MENTAL RETARDATION AND DEVELOPMENTAL DISABILITIES
RESEARCH REVIEWS 8: 298–308 (2002)
NEURODEVELOPMENTAL CARE
Susan Aucott*, Pamela K. Donohue, Eileen Atkins, and Marilee C. Allen
Eudowood Division of Neonatology, The Johns Hopkins University School of Medicine,
Baltimore, Maryland
Neurodevelopmental care, which is any NICU intervention under-
taken to improve neurodevelopmental outcome, includes NICU design,
nursing routines, nursing care plans, management of pain, feeding meth-
ods and, most importantly, encouraging parental involvement with their
NICU infant. Recognition that sensory stimulation can overwhelm preterm
infants and increase physiologic signs of stress led to attempts to reduce
sensory input. More recent approaches judiciously add back soothing sen-
sory input (e.g., therapeutic touch, soft music). Circadian light/dark cycles
and physical activity improve preterm growth. Attention to infant position-
ing and handling affects physiologic variables and joint mobility, if not
functional motor abilities. A highly organized system of care for NICU in-
fants is Als’ NIDCAP (i.e., Neonatal Individualized Developmental Care and
Assessment Program). Although NIDCAP may reduce need for respiratory
support and hospital length of stay, it does not significantly influence neu-
rodevelopmental outcome at 2-3 years. Pain management includes benign
interventions (e.g., nonnutritive sucking, oral glucose), but the prolonged
use of narcotics must be balanced against the consequences of sedation
and dependency. The foremost challenge for NICUs remains parent disen-
franchisement. Kangaroo care, which involves parent/infant skin-to-skin
contact, improves preterm growth, decreases nosocomial infections and
may shorten hospital length of stay. A great deal of work needs to be done
to identify and demonstrate efficacy of specific interventions and changes
that humanize the NICU, encourage parental involvement, support infant
development and optimize preterm neurodevelopmental outcomes.
© 2002 Wiley-Liss, Inc.
MRDD Research Reviews 2002;8:298 –308.
Key Words: prematurity; early intervention; NIDCAP; developmental care;
preterm development; NICU
P
reterm infants are born into a hostile world that expects
them to use their very immature organ systems for sur-
vival. Over the last half century, tremendous efforts to
improve survival of these vulnerable infants has resulted in
numerous medical and technological advances and systems of
regionalized obstetric high risk and neonatal intensive care with
highly trained personnel from a variety of disciplines (e.g.,
nursing, medicine, respiratory therapy, social work). These ef-
forts in developed countries have resulted in improved preterm
survival and lower limits of viability [Alexander and Slay, 2002].
However, the U.S. has not changed its incidence of prematurity
and has made only modest unsustained efforts to systematically
follow the development of high risk preterm infants, support
their families and provide needed additional health, develop-
mental and educational resources.
The focus of neonatal intensive care has been physiologic
support of the preterm infant’s respiratory, cardiac, gastrointes-
tinal, renal, immune and dermatological systems. Outcomes
studies have consistently found that preterm children have a
© 2002 Wiley-Liss, Inc.
IN THE NICU
higher rate than fullterm controls of major disabilities, sensory
impairments and the high prevalence/low severity disorders that
lead to school and behavior problems [Allen, 2002; Aylward,
2002; Bracewell and Marlow, 2002; Msall and Tremont, 2002].
An effort to improve outcomes has shifted attention toward
neuroprotective strategies and neurodevelopmental support.
Neuroprotection includes giving medications (e.g., indometha-
cin to prevent intraventricular hemorrhage) and modifying re-
spiratory and cardiovascular support strategies (e.g., avoiding
hyperventilation and providing blood pressure support) to pre-
vent or ameliorate central nervous system (CNS) injury [Fowlie
and Davis, 2002; O’Shea, 2002]. Neurodevelopmental support
includes modifying neonatal intensive care and improving neo-
natal intensive care unit (NICU) design to support preterm
neuromaturation.
The NICU environment influences preterm neurodevel-
opment just as the intrauterine environment influences fetal
neurological development. One example of this is that the
uterus constricts fetal movement and leads to a tightly flexed
fetal posture. The fullterm neonate demonstrates a high degree
of flexor tone, called flexor hypertonia, which is abnormal at any
other time of life. As preterm infants’ subcortical system devel-
ops, they too develop extremity flexor tone, which peaks at
38-40 weeks postmenstrual age (PMA, gestational age plus chro-
nological age) [Allen and Capute, 1990; Amiel-Tison, 1995].
However, preterm infants at term have less flexor hypertonia as
fullterm neonates and often have more extensor tone which
interferes with the development of head control, rolling over
and getting into and out of sitting [Georgieff and Bernbaum,
1986]. Positioning and handling the preterm infant in a flexed
posture mimics intrauterine conditions, supports the develop-
ment of flexor tone prior to term and provides the infant with
a sense of containment that allows better self-organization.
Understanding how the central nervous system (CNS)
develops and functions is one of the most daunting challenges of
science. The physiologic development of the CNS, including
neuromotor, neurosensory and neurocognitive systems and later
executive function are much less well understood than the fetal
respiratory, cardiac or gastrointestinal systems. Neuromaturation
*Correspondence to: Susan Aucott, MD, CMSC 210, The Johns Hopkins Hospital,
600 N. Wolfe St., Baltimore, MD 21287-3200.
E-mail: saucott@jhmi.edu
Received 18 June 2002; Accepted 30 September 2002
Published online in Wiley InterScience (www.interscience.wiley.com).
DOI: 10.1002/mrdd.10040
is the process of achieving full develop-
ment and growth of the CNS. Deter-
mining how to provide NICU neurode-
velopmental support requires knowledge
of preterm neuromaturation, including
how a fetus or preterm infant perceives
surrounding auditory, visual, tactile and
olfactory environmental stimuli and how
the infant’s responses, posture and move-
ment influence CNS development. It is
no longer a question of genes vs environ-
ment: they continuously interact during
development and determine who we are
and what we become [Cotman and
Berchtold, 1998; Pomeroy and Kim,
2000]. Successive turning on and then off
specific genes propel CNS development
forward, with genetic control of cell di-
vision, differentiation, migration and func-
tion. Surrounding cells, nutrients, temper-
ature and many other factors influence cell
division, migration, connections and func-
tion.
The intrauterine environment, in-
cluding the mother’s health and ade-
quacy of the uteroplacental supply, plays
a crucial role in fetal growth and devel-
opment. Likewise, fetal and preterm
movement, behavioral responses and
learning guide CNS shaping and remod-
eling [Cotman and Berchtold, 1998,
Pomeroy and Kim, 2000]. The fetal heart
beats and the fetus moves within weeks
after the CNS begins with neural induc-
tion and neurulation to form the brain
and spinal cord. Normal limb and brain
development requires fetal body move-
ment just as normal lung development
requires fetal breathing. Vast networks of
neuronal interconnections are formed
during synaptogenesis, and these synaptic
networks are shaped by patterns of elec-
trical activity: use fosters and drives CNS
development. Later in infancy, the syn-
aptic network is pruned and refined, ac-
cording to use. CNS function is intri-
cately related to CNS structure.
Preterm delivery dictates that in-
teraction with the extrauterine NICU
environment shapes the preterm infant’s
developing CNS. Neuronal migration,
differentiation, synaptogenesis, myelina-
tion and refining synaptic connections
continue, even if the preterm infant has
sustained CNS injury [Cotman and Berch-
told, 1998]. The fragility of the develop-
ing CNS and the crudeness of a NICU’s
attempts to recreate the intrauterine en-
vironment raise the question as to why all
preterm infants are not disabled. In addi-
tion to medications and medical strategies
to prevent or ameliorate preterm CNS
injury, features of the infant’s isolette or
warmer, nutrition, nursing care, medical
interventions, NICU and family involve-
MRDD RESEARCH REVIEWS ● NEURODEVELOPMENTAL CARE
ment can support neurodevelopment and
neurorecovery. This review will begin
with a historical perspective of NICU
developmental intervention, then discuss
a variety of interventions designed to
provide neurodevelopmental support.
We emphasize the importance of clinical
research to evaluate efficacy (in a research
environment) and effectiveness (in real
NICUs) of specific interventions.
EARLY INTERVENTION AND
SENSORY STIMULATION
Manipulations of a child’s environ-
ment to promote cognitive and neuro-
logical development have traditionally
been called “early intervention.” Initial
efforts were directed toward preschool
Vast networks of
neuronal interconnections
are formed during
synaptogenesis, and these
synaptic networks are
shaped by patterns of
electrical activity: use
fosters and drives CNS
development. Later in
infancy, the synaptic
network is pruned and
refined, according to use.
CNS function is
intricately related to
CNS structure.
children with neurodevelopmental dis-
abilities and environmental risks factors.
Extending these efforts downward to
younger children culminated in the U.S.
in legislation in 1986 promoting early
intervention services for infants and tod-
dlers with developmental delay or at risk
for substantial delay [http://www.ed.
gov/pubs/OSEP95AnlRpt/ch2a.html].
There continues to be considerable con-
troversy as to efficacy of early interven-
tion and/or sensory enrichment in infants
with and at risk for disability [Otten-
bacher and Petersen, 1984; Ottenbacher
et al., 1987; Harris et al., 1988; Vargas
and Camilli, 1999; Butler and Darrah,
2001;].
IN THE NICU ● AUCOTT
With prematurity as a major dis-
ability risk factor, initial early interven-
tion efforts provided sensory stimulation
to preterm infants in NICUs [Masi,
1979; Field, 1980]. Stimulation included
rocking, stroking, holding, moving,
playing recordings of mother’s voice,
providing a pacifier for nonnutritive
sucking and providing visual decorations.
There has been some evidence that tac-
tile-kinesthetic, auditory or visual stimu-
lation promoted physiologic stability,
oral feeding, weight gain, responsiveness
and development of preterm infants, but
most studies have had serious flaws [Masi,
1979; Field, 1980; Barnard and Bee,
1983; Mueller, 1996; Vickers et al.,
2002]. Flaws included unequal groups
with respect to important confounders,
very small sample sizes, lack of random-
ization, failure to measure background
rate of stimulation in controls, lack of
masked outcome evaluators as to treat-
ment group and no long-term follow up.
Often the subjects’ states of alertness,
whether stimuli were arousing or sooth-
ing and individual differences in percep-
tions and responses were not considered.
It is difficult to confine interventions to
the study group without applying them
to controls. Sick preterm infants and in-
fants with serious medical complications
were generally excluded. There has been
controversy as to when supplemental
stimulation should begin, what its fre-
quency and duration should be, who
should administer it and whether to con-
tinue it after discharge home. Although
these intervention programs provided an
opportunity to work with parents, few
studies measured effects on parental be-
havior or parent-infant interactions.
Whether the stimulation is applied
invariably or contingent on the infant’s
state or behavior is an important consider-
ation [Masi, 1979; Field, 1980; Barnard and
Bee, 1983]. Learning occurs when infants
can control the frequency, duration and/or
intensity of stimuli. A contingency-based
intervention requires infant assessment of
state and response. During invariable sen-
sory stimulation sessions, many preterm in-
fants closed their eyes, averted their gaze or
even became physiologically unstable with
color changes, apnea or bradycardia. Pre-
term infants in NICUs have not suffered
sensory deprivation but have been bom-
barded by aversive stimuli, including bright
fluorescent lights, noisy equipment and
painful procedures [Blennow et al., 1974;
Lawson et al., 1977; Gottfried et al., 1981;
Newman, 1981; Robertson et al., 1998a;
1999a; b; Chang et al., 2001]. Although
they habituate to repeated stimuli by 28-30
weeks postmenstrual age (PMA, chrono-
ET AL. 299
logical age plus gestational age) [Allen and
Capute, 1986a], even healthy preterm in-
fants remain vulnerable to sensory input
overload.
There is no doubt that fetuses and
very immature infants react to sensory
stimuli [Haith, 1986]. Fetuses and pre-
term infants as young as 24-26 weeks
gestation move in response to sound
[Allen and Capute, 1986a; Johansson et
al., 1992]. Movement of the mother
stimulates the fetal vestibular apparatus;
fetal movement provides kinesthetic
stimulation; and amniotic fluid stimulates
tactile receptors and conducts sound
well. Visual fixation and visual pattern
preference occur by 30-32 weeks gesta-
tion, as do somatosensory evoked re-
sponses to tactile stimuli [Dubowitz et
al., 1980; Hack et al., 1976; 1981; Hrbek
et al., 1973]. Tactile and vestibular stim-
uli are often used to stimulate apneic
preterm infants. Sensory stimulation is
part of life, and our challenge is to deter-
mine how the NICU environment can
be changed to support preterm sensory,
motor and cognitive neurodevelopment.
NIDCAP
Although there have been many
individual contributions, many equate
NICU developmental care with Heidelise
Als’ highly organized system, Neonatal In-
dividualized Developmental Care and As-
sessment Program (NIDCAP) [Als, 1998].
Systematic implementation requires NICU
developmental care teams and training and
certification of staff. Although many have
voiced concerns that implementation of
NIDCAP is expensive and time-consum-
ing, NIDCAP has popularized important
concepts regarding the need for infant as-
sessment and individualizing care for infants
and families.
The NIDCAP uses systematic be-
havioral observations of the individual
at-risk newborn to provide the basis for
coordinating the care of that infant.
Trained observers use an instrument de-
signed for this purpose which evaluates
the infant in five systems: autonomic
physiologic, motor, state organizational,
attentive-interactive and self-regulatory.
These include items such as respiratory
status, color, visceral responses (e.g., gag-
ging, hiccuping), tone posture, facial ex-
pressions and attention. This assessment,
along with the infant’s behavioral reac-
tions to internal and external sensory
stimuli, is used to measure the infant’s
ability to tolerate his or her environment
and caregiving activities. An individual
developmental care plan is then designed
to decrease potential detrimental effects
of the NICU environment.
300 MRDD RESEARCH REVIEWS
The NIDCAP program recom-
mends salaried positions for a develop-
mental specialist and a developmental
care nurse educator, a 6-7 member mul-
tidisciplinary leadership support team and
a trained core group of nursing staff. The
training involves 2 levels: NIDCAP level
I consists of training in the infant behav-
ioral observation, developmental care
planning, and implementation of the care
plan based on the behavior observation.
Level II training includes consultation to
the NICU regarding its environment,
the building of a developmental team,
and implementation of developmental
care, with specific training for the devel-
opmental specialist, the developmental
care nurse educator and consultation to
the multidisciplinary support team. The
full development of the program is ex-
pected to be a five-year process.
Several studies have attempted to
Sensory stimulation is
part of life, and our
challenge is to determine
how the NICU
environment can be
changed to support
preterm sensory, motor
and cognitive
neurodevelopment.
evaluate the effect of the NIDCAP in-
terventions by looking at various short
and longterm outcomes. In two trials by
Als [Als et al., 1986; 1994], infants re-
ceiving routine care were compared to
infants cared for by those specially trained
in NIDCAP. The NIDCAP intervention
group had a decrease in the total number
of ventilator days, in addition to fewer
tube feeding days, shorter hospital stays
and discharge at an earlier gestational age.
There was no difference in the inci-
dences of intraventricular hemorrhage,
retinopathy of prematurity, or weight
gain between the groups. In the later
study [Als et al., 1994], the NIDCAP
intervention group had higher scores on
their Bayley developmental assessment at
9 months of age.
A randomized trial of routine care
compared to NIDCAP found no group
differences in death, retinopathy of pre-
● NEURODEVELOPMENTAL CARE
maturity, weight gain or days on a ven-
tilator [Westrup et al., 2000]. However,
the NIDCAP group had fewer days on
CPAP and supplemental oxygen and
lower postmenstrual age (PMA, gesta-
tional age plus chronologic age) at dis-
charge than the routine care group. Oth-
ers have reported that very low
birthweight infants who received devel-
opmental care had lower hospital costs
due to an earlier move to a transitional
unit with lower nursing costs, and an
earlier discharge [Petryshen et al., 1997].
However, this study did not take into
account the cost of the program and the
need for specially trained personnel.
Studies assessing developmental outcome
at two and three years of age [Ariagno et
al., 1997; Kleberg et al., 2000] have not
found differences in the developmental
quotient in those infants who received
NIDCAP care as a newborn compared
with those who did not.
Most of the trials of NIDCAP suf-
fer from small sample size, lack of mask-
ing for those assessing outcomes and use
of historical controls. Meta-analysis of
the three trials [Als et al., 1986; 1994;
Westrup et al., 2000] that meet at least
some of the criteria for inclusion in a
Cochrane Review (i.e., masked random-
ization, masked intervention, complete
follow-up and masked outcome assessors)
provides evidence that NIDCAP de-
creases duration of oxygen support
(weighted mean difference, –39.4 days,
95% CI— 64.6, –14.1), number of tube
feeding days (weighted mean difference,
–32.0 days, 95% CI— 48.4, –15.6), and
length of hospital stay, as measured by
lower PMA at discharge (weighted mean
difference, –2.19 weeks, 95% CI— 4.33,
– 0.05) [Symington and Pinelli, 2002].
The evidence for improved neurodevel-
opmental outcome is conflicting, with
most of the improved development be-
ing demonstrated at earlier ages but no
significant differences at two to three
years.
Despite the potential benefits, the
NIDCAP has not been universally
adopted. In a survey of developmental
care in NICUs, half of the respondents
had NIDCAP certified staff at their insti-
tution, but most initiated consults only
“when the need arises” rather than as a
protocol [Ashbaugh et al., 1999]. Only
30% of NICUs with a developmental
care team had a dedicated budget. Imple-
mentation as outlined by NIDCAP was
unusual. Because NIDCAP incorporates
stimuli reduction, nursing interventions
and modification of the NICU environ-
ment for each infant, it is not clear which
aspects are more beneficial, and assumes
IN THE NICU ● AUCOTT ET AL.
that all excess stimuli are detrimental.
Many NICUs incorporated aspects of the
NIDCAP that are widely acknowledged
to be sensible (e.g., coordinating an in-
fant’s cares with feedings to prolong sleep
time) and promote family interactions
with their infant.
Studies evaluating other individu-
alized developmental care programs not
based on NIDCAP have found no dif-
ferences in weight gain, hospital charges
or length of stay [Brown et al., 1980;
Fleisher et al., 1995]. One study did find
a decrease in ventilator days in infants
receiving developmental care [Fleisher et
al., 1995]. There were no differences in
12 month developmental outcome
[Brown et al., 1980].
THE NICU ENVIRONMENT
Many studies have attempted to in-
tervene in specific areas of the NICU
environment in order to assess its indi-
vidual contribution to outcome. It is well
known that excessive exposure to loud
sound can be damaging to hearing. It is
not as clear what level and duration of
sound exposure is harmful to the devel-
oping auditory system of a preterm in-
fant. As a result, the focus in NICUs has
been to minimize excess noise exposure
[Saunders, 1995; Robertson et al.,
1998b; 1999a; b; Philbin et al., 1999;
Walsh-Sukys et al., 2001]. Less clear are
the potential positive effects of either
quiet or soothing stimuli such as lullabies
or maternal voice. Minimizing auditory
input by placing ear muffs on preterm
infants for 2 days found no acute changes
in physiologic parameters [Zahr and de
Traversay, 1995]. Decreasing sound and
light for 12 hours at night resulted in
improved weight gain and increased time
sleeping [Mann et al., 1986]. The use of
lullaby or parent voice during feeding has
not been shown to improve growth or
duration of tube feeding [Chapman,
1984; Gatts et al., 1994], but when com-
bined with rocking, it decreased hospital
length of stay [Gatts et al., 1994].
Noxious stimuli are unfortunately
common in the NICU due to the need
for frequent monitoring and procedures
related to caring for a critically ill infant.
Providing soothing measures such as
nonnutritive sucking during minor pro-
cedures may be of benefit [Field and
Goldson, 1984; Stevens et al., 1999]. In
addition to minimizing tactile stimula-
tion through clustering of cares and treat-
ing or supporting infants during noxious
stimuli, there has been interest in provid-
ing positive tactile stimulation, such as
stroking or massage. Positive stimulation
around the time of feeding has been
MRDD RESEARCH REVIEWS ● NEURODEVELOPMENTAL CARE
shown to improve weight gain that per-
sists through 12 months PMA, but has
not changed the time needed to become
fully nipple fed [Helders et al., 1989;
Gaebler and Hanzlik, 1996].
In an attempt to simulate the
rhythmic motions found in the in utero
environment, a number of investigators
have looked at providing vestibular stim-
ulation to preterm infants. Rhythmic
stimulation has been provided by use of
devises such as oscillating or rocking mat-
tresses, waterbeds, and a breathing teddy
bear that is placed in isolettes. Vestibular
stimulation facilitates quiet sleep [Tho-
man et al., 1991] but has no impact on
weight gain, feeding outcomes or apnea
[Saigal et al., 1986; Henderson-Smart
and Osborn, 2002]. Developmental as-
sessment at 12 months [Saigal et al.,
1986] and 18 months [Darrah et al.,
1994] was not different between groups.
The sudden exposure to bright
lights after the darkened in utero envi-
ronment has brought concerns of the ef-
fect of light on the immature retina. Most
NICUs have significantly decreased am-
bient lighting [Walsh-Sukys et al., 2001],
and the addition of isolette covers re-
duces light to the infant even further.
Although avoiding bright light exposure
makes sense, reduction of light exposure
has not been shown to reduce the inci-
dence of retinopathy of Prematurity
[Reynolds et al., 1998; Phelps and Watts,
2002]. Although it is the practice in
many NICUs to cover isolettes and min-
imize light exposure, isolette covers
should not totally block a preterm infant
from view, because of the need in inten-
sive care to view the patient as well as
respond to alarms.
Infants demonstrate variations in
their vital signs in accordance with a cir-
cadian cycle, and may respond to inter-
ventions differently based on that cycle
[Glotzbach et al., 1995]. The in utero
environment establishes rhythmic pat-
terns from the influences of maternal
sleep, temperature, heart rate and hor-
monal cycles. The continuous reduction
of light and other sensory input may
make it more difficult for the preterm
infant to establish circadian rhythms. Cy-
cling light exposure may provide a ben-
eficial rhythmicity for the infants. Bran-
don et al. [2002] assigned preterm infants
to one of three groups: cycled light from
birth, cycled light beginning at 32 weeks
PMA, or cycled light beginning at 36
weeks PMA in preparation for discharge.
Those infants receiving cycled light from
birth and 32 weeks PMA gained weight
faster than those who did not receive
cycled light until 36 weeks PMA. There
IN THE NICU ● AUCOTT
were no differences in length of stay or
number of ventilator days. Interestingly,
those infants in near darkness until 36
weeks appeared to have more severe ret-
inopathy of prematurity earlier than
those in cycled light do.
POSITIONING AND HANDLING
Because of the fragility of preterm
infants, most NICUs have adopted a
minimal handling and stimulation ap-
proach for very immature and/or sick
infants [Ashbaugh et al., 1999]. Nurses
have primary responsibility for position-
ing NICU infants for monitoring and
accessibility (e.g., to allow stabilization of
the infant’s airway and intravenous or
arterial catheters) and for rotating their
position on a regular basis. Attention
should always be paid to the infant’s
physiologic parameters: heart and respi-
ratory rate, oxygen saturations, blood
pressure, ease of breathing and perfusion.
When supine, 21 intubated NICU in-
fants on ventilators had evidence of ob-
structed cerebral venous drainage when
their heads were turned to the side,
which suggests that acutely ill infants in
supine should be positioned with their
heads midline [Pellicer et al., 2002]. Sev-
eral studies have found more effective
breathing and oxygenation in preterm
infants with lung disease in the prone
position (compared to supine and side-
lying) [Martin et al., 1979; Lioy and
Manginello, 1988; Baird et al., 1991; Mi-
zuno and Aizawa, 1999; Maynard et al.,
2000; Chang et al., 2002], but not in
healthy preterm infants [Fox et al., 1993].
Repositioning the infant is an effective
method for treating apnea of prematu-
rity. Preterm infants symptomatic with
apnea of prematurity had no significant
differences between prone and supine
positions in frequency of apnea, brady-
cardia or desaturations [Keene et al.,
2000]. Neonates with narcotic abstinence
syndrome had fewer signs of withdrawal
and lower caloric intake in the prone vs
the supine position [Maichuk et al.,
1999].
Promoting neuromaturation is the
goal of positioning and handling conva-
lescent infants, but is also a consideration
for more acutely ill infants. Although
several small randomized controlled trials
did not find that a positioning and han-
dling program conducted by physical
therapists altered incidence of disability in
preterm infants [Goodman et al., 1985;
Piper et al., 1986], failure to attend to
how preterm infants are positioned in the
NICU influences infant posture and mo-
tor function. Many of the common neu-
romotor abnormalities (e.g., asymme-
ET AL. 301
tries, extensor hypertonia) seen in
preterm infants during their first year that
do not signal disability may be the result
of positioning while in the NICU [Geor-
gieff and Bernbaum, 1986; Downs et al.,
1991; de Groot et al., 1995, Konishi et
al., 1986; 1987; 1997; Bracewell and
Marlow, 2002].
Konishi et al. [1986; 1987; 1997]
found that a preterm infant’s predomi-
nant position in the NICU influenced
infant motor development. One study
assigned low risk preterm infants by date
of birth to predominantly prone or su-
pine positions in the NICU. [Konishi et
al., 1987] The groups were comparable
with respect to birthweight, gestational
age, sex, respiratory distress, apnea and
length of hospital stay. Infants positioned
predominantly in supine were more
likely to demonstrate 1) a marked pref-
erence for turning to the right and keep-
ing their head on the right, 2) an asym-
metric posture, 3) asymmetrical occipital
skull flattening, 4) an asymmetrical trunk
at 6 months, 5) an early (before 6
months) right hand preference, and 6) an
asymmetrical gait with a mild gait distur-
bance. A marked lateral head preference
can therefore promote asymmetric
movements in early infancy. This may be
related to the asymmetric tonic neck re-
flex (when the infant’s head is turned to
the side, limbs on the occiput side flex
and on the face side extend) in preterm
infants from 30 weeks PMA until it is
suppressed by higher cortical function at
4-6 months from term [Allen and Ca-
pute, 1986b; 1990].
A developmental study of 213 pre-
term infants with birthweights below
1750 grams found that prone positioning
improved head control but not perfor-
mance on the Bayley Mental or Psy-
chomotor Scales at 56 and 92 weeks
[Ratliff-Schaub et al., 2001]. Prone po-
sition gives infants opportunities to
strengthen muscles and utilize balance
skills when lifting their heads. Parents
should be encouraged to play with their
awake preterm infant in prone on a firm
surface (not a soft mattress) [Mildred et al.,
1995, Ratliff-Schaub et al., 2001] be-
cause play in prone facilitates upper body
antigravity control, trunk and shoulder
stability, fine motor function and bring-
ing their hands to the midline.
In a similar manner, positioning
preterm NICU infants in flexion mimics
intrauterine posture and supports the de-
velopment of flexor tone, which nor-
mally peaks at term [Allen and Capute,
1990]. Placing rolled towels or blankets
to position the infant with flexed limbs
and shoulders slightly forward also helps
302 MRDD RESEARCH REVIEWS
to contain the infant, providing firm
boundaries. The infant’s head should be
neither flexed nor extended, but in line
with the body. It is not necessary to
position infants with respiratory distress
with neck extension; in fact too much
neck extension collapses the airway just
as too much neck flexion does. Lack of
attention to flexed posture and neutral
head position leads to the higher neck,
trunk and extremity extensor tone seen
in preterm infants in NICUs and fol-
lowup clinics [de Groot et al., 1995;
Georgieff and Bernbaum, 1986].
The neck extensor muscles are
stronger than flexors at approximately
32-34 weeks gestation [Amiel-Tison,
1995], giving preterm infants a slight ten-
dency to position themselves with their
neck extended. By 30 weeks gestation,
most of the primitive reflexes seen in full
term infants are evident in preterm in-
fants [Allen and Capute, 1986b]. This
includes the tonic labyrinthine, in which
the trunk and legs extend and shoulders
retract with neck extension and neck
flexion leads to lower extremity flexion
and shoulder protraction. Positioning a
preterm infant in supine with neck ex-
tension stimulates the tonic labyrinthine
reflex, thereby promoting shoulder re-
traction and the extensors of the neck,
trunk and legs. This posture can persist
during infancy [Georgieff and Bernbaum,
1986; de Groot et al., 1995] and interfere
with midline hand play (a 3 month skill),
rolling over (4-5 months), sitting well
(6-8 months) and getting into and out of
sitting (7-8 months). When staff recog-
nize signs of neck extensor hypertonia in
a NICU infant, careful positioning and
handling of that infant is indicated to
keep the infant contained or snug with
firm boundaries, neck neutral, shoulders
protracted, and body symmetric.
Pediatric physical and occupational
therapists can be an important resource
for NICUs because of their experience
with neuromotor abnormalities in infants
with cerebral palsy. They may function as
part of a NICU developmental team, or
may be consulted about specific patients.
The NICU infant with neck extensor
hypertonia who is difficult to position
warrants consultation with a therapist,
who may demonstrate how to swaddle
the infant or use sandbags to position the
infant in a lateral decubitus position with
head neutral. Therapists can also help de-
velop intervention strategies for infants
with asymmetries, infants with hand ab-
normalities (e.g., cortical thumbs) and in-
fants with joint contractures. Most im-
portantly, therapists can play a major role
● NEURODEVELOPMENTAL CARE
in working with parents on developmen-
tal handling and positioning techniques.
One type of joint contracture that
can be avoided by careful positioning is
hip abduction and external rotation con-
tracture (also known as tensor fascia latae
contracture or shortened tibial band)
[Amiel-Tison and Grenier, 1986]. Sick,
sedated or very immature infants tend to
lie frog-legged in either prone or supine.
Frog-legged posture for days to weeks
(especially if paralyzed) fixes the hips in
abduction and results in contractures that
interfere with subsequent neuromotor
development (e.g., rolling over, getting
into and out of sitting). Positioning an
infant’s legs with hips neutral (with some
adduction) can prevent this unnecessary
complication of hypotonia [Downs et al.,
1991].
Neonates have traditionally been
swaddled. Wrapping them tightly in a
blanket with limbs flexed, hips neutral
without rotation, shoulders forward, head
neutral and hands accessible for exploration
provides containment and predictable sup-
port, mimicking the security of the womb.
They should be moved slowly, with atten-
tion to how they are positioned. This is
especially true for irritable infants with nar-
cotic withdrawal symptoms, chronic lung
disease or the hyperexcitability of hypoxic-
ischemic encephalopathy. Even very pre-
term infants when placed in an isolette tend
to migrate towards a side or corner. Strat-
egies that use positioning aides (e.g. blanket
rolls, support wedges) to contain the infant
in flexion and with hips neutral are often
rewarded by reduced signs of stress. Vul-
nerable preterm infants should be moved
carefully as a whole, keeping body and
head aligned and limbs tucked in.
Although there is no evidence that
range of motion exercises or other forms
of physical activity influence later neuro-
motor development, 2 small randomized
controlled studies in preterm NICU in-
fants found greater weight gain and bone
mass (bone length, area and mineral con-
tent) with physical activity [Moyer-
Mileur et al., 1995; 2000]. These studies
reassure us that once infants have
achieved physiologic stability, NICU
staff and families should not be afraid to
hold and handle them. A sensible ap-
proach is to incorporate movement and
gentle tactile, vestibular and kinesthetic
stimulation into therapeutic holding, po-
sitioning and handling preterm infants in
a NICU.
NON-NUTRITIVE SUCKING
Non-nutritive sucking behavior is
present in the preterm infant as early as 27
weeks gestation [Hafstrom and Kjellmer,
IN THE NICU ● AUCOTT ET AL.
2000]. It is characterized by organized pe-
riods of rapid sucking separated by brief
periods of rest. This is significantly different
from nutritive sucking which is slower and
almost continuous in nature. In some stud-
ies, non-nutritive sucking, or giving the
preterm infant the opportunity to suck on a
pacifier during gavage feeding and during
the transition from tube to nipple feeding,
has facilitated the development of a mature
nutritive suck and promoted feeding toler-
ance. Non-nutritive sucking has also been
associated with increased weight gain and
oxygen saturation, and decreased crying
with heel sticks, defensive behavior with
gavage feeding and hospital length of stay
[Field et al., 1982; Bernbaum et al., 1983;
Paludetto et al., 1984; Field and Goldson,
1984; Widstrom et. al., 1988; DiPietro et.
al., 1994].
In a recent Cochrane Review of
randomized trials [Pinelli and Symington,
2002], non-nutritive sucking was associ-
ated with a significant reduction in dura-
tion of hospitalization (weighted mean
difference –7.1 days, 95% CI—12.6,
–1.7), but had no effect on weight gain
(weighted mean difference 1.57 grams
per day, 95%CI— 0.37, 3.50) or oxygen
saturation (weighted mean difference 1%,
95% CI— 0.04, 2.1). A reduction in time
from tube feeding to bottle feeding and
improved feeding performance has also
been demonstrated with non-nutritive
sucking in trials that evaluated these end-
points [Field et al., 1982; Widstrom et al.,
1988; Sehgal et al., 1990; Yu and Chen,
1999]. A significant decrease in soma-
tostatin levels has been associated with
non-nutritive sucking [Widstrom, 1988],
but this has not been shown with moti-
lin, gastrin or insulin levels [Kanarek and
Shulman, 1992]. Several individual trials
failed to demonstrate that non-nutritive
sucking in gavage fed infants has an effect
on a variety of other physiologic and
biochemical measures including intestinal
transit time or caloric intake [DeCurtis et
al., 1986], energy expenditure or nutrient
retention [DeCurtis et al., 1986; Ernst et
al., 1989], heart rate [Pickler et al., 1993;
1996; DiPietro et al., 1994; McCain,
1995] or vagal tone [DiPietro et al.,
1994]. No harmful effects have been re-
ported with non-nutritive sucking.
FAMILY INVOLVEMENT
An essential component of any
neurodevelopmental intervention pro-
gram is family involvement. Parent in-
volvement in the care of preterm infants
has varied markedly during the last cen-
tury. Pierre Budin promoted maternal
involvement in the care of their preterm
infants in his book Les Nourissons pub-
MRDD RESEARCH REVIEWS ● NEURODEVELOPMENTAL CARE
lished in 1900 (in English in 1907). Sub-
sequent endeavors focused on technolog-
ical details of preterm care, including
feeding and temperature control in iso-
lettes. Most early preterm nurseries
tended to isolate preterm infants from
their families who were often unable to
visit their infants because of distance and
other factors. Typically, preterm infants
who survived delivery at home would be
transported to the nursery (by the family,
or in some cases by specialized transport
vehicles staffed and maintained by the
nursery). When the infant had grown and
developed sufficiently to be discharged
from the nursery, the parents would be
notified to come pick up their infant.
The importance of parent involve-
ment in the care of their preterm infant
became clear when tertiary care centers
noted a high incidence of child abuse and
neglect in these preterm children. Klaus
Family-centered NICU
care, the ideal for which
most NICUs strive,
promotes family
involvement in child care
activities and empowers
parents to nurture their
child even in the highly
technical NICU
environment.
and Kennel [1982] recognized the im-
portance of the time immediately follow-
ing delivery, when the infant is generally
in a quiet alert state and both mother and
infant are most receptive to bonding.
When given the opportunity to hold
their baby for the first time, mothers look
into the baby’s eyes, talk to them and
examine them, from head to toe. Failure
to form an attachment during the first
few weeks and months, or disruption of
the attachment process, leads to a higher
risk of abuse and neglect of the depen-
dent infant. Because this process is dis-
rupted when the infant is sick or prema-
ture, NICU staff realized that they had to
work at promoting parent-infant attach-
ment by providing opportunities for par-
ents to visit, hold and talk to their infant.
Recognition came much later that the
NICU is often an ideal place to work
with young and inexperienced mothers
IN THE NICU ● AUCOTT
on parenting skills and developmental
support of their infant.
Family-centered NICU care, the
ideal for which most NICUs strive, pro-
motes family involvement in child care
activities and empowers parents to nur-
ture their child even in the highly tech-
nical NICU environment [McGrath,
2000]. In an effort to provide family-
centered care, most NICUs have twenty-
four hour a day visiting policies for par-
ents, encourage sibling visitation, have
parental support groups and attempt to
arrange specific child care activities, like
nipple feeding, bathing and time for kan-
garoo care, around parents schedules.
Decoration of their infant’s isolette with
family pictures individualizes the infant
by enabling staff to picture the infant as
part of a family.
Although most would agree that
parental participation in child care during
the NICU hospitalization is essential for
parental coping and promotes a long-
term healthy parent-child relationship,
how this participation occurs remains
one of the biggest challenges to NICU
care. Family-centered care assumes that
parents want to be actively involved in
the day-to-day care and decision-making
regarding their child. The literature sug-
gests however, that many parents do not
wish to assume this level of responsibility
[Coyne, 1995]. Some parents are com-
fortable providing nurturing care such as
holding, comforting and feeding but do
not want to perform tasks that NICU
nurses perceive as part of the child’s daily
care, such as changing dressings, giving
medication and trouble shooting equip-
ment alarms. These differences in per-
ceptions make providing family-centered
care particularly challenging for NICU
nurses. Family-centered care requires a
partnership between parents and the
NICU staff with both parties realizing
that every child and family is different
and what works for one may not work
for another.
BREASTFEEDING
Breastfeeding is one of the primary
ways mothers can be involved in their
child’s care from the time of birth
throughout the NICU hospitalization.
Breastfeeding or providing pumped
breastmilk allows mothers to nurture
their child when there is little else they
can do [Meier, 2001]. Mothers who have
been encouraged to breastfeed report that
providing breastmilk helped them cope
with the NICU and kept them con-
nected to their infant during the long
hospitalization [Kavanaugh et al., 1997].
ET AL. 303
 Breastfeeding is beneficial for both
mother and child. Infants who are breast-
milk fed have a reduced risk of infection
and necrotizing enterocolitis [AAP,
1997]. Breastmilk may also provide a
protective effect against the development
of chronic diseases of the gastrointestinal
tract and allergies [AAP, 1997]. When an
infant cannot be put to the breast, bottle
feeding breastmilk may decrease the risk
of aspiration. Mizuno et al. [2002] has
shown that newborns demonstrate a
more coordinated suck/swallow/ breath-
ing pattern when bottle feeding breast-
milk compared with bottle feeding for-
mula or sterile water. Infants feeding
breastmilk are much less likely to inspire
after swallowing, a pattern which places
the child at increased risk for aspiration,
than when bottle feeding other liquids.
Recent evidence suggests that duration
of breastfeeding also exerts a positive ef-
fect on intelligence in young adults with
mean adjusted scores on the Wechsler
Adult Intelligence Scale of 99.4, 101.7,
102.3, 106.0 and 104.0 for those who
were breastfed for less than 1 month, 2 to
3 months, 4 to 6 months, 7 to 9 months
and more than 9 months, respectively
[Mortensen et al., 2002].
Women who breastfeed have less
postpartum blood loss, enhanced bone
mineralization and a reduced risk of
ovarian and breast cancer [AAP, 1997].
Mothers of NICU infants also report that
breastfeeding allowed them to feel like
they had some control over their child’s
care and were directly contributing to
their child’s well-being. Physicians and
nurses are instrumental in a NICU moth-
er’s decision to breastfeed. As many as
40% of mothers who are undecided
about how they want to feed their child
chose to breastfeed after talking with
NICU staff about the benefits of breast-
milk [Meier, 2001]. Speaking with other
NICU mothers who have breastfed also
plays an influential role in the decision to
continue breastfeeding or providing
pumped breastmilk throughout the
NICU hospitalization [Meier, 2001].
Furman et al. [2002] reported that moth-
ers of very low birthweight infants were
more likely to continue to breastfeed be-
yond 40 weeks PMA if they began ex-
pressing breastmilk before 6 hours after
delivery, pumped at least 5 times each
day, and practiced kangaroo care.
KANGAROO CARE
Kangaroo care or skin-to-skin
contact between mother and infant was
developed in Bogotá, Columbia as a low
cost way to assist low birthweight infants
with thermal regulation and provide nu-
304 MRDD RESEARCH REVIEWS
trition and stimulation [Charpak et al.,
1996]. Patterned after marsupial caregiv-
ing behaviors, kangaroo care involves
placing the naked infant against the
mother’s bare chest, between her breasts,
in an upright position for several hours a
day and providing breastmilk only.
A Cochrane Review of kangaroo
care [Conde-Agudelo et al., 2002] cited
nine trials comparing kangaroo care with
conventional care, only three of which
were randomized [Sloan et al., 1994;
Charpak et al., 1997; Cattaneo et al.,
1998]. Each of the randomized trials was
conducted in a developing country using
a similar intervention protocol. In each
study, infants were eligible for kangaroo
care only after a period of routine care
stabilization. On average, infants were
randomized to conventional or kangaroo
care at 3 to 13 days of age and weighed
1574 to 1715 grams. Kangaroo care was
associated with a reduction in nosoco-
mial infections (relative risk 0.49, 95% CI
0.25, 0.93), severe illness (relative risk
0.30, 95% CI 0.14, 0.67) and respiratory
disease (relative risk 0.37, 95% CI 0.15,
0.89) at 6 months follow-up. Although
encouraging, these data were provided
by only one trial. There was no associa-
tion with rehospitalization. Infants who
received kangaroo care gained, on aver-
age, 3.6 grams more weight each day
than those who did not received kanga-
roo care (weighted mean difference, 95%
CI 0.8, 6.4), a small and probably clini-
cally insignificant difference. Similarly,
women who provided kangaroo care
were less likely to discontinue breastfeed-
ing prior to hospital discharge than those
who did not (likelihood of not exclu-
sively breastfeeding at discharge, relative
risk 0.41, 95% CI 0.25, 0.68), but there
was no difference between the groups at
one and six month follow-up. Again, this
endpoint was reported in only one trial.
Mothers providing kangaroo care were
less likely to be dissatisfied with NICU
care (relative risk 0.41, 95% CI 0.22,
0.75) than those who did not in the sin-
gle trial that studied this endpoint. Data
concerning length of hospitalization is
conflicting between the three random-
ized trials, providing no clear evidence
that kangaroo care decreases duration of
hospitalization.
Kangaroo care may provide pro-
tection from infection in the NICU en-
vironment, increase daily weight gain
and improve maternal satisfaction with
hospital care. Future research is needed
to define how kangaroo care can benefit
children and parents in developed coun-
tries.
● NEURODEVELOPMENTAL CARE
PAIN
In 2001, the American Academy of
Pediatrics and the International Evi-
dence-Based Group for Neonatal Pain
published recommendations for the man-
agement of pain in newborns [AAP,
2001; Anand et al., 2001]. Both consen-
sus statements recognized that health care
providers may lack knowledge about the
newborn’s ability to feel pain, are not
adequately trained in pain assessment
techniques and effective treatment and
prevention strategies, and fear the side
effects of analgesics. Therefore, new-
borns may not receive appropriate pain
relief for invasive procedures. This may
be particularly true for preterm infants
who undergo frequent blood sampling
and other diagnostic and therapeutic pro-
cedures over a prolonged period. In a
retrospective review of practices in six
neonatal intensive care units, Kahn et al.
[1998] reported a 28.6 fold variation in
the use of narcotics for infants on venti-
lators. No major adverse effects were
found among those infants receiving nar-
cotics, but long-term effects of depen-
dence and behavioral outcomes were not
studied.
Preterm infants feel pain [Anand and
Hickey, 1987]. Nociceptive pathways de-
velop early in fetal life with fetuses as young
as 23 weeks gestation increasing cortisol
and endorphin production in response to in
utero transfusions [Franck et al., 2000]. Al-
though afferent fibers are present and func-
tional in preterm infants at birth, descend-
ing neurotransmitters that modulate pain
develop later in postnatal life. As a result,
preterm infants have an increased sensitivity
to pain compared with adults [Anand,
1998; Fitzgerald et al., 1988]. Not only is
the ability to attenuate pain diminished in
preterm infants, but also painful stimuli are
accentuated by windup phenomenon, or
increased expression in excitatory nocicep-
tive neurons in the dorsal horn of the spinal
cord [Fitzgerald et al., 1989]. Prolonged
periods of windup may result in exagger-
ated responses to non-noxious stimuli, or
in the preterm infant, perceiving manipu-
lations not generally felt to be noxious,
such as handling, as painful [Anand, 1998].
Preterm infants undergo frequent
painful experiences during their NICU
hospitalization which may have longterm
consequences. One study documented
that 3000 procedures were performed on
fifty-four infants consecutively admitted
to the NICU [Barker and Rutter, 1995],
and another reported that, on average,
134 painful procedures were performed
during the first two weeks of life on very
low birthweight infants [Stevens et al.,
1999]. Several investigators suggest that
IN THE NICU ● AUCOTT ET AL.
because of these early experiences, pre- al., 2002]. Eleven out of twelve studies
term infants may have both structural and that assessed crying as an endpoint re-
functional reorganization of their ner- ported decreased crying behavior for in-
vous system, similar to the effects seen in fants that received sucrose administration
animal studies of prolonged pain expo- compared to controls. Seven of the
sure. This reorganization could result in eleven studies that assessed heart rate also
long-term alterations in pain response reported decreased heart rate among in-
[Anand, 1998; Grunau et al., 1998]. fants receiving sucrose. The majority of
Clinical studies seem to support this hy- studies (5/6) that used a behavior pain
pothesis. scale reported decreased scores among
Lower gestational age and in- infants receiving sucrose. For the three
creased number of previous painful pro- studies that utilized the Premature Infant
cedures were independently related to Pain Profile, a behavioral, physiologic
diminished behavioral and autonomic and contextual measure of pain, scores
pain reactivity to an invasive procedure were reduced for those infants receiving
performed at 32 weeks PMA in two sep- sucrose compared with controls at 30
arate studies of preterm infants [Johnston seconds [weighted mean difference,
and Stevens, 1996; Grunau et al., 2001]. –1.64 (95% CI—2.47, – 0.81)] and 60
Grunau et al. [1998] reported that at seconds after a heelstick [weighted mean
eight to ten years of age, extremely low difference, –2.05 (95% CI—3.08,
birthweight children rated the perceived –1.02)]. Only one of the four studies that
intensity of pain related to pictures of evaluated adverse effects reported prob-
medical procedures (stitches in the arm) lems with sucrose administration; three
as higher than the perceived pain related infants had desaturations when receiving
to pictures of psychosocial embarrassing sucrose by syringe (this did not occur
situations (reprimanded by teacher). This when given in conjunction with a paci-
is in direct contrast to how their full-term fier) and 3 infants in the control group
peers rated the pain intensity in the two desaturated or choked when receiving
situations. water, with or without a pacifier. None
Morphine and fentanyl are the of the infants required intervention. Su-
most commonly used pharmacological crose administration appears to be a safe
agents in the NICU for pain manage- and effective strategy for reducing pain
ment [Stevens et al., 2000]. Both drugs associated with blood drawing.
provide analgesic effects for mild to se- Additional research is critical to the
vere pain in neonates as agonists for en- development of a comprehensive ap-
dogenous opioid receptors. Although proach to pain management in the
concern about respiratory depression has NICU. Strategies must weigh the poten-
historically limited use of these analgesics, tial risks and benefits of both pharmaco-
recent evidence suggests that morphine logical and behavioral interventions
may be beneficial to the neurological without losing sight of the human factors
outcome of preterm infants. Anand et al. of pain and suffering.
[1999] reported a decreased incidence of
death, severe IVH or PVL among pre- CONCLUSIONS
term infants that received continuous, Providing neurodevelopmental sup-
low-dose morphine (4%) when com- port in a NICU is more than a protocol or
pared to infants that received either mi- an order list. It is an attitude that should be
dazolam (32%) or 10% dextrose (24%). In shared by every staff member and every
contrast, animal studies of mice and one discipline providing care to infants and
study of preterm infants has suggested families in the NICU. It should be shared
that fentanyl may increase the risk of PVL by everyone who enters the NICU: visi-
[Gressens et al., 2002]. Other pharmaco- tors, technicians, maintenance workers and
logic agents are available to reduce pain administrators should be cautioned to keep
in the NICU setting, including non-opi- their voices low, avoid shining bright lights
oid analgesics such as acetaminophen and in an infant’s face, respect a family’s privacy
topical anesthetics such as EMLA. and be supportive in any way they can.
Oral sucrose is the most widely Some of the proposed interventions dis-
studied non-pharmacological interven- cussed in this review require a great deal of
tion for pain relief in neonates. There training, preparation, organization, time
have been 17 randomized controlled tri- and money and their influence on neuro-
als that meet Cochrane Review criteria developmental outcome is uncertain.
that compared physiologic and behav- However, many others are inexpensive,
ioral responses, and scores on pain scales non time-consuming, family-centered in-
between infants given oral sucrose and terventions that can easily be implemented.
those given placebo (generally water) af- Many can be incorporated into an infant’s
ter a heelstick or venapucture [Stevens et cares without taking extra time. Many
MRDD RESEARCH REVIEWS ● NEURODEVELOPMENTAL CARE IN THE NICU ● AUCOTT
merely involve changing how we do things
or changing our attitude towards what we
are doing.
Assessing each infant and individu-
alizing care has been a central feature of a
number of proposed intervention strate-
gies, but NIDCAP has made a major
contribution to the field by popularizing
this concept. Preterm infants are individ-
uals who differ a great deal with respect
to size, maturity, medical status, nutri-
tional status and neuromotor and neu-
robehavioral abilities. Their families also
differ as to their needs, strengths, capa-
bilities, degree of understanding of med-
ical and neonatal intensive care, commu-
nity supports and socioeconomic status.
All supportive intervention, for the child
and family, needs to be individualized for
it to be most effective. The major chal-
lenge is to determine who benefits from
which intervention, applied in what way
for how long.
There is no doubt that one of the
most effective neurodevelopmental in-
terventions that a NICU can provide is
to promote family involvement and
guidance regarding neurodevelopmental
support. Even the busiest NICUs with
the sickest infants should not lose sight of
their overall goals, and how important
families are to these goals. Nurturing and
enrichment experiences support a child’s
development and have effects that con-
tinue throughout that child’s lifetime.
Every NICU should be easily accessible
to families, value effective parent com-
munication, have a sibling visitation pro-
gram and provide guidance to parents in
how they can support their infant’s neu-
romaturation.
Efforts to determine efficacy and
effectiveness of specific NICU neurode-
velopmental interventions have contin-
ued over the last two decades, utilizing a
variety of outcomes. What are we trying
to change when we introduce interven-
tions? Primary outcome variables are
measures of cognitive, neuromotor and
neurosensory abilities generally obtained
at 1-2 years or later. A less expensive and
time-consuming approach has been to
utilize variables related to earlier dis-
charge to a more nurturing environment
(i.e., home or a convalescent care unit).
Many studies therefore utilize length of
hospital stay, weight gain and duration of
mechanical ventilation or supplemental
oxygen. A few studies have directly mea-
sured the preterm infant’s neurobehav-
ioral status at term or NICU discharge,
but how these measures relate to later
neurodevelopmental outcome remains a
question. Rate of neuromaturation has
not been specifically measured or used as
ET AL. 305
outcome measures. The work that has
been done raises many questions that re-
quire further research.
The fragility and health of the pre-
term infant and family must be taken into
account when formulating a plan for
neurodevelopmental support. Any inter-
ventions that pose a degree of risk to the
fragile preterm infant must be postponed
or abandoned. A central feature of neu-
rodevelopmental support is that it must
be individualized. There is no doubt that
how preterm infants are positioned and
handled influences their development.
The greatest challenge in neonatal inten-
sive care at this juncture is to determine
the neurodevelopmental consequences of
what we are currently doing and how
these interventions affect development so
that we can identify and modify them, or
implement new interventions that are
more effective. Just as new neuroprotec-
tive medications are being developed,
there is an exciting potential to design the
NICU and neonatal intensive care of in-
fants and their families in a way that
enhances normal CNS development,
supports recovery from CNS injury and
protects the developing CNS from fur-
ther injury. f
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