Transcript
Early Human Development (2007) 83, 433–442
a v a i l a b l e a t w w w. s c i e n c e d i r e c t . c o m
w w w. e l s e v i e r. c o m / l o c a t e / e a r l h u m d e v
Individualized developmental care for high risk
newborns in the NICU: A practice guideline
Kathleen A. VandenBerg ⁎
West Coast NIDCAP & APIB Training Center, California Special Start Training Program, Department of Education, Mills
College, 5000 MacArthur Blvd, Oakland, CA 94603, USA
KEYWORDS
Preterm infants;
Developmental care;
NIDCAP;
Synactive Theory of
Development;
Infant developmental
specialist
Abstract The newborn infant in the neonatal intensive care unit (NICU) is cared for with highly
advanced medical technology, but the incidence of disability and neurodevelopmental problems
among survivors remains high and problematic. Preterm birth disrupts the developmental
progression of brain structures and affects development of the sensory systems. The Synactive
Theory of Development provides a framework to conceptualize the organization of the
neurobehavioral capabilities in the early development of the fetus, newborn and young infant.
The infant's ability to regulate and control behavior emerges through continued interaction with
the environment and is expressed through five systems: autonomic/physiology, motor, state,
attention/interaction and self-regulation. In the healthy full term newborn the five subsystems
are mature, integrated, synchronized and managed smoothly. The less mature, healthy or sick
preterm newborn may be unable or partially able to manage environmental inputs,
demonstrating over-reactive responses and poor tolerance from even minimal input. Loss of
control and stress responses become frequent unless the environment and caregivers work to
read the infants' messages and thresholds for sensitivity and adjust care and handling and the
environment based on the infant's behavioral communications. The Newborn Individualized
Developmental Care and Assessment Program (NIDCAP) is a comprehensive program which
includes a behavioral observation methodology and creation of individual family centered
developmental caregiving support of the infant's own developmental goals. The NIDCAP approach
seeks to support the infant's stabilization and organization of the autonomic, motor, and state
systems at each level of maturation, while minimizing stressful events.
© 2007 Elsevier Ireland Ltd. All rights reserved.
Contents
1.
2.
3.
Introduction. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 434
Why developmental care? . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 434
Early brain development . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 434
⁎ Tel.: +1 510 430 2105.
E-mail address:
[email protected].
0378-3782/$ - see front matter © 2007 Elsevier Ireland Ltd. All rights reserved.
doi:10.1016/j.earlhumdev.2007.03.008
434
K.A. VandenBerg
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Sensory systems development . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
4.1. Visual system. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
4.2. Auditory system . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
5. Neonatal neurobehavioral development . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
5.1. Development of self-regulation . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
5.2. The Newborn Individualized Developmental Care and Assessment Program (NIDCAP) . . . . . . . . . .
6. Individualized developmental family-centered care in the NICU . . . . . . . . . . . . . . . . . . . . . . . . . . . .
6.1. Approach to NIDCAP care in the NICU . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
6.2. The interpretation of behavior. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
6.3. The role of the infant development specialist (IDS) . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
7. Guidelines for implementation of individualized family-centered developmental care in the NICU (Table 4) .
7.1. Individualized family-centered developmental care and the NICU system . . . . . . . . . . . . . . . .
References . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
1. Introduction
The newborn infant in the neonatal intensive care unit (NICU)
is cared for with highly advanced medical care, which has
demonstrated remarkably effective success in treating high
risk infants and premature illness [1]. However impressive the
advanced medical technology, the incidence of disability and
neurodevelopmental problems among survivors of neonatal
intensive care remains high and problematic [2–6]. In spite of
increased survival rates in high risk newborns, the incidence of
premature born infants in the United States has risen to 12% of
all live births and 18% of African–American births (US Health/
Human Services, 2003). Infants who begin life in the NICU have
high morbidity issues and a disproportionate need for medical
care. Several factors associated with low birth weight impact
outcome including severity of illness, chronic lung disease,
bronchopulmonary dysplasia, brain injury and retinopathy of
prematurity [2]. These factors have been associated with a
significant increase in the likelihood of poor neurodevelopment outcome of low birth weight infants. Increasing numbers
of fragile and low birth weight infants are represented in the
less than 1500 gram newborn population [2]. The incidence of
cerebral palsy has not changed over the past 10 years.
Moreover, by the age of 8 years, over 50% of very low birth
weight preterm children require special educational services
and 15% have repeated at least one grade in school [7].
2. Why developmental care?
Neurodevelopmental outcome has become a benchmark in
determining the effectiveness of medical neonatal care [2]. In
the first developmental outcome studies, the primary focus
was on identification of major disabilities including moderate
to severe mental retardation, sensorineural hearing loss/
blindness, cerebral palsy and epilepsy [1]. Depending on birth
weight, high risk newborns have shown up to a 25% incidence of
handicapping conditions [1,8]. Due to extended follow-up
developmental monitoring, more refined assessment techniques and improved survival rates [2] an increase in neurodevelopmental problems has been identified. These problems
include learning disabilities, low average IQ scores, attention
deficit hyperactivity disorder, neuropsychological deficits,
visual motor integration, executive function, varying temperament difficulties, language delays, emotional problems
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and regulatory disorders [1,2,6,7,9]. These neurodevelopmental dysfunctions are present in up to 50–70% of very low
birth weight premature infants whose developmental outcome
will be questionable for years.
More than one half of very low birth weight children will
require special education; more than 20% will need selfcontained disabilities management [9,10]. The outcome
studies to date demonstrate that the effects of premature
birth not only are found in neuroimaging studies, but
manifest in subtle, but long term deficits in several areas
of life function [2,4,10–12]. Such difficulties have been
shown to place the low birth weight premature infant at
higher risk for child abuse [13,14], regulatory disorders [15]
and poor relationships [16,17].
3. Early brain development
The impact of the NICU environment on the long term
development of the brain has been acknowledged [1,18]. At
the time of premature birth, the developing fetal brain is
displaced to the NICU during a critical rapid period of brain
maturation [19]. Preterm birth disrupts the developmental
progression of brain structures [20]. Several critical areas of
brain development are affected and include specifically the
processes of brain growth, cell migration, synaptogenesis,
myelination and brain organization [21].
The preterm sick infant is a misplaced fetus who is
developing in an extra-uterine environment at a time when
the fetal brain is growing more rapidly than at any other time in
the lifespan [19]. The fetal phase of development for the full
term infant typically occurs in the mother's womb with
complete maternal protection from the environment. The
fetus is provided with an ongoing supply of nutrients,
regulation of temperature, and several maternal regulating
processes [22]. Thus, the premature infant who has been
removed from the warm, fluid filled womb prior to the 37th
week of gestation, experiences a dramatic “mismatch” with a
replacement of the mother's protective nourishing womb by a
highly variable NICU environment. Research has documented
the vastly different sensory exposures experienced by the
infant in the NICU compared to that of a full term healthy
newborn taken home immediately after birth. Studies
increasingly document that the environment of the NICU itself
exposes infants, parents and staff to a constant barrage of
negative, variable, non-contingent stimuli [23–25]. The
Individualized developmental care for high risk newborns in the NICU: A practice guideline
Table 1
Sequence of the development of sensory systems [28]
1.
2.
3.
4.
5.
Touch
Kinesthetic/proprioception
Vestibular
Smell and taste
Vision
discrepancy between the maternal experience in the womb
and the NICU experience presents the early born infant with
significant challenges that influence the infants' physiological,
emotional and social development [22,26,27].
4. Sensory systems development
Neonatal sensory development emerges in specific sequence
over the course of fetal life (Table 1). During the rapid period
of maturation of each sensory system, other sensory stimuli
do not advance, and avoid competing with the currently
emerging system [28]. Each emerging event takes place in a
biologically ordered chain of events. For example the
maturation of hearing in the fetus is most intense during
the specific time that vision is not developing and is not being
stimulated by light. Animal studies have shown [29–31] that
if one system is stimulated to occur out of the typical
sequence the development of that system will interfere with
the development of the currently emerging system (for
example, the premature infant experiences ongoing exposure to environmental stimuli in the NICU and develops
hearing and vision at the same time, instead of in the
intended sequence). In addition interference will also occur
to other sensory systems as they try to mature [32]. For
example, in animals it has been shown that inappropriate
visual activation during the stage of the development of
hearing, not only will alter hearing, but will also affect vision
[28,33,34]. Thus sensory input introduced to the growing
organism before the sequence is ready to be activated, may
interfere with that organism's development of perceptual
and behavioral development [33].
NICU light has a direct impact on physiological stability
and central nervous system organization [34]. Infants in the
NICU may experience intense arousal effects from light and
noise. Light changes in the NICU are often due to treatment
and do not consider for the developing diurnal rhythmic
patterns of the infant. It has been suggested that the visual
environment of the NICU may alter visual acuity, color vision,
problems with visual processing, visual attention, pattern
discrimination, visual recognition memory, and visual motor
regulation [35,36]. Measurements used to describe
light environments include irradiance (kind of light) or
illuminance (brightness) and are described in terms of lux
(lumens/m2) [37,38] or foot-candles (ftc). Lux divided by 10
is closely equivalent to foot-candles. The American Academy
of Pediatrics in the l970s recommended that light in the NICU
should not be brighter than 100 ftc for adequate visualization
of NICU patients. Light intensity in the NICU has been
measured to show ranges from 192 to 1488 lx (or l9 to 148 ftc)
with greater intensity during day rather than night hours
435
[39]. Treatment lamps used in the NICU average up to 350 ftc
and bilirubin lights may be as high as 10,000 ftc [34].
Studies to date have reported that infants who experience
reduced light levels for some portion of the NICU day shifts
demonstrate reduced heart rate, decreased activity,
enhanced biologic rhythms, increased sleep and improved
feeding and weight gain [35]. Increased infant stability and
energy conservation has been demonstrated when environmental stimuli is reduced and monitored [39].
These studies represent the current state of the science in
NICU lighting and demonstrate that appropriate and safe
lighting levels in the NICU have not been established. The
Committee for Recommended Environmental Standards in
the NICU [40] recommends that until such data are available
that baseline levels of ambient light should be monitored in
NICUs at the range of 1–60 ftc and staff should be informed
about the current concerns of intense stimuli exposure and
the effects on newborns and adults. In fact, recent evidence
suggests that light levels should be “very dim” for part of a
day in the NICU. Recommendations state that moderate light
levels should prevail throughout the day. Light levels need to
take into account flexible accommodation to meet the
developmental range of infant function in the NICU from very
immature to recovering postterm infants. Direct ambient
light in infant care spaces should be avoided except during
procedures [40]. Graven [28] states that premature infants in
the NICU need not be exposed to light until reaching term
age. Premature infants only need exposure to light to
facilitate biologic rhythms [28]. Working to decrease light
and sound in the NICU is an important part of providing
developmental support and safe caregiving [37,41] (Table 2).
4.1. Visual system
The visual system begins its complex developmental course
in fetal life between 30 and 32 weeks of gestation. This
Table 2
Recommendations: light in the NICU
– Avoid direct light of infant care space except for
procedures
– Avoid sensory overstimulation in the NICU environment
– Individualize light exposure — provide several choices
for light reduction at each bedside through small
shields, covers for incubator
– Protect and facilitate REM sleep [28]
– Support quiet alertness and restful sleep
– Support for smooth transition from sleep to wake and
vice versa
– Note each infant's level of threshold for light via
behavioral signals for disorganization/stress
– Know light equipment lux levels of brightness and adjust
to reduce infant exposure (i.e., warming lights during
bath time should be directed from back of infant, not
side or front facing head on)
– Provide for day/night cycling with protocols for lower
lights during night time hours
– Limit intense competing stimuli from other NICU sources
and noise
436
system is fully developed by three years of age. The visual
system is the last of the sensory systems to develop and is the
most mature sensory system at full term birth. Full term
newborns are born with still undeveloped vision. The visual
system undergoes significant maturation during the first
4 months postterm. Rapid development of visual neuronal
connections and processing occurs between 28 and 34 weeks
of gestation [34]. The visual system develops through
interaction with the visual environment and exogenous
stimuli from the normal environment over the course of
three years. Activities of the visual system through its
developmental course include the function of reception,
perception and recognition of visual images. As the system
matures visual input takes on meaning and images interrelate and interconnect in order to complete development
[28].
4.2. Auditory system
The auditory system or the infant's hearing system is well
underway at term birth. The neurological structures required
for hearing development evolve early in utero. Fetal
response to sound has been shown to be evident as early as
23 weeks of gestation. The auditory system matures
gradually and by full term birth, newborns have experienced
listening for at least 10–12 weeks [42]. Sound is produced
when a physically vibrating source creates a pressure change
in the surrounding medium, called sound waves, which vary
in loudness and frequency. The human ear is sensitive to
these vibrations which may range from 20 to 20,000 vibrations per second [43]. Loudness of sounds is described by
decibels (dB). Normal calm adult conversation ranges in
loudness between 45 and 55 dB. If a sound increases 10 dB it
actually increases exponentially because sound loudness is
quantified in units of decibels (dB) and is a logarithmic scale.
Sensitivity to excessive noise begins at 6 months gestation
and extends through the newborn period to 2–3 months after
birth. Premature infants are more vulnerable to the effects
of noise exposure because of their immaturity. Ongoing
exposure to alarms, noisy incubators (up to 80 dB) and loud
jarring sounds occurring regularly in the NICU environment
places premature infants at risk of noise induced hearing loss
[44]. NICU infant stress reactions including physiological and
behavioral changes have been associated with sound levels in
the incubator [32,45].
Table 3
Recommendations: noise in the NICU [40]
– Provision of minimal background noise and sound
absorption in infant care spaces
– Sound levels shall not exceed 50 dB and hourly L10 of
55 dB
– Transient sounds should not exceed 70 dB
– Equipment in NICU should have noise levels of b 40 dB
– Spaces and adjacent areas to NICU should not amplify
sound levels
– Creation of a developmental multidisciplinary team to
facilitate staff agreement to reduce and monitor sound
reduction in NICU
K.A. VandenBerg
Even though several recommendations have been published to reduce sound and monitor noise in the NICU, the
reduction of consistent sound levels in the NICU continues to
be an ongoing issue [37]. Staff regularly works hard at the
bedside to adjust sound levels however, until sound absorption is mitigated through NICU redesign, the problem of
excessive sound reverberation will persist in the NICU
[40,46]. The most successful reduction in sound reduction
in the NICU takes place when sound absorbing materials are
integrated into architectural unit design [46].
Attention to reducing sound levels should be a basic tenant
of all developmental programs in the NICU (Table 3). Hearing
is not only essential for normal language development, but is
important for the development of attention and perception.
Difficulties in processing sound and sound interpretation
result when sound does not develop appropriately. Attention
to tasks, and to visual stimuli, to integration of sound with
touch and vision are important and necessary functions. The
ability to screen out sound appropriately and to inhibit sound
input is an essential auditory system function. Developmental
difficulties resulting from sound processing can be seen in
distractibility, hyperactivity, inhibited or disorganized
responses to sound [46].
5. Neonatal neurobehavioral development
The Synactive Theory of Development [47] provides the
framework to conceptualize the organization of the neurobehavioral capabilities in the early development of the
fetus, newborn and young infant. The Synactive Theory of
Development specifies the degree of differentiation of early
infant development [47]. This model is based on the
assumption that the infant actively and consistently, through
his behavior, communicates his/her thresholds for sensitivity
versus competence. The range of infant behaviors becomes
evident as the infant matures.
The infant's ability to regulate and control behavior
emerges through continued interaction with the environment (whether the womb, NICU, home) and is expressed
through five systems: autonomic/physiology, motor, state,
attention/interaction and self-regulation [47]. A major
tenant of the Synactive Theory states that practitioners do
not attend solely to behavior cataloguing of infant behavior,
but attend to and appreciate exquisitely the infant's unique
individual capacity to manage input from the external world
surrounding him/her.
The five subsystems are interdependent and interrelated.
For example, physiological stability lays the foundation for
motor and state system control. State organization, the
management of sleep–wake cycles, creates a component of
self-regulatory competence. Concomitantly, the loss of
integrity in one system influences the other systems, as
they manage environmental demands.
In the healthy full term newborn the five subsystems are
mature, integrated, synchronized and managed smoothly. All
five systems are managed easily and without stress. The less
mature, healthy preterm or sick preterm may be unable or
partially able to manage environmental inputs, demonstrating over-reactive responses and poor tolerance from even
minimal input. Loss of control and stress responses become
frequent unless the environment and caregivers work to read
Individualized developmental care for high risk newborns in the NICU: A practice guideline
the infants' messages and thresholds for sensitivity and
adjust care and handling and the environment based on the
infant's behavioral communications. Thus, Als and Lawhon
[22] state that “stimuli that are poorly timed are seen to
penetrate and disrupt all subsystems, whereas appropriately
timed stimuli appear to maintain and enhance functional
integration and support growth”.
5.1. Development of self-regulation
The ability to regulate or control one's autonomic, motor and
state organization is a requirement of early development
[48]. Early self-regulation is accomplished in the mother's
body as a fetus, and continues over the course of the first
three years of life after birth. Initially, the tasks involve the
regulation of physiological function including maintenance
of body temperature, regulation of day–night cycles, homeostasis of physiologic function including breathing, heart rate
regulation and maintenance of visceral control. Eventually,
the infant learns to begin to calm himself and relax even
after mild stress. As an infant matures in the context of daily
interactive care from consistent primary caregivers, selfregulation becomes the task of learning to control motor
behaviors, sleep–wake cycles, attention and interaction
[48–50]. Eventually, these capacities merge into emotional
regulation.
The process of learning self-regulation in the newborn
period and thereafter is deeply embedded in the context of
relationships [50,51]. Caregivers and parents become the
infant's “co-regulators” and support infants by accurately
reading and interpreting the infant's behavioral signals. From
infant communicated information, the caregiver facilitates
the infant's balance of internal systems. These interactions
require caregiver sensitivity, knowledge and energy to
provide the infant with mutually satisfying experiences. As
the ability to achieve self-regulation progresses beyond
infancy, parents and caregivers gradually shift the independent task of self-regulation to the child [51].
The developmental and social agenda of infants from
birth include the necessity to engage in social interaction
with others, maintain proximity to the caretaker, act on
objects and engage in interactions which give pleasure and
reciprocity [50–53]. Infants possess sensitivity to intentional
behavior in others, demonstrate joy, interest [51], effort and
vitality [52]. The human infant appears to be programmed to
detect and relate to qualitative differences in caregivers and
to elicit from birth an emotional relationship.
5.2. The Newborn Individualized Developmental
Care and Assessment Program (NIDCAP)
The Newborn Individualized Developmental Care and Assessment Program (NIDCAP) is a comprehensive program which
includes a behavioral observation methodology and creation
of individual developmental caregiving support of the
infant's own developmental goals [54,55]. By observing the
infant throughout routine care (before, during and after) and
documenting the infant's behavioral communications, the
professional may estimate the immature nervous system's
ability to tolerate the environment and caregiving events.
Such an assessment provides the opportunity to determine
437
the readiness and appropriateness of environmental and
caregiving events for the infant [49].
The observation is a continuous systematic 2 minute time
sampling, which identifies and catalogues the autonomic,
motor, state and attention behaviors [56] during NICU
caregiving. From the information collected the developmentalist interprets and translates the behavioral information
into a descriptive narrative which identifies the infant's
current goals. The assessment becomes the basis for creation
of specific individualized developmental caregiving plans in
order to support the infant's developmental agenda. The
implementation and education of the individualized careplans is facilitated by an infant developmental specialist.
Without compromising medical care delivery, the infant
development specialist continually supports the adjustment
of the environment and caregiving in the direction of the
infant and parents' developmental needs. Specialized training is available from sixteen NIDCAP Training Centers.
The NIDCAP approach is based on the premise that the
infant's own behavior provides the necessary information in
order to determine the infant's current capabilities. The
focus is on what the infant requires to accomplish to achieve
neurodevelopmental and behavioral competence [49].
The infant's behavioral language may indicate disorganization (stress) or smooth function (stability) through five
subsystems of behavior [56] including autonomic/physiologic, motor system, state system, and attention and interaction, as well as self-regulation behaviors [56]. Sensitivity to
these signs of organization or disorganization provides the
caregiver with an understanding of each infant's threshold
for activity and stimulation. The healthy full term infant
easily achieves stability of the systems within the initial
days after birth. The regulation of breathing, temperature
stability, digestion and cardiac function is established
smoothly. Motor stability is seen in the emerging smooth
movements, controlled postures and consistent regulation of
tone. Sleep and waking cycles are differentiated and a calm,
bright alert state appears in the first few days [57]. This
stability of the systems manifests in smooth function and
reflects intact organization and central nervous system
control.
The less mature newborn who spends the first weeks and
months in the NICU may demonstrate a less mature level of
balance between the systems reflecting central nervous
system disorganization [47,56]. The responses of the young
sick premature infant may be expressed physiologically
rather than behaviorally [25,49]. Very subtle cues in the
infant's physiologic patterns may show variations in skin
color, fluctuations in heart rate or breathing, presence of
startles or tremors [56]. Such reactions may indicate that
environmental stimuli of light or noise or even caregiving
events such as turning the infant or changing the diaper, may
be overwhelming. Deciphering the infant's immediate
responses becomes essential to effectively plan individualized developmental caregiving. Moreover, because the
function of systems occurs simultaneously, the regulation
of autonomic function takes place in conjunction with
regulation of motor balance, and organized state management. The process of development requires initial stabilization and integration of the autonomic, motor, state and
attention systems, which then allows for emergence of new
capacities, which yield an integrated regulated system
438
K.A. VandenBerg
evolving toward more sophisticated levels of organization
throughout the lifespan [22,56,58,59].
6. Individualized developmental family-centered
care in the NICU
6.1. Approach to NIDCAP care in the NICU
The approach to providing individualized developmental
care includes fostering neurobehavioral and physiologic
organization of the infant's systems of autonomic, motor,
state and attention and self-regulation [49]. Strategies to
support the achievement of stability and reducing stress
must include an ongoing accurate and sensitive assessment
of the infant's current developmental capacities taking
into account the infant's medical status. An assumption
underlying such an approach recognizes that the NICU infant
is vulnerable to sensory overload and overstimulation
[25,47,49]. Thus, the approach to the provision and implementation of developmental care does not focus on the
achievement of developmental milestones, nor does it seek
to stimulate the infant to demonstrate skills and performance. Rather, individualized developmental care seeks to
support the infant's stabilization and organization of the
autonomic, motor, and state systems at each level of
maturation and while reducing stress. The NIDCAP approach
supports the infant to demonstrate increasing tolerance for
stimuli and minimize stressful events, which have the
potential to be costly in terms of energy expenditure, caloric
utilization and physiological homeostasis [60]. The NIDCAP
approach has also shown that a reduction in the need for
sedation results when behavioral support is included with
pharmacologic intervention [61].
The developmental approach views sensory input as an
important and necessary parameter in fostering central
nervous system development. Sensory input must be appropriate and individualized to the infant's physiological and
neurobehavioral tolerance as the infant achieves increasing
stabilization. Each caregiver, whether medical staff or parent
needs to recognize that for the ill, unstable or fragile infant the
best form of sensory input, may be no input at all,
necessitating a plan of reduction of surrounding stimuli.
Ongoing observations, including the formal, systematic NIDCAP assessment provide essential information, help caregivers
recognize early signs of sensory overload and initiate appro-
Figure 2
priate care strategies to avoid overstimulation and support
balance [37]. A thorough and accurate assessment and
translation of the NICU infant's communications behaviorally,
furnishes the developmentalist with the information necessary
to recommend a construction of the caregiving environment to
adapt the NICU to the infant's needs.
The infant's care involves numerous medical procedures
and handling events carried out by many medical professionals in the course of a NICU stay. Provision of consistency
in caregiving at all levels and across shifts supports the infant
to be regularly “heard” and promotes energy saving
interventions for the infant.
One of these caregiving practices involves primary nursing,
which provides continuity of caregivers. The consistent
primary nurse who comes to know along with parents, the
unique and intimate interactions of the infant can effectively
utilize the infant's behavioral messages in consistent individualized care delivery. To be even more effective, a primary
care team including a primary physician, respiratory therapist,
social worker, and an infant developmental specialist may
enhance the provision of consistent care. NIDCAP research
studies have shown that this component of care delivery is a
significant and essential part of individualized developmental
care implementation [18,22,62–64].
6.2. The interpretation of behavior
In order to determine the infant's current developmental
needs, the developmental nurse or professional must review
the infant's medical and family history, as well as the infant's
current medical status. Questions to ask include:
1.
2.
3.
4.
Figure 1
Appropriate positioning aides support flexed positions.
Handling is slow and based on infant's cues.
What are the infant's physiological communications?
How does he tell us he is tired, exhausted?
What is he trying to do to help himself?
What is this baby's behavior saying in terms of what he
wants to accomplish?
Care in this mode becomes infant-centered and not
caregiver-centered. The caregiver, seeing and acknowledging the behavior of the infant, then supports the infant in
order to provide care to facilitate the infant's self-calming,
always watchful of any signs of stress that may need to be
managed. Attention to the infant's thresholds and need for
rest or stopping handling altogether is essential.
Individualized developmental care for high risk newborns in the NICU: A practice guideline
439
6.3. The role of the infant development specialist
(IDS)
Table 4
Key elements for implementation of individualized
developmental family-centered care
Provision of consistent individualized developmental care
requires the support and collaboration of all professionals in
the NICU, who with parents, provide the delivery of care
practiced in consultation with professional developmental
disciplines. The developmental professional provides individual NIDCAP assessment and creates a written plan of
suggestions, which invite bedside caregivers to review,
consider and discuss specific aspects of care based on the
infant's communicated developmental needs.
Areas for review include positioning the infant, handling,
and support during diapering, bathing and turning, to name a
few. Additional suggestions may include preparation for
handling, support throughout medical procedures and
caregiving events, and for management of the infant's
recovery after the caregiving in order to facilitate the
infant's returning to stable relaxation (Figs. 1 and 2).
Parents are active members of the primary care team and
participate as members of the health care team including
posting notes in the chart, presence at daily rounds, having
access to their infant at all times and participation in
decision making. Research has shown repeatedly that highly
trained NIDCAP reliable developmental professionals are
essential to improve developmental and medical outcome
for NICU infants and enhance confidence and reduce stress
for parents [18,22,62,63].
The role of the infant development specialist (IDS) in the
NICU has been well described [65]. Typically the position in the
NICU is provided by a highly trained, experienced infant
developmentalist. The position requires one full time equivalent per 30 bed NICU and may be filled by an experienced
advanced graduate degree professional who is knowledgeable
in the atypical, normal and neonatal development. The
developmental professional also must be experienced in
understanding the NICU culture, staffing issues, medical
conditions and course of patients, as well as the social
dynamics of parents. The IDS provides the NICU and family
with specialized developmental assessment of the infant's
neurodevelopment and creates and implements the individualized developmental recommendations with family input and
staff coordination. The IDS supports the NICU personnel and
family to maintain a developmental perspective throughout all
care delivery. This includes review and documentation of the
1. The parent is the primary caregiver and needs support
to begin to establish a mutually satisfying relationship
with their infant in the NICU. NICUs support parent–
infant relationships through recognition of parents as
members of the health care team with provision of
consistent parental involvement in caregiving,
2. The presence and active involvement of at least one
funded NIDCAP reliable infant developmental specialist
who:
a. provides consistency of developmental support to
medical staff, family and the infant,
b. conducts regular NIDCAP observations and bedside/
staff/parent teaching; articulates and adjusts the NICU
to the developmental needs of the infant including
facilitation of sensitive, flexible direct caregiving,
modifications and provision of appropriate bedding,
positioning and facilitation of state organization,
attention, sleep and alertness, and
c. articulates the tenants of individualized
developmental care and implementation into a systems
wide approach and guide the developmental program
with sustainable leadership.
3. Creation of a calm NICU environment with adjustable
low levels of light, minimal low levels of sound, sound
absorption and a calm ambience. Such an environment
also includes space for the families needs and meets the
developmental needs of individual infants. NICU
practices allow and respect the privacy of parents and
their infants.
4. Provision of sensitive care and handling based on an
accurate reading of infant behavioral signals and
respect for the message that the infant communicates,
along with recognition that the infant actively
participates in all aspects of care delivery.
Figure 3
A key goal is facilitation of parent-infant interaction.
infant's 24 hour daily cycle and review of infant sleep–wake
patterns, timing of all procedures and caregiving events. The
IDS is responsible for communication of the developmental
information and careful planning with staff to implement the
developmental recommendations. Partnering with medical
staff to work “through” the nurse and/or parent is essential.
The delivery of developmental intervention suggestions may
be more successfully implemented when intervention strategies are discussed and evaluated at the bedside with staff and
parents. Suggestions are made with attention to appropriate
and sensitive evaluation of the infant's state and readiness for
developmental handling. Suggestions become part of all care
and handling for the primary caregivers, the nurse and
the parent, and are delivered through the hands of these
caregivers.
A primary goal for the NICU staff and IDS/Team is fostering
of a positive parent–infant relationship with mutual responsiveness in their interactions with their infant. The infant in
the NICU should be viewed as an active participant in the
parent–infant interaction [66,67] (Fig. 3). The first weeks
and months of an infant's life during their NICU stay, can lay a
foundation of positive feelings or of ambivalence and
440
negativity, which has consequence for nurturing stability of
the parent–infant relationship. This important relationship is
biologically and psychologically essential for the infants'
survival and development.
Infant reactions to being touched may yield a series of
startles and limb extensions followed by flailing, arching and
uncontrollable squirming, which becomes an ongoing continuous movement. The infant may experience an unbreakable cycle of costly energy expenditure, which cannot be
detected until the infant either stops breathing or drops his
oxygen level or heart rate [41]. The infant then is using
energy he desperately needs to maintain his physiological
stability. This high reactivity interferes with his growth and
may prevent recovery [49,68]. Another reactive issue for the
premature infant may be seen in a pattern of lethargic,
depressed responses by an infant who cannot respond to
environment or handling stimuli [47,56]. This infant may be
unresponsive and lie in the bed, limp and flaccid, unable to
put any energy into responding to his/her nurse or parent. He
may develop minimal ranges of responsiveness [49]. This
infant is uncommunicative. He appears depressed to his
caregivers and is unable to respond to their efforts to
interact with him/her.
Many low birth weight premature newborns in the NICU
demonstrate these response patterns during their most
stressful and sickest days in the NICU. They continue to
react with intense sensitivity to their environment and to
handling. As the infant continues to recover, with the
supports in place and sensitive caregivers, who understand
his signals for slowness, gentleness and quiet, the stressful
behaviors begin to disappear and are replaced by a more
modulated level of responsiveness. Infants may demonstrate
more energy after care, and less irritability and may eventually begin some brief interactions [69].
In this way, increased awareness of management of
environmental stress, agitation, overstimulation and
instability have led to changes in caregiving in NICUs. Staff
now provides protective nurturing environments with
increased understanding of the behavioral and developmental needs of NICU patients.
7. Guidelines for implementation of
individualized family-centered developmental
care in the NICU (Table 4)
Implementation of individualized family-centered developmental care includes a multidisciplinary and collaborative
approach (Table 4). NICU management and hospital administration, along with medical, social and developmental professionals establish working relationships with professional
NIDCAP trainers who are certified by the NIDCAP Federation
International (NFI), the international governing board of the
NIDCAP Model (see http://www.nidcap.org/centers.html for
NIDCAP Training Centers).
7.1. Individualized family-centered developmental
care and the NICU system
The NICU is a system unto itself, but it is also part of a larger
entity — the hospital. Understanding systems wide processes
is helpful in order to recognize the changes, attitudes and
K.A. VandenBerg
adaptations that have occurred due to individualized
developmental care (NIDCAP). The implementation of NIDCAP in the NICU encompasses changes in values, increased
collaboration, incorporation of behavioral science knowledge, and adaptations which could lead to improvement in
the life and culture for professionals and patients in the NICU
system [70]. The implementation of a focus on relationshipbased care induces a change in values within the NICU,
marked by realization that personal growth and development
is important. In addition, developmental practitioners work
to support many disciplines within the NICU and focus to
integrate the differences in those disciplines, while valuing
the similarities of each. The primary focus for all becomes
care of the infant and family. Effectiveness in achieving this
goal is paramount in spite of dramatic changes occurring in
medicine, nursing, and hospital administration. NICUs are
part of the overall goal of the hospital organization which
strives to meet financial goals, improve care for patients,
and meet the goals of their corporate leaders.
Individualized developmental care is a method of care
which is changing how the hospital organization addresses
patient needs, and it is changing care directly at the bedside.
It has been part of the impetus for direction in remodeling
and restructuring the environments of NICUs throughout the
world. Increased respect and sensitivity has become an
integral value in the NICU, and in spite of the technology,
care is changing toward an awareness of the tiny infant at the
center of it all.
A NICU, which has implemented the NIDCAP approach,
provides a primary team of physicians, nurses, social workers, and infant developmental specialists identified within
the first 24 h after birth. This team of NICU professionals will
become a primary team for each infant and family throughout their course in the NICU. An individualized plan of care
will be developed by this team of professionals who work
together and with the family to implement the developmental family-centered care-plan [22]. The infant development specialist becomes a resource and facilitator reviewing
the infant's unique developmental needs and consistently
supporting the staff and family through changes and
adjustments in caregiving at each stage of NICU care. The
multidisciplinary professional team of developmental specialists will support the NICU in advancing the implementation of developmental care throughout the NICU. Such a
focus could include planning and presenting individual case
presentations in developmental rounds, creating working
committees to carry out specific unit developmental
projects, adjusting and modifying the environment, and/or
developing a parent advisory or support group.
Individualized developmental care for NICU infants has as
its goal the preservation of energy for the infant, fostering selfregulation, prevention of agitation and stabilization of the
physiological system. Strategies to enhance infant regulation
of autonomic, motor, and state function are based on careful
behavioral observation throughout care and handling and
individualized to the age and clinical condition of the infant.
Support may be specific to the fragile infant who needs
protection from environmental stimuli, as well as for the
recovering infant who needs facilitation for appropriate social
interaction. Ongoing observation of the infant's responsiveness
to handling and the environment is a continuous focus.
Activities which disturb or disrupt the infant's balance, as
Individualized developmental care for high risk newborns in the NICU: A practice guideline
evidenced by avoidance or stressful patterns of behaviors
should be avoided and stopped.
It is now recognized that implementation of the NIDCAP
approach involves much more than offering reduced light
and noise and provision of a positioning aide for infants. The
complete adoption of the NIDCAP methodology supports a
NICU to undergo a paradigm cultural shift. A NIDCAP NICU
provides an experience for infants and families, which, along
with advanced medical care, offers flexible sensitive
caregiving based on the infant's behavior as a guiding
principle. Such care ensures a unique caregiving experience
for the infant and family and creates the opportunity for
significant improved outcome.
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