Early Human Development 139 (2019) 104840

Contents lists available at ScienceDirect

Early Human Development

journal homepage: www.elsevier.com/locate/earlhumdev

Best practice guidelines

Individualised developmental care for babies and parents in the NICU: Evidence-based best T

practice guideline recommendations

A R T I C LE I N FO A B S T R A C T

Keywords: Advances in neonatal care have improved survival of premature and critically ill infants; and while rates of some
Neuroprotective care long-term neurodevelopmental problems in survivors have improved, such as cerebral palsy, there are others
Developmental care such as learning and behavioural difficulties that have not. The goal of improving long term neurodevelopmental
Neurosupportive developmental care morbidity has led to an increased focus on improving developmental care not only in neonatal long term follow-
Neonate
up clinics but within the NICU itself to capture the period of earliest brain neuroplasticity. The application of a
systematic approach to improve practice is considered the most effective strategy for implementing neuropro-
tective developmentally supportive care. The content of this paper incorporates evidence-based systematic re-
views to guide clinicians in the application of developmentally supportive interventions.

1. Background 2.1. Search strategy

Advances in neonatal care have improved survival of premature and
critically ill infants; and while rates of some long-term neurodevelop-
mental problems in survivors have improved, such as cerebral palsy [1],
clearly there are some other neurodevelopmental problems that have
not, such as learning and behaviour difficulties [2]. Complications and
the presence of associated congenital anomalies lead to an increased
risk of neurodevelopmental, learning and behavioural problems which
have a deleterious effect on quality of life [3,4]. The goal of improving
long-term neurodevelopmental morbidity has led to an increased focus
on improving developmental care not only in neonatal long-term
follow-up clinics but within the neonatal intensive care unit (NICU)
itself to capture the period of earliest brain neuroplasticity [5]. Con-
sequently, there is a requirement for clinicians to apply interventions in
the NICU setting that are supported by evidence and focussed on im-
proving neurodevelopmental outcomes.
2. Development and implementation of an evidenced-based
clinical practice guideline
The search strategy aimed to find published systematic reviews. A
three-step search strategy was utilised, including an initial limited
search of MEDLINE, CINAHL, PROQUEST and OVID followed by an
analysis of the text words contained in the title and abstract, and of the
index terms used to describe article. A secondary search using all
identified keywords and index terms using MeSH criteria occurred
across all included databases. Thirdly, the reference list of all identified
reports and articles was searched for additional systematic reviews. In
the absence of published systematic reviews, other published papers
were considered to support neuroprotective developmentally suppor-
tive care (NDSC) components. Studies published in English and pub-
lished between the years 2009–2018 were included in this review.
2.2. Inclusion criteria
The search results were screened by two researchers independently.
Systematic reviews, evidence-based summaries and meta-analysis were
included.

The application of a systematic approach to improve practice is 2.3. Database search

considered the most effective strategy for identifying potential pro-
blems and translating policy to frontline patient care [6]. The content of
this paper incorporates evidence-based systematic reviews to guide
clinicians in the application of developmentally supportive interven-
tions.
MEDLINE, CINAHL, PROQUEST, OVID, Cochrane Database of
Systematic Reviews, Joanna Briggs Institute Systematic Reviews.
2.4. Initial keywords utilised in the search strategy included Medical Subject
Headings (MeSH)

Neuroprotective effects, Neonate, Neonatal Intensive Care.

Abbreviations: CPG, Clinical Practice Guideline; JBI, Joanna Briggs Institute; MeSH, Medical Subject Headings; NDSC, Neuroprotective Developmentally Supportive
Care; NICU, Neonatal Intensive Care Unit; NIDCAP, Newborn Individualized Developmental Care and Assessment Program; SSC, Skin to Skin Care

https://doi.org/10.1016/j.earlhumdev.2019.104840

0378-3782/ Crown Copyright © 2019 Published by Elsevier B.V. All rights reserved.
Best practice guidelines Early Human Development 139 (2019) 104840

2.5. Other additional search terms included Table 2

Developmental care model recommendations.
Developmental care, Neurosupportive Developmental Care, Best practice recommendations for NDSC models JBI Grade References
Developmental Care theory, Neurodevelopmental outcomes, parent/
infant separation, NICU environment, noise, NICU design, sleep, de- • The use of individualised developmental care
models such as Newborn Individualized
B [14]
velopmental care education/training, feeding, pain assessment/man-
Developmental Care and Assessment Program
agement, caregiving, discharge. (NIDCAP) are recommended to optimise
neurodevelopmental outcomes in preterm infants

2.6. Scope and purpose

This paper has been produced to assist clinicians in the development
of unit based clinical practice guidelines (CPG) enabling them to
benchmark practice recommendations against systematic reviews that
explore NDSC publications.
3.1. Concepts underpinning neuroprotective developmentally supportive
care
The following provide a conceptual basis for neuroprotective care
centred on supporting neurodevelopmental outcomes (Tables 2–13).

3.1.1. Developmental care theoretical basis

2.7. Utilising systematic reviews to inform clinical practice guideline content
CPG's are designed to assist health care practitioners when making
decisions by assimilating, evaluating and implementing pieces of evi-
dence and opinions on current best practice [7]. Systematic reviews are
often considered best available evidence in this context as they involve
searching, selecting, critically appraising, and summarizing the results
of primary research [8,19]. The more rigorous the review methods
utilised in a systematic review the higher the quality of the synthesised
findings, with the subsequent CPG considered more evidence-based
[10].
A limitation of relying on systematic reviews is the need for critical
appraisal of the original studies. Multiple authors suggest clinicians
should never accept results of systematic reviews or recommendations
of guidelines at face-value [7,8]. To minimise bias in interpreting evi-
dence presented via systematic reviews, a framework to understand and
grade the quality of the body of evidence and strength of re-
commendations is required [10].
3. Guideline recommendations
Developmental care refers to a range of strategies designed to
modify the neonatal unit environment and modes of care to reduce the
stressors on the developing brain. The concept of ‘developmental care’
evolved from Als' work based on the Synactive Theory of Infant
Development [12]. The theory provides a framework within which to
understand the behaviour of premature and sick infants [13]. Re-
commendations pertaining to developmental care are highlighted in
Table 2.
3.1.2. Neurodevelopmental outcomes
Vulnerable neonates including those born prematurely or ill face
many risk factors that contribute to abnormal brain development.
Hospitalisation of neonates in the NICU occurs during a period of rapid
and critical brain growth yet the pathophysiologic mechanisms for
adverse neurodevelopmental outcomes in NICU survivors are complex
and to some extent poorly understood [1]. The broader construct of
developmentally supportive care consists of a range of strategies re-
commended in other sections of this paper that are designed to modify
neonatal caregiving and the surrounding environment to reduce the
stressors on the developing brain. Evidenced based recomendations are
outlined in Table 3

The recommendations in this paper are based on the level of quality,
relevance and strength of the systematic reviews applied to each. The
evidence levels were determined using the Joanna Briggs Institute (JBI)
Levels of Evidence and Grades of recommendation [11]. The re-
commendation and underlying research is graded up or down based
upon feasibility, appropriateness, meaningfulness and effectiveness
described in the FAME scale [11]. Given a broad range of NDSC re-
search consists of qualitative research this model supports the grading
of evidence based upon a broader view of what constitutes research
evidence for practice [11]. The JBI Grades of Recommendation are
outlined in Table 1.
3.2. Key components of neuroprotective developmentally supportive care
Incorporating the following components in clinical practice guide-
lines is considered essential to optimise neuroprotection and neurode-
velopmental outcomes.
3.2.1. Minimising parent/infant separation
There are many benefits for early parent-infant closeness during
hospitalisation [18]. Physical and emotional closeness between the
infant and parent in the neonatal unit are considered crucial to the
physical, emotional and social well-being of both the infant and parent
[18]. Minimising infant and parent separation has been demonstrated
to have positive effects on infant brain development, parent

Table 1
JBI grades of recommendations [11].
Grade A A ‘strong’ recommendation for a certain health management strategy where:

1. It is clear that desirable effects outweigh undesirable effects of the strategy

2. There is evidence of adequate quality supporting its use
3. There is a benefit or no impact on resource use
4. Values, preferences and the patient experience have been taken into account
Grade B A ‘weak’ recommendation for a certain health management strategy where:

1. Desirable effects appear to outweigh undesirable effects of the strategy, although this is not as clear
2. Where there is evidence supporting its use, although this may not be of high quality
3. There is no benefit, no impact or minimal impact on resource use
4. Values, preferences and the patient experience may or may not have been taken into account

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Best practice guidelines Early Human Development 139 (2019) 104840

Table 3
Neurodevelopmental outcome recommendations.
Best practice recommendations for NDSC models JBI grade References

• Systematic follow-up and/or assessment at school entry is beneficial to improve the outcomes of infants born late preterm A [15]
• Infants receiving major surgical interventions, especially those with complex cardiac conditions, are at risk of neurodevelopmental delay and should
be enrolled in developmental follow up screening
A [16]

• Reduce delays in the identification of developmental delay. This is important to ensure interventions may be started as early as possible to prevent/
ameliorate progression
A [17]

• Increase the level of awareness of neurodevelopmental outcomes issues in NICU graduates among parents and educators to identify impairments
early. If undetected by school age, these milder disabilities may have a negative cumulative effect on development
A [17]

Table 4
Parent/infant separation recommendations.
Best practice recommendations for NDSC models JBI grade References

• 24Sensitive
h per day parent/carer access to their infant(s) A [18,20]
•- parent–infant
care practices, procedures and the physical environment need to be organized to support:
closeness
A [18,20,21]

- early and prolonged skin-to-skin contact

- family-centered care
- family rooms
- optimization of space during unit redesign
• Supporting parents in their skills to observe and interpret their infant's behaviour has been associated with improved cognition in later life and
should be incorporated in clinical practice
A [21]

• Provide families with education and support to improve parent/caregiver–child interactions through play, reading and positive interactions.
Supporting bonding and attachment
A [3,17]

• Provide parents with education to assist in the recognition of infant behavioural cues A [17]

Table 5
Sensory environment recommendations.
Best practice recommendations for NDSC models JBI Grade References

• safe
Implement early positive sensory exposures such as tactile, auditory, visual, kinaesthetic, gustatory, olfactory, which have been identified as being
and potentially important for optimizing infant and parent outcomes in the NICU
B [22]

• AInterventions
cohesive plan of sensory exposure is required for each individual infant B [22]
• Single family rooms
should continue to focus on reducing ambient noise of equipment and general NICU activity A [23]
• of the environment, are recommended as they can improve outcomes for preterm neonates, with increasing parental involvement and better control
resulting in fewer inappropriate stimulations such as high levels of noise and illumination
A [24]

• Single family rooms may be considered for vulnerable infants as they help parents and staff focus on the importance of the sensory environment
during a period of critical brain growth and development
B [22]

• Instimuli
the absence of their family, a combination of unit design that includes open settings should be available for infants who do not receive adequate A [23]

• Appropriately
developmental care
timed sensory interventions that places the parents at the centre of the infant's care should be provided within the context of B [22]

• Sound-activated noise meters should be considered in NICUs as part of the effort to provide an appropriate sound environment for fragile infants A [25]
• Adjusted to the sensitivity of the infant and their developmental and medical stages, human voice can assist in reducing infant stress, promote
attachment with parents; and/or to facilitate neurologic, communication, and social development
A [26]

• Silicone earplugs can reduce sound levels for newborn infants with better growth and developmental outcomes B [27]
• Cycled
of day
lighting over 24 h appears preferable to continuous bright lights and should be individually implemented based on an infant's state and time B [23,28]

• Reading to infants in the NICU should be encouraged as it can have a positive impact on parenting behaviours and attitudes and the infant's cognitive
development.
A [29]

Table 6
Sleep recommendations.
Best practice recommendations for NDSC models JBI grade References

• Promotion and protection of sleep should be taught as a cornerstone of neonatal care for the treatment of patients in the NICU via integrated teaching
programs targeted to nurses, medical staff, parents and other caregivers
A [34]

• Sleep measurements should be incorporated into daily ward rounds to increase awareness of sleep as a key factor in neonatal health and to improve
sleep outcomes
A [34]

• Elective care procedures should be postponed during sleep A [34]

• Cyclical lighting should be used to assist in the establishment of a daily melatonin rhythm A [35]
• Completing caregiving as a neonate transitions to sleep is not recommended as preterm infants are unable to display the various overt behaviours
associated with differing sleep-wake states, and responses may consequently be misinterpreted
B [3,32]

• Avoid sleep interruption as a relationship has been established between quantity and quality of sleep in preterm infants and neurocognitive and
socio-emotional outcomes. The interruption of normal sleep can lead to the modification of the expression of several genes that can reduce the brain
B [33]

plasticity

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Best practice guidelines Early Human Development 139 (2019) 104840

Table 7
Feeding recommendations.
Best practice recommendations for NDSC models JBI grade References

Nutrition is closely linked to neurodevelopmental outcomes with breastfeeding identified as the optimal method of infant feeding to reduce risks of A [36]
infant morbidity and mortality and improve long-term cognitive functioning
Early initiation of breastfeeding can improve survival and should be promoted in the NICU as the first choice for the first oral feed. The first suck feed of A [37]
any infant in the NICU should be a breastfeed unless otherwise indicated by their medical condition
A delay in acquiring feeding skills is a common cause of prolonged hospitalisation in the NICU, thus attention to promoting feeding should be a priority A [38]
in NICU management plans
NICUs where staff are educated on breastfeeding and available to support mothers of low birth weight infants, have infants who are more likely to be A [38]
discharged breastfeeding
Safe and efficient feeding should be promoted by taking into account the infant's arousal, physiological regulation, posture, oropharyngeal structure and B [39]
function, in addition to suck-swallow-breathe patterns
A focus on cue based individualised feeding experiences should be implemented as it has been demonstrated to lead to earlier achievement of full suck B [39]
feeds
Responsive sensitive feeding is associated with the parent or caregiver's capacity to respond to the infant's physiological and behavioural B [40]
communication. The transition from tube to suck feeds should be undertaken according to the infant's behavioural cues for readiness
Advice and support for mothers initiating breastfeeds in premature infants needs to be consistent. B [38]
Mothers should be counselled after birth as to the increased importance of human milk A [38]
There is a trend towards reaching full feeds earlier with the early introduction of trophic feeds B [41]

Table 8
Skin to skin recommendations.
Best practice recommendations for NDSC models JBI grade References

• SSC increases breast milk supply and breast feeding. Facilitating SSC for at least 1 h a day increases the length of breast feeding after discharge and
should be offered to mothers where the infant's medical condition allows
A [43]

• SSC can support physiological regulation of temperature and heart rate and is used to promote physiological stability in infants A [43]
• SSC should be offered during painful procedures where practical to help minimise stress and behavioural responses A [43]
• Ensuring staff are competent and confident in supporting infants and parents during transfers can assist to facilitate skin to skin episodes A [43]
• healthcare
SSC has been shown to be feasible and safe in the NICU in stable infants as young as 26 weeks' gestation, with benefits for both parents and infants;
professionals are encouraged to offer SSC frequently as a part of routine care
A [43]

Table 9
Pain and stress recommendations.
Best practice recommendations for NDSC models JBI grade References

Treatment interventions such as tracheal intubation, insertion of intravenous cannulas and heel sticks are painful procedures resulting in continuous pain A [44,45]
and need to be managed appropriately
Minimise invasive procedures in very preterm infants as those who have a greater number of invasive procedures during their hospital stay have been A [46]
shown to have an altered brain microstructure and poorer cognitive outcome at 18 months' corrected age
Neonatal procedural pain/stress exposure should be minimised as it has been identified as being significantly associated with specific changes in brain A [47]
development in the premature infant
Adverse sensory experiences such as noise, light and repeated activities are known to influence brain development, potentially resulting in abnormal B [48]
neurodevelopment and need to be kept to a minimum
Regular pain assessment using an appropriate assessment tool (such as the Premature Infant Pain Profile-Revised) should be used as standard practice in A [49]
the NICU
Non-pharmacological pain interventions such as breastfeeding, breast milk, sucrose or glucose, as well as positioning, swaddling, non-nutritive sucking B [50,51]
and odour should be used for potentially painful interventions such as heel lance and venepuncture in both term and preterm infants, depending on
the infant's medical condition
Pharmacological interventions such as morphine or fentanyl should be titrated according to the infant's pain scores following developmental care A [52]
interventions and a risk to benefit assessment
Simultaneous recordings of multiple measures such as electroencephalography and near-infrared spectroscopy can be considered to assess pain as they B [53]
can provide a more complete picture of the response to a procedure and how this response may be affected by analgesics
Parents should be given information and education about their baby's pain so they can be better prepared to take an active role in their infant's pain care A [54]

Table 10
Caregiving recommendations.
Best practice recommendations for NDSC models JBI grade References

• Healthcare professionals require extensive education and support to implement developmentally supportive care giving A [14]
• Age appropriate individualised care giving should be implemented as it enhances the developing competencies of the infant A [21]
• Timing of caregiving should be optimised to support sleep and paced to minimise stress and promote stability A [21]

psychological well-being and on the parent–infant relationship [18,19].
Evidence advocating to minimse seperation is graded in Table 4.
3.2.2. Supportive sensory environment
The clinical environment can impact on neurodevelopment and
contribute to the stressors for neonates requiring hospitalisation.
Environmental noise is a primary stressor for sick neonates, families/
caregivers, and staff within the neonatal intensive care unit (NICU)
setting. Strategies to assist in the modification of environmental stres-
sors are part of developmentally supportive care they are summarised

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Best practice guidelines Early Human Development 139 (2019) 104840

Table 11
Positioning recommendations.
Best practice recommendations for NDSC models JBI grade References

• positioning
There is insufficient evidence to determine effects of body positioning on apnoea, bradycardia and oxygen saturation in preterm infants, however
should be considered when trying to optimise an infant's condition
A [55,56]

• Prone
supine
positioning slightly improves oxygenation in neonates undergoing mechanical ventilation and can be considered as an alternate position to A [57]

• Swaddling preterm infants should be promoted as it can decrease physiological distress and improve self-regulation attempts A [21]
• Support infants with motoric containment in a side-lying position after a painful procedure as it reduces crying and sleep disruption A [21]
• Physiological stability can be promoted by moving the preterm infant slowly and maintaining alignment and flexion A [21]
• The use of postural supports can aid in ensuring functional support. Extra consideration should be taken when altering body position from horizontal
to head-tilt to decrease the impact on cerebral perfusion
A [58]

• Preventive positioning (i.e. alternating positions) should be implemented to avoid the likelihood of preterm infants acquiring postural deformations
which can decrease body movement and limit exploration of the infant's environment
A [21]

Table 12
Continuity in caregiving recommendations.
Best practice recommendations for NDSC models JBI grade References

• Involving
beyond
parents in their baby's care in the neonatal unit empowers and enables their competence and confidence as caregivers in the NICU and A [60]59

• Inprocedures
collaboration with parents, a case management plan should be made in order to efficiently plan and coordinate required investigations and
and follow-up planning, as well as to ensure the acquisition of needed parental competences
A [61]

• Parenting education is considered a key intervention component to decrease maternal anxiety A [62]
• Parents
care
of preterm and vulnerable infants should be trained and provided with sufficient instructions to perform tasks associated with developmental A [14]

• should
Staff who are trained and experienced in mental health care and psychological screening for stress, depression and other forms of emotional distress,
be utilised to support the delivery of family-centred care in the neonatal unit
B [60]59

• Supportive interventions that include psychosocial support should be provided as they result in better outcomes for mothers of preterm infants A [62]

Table 13
Education and training recommendations.
Best practice recommendations for NDSC models JBI grade References

• Developmental care education should be included in the orientation of all new staff to the neonatal setting A [21,63]
• Insupportive
order to effectively support parents, staff require extensive and ongoing training to understand infant behavioural responses and role model
care
A [14,20,64]

• Information regarding expected infant development and the influence of the neonatal setting should be provided to al staff A [24]59
• Developmental care training should be offered in post-graduate and advanced practice courses in neonatal care A [24]

and graded in Table 5.
3.2.3. Protecting sleep
Sleep is the predominant state for neonates. A lack of sleep in the
neonatal period is associated with behavioural problems and reduced
cerebral cortical size [30,31]. Protecting sleep is considered essential in
the provision of neuroprotective care in the NICU [32,33]. Strategies to
protect sleep are summarised in Table 6.
3.2.4. Feeding
Many high-risk and preterm infants have difficulty with successful
feeding and subsequent optimal growth during their stay in the NICU.
The environment, medical procedures, and the infant's underlying
medical condition present challenges for the development of successful
eating skills. Sucking and tolerating feeds is a neurodevelopmental
process that depends on the infant's organisation, motor tone and
movement, level of arousal, and ability to simultaneously regulate these
processes. Grading of evidence based feeding recommendations are
presented in Table 7.
their cognitive and communication performance in later life [42]. A
summary of skin to skin evidence grading is documented in Table 8.
3.2.6. Pain and stress management
The terms “neonatal pain” and “neonatal stress” are often used in-
terchangeably. Stress responses can be specific to a particular source or
nonspecific and more generalised. Pain is always stressful; however
stress is not necessarily painful. It remains very difficult to distinguish
where stress ends and the painful experience begins. It remains im-
perative that pain is avoided or managed appropriately.
Recommendations for best practice approaches to pain management are
graded and presented in Table 9.
3.2.7. Caregiving interactions
Adaptive individualised and sensitive caregiving is considered an
essential component for healthcare professionals in the neonatal unit.
Evidence supportin an individualised approach to caregiving is outlined
in Table 10.

3.2.5. Skin to skin care (SSC)

Skin to skin (Kangaroo) care is recognised as one of the most well-
researched and frequently applied components of developmental care,
with benefits for neurosensory development, bonding and attachment,
thermoregulation, weight gain and improved breast-feeding outcomes
[42]. Recent evidence suggests there is an association between early
and frequent skin-to-skin care (SSC) for extremely preterm infants and
3.2.8. Positioning
Positioning of infants is considered a basic task of healthcare pro-
fessionals in the neonatal unit. A variety of physiological and motor
outcomes are affected by different body positioning of infants [75].
Recommendations supporting positioing interventions are presented in
Table 11.

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Best practice guidelines
3.2.9. Continuity in caregiving
The adverse effect of the NICU post -discharge on families is in-
creasingly recognised in the neonatal community; thus, ensuring par-
ents are supported in the antenatal period during their NICU journey
and through to discharge is essential [79]. Extending the provision of
care beyond the NICU requires creativity and is often dependent on
funding and practical support. With increasing numbers of premature
births and NICU survivors collectively we have a responsibility to en-
sure NICU graduates and their families are supported long term to meet
their potential. Evidence supporting the application of continuity in
caregiving is presented in Table 12.
3.2.10. Staff education and training
Education from qualified experts in neonatal behavioural inter-
pretation is necessary to ensure the neonate is ‘seen’ as an individual
with unique responses and needs. Ultimately this approach to under-
standing and responding to neonates can be viewed as the essential
framework to enact neuroprotective caregiving and clinical practice
guidelines. Research supporitng the requirement for neonatal health
care professionals to complete spcialised trianing is presented in
Table 13.
4. Ensuring sustainability for clinical practice recommendations
In addition to identifying relevant evidence-based practice re-
commendations the following components are recommended to facil-
itate the introduction, uptake and sustainability of NDSC components
when developing CPG's:
• The unit leadership team supports both implementation and sus-
tainability of NDSC recommendations [63].
• The CPG implementation team consists of members with both de-
velopmental care experience and clinical/clinician influence [63]
• Changes to practice are undertaken based on NDSC reviewed evi-
dence [63]
• Data is collected (audits) for NDSC components to evaluate and
monitor practice change, ideally before and after the implementa-
tion of components [63]
A recent joint publication from speciality neonatal nursing groups
suggests the following components should be considered when devel-
oping NDSC guidelines [63]:
- Guidelines involve changes in all aspects of the health-care setting:
clinical care, education, management, and research.
- Guidelines are operationalized over different phases and steps over
time, and outcomes are measured for quality improvement and re-
search publication purposes.
McGrath and Valenzulea [65] over twenty years ago highlighted the
best chance for a successful integration of NDSC philosophy and its
implementation is patience, endurance, and persistence. These authors
suggest the successful application of NDSC guidelines is not likely to be
reflected by immediate and easy adoption; instead a focus on under-
standing change management processes, establishing strong leadership
and focussing on unit culture that may embrace or reject practice are
required [6]. The development of a policy alone does not ensure con-
sistency in NDSC practices – a broader strategy that reviews unit cul-
ture, enablers and barriers to sustainability is required.
5. Limitations
This paper has graded systematic reviews to demonstrate their use
in the development of neuroprotective recommendations for CPG's. The
JBI allocated category refers to the reviewers grading of the feasibility,
appropriateness, meaningfulness and effectiveness of the
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Early Human Development 139 (2019) 104840
recommendation contained in the systematic review or equivalent pa-
pers, and not the individual studies within the reviews. Hence further
analysis of the evidence provided in the systematic reviews is re-
commended.
6. Conclusion
This paper demonstrates systematic reviews are useful supporting
documents to establish practice recommendations when developing
NDSC CPG's. A critique of systematic reviews has identified there is a
broad body of evidence to support NDSC strategies. Translation of this
information to the clinical practice setting should be undertaken with
consideration of the individual setting in which recommendations are
implemented. Reviewing the literature is one of many steps in estab-
lishing CPG's relevant to clinicians and the health setting. Ensuring the
process is rigorous is essential. Existing standards of care re-
commendations are available for further reference [66, 67].
7. Key guidelines
7.1. Research directions
• This evidenced based guideline has been developed to enable re-
commendations to be used in varying contexts of newborn care.
• To enable the utilisation of evidence clinicians need to consider each
recommendation and the efficacy and efficiency of each in their
practice.
• Further research continues into the expanding volume of evidence
for developmental care and it remains the responsibility of all
clinicians to keep abreast of this body of research.
Due to space considerations, it was not possible to include a full-list
of the evidence. A more comprehensive list of references is available
from the corresponding author.
Contributions
Nadine Griffiths: manuscript conception and design, article
searching and grading, manuscript drafting.
Kaye Spence: manuscript conception and design, article searching
and grading, manuscript drafting.
Alison Loughran-Fowlds: manuscript conception and design, article
grading, manuscript formatting and review.
Bjorn Westrup: manuscript conception and design, manuscript re-
view.
All authors have approved the final article.
Funding
This research did not receive any specific grant from funding
agencies in the public, commercial, or not-for-profit sectors.
Declaration of competing interest
Declarations of interest: none.
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⁎
Corresponding author at: Grace Centre for Newborn Intensive Care, The Children's Hospital at Westmead, Locked Bag 4001, Westmead, NSW 2145, Australia.