The Newborn Individualized Developmental Care & Assessment Program (NIDCAP):

A Critical Appraisal of Clinical Implications for NICU Practice

Danielle Goddard, OTS, CCLS, and Natalie Noss, OTS
Touro University Nevada, School of Occupational Therapy, Henderson, NV, 89014

Background & Clinical Scenario

According to statistics from the United States Center for Disease Control
and Prevention (CDC), pre-term births currently account for over 12.5%
of all births nationwide (CDC, 2013).
Babies who are born pre-termor before the thirty-seventh week of fetal
developmentare highly at risk for mortality as well as being very low
birth weight (VLBW) and experiencing developmental, neurological,
respiratory, and other complications.
Premature infants overall are hypersensitive, difficult to feed, and
difficult to calm. These characteristics can also affect bonding,
especially if parents are not knowledgeable about what behaviors to
expect from their premature babies.
In addition to being generally at-risk due to their early delivery, infants
who are treated in the neonatal intensive care unit (NICU) are
immediately exposed to a harsh medical environment full of excessive
and inappropriate sensory stimuli.
Some studies, in fact, indicate that the overwhelming stimuli in the NICU
environment may directly affect the development, structure, and function
of the infants neurological system (Als et al., 1994).

Implications for OT Practice

Search Methods
Focus Question: Does the use of the Newborn Individualized Developmental Care and Assessment
Program (NIDCAP) promote achievement of developmental milestones for infants treated in the NICU?
Inclusion Criteria:
Experiment al treatment to include application of NIDCAP protocol
Level I evidence (highest level of scientific rigor)
Randomized controlled trials & their follow-up studies only

10 RCTs were
chosen for this critical
appraisal
(Level I evidence)

Only studies completed in the past 20 years

Exclusion Criteria:
Studies published in languages other than English
Studies Reviewed:
1 systematic review was hand-searched
10 randomized controlled trials (RCTs)
were appraised for this review

Hierarchy of levels of research evidence.

Results

Retrieved from http://www.womenandinfants.org/havingababy/Neonatal-Intensive-Care.cfm

NIDCAP Treatment Protocol

NIDCAP was developed by Heidelise Als & associates to address the
development & unique needs of the premature and LBW infant. Infants
are assessed based on five interrelated subsystems: autonomicphysiological, motor, state organizational, attentional-interactive, & selfregulatory systems. The goal of NIDCAP is to create a personalized plan
based on individualized needs for caregiving & stimulus control.
1. Regularly-scheduled behavioral observations of the infants are
completed by trained, certified, NIDCAP developmental specialists.
Often provided during caregiving or medical procedures or at other
intervals throughout the day, these observations allow observers to
rate infants on their stress responses, overall levels of arousal, ability
to self-regulate, and sleep patterns.
2. Individual care plans that are based on these observations, with
caregiving recommendations, are formulated with parents' and
caregivers' input and are available at the infant's bedside.
3. Parents are provided with education in order to promote understanding
of their infant's behavior and how to approach and support their infant
during caregiving interactions.
4. Infants in the treatment groups are cared for by NIDCAP-certified
nurses.
5. Incubator covers, nests, and positioning aids are often used to
encourage flexion and containment while decreasing stressful external
stimuli from the NICU environment (Als et al., 2003).

Corrected age (CA)

Overall findings*
2 weeks
Reduced mechanical ventilation and earlier oral feeding compared to the control
Better overall growth (weight, height, head circumference)
Better neurobehavioral performance in terms of the Assessment of Pre-term Infant
Behavior [APIB]: autonomic, self-regulation, and motor system scores
Discharge
Fewer days of parenteral (IV) feedings, shorter transition periods to full enteral (tube)
feeding, better average daily weight gain, fewer days in intensive care and in the
hospital, and lower total hospital charges
36 weeks
Higher mean head growth
9 months

12 months
18 months
2 years

Preschool

8 years

Significantly better neurobehavioral functioning in terms of Bayley Scales of Infant

Development II (BSID-II) scores
Favorable differences in terms of gross and fine motor modulation, overflow
postures, social play, and ability to stay engaged than control groups
Overall better cognitive development & were more likely to stay alive than the control
14-20% lower incidences of mild, moderate, & severe cognitive/developmental
delays
No statistically significant results found for differences in growth, neurologic
impairment, or cognitive and psychomotor developmental outcomes based on the
BSID-II assessment
No statistically significant differences in any of the three forms of IQ tested by the
Wechsler Preschool and Primary Scale of Intelligence-Revised (WPPSI-R), though
NIDCAP group children overall had higher scores
Higher percentage of disability in the control group (i.e. attention deficits, ID)
Better performance in areas of spatial visualization, mental control, attention,
integrative processing, semantic processing, and organization of thought and actions
than control group infants
*Please see our CAT Evidence Table for more information and for our full list of references.

The clinical & community-based practice of OT: Though advances

in medical sciences have allowed babies to survive at earlier & earlier
ages, many of these children grow up facing significant neurological,
developmental, & behavioral impairments. These impairments may
cause significant delays as the child ages & are often the focus of OT
treatment in early intervention, pediatric, & school-based settings. The
implication that NIDCAP can affect both short-term & long-term
medical, developmental & disability outcomes has the potential to
hugely impact OT treatment as the child ages.
Program development: Since babies are being born earlier & are
able to survive (though not disability-free), it is important to implement
highly-structured & developmentally-supportive programs such as
NIDCAP in order to vastly decrease negative infant health outcomes &
associated healthcare costs. However, NIDCAP can be expensive &
time-consuming to implement. Therefore, hospital administrators
should carefully weigh the costs & benefits of implementing NIDCAP.
Societal needs: NIDCAP has the potential to decrease LOS &
significant medical complications which will in turn decrease costs for
complex medical care. It also provides parents with valuable education
regarding normal pre-term infant behavior & may therefore help
prevent abuse & neglect. Long-term implications of decreased disease
and disability are directly correlated to positive outcomes in infants and
young children reaching developmental milestones on time and may
often predict later social, psychological, & educational success.
Healthcare delivery and policy: NIDCAP & similar developmental
programs should be implemented in all NICUs to provide the highest
standard of individualized newborn care. Once further studies support
the long-term effects of NIDCAP, policymakers should be informed of
the overall savings from not overcrowding special resource programs &
providing additional services to these infants as they age.
Education & training of OT students: Students should be educated
on the importance of developmentally-supportive, family-centered care.
Students should be well-versed in fetal development, typical infant
milestones, stress responses /reactions (& how to decrease stress &
sensory over-stimulation), reflexes, proper infant handling, & skilled
observation of newborns. They should also be familiar with
implementing standardized pediatric assessments.
Refinement, revision, and advancement of factual knowledge or
theory: It is believed that developmentally-appropriate & individualized
care which meets the unique needs of infants in terms of
environmental stress reduction, caregiver bonding, & promotion of
growth & feeding will help minimize the negative & potentially
traumatizing effects of early hospitalization. After further studies are
completed with larger sample sizes, refinement of theory regarding the
efficacy of specific programs (i.e. NIDCAP) may then be appropriate.

References (A Partial List)*

Als, H., Duffy, F. H., McAnulty, G. B., Fischer, C. B., Kosta, S., Butler, S. C., . . . Ringer, S. A. (2011). Is the
Newborn Individualized Developmental Care and Assessment Program (NIDCAP) effective for preterm
infants with intrauterine growth restriction? J Perinatol, 31(2), 130-136. doi: 10.1038/jp.2010.81
Als, H., Gilkerson, L., Duffy, F. H., McAnulty, G. B., Buehler, D. M., Vandenberg, K., . . . Jones, K. J. (2003). A
three-center, randomized, controlled trial of individualized developmental care for very low birth weight
preterm infants: medical, neurodevelopmental, parenting, and caregiving effects. J Dev Behav Pediatr,
24(6), 399-408.
Als, H., Lawhon, G., Duffy, F. H., McAnulty, G. B., Gibes-Grossman, R., & Blickman, J. G. (1994).
Individualized developmental care for the very low-birth-weight preterm infant: Medical and
neurofunctional effects. The Journal of the American Medical Association, 272(11), 853-858.