Altimier 2016

The Neonatal Integrative Developmental Care Model: Advanced Clinical Ap-
plications of the Seven Core Measures for Neuroprotective Family-Centered
Developmental Care
Leslie Altimier DNP, RN, MSN, NE-BC, Raylene M. Phillips MD, IB-
CLC, FABM, FAAP
PII: S1527-3369(16)30111-8
DOI: doi: 10.1053/j.nainr.2016.09.030
Reference: YNBIN 50706
To appear in: Newborn and Infant Nursing Reviews
Please cite this article as: Altimier Leslie, Phillips Raylene M., The Neonatal Integrative
Developmental Care Model: Advanced Clinical Applications of the Seven Core Measures
for Neuroprotective Family-Centered Developmental Care, Newborn and Infant Nursing
Reviews (2016), doi: 10.1053/j.nainr.2016.09.030
This is a PDF file of an unedited manuscript that has been accepted for publication.
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The Neonatal Integrative Developmental Care Model:
Advanced Clinical Applications of the
Seven Core Measures for Neuroprotective Family-Centered Developmental Care
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Leslie Altimier, DNP, RN, MSN, NE-BC
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LAltimier@gmail.com
Director of Global Education Programs
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Philips Healthcare
35 Warren St.
Newburyport, MA 01950
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513-706-8813
Raylene M. Phillips, MD, IBCLC, FABM, FAAP

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rphillips@llu.edu
Assistant Professor of Pediatrics
Loma Linda University School of Medicine
Loma Linda University Children's Hospital, Division of Neonatology
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11175 Campus Street, CP 11121

Loma Linda, CA 92354
Cell: 909-226-3748
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Altimier & Phillips – Neonatal ICD
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Abstract
The Neonatal Integrative Developmental Care Model, which outlines seven core
measures for neuroprotective family-centered developmental care of premature infants,
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is a framework that guides clinical practice in many neonatal intensive care units
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(NICUs) around the globe. The seven neuroprotective core measures are depicted as
overlapping petals of a lotus as the 1) Healing Environment, 2) Partnering with Families,
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3) Positioning & Handling, 4) Safeguarding Sleep, 5) Minimizing Stress and Pain, 6)
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Protecting Skin, and 7) Optimizing Nutrition (Figure 1). Skin to Skin Contact (SSC) is
considered the foundation for care of infants in the NICU and its importance as the
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“normal environment” and the ideal place of care is described. The mother/child dyad is
the center of the lotus surrounded closely by symbols representing various aspects of
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the Healing Environment, highlighting the physical, extra-uterine environment in which

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the infant now lives, the significance of the developing infant’s sensory system, and the
influence of people (patient, family, and staff) who help to create a healing environment
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for hospitalized infants and their families. The Neonatal Integrative Developmental Care
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Model utilizes neuroprotective interventions as strategies to support optimal synaptic
neural connections, promote normal neurological, physical, and emotional development
and prevent disabilities.
Keywords: Core Measures, Integrative, Neuroprotection, Developmental, Family-
Centered, Infant, Premature, NICU, infant

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Introduction
In the United States, approximately 500,000 babies each year are born
prematurely at less than 37 weeks’ gestational age (GA) or low birth weight (less than
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2500 grams), and as many as 10 to 15% of these babies require treatment in the
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Neonatal Intensive Care Unit (NICU).[1, 2] The management of premature infants has
advanced over the past decades to the point that infants born as early as 23 weeks’
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gestation now have a chance of survival due to a multitude of technologic advances.
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This progress comes with great costs as premature infants are in the NICU for many
weeks or months, and many have impaired short and long-term outcomes.[3-7]
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Although physical and motor disorders may be more noticeable, preterm and
medically fragile infants are at greater risk for cognitive, social-emotional, mental health,
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behavioral, speech-language, and regulatory difficulties well into school age and
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beyond. [8-17]
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Neurodevelopment
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To better understand the developmental problems associated with prematurity
and other high-risk events, it is essential to understand the basics of neurosensory
development of the neonate, paying particular attention to the stage of development that
occurs in the third trimester, the period of time in which preterm infant brains are
developing in the NICU in an environment entirely different than the protective
environment of the womb.
The neurologic and sensory systems do not exist as separate entities, but are
interdependent and comprise the neurobehavioral and neurosensory development of

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the infant. Every sensory experience is recorded in the brain, leading to a behavioral
response, thereby leading to yet another sensory experience. This cyclic interdependent
action and reaction is the basis for neurobehavioral and neurosensory development.
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When premature infants have sensory experiences that are inappropriate for their stage
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of development (as often occurs in the NICU), their neurodevelopment occurs differently
than it would have in the protective environment of the womb. It is not surprising, then,
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to see different neurosensory and neurobehavioral outcomes in babies born
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prematurely compared to those born at term.
Recent evidence suggests that early preterm birth (<32 weeks GA) is a risk factor
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for Autism Spectrum Disorders (ASD). ASD is a group of complex neurodevelopmental
syndromes of the central nervous system characterized by impaired communication,

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social interaction challenges, and restricted behaviors. Although neuropathology of ASD

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is not fully understood, the most consistent pathology includes curtailment of normal
development of the limbic system and abnormal development of the cerebellum and
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associated nuclei in children with a genetic susceptibility who experience abnormal

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stressors during a critical period of brain development.[18-21] The prevalence of ASD
has increased over the past two decades and is estimated to affect one in 88 children in
the United States, according to the Centers for Disease Control & Prevention
(CDC).[22] Estimated prevalence of ASD in all preterm infants ranges from 12%-41%.
[19, 23-29] Neurodevelopmental abnormalities are well recognized among of very low
birth weight (<1500 grams) and very preterm infants (<32 weeks GA) and a growing line
of evidence supports prematurity as a risk factor for ASD. [30]

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The fetal neurologic system is in a highly active stage of development during the
third trimester of gestation. With volumes of research documenting long-term disabilities
in prematurely-born children, understanding how we can better support the preterm
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infant’s fragile neurologic system can pave the way to decreasing the negative effects of
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fetal development occurring outside the protective womb, in the extra-uterine
environment of the NICU. [31-34]
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Both the structural and functional development of the brain are shaped by the
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influence and interaction of several major factors. These include genetic endowment,
internal, endogenous, or hormonal stimulation, and external experiences from the

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environment that stimulate the sensory organs. Outside stimulation from the
environment can influence or alter the expression or effect of genes through a process
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called epigenetics.
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Although initial stimulation of each sensory system is internal or endogenous, at
a critical or sensitive point in development, external stimulation and experiences are

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needed for further development. Experiences that influence fetal, infant, and child
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development can come from their physical, sensory, chemical, nutritional, social, and/or
emotional environments. Events and stimuli from any of these components of
environment are capable of altering the course and outcome of developmental
processes producing changes in brain development that can be either positive or
negative [35].
Neuroprotection in the NICU

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Neuroprotection has been defined as strategies capable of preventing neuronal
cell death. [36] Neuroprotective strategies are interventions used to support the
developing brain or to facilitate the brain after a neuronal injury in a way that decreases
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neuronal cell death and allows it to heal through developing new connections and
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pathways for functionality.[37]
The earlier in gestation a baby is born, the more vulnerable is its fragile brain and
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the more critical it is to provide effective and consistent neuroprotective care from the
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moment of birth in order to protect and support optimal brain development. As we strive
to continue to improve our morbidity and mortality rates, we are challenged to enhance
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the neuroprotective strategies for these infants, thus demonstrating the need for a
developmentally supportive environment that focuses on the interpersonal experiences

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of the preterm infant and family in the NICU. Every baby, regardless of gestational age,
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deserves neuroprotective care throughout their hospitalization due to rapid brain growth
and neurologic development occurring during the early neonatal period.

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Family-integrated, neuroprotective, developmentally supportive care includes

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creating a healing environment that manages stress and pain while offering a calming
and soothing approach that keeps the whole family involved in the infant’s care and
development [38-41]. Neuroprotective developmental care is grounded in support by
research from a number of disciplines including nursing, medicine, neuroscience, and
psychology. [39, 42-46]. Improvements in health outcomes, lengths of stays, as well as
hospital costs have been documented when neuroprotective education and subsequent
change of care practices were implemented [47-50].

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The Neonatal Integrative Developmental Care Model: Clinical Applications
The Neonatal Integrative Developmental Care Model (IDC) (Philips Healthcare)
identifies seven distinct core measures that provide clinical guidance for NICU staff in
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delivering neuroprotective family-centered developmental care to preterm infants and
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their families in the NICU (See Figure 1).[41, 51, 52] Each core measure has a
Standard(s) with a policy or protocol that guides care of the infant/family as it relates to
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that specific core measure. Corresponding infant characteristics, which are measurable
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reflections of the desired core measure outcomes, are identified, and specific goals
target the improvements/outcomes desired. Clinical applications include neuroprotective

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Interventions that define and specify the actions required to meet the goal(s).[52] These
must be evidence-based, reliably applied and scientifically valid.

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To effectively implement many neuroprotective interventions, a cultural shift

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within the NICU must occur in order to adopt new evidence-based practices. Changes
in care practices are usually not easy and success is dependent on introducing change
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in a systematic fashion. Quality improvement (QI) methods such Plan/Do/Study/Act

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(PDSA) have proven effective in initiating and sustaining changes that can result in
improved outcomes.[53] Examples of neuroprotective interventions and sample QI
projects will be further explained below and consolidated in Appendices A and B.
Foundation for Infant Care in the NICU: Skin to Skin Contact (SSC)
Skin-to-Skin contact (SSC) is the optimal environment for any newborn, but
particularly for the premature infant in the NICU. The defining feature of SSC is direct
contact between parental skin and infant skin, holding a diaper-clad infant on a parent’s
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bare chest in an upright prone position. Essentially, this is a PLACE of care, the “normal
environment.” Skin-to-skin contact care provides the right environment (place) for the
epigenes and the DNA and the neural circuits and the physiological regulation to
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function optimally. A mother and her baby are inextricably linked and to separate the
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two is highly stressful to both. Incubator care, while necessary if mother is unavailable,
is actually abnormal to the epigenes, DNA and the developing brain of an infant. Skin-
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to-skin contact (sometimes called Kangaroo Care) is a fundamental, essential
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component of neuroprotective and patient-family oriented care for hospitalized preterm
infants [54, 55]. Being skin to skin with mother protects the newborn from the well-
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documented negative effects of separation, supports optimal brain development and
facilitates attachment, which promotes the infant’s self-regulation over time.[56]SSC

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became codified through the World Health Organization (WHO) into what is called
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“Kangaroo Mother Care” (KMC), a full-care strategy. [55] While SSC in most NICUs in
the United States is often not as comprehensive as KMC, any amount of SSC should be
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encouraged and facilitated.

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Skin-to-skin contact with mother (or father) is directly neuroprotective and
supports brain plasticity.[57] When practiced only six hours a week for 8 weeks, it has
been shown to accelerate brain maturation in electroencephalogram (EEG) tracings of
infant brain activity. [58] Both maternal and paternal oxytocin levels have been shown to
significantly increase during SSC, reducing stress and anxiety responses in mothers
and fathers of preterm infants.[59] With this single activity, each of the 7
Neuroprotective Core Measures are supported. Skin-to-skin contact with mother (or
father) is the ultimate healing environment for newborn infants (Core Measure #1) [55],
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provides an opportunity to partner with families by giving parents an active role in their
infant’s care and healing (Core Measure # 2), facilitates supportive positioning and
handling (Core Measure # 3). Promotes maternal odors, which contributes to sleep
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cycling, thus safeguarding sleep [60] (Core Measure #4). SSC has been shown to
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foster optimal autonomic and physiologic stability and to reduce indices of pain, helping
to minimize stress and pain (Core Measure #5). It protects skin by providing humidity
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and supporting thermoregulation (Core Measure # 6). It increases mother’s milk supply
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and facilitates breastfeeding, optimizing nutrition (Core Measure # 7. In all these ways,
SSC promotes optimal brain development, supports healing and growth, improves
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maternal-infant bonding, reduces infection rates, and decreases length of hospital stay.
[54] For these reasons, SSC is seen as the foundation of all neuroprotective care.[55]
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Neuroprotective Core Measure # 1: Healing Environment (Insert Figure 2)
The Healing Environment, Core Measure # 1, addresses the physical

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environment of the NICU, including space, privacy and safety, the sensory environment
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of temperature, touch, proprioception, smell, taste, sound, and light, as well as people
(families and staff) and their interactions.[41] Premature infants have demonstrated
markedly improved outcomes when the stress of environmental sensory overstimulation
is reduced. This can be accomplished by incorporating neuroprotective strategies into
the care of infants and also by aspects of NICU design. [61]
NICUs should be designed to encourage family reunification and presence,
facilitate psychosocial support, address/minimize sensory impact, offer social
connection, and enable positive parental experiences. NICUs should also be designed
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to facilitate staff work and self-care, including quiet rooms for respite and debriefings
after stressful events. Nurses working in single family room NICU’s are less likely to
experience burnout and more likely to rank quality of care higher
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Single Family Room (SFR) designs continue to gain broad acceptance as a way
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to improve the physical environment for the infant and improve family accommodations
for parents. Enhanced ability to control light and noise can result in improved infant
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sleep. SFR can also lead to reduced infection rates.[62] In January 2017, a new
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prototype room (“Extended Family Room/EFR”) will open at Memorial Children’s
Hospital in South Bend IN, which is modeled after Sweden’s University Hospital of
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Karolinska. The goal is to, not only, keep mothers and infants together, but to
accommodate the entire family unit in this new room. A second headwall for the mother,
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and space for an adult patient bed, including the required code clearances around the
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bed will increased the size of the new EFR to 430 SF. Each room will have a dedicated
Kangaroo Care chair to support both mothers and fathers in providing SSC.[62]
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While the ideal scenario is to have families intimately involved in care of their
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babies, when families cannot be present, rather than isolating those infants in SFRs,
which can cause developmental delays[63], infants placed together in a pod
arrangement can be better supported developmentally through appropriate sensory
stimulation, such as hearing the soft sounds of the human voices of staff. [62]
Communicating with infants in a developmentally supportive fashion remains the
responsibility of the primary caregiver, which when the family is not present, is the
bedside nurse; and this appropriate age-based communication is a neuroprotective
intervention for language development. When an adult patient is hospitalized and does
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not have the opportunity for family or visitors, the nurse takes time to talk to them, which
is a practice that should be replicated with the infant.
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Core Measure # 2: Partnering with Families
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Partnering with Families, Core measure # 2, is essential in order to optimize
developmental outcomes of infants in the NICU. Prematurely born infants have
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“premature” parents who are usually unprepared crisis of having their newborn in the
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NICU. Preterm deliveries are usually unexpected, families are often separated from
their support systems when their newly born infant is admitted to the NICU, a place
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many parents did not even know existed before this event. For most parents, the NICU
is an alien environment and their first experience in the NICU is usually a profound
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shock and very traumatic.[64] Their infant is attached to wires, cables, and equipment in
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a place that is far different from what they had planned. Parents of these NICU babies
are likely to experience greater emotional stress, depression, uncertainty about their
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baby’s future, financial stress and Post-Traumatic Stress Disorder (PTSD) than do
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parents of term infants. [65-67] Parents and families worry constantly while trying to
maintain optimism and hope. It is important to recognize that the intensive care
experience is not uniform and that family responses differ. Mental health providers
should be integrated into the NICU caregiving team to provide psychosocial support at
the level required for each individual family[68].
With every NICU admission, normal parent-infant bonding is forever altered. The
experience of having an infant in an intensive care unit impacts not only the vulnerable
infant and the parents’ physical and emotional health, but also affects the developing
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bond between the newborn and his or her parents.[69, 70] The NICU experience
impacts all family dynamics, not just during the intensive care unit stay, but also in the
months and years afterwards. For each family, the first experiences with their baby,
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whether in the home or the intensive care unit, can set the trajectory for the long-term
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parent-child relationship and the parent’s perspective of their parent roles.[71] Many
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NICU parents leave the NICU with mental health issues either caused or exacerbated
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by what happens to them there.[72]
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The emerging concept of “trauma informed care” is a transformative one.[73] The
NICU is a place of trauma and the integration of trauma-informed care into all aspects of
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care for infants and their families in the NICU can alleviate or transform some of the
trauma they have experienced in a more positive way.[68, 73-77] In recent years, health
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care organizations have become increasingly aware of the importance of providing

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psychosocial support for parents of hospitalized infants and to recognize the emotionally
traumatic impacts of having an infant with medical illness. Parents learn their first
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lessons about being a parent inside of the NICU, and while many of these lessons will
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be useful in the future, an equal number will not only be unhelpful but potentially
damaging.[78] Infants who are hospitalized in intensive care experience a number of
threats to the establishment of secure and nurturing relationships, are at the mercy of
their hospital environment and often experience medical procedures and practices that
result in altered social interactions and emotional resilience.[79] Maternal distress early
in a child’s life has long-term effects on child behavior.[80]

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Attachment theory’s key concept is the necessity of the formation of an emotional
bond between an infant and primary caregiver and how the bond affects the child's
behavioral and emotional development into adulthood.[81]) Grounded in Attachment
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Theory, infant mental health involves the shared attention to the infant, the parent, and
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the early developing attachment relationship.[77, 82] There is increasing awareness in
psychology and obstetrics of the maternal mental health environment’s effect on fetal
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brain development and the psychological transition that occurs during pregnancy.[83]
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With this increased awareness, there is an accompanying understanding that
pregnancy marks the beginning of the parent-child relationship that is vital for the
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infant’s wellbeing. Even early fetal environment can alter mechanisms within the fetus
that persist into adulthood.[84] The importance of experiencing early relationships as

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warm, caring, and stable is clear, as it results in the infant's ability to develop
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appropriate social–emotional development and long-term mental health.[85]
Because families are the constant in the infant’s environment, helping families
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achieve a positive outcome from their NICU experience should be a priority for staff
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[86]. Equilateral respect among all members involved in the partnership will promote
optimal patient care, enhance family satisfaction, and engage the healthcare team in
ways that increase job satisfaction and a sense of fulfillment.
Zero separation from parents should be the ultimate goal to ensure
neurodevelopment is supported to normal standards (as in optimal development
assumed for term infants), not merely protected from effects of toxic stress. [87] Early
bonding with both physical and psychological components, leads to emotional
connections and secure attachment [88]. A baby’s interaction with mother makes a
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significant difference in brain development, including brain structure and function.
Reciprocal tactile stimulation between mother and infant contributes to increased
maternal responsiveness and infant attachment [89]. SSC helps fathers in attachment,
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confidence, caregiving, and interactions with their premature infants. When the quality
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and/or quantity of parental care toward infants is limited, such as with preterm infants in
the traditional NICU setting, these adverse experiences can lead to negative changes in
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brain architecture and function [90].
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The NICU environment, although initially strange and even frightening to parents,
can become comforting and inviting with attentive and compassionate caregivers who
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enable parents to be at the bedside of their infant, coach them on how to understand
their baby’s behavioral cues and how to provide appropriate caregiving. Sensitive NICU
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staff can provide active listening as parents process their shock, anger, and grief over
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the loss of a normal pregnancy and/or normal healthy term infant, and empower them to
be active participants on the caregiving team.

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The family is integral to developmental care, and normal development cannot

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occur without the family. An example of this type of NICU care is seen in the Family
Integrative Model (FIC), a model of care focusing on partnering with families where, the
nurses support the parents through education, coaching and mentoring, to become
primary caregivers in their infant’s journey through neonatal care.[91] The practice of
Family Integrated Care has been successful in Estonia and in Canada, and is being
introduced in the United States.[92, 93]
All families, even those who are struggling with difficulties, bring important
strengths to their infant’s experiences in the NICU. Parents must be viewed as vital and
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essential members of the caregiving team and active partners in the care of their infant,
rather than visitors to the NICU, and should be given 24-hour access to their infant.
Individualized family-centered developmental care is a framework for providing care that
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enhances the neurodevelopment of the infant through interventions that support both
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the infant and family unit.
Creating an effective partnership between professionals and families has shown
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benefits such as decreased length of stay, increased satisfaction for both staff and
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parents, and enhanced neurodevelopmental outcomes for infants [94]. Having parents
provide much of their infant’s care in the NICU also improves short- and long-term
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outcomes among infants and reduces stress among parents.[93] A comprehensive
approach to discharge/transition planning that includes psycho-social support and a

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focus on the caregiver-child relationship offers families the support they need and
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deserve at a critical time in their lives.[95] Establishing family-professional partnerships
in the NICU environment can be challenging; however, family-integrated care is

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recognized as a best practice which includes mutual respect, information sharing,

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collaboration, confidence-building, and joint decision-making.[96]
The concept of Partnering with Families in the NICU includes a philosophy of care,
which acknowledges that over time, the family has the greatest influence over an
infant’s health and wellbeing. Compassionately delivered family-integrated care, with
zero-separation, where skin-to-skin contact is the norm, is the ideal model of care to
encourage normal development, attachment and bonding, and empower parents to be
equal partners on the caregiving team.[41, 52, 55, 93]
Core Measure # 3: Positioning & Handling

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Position and Handling, Core Measure #3 has the inherent goal of supporting the
premature infant’s body as closely as possible to the position the baby would have been
in the womb. In utero, the infant is contained in a circumferential enclosed space with
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360 degrees of well-defined boundaries. Providing developmentally supportive
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positioning in the NICU is essential for optimal musculoskeletal development, which
influences not only neuromotor and musculoskeletal development, but also physiologic
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function and stability, thermal regulation, bone density, neurobehavioral organization
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and sleep facilitation, calmness and comfort, skin integrity, optimal growth, and brain
development [97]. Developmentally supportive positioning is an intervention that has

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been proven to improve postural and musculoskeletal outcomes as well as improve
physiologic outcomes and sleep states; however, developmental positioning has not yet
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become a standardized intervention. [98-101] There remains a gap between what is

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known in the evidence and what is practiced in some NICUs, and although it is clear
that developmental positioning is effective in improving outcomes, less is known about

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how to improve the developmental positioning proficiency of the nurses providing the
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care. Incorporating a standardized Infant Positioning Assessment Tool (IPAT), along
with education, is effective in improving developmental positioning proficiency of NICU
nurses, as well as improving consistency in positioning.[99, 100]
Supporting body containment of the infant in the NICU environment increases the
infant’s feelings of security, decreases stress, and reduces excessive energy
expenditure. Forming a “nest” with soft boundaries, as well as a padded foot-roll for
foot-bracing, provides postural, behavioral, and physiological stability to the newborn.
Infants who are contained within soft boundaries are usually more calm, require less
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medication, sleep longer and gain weight more rapidly. Ensuring secure containment
with firm bendable positioning aids [Bendy Bumper, (Philips)] promotes a reflex stimulus
for extremity extension and subsequent flexion recoil, furthering the ability of the baby to
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remain in a midline, flexed and contained position. Therapeutic supportive positioning
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devices must allow spontaneous movement, provide tactile and proprioceptive
containment, and displace infant body weight when placed in alternative positions, such
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as prone. Providing ventral support [such as with the Prone Plus (Philips, Boston, MA)]
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utilizes the natural force of gravity to assist in proper prone positioning and ventral
support of premature infants, by making it possible to keep their shoulders rounded and
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hips flexed, as they would have been inside the womb. The unique memory foam
elevates the infant’s upper body to promote flexion without placing excessive pressure
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on the knees and elbows. are in prone position makes it

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Handling of infants should be done with slow, gentle, modulated movements,
with the infant’s extremities flexed and contained, which may require a four-handed
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technique in very fragile infants. A preterm infant, when handled for reasons such as
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diaper changes, feeding, bathing, diagnostic or therapeutic procedures can react
negatively for several minutes during and after the procedure until becoming exhausted.
This results in an unnecessary expenditure of energy that can, even well after the
procedure has ended, result in signs of distress, pain and/or instability that may be
manifested physiologically (bradycardia, tachycardia, drop in oxygen saturation and
apnea) or behaviorally (flaccidity, fatigue and difficulty sleeping).
Frequent handling and touching can disturb sleep leading to decreased weight
gain, decreased state regulation, and more importantly, detrimental effects on brain
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development. Attention to appropriate timing of caregiving according to the infant’s
sleep and arousal is important, as better sleep organization has been correlated with
improved outcomes [102]. Because infants do not always tolerate all of the handling
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and care that is being clustered into one caregiving period, the practice of clustering
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care should be based on infant’s behavioral cues. Cues provide communication about
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an infant’s physiological status and needs at any given time. Caregiving based on infant
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cues involves a relationship where messages that the infant communicates may guide
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the timing for interventions or opportunities for sensory input and interaction. These
cues also indicate how the infant tolerates stimuli and stimulation and when they need a
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break or individualized support.
Caregiving behaviors must be adapted to alleviate as much aversive or negative

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sensory input from caregiving activities as possible. Collaborative interprofessional care,

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should be coordinated to negotiate timing, intensity, and appropriateness of
interventions, tests, and procedures. Educating, coaching, and mentoring parents in

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developmentally appropriate positioning and handling will not only be beneficial to

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parents and babies, but can save nurses time by involving parents in caregiving tasks
they can competently accomplish. Altering care practices by responding to the
individual infant cues requires a paradigm shift from task-oriented and scheduled care
towards infant-responsive care, which is needed to promote optimal developmental
outcomes.
Core Measure # 4: Safeguarding Sleep
Safeguarding Sleep, Core Measure #4 emphasizes the multi-faceted importance
of sleep for the infant in the NICU. Sleep patterns of preterm infants undergo age-
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dependent maturational changes and sleep preservation is essential for the normal
neurodevelopment and adequate growth and healing of these infants[103, 104]. Quiet
sleep (QS) is necessary for energy restoration and the maintenance of bodily
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homeostasis. Active sleep (AS is important for sensory input processing, memory
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encoding, and consolidation and learning. Sensory inputs, especially during critical
periods of development; therefore, may influence normal sleep-wake cycling[105].
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At approximately 28 weeks’ gestation, individual sleep patterns begin to emerge
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characterized by rapid eye movement (REM) and non-rapid eye movement (NREM)
sleep periods. REM and NREM sleep cycling are essential for early neurosensory
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development, learning and memory, and preservation of brain plasticity for the life of the
individual [106]. Preservation of “brain plasticity”, the ability of the brain to constantly
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change its structure and function in response to environmental changes, is an essential

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process throughout childhood and adult life. Sleep deprivation (both REM and NREM)
results in a loss of brain plasticity which is manifested by smaller brains, altered

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subsequent learning, and long-term effect on behavior and brain function. Facilitation
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and protection of sleep and sleep cycles are essential to long-term learning and
continuing brain development through the preservation of brain plasticity[107].
Safeguarding sleep is also essential to promote healing and growth.
Consideration to positioning should be given in order to promote quality sleep
and decrease arousals from sleep. Preterm infants are more likely to remain in a
sleeping state when they are in the prone position.[108] The number of arousals per
hour from sleep is highest in the supine position and least in the prone position.[109]
Documentation of the infant’s state, utilizing validated scales, promotes consistency in

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the assessment of infants’ sleep states and cues, leading to more standardized
practices with incorporating infant cues into caregiving schedules.
The design of SFR’s, where every patient room has a window can help maintain
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circadian rhythms for the baby, parents, and staff. NICU babies and their parents may
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have long stays in the hospital, and daylight supports a sense of normalcy by providing
connection to the daily cycles of light.[62]
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Core Measure # 5: Minimizing Stress & Pain
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Minimizing Stress and Pain, Core Measure # 5 is especially important in the
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developmentally unexpected, and often harsh, environment of the NICU where even
routine cares can be stressful, and often painful, to premature infants. From the first
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moments after birth, the premature infant is subjected to noxious sounds, bright lights,
and a multitude of stressful and painful procedures along with repetitive, non-nurturing
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handling and separation from mother. Seemingly typical handling and caregiving by the
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NICU staff such as bathing, weighing, and diaper changes are perceived as stress to
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the prematurely born infant [110, 111]. This altered sensory experience is inherently
stressful and has negative effects on the infant’s brain development.
Infants who spend their first weeks or months of life in the NICU may
demonstrate a toxic stress response. Exposed to painful, repeated, and unpredictable
medical procedures, and possibly to physical pain or discomfort related to illness, these
infants may not have consistent support from a parent or professional caregiver to
provide a buffer to help them stay regulated and recover from these stresses. Toxic
stress has been linked to changes in the developing brain, negatively impacting the
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creation of neural connections and this impact is likely to be more pronounced in
preterm infants and particularly those without a supportive caregiver present.[112]
NICU stressors and painful interventions can raise cortisol levels, limiting
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neuroplastic reorganization and therefore, learning and memory of motor skills. Infants
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who are exposed to repeated painful experiences can have negative short- and long-
term consequences for brain organization during sensitive periods of development [113,
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114]. Adverse neurodevelopmental outcomes following neonatal intensive care are well
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documented. Increased exposure to procedural pain has been associated with poorer
cognitive and motor scores, impairments of growth, reduced white matter and
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subcortical gray matter maturation, and altered corticospinal tract structure.[115-118]
Minimizing stress in preterm infants has many neurologic benefits such as

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reducing the likelihood of programming abnormal stress responsiveness which will help
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preserve existing neuroplastic capacity. [119] Effective prevention and management of
procedural and postoperative pain in neonates is required to minimize acute

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physiological and behavioral distress and may also improve acute and long-term
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outcomes.[120]
To consistently manage stress and pain in neonates, accurate monitoring of pain,
as the “fifth” vital sign needs to be assessed utilizing a standardized pain assessment
tool. With the assessment of pain, comes management through pharmacologic and
non-pharmacologic measures. For common painful procedures, such as heelsticks,
venipunctures, OG insertions, non-pharmacological interventions should be the first
choice in non-compromised infants. [121] Non-pharmacological interventions that have
demonstrated efficacy are: maternal presence, breastfeeding, breastmilk, SSC,

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sucrose, non-nutritive sucking, facilitated tucking, swaddling, and developmentally
supportive positioning.[121-123] Additionally, maternal-related olfactory stimuli
(mother’s milk) has been associated with comfort and diminished pain response in both
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term and preterm infants.[124] These findings support the hypothesis that infants
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remember, recognize, and prefer smell that is associated with their prenatal
environment including maternal-related olfactory stimuli (mother’s milk), auditory
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recognition (mother’s voice, heartbeat, and music).[125-127]
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Core Measure # 6: Protecting Skin MA
Protecting Skin, Core Measure # 6 is multifaceted. Functions of the skin include
thermoregulation, fat storage and insulation, fluid and electrolyte balance, barrier
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protection against penetration and absorption of bacteria and toxins, sensation of touch,
pressure, and pain, and conduit of sensory information to the brain, thus impacting
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neurodevelopment. Immature skin structures of premature infants are very different than
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the skin of full-term infants. The premature infant has an underdeveloped skin barrier,
which puts the infant at risk for high water loss, electrolyte imbalance, thermal instability,
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increased permeability, additional skin damage, delayed barrier maturation, and
infection.[128] Infants in the neonatal intensive unit are at risk for skin compromise due
to immature skin, compromised perfusion, fluid retention, being immunocompromised,
medical diagnosis, etc., as well as the presence of dressings, tapes, adhesives and
various medical devices, such as IVs, and CPAP or nasal prongs, that are essential to
their care.[129]
Skin care practices outlining bathing protocols, emollient usage, humidity
practices, and use of adhesives for babies in each stage of development should be
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incorporated into unit practices and policies. Improved skin outcomes can be realized by
utilizing the most evidence-based skin care guidelines available along with careful
monitoring and gentle, consistent handling, positioning and cares, The key to achieving
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optimum skin condition is through the utilization of validated skin assessment tools to
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assess the skin condition and evaluate attributes that indicate skin compromise.[130]
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Core Measure # 7: Optimizing Nutrition
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Optimizing Nutrition, Core Measure # 7 has well-documented effects on infant
brain development. Scientific evidence overwhelmingly indicates that breastfeeding is

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the optimal method of infant feeding and should be promoted and supported to ensure
optimal nutrition in infants. Breastfeeding is the single most powerful preventive

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modality available to health care providers to reduce the risk of common causes of
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infant morbidity. Because breast milk is the most well-tolerated substrate for enteral
feedings in the premature infant, full enteral feedings are reached sooner when breast
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milk is used, thereby decreasing the total days of TPN needed and the potential for
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TPN-induced side effects.[131]
The protective properties of breast milk cannot be duplicated. Significantly
decreased risks of necrotizing enterocolitis (NEC), sepsis, and retinopathy of
prematurity (ROP) have been demonstrated when breast milk is used for enteral
feedings.[132] Additionally, deeper nuclear gray matter brain volume and better IQ,
improved academic achievement, working memory, and neurodevelopmental outcomes
have also been found in preterm infants fed breast milk.[133, 134] Because of the
many documented benefits of human milk for the preterm infant, supporting mothers in
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the initiation and maintenance of adequate breast milk supply should be a major focus
in the NICU.
Even when adequate breast milk is available, most premature neonates learn to
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eat via nipple (bottle) feeding. Immature feeding is a common reason for prolonged
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hospital stays for premature infants and persistent poor feeding can result in hospital
readmissions. Maturational and developmental issues in premature infants affect oral
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feeding success because only 53% of brain cortical volume is present at 34-weeks
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gestation when an infant is just beginning oral feeds.
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Oral feeding is a complex task for premature infants and requires a skilled
caregiver in assisting the infant in achieving a safe, effective, and pleasurable feeding
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experience. Infant-driven feeding scales that addresses feeding readiness, quality of
feeding, as well as developmentally supportive caregiver interventions are beneficial

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when initiating oral feedings in the premature neonate. Goals for successful infant-
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driven feedings are that oral feedings be safe, functional, nurturing, and individually and
developmentally appropriate.[49] State organization and ingestive behaviors are

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regulated by the same autonomic nervous system. The autonomic control of the
stomach includes a cephalic phase that prepares the stomach for food, followed by a
gastric phase. The cues for these phases are primarily olfactory, but also linked to state
organization; therefore, consideration should be given to matching the neonate’s
feeding schedule to his own sleep cycle, rather than the clock.[135]
Educating staff and parents about infant cues and specialized feeding
techniques for breastfeeding and bottle feeding are essential as they are the foundation
for continued success and prevention of future oral aversions.[136] As with the previous
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core measures, a validated tool (feeding readiness, quality of feeding, and caregiver
techniques) should be utilized to promote consistency in assessing readiness,
evaluating quality, as well as caregiver efforts and techniques.[137]
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Breastfeeding difficulties can impact the fragile mother-infant relationship;
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therefore, providing support for breastfeeding mothers in learning to feed their preterm
infants at the breast, as well as learning to feed with a bottle (with expressed breast milk
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or preterm formula) is important and should not be left for the day of discharge.[138]
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Daily skin-to-skin contact/holding can facilitate early “practice” breastfeeding sessions
for mothers and babies. Assuring that breastfeeding infants are competent and mothers
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are comfortable with breastfeeding well before discharge should be a priority.
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Neuroprotection for NICU Staff

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Working in the NICU is, by nature, a highly stressful job and rates of burnout and
compassion fatigue are high among NICU staff. Protecting the mental health of NICU
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staff is not only important for their personal wellbeing, but ultimately protects the quality
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and integrity of their work in caring for babies and families. When efforts are made to
support staff, job satisfaction increases and employee turnover decreases.
Because of the highly technical nature of medical care in the NICU, much
attention is paid to clinical training, but relatively little training is provided on optimizing
interpersonal relationships, communication and teambuilding and almost no training is
given on how to educate, coach and mentor parents and families of babies in the NICU.
In the integrative, family-centered developmental care model, NICU staff is asked to
educate, coach and mentor parents to become active participants in their infant’s care
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and are also expected to provide active listening and psychosocial support to parents as
they negotiate the crisis of having a baby in the NICU. This is a monumental task with
short- and long-term implications for the quality of life during the NICU admission for
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both parents and NICU staff, which can ultimately influence the baby’s health and well-
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being. NICU staff cannot be expected to meet this expectation without specific and
ongoing education and training. Equipping NICU staff with the skills necessary to
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education, coach, mentor and support parents and providing NICU staff with the support
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they need to do so is critical to the success of family-centered developmental.
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Mental health professions should be an integral part of the NICU team and can,
not only support parents, but can also provide support for staff. Comprehensive
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psychosocial support requires interdisciplinary collaboration.[139] Providing
psychosocial support to parents whose infants are hospitalized in the NICU can provide
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parents’ functioning as well as their relationships with their babies.[140]

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Staff who develop burnout may have further reduced ability to provide effective
support to parents and babies.[140] Education about self-care and recognizing signs of
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burnout and compassion fatigue can be provided by mental health professions. Staff
should be supported in ethical decision making and coached in sorting out personal and
NICU family moral values that may differ. Debriefings and “pauses” after stressful
events can provide peer support for NICU staff.
To support the entire interdisciplinary team from a psychosocial perspective, a
multidisciplinary workgroup of professional organizations and NICU parents was
convened by the National Perinatal Association, which included six interdisciplinary
committees (family-centered developmental care, peer-to-peer support, mental health

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professionals in the NICU, palliative and bereavement care, follow-up support and staff
education and support). Each committee developed recommendations for program
standards related to each the above stated topics to promote the psychosocial support
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of parents with babies in the neonatal intensive care unit.[67, 68, 139-144]
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Perhaps the most important aspect of “neuroprotection” for NICU staff is
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frequent, regular, and sincere appreciation for their dedication and the quality of care
they provide in the NCIU. Both private and public acknowledgements of ongoing and
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extraordinary efforts can boost morale and motivate staff to continue to improve the
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care they provide to babies and families in the NICU
Transforming Practices through Quality Improvement

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Creating an organizational structure that promotes patient safety and achieves

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quality outcomes requires shared accountability and teamwork within organizations.

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Applying a systematic approach to improving key processes is the most effective
strategy for reliably identifying the source of problems and testing changes designed to
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improve and sustain change. It is always challenging to find ways to translate ideas into
actionable change at the frontline where patient care can be impacted. Utilizing Edward
Deming's PDSA cycle is an effective model for learning and change management. This
model incorporates the application of Plan, Do, Study, Act (PDSA) in order to help
teams improve the quality of care. Improving quality is about making healthcare safer,
more efficient, patient-centered, timely, effective and equitable. The PDSA cycle can
help identify, describe, and provide structure for a natural process whereby
groups/teams initiate change within their system. Using this explicit framework for
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managing a change program ensures the team does not drift from the initial objectives,
and also ensures actual achievable and valid measurements are identified. Clinically
advanced Neuroprotective Interventions related to SSC, each of the 7 Core Measures,
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as well as to promote teamwork, are further outlined in Appendix A.[52, 145, 146]
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This model of quality improvement emphasizing change management principles
related to neuroprotective practices has been utilized world-wide via the Wee Care
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Neuroprotective NICU Program (Wee Care; Philips).[147] The Wee Care training and
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consultative program combines evidence-based practices with seven core measures for
neuroprotective family-centered developmental care aimed at standardizing

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neuroprotective care practices in the NICU. The Wee Care program, which trains all
NICU staff, has been shown to improve noise and light levels in the NICU, improve
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infant medical outcomes, improve staff satisfaction/engagement, improve family

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satisfaction, decrease length of hospital stay, and decrease hospital costs.[43, 49, 148-
150] Facilitating the best outcomes for premature infants and their families has been
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achieved by optimizing the NICU environment, caregiving practices, caring for staff, as
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well as families. [41, 52] The identification of overarching goals with defined aim
statements for each core measure has assisted many NICUs across the globe in
providing a structured approach to changing and maintaining their neuroprotective
family-centered developmental care practices. Several examples of PDSA action plans
are outlined in Appendix B.
Summary
High-risk infants are both dependent on and vulnerable to the NICU environment.
While dependent on the NICU for the maintenance of their physiologic functions during
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recovery from the insult of being born too soon, they are also vulnerable to all the
stressors inherent in having fetal development occur outside the womb in the artificial
environment of the NICU. As the preterm infant matures, the quality of the environment
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in which the infant resides plays a critical role in the trajectory of recovery, growth and
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development.
Learning the principles of neurodevelopment and understanding the meaning of
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preterm behavioral cues makes it possible for NICU caregivers and parents to provide
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individualized developmentally appropriate, neuroprotective care to each infant.
Partnering with families and restoring parent-infant attachment supports both

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physiologic and emotional stability of infants and their parents. Providing gentle
containment, supportive boundaries, and flexed positions help to simulate the womb
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that was lost prematurely. By minimizing stress and pain, safeguarding sleep,
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protecting skin and optimizing nutrition, NICU caregivers can enhance the daily
experience of the infants in their care and increase the chances of achieving optimal
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physical, cognitive, and emotional outcomes. NICU staff do not learn these skills during
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their clinical training and require specific education in neuroprotective, family-centered,
developmental caregiving theory and practice. They also need education on how to
provide psychosocial support and effectively communicate with families who are
experiencing the crisis of having a baby in the NICU. It is important to “care for the
caregiver” by providing NICU staff with the support they need due to the stressful nature
of working in the intensive care setting.
Changes in developmental care can often begin with a few motivated caregivers
altering the way they care for premature infants. Role modeling, mentoring, and
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collaboration are key in the promotion of optimal developmental care. An overarching
goal is to achieve an effectively healing, peaceful, and satisfying environment for NICU
staff, families and the infants entrusted to our care.
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Developmentally supportive care is sometimes perceived as “nice,” yet optional.
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It is sometimes thought of as “fluff” in a primarily technologically-driven environment.
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Ignorance of, or dismissal of, the growing body of evidence about the importance of
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providing neuroprotective care for preterm infants is no longer acceptable. Consistent
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acceptance, practice, and accountability must be established to provide the high-quality
care every infant and family deserves. Use of established guidelines, policies, and
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procedures to guide neonatal practice is essential. Healthcare professionals must be
cognizant of the growing body of research regarding the impact of the NICU
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environment on neurodevelopmental outcomes of premature and sick infants.

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Figure 1: Neonatal Integrative Developmental Care Model
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Figure 2: Core measure # 1 of The Neonatal Integrative Developmental Care model:
The Healing Environment
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Appendix A: Clinical Applications of Neuroprotective Interventions related to the Seven
Core Measures of Neuroprotective Family-Centered Developmental Care
Core Measure # 1: Healing Environment[34, 41, 52, 55, 61, 139, 141, 145]
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Standard: A policy/procedure/guideline on the Healing Environment including physical space and privacy as well as the
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protection of the infant’s sensory system exists and is followed throughout the infant’s stay
Infant Goals Neuroprotective Interventions
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Characteristics
Stability of the infant’s An environment will be General
autonomic, sensory, maintained that promotes ~Educate, coach, and mentor parents on the importance of creating a
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motoric, and state healing by minimizing the healing environment that protects the developing sensory system of the
regulation systems impact of the artificial preterm infant. Emphasize their central role in the healing environment as
extrauterine NICU parents and as active members of the caregiving team.
environment on the Skin-to-skin Contact
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developing infant’s brain ~ Facilitate early, frequent, and prolonged skin-to-skin contact (SSC)
~ Encourage zero-separation between parents and infant
~ Provide comfortable and safe reclining chair or adult bed for early,
frequent, and prolonged SSC
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Space
~ Maintain a private and safe environment for the infant and family that
consists of a minimum of 120 sq. ft. per patient
~ Provide organized, non-cluttered space for family to support comfortable
and private caregiving
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~ When renovations are planned, advocate for SFR and promote utilization
of the latest standards from the “Recommended Standards for Newborn
ICU Design” at http://www3.nd.edu/~nicudes
Tactile:
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~ Provide a neutral thermal environment for the infant incorporating the

following factors:
- Facilitate early, frequent, and prolonged skin-to-skin contact.
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- If ELBW, provide humidity during the first two weeks after birth
- Provide care in incubator or SSC until infant can maintain own
temperature
Vestibular:
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~ Change infant’s position gently and slowly without sudden movements

~ Eliminate moving infants to different bed-spaces to accommodate staffing
patterns
Olfactory:
~ Maintain a scent-free & fragrance-free unit
~ Minimize exposure to noxious odors
~ Expose infant to mother’s scent when possible via breast pad, soft cloth,
or Snoedel
Gustatory:
~ Position infant with hands near face
~ Provide colostrum or expressed breast milk (EBM) oral care per protocol
~ Provide positive oral feeding experiences as outlined in “Optimizing
Nutrition” section
Auditory:
~ Support infants with consistently calm, relaxing environment with muted
sounds and lighting between and during caregiving interactions
~ Be mindful of own voice and other sounds produced in the NICU
~ Monitor sounds levels to maintain sound levels of < 50 dB
~ Silence alarms as quickly as possible and avoid unnecessary alarms
~ Comfort crying infants as quickly as possible
~ Expose infant to audible maternal/paternal voice
Visual:
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~Provide adjustable light levels up to a maximum of 60 fc
~ Gently shield infant’s eyes during cares if overhead light is needed
~ Be mindful of structuring an infant’s visual field to support alert
wakefulness as appropriate, transition to sleep, or quiet, restful sleep
~ Minimize purposeful visual stimulation until 37 weeks gestation
Overall Healing Environment:
~ Consider all the sources of light, sound, movement, smell and taste
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confronting an infant during care and eliminate all inappropriate or
unnecessary sources of stimulation
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~ Create and implement an individualized developmental care plan for each
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infant
~ Provide guidance to parents on how to create and sustain a healing
environment with respect to sensory exposures and experiences
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~ When renovation the NICU environment, advocate for optimal family
support spaces and resource-supports
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Core Measure # 2: Partnering with Families[52, 55, 67, 87, 141-143, 145, 151]
Standard 1: A policy/procedure/guideline on Partnering with Families to include unlimited access to ensure around-the-clock
information and access to their baby exists and is followed throughout the NICU.
Standard 2: There is a specific mission statement addressing Partnering with Families
Standard 3: NICU staff are competent in educating, coaching and mentoring parents in infant caregiving skills and in providing
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psychosocial support to NICU families.
Infant Characteristics Goals Neuroprotective Interventions
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~ Infant’s response to ~ Family-centered care is ~ Facilitate early, frequent, and prolonged skin-to-skin contact
parental interactions supported from birth or as ~ Encourage zero-separation between parents and infant
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soon as a NICU stay is ~ Educate, coach, and mentor parents in becoming active participants in
anticipated (antenatally if their baby’s care in supporting their infant’s developmental goals
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possible) ~ Acknowledge where the family is in regards to stages of grief and loss
and provide individualized and appropriate resources as needed
~ Parents will be viewed not ~ Actively listen to families’ feelings and concerns (both verbal and non-
as “visitors” but as equal & verbal)
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vital members of the ~ Incorporate parents as full participator
caregiving team with zero- ~ Accommodate the presence of families in the NICU and encourage
separation supported and participation in medical rounds and nursing hand-offs
encouraged (24-hr/day) ~ Share information with families in a tone of voice that preserves
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confidentiality
~Parents will be supported ~ Support families with a warm, respectful, and welcoming manner
& encouraged as the ~ Promote flexibility to welcome and families and support consistently at
primary and most important all times of the day
caregivers for their infant, ~ Encourage families to personalize their infant’s bed space and make the
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incorporating them as full NICU environment more home-like

participatory, essential ~ Include and support sibling and extended family participation as desired
healing partners within the by parents
NICU caregiving team ~ Communicate the infant’s medical, nursing, and developmental needs in
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a culturally appropriate and understandable way

~ Infant will develop ~ Support breastmilk expression and breastfeeding
emotional connection & ~ Educate parents on infant attachment, developmental and safety issues
secure attachment with ~ Provide social networking opportunities for parents of premature infants
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parents in the NICU

~Provide peer-to-peer support with parents who have gone through
~Parents who lose a baby similar NICU stays
before, during, or shortly ~ Honor both Health Insurance Portability and Accountability Act (HIPPA)
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after birth, or later in the and safety concerns while in the NICU
NICU will be supported at all ~ Provide parents with full access and input to both written and electronic
points of care medical records
~ Encourage and empower parents as they develop confidence in their
own abilities to continue caring for their baby when going home
~Provide staff education related to principles of Family-centered care and
how to support parents’ caregiving roles
~ Provide anticipatory guidance regarding the grieving process to mothers
and fathers, and other family members, recognizing they all may grieve
differently
~ Provide psychosocial support for all members of the family, including
grandparents and the baby’s siblings
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Core Measure # 3: Positioning & Handling:[41, 52, 98, 141, 145]

Standard: A policy/procedure/guideline on Positioning & Handling exists and is followed throughout the infant’s stay that includes
educating, coaching and mentoring parents on how to position and handle their infant.
-Autonomic stability ~Autonomic stability will be ~Facilitate early, frequent, and prolonged skin-to-skin contact
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during handling maintained throughout ~ Educate, coach, and mentor parents in how to positon, contain and
positioning changes and handle their infant in a developmentally appropriate manner
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-Ability to maintain tone handling activities as well as ~ Provide infants with positioning supports needed to maintain optimal
and flexed postures with during periods of rest and tone and position and to remain either in a quiet, restful sleep or a
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and without supports sleep. relaxed, comfortable wakefulnes
~Parents will be educated, ~ Utilize a validated & reliable positioning assessment tool [i.e. Infant
Positioning Assessment Tool (IPAT)] routinely to ensure appropriate
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coached, and mentored in
how to position and handle positioning and encourage accountability
their infant ~ Maintain a midline, flexed, contained, and comfortable position at all
~Preventable positional times utilizing appropriate positioning aids and boundaries
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deformities will be ~ Provide appropriate ventral support to ensure flexed shoulders/hips
eliminated or minimized by ~ Provide swaddling when bathing and weighing
maintaining infants in a ~ Avoid doing procedures with infant in a prone position where he/she is
midline, flexed, contained, unable to use self-comforting abilities
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and comfortable position ~ Anticipate, prioritize, and support the infant’s individualized needs
throughout their NICU stay during each care-giving interaction to minimize stressors known to
-The caregiver sees her or interfere with normal development
himself in partnership with ~ Engage with infant and let behavior of infant guide care
the baby so that caregiving ~ Assess infant sleep-wake cycle to evaluate appropriate timing of
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procedures are performed positioning and caring

“with” the infant rather than ~ Reposition infant with cares and minimally every 4 hours
“to” the infant. ~ Provide 4-handed support during positioning and caring activities
-Infants will be provided ~ Promote hand to mouth/face contact
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developmentally ~ When providing caregiving activities:

appropriate stimulation/play - Collect all supplies prior to approaching infant so infant is not left
as they mature (i.e. mobiles, unattended, or unsupported once hands-on care has begun
swings, etc.) - Seek another person to support infant care during a potentially
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stressful experience, including bathing and weighing

- Include parents in providing support when available and willing
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Core Measure # 4: Safeguarding Sleep[52, 102, 103, 141, 145]
Standard 1: A policy/procedure/guideline on Safeguarding Sleep exists and is followed throughout the infant’s stay
Standard 2: A policy/procedure/guideline on Back-to-Sleep Practices exists and is followed prior to discharge
-Infant sleep-wake states, -Infant sleep-wake states ~Facilitate early, frequent, and prolonged skin-to-skin contact
cycles, and transitions will be assessed before ~Educate, coach, and mentor parents on sleep-wake states and how to
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initiating all caregiving promote sleep in their infant
-Infant’s maturity and activities ~ Utilize a validated & reliable scale to assess sleep-wake states to
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readiness for Back-to-Sleep promote sleep
Protocol -Prolonged periods of  ~ Protect sleep cycles, and especially REM sleep. Avoid sleep
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uninterrupted sleep will be interruptions, bright lights, loud noises, and unnecessary disturbing
protected activities.
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~ Protect quiet sleep states by providing flexibility in timings of care
- Infants will be ~ Engage with infant and let behavior of infant guide care
transitioned to Back-to- ~ Individualize all caregiving activities by clustering cares based on infant
Sleep Protocol when sleep-wake states. Take care not to over-stress infant with too many
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developmentally clustered cares at once.
appropriate ~ If necessary to arouse a sleeping infant, approach using a soft
voice/whisper followed by gentle touch
~ Support smooth transitions back to restful sleep before stepping away
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from bedside
~ Promote a quiet environment to ensure uninterrupted sleep
 ~ Protect the eyes from direct light exposure and maintain low levels of
ambient light
~ Use incubator covers to protect the infant from direct light
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 ~ Provide some daily exposure to light, preferably including shorter

wavelengths, for entrainment of the circadian rhythm.
 ~ Avoid (when possible) high doses of sedative and depressing drugs
which can depress the endogenous firing of cells; thus interfering with
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visual development, REM, and NREM sleep cycles, and thus optimal brain
development.
 ~ Provide developmental care appropriate for the age and maturation of
the infant including supportive positioning to promote restful sleep
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 ~ Provide guidance to parents on how to safeguard their baby’s sleep,

recognizing the importance of sleep to healing, growth and brain
development 
~Assure infant is able to maintain normal sleep pattern during Back-to-
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Sleep well before discharge and role model this behavior in the NICU
~Provide tummy-time/prone-to-play time routinely for infants that are
Back-to-Sleep
~Coach, educate, and mentor parents about the importance and rationale
for Back-to-Sleep and tummy-time
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Core Measure # 5: Minimizing Stress & Pain:[52, 123, 141, 145, 152, 153]
Standard: A policy/procedure/guideline on the assessment and management of pain exists and is followed throughout the
infant’s stay.
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-Behavioral cues indicating -Promote self-regulation ~Facilitate early, frequent, and prolonged skin-to-skin contact
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stress or self-regulation and neurodevelopmental ~Educate, coach, and mentor parents on infant cues related to stress and
organization pain and how to provide their infant with nonpharmacological support
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during stressful or painful procedures
~Utilize a validated & reliable pain assessment tool to evaluate the need
for pharmacologic support
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~Provide non-pharmacologic support (breastfeeding, SSC, sucrose,
pacifier) with all minor invasive interventions
~Provide individualized care in a manner that anticipates, prioritizes, and
supports the needs of infants to minimize stress and pain
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~Provide midline, flexion, and containment with all positioning to promote
comfort
~ Provide therapeutic positioning aids to promote supportive positioning
~ Provide guidance to parents on how to collaborate with NICU staff to
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minimize their baby’s stress and pain in the developmentally-unexpected
environment of the NICU
~ Reserve family activities for families (bathing, feeding, etc.)
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Core Measure # 6: Protecting Skin[52, 128, 129, 141, 145]

Standard: A policy/procedure/guideline on Skin Care exists and is followed throughout the infant’s stay
- Maturity and integrity of -Reduce trans epidermal ~Facilitate early, frequent, and prolonged skin-to-skin contact
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infant skin water loss of ELBW infants ~Educate, coach, and mentor parents on skin care, swaddled bathing, and
delivery of developmentally appropriate infant massage
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-Maintain skin integrity of ~Utilize a validated & reliable skin assessment tool (i.e. Braden Q) on
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the infant from birth to admission and routinely according to hospital protocol
discharge ~Provide individualized care in a manner that anticipates, prioritizes, and
supports the needs of infants to optimize neuromotor development
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-Provide developmentally ~Provide humidity for ELBW infants during the first two weeks after birth
appropriate infant massage (50% humidity is provided when infant is in SSC)
~Provide appropriate positioning support utilizing gel products to prevent
skin breakdown
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Èxamine position of nasal prongs per protocol to protect against
breakdown of nasal septum
~Provide humidity for ELBW infants during the first two weeks after birth
(50% humidity is provided when infant is in SSC)
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~Minimize use of adhesives and use caution when removing adhesives to
prevent epidermal stripping
~Avoid soaps and routine use of emollients
~Use water only for bathing < 1000 gram infants
~Use pH neutral cleansers for bathing > 1000 gram infants
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~When bathing, do swaddled bathing in bed or tub (to reduce stress and
promote relaxation) with overhead warmer (to prevent risk of
hypothermia).
~Priority should be given to parents to bathe their own infant whenever
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possible.
~Provide bathing no more than every 72 to 96 hours
~ Provide parents guidance on how to protect their baby’s skin and its
many functions, including its role as a conduit of neurosensory
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information to the brain

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Core Measure # 7: Optimizing Nutrition[52, 67, 139, 141, 145]

Standard 1: A policy/procedure/guideline on Optimizing Nutrition (Cue-based/Infant-driven Breast or Bottle feeding)
which includes infant readiness, quality of feeding and caregiver techniques) is followed throughout the infant’s stay
Standard 2: A policy/procedure/guideline on skin-to-skin contact (Kangaroo Care) exists and is followed throughout the
infant’s stay
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-Physiologic stability with -Feeding will be safe, ~Facilitate early, frequent, and prolonged skin-to-skin contact
feeding & handling functional, nurturing, and ~Educate, coach, and mentor parents about infant feeding cues, and guide
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developmentally them with pacing and other feeding techniques
-Feeding readiness cues appropriate. ~Utilize a validated & reliable Infant-Driven Readiness – Feeding -
Caregiving Scale
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-Coordinated -Optimized nutrition will be ~ Ensure every feeding experience is a positive, pleasant, and nurturing
Suck/Swallow/Breathing enhanced by individualizing experience
(SSB) throughout breast or all feeding care practices ~Individualize care by incorporating cue-based/Infant-driven feeding
bottle feeding practices
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-Oral aversions will be ~Support and encourage mother’s expressed breast milk (EBM) supply
-Endurance to maintain prevented by assuring is a ~Support and encourage breastfeeding well before discharge
nutritional intake and positive experience for ~Minimize negative perioral stimulation (adhesives, suctioning, etc.)
support growth infant ~Utilize indwelling gavage tubes rather than intermittent tubes.
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~Promote positive oral stimulation, Non-Nutritive Sucking (NNS) at
-Infants of breastfeeding mother’s pumped breast during gavage feeds
mothers will be competent ~Hold infant and use NNS with appropriate sized pacifier during gavage
at breastfeeding prior to feeds when mother is not available
discharge ~Provide taste and smell of breast milk with gavage feedings
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~Promote side-lying position close to parent/caregiver when bottle-

feeding
~Provide guidance to parents on how to provide supportive oral feeding
experiences for their infant
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Teamwork & Collaboration[139-142, 145, 147]
Standard 1: An interdisciplinary team of caregivers works together collaboratively to support the infant’s and family’s
goals
Standard 2: Hospital leadership facilitates education related to self-care of all NICU staff to prevent burn-out and
compassion fatigue
Standard 3: A policy/procedure/guideline on roles and responsibilities of team members and collaboration thereof exists
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and is followed
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-Infant and family are -An individualized ~ Support parents as the primary givers by educating, coaching, and
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central to each team developmentally mentoring parents
member’s plans, decisions appropriate environment is ~Include parents in all medical decision making
and caregiving provided for every infant ~ Consistently share information about infant’s behavioral competencies,
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and family vulnerabilities and thresholds when communicating with colleagues during
rounds or shift change
~ Prior to performing a procedure, care, or exam on an infant under the
care of another team member (or parent), needs of that team member
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will be discussed to mutually agree on the timing
~ Willingly and proactively assist colleagues to provide support for infants
in their care during potentially stressful procedures
~ Provide as much space and comfort as possible for family caregiving,
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keeping charts and equipment nicely organized and avoiding clutter
~ Respect and support the roles of other individuals and disciplines when
caring for infants – support each other through mentoring relationships
~ Ensure all infants and families are treated consistently with support,
dignity, and respect by all team members, and constructively confront
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team members if discrepancies are noted

~ Educate all staff on Neuroprotective family-centered developmental
care principles
~ Educate staff about methods for improving and expanding family-
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centered developmental care in the NICU

~ Educate staff on the differences and value of cultural practices other
than their own
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~ Educate staff on optimal methods of communication with parents in

distress
~ Educate staff on elements of self-care to proactively prevent and
minimize burn-out and compassion fatigue
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~ Ensure that channels of communication between nursing staff and their

supervisors are clear with an outlet to access support
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Appendix B
Appendix B-1: Sample PDSA for CORE Measure # 3 – Positioning & Handling
GOALS AIM PLAN Do: ACTIONS Do (Contact) TIMELINE Comments REWARDS
UPDATES CONSEQUENCES
Goal CM # 3: 1). 100 % infants 1.Positioning of 1.Educate staff on: 1. Educator/DC 1. Jan. 10 – Measurement: Rewards
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will be each infant will be a. principles of positioning Champion 1 Mar 10 1.Scoring on
Positioning
positioned in a assessed and b. Use of positioning aids (Beth/Jane) IPAT will be 10-
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& Handling midline, flexed scored utilizing c. IPAT tool 12 on 100% of Consequences
and contained the Infant Cases
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position with an Positioning 2. Create NICU Competency on 2. Jan. 5
IPAT score Assessment Tool positioning 2. Educator (Beth)
between 10 – 12. (IPAT) every shift
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and twice a week 3.Create NICU guideline on 3. Jan 5
by audit team (DC positioning 3. DC Champion 2
Champion) (Joe)
4.Create par level of 4. Jan 10
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positioning supplies with
appropriate supply and access 4. DC Champion
3/Supply Tech
5.Incorportate IPAT into NICU 5. Feb 1
documentation
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6.Create audit tool for 6. Mar 1
measuring positioning of
infants 6. DC Champion 4
(with QI support)
7.Prepare dashboard for 6. Mar 1
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reporting IPAT audit scores to

enable trend analysis 7. DC Champion 4
(with QI support)
8.Create communication plan
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for all staff/families)

8. DC
Lead/Educator/Mgr
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Status update/
communication
Date Update
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To appear in: Newborn and Infant Nursing Reviews

The Neonatal Integrative Developmental Care Model:

Advanced Clinical Applications of the

Seven Core Measures for Neuroprotective Family-Centered Developmental Care

Raylene M. Phillips, MD, IBCLC, FABM, FAAP

11175 Campus Street, CP 11121

measures for neuroprotective family-centered developmental care of premature infants,

overlapping petals of a lotus as the 1) Healing Environment, 2) Partnering with Families,

the Healing Environment, highlighting the physical, extra-uterine environment in which

Model utilizes neuroprotective interventions as strategies to support optimal synaptic

neural connections, promote normal neurological, physical, and emotional development

and prevent disabilities.

Keywords: Core Measures, Integrative, Neuroprotection, Developmental, Family-

Centered, Infant, Premature, NICU, infant

To better understand the developmental problems associated with prematurity

and other high-risk events, it is essential to understand the basics of neurosensory

developing in the NICU in an environment entirely different than the protective

environment of the womb.

interdependent and comprise the neurobehavioral and neurosensory development of

syndromes of the central nervous system characterized by impaired communication,

social interaction challenges, and restricted behaviors. Although neuropathology of ASD

associated nuclei in children with a genetic susceptibility who experience abnormal

stressors during a critical period of brain development.[18-21] The prevalence of ASD

of evidence supports prematurity as a risk factor for ASD. [30]

third trimester of gestation. With volumes of research documenting long-term disabilities

in prematurely-born children, understanding how we can better support the preterm

environment of the NICU. [31-34]

internal, endogenous, or hormonal stimulation, and external experiences from the

Although initial stimulation of each sensory system is internal or endogenous, at

a critical or sensitive point in development, external stimulation and experiences are

emotional environments. Events and stimuli from any of these components of

environment are capable of altering the course and outcome of developmental

processes producing changes in brain development that can be either positive or

Neuroprotection in the NICU

developmentally supportive environment that focuses on the interpersonal experiences

and neurologic development occurring during the early neonatal period.

Family-integrated, neuroprotective, developmentally supportive care includes

development [38-41]. Neuroprotective developmental care is grounded in support by

research from a number of disciplines including nursing, medicine, neuroscience, and

psychology. [39, 42-46]. Improvements in health outcomes, lengths of stays, as well as

change of care practices were implemented [47-50].

The Neonatal Integrative Developmental Care Model (IDC) (Philips Healthcare)

target the improvements/outcomes desired. Clinical applications include neuroprotective

must be evidence-based, reliably applied and scientifically valid.

To effectively implement many neuroprotective interventions, a cultural shift

in a systematic fashion. Quality improvement (QI) methods such Plan/Do/Study/Act

improved outcomes.[53] Examples of neuroprotective interventions and sample QI

projects will be further explained below and consolidated in Appendices A and B.

facilitates attachment, which promotes the infant’s self-regulation over time.[56]SSC

encouraged and facilitated.

Skin-to-skin contact with mother (or father) is directly neuroprotective and

been shown to accelerate brain maturation in electroencephalogram (EEG) tracings of

Neuroprotective Core Measure # 1: Healing Environment (Insert Figure 2)

The Healing Environment, Core Measure # 1, addresses the physical

markedly improved outcomes when the stress of environmental sensory overstimulation

is reduced. This can be accomplished by incorporating neuroprotective strategies into

the care of infants and also by aspects of NICU design. [61]

NICUs should be designed to encourage family reunification and presence,

facilitate psychosocial support, address/minimize sensory impact, offer social

experience burnout and more likely to rank quality of care higher

which can cause developmental delays[63], infants placed together in a pod

arrangement can be better supported developmentally through appropriate sensory