better motor and mental performance at
1 year (Nelson et al., 2001). In another study of cocaine-
exposed newborns who received this multisensory interven-
tion, White-Traut, Studer, Meleedy-Rey, Labovsky, and
Kahn (2002) concluded that the stimulation promoted nor-
mal physiologic and behavioral function in a sample of 72
nonexposed and 45 drug-exposed infants. The research is
conclusive that nursing care delivered to newborns should
be within a developmental framework.
Certain environmental factors of the NICU have been
shown to have deleterious effects on infant outcomes. Re-
search has been published that documents efficacy of nurs-
ing interventions to decrease noise and stress (Bremmer, By-
ers, & Kiehl, 2003; Johnson, 2003; Morrison, Haas,
November/December 2005
Shaffner, Garrett, & Fackler, 2003). Most of these strate-
gies are cost-effective, are simple to implement, and include
limiting door closings, portable x-rays, high-volume
nonessential personnel, visitors, and unattended alarms in
the NICU to decrease noise.
Teaching parents how to position their infant for sleep
compared with current nursing practice has been explored
with troubling results. Although nurses reported being
aware of the American Academy of Pediatrics’ guidelines
of “back to sleep,” in two large studies (Bullock, Mickey,
Greene, & Heine, 2004; Stastney, Ichinose, Thayer, Olson,
& Keens, 2004), the majority of nurses reported position-
ing infants on their sides and advised mothers to do the
same. Only 53% of the nurses reported knowing about the
policy for newborn sleep positioning, and of those 80%
still believed that the lateral position was preferred (Bullock
et al., 2004).
Significant advances have been made in
neonatal nursing care that have positively
affected even the smallest of babies.
2. Neonatal Skin Care
Nurse researchers have also studied newborn bathing:
Medves and O’Brien (2004) reported the results of their
randomized clinical trial with 111 full-term infants and
found evidence of neonatal heat loss during bathing, not
related to who bathes or the location of the bath; in anoth-
er study, Behring, Vezeau, and Fink (2003) found that the
timing of the bath (within 1 hour of birth compared with 4
to 6 hours after birth) did not significantly impact infant
temperature.
Infant massage has been studied and found to assist
mothers in better understanding their infant’s behavior and
in decreasing parental stress (Beyer & Strauss, 2002; Ram-
sey, 2001). While these studies were qualitative in design,
results seem to indicate that teaching parents infant mas-
sage techniques is a noninvasive approach to assisting par-
ents to better understand infant development, the parenting
role, and how to interact with their babies. Harrison
(2001) conducted an integrative review of the literature on
comfort touch in the NICU and reported that when infants
are physiologically fragile, they respond well to gentle
stroking and massage, specifically with decreased motor
variability and distress. Modrcin-Talbott, Harrison, Groer,
and Younger (2003) confirmed these findings, specifically
concluding that gentle human touch nursing intervention is
neither aversive nor stressful to premature infants.
November/December 2005
Perhaps the most exciting and important advance in
neonatal nursing practice during this period came from the
joint venture by the Association of Women’s Health, Ob-
stetric and Neonatal Nurses (AWHONN) and NANN in
their publication of an evidence-based clinical practice
guideline for neonatal skin care (AWHONN, 2001). This
document made major recommendations for nursing care
based on 148 references of research and expert opinion
conducted by physicians and nurses from as early as 1957
through 2001. Their guidelines for nursing care include
recommendations on newborn skin assessment, bathing,
cord care, circumcision care, disinfectants, diaper dermati-
tis, adhesives, emollients, transepidermal water loss, skin
breakdown, intravenous infiltration, and skin nutrition
(AWHONN, 2001). Lund et al. (2001) evaluated the effec-
tiveness of these guidelines in 51 NICUs and newborn
nurseries across the United States. Results showed that im-
plementation of the AWHONN newborn skin care guide-
lines was successful and that changed skin care practices re-
sulted in improved skin condition in premature and full-
term newborns. Barriers to the utilization of these guide-
lines were explored by Johnson and Maikler (2001), who
found that in a sample of 136 nurses from 26 hospitals,
some nurses perceived preexisting practice as superior to
some protocols. Other nurses reported difficulty in reading
and understanding research, lack of authority to implement
the protocols, and lack of physician support
3. Feeding
Studies exploring breastfeeding and studies on maternal ex-
periences of infant feeding were most often reported in the
literature. DiGirolamo and Grummer-Strawn (2003) fol-
lowed 1620 women from their prenatal visits through 12
months postpartum. They found that when staff had
recorded “no stated preference for feeding method” on the
medical record, there was a significant relationship to dis-
continuance of breastfeeding after 6 weeks, with the major-
ity of subjects reporting that they did not receive positive
breastfeeding messages from hospital caregivers. Hong,
Callister, and Schwartz (2003) further confirmed the criti-
cal role nurses play in supporting breastfeeding with new
mothers. Mothers reported that emotional support in terms
of offering reassurance, being concerned, remaining pre-
MCN 399
 Neonatal nurse researchers have made
many important contributions, especially
in the areas of developmental care, skin
care, skin-to-skin (kangaroo) care, pain
management, and breastfeeding.
sent, offering proactive help, providing specific teaching,
and offering tangible support (ointment for sore nipples,
videos, pamphlets, and phone numbers) was viewed as
most supportive. The finding that nurses who do not sup-
port breastfeeding may send conflicting messages to moth-
ers was further supported by Kaewsarn, Moyle, and
Creedy (2003).
Successful breastfeeding has also been found to be re-
lated to maternal confidence. Hall, Shearer, Mogan, and
Berkowitz (2002) found that mothers whose infants were
weighed before and after breastfeeding had no significant
increase in confidence and feelings of competence early on
in the postpartum period, but that over time this practice
did significantly increase the mothers’ competence and
confidence in their breastfeeding skills. Dennis (2003)
conducted a study testing the psychometric properties of
the revised Breastfeeding Self-Efficacy Scale (BSES) and
found it to be an effective measure of breastfeeding self-
efficacy, concluding that this scale is ready for clinical use
to identify mothers at risk and to identify behaviors that
could then guide practitioners in confidence-building in-
terventions.
Successful transition to oral feeding has been studied in
terms of development of early oral feeding skills (Ross &
Browne, 2002; Thoyre, 2003; Thoyre & Carlson, 2003),
how feeding opportunities and challenges are discussed by
providers with parents (Pickler & Reyna, 2003; Pridham,
Saxe, & Limbo, 2004), maternal perceptions (Wooldridge
& Hall, 2003), indicators of oxygen decline during oral
feeding (Thoyre & Carlson, 2003), and the effects of mu-
sic-reinforced nonnutritive sucking on feeding rates (Stand-
ley, 2003). The comprehensive literature reviews conducted
by Thoyre (2003) and Ross and Browne (2002), while not
original research, have stressed the importance of viewing
feeding through a developmental lens and reiterate the im-
portance of the nurse’ role in recognizing infant readiness
to begin and advance oral feeding. Nurses also must help
mothers deal with their perceptions and misconceptions
around adequacy of milk supply, which has been found to
be a key factor in the transition from hospital to home
(Wooldridge & Hall, 2003). Providing increased bottle-
feeding opportunities (Pickler & Reyna, 2003) and con-
sciously being aware of how nurses label feeding issues
(Pridham, Saxe, & Limbo, 2004) will positively influence
feeding success in preterm infants.
400 VOLUME 30 | N UMB E R 6
4. Skin-to-Skin (Kangaroo) Care
A significant amount of nursing research has been pub-
lished during the last few years on the efficacy of skin-to-
skin or kangaroo care (KC) for premature infants and their
parents. McGrath and Brock (2002) reviewed the research
to date and concluded that KC is safe and therapeutic for
premature infants and parents in terms of enhancing
growth, decreasing mortality, facilitating attachment, de-
creasing maternal stress, and increasing maternal self-confi-
dence in parenting. Other research has shown that KC is
effective in increasing the quality and amount of contact
between infants and their parents (Anderson et al., 2003),
decreasing energy expenditure during transfer (Neu,
Browne, & Vojir, 2000), and decreasing episodes of apnea,
bradycardia, and periodic breathing (Luddington-Hoe, An-
derson, Swinth, Thompson, & Hadeed, 2004). Chwo and
colleagues (2002), in a randomized clinical trial of 34
mother-baby dyads, found that preterm infants who re-
ceived KC were more likely to have higher mean tympanic
temperatures, more quiet sleep, and less crying than con-
trol-group infants who did not receive KC.
The results of the effects of KC on successful breastfeed-
ing remain mixed (Carfoot, Williamson, & Dickson,
2003). Results of studies examining effectiveness of KC
with ventilated infants and infants less than 28 weeks post-
conceptual age are also less conclusive. Smith (2001) found
that very low birthweight infants showed instability in tem-
perature and oxygen saturation during KC. In a case study
of a ventilated infant, Swinth, Anderson, and Hadeed
(2003) found that KC may accelerate recovery from respi-
ratory distress while enhancing maternal relaxation and de-
creasing stress. Future research is needed in this area.
In spite of well-documented positive outcomes of this
technique for most premature infants, many NICUs and
nurses are still resistant to the practice of KC (Engler et al.,
2002). Franck, Bernal, and Gale (2002) found that in 215
NICUs across the country, practice of KC was much less
than expected, especially for intubated infants. Anderson
and colleagues further supported this in 2003 when they
found that holding times of infants receiving KC were
more than double that of controls. Many infants do not
experience KC because of fears by nurses that KC with
mothers will put them at greater risk for heat loss than if
they were either in an incubator or under warming lights.
Other barriers to KC include concerns for safety, unavail-
November/December 2005
 TABLE 1. Well-Documented Evidence for Neonatal Nursing Practice
RESEARCH TOPIC CLINICAL IMPLICATIONS
Developmental care • Developmentally based care in the NICU improves short-term outcomes for infants and includes
management of the environment, flexed positioning, clustering of care, promotion of nonnutritive
sucking, kangaroo care (KC), co-bedding of multiples. Multisensory stimulation of preterm infants is
safe and has positive physiological and behavioral outcomes.
Skin care • Nurses should implement the AWHONN Clinical Practice Guideline for Neonatal Skin Care.
Infant bathing • Although there is neonatal heat loss during bathing, it is not related to who bathes or the location
of the bath.
• The timing of the does not significantly influence infant temperature.

The NICU environment • By limiting door closings, portable x-rays, high-volume nonessential personnel, visitors, and unat-
tended alarms, nurses can effectively decrease noise and infant stress.

Skin-to-skin • KC is safe and effective for premature nonventilated infants 28+ weeks and their parents.

Pain management • Most nurses do not document or evaluate pain and do not use well-validated pain assessment
tools.
• The PAIN and NIPS scales have strong validity and are ready for clinical use.
• Nonpharmacologic interventions are effective (especially oral sucrose) in relieving pain during
invasive procedures.
• Oral sucrose is more effective than EMLA cream during venipuncture.
• Nonpharmacologic measures in conjunction with procedural anesthesia should be used during
circumcision.
• Swaddling and facilitated tucking is effective during heel sticks and suctioning.

Sleep position • Nurses should put infants to sleep on their backs and advise parents to do so as well.

Breastfeeding • No stated preference for breastfeeding by nurses is significantly related to discontinuance of

breastfeeding after 6 weeks.
• Mothers need emotional support, reassurance, remaining present, teaching, and tangible support
to be successful breastfeeders.
• Successful breastfeeding is related to maternal self-confidence.
• The Breastfeeding Self-Efficacy Scale is ready for practice to identify mothers at risk
Transition to oral feeding • Nurses have a pivotal role in recognizing infant readiness to begin and advance oral feeding, as well
as helping mothers deal with misconceptions around adequacy of milk supply.

ability of staff and mothers, and staff interruptions (Ander-
son et al., 2003). Ludington-Hoe, Nguyen, Swinth, and
Satyshur (2000) reported that in a small sample of prema-
ture infants, there was no change in abdominal tempera-
ture and actually an increase in toe and maternal breast
temperature in the KC group. Further research about KC is
needed with all newborns as well as with premature in-
fants, with adoptive parents, with ventilator-supported in-
fants, and with mothers who are depressed. Nurses need
additional education to overcome barriers to practice.
5. Pain Management
It is well documented that infants experience pain. Much
of the research during the last decade has focused on the
development of infant pain measurement tools (Bakewell-
Sachs & Blackburn, 2003; Franck, 1987). Research pub-
lished during the past few years has focused on nonphar-
macologic interventions as well as continued interest in
nursing assessment of infant pain. Reyes (2003), in a de-
scriptive survey of 24 nurses and an audit of 107 records,
found that while nurses believed that neonatal pain assess-
ment was important, and that they were capable of doing
it, evidence that they either documented pain or evaluated
pain management interventions was lacking from the ma-
jority of patient records. Dodds’ study (2003) confirmed
these findings that pain assessment tools were used by less
than half of the 21 nurses surveyed. Further results showed
that the majority used nonnutritive sucking to relieve pain
and rarely used medications or other nonpharmacologic in-
terventions. While the validity of the Pain Assessment in
Neonates (PAIN) Scale and the Neonatal Infant Pain Scale
(NIPS) (Hudson-Barr et al., 2002) has been reported, Boyd
(2003) concluded that they are rarely used by nurses. Duhn
and Medves in 2004 evaluated 35 infant pain assessment
tools and concluded that several were not published or val-
idated. They cautioned nurses to use only validated multi-

November/December 2005 MCN 401

dimensional pain instruments and to be aware of the infant
population and setting as well as the type of pain.
Other studies have reported on pain behaviors and
parental perceptions of their infant’s pain experiences. Fuller
(2000) reported that high arousal behaviors are not consis-
tent with established pain, and that using arousal behaviors
to assess infant pain may not be helpful. Warnock and San-
drin (2004) also differentiated between distress behaviors and
prolonged distress-related pain expression. In a qualitative
study of 12 parents, Gale, Franck, Kools, and Lynch (2004)
reported that infant pain is a source of parental distress.
Nonpharmacologic interventions for infant pain have
been studied, and oral sucrose has been found to effectively
relieve pain as documented by decreased crying and other
behavioral indicators during invasive procedures (Benis,
2002; Gibbins & Stevens, 2003; Mitchell & Waltman,
2003; Stevens, Yamada, & Ohlsson, 2001). Gradin, Eriks-
son, Holmqvist, Holstein, and Schollin (2002) found that
oral sucrose was superior to EMLA cream during venipunc-
ture. However, for circumcision pain, nonpharmacologic
interventions should be used in conjunction with procedur-
al anesthesia, as recommended by the American Academy
of Pediatrics (1999). Swaddling (Prasopkittikun & Tilok-
skulchai, 2003) and facilitated tucking (Ward-Larson,
Horn, & Gossnell, 2004) were also found to be effective in
reducing infant pain during heel sticks and endotracheal
suctioning respectively.
Clinical Implications and
Future Research
Neonatal nurse researchers have made significant contribu-
tions, especially in the areas of nursing interventions such
as developmental care, neonatal skin care, infant feeding,
skin-to-skin (KC) care, and pain management (Table 1). As
a result of a large body of research, national guidelines
have been published on neonatal skin care, many newborn
pain assessment tools have been found to be valid and reli-
able, and standards for developmentally based newborn
care have been published. While there have been significant
achievements in the advancement of evidence-based prac-
tice in neonatal nursing, several of the studies reviewed
were descriptive in nature and conducted with small sam-
ple sizes, thereby limiting generalizability. Also of concern
is the fact that many clinical nurses do not incorporate into
practice the research findings published to date. Nurse re-
searchers must work collaboratively with clinical nurses to
study those clinical issues that are of great importance to
clinicians and to engage them in the excitement of the re-
search process and the use of evidence in their practice. Fu-
ture research must expand the findings to date on the effec-
tive use of pain scales, the outcomes of skin-to-skin care
and infant massage as standard practice for all neonates,
the effectiveness of nursing interventions to support the de-
velopmental sequelae of prematurity, and the impact of the
environment on long-term childhood outcomes. <
Judy A. Beal, DNSc, RN, is Chair and Professor of Nursing
402 VOLUME 30 | N UMB E R 6
and Associate Dean, School for Health Studies at Simmons
College, Boston, and an Editorial Board Member of MCN.
She can be reached via e-mail at judy.beal@simmons.edu.
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ONLINE
American Academy of Pediatrics
www.aap.org
Association of Women’s Health,
Obstetric and Neonatal Nurses
www.awhonn.org
National Association of Neonatal Nurses
www.nann.org
MCN 403